Education and Intervention Strategies for Tackling Antimicrobial Resistance in Primary Health Care: Evidence from Africa

Education and Intervention Strategies for Tackling Antimicrobial Resistance in Primary Health Care: Evidence from Africa | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Education and Intervention Strategies for Tackling Antimicrobial Resistance in Primary Health Care: Evidence from Africa Toluwase Oluwajomiloju Ogundipe, Temitope Lydia Ayodele, Godsdelight Adeola Odewale, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8702660/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract BACKGROUND Antimicrobial resistance (AMR) is an increasing threat to public health systems worldwide, particularly in Africa, where primary health care (PHC) settings often serve as the initial point of interaction for the majority of the population. These settings are especially exposed to AMR due to widespread antimicrobial misuse, insufficient diagnostic tools and resources, lack of knowledge and limited understanding among health care providers and the public. This review aims to synthesize existing evidence on education and intervention strategies aimed at mitigating AMR in PHC systems across African countries. METHODS This scoping review followed the framework proposed by Arksey & O’Malley and PRISMA-ScR. A systematic search was conducted across four databases which are PubMed, Google Scholar, SCOPUS, and AJOL for reviewed articles published between January 1, 2015 and April 11, 2025. Studies involving AMR-related educational or interventional strategies involving PHC workers, patients, or communities in Africa were included in this review. This encompassed strategies such as antimicrobial stewardship (AMS) initiatives, diagnostic improvements, and regulatory or policy measures with defined intervention or feedback mechanisms. Data from eligible studies were analyzed and summarized. RESULT A total of 20 studies were included. The majority of studies originated from Ghana and South Africa. Most interventions focused on healthcare provider training, public awareness campaigns via social media, and Antimicrobial stewardship (AMS) programs. Key implementers were health workers (35%) and public health authorities (20%). Barriers included restrictive policies, resource constraints, health worker resistance, and poor guideline compliance. Enablers like diagnostics and funding supported implementation. Outcomes showed improved prescribing practices and increased AMR awareness, but sustainability was limited by short-term funding and lack of system-wide integration. CONCLUSION This review highlights significant efforts in recent years to address AMR in African PHC systems through education and intervention strategies. However, due to the small scale, short duration, and lack of long-term planning in many interventions there is a need for more robust, scalable, and clear solutions. Effective AMR control requires not only continuous training and public engagement but also strong policy support, adequate resources, and the integration of AMS frameworks customized to PHC settings. Antimicrobial Resistance (AMR) Primary Health Care (PHC) Africa Antibiotic Stewardship Educational Interventions Figures Figure 1 Figure 2 Figure 3 BACKGROUND Infections that no longer respond to standard antibiotics are undermining medical and pharmacological progress by turning previously effective treatments into no longer guaranteed cures. This phenomenon is known as antimicrobial resistance (AMR), which refers to the ability of microorganisms to withstand the effects of medicines that once treated them effectively. Globally, antimicrobial resistance is an urgent public health concern. In 2019, bacterial AMR was linked to approximately 4.95 million deaths worldwide [ 1 ]. Africa bears a disproportionate burden due to high infectious disease prevalence and limited resources [ 2 , 3 ]. AMR arises from multifaceted factors, including inherent traits of the microbes themselves and human-related factors, such as how drugs are prescribed, accessed, and used [ 4 ]. While AMR is a global issue, its consequences are particularly pronounced in developing countries [ 5 ]. Subnational data from Ghana and South Africa highlight high antibiotic rates in PHC [ 3 ]. In many low- and middle-income countries (LMICs), primary health care centres are the first point of contact for people seeking medical attention and the backbone of healthcare services in Africa [ 6 ]. However, these centres face a range of challenges that hinder their ability to effectively combat antimicrobial resistance (AMR). In Africa, primary health care settings are uniquely vulnerable to AMR due to a high burden of infectious diseases, inadequate health education for providers and patients, and the misuse of antibiotics for conditions like viral infections. These challenges are further worsened by poor prescription practices, limited .diagnostic tools, weak regulation, and widespread misuse of antimicrobials in both human and non-human sectors [ 5 ]. Consequently, AMR spreads unchecked, posing a significant threat to public health and limiting the ability of health systems to effectively respond to emerging infectious diseases. In this review, primary health care (PHC) is defined as a holistic approach to health that prioritizes accessible, integrated services - including primary care and public health functions - delivered through community-based clinics, health centers, and tailored to local needs and empowering communities [ 7 , 8 ]. Despite these challenges, primary health care remains one of the most strategic points to fight antimicrobial resistance. Because PHC workers are usually the first to see and treat infections in their communities, they are in a strong position to shape how antibiotics are used. But for any intervention to work, it has to fit the systemic realities on ground, including how the local health system works, the cultural beliefs people hold, and the common illnesses found in the local communities. Despite PHC’s strategic role in shaping antibiotic use, few reviews have synthesized context-specific strategies for AMR control in African PHC system, unlike hospital-focused studies [ 9 ]. This review aims to address a critical evidence gap by examining education and intervention strategies for tackling AMR in primary health care settings across Africa. It explores the effectiveness of current approaches, identifies key barriers to implementation, and highlights practical, system specific solutions offering actionable insights to strengthen AMR control efforts at the community level. We seek to answer the following questions: What types of education and intervention strategies have been implemented to promote antimicrobial stewardship and rational use of antibiotics in primary care or community settings in Africa? Who are the key actors involved in implementing these interventions, and in what settings? What are the common barriers and facilitators to effective implementation of these strategies? What outcomes or impacts have been reported from these interventions? How are these interventions monitored and sustained? METHODS This review was guided by the five stages described in Arksey & O’Malley’s framework for scoping reviews [ 10 ]. