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

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.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• Rich qualitative insights from community health extension workers in six districts of East Central Uganda.

• Multiple strategies strengthened trustworthiness of the findings.

• Self-reported data may be affected by social desirability bias.

• One researcher conducted all interviews, limiting interpretive perspectives.

• Findings may have limited generalisability, but consistent themes strengthened credibility.

Introduction

Antimicrobial resistance (AMR) is widely recognised as one of the most pressing global health challenges of the 21st century.¹ The World Health Organization identifies AMR among the top global public health threats, driven in large part by the misuse and overuse of antibiotics in human and animal health. Global policy responses have emphasised stewardship, surveillance and optimal antibiotic use, framing antibiotic use primarily as a technical and regulatory problem.^{2 3} Yet such approaches often abstract prescribing from the social, moral and material conditions in which it occurs. In many low-income and middle-income settings, antibiotics are not merely pharmaceutical agents they are embedded in relations of care, responsibility and survival.²

Across sub-Saharan Africa, high burdens of infectious disease intersect with fragile health systems, constrained diagnostic infrastructures and chronic medicine shortages. In these contexts, clinical decision-making frequently unfolds in conditions of uncertainty.⁴ Laboratory confirmation is often unavailable at primary care levels, compelling health workers to rely on symptom-based assessments.⁵ Antibiotics, therefore, become tools for managing not only biological risk but also social and moral risk the risk of failing to act, of losing community trust or of being perceived as withholding care.⁶ Stewardship principles that prioritise restraint may conflict with frontline realities that prioritise responsiveness and relational accountability.⁷

Uganda reflects these broader regional dynamics. While the country has adopted a National Action Plan on AMR aligned with global policy frameworks, implementation takes place within a decentralised health system marked by uneven resource distribution and supply chain disruptions.² At lower-level health facilities, essential medicines are frequently out of stock, diagnostic capacity is limited and patient volumes are high.⁷ Prescribing practices are therefore shaped not only by clinical guidelines but also by structural constraints and local expectations.⁴ Antibiotics are commonly prescribed empirically, especially where confirmatory testing is inaccessible.⁸ At the same time, communities often associate antibiotics with potency and rapid recovery, reinforcing demand for their use even in cases where they may not be clinically indicated.⁶

In East Central Uganda, these dynamics are particularly pronounced.⁶ The region continues to experience significant burdens of malaria, respiratory tract infections and other communicable diseases, often in settings of poverty and limited referral access.⁹ Primary healthcare facilities function as critical nodes of care, where health workers must respond swiftly to acute illness with limited tools.⁹ Community Health Extension Workers (CHEWs), positioned at the interface of policy and community life, embody this tension. Their prescribing decisions are shaped by medicine shortages, diagnostic uncertainty, community expectations for immediate treatment and concerns about professional accountability.⁶

In Uganda, CHEWs are the lowest cadre of health workers trained by the Ministry of Health to deliver basic primary health services at community level. They are not formally licensed prescribers under the Ugandan Allied Health Professionals Act; however, in practice, particularly in underserved rural areas, CHEWs routinely handle and dispense commonly available antibiotics under standing orders or informal facility protocols. This regulatory ambiguity is itself a driver of prescribing practices and is central to understanding the findings of this study.

From an anthropological perspective, antibiotic prescribing in such settings can be understood as a form of ethical labour and everyday practice through which health workers negotiate competing obligations to guidelines, to patients, to communities and to their own moral sense of responsibility. Rather than viewing antibiotic use outside of guidelines solely as a failure of knowledge or regulation, it is necessary to examine the moral economies and structural conditions that shape prescribing practices. Understanding CHEWs’ perceptions and experiences offers insight into how stewardship efforts can be made responsive to lived realities rather than imposed as abstract directives.

Study objective

To explore CHEWs’ perceptions, practices and experiences of antibiotic prescribing and dispensing in resource-constrained community health settings in East Central Uganda.

