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Peer-reviewedCC BY-NC 4.0BMJ Open

Antibiotic prescribing practices of community health extension workers in East Central Uganda: an exploratory qualitative study

  • Enid Kawala Kagoya1,2
  • Christopher Aturinda2
  • Richard Gamubaka1
  • Samuel Mugabi1
  • Joseph L Mpagi3
  • Paul Waako4
  • Dan Kibuule4
4 affiliations
  1. 1Department of Community Health, Busitema University Faculty of Health Sciences, Mbale, Uganda
  2. 2Clinical Epidemiology Unit, Makerere University CHS, Kampala, Central Region, Uganda
  3. 3Department of Microbiology and Immunology, Busitema University, Tororo, Uganda
  4. 4Department of Pharmacology and Therapeutics, Busitema University Faculty of Health Sciences, Mbale, Eastern Region, Uganda
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Abstract

Background: Antibiotic misuse at the community level remains a critical contributor to antimicrobial resistance, particularly in resource-constrained settings. Community Health Extension Workers (CHEWs) play a pivotal role in primary healthcare delivery and antibiotic access, yet little is known about how they navigate prescribing decisions amid systemic limitations, social expectations and ethical pressures.

Objective: This study explored CHEWs’ perceptions, practices and experiences related to antibiotic prescribing and dispensing in resource-constrained settings, with particular attention to decision-making processes, ethical reasoning and everyday care realities.

Methods: An exploratory qualitative study was conducted involving in-depth interviews with 25 community health extension workers. Data were analysed thematically using an inductive approach. Themes were developed through iterative coding and constant comparison, with attention to both structural and social influences on antibiotic use. Data were collected using a semi-structured interview guide, audio-recorded, transcribed verbatim and translated into English.

Results: Four major themes emerged: (1) decision-making under resource constraints, characterised by medicine shortages, stock-outs and limited diagnostic capacity; (2) negotiating community expectations versus guidelines, where social pressure and cultural norms influenced prescribing practices; (3) ethical dilemmas and moral reasoning, reflecting CHEWs’ strong sense of responsibility for patient outcomes amid competing professional and community obligations; and (4) informal antibiotic practices and improvisation, including borrowing medicines, adjusting dosages due to financial constraints and integrating traditional knowledge. Across themes, CHEWs demonstrated adaptive, contextually grounded decision-making shaped by scarcity, trust and moral accountability.

Conclusion: CHEWs’ antibiotic prescribing practices are not simply acts of non-adherence to clinical guidelines but represent complex, morally informed responses to structural constraints and community realities. Effective antimicrobial stewardship in resource-limited settings must therefore move beyond individual behaviour change to address health system limitations, ethical complexity and the social dimensions of care.

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Cite

BibTeXRIS
BibTeX
@article{kagoya2026antibiotic,
  title = {{Antibiotic prescribing practices of community health extension workers in East Central Uganda: an exploratory qualitative study}},
  author = {Enid Kawala Kagoya and Christopher Aturinda and Richard Gamubaka and Samuel Mugabi and Joseph L Mpagi and Paul Waako and Dan Kibuule},
  journal = {BMJ Open},
  year = {2026},
  month = oct,
  doi = {10.1136/bmjopen-2026-122224},
  url = {https://bmjopen.bmj.com/lookup/doi/10.1136/bmjopen-2026-122224},
  note = {CC BY-NC 4.0},
}
RIS
TY  - JOUR
TI  - Antibiotic prescribing practices of community health extension workers in East Central Uganda: an exploratory qualitative study
AU  - Enid Kawala Kagoya
AU  - Christopher Aturinda
AU  - Richard Gamubaka
AU  - Samuel Mugabi
AU  - Joseph L Mpagi
AU  - Paul Waako
AU  - Dan Kibuule
PY  - 2026
DA  - 2026/10/01
JO  - BMJ Open
DO  - 10.1136/bmjopen-2026-122224
UR  - https://bmjopen.bmj.com/lookup/doi/10.1136/bmjopen-2026-122224
AB  - Background: Antibiotic misuse at the community level remains a critical contributor to antimicrobial resistance, particularly in resource-constrained settings. Community Health Extension Workers (CHEWs) play a pivotal role in primary healthcare delivery and antibiotic access, yet little is known about how they navigate prescribing decisions amid systemic limitations, social expectations and ethical pressures.  Objective: This study explored CHEWs’ perceptions, practices and experiences related to antibiotic prescribing and dispensing in resource-constrained settings, with particular attention to decision-making processes, ethical reasoning and everyday care realities.  Methods: An exploratory qualitative study was conducted involving in-depth interviews with 25 community health extension workers. Data were analysed thematically using an inductive approach. Themes were developed through iterative coding and constant comparison, with attention to both structural and social influences on antibiotic use. Data were collected using a semi-structured interview guide, audio-recorded, transcribed verbatim and translated into English.  Results: Four major themes emerged: (1) decision-making under resource constraints, characterised by medicine shortages, stock-outs and limited diagnostic capacity; (2) negotiating community expectations versus guidelines, where social pressure and cultural norms influenced prescribing practices; (3) ethical dilemmas and moral reasoning, reflecting CHEWs’ strong sense of responsibility for patient outcomes amid competing professional and community obligations; and (4) informal antibiotic practices and improvisation, including borrowing medicines, adjusting dosages due to financial constraints and integrating traditional knowledge. Across themes, CHEWs demonstrated adaptive, contextually grounded decision-making shaped by scarcity, trust and moral accountability.  Conclusion: CHEWs’ antibiotic prescribing practices are not simply acts of non-adherence to clinical guidelines but represent complex, morally informed responses to structural constraints and community realities. Effective antimicrobial stewardship in resource-limited settings must therefore move beyond individual behaviour change to address health system limitations, ethical complexity and the social dimensions of care.
SN  - 2044-6055
SN  - 2044-6055
ER  -