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist for presenting the results [ 11 ]. Search strategy and study selection A comprehensive search for peer-reviewed articles published between January 1, 2015 and April 11, 2025 was conducted using 4 databases: PubMed, Google Scholar, SCOPUS and African Journals Online (AJOL). The search query for each database is presented in Additional File 1. The search results were imported into Zotero where duplicates were removed. Title and abstract screening was carried out in Raayan. Each title and abstract was independently screened by two reviewers. In case of disagreement, a third reviewer was consulted and consensus was reached. Full text was assessed by six reviewers using predefined inclusion/exclusion criteria. A manual search was conducted to identify articles that fit our inclusion criteria and might have been missed. The search and selection process is summarised in Fig. 1 . Criteria for study inclusion and exclusion Study eligibility was determined using the PCC (Population–Concept–Context) framework (Table 1). PCC Component Study Criteria Population PHC workers (e.g., doctors, nurses, CHWs), patients, community members accessing PHC services Concept AMR strategies/interventions such as training, policy implementation, stewardship, education, behavioral change Context Primary health care or community-based settings in Africa (2015–2025) Studies with strategic components targeting AMR in Africa’s PHC system were also included. This includes evaluation of AMR-related programs and structured assessments identifying needs or barriers in AMR control relevant for planning interventions. Education and intervention strategies in this study encompass targeted actions with feedback mechanisms to improve antibiotic use, including health worker training, antimicrobial stewardship (AMS) programs, diagnostic testing, and public education campaigns. Only primary peer reviewed studies published in the English language were included as this was the language reviewers were fluent in. However, studies that focused exclusively on hospitals with no linkage to PHC or the community were excluded. Also studies conducted in veterinary or agricultural settings, those that only assessed knowledge, awareness, or prescribing practices without any intervention or strategic component targeting AMR, case reports, comments, and editorials were excluded. Data extraction and synthesis Data was extracted into a predefined data extraction form using Google Sheets. Extracted information included study characteristics (e.g., authorship, publication year, study design, country), population details, intervention details (e.g., Type of intervention, implementers of intervention and mode of delivery), information on outcome (e.g., main finding, impact on AMR, barriers and enablers), key gaps and lesson learned. A narrative synthesis was done due to the heterogeneity of outcomes and methodology in included studies. Characteristics and recurring themes in included studies were descriptively summarised by using frequency and percentages. RESULTS The search yielded 514 records (with duplicates removed). Title and abstract screening left 80 articles for full text assessment (Fig. 1 ). On assessment of full-text, 17 papers met inclusion criteria and 3 papers were added from manual searching. A total of 20 studies met the inclusion criteria and were included in this review, providing evidence on education and intervention strategies aimed at addressing antimicrobial resistance (AMR) in primary health care (PHC) settings across Africa. 3.1 Characteristics of Included Studies The included studies spanned 12 African countries, with the majority conducted in Ghana and South Africa (Fig. 2 ). Figure 3 shows the timeline of the studies between 2015–2025. None of the included studies were from 2015, 2016 and 2025. The included studies employed a range of designs. Four used qualitative approaches, four used pre–post intervention designs, three were mixed-methods, three were retrospective analyses, two were randomized controlled trials (RCTs), and four were cross-sectional studies.This distribution illustrates highlights the dominance of descriptive and observational research over experimental approaches. The majority of interventions (n = 14, 67%) were conducted in primary health care facilities, often in public-sector clinics or health centres. A smaller number of studies were situated in combined primary and intermediate-level services (n = 3, 14%), and others in community-based or outreach settings (n = 2, 10%). One study incorporated a multi-setting approach involving PHC facilities, pharmacies, informal providers, and correctional centers. Another focused on community drug outlets. Detailed study characteristics are summarised in Table 2 . Table 2 Summary of Included Studies References Country Study Design Setting AMR Focus Intervention Type Key Outcomes Afari-Asiedu et al., 2021 [ 12 ] Ghana Qualitative Community-Based / Outreach Setting Knowledge/attitude/practice changes Health worker training While some institutions supported the suggestion that training of unqualified drug sellers was enough for them to prescribe antibiotics, another institution opposed it Engler et al., 2021 [ 13 ] South Africa Mixed-Methods Primary Health Care Facility (PHC) Knowledge/attitude/practice changes Surveillance systems It was discovered that many prescribing health care providers have little knowledge on AMR and that not all health care provider was included in trainings which shouldn't be so Kiemde et al., 2023 [ 14 ] Burkina Faso Randomized Controlled Trial (RCT) Primary Health Care Facility (PHC) Compliance with guidelines Antimicrobial stewardship (AMS) The study found that seasonal malaria chemoprevention (SMC) with sulfadoxine–pyrimethamine plus amodiaquine (SPAQ) remains effective in reducing malaria incidence among children under five years of age in Burkina Faso, despite the presence of molecular markers of resistance. However, the paper emphasizes the need for continuous monitoring of the efficacy and safety of SMC due to increasing resistance levels. Kaawa-Mafigiri et al., 2023 [ 15 ] Uganda Qualitative Primary Health Care Facility (PHC) Changes in antibiotic use/prescription Others This study demonstrated that the T&C package can be useful in bringing about behavior change and improving adherence to prescriptions among both healthcare workers and their patients Nyamu et al., 2021 [ 16 ] Kenya Pre-Post Interventional Primary Health Care Facility (PHC) Compliance with guidelines Health worker training The findings suggest that education and participatory discussion that sought to influence the knowledge and prescribing behaviour of health personnel, had a positive effect on antibiotic stewardship and resulted in a reduction in AM prescription post-intervention. Owusu et al., 2022 [ 17 ] Ghana Retrospective Primary Health Care Facility (PHC) Compliance with guidelines