Reconciling imperatives: Clinical guidelines, antibiotic prescribing and the enactment of good care in lower-level health facilities in Tororo, Uganda

Abstract

Faced with the threat of antimicrobial resistance, health workers are urged to reduce unnecessary prescription of antimicrobials. Clinical guidelines are expected to form the basis of prescribing decisions in practice. Emerging through evaluations of best practice – bundling clinical, technological and economic dimensions – guidelines also create benchmarks through which practice can be assessed with metrics. To understand the relationships between guidelines and practice in the prescribing and dispensing of antibiotics, ethnographic fieldwork was undertaken in lower-level health care facilities in rural Eastern Uganda for 10 months between January and October 2020, involving direct observations during and outside of clinics and interviews with staff. In a context of scarcity, where ‘care’ is characterised by delivery of medicines, and is constituted beyond algorithmic outputs, we observed that clinical practice was shaped by availability of resources, and professional and patient expectations, as much as by the clinical guidelines. For stewardship to care for patients as well as for medicines, a better understanding of clinical practice and expectations of care is required in relation to and beyond clinical guidelines.

“Arming half-baked people with weapons!” Information enclaving among professionals and the need for a care-centred model for antibiotic use information in Uganda, Tanzania and Malawi

“…The WHO’s Global Action Plan highlights raising awareness, providing information and improving understanding of AMR as necessary first steps towards making long-term gains against AMR as a global threat [ 6 ]. Currently, messaging about AMR focuses on raising awareness of the prevalence and danger of AMR, which can be understood by prescribers and dispensers as a reason to escalate to the use of what they consider to be stronger antibiotics [ 7 , 8 ].…”