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The know-do gap in sick child care in Ethiopia.

ABSTRACT: BACKGROUND:While health care provider knowledge is a commonly used measure for process quality of care, evidence demonstrates that providers don't always perform as much as they know. We describe this know-do gap for malaria care for sick children among providers in Ethiopia and examine what may predict this gap. METHODS:We use a 2014 nationally-representative survey of Ethiopian providers that includes clinical knowledge vignettes of malaria care and observations of care provided to children in facilities. We compare knowledge and performance of assessment, treatment and counseling items and overall. We subtract performance scores from knowledge and use regression analysis to examine what facility and provider characteristics predict the gap. 512 providers that completed the malaria vignette and were observed providing care to sick children were included in the analysis. RESULTS:Vignette and observed performance were both low, with providers on average scoring 39% and 34% respectively. The know-do gap for assessment was only 1%, while the gap for treatment and counseling items was 39%. Doctors had the largest gap between knowledge and performance. Only provider type and availability of key equipment significantly predicted the know-do gap. CONCLUSIONS:While both provider knowledge and performance in sick child care are poor, there is a gap between knowledge and performance particularly with regard to treatment and counseling. Interventions to improve quality of care must address not only deficiencies in provider knowledge, but also the gap between knowledge and action.

SUBMITTER: Gage AD

PROVIDER: S-EPMC6291134 | biostudies-literature | 2018

REPOSITORIES: biostudies-literature

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The know-do gap in sick child care in Ethiopia.

Gage Anna D AD Kruk Margaret E ME Girma Tsinuel T Lemango Ephrem T ET

PloS one 20181212 12

<h4>Background</h4>While health care provider knowledge is a commonly used measure for process quality of care, evidence demonstrates that providers don't always perform as much as they know. We describe this know-do gap for malaria care for sick children among providers in Ethiopia and examine what may predict this gap.<h4>Methods</h4>We use a 2014 nationally-representative survey of Ethiopian providers that includes clinical knowledge vignettes of malaria care and observations of care provided ...[more]

PMID: 30540855

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Project description:ObjectiveThough efforts were made to expand community-based sick child healthcare in Ethiopia, the quality of care provided remained low. Improving quality of care requires understanding providers' knowledge of appropriate care and their actual execution of tasks. This study examined gap between what health extension workers (HEWs) knew and did during the management of sick children in Ethiopia.DesignFacility-based cross-sectional study was conducted.SettingThe study was carried out in 52 districts across 4 regions in Ethiopia.ParticipantsWe interviewed 274 HEWs and performed observations of consultations done by 150 HEWs supplemented with facility assessment from December 2018 to February 2019.OutcomeWe compared providers' knowledge and performance in the management of childhood pneumonia and diarrhoea. Know-do gap implies the difference in proportion between knowledge and actual practice of HEWs. Logistic regression was used to identify predictors of knowledge and actual practice.ResultsProviders' correct knowledge ranged from 27.8% to 76.0% for signs and symptoms of pneumonia, and 32.0% to 84% for dehydration signs. Their actual practices ranged from 15.1% to 47.3% for pneumonia and 27.0% to 42.6% for dehydration. The correct knowledge and actual practices for pneumonia and dehydration management were 88.3% vs 15.6% and 93.9% vs 51.3%, respectively. There was significant know-do gap in assessments (16.7%, p=0.002) and management of childhood conditions (68.5%, p<0.0001). Mentorships were associated with providers' knowledge of clinical management, while medicines availability was associated with their actual management practice.ConclusionsWhile knowledge and actual practice for assessment and management of pneumonia and dehydration ranged from very low to high, what is more concerning is the huge know-do gap among HEWs. Our findings suggest that knowledge-based training is necessary but not sufficient for ensuring correct assessment and management of sick children by HEWs. Continuous support through mentorships and the supply of commodities are critically needed.

Project description:BackgroundAs community case management of childhood illness expands in low-income countries, there is a need to assess the quality of care provided by community health workers. This study had the following objectives: 1) examine methods of recruitment of sick children for assessment of quality of care, 2) assess the validity of register review (RR) and direct observation only (DO) compared to direct observation with re-examination (DO+RE), and 3) assess the effect of observation on community health worker performance.MethodsWe conducted a survey to assess the quality of care provided by Ethiopian Health Extension Workers (HEWs). The sample of children was obtained through spontaneous consultation, HEW mobilization, or recruitment by the survey team. We assessed patient characteristics by recruitment method. Estimates of indicators of quality of care obtained using RR and DO were compared to gold standard estimates obtained through DO+RE. Sensitivity, specificity, and the area under receiver operator characteristic curve (AUC) were calculated to assess the validity of RR and DO. To assess the Hawthorne effect, we compared estimates from RR for children who were observed by the survey team to estimates from RR for children who were not observed by the survey team.ResultsParticipants included 137 HEWs and 257 sick children in 103 health posts, plus 544 children from patient registers. Children mobilized by HEWs had the highest proportion of severe illness (27%). Indicators of quality of care from RR and DO had high sensitivity for most indicators, but specificity was low. The AUC for different indicators from RR ranged from 0.47 to 0.76, with only one indicator above 0.75. The AUC of indicators from DO ranged from 0.54 to 1.0, with three indicators above 0.75. The differences between estimates of correct care for observed versus not observed children were small.ConclusionsMobilization by HEWs and recruitment by the survey teams were feasible, but potentially biased, methods of obtaining sick children. Register review and DO underestimated performance errors. Our data suggest that being observed had only a small positive effect on the performance of HEWs.