Surveillance systems The study from a primary health facility of Ghana showed that about nine in ten patients with uncomplicated UTIs were prescribed an empirical antibiotic, of whom 60% were as recommended in the STGs Opoku et al., 2020 [ 18 ] Ghana Retrospective Primary Health Care Facility (PHC) Knowledge/attitude/practice changes Diagnostic/testing interventions The rate of antibiotic prescription for febrile outpatients is high so, to reduce this advocacy for the increased use of laboratory testing before prescribing antibiotics is recommended Sefah et al., 2024 [ 19 ] Ghana Cross-Sectional Primary and Intermediate Levels Healthcare Services Knowledge/attitude/practice changes Antimicrobial stewardship (AMS) There was sub-optimal performance for almost all the core elements of antimicrobial stewardship programs in the public hospitals Kandeel et al., 2019 [ 20 ] Egypt Pre-Post Interventional Primary and Intermediate Levels Healthcare Services Changes in antibiotic use/prescription Public/community education Antibiotics prescription for ARIs decreased and the knowledge and attitude scores regarding appropriate use among physicians, pharmacists, and patients improved compared to the surveys conducted pre-intervention. Korom et al., 2017 [ 21 ] Kenya Pre-Post Interventional Primary Health Care Facility (PHC) Compliance with guidelines Health worker training The study showed a series of brief educational interventions that were associated with significant improvement on appropriate antibiotic prescribing for urinary tract infections. Mokwele et al., 2022 [ 22 ] South Africa Cross-Sectional Community Pharmacy / Drug Outlet Compliance with guidelines Policy/guideline development This study shows that dispensing antibiotics without prescription for managing UTIs appears to be common practice among privately owned pharmacies. Emgård et al., 2021 [ 23 ] Tanzania Qualitative Primary Health Care Facility (PHC) Understanding of antibiotic resistance and prescribing practices Antimicrobial stewardship (AMS) This study shows that primary healthcare workers in Northern Tanzania often rely on clinical judgment and parental input to prescribe antibiotics for children, but have limited understanding of antibiotic resistance as a public health threat, viewing it mainly as an individual concern. Altaye et al., 2024 [ 24 ] Ethiopia Mixed-Methods Primary Health Care Facility (PHC) Knowledge/attitude/practice changes Deselect This study shows that antibiotic prescribing at primary healthcare facilities in Addis Ababa is influenced by a mix of factors including prescribers' lack of up-to-date knowledge and attention to resistance, patient pressure, resource shortages, and systemic issues such as lack of lab reagents and AMR data, pointing to an urgent need for targeted interventions to improve rational antibiotic use Sambakunsi et al., 2019 [ 25 ] Malawi Mixed-Methods Community-Based / Outreach Setting Knowledge/attitude/practice changes Public/community education The study found that self-medication with antimicrobials is widespread in Lilongwe, Malawi, largely due to poor knowledge, misconceptions, and limited access to healthcare. Most participants could not correctly identify antimicrobials or understood their proper use, and many believed they were effective for conditions like fever and the common cold. Stocking antibiotics at home was linked to increased self-medication, while awareness of antimicrobial resistance reduced it. Bessat et al., 2019 [ 26 ] Burkina Faso Qualitative Primary Health Care Facility (PHC) Changes in antibiotic use/prescription Others Findings showed that the use of an electronic device to guide the clinician’s daily practice might have potentially positive impacts on several aspects of the health care system, which go beyond the quality of the care and the decrease of unnecessary antibiotic prescriptions. Adegbite et al., 2022 [ 27 ] Gabon Cross-Sectional Primary and Intermediate Levels Healthcare Services Knowledge/attitude/practice changes Health worker training Prescribers in Lambaréné recognise the AMR as a public health challenge in health facilities and in Gabon. Prescribers strongly believed that antimicrobial stewardship should be implemented in their health facilities to reduce the spread of AMR. Adjei et al., 2023 [ 28 ] Ghana Randomized Controlled Trial (RCT) Primary Health Care Facility (PHC) Changes in antibiotic use/prescription Diagnostic/testing interventions The intervention package of POCTs, diagnostic algorithms, and behavioral change communication for healthcare workers can reduce antibiotic prescriptions. Gasson et al., 2018 [ 29 ] South Africa Retrospective Primary Health Care Facility (PHC) Changes in antibiotic use/prescription Health worker training The intervention achieved: 1) 28-percentage-point increase in guideline adherence (19% to 47%), 2) 19% reduction in antibiotic consumption (12.9 fewer DDDs/100 prescriptions), and 3) sustained improvement over 24 months, proving peer audits effectively combat AMR drivers in resource-limited settings. de Vries et al., 2022 [ 30 ] South Africa Pre-Post Interventional Primary Health Care Facility (PHC) Changes in antibiotic use/prescription Others The study revealed critically low antibiotic guideline adherence (45.1%) in Cape Town clinics, with 68.7% of patients receiving antibiotics − 30.5% lacking diagnosis documentation and 21.6% prescribed unnecessarily, exposing systemic AMR risks in primary care prescribing practices. Brinkmann & Kibuule, 2019 [ 31 ] Namibia Cross-Sectional Primary Health Care Facility (PHC) Changes in antibiotic use/prescription Antimicrobial stewardship (AMS) Awareness of AMS policies was high (90%); Compliance with AMS practices was suboptimal (30.8% in health centers; 9.1%–36.4% in clinics) 3.2 Typology of Interventions to Tackle AMR in PHC Several intervention methods were noted from the studies considered, and they have been grouped into seven main categories in this review as seen in Table 3 . Table 3 Types of Interventions and Educational Strategies for AMR in PHC Interventions Description of intervention Comparative Analysis Source Study Antimicrobial stewardship (AMS) The intervention involved the evaluation of the several methods that are involved in curbing AMR such as AMS policies and training with the barriers and enablers that impact them. AMS programs implemented were conducted in majorly health facilities (facility- based), short term, pilot scaled, and the adaptation is not specifically tailored to a local context, as the utilized tools were adapted from already existing organizations’ toolkit or framework such as WHO. Some of the interventions were a multi-component assessment. The government systems (Ghana) facilitated the intervention due to implementation of the stewardship program into its National action plan to fight AMR. Some negative government effects were noted in Namibia such as weak implementation and inadequate facilities. Sefah et al., 2024 [ 19 ] Brinkmann & Kibuule, 2019 [ 31 ] Surveillance systems[ 13 ] The intervention entails examination of cases of diagnosed patients in relation to Antimicrobial