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

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.