Impact of WHO AWaRe Antibiotic Handbook training on antibiotics prescribing knowledge among private primary care providers: a vignette-based, prep–post pilot study in Patna, India

Abstract

Introduction: Inappropriate antibiotic prescribing is a major concern in low- and middle-income countries (LMICs), particularly at the primary care level. The WHO AWaRe Antibiotic Handbook was introduced to promote rational antibiotic use, yet its real-world feasibility and potential impact remain underexplored. Our study evaluated the impact and usefulness of the WHO AWaRe Handbook training among private primary care providers (PCPs) in Patna, India. Methods: We conducted a pre–post pilot study among 145 private PCPs (40 formal PCPs (FPs) and 105 informal PCPs (IPs) in Patna, India. Participants received training from an infectious disease physician on the WHO AWaRe Antibiotic Handbook. Antibiotic prescribing knowledge was assessed before and after the intervention using clinical vignettes for four conditions: acute diarrhea, urinary tract infection (UTI), cellulitis, and community-acquired pneumonia (CAP). An endline survey evaluated the perceived usefulness of the intervention. Changes in prescribing knowledge was analyzed using McNemar’s test for paired data. Results: The intervention significantly reduced overall antibiotic prescribing knowledge for acute diarrhea (p = 0.0003) and UTI (p = 0.0113), with greater reductions among IPs. No significant changes were observed for cellulitis (p = 0.3692) or CAP (p = 0.7150). Watch-category antibiotic prescribing significantly decreased for acute diarrhea (p < 0.0001), with no significant changes for other conditions. IPs showed greater improvements overall compared to FPs. The majority of PCPs (75%; n = 107) rated the training as moderately or very useful. Conclusion: Training private PCPs using the WHO AWaRe Handbook improved antibiotic prescribing knowledge for some common conditions, particularly among IPs. Future research should combine training with strategies that address broader contextual barriers, alongside tailored reinforcement interventions, and longer-term follow-up.