prescription and from these results, seeks to suggest and ensure the adherence of health workers to prescription guidelines. Intervention was done across multiple PHCs (facility-based), a pilot study aimed at providing a basis for future improvement by assessing the baseline situation, and a multicomponent assessment (including a mixed-methods and a retrospective prescription audit.) The government systems (Ghana and South Africa) of the country had a significant involvement in the intervention due to the development or provision of framework and guidelines needed for the intervention, though certain negative influences (such as poor infrastructure and systemic failures) were noted.The duration is variable (short-term or sustained) Owusu et al., 2022 [ 17 ] Engler et al., 2021 [ 7 ] Health worker training The intervention assessed a variety of health workers on their knowledge of and educated them on AMR regulation and prevention strategies. The intervention majorly employed coordinated monitoring and active physical facilitation. The intervention was a facility based, pilot program (which was either a single site or multi site). The intervention is short term, either adapted to a local context or not. The intervention was single component (diagnostic/descriptive) and in some cases multi component to include an audit component to track change post intervention. The impact of government systems is not extensively outlined, and in some cases noted, they were negative (Kenya.) Korom et al., 2017 [ 21 ] Nyamu et al., 2021 [ 16 ] Public or community education The intervention was aimed at the general population including the pharmacists, NGOs, seeking to enlighten them on AMR and how to mitigate its advancement. Several means to implement this intervention were put to use, including social media networking platforms, group discussions, and distribution of AMR-related materials. The intervention was hybrid (facility and community based). Other notable analytical features of the intervention include, pilot study, short term, multi-component, adapted to the local context, and government's influence (Egypt) was strong and positive on the intervention (through the involvement of the government health sector.) Kandeel et al., 2019 [ 20 ] Policy or guideline development The intervention sought to address AMR through implementation of directives concerning AMR prescription by physicians and enforcement of adherence to dispensing guidelines by pharmacists and drug sellers. The intervention was a community based pilot study. The other features of the intervention include short term, adapted to a local context, single component (observational), Government's influence (South Africa) was not pronounced but negative due to failure of the government to enforce existing regulations. Mokwele et al., 2022 [ 22 ]. Diagnostic or testing interventions The intervention exploited the use of digitalized health tools and programmes, enabling specific PHC workers to properly diagnose, adhere to guidelines, prescribe appropriately, thus limiting AMR. The intervention was a facility-based pilot program. Other features include short term, adapted to a local context, multi-component. (In some cases, it was a sustained large-scale implementation across multiple PHCs in a country, e.g Burkina Faso.) The government's influence (Ghana and Burkina Faso) on the intervention was positive and facilitating (the country's health authorities and research centers were collaborated with.) Adjei et al., 2023 [ 28 ]. Bessat et al., 2019 [ 20 ] Training and Communication (T&C) package The T&C package was for both health workers and patients. This had strategies targeted at reducing AMR prescription or adherence to prescription guidelines by health workers. The intervention was a facility based pilot, short term (precursor to a randomized trial), and multi-component with significant governmental influence (Uganda). Some of the interventions were tailored to a local context. Kaawa-Mafigiri et al., 2023 [ 15 ] Most studies targeted primary healthcare workers (n = 9). Several studies focused on patients (n = 4) and community members (n = 2), while others addressed general populations (n = 2) or specific informal providers such as drug shop operators (n = 1). Some studies featured a mixed population approach (e.g., involving both patients and healthcare providers). This reflects a broad interest in addressing both provider-side prescribing behavior and community-level knowledge, attitudes, and practices related to antimicrobial use. While the interventions were directed to certain groups, the implementers varied; health workers and public health authorities were the top implementers (35% and 20% respectively), 25% did not specify the implementers, 10% were academics, while NGOs and government were acknowledged as implementers (5% each). Public health authorities such as national health service and pharmacy councils were instrumental in the implementation of intervention [ 12 , 19 ]. Some studies noted the involvement of ministries of health in establishing regulatory guidelines for antibiotic dispensing and in the implementation of AMS initiatives [ 19 , 22 ]. Many of the interventions’ modes of delivery included an element of physical in-person training including discussions and inspections, especially those directed at the health workers.Training of healthcare workers and diagnostic testing in laboratories were the most common interventions implemented. It was found that educational programs to improve clinicians’ knowledge, communication training for health facility staff, audits on prescription practices, and sensitization of health workers on the dangers of antimicrobial resistance (AMR) were necessary [ 16 ]. The feasibility of training over-the-counter medicine sellers (OTCMS) and Community-based Health Planning and Services (CHPS) workers for the appropriate prescription of antibiotics was also considered in order to improve antibiotic access and use at the community level [ 12 ]. Diagnostic tests conducted on febrile outpatients could further reduce the irrational dispensing of antibiotics, as patients were less likely to be wrongly prescribed antibiotics following laboratory investigations [ 18 ]. Several other methods such as the use of social media, infographics, and public campaigns were exploited for the delivery of the information, majorly those aimed at the education of the general public. 