Methods

Study design

This study employed a qualitative descriptive design to explore CHEWs’ perceptions, practices and challenges related to antibiotic prescribing and dispensing in resource-constrained settings. A qualitative approach was appropriate because it allowed for in-depth examination of lived experiences, everyday clinical judgement and ethical reasoning within real-world healthcare contexts characterised by scarcity and uncertainty. Thematic analysis followed the framework described by Braun and Clarke (2006), using an inductive approach to allow themes to emerge directly from the data. This approach was selected for its flexibility and its appropriateness for exploring participants’ perspectives and experiences in context.

Study setting

The study was conducted in community health settings in six districts of East Central Uganda: Bugiri, Mayuge, Bugweri, Namayingo, Namutumba and Iganga. In these settings, resources are limited and healthcare delivery is shaped by frequent medicine stock-outs, high patient demand and restricted access to diagnostic tools. CHEWs function as frontline providers responsible for diagnosing common illnesses, prescribing and dispensing antibiotics, and sustaining long-term relationships with community members. Their practice is embedded within social, cultural and institutional expectations that influence clinical decision-making.

Study participants

A total of 25 community health extension workers participated in the study. Participants were purposively sampled from six districts: Bugiri, Mayuge, Bugweri, Namayingo, Namutumba and Iganga. Eligibility criteria included: active involvement in antibiotic prescribing and dispensing at the time of the study, a minimum of 1 year of experience in community-based healthcare delivery, and residence in a rural or peri-urban area of Eastern Uganda. Recruitment was facilitated through district health offices and community health supervisors, who identified eligible CHEWs and facilitated initial contact. Potential participants were then approached directly by the researcher, provided with study information and invited to participate. All participants had a minimum of 1 year of professional experience, ensuring that data reflected sustained engagement with routine antibiotic use rather than isolated clinical encounters. ‘Professional experience’ was defined as active deployment as a CHEW in community health service delivery.

Data collection

Data were collected through in-depth, semi-structured interviews conducted between August and November 2025. The interview guide (see online supplemental file 1) was developed based on a review of relevant literature and guided by the study objectives. It explored participants’ experiences with antibiotic prescribing, challenges related to medicine availability and diagnostics, interactions with patients, ethical tensions and coping strategies. The guide was pilot-tested with two CHEWs outside the study sample and refined accordingly. Interviews were conducted in private settings to promote confidentiality and openness, lasted approximately 45 to 60 min and were audio-recorded with participants’ informed consent. Field notes were taken to document contextual details and researcher reflections. All interviews were conducted by the first author (EKK), who has prior experience in qualitative data collection in community health settings in Uganda.

Data analysis

Data were analysed using Braun and Clarke’s (2006) six-phase thematic analysis framework: familiarisation with data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and producing the report. All interviews were transcribed verbatim and, where necessary, translated from Lusoga or other local languages into English by a bilingual research assistant, with back-translation checks to ensure fidelity. Thematic analysis was conducted using Dedoose qualitative analysis software. Initial coding was performed by the first author (EKK), who read transcripts repeatedly to achieve immersion in the data before generating codes. A second researcher (CA) independently coded a randomly selected 20% of transcripts. Codes were compared, discrepancies discussed and consensus reached through iterative review meetings. Codes were then organised into categories and refined into broader themes through constant comparison across all transcripts. Participants were not asked to provide feedback on the findings; however, emerging themes were discussed with co-investigators during the analytic process to strengthen confirmability.

Trustworthiness

Several strategies were used to ensure the trustworthiness of the study. Credibility was strengthened through prolonged engagement with the data and the use of direct participant quotations to support key findings. Dependability was ensured by maintaining a transparent and well-documented analytic process, including an audit trail of coding decisions. Confirmability was enhanced through reflexive practices: the first author maintained a reflective journal throughout data collection and analysis to acknowledge personal assumptions and minimise interpretive bias. The first author (EKK) is an academic researcher and clinician with contextual familiarity with the study setting, which was considered both an asset and a potential source of bias, and was managed through regular reflexive discussion with the supervisory team. Transferability was supported through rich descriptions of the study context and participant characteristics.

