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.

KEYWORDS:

• Antibiotics
• healthcare facilities
• Uganda
• stewardship
• care

Acknowledgements

We wish to thank the health care providers in Tororo that made it possible to collect the data presented in this paper. We are grateful to the Tororo district health team that provided support and guidance during the data collection process.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Ethics clearance

We obtained ethics approval for the study from the School of Biomedical Sciences Research and Ethics Committee, Makerere University College of Health of Sciences (SBSREC REF no.562), the Uganda National Council for Science and Technology (SS 4679) and the London School of Hygiene and Tropical Medicine Ethics Committee (LSHTM Ethics Ref: 15244).

Additional information

Funding

This work was funded under the Antimicrobials In Society (AMIS) grant awarded by the Economic and Social Research Council (ESRC) on behalf of the Antimicrobial Resistance Cross Council Initiative supported by the seven Research Councils UK (RCUK) in partnership with other funders [ES/P008100/1], and the Fogarty International Center of the National Institutes of Health (NIH) [D43TW010526].