3.4 Barriers and Enablers to Effective Intervention Efforts to curb antimicrobial resistance (AMR) are often hindered by challenges. Some of the studies highlighted challenges and facilitators of the strategies employed to tackle AMR in PHCs. Barriers Policy and regulatory limitations: Several regulatory policies by institutions such as pharmacy councils inhibited the widespread adoption of educational intervention strategies due to skepticism on the ability (knowledge base) of unqualified drug sellers to receive the training, which is quite unique in the tackling of AMR [ 12 ]. Other policy limitations included the lack of AMS policies that promote intervention in PHCs. Health workers resistance: Some privately owned pharmacies were unsupportive to the intervention by inconsistent compliance to the dispensing guidelines given [ 22 ]. Also, a limitation in communication/counseling skills leading to prescribing inertia [ 10 ]. Human resource limitation: The lack of adequate and required resources for public awareness AMR-intervention, limited funding and insufficient necessary health facilities at PHC for implementation of intervention strategies have been linked to the barriers hampering AMR intervention [ 13 , 17 , 19 ]. Other barriers to AMR related intervention observed include prescribers poor compliance to prescription guidelines and their lack of sufficient awareness on AMR [ 24 ]. Also, drug stock outs at the health facilities made patients to be influenced by dispensers at the drug shops [ 15 ]. Further specific barriers such as competing clinical priorities with respect to intervention and seasonal prescription variation were highlighted [ 29 ]. However, it is important to note that some of these barriers do not exist in isolation; they intersect to create a more challenging environment, especially for PHC facilities. For example, the lack of microbiology laboratory support (Weak Infrastructure) prevents facilities from having local AMR surveillance data. Without this data, Continuous Education is hindered, making AMS programs "blind" and ineffective, which in turn necessitates more human effort [7]. Furthermore, the high patient workload (Human resource limitations) creates time pressure on health workers. This pressure, combined with difficulties in addressing patient concerns and managing expectations, incentivizes the quick, default action of over-prescribing antibiotics (Health Workers Resistance) rather than engaging in time-consuming communication or adherence to guidelines [10]. Enablers Most studies reviewed did not clearly specify an enabler towards the intervention strategies. However, three studies attributed the availability of enabling tools (guidelines, diagnostics, IT) as a facilitator for the intervention implementation. Four studies mentioned funding as an enabler, as the availability of funds promoted the specific intervention strategies such as formal training on antimicrobial stewardship programs, laboratory infrastructure and point-of-care testing (it is to be noted that the infrastructure mentioned refers to but not limited to diagnostics test because while establishing full labs is difficult, expanding POCT use is a more practical and scalable approach for AMR interventions in PHC) [ 19 ]. Importantly, certain study noted the government as an enabler for the intervention, for example, the government's role is described through the Ghana National Action Plan to fight antimicrobial resistance , which identifies the Antimicrobial Stewardship Program (ASP) as one of its five strategic areas [ 13 ]. 3.5 Reported Outcomes and Impact on AMR Changes in Prescribing Practices Prescription practices by the primary health workers was highlighted as one of the major drivers of AMR. The practices include inappropriate prescription of medicines in healthcare settings and prescription without proper diagnosis [ 13 , 24 , 30 ]. This was attributed to lack of knowledge as some primary health workers do not recognise AMR as a problem in their health facilities [ 20 ]. Some other primary health workers knew little about practices that contribute to the spread of AMR, due to lack of training in this aspect [ 27 ]. There was also the case of self medication and inappropriate use of antibiotics amongst community members which was due to Inappropriate access of drugs from improper providers e.g drug shops [ 12 , 25 ]. This is further worsened by weak implementation of regulations. Although only a few studies addressed regulations, most of them sought to address knowledge which was found to positively change prescription practices in studies that reported it as an outcome. Improvements in Awareness and Knowledge Improvement in awareness and knowledge of AMR can serve as a good solution in reducing the use and inappropriate dispensing of antibiotics and this can be achieved through pharmacist and pharmacy assistant education programs, enforcement of regulations by authorities and regular inspections [ 22 ]. Also, some other points were raised in improving awareness and knowledge across reviewed studies. There should be several methods put in place for community awareness such as social media campaigning targeted towards the general public, training of physicians and pharmacists, and multiple focus group discussions were conducted targeted at physicians, pharmacists, NGOs and the general public [ 20 ]. Prescribers should be equipped with the right knowledge on antimicrobial prescription and use [ 24 ]. Primary health professionals must be empowered through formal training and certificate programs in infectious disease management and antimicrobial stewardship principles and strategies [ 19 ]. Kaawa-Mafigiri et al. (2023) through a baseline assessment conducted between 23rd of February and 12th of March 2010, demonstrated that the training and communication (T&C) package can be useful in bringing about behavior change and improving adherence to prescriptions among both healthcare workers and their patients [ 15 ].This findings also suggests that education and participatory discussion can influence the knowledge and prescribing behaviour of health personnel and have a positive effect through antibiotic stewardship which would resulted in a reduction in antimicrobial prescription post-intervention [ 16 ]. Findings also showed that the use of an electronic device to guide the clinician’s daily practice might have potentially positive impacts on several aspects of the healthcare system, which go beyond the quality of the care and the decrease of unnecessary antibiotic prescriptions [ 26 ]. 3.6 Sustainability and Scalability of Strategies Most of the interventions reported in the reviewed studies were implemented on a small scale without clear plans for long-term sustainability or integration into national health systems [ 16 , 20 , 21 ]. Kaawa-Mafigiri et al. (2023), Kandeel et al. (2019) and Mokwele et al. (2022) were pilot studies [ 15 , 20 , 22 ]. In several cases, the interventions were conducted solely for the purpose of the study, with no structured mechanisms to maintain them beyond the project period [ 17 , 22 ]. Only a few studies, such as those supported by external funders including the Swiss Agency for Development and Cooperation (SDC), the Federal Ministry of Economic Cooperation and Development (BMZ), and the UK Department for International Development (DFID) demonstrated more structured implementation efforts and hinted at potential for scale-up or adoption by national ministries of health [ 14 , 15 ]. However, even in these cases, sustainability was not guaranteed, and long-term scalability remained uncertain.Sustainability was however supported by encouragement of pharmaceutical governance at multiple levels, particularly through leadership in implementing Antimicrobial stewardship programs in hospitals [ 8 , 12 ]. The regular updating of guidelines with clear, practical instructions was also key as it enabled health workers to avoid unnecessary use of antibiotics [ 12 ]. Policies developed on the basis of before-and-after intervention surveys encouraged the scaling of interventions [ 9 ]. DISCUSSION This review revealed that educational programs to improve primary healthcare workers’ knowledge, audits on prescription practices and sensitization of health workers on the dangers of AMR are necessary to curb AMR. The feasibility of training over-the-counter medicine sellers on dispensing of antimicrobials and other community-based educational interventions were considered. Conducting diagnostic tests before prescription of antimicrobials was also highlighted as a strategy to reduce the irrational dispensing of antimicrobials as patients were less likely to be prescribed antibiotics following laboratory investigations. To better explain how these interventions influence behavior, the COM-B (Capability, Opportunity, Motivation–Behavior) model was integrated into our analytical framing.[ 32 ] This framework illustrates that effective antimicrobial interventions require not only improved capability through knowledge and skills, but also enabling opportunities such as diagnostic access and supportive institutional environments and sustained motivation including supervision, feedback, and cultural reinforcement.[ 32 ] Applying this lens clarifies how interventions such as health worker training (Nyamu et al., 2021), educational campaigns (Kandeel et al., 2019), and peer audit programs (Gasson et al., 2018) function to influence prescribing and community antibiotic-use behavior. These studies collectively demonstrate that knowledge interventions alone are insufficient unless supported by opportunity and motivation-enabling systems within PHC contexts. A number of studies highlighted the low level of public awareness about antimicrobial resistance, leading to inappropriate antimicrobial prescriptions among healthcare providers, thereby causing greater burdens, such as increased risk of death, increased cost of care and ineffectiveness of first-line treatments of common endemic diseases as a result of drug-resistant infections on the PHC system in Africa. While some healthcare providers in some places are not up-to-date concerning AMR, others are knowledgeable about it but they still inappropriately prescribe antimicrobials due to other factors such as high workload; however, in both cases, educational interventions such as regular health audits and Continuous Medical Education for healthcare providers were suggested [ 10 , 18 ]. In light of this, a multidisciplinary approach by healthcare professionals is needed in creating a robust public awareness of antimicrobial use and antimicrobial resistance. The leverage of public engagement facilitates behavior change leading to the perception that the AMR issue is a society-wide concern, therefore particular efforts have to be carried out by everyone [ 33 ]. Adequate knowledge gaps resulting in improper use and misuse of antimicrobials driving AMR was also identified among healthcare workers. In addition, there is limited awareness regarding the importance of antibiograms; there is poor hygiene, and weak infection prevention and control (IPC) measures, thereby calling for proper sensitization through education and intervention [ 34 , 35 ]. Based on these findings, healthcare workers should be more informed about the risks associated with inappropriate antibiotic dispensing. Additionally, antimicrobial stewardship programs should be established to promote and raise community awareness about the proper use of antimicrobials and the dangers posed by antimicrobial resistance [ 13 ]. In countries where unauthorized personnels like OTCMS prescribe antibiotics, they should be sensitized on the dangers and regulations against such should be enforced. On the other hand, countries should consider training healthcare workers with adequate education on prescribing some antibiotics. This was noted in Afari-Asiedu et al., 2021 where CHPS facilities with midwives in Ghana were allowed to dispense some antibiotics [ 12 ]. Importantly, this review identified a critical gap regarding the paucity of evidence on strategies for curbing AMR in Africa’s primary healthcare system. Despite some studies reporting good knowledge among PHC workers, the lack of strategies such as AMS guidelines specific to PHC, presents a critical challenge [ 16 , 31 ]. The limited evidence on the effectiveness of strategies to tackle AMR at this level of healthcare calls for a need for more studies tailored to finding options that work best in the African context [ 31 ]. Table 4 presents studies conducted in district-level hospitals, which usually act as immediate referral hospitals for PHCs. These studies give more insight into possible studies that can be conducted and strategies that can be adapted for PHC settings. Table 4 Summary of insightful studies conducted in district-level hospital settings. Paper Title Country / Setting Facility Type Intervention Focus Methodology Relevance to PHC Key Takeaway Assessing the impact of antimicrobial stewardship implementation at a district hospital in Ghana using a health partnership model [ 36 ] Ghana a district hospital Antimicrobial Stewardship (AMS) program, which included continuous education and training for hospital staff on appropriate antibiotic use The program utilized Point Prevalence Surveys (PPS) to assess antibiotic use at baseline, midpoint, and end of the project The successful elements of the intervention, such as staff training, feedback mechanisms, and the use of practical toolkits, can be adapted for PHC settings. It addressed the problem of excessive antibiotic use by targeting hospital staff, especially prescribers Improving antimicrobial stewardship in the outpatient department of a district general hospital in Sierra Leone [ 37 ] Sierra Leone Outpatient department of a rural district general hospital Development and implementation of a full, empirical antimicrobial guideline tailored to the local context. A quality improvement project designed to improve the antimicrobial prescriptions practices of paramedical staff. The guidelines were developed by multiple experts. It was placed in each outpatient room to ensure easy access PHC in low resource settings will benefit from tailored local guidelines, training of healthcare providers, regular audit, support and evaluation. The intervention contextualized international guidelines (based around drug availability and cost) and was able to address the issue of inappropriate antimicrobial prescriptions. Evaluating hospital performance in antibiotic stewardship to guide action at national and local levels in a lower-middle income setting [ 38 ] Kenya 16 public hospitals Assessment of existing antibiotic stewardship (ABS) policies and structures in the selected hospitals. A survey conducted in the hospitals. Included both quantitative assessments using developed indicators and qualitative data gathered from semi-structured interviews