<b>Prevalence, Patterns and Determinants of Self-Medication with Antibiotics among Adults in Sub-Saharan Africa: A Systematic Review and Meta-Analysis</b>

Background: Self-medication with antibiotics (SMA) is a major avoidable driver of antimicrobial resistance (AMR), and sub-Saharan Africa (SSA) is considered disproportionately affected because of weak pharmaceutical regulation, over-the-counter antibiotic availability and constrained access to formal healthcare. An updated, adult-focused quantitative synthesis of primary evidence is needed. Methods: Following PRISMA 2020 guidance, a structured literature search of PubMed-indexed journals, publisher platforms and medRxiv was conducted for observational studies published in English that reported antibiotic self-medication among adults (≥18 years) in SSA. Study selection, data extraction and an adapted Hoy et al. risk-of-bias assessment were performed. Pooled prevalence was estimated using a random-effects (DerSimonian-Laird) model with the Freeman-Tukey double-arcsine transformation; heterogeneity was quantified with I². Patterns and determinants were synthesised narratively. Results: Eleven cross-sectional studies (N = 6,624 adults) from nine countries (Nigeria, Ethiopia, Eritrea, Ghana, Cameroon, Tanzania, Uganda, Sudan and Malawi), published between 2018 and 2025, met inclusion criteria. The pooled prevalence of antibiotic self-medication was 53.2% (95% CI: 41.1–65.1%; I² = 99.0%), with study-level estimates ranging from 10.4% to 76.0%. Community-based studies yielded a higher pooled estimate (61.4%, 95% CI: 52.2–70.2%) than facility-based studies (31.3%, 95% CI: 9.5–58.9%). Amoxicillin/penicillins were the most commonly self-medicated antibiotics, mainly sourced from community pharmacies and drug shops and used for respiratory symptoms, cough, fever and sore throat. Recurring determinants included low antibiotic-related knowledge, previous successful antibiotic use, poor healthcare-worker attitudes, cost and access barriers, lack of health insurance, and (with mixed direction) educational attainment. Conclusion: Roughly one in two adults in SSA self-medicates with antibiotics, though estimates vary widely by setting and population. Strengthening prescription-only dispensing enforcement, community pharmacist stewardship, and public antibiotic-literacy campaigns are priority interventions.