Antibiotic dispensing practices and determinants among informal healthcare providers in low- and middle-income countries: a mixed-methods scoping review
Poshan Thapa, Meera Tandan, Buna Bhandari, Sumanth Gandra, Diwash Timalsina, Swostika Thapaliya, Anupama Bhusal, Shweta Bohora, Genevieve Gore, Charity Oga-Omenka, Md Asadullah, Prachi Shukla, Chandrashekhar Joshi, Surbhi Sheokand, Mili Dutta, Samira Abbasgholizadeh Rahimi, Madhukar Pai, Giorgia SulisIntroduction
Antimicrobial stewardship efforts in low- and middle-income countries (LMICs) largely focus on qualified practitioners, yet informal healthcare providers (IPs) deliver much of the primary care. Although these providers frequently dispense antibiotics, their practices remain poorly documented and are not captured in existing surveillance systems.
Methods
Using the Joanna Briggs Institute methodology, this scoping review synthesised evidence on antibiotic dispensing and its determinants among IPs in LMICs. Nine databases (MEDLINE, EMBASE, SCOPUS, Global Health, CINAHL, Web of Science, LILACS, African Journals Online via Africa-Wide Information and Index Medicus for the South-East Asia Region) were searched, yielding 12 095 records, of which 37 studies met the inclusion criteria.
Results
Across 31 studies reporting dispensing practices, antibiotic use by IPs varied widely: 18%–74% in studies using standardised methods, 5%–96% in provider-reported studies and 2%–86% in consumer-reported studies. Eight qualitative studies identified key behavioural and contextual determinants shaping dispensing, including limited knowledge, experience-based learning, patient expectations, peer and pharmaceutical influence, perceived consequences of withholding antibiotics and economic incentives.
Conclusion
Antibiotic dispensing by IPs is widespread and represents a large but unmeasured component of antibiotic use in LMICs. These findings highlight a critical gap in antimicrobial resistance surveillance and highlight the need for stewardship strategies that effectively engage this provider group.