with frontline healthcare workers and hospital managers. There is a significant gaps in formal ABS programs in Kenyan hospitals and lack of a coordinated approach to implement the national AMR policies at the county level Existing structures can be leveraged to improve antibiotic stewardship practices. Antimicrobial Stewardship Activities in Public Healthcare Facilities in South Africa: A Baseline for Future Direction [ 13 ] South Africa Public healthcare facilities (9 national central hospitals, 10 referral hospitals and 18 community health centre) Antimicrobial Stewardship Programs (ASPs) aimed at improving antibiotic prescribing practices and adherence to the AMR framework A mixed method study conducted in 2 phases. A questionnaire was first completed by healthcare professionals (HCPs), then a qualitative component involving focus group discussions and in-depth interviews. Points out peculiar challenges such as resource limitations in entry level primary healthcare facilities. AMS activities and ASPs were found to not yet be fully implemented at PHCs. Improving antibiotic prescribing practices at PHC will be an effective strategy in tackling AMR Development of Antimicrobial Stewardship Programmes in Low and Middle-Income Countries: A Mixed-Methods Study in Nigerian Hospitals [ 39 ] Nigeria Tertiary and secondary care hospitals The intervention was a multifaceted AMS program. It included strategies such as increasing awareness of antibiotic resistance, developing guidelines for antibiotic use and implementing local audits. A mixed method study was conducted in 3 stages. Stage 1: A survey of antibiotic use was conducted, along with interviews with prescribers Stage 2: An established theoretical model for behavioral change was applied to develop an AMS strategy Stage 3: Consultation with purposively selected stakeholders It emphasizes the importance of local data in developing tailored strategies can be more effective at the PHC-level in combating AMR and improving antibiotic use It highlighted the necessity of understanding local contexts when developing AMS programs. Antimicrobial stewardship in a rural regional hospital – growing a positive culture [ 40 ] South Africa A rural regional hospital A comprehensive antibiotic stewardship program that included audits on antibiotic use, and educational initiatives (for healthcare professionals, non-clinical staff and the public) A quality improvement project delivered through face-to-face training sessions for healthcare staff and development of online learning modules for new medical staff. Posters were also distributed around the hospital to educate non-clinical staff and the public It demonstrates the efficacy of tailored educational programs and community engagement initiatives Continuous education and a structure that encourages staff to engage in stewardship efforts is important for the success of strategies to combat AMR In comparison with the World Health Organization’s Global Action Plan on Antimicrobial Resistance (2015), our study also emphasizes the critical role of public awareness and professional education in combating AMR [ 41 ]. Similar to the gaps identified in African primary healthcare settings, the WHO reports widespread shortcomings in AMR awareness campaigns and professional training, especially in low- and middle-income countries. Moreover, the WHO’s GLASS data underscores limited laboratory capacity, poor infection prevention and control (IPC) implementation, and scarce use of antibiograms—issues echoed by this study [ 42 ]. The WHO’s 2021 report also notes that despite many African countries developing National Action Plans (NAPs) for AMR, implementation remains weak due to insufficient funding, fragmented governance, and a lack of coordination between human and animal health sectors [ 43 ]. These systemic gaps reinforce the current study’s findings, especially the limited integration of multisectoral approaches and poor dissemination of AMR guidelines at the primary healthcare level. The review by Huttner et al. (2010) focusing on educational interventions show that context-sensitive training programs and institutional support significantly improve antimicrobial stewardship outcomes - underscoring the need for targeted, scalable interventions in African primary care [ 44 ]. Strengths and Contributions of the Review This study makes a significant contribution by reviewing the education and intervention strategies that have been implemented to tackle AMR in primary care or community settings in Africa. This is an area that is often underrepresented in global AMR literature, despite its role as the first point of contact of the populace with the health system. The review included all relevant evidence found in the searched databases and employed a methodologically rigorous process. The evidence synthesized uses different methodological approaches and were conducted in different countries across the continent, thereby improving the generalizability of results reported in this review. The absence of a published framework for AMS in Africa’s PHC settings further underscores the need for a context-sensitive synthesis. Limitations of the Review Despite the contributions, the study is not without limitations. Included studies were limited to those published in English language and accessible through selected databases. Policy documents, national action plans (NAPs) and gray literature which could give leads on implemented strategies were not retrieved. Due to poor data infrastructure in Africa, this study might not be able to properly capture the strategies implemented to promote antimicrobial stewardship and rational use of antibiotics at the PHC-level in Africa. Additionally, determining study setting was based on the authors’ report and to delineate PHC and district-level hospitals was difficult in a few studies, especially those conducted in countries where distinction between some facility levels is blurred. The heterogeneity of outcomes and varying methodological approaches in included studies made it difficult to compare the effectiveness of strategies. Also, the findings from the studies are based on the content of included studies and does not involve stakeholder engagement, which could have added more contextual relevance. Recommendations for Practice and Policy The findings across our highlighted studies show that simply raising awareness among healthcare workers and the public is not enough, resource allocation, AMS tailored strategies and consistent policy enforcement are critical to shaping better antibiotic use [ 23 ]. One of the identified issues is the prescribing of antibiotics by local over-the-counter drug sellers, many of whom are not qualified to do so. This reveals a systemic gap in both regulation and training, pointing to a clear role for the Ministries of Health in ensuring that only authorized personnel prescribe antibiotics [ 12 ]. There’s also a strong call for regular and updated training for health workers to keep pace with evolving best practices [ 13 ]. In this context, tailored training packages and communication strategies should be