Health system barriers to implementation of the WHO AWaRe classification in Zambia: implications for antimicrobial stewardship

Background: Antimicrobial resistance (AMR) is a major global health threat, particularly in low- and middle-income countries (LMICs).The (World Health Orgnaisation) -WHO AWaRe (Access, Watch and Reserve) classification was developed to promote rational antibiotic use. This study assessed awareness and knowledge of the AWaRe classification among healthcare providers (HCPs) at Livingstone University Teaching Hospital (LUTH), Zambia. Methods: A cross-sectional study was conducted among 173 HCPs (doctors, nurses, pharmacists, and clinical officers) using stratified random sampling. Data was collected using a structured, self-administered questionnaire and analysed using SPSS version 20. Descriptive statistics, chi-square tests, ANOVA, and multivariable logistic regression was applied. Results: Only 37.6% of participants were aware of the AWaRe classification, and 6.9% demonstrated extensive knowledge. Awareness and knowledge were significantly associated with profession, years of experience, prior antimicrobial stewardship (AMS) training, and guideline use. Awareness was higher among doctors (69.4%) and pharmacists (73.1%) compared with nurses (17.5%). Independent predictors of good knowledge included >10 years' experience (OR=2.0, p=0.028), AMS training (OR=2.8, p=0.001), and consistent guideline use (OR=3.0, p<0.001). Key barriers to appropriate prescribing included drug availability (17.9%) and inadequate training (15.0%). Conclusions: Awareness and knowledge of the AWaRe classification among HCPs at LUTH are suboptimal. Targeted educational interventions and strengthened AMS programmes are urgently needed. Integrating AWaRe principles into clinical protocols and continuous professional development may improve rational antibiotic use and help mitigate AMR.