A cluster-randomised controlled trial in Burkina Faso and DR Congo evaluated whether a co-created community-based intervention bundle (health education campaigns + provider education/feedback on WHO AWaRe guidance, over 9 months) reduced Watch-group antibiotic use and improved patient management across all community-level health-care providers.
Watch-group antibiotic use fell from 26.8% to 17.1% in the intervention group but rose from 13.4% to 21.2% in controls (adjusted prevalence ratio 0.33, 95% CI 0.14–0.78); patient management scores showed minimal change in either group.
Baseline Watch-group antibiotic prevalence differed notably between arms (26.8% vs 13.4%), raising concerns about comparability. Providers with fewer than 20 completed surveys were excluded, potentially limiting generalisability. Simulated patient visits may not fully reflect real-world prescribing behaviour.
A multi-round community and provider education programme using WHO AWaRe guidance can cut Watch-group (broad-spectrum) antibiotic use by roughly two-thirds without harming patient care. Health systems in sub-Saharan Africa should consider scaling co-created AWaRe-based stewardship to informal and private community providers, not just formal facilities.
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