Drivers and Barriers to Appropriate Antibiotic Use in LMICs: A Scoping Review

Title: Drivers and Barriers to Appropriate Antibiotic Use in Low- and Middle-Income Countries: A Scoping Review Background and Rationale: Antimicrobial resistance (AMR) is a significant global public health concern that disproportionately affects Low- and Middle-Income Countries (LMICs), where it was directly responsible for approximately 255,000 deaths in sub-Saharan Africa alone in 2019. Inappropriate antibiotic use including overuse, misuse, and self-purchase without prescription is a primary driver of AMR and threatens patient safety while burdening healthcare systems. In LMICs, inappropriate antibiotic use is influenced by complex, multi-level factors. At the patient level, these include knowledge gaps about antibiotics, misconceptions regarding their effectiveness, self-diagnosis practices, and pressure on healthcare providers. At the health system level, barriers include limited access to diagnostic services, weak regulatory enforcement, and the availability of antibiotics without prescription. Community-level factors such as cultural beliefs, economic constraints, and healthcare access also play crucial roles. While many antimicrobial stewardship programs have focused on healthcare providers, understanding the broader drivers of and barriers to appropriate antibiotic use across different contexts is essential for designing effective, contextually relevant interventions. Previous reviews have examined prescribing patterns and quality indicators, but a comprehensive synthesis of evidence mapping the full range of factors influencing antibiotic use across healthcare and community settings in LMICs is needed. A scoping review is an appropriate methodology for this project as it allows for the comprehensive exploration of a heterogeneous evidence base, identification of key themes and patterns, and mapping of knowledge gaps across diverse study designs and contexts. Purpose and Objectives: Primary Objective: To identify and map the key drivers of and barriers to appropriate antibiotic use across healthcare and community settings in Low- and Middle-Income Countries. Secondary Objectives: 1. To describe the types of studies, populations, and contexts where research on antibiotic use drivers and barriers has been conducted in LMICs. 2. To identify regional variations in drivers and barriers, with particular attention to evidence from sub-Saharan Africa . 3. To identify gaps in the existing evidence base to inform future research and policy directions. Review Questions: 1. What are the key drivers and barriers to appropriate antibiotic use in LMICs? 2. What populations, healthcare settings, and geographical contexts have been studied in relation to antibiotic use drivers and barriers? 3. Where are the evidence gaps regarding antibiotic use in LMICs? Expected Outcomes: This scoping review is expected to produce several important outcomes: 1. Comprehensive Evidence Map: The review will produce a systematic mapping of the existing literature on antibiotic use drivers and barriers in LMICs, synthesizing findings from qualitative, quantitative, and mixed-methods studies. 2. Identification of Key Themes: A narrative synthesis will summarize key themes and patterns related to knowledge, attitudes, motivations, expectations, prescribing behaviors, health system factors, and economic factors influencing antibiotic use. 3. Knowledge Gap Analysis: The review will identify geographical, population, and thematic gaps where evidence is lacking, helping to prioritize future research efforts. 4. Framework for Interventions: The findings will provide a foundation for understanding the multi-level factors that must be addressed to promote appropriate antibiotic use in LMICs, informing the design of stewardship interventions. 5. Policy and Practice Recommendations: The review will offer region-specific insights that can inform national action plans and healthcare policies in LMICs. Significance: This scoping review will contribute to the broader understanding of AMR drivers in LMICs by providing a comprehensive synthesis of patient, provider, and system-level factors influencing antibiotic use. The findings will support the development of contextually appropriate interventions to reduce inappropriate antibiotic use and combat AMR. Dissemination: The findings of this scoping review will be disseminated through publication in a peer-reviewed journal, presentation at relevant conferences and workshops, and collaboration with policymakers and healthcare stakeholders.