Durham, NC — 23 September 2025 — Researchers from USC and Duke report that the persistent "know-do gap" — where clinicians know guidelines but practice differently — is the primary driver of antibiotic overprescribing for pediatric diarrhea in India's private sector, not lack of knowledge, point-of-sale profits, or stockouts of clinically recommended treatments such as oral rehydration salts (ORS).
In a sample of 2,282 private providers across 253 towns, 70 percent prescribed antibiotics without signs of bacterial infection, and among those who knew antibiotics were inappropriate, 62 percent still prescribed them to standardized patients, indicating a large know-do gap. The study found that eliminating the knowledge gap alone would cut inappropriate antibiotic use by about 6 percentage points, whereas closing the know-do gap could reduce it by roughly 30 percentage points.
Randomized experiments showed that the know-do gap was driven by providers' beliefs about patient preferences and not profits from selling antibiotics or limited supplies of ORS. When patients expressed a preference for ORS, inappropriate antibiotic use fell by 17 percentage points on average, with especially large reductions among pharmacies. By contrast, removing point-of-sale financial incentives and supplying ORS had no meaningful effect on antibiotic prescribing.
A discrete choice experiment with 1,189 caregivers further found that patients did not prefer providers who give antibiotics over those who provide ORS, underscoring the misalignment between provider perceptions and actual patient preferences.
"Our data reveal a striking disconnect: clinicians know antibiotics are wrong for most diarrhea cases, yet prescribe them anyway because they think parents expect 'strong' medicines," said corresponding author Zachary Wagner of USC's Center for Economic and Social Research. "Correcting that perception, rather than another training seminar, offers the biggest win for global antibiotic stewardship."
"A lot of children are given antibiotics when they don't need them, and that can lead to drug-resistant bacteria — a problem for the whole world, not just India. By showing that patient–provider communication trumps financial motives, we give policymakers a laser-focused lever: help doctors understand real patient preferences," added coauthor Neeraj Sood of the USC Schaeffer Center and Price School.
The authors note the largest know-do gaps among less formally trained providers and pharmacies, where preference signaling by patients yielded the biggest improvements, suggesting targeted interventions could deliver outsized benefits.
"Pharmacies and informal providers, often the first stop for care, showed the largest know-do gaps," noted Manoj Mohanan of Duke University. "Interventions that empower caregivers to voice a preference for ORS, or public campaigns signaling that parents don't demand antibiotics, could slash misuse at scale."
Funding for this research was provided by the National Institute of Diabetes and Digestive and Kidney Diseases (PI Wagner; 5R01DK126049).
CITATION: "Investigating the know-do gap in antibiotics prescribing: Experimental evidence from India," Zachary Wagner, Manoj Mohanan, Arnab Mukherji, Rushil Zutshi, Sumeet Patil, Jagadish Krishnappa, Somalee Banerjee, Neeraj Sood. Science Advances, 10 September 2025, DOI: 10.1126/sciadv.ady9868 .
