Few health care providers in rural India know the correct treatments for childhood diarrhoea and pneumonia – two leading killers of young children worldwide and even when they do, they rarely prescribe them properly, according to a new study.

Medical practitioners typically fail to prescribe lifesaving treatments such as oral rehydration salts (ORS). Instead, they typically prescribe unnecessary antibiotics or other potentially harmful drugs, said Manoj Mohanan, a professor in Duke University’s Sanford School of Public Policy, and lead author of the study.

Diarrhoea and pneumonia accounted for 24 per cent of deaths among children 1 to 4 years old, totalling approximately 2 million deaths worldwide in 2011.
Bihar – where the study was conducted – has an infant mortality rate of 55 per 1000 live births, the highest in the country, researchers said.

“We know from previous studies that providers in rural settings have little medical training and their knowledge of how to treat these two common and deadly ailments is low,” Mohanan said.
“Eighty per cent in our study had no medical degree. But much of India’s rural population receives care from such untrained providers, and very few studies have been able to rigorously measure the gap between what providers know and what they do in practice,” said Mohanan.

The study involved 340 health care providers. Researchers conducted “vignette” interviews with providers to assess how they would diagnose and treat a hypothetical case.
Later, standardised patients – individuals who portrayed patients presenting the same symptoms as in the interviews – made unannounced visits.
This strategy enabled researchers to measure the gap between what providers know and what they actually do – the “know-do” gap.

Providers exhibited low levels of knowledge about both diarrhoea and pneumonia during the interviews and performed even worse in practice.

For example, for diarrhoea, 72 per cent of providers reported they would prescribe oral rehydration salts – a life-saving, low-cost and readily available intervention – but only 17 per cent actually did so. Those who did prescribe ORS also added other unnecessary or harmful drugs.

In practice, none of the providers gave the correct treatment: only ORS, with or without zinc, and no other potentially harmful drugs, researchers said.

Instead, almost 72 per cent of providers gave antibiotics or potentially harmful treatments without ORS.
“It clearly is not demand from patients alone, which is a common explanation, since none of our standardised patients asked for antibiotics but almost all of them got them,” he said.

Providers with formal medical training still had large gaps between what they knew and did, but were significantly less likely to prescribe harmful medical treatments.
The study was published in the journal JAMA Pediatrics.