included in the broader toolkit to curb AMR [ 14 ]. When compared to global health strategies, these recommendations align with WHO’s call for improved antimicrobial stewardship (AMS) in PHC. However, the implementation in many LMICs remains suboptimal, as current AMS efforts tend to be mostly focused on healthcare facilities while often neglecting the primary care and community level. There is a growing consensus that AMS strategies need to be customized for PHC environments, accompanied by institutionalized guidelines and allocation of resources for effective implementation [ 23 ]. Furthermore, Family physicians and PHC workers could be central to this change. By applying Community-Oriented Primary Care (COPC) principles, they can help build awareness at the grassroots level and serve as stewards for antibiotic use [ 16 ]. Furthermore, expanding the use of mobile apps for prescribing guidelines and empowering pharmacists to serve as gatekeepers could improve prescription accuracy and reduce unnecessary antibiotic use. The evidence also highlights the importance of multi-sectoral collaboration. Ministries alone cannot shoulder the responsibility hence, NGOs, donors, and private sector organizations need to support funding and capacity-building initiatives for AMS programs [ 19 ]. Despite these promising approaches, there are several gaps to address. Many regions still lack formal surveillance systems for AMR, which undermines long-term monitoring and evaluation at the national level [ 17 ]. In addition, laboratory testing before prescribing antibiotics is still not consistently practiced, which makes it difficult to determine whether an infection is bacterial or viral [ 18 ]. This further perpetuates inappropriate antibiotic use. Ministries of Health, NGOs, and PHC centres should prioritize the institutionalization of AMS guidelines, fund PHC-specific stewardship programs, and promote training systems that reflect the realities of rural and under-resourced areas. Additionally, integrating community engagement and empowering healthcare professionals with the right tools and knowledge will be critical to the fight against AMR [ 21 , 22 ]. There is still room and an urgent need for more tailored, inclusive, and systemic responses to safeguard the effectiveness of antibiotics for future generations. CONCLUSION This review reveals a growing but still limited research on educational and intervention strategies aimed at combating antimicrobial resistance in Africa's primary health care systems. Although many recent studies demonstrate innovative approaches such as training programs for healthcare providers and community focused awareness campaigns, the majority of these approaches are small-scale interventions with limited potential for long-term impact. The persistence of inappropriate antibiotic use, particularly among primary health care providers, continues to drive resistance. Furthermore, the absence of antimicrobial stewardship guidelines tailored to PHC settings remains a significant gap. To effectively manage AMR, future s strategies sustainability, cross-sector collaboration, and strong policy enforcement must be prioritized. Investments in the health system would also strengthen this awareness particularly at the community and primary care levels,which are crucial to ensuring that interventions are not only impactful but sustainable. This calls for a shift from short-term, fragmented efforts to comprehensive, system-wide approaches that are responsive to the realities of healthcare delivery across the African continent. Abbreviations ABS Antibiotic Susceptibility AJOL African Journals Online AMR Antimicrobial Resistance AMS Antimicrobial Stewardship ASP Antimicrobial Stewardship Program BMZ German Federal Ministry for Economic Cooperation and Development CHPS Community–based Health Planning and Services CHW Community Health Worker COPC Community–Oriented Primary Care DFID Department for International Development (UK) HCP Health Care Provider IPC Infection Prevention and Control LMIC Low–and Middle–Income Countries NAP National Action Plan OTCMS Over–the–Counter Medicine Sellers PPC Public Primary Care PHC Primary Health Care PPS Point Prevalence Survey RCT Randomized Controlled Trial SDC Swiss Agency for Development and Cooperation SMC Seasonal Malaria Chemoprevention SPAQ Sulfadoxine–Pyrimethamine and Amodiaquine SMC Seasonal Malaria Chemoprevention Declarations Ethics approval and consent to participate Because of the nature of scoping reviews, ethical approval is not required. Consent for publication Not applicable Availability of data and materials All data and materials used for this study are publicly available online and have been properly cited in the reference list. Competing Interest The authors declare that they have no competing interests. Funding The authors received no funding for this study. Authors’ Contributions TOO: Conceptualization, Methodology, Formal Analysis, Supervision, Writing - Original Draft,Writing - Review & Editing. TLA: Data Curation, Writing - Original Draft , Visualization. GAO: Data Curation, Writing - Original Draft ,Writing - Review & Editing. ORE: Data Curation, Writing - Original Draft. IR: Data Curation, Writing - Original Draft. AOA: Data Curation, Writing - Original Draft. All authors approved the final version of the work Acknowledgements None. References Murray CJL, Ikuta KS, Sharara F, et al. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. The Lancet 2022; 399: 629–655. 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09:05:40","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":132584,"visible":true,"origin":"","legend":"\u003cp\u003eGeographical Distribution of Studies\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8702660/v1/9dee106353c0ac9742c9563e.png"},{"id":102596586,"identity":"286628ee-8155-4da7-b0a3-795ef4cb45e6","added_by":"auto","created_at":"2026-02-13 12:22:37","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":11519,"visible":true,"origin":"","legend":"\u003cp\u003eTimeline of Studies Published (2015–2025)\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8702660/v1/985582ab9db9068102484993.png"},{"id":104405181,"identity":"5668f7b6-8e07-4ea6-b0a8-6f482745bed2","added_by":"auto","created_at":"2026-03-11 12:22:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1327785,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8702660/v1/0e2c8703-dc16-4eae-a728-8e09342c19fe.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Education and Intervention Strategies for Tackling Antimicrobial Resistance in Primary Health Care: Evidence from Africa","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eInfections that no longer respond to standard antibiotics are undermining medical and pharmacological progress by turning previously effective treatments into no longer guaranteed cures. This phenomenon is known as antimicrobial resistance (AMR), which refers to the ability of microorganisms to withstand the effects of medicines that once treated them effectively. Globally, antimicrobial resistance is an urgent public health concern. In 2019, bacterial