Ethical considerations

All procedures were in accordance with the Declaration of Helsinki. Written informed consent was obtained from all participants prior to data collection. Confidentiality and anonymity were maintained by removing identifying information from transcripts and using participant codes throughout all study documents. Participants were informed of their right to withdraw from the study at any stage without penalty. Ethical approval for the study was obtained from Busitema University Faculty of Health Sciences Research Ethics Committee (BUFHS-2025-86)

Results

25 CHEWs from six districts of East Central Uganda participated in the study. Participant characteristics are summarised in table 1. Participants ranged in age from 21 to 38 years (mean 30.0 years); 12 (48%) were female and 13 (52%) were male. All resided in rural or peri-urban areas. Districts represented were Bugiri (n=7), Mayuge (n=7), Bugweri (n=3), Namayingo (n=3), Namutumba (n=3) and Iganga (n=2).

Table 1. Summary of participant characteristics (n=25).

Characteristic	N (%) or range
Sex: female	12 (48%)
Sex: male	13 (52%)
Age range (years)	21–38
Mean age (years)	30.0
District: Bugiri	7 (28%)
District: Mayuge	7 (28%)
District: Bugweri	3 (12%)
District: Namayingo	3 (12%)
District: Namutumba	3 (12%)
District: Iganga	2 (8%)
Residence type: rural	19 (76%)
Residence type: peri-urban	6 (24%)
Minimum experience (years)	≥1

Thematic areas

Four overarching themes emerged from the analysis, reflecting participants’ perceptions and experiences of antibiotic prescribing and dispensing in resource-constrained settings. These were: (1) decision-making under resource constraints; (2) negotiating community expectations versus guidelines; (3) ethical dilemmas and moral reasoning; and (4) informal antibiotic practices and improvisation. Table 2 provides a summary of themes and sub-themes.

Table 2. Summary of thematic areas.

Main theme	Sub-theme	Description/key issues
Decision-making under resource constraints	Navigating medicine shortages and stock-outs	Managing antibiotic prescribing when essential medicines are unavailable or insufficient.
	Balancing patient expectations with limited resources	Responding to patient demands for antibiotics despite lack of supplies or clinical indication.
	Making clinical decisions with limited diagnostic tools	Reliance on symptoms and experience due to absence of laboratory or diagnostic support.
Negotiating community expectations vs guidelines	Pressure from patients to prescribe unnecessarily	Patients expecting antibiotics for quick relief, even for non-bacterial illnesses.
	Social and cultural obligations to treat promptly	Cultural norms emphasising immediate treatment, influencing prescribing behaviour.
	Managing community trust and relationships	Preserving trust by meeting expectations while attempting to follow treatment guidelines.
Ethical dilemmas and moral reasoning	Moral responsibility for patient outcomes	CHEWs’ concern over patient well-being when withholding or altering antibiotic treatment.
	Ethical tensions between guideline adherence and patient satisfaction	Conflict between following protocols and maintaining patient approval.
	Risk of professional reprimand vs community needs	Fear of sanctions from supervisors contrasted with pressure to meet local health needs.
Informal antibiotic practices and improvisation	Borrowing or repurposing medicines in emergencies	Informal sharing or reallocating antibiotics during urgent situations.
	Adjusting dosages due to patient financial constraints	Modifying prescribed doses based on patients’ ability to pay.
	Use of traditional knowledge alongside biomedical approaches	Integrating traditional remedies with formal medical practices when antibiotics are limited.

CHEWs, community health extension workers.

Theme 1: Decision-making under resource constraints

CHEWs operate in environments characterised by limited resources, which significantly shape their antibiotic prescribing practices. The interviews highlighted how shortages of medicines, lack of diagnostic tools and patient expectations force CHEWs to make complex, high-stakes decisions.

Sub-theme 1: Navigating medicine shortages and stock-outs

CHEWs consistently reported that frequent stock-outs of antibiotics required them to ration medications, prioritise patients or find alternative solutions. These shortages often created stress and difficult choices about who receives treatment first.

Sometimes we only have one bottle of antibiotic left, and we have three very sick children. Deciding who gets it is the hardest part of my day.

Stock-outs are common. I have had to tell parents to come back next week when the medicine arrives, even when their child is ill. It’s very stressful.

We often borrow antibiotics from nearby facilities to fill the gaps, but it’s not always reliable, and sometimes we have to improvise.

