Journal Article

“We might have been prescribing antibiotics to clients who do not need them”: a mixed-methods study of knowledge, attitudes, and practices related to antibiotic use for pediatric acute respiratory illness among community health workers in Uganda

Reyes, Raquel, Mwebembezi, Fred, Kibaba, Georget, Shelus, Victoria, Nyangoma, Grace, Baguma, Emmanuel, Boyce, Ross M., Mulogo, Edgar M., Ciccone, Emily J., Ntaro, Moses, Gutierrez, Ana T. Bravo, Juliano, Jonathan J.

2025

Overview

Background In many resource-constrained settings, community health workers (CHW) often provide the initial care for children under five years of age. As part of integrated community case management (iCCM) programs, CHW frequently diagnose and treat acute respiratory illness (ARI), a leading cause of pediatric mortality and indication for antibiotic use globally. Yet knowledge and perceptions of antibiotic prescribing for ARI among CHW are not well-studied. The goal of this study was to assess knowledge, attitudes, and practices related to antibiotics among CHW implementing a stepped-wedge trial of an enhanced iCCM algorithm for children with ARI in rural Uganda to inform future antimicrobial stewardship strategies. Methods We conducted a nested mixed methods study with a convergent parallel design, administering surveys before and after the stepped wedge trial and individual semi-structured interviews at study end. We employed descriptive statistics, Wilcoxan rank sum tests, and thematic content analysis methods. Results A total of 63 of 67 (94.0%) CHW completed both baseline and follow-up surveys, and 15 CHW were interviewed. The median age of the full cohort was 40 (IQR: 35–47) years with 9.5 years of CHW experience (IQR: 4.0–14.0 years). Almost all CHW (95.2%) identified amoxicillin as an antibiotic at baseline, and most associated antibiotics with treating bacterial diseases (baseline: 82.5%, follow-up: 93.7%, p  = 0.05). Most perceived antibiotics as harmful to patients when prescribed unnecessarily. At follow-up, more CHW disagreed that antibiotics should be prescribed when in doubt. They welcomed additional education about antimicrobial resistance and diagnostic tools to advance antimicrobial stewardship (AMS). Conclusion CHW were overall familiar with antibiotics and their potential harms. They were eager to gain knowledge regarding AMS and AMR and share it with their communities. CHW represent an underutilized resource for AMS interventions and should be included in their design and implementation.

• Publisher: BioMed Central,BioMed Central Ltd,Springer Nature B.V,BMC
• Subject: Acute respiratory illness / Algorithms / Antibiotics / Antimicrobial agents / Antimicrobial resistance / Antimicrobial stewardship / Attitudes / Bacterial diseases / Biostatistics / C-reactive protein / Caregivers / Case management / Community health aides / Community health care / Community health workers / Content analysis / Data analysis / Diagnosis / Diarrhea / Dosage and administration / Drug resistance / Drug resistance in microorganisms / Drug therapy / Environmental Health / Epidemiology / Illnesses / Integrated community case management / Interviews / Knowledge / Malaria / Medical personnel / Medicine / Medicine & Public Health / Mixed methods research / Pediatrics / Pneumonia / Practice / Prescription writing / Prevention / Public Health / Respiratory diseases / Respiratory tract diseases / Risk factors / Sociodemographics / Statistical analysis / Surveys / Towns / Uganda / Vaccine / Viral infections