Know-do gaps in the clinical management of childhood illness: evidence from three countries in sub-Saharan Africa

TL;DR

This study examines why healthcare providers in sub-Saharan Africa don't follow treatment guidelines for childhood illnesses, finding that knowledge gaps are not the main issue.

Contribution

The study introduces the 'know-do gap' concept to distinguish between knowledge and other barriers to guideline adherence in clinical practice.

Findings

Provider knowledge of guidelines was high (75-87%) but actual adherence during patient care was lower (51-76%).

Knowledge gaps explained up to 40% of non-adherence for pneumonia treatment in the DRC but less in other cases.

Non-adherence is driven more by factors like motivation and workload than by lack of knowledge.

Abstract

After neonatal conditions, the leading causes of child mortality in sub-Saharan Africa are malaria, lower respiratory infections, and dehydration. Many of these deaths could be averted with basic and widely-available health interventions, but quality of care remains low. We aimed to assess adherence to clinical guidelines for these conditions in Burundi, the Democratic Republic of the Congo (DRC), and Nigeria, and estimate the proportion of guideline non-adherence that is explained by gaps in health care provider knowledge versus other factors.

We conducted an observational study in randomly-sampled health facilities in each study country, linking data from direct observations of under-5 sick child visits, knowledge assessments of the treating health care providers, and interviews with caregivers. For children diagnosed with malaria, severe respiratory infection, or dehydration, we defined the “adherence gap” as the percentage who did not receive correct treatment, and the “know-do gap” as the percentage who received incorrect care despite the provider knowing the correct treatment. We evaluated the portions of overall adherence gaps that were explained by know-do gaps, and described factors associated with know-do gaps.

A total of 2,212 sick child visits treated by 852 providers were analyzed. In the pooled sample, 87%, 75%, and 77% percent of providers were familiar with the main treatment recommendations for malaria, pneumonia, and dehydration, respectively. When observed by survey staff during consultations with sick children, compliance with the same guidelines was 76%, 74%, and 51%. Knowledge gaps explained between 0% of the total adherence gap for pneumonia treatment in Burundi and 40% of the gap for pneumonia treatment in the DRC.

To improve quality of care, it is critical to understand why providers do not consistently follow clinical guidelines. Our findings suggest that adherence to protocols is low, but that knowledge is not the primary barrier. Interventions to improve quality must go beyond improving knowledge to also address other drivers of provider behavior such as motivation, workload, and systemic constraints.

The online version contains supplementary material available at 10.1186/s12889-025-24852-0.

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