Sub-theme 2: Balancing patient expectations with limited resources

CHEWs described the tension between patients’ immediate expectations and the realities of limited medicine availability. Managing these expectations requires communication skills and careful prioritisation.

Parents expect to leave with medicine every time, and when we do not have it, some get angry. I have to explain patiently why we cannot give it now.

It is challenging because even if I know the child doesn’t need antibiotics, parents insist. I must decide whether to follow the guideline or keep their trust.

Sometimes I feel like I am letting the family down if I do not prescribe, even when I know the medicine is not necessary or not available.

Sub-theme 3: Making clinical decisions with limited diagnostic tools

A major challenge was working without proper diagnostic support, forcing CHEWs to rely on symptoms, experience and judgement. This limitation increases the risk of incorrect prescribing but also highlights their adaptability.

We often diagnose based on what we see and what caregivers describe, because there are no labs or tests available.

It’s worrying at times because I might give the wrong antibiotic, but I have to make a decision to help the patient immediately.

I rely on experience and symptom patterns a lot. Without diagnostic tools, I must use my judgment, and sometimes I feel uncertain about the outcome.

Decision-making under resource constraints is a daily reality for CHEWs. Limited antibiotic supplies, stock-outs, patient expectations and lack of diagnostic tools all influence their clinical choices. CHEWs demonstrate careful prioritisation, adaptive problem-solving and pragmatic clinical judgement, balancing the need to follow guidelines with the practical realities of their communities.

Theme 2: Negotiating community expectations versus guidelines

CHEWs operate at the intersection of formal clinical guidelines and community expectations. While medical protocols provide a framework for antibiotic use in accordance with stewardship principles, social and cultural pressures often challenge adherence. CHEWs must navigate these tensions to maintain both clinical integrity and community trust.

Sub-theme 1: Pressure from patients to prescribe antibiotics unnecessarily

Sometimes parents insist their child must have antibiotics for a simple fever. Refusing can upset them and make them lose trust in our care.

Even when guidelines say no, people pressure me to prescribe. It feels like a constant tug-of-war between doing what is right and satisfying them.

Parents often come with expectations based on past experiences. They expect antibiotics for everything, and it’s difficult to explain why it’s not necessary.

Sub-theme 2: Social and cultural obligations to treat promptly

There’s a cultural expectation that a child must receive medicine immediately. I sometimes give antibiotics just to respect that norm.

We are judged not only by outcomes but also by how quickly we act. Communities appreciate immediate care, which often influences our decisions.

Sub-theme 3: Managing community trust and relationships

If I strictly follow the guidelines, some parents might lose confidence in me. Sometimes giving the medicine preserves trust for future care.

Trust is everything. I explain why I might not prescribe antibiotics, but sometimes I still give them so families continue to listen to my advice.

Our work depends on community cooperation. If families feel neglected, they might stop following other health advice, so I have to be careful with every decision.

CHEWs constantly navigate tensions between formal guidelines and community expectations. Pressure from patients, social norms favouring prompt treatment and the imperative to maintain trust all shape prescribing practices. To reconcile these pressures, CHEWs employ communication, compromise and strategic flexibility.

Theme 3: Ethical dilemmas and moral reasoning

CHEWs frequently encounter ethical tensions in their daily work, balancing guideline adherence, patient welfare and community expectations. These dilemmas reflect both their professional responsibility and personal moral reasoning, highlighting the complex decision-making required in resource-constrained settings.

Sub-theme 1: Moral responsibility for patient outcomes

Even when the guideline says no antibiotics, I worry what will happen if I do not give them. I feel personally responsible for the child’s recovery.

I cannot ignore a sick child just because rules say not to prescribe. My conscience will not allow it.

Sometimes I prescribe to protect the patient, even if it goes against protocol. Their life comes first.

Sub-theme 2: Ethical tensions between guideline adherence and patient satisfaction

If I follow the guidelines strictly, the family may feel neglected. But if I give antibiotics unnecessarily, I am not following the rules. It’s a constant ethical struggle.

I want to do what is medically correct but also want the parents to trust me. Balancing both is very challenging.

