The inappropriate use of antibiotics is a major driver of antimicrobial resistance worldwide. Antimicrobial resistance is an alarming public health problem leading to significant morbidity and mortality, particularly in low- and middle-income countries (LMICs). Thus, addressing the inappropriate use of antibiotics is key to reducing the development and spread of antimicrobial resistance. This systematic review aimed to synthesize evidence-based drivers of inappropriate use of antibiotics from qualitative data in low- and middle-income countries. A search was conducted in Google Scholar, PubMed, Web of Science, and Cochrane Library databases to identify qualitative data from published English qualitative and mixed methods studies conducted in LMICs from 2010 until the first week of September 2023. A total of nine studies that used in-depth interviews and focus group discussions tools were included in the final analysis. The quality and risk of bias assessment of the included studies was conducted using the 10 criteria of the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for qualitative studies. The themes identified in this review included knowledge on diseases symptoms, indications, and use of antibiotics; using previous prescription to purchase and use antibiotics for treating the current disease, fear of buying and using suboptimal antibiotics available in market; limited healthcare access hinders them getting doctor’s prescription; economic constraints cause patients not to afford treatment; and perceived severity of illnesses determine when to go to health facility. It was uniformly observed that lack of proper knowledge and misinterpretation of symptoms facilitated unnecessary use of ABs. In addition, use of the previous prescription, recommendations from the drug sellers, unavailability of competent doctors for consultations, low socioeconomic status, mild disease symptoms were found to create an environment of self-medication and inappropriate AB use. Evidence of the findings was presented by active voices of the participants, who supported the explored themes. It is recommended that health ministries in LMICs invest in providing quality health education in communities for proper use of antibiotics. In addition, improved health systems and economic status are critical for appropriate antibiotic use in LMICs.

Dispensing antibiotics without prescription is among the major factors leading to antimicrobial resistance. Dispensing of antibiotics without prescription has negative impact at the individual and societal level leading to poor patient outcomes, and increased risks of resistant bacteria facilitated by inappropriate choice of antibiotics doses/courses. Antimicrobial resistance is a global public health threat which is projected to cause 10 million deaths by 2050 if no significant actions are taken to address this problem This study explored the practices and motives behind dispensing of antibiotics without prescription among community drug outlets in Tanzania. Finding of this study provides more strategies to antibiotics stewardship intervention. In-depth interviews with 28 drug dispensers were conducted for three months consecutively between November 2019 and January 2020 in 12 community pharmacies and 16 Accredited Drug Dispensing Outlets (ADDOs) in the Mwanza, Kilimanjaro and Mbeya regions of Tanzania. Transcripts were coded and analyzed thematically using NVivo12 software. Majority of dispensers admitted to providing antibiotics without prescriptions, selling incomplete courses of antibiotics and not giving detailed instructions to customers on how to use the drugs. These practices were motivated by several factors including customers’ pressure/customers’ demands, business orientation-financial gain of drug dispensers, and low purchasing power of patients/customers. It is important to address the motives behind the unauthorized dispensing antibiotics. On top of the existing regulation and enforcement, we recommend the government to empower customers with education and purchasing power of drugs which can enhance the dispensers adherence to the dispensing regulations. Furthermore, we recommend ethnographic research to inform antibiotic stewardship interventions going beyond awareness raising, education and advocacy campaigns. This will address structural drivers of AMR such as poverty and inadequate government health services, and the disconnect between public messaging and/or policy and the public itself.

Antenatal care is essential to promote maternal health. Prior research has focused on barriers women face to attending antenatal care, and improving quality of care is seen as a precondition for better attendance. Digital health tools are seen as a promising instrument to increase the quality of healthcare. It is less clear to what extent the use of digital health tools in low- and middle-income counties would be perceived as beneficial by end-users. The aim of this research was to explore women’s experiences with antenatal care, and whether digital health tools would change their perceptions of quality of care. This qualitative research utilised an interpretative phenomenological approach on data from semi-structured in-depth interviews collected in 2016 with 19 randomly selected pregnant women from six different dispensaries in Magu District. Findings showed that pregnant women are motivated to attend antenatal care and are grateful for the services received. However, they also articulated a need for improvements in antenatal care services such as the availability of diagnostic tests and more interactions with healthcare workers. Participants indicated that a digital health tool could help in storing patient files and improving communication with health workers. Our results indicate that pregnant women are positive about the use of digital health tools during antenatal care but that the implementation of such a tool should be implemented in parallel to structural service delivery improvements, such as testing availability.