Project description:BACKGROUND:Community health worker (CHW) interventions to manage childhood illness is a strategy promoted by the global health community which involves training and supporting CHW to assess, classify and treat sick children at home, using an algorithm adapted from the Integrated Management of Childhood Illness (IMCI). To inform CHW policy, the Government of Tanzania launched a program in 2011 to determine if community case management (CCM) of malaria, pneumonia and diarrhea could be implemented by CHW in that country. METHODS:This paper reports the results of an observational study on the CCM service delivery quality of a trial cohort of CHW in Tanzania, called WAJA. In 2014, teams of data collectors, employees of the Ministry of Health and Social Welfare trained in IMCI, assessed the IMCI skills rendered by a sample of WAJA on sick children who presented to WAJA with illness signs and symptoms in their communities. The assessment included direct observations of WAJA IMCI episodes and expert re-assessment of the same children seen by WAJA to assess the congruence between the assessment, classification and treatment outcomes of WAJA cases and those from cases conducted by expert re-assessors. RESULTS:In the majority of cases, WAJA correctly assess sick children for CCM-treatable illnesses (malaria, pneumonia, and diarrhea) and general danger signs (90% and 89%, respectively), but too few correctly assess for physical danger signs (39%); on classification in the majority of cases (73%) WAJA correctly classified illness, though more for CCM-treatable illnesses (83%). In majority of cases (78%) WAJA treated children correctly (84% of malaria, 74% pneumonia, and 71% diarrhea cases). Errors were often associated with lapses in health systems support, mainly supervision and logistics. CONCLUSION:CCM is a feasible strategy for CHW in Tanzania, who, in the majority of cases, implemented the approach as well as IMCI expert re-assessors. Nevertheless, for CCM to be effective, in Tanzania, a strategy to implement it must be coordinated with efforts to strengthen local health systems.

Project description:ObjectivesFathers play an important role in household decision-making processes and child health development. Nevertheless, they are under-represented in child health research, especially in low-income settings. Little is known about what roles fathers play in the care-seeking processes or how they interact with the health system when their child is sick. This study aimed to understand Ethiopian fathers' roles and responsibilities in caring for their children when they are or become ill.DesignQualitative study using semistructured interviews with fathers.SettingThis study was conducted in three rural districts of the Southern Nations, Nationalities and People's Region of Ethiopia.ParticipantsTwenty-four fathers who had at least one child between 2 and 59 months who visited a health extension worker with fever.ResultsThe overarching theme of this study was 'changing perceptions of paternal responsibilities during children's ill health'. It constituted three subthemes, namely, 'fathers' burden of earning money for care', 'fatherhood entails advocating children's healthcare needs' and 'investing in children's health can benefit the family in the future'. Fathers described that they were the ones mainly responsible for the financial arrangement of care and that this financial responsibility can involve stress when resources are scarce. Fathers knew what health services were available and accessible to them and were involved in different ways in the care seeking of the child. Changes in the importance ascribed to child health were expressed by fathers who described being more alert to children's ill-health.ConclusionFathers play various roles in the care-seeking process during children's illness episodes. This included, for instance, arranging resources to seek care, (co)-deciding where to seek care as well as accompanying the child to the health facility. The inability to organise necessary resources for care can lead to involuntary delays in care seeking for the child. This demonstrates the importance of including fathers in future interventions on maternal and child health.

Project description:ImportanceIn rural India, as in many developing countries, childhood mortality remains high and the quality of health care available is low. Improving care in such settings, where most health care practitioners do not have formal training, requires an assessment of the practitioners' knowledge of appropriate care and the actual care delivered (the know-do gap).ObjectiveTo assess the knowledge of local health care practitioners and the quality of care provided by them for childhood diarrhea and pneumonia in rural Bihar, India.Design, setting, and participantsWe conducted an observational, cross-sectional study of the knowledge and practice of 340 health care practitioners concerning the diagnosis and treatment of childhood diarrhea and pneumonia in Bihar, India, from June 29 through September 8, 2012. We used data from vignette interviews and unannounced standardized patients (SPs).Main outcomes and measuresFor SPs and vignettes, practitioner performance was measured using the numbers of key diagnostic questions asked and examinations conducted. The know-do gap was calculated by comparing fractions of practitioners asking key diagnostic questions on each method. Multivariable regressions examined the relation among diagnostic performance, prescription of potentially harmful treatments, and the practitioners' characteristics. We also examined correct treatment recommended by practitioners with both methods.ResultsPractitioners asked a mean of 2.9 diagnostic questions and suggested a mean of 0.3 examinations in the diarrhea vignette; mean numbers were 1.4 and 0.8, respectively, for the pneumonia vignette. Although oral rehydration salts, the correct treatment for diarrhea, are commonly available, only 3.5% of practitioners offered them in the diarrhea vignette. With SPs, no practitioner offered the correct treatment for diarrhea, and 13.0% of practitioners offered the correct treatment for pneumonia. Diarrhea treatment has a large know-do gap; practitioners asked diagnostic questions more frequently in vignettes than for SPs. Although only 20.9% of practitioners prescribed treatments that were potentially harmful in the diarrhea vignettes, 71.9% offered them to SPs (P < .001). Unqualified practitioners were more likely to prescribe potentially harmful treatments for diarrhea (adjusted odds ratio, 5.11 [95% CI, 1.24-21.13]). Higher knowledge scores were associated with better performance for treating diarrhea but not pneumonia.Conclusions and relevancePractitioners performed poorly with vignettes and SPs, with large know-do gaps, especially for childhood diarrhea. Efforts to improve health care for major causes of childhood mortality should emphasize strategies that encourage pediatric health care practitioners to diagnose and manage these conditions correctly through better monitoring and incentives in addition to practitioner training initiatives.

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The know-do gap in sick child care in Ethiopia.

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The know-do gap in sick child care in Ethiopia.

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