Every day I face decisions where guidelines and patient satisfaction conflict. I must weigh both carefully.

Sub-theme 3: Risk of professional reprimand versus community needs

If I strictly follow the rules, the community may see me as uncaring. But if I do not, I risk being reprimanded by supervisors. It’s a difficult balance.

I sometimes take calculated risks, giving medicine to satisfy urgent needs while knowing I might face consequences later.

I have to constantly evaluate what is best for the patient while thinking about my professional responsibility. It’s not easy.

CHEWs face daily ethical dilemmas that require balancing professional standards, moral responsibility, and patient or community expectations. Their accounts demonstrate a deep moral reasoning process, where decisions are influenced not only by clinical knowledge but also by personal values, empathy and long-term considerations of trust and community welfare.

Theme 4: Informal antibiotic practices and improvisation

CHEWs often operate in settings where standard resources, medications and patient adherence are limited, prompting them to adopt informal practices and creative problem-solving. These improvisations reflect both pragmatic decision-making and a commitment to ensuring patient care despite systemic challenges.

Sub-theme 1: Borrowing or repurposing medicines in emergencies

When a child is critically ill and we do not have the required antibiotic, I sometimes borrow from a neighbor facility to save the child.

There are times we use leftover medicine from other patients. It’s not perfect, but it’s better than doing nothing.

Stock-outs are common, and emergencies do not wait. Borrowing or sharing medicine is sometimes the only option.

Sub-theme 2: Adjusting dosages due to patient financial constraints

Some parents cannot pay for the full dose. I give what they can afford and try to advise them to return for the rest.

I adjust dosages to match the family’s ability to pay. It’s not ideal medically, but it helps ensure some treatment.

Financial constraints often force us to improvise dosing. We do our best to balance affordability with effectiveness.

Sub-theme 3: Use of traditional knowledge alongside biomedical approaches

When patients insist on traditional remedies, I combine them with what medicine we have. This way, they feel cared for, and the child still receives treatment.

I sometimes use local herbs alongside antibiotics to improve acceptability and adherence.

We cannot ignore cultural practices. Blending them with available antibiotics helps maintain trust and ensures some level of effective care.

Informal antibiotic practices and improvisation reflect the resourcefulness and adaptability of CHEWs in challenging environments. These practices underscore the pragmatic problem-solving that CHEWs employ, highlighting their commitment to patient welfare while navigating systemic constraints and cultural expectations.

Discussion

This study explored CHEWs’ perceptions, practices, experiences and challenges related to antibiotic prescribing and dispensing in resource-constrained community health settings in East Central Uganda. The findings reveal that antibiotic use at the community level is shaped by a complex interaction of structural constraints, social expectations, ethical reasoning and pragmatic improvisation rather than reflecting simple non-adherence to guidelines. CHEWs’ practices represent contextually rational responses to competing demands and limited resources.

A key conceptual clarification is warranted at the outset of this discussion. The term ‘rational antibiotic use’ is used in global policy discourse to denote prescribing that conforms to stewardship principles that is, optimal antibiotic use. However, as the findings of this study demonstrate, CHEWs are in fact highly rational decision-makers: their choices are logical, morally grounded and contextually appropriate given the constraints they face. The substantive challenge is not irrationality on the part of CHEWs but rather that the structural contexts in which they work make guideline-concordant prescribing difficult or impossible. This distinction, consistent with calls in the revised WHO Global Action Plan on AMR to address the enabling environment for stewardship, is central to interpreting these findings.

Across all four themes, CHEWs demonstrated a strong commitment to patient welfare and community trust, even when operating under conditions that complicate antibiotic use in accordance with stewardship principles. These findings contribute to a growing body of evidence showing that antimicrobial stewardship challenges at the primary and community health level are deeply embedded in health system realities rather than individual provider behaviour alone.¹⁰

The first theme highlights how structural limitations particularly medicine shortages, stock-outs and lack of diagnostic tools fundamentally shape CHEWs’ antibiotic prescribing practices. This aligns with existing evidence from low-resource settings showing that guideline adherence is often contingent on the availability of medicines and diagnostics.¹¹ Frequent stock-outs disrupted planned care and forced CHEWs to prioritise patients based on perceived severity, age or vulnerability ethical decisions that underscore the moral burden placed on frontline health workers. The lack of diagnostic tools further compounded uncertainty. Without laboratory confirmation, CHEWs relied heavily on symptoms, patient history and experiential knowledge, reflecting adaptive clinical reasoning in contexts where diagnostic support is absent. These findings reinforce arguments that efforts to improve antibiotic stewardship must address diagnostic capacity alongside provider training.¹²

The second theme reveals how CHEWs continuously negotiate between formal clinical guidelines and community norms. Antibiotics were often perceived by community members as a symbol of effective care; withholding them, even when clinically appropriate, risked being interpreted as neglect or incompetence.¹³ Social and cultural norms emphasising prompt treatment further intensified this pressure.¹⁴ Managing community trust was therefore a critical consideration trust that was important not only for individual patient encounters but also for broader public health efforts such as immunisation campaigns and disease surveillance. These findings resonate with the broader literature emphasising that healthcare delivery in community settings is deeply social and culturally embedded.¹²

The third theme illustrates that antibiotic prescribing decisions are deeply intertwined with ethical reasoning and moral responsibility. CHEWs expressed strong accountability for patient outcomes, particularly for children or severely ill patients’ moral responsibility that often-outweighed strict adherence to guidelines when the consequences of inaction were perceived as severe. This highlights the moral labour inherent in frontline healthcare delivery. Recognising this moral dimension is essential for designing supportive supervision structures that emphasise guidance rather than punishment.¹⁵

The fourth theme demonstrates how CHEWs engage in informal practices and improvisation to overcome systemic limitations. Borrowing or repurposing medicines during emergencies, adjusting dosages due to financial constraints and integrating traditional knowledge alongside biomedical approaches were all documented. These practices, while deviating from formal protocols, reflect the ethical dilemma of choosing between ideal care and feasible care, and underscore CHEWs’ role as adaptive problem-solvers and cultural intermediaries.¹² Rather than viewing such informal practices solely as deviations, they should be understood as responses to structural inequities and resource gaps.^{5 13}

Implications

The findings of this study have several important implications. First, improving antibiotic stewardship at the community level requires system-level investments, including reliable medicine supply chains and expanded diagnostic capacity.¹⁶ Without these, expecting strict guideline adherence is unrealistic. Second, stewardship interventions should incorporate communication and negotiation skills, enabling CHEWs to manage patient expectations without compromising trust.¹⁷ Specifically, training in motivational interviewing (MI) would equip CHEWs with evidence-based communication techniques for situations where patients desire antibiotics that are not clinically indicated. MI is a well-researched counselling approach that has been applied in antibiotic stewardship contexts and could support CHEWs in having productive conversations about appropriate antibiotic use without damaging the therapeutic relationship. Community education campaigns that address misconceptions about antibiotics could also reduce demand-side pressure on providers.¹⁸

Third, supportive supervision frameworks should recognise the ethical complexity of CHEWs’ work.¹⁹ Rather than punitive approaches, supervision should emphasise mentorship, ethical reflection and shared problem-solving. Fourth, policies should acknowledge and engage with the realities of informal practices.²⁰ Ignoring these practices risks creating guidelines that are disconnected from lived experience.²¹ Pragmatic and context-sensitive guidance may better support safe and effective antibiotic use.²² Finally, the regulatory ambiguity surrounding CHEWs’ prescribing role must be addressed. Clear policy guidance that acknowledges frontline realities while establishing boundaries would reduce the professional and ethical precarity that CHEWs currently experience.²³

Conclusion

This study demonstrates that CHEWs’ antibiotic prescribing and dispensing practices are shaped by resource constraints, community expectations, ethical reasoning and pragmatic improvisation. Their actions reflect thoughtful, contextually grounded decision-making rather than simple non-compliance with guidelines. Addressing antimicrobial resistance and promoting optimal antibiotic use at the community level therefore requires interventions that engage with health system realities, social dynamics and the moral dimensions of care.

Data availability statement

Data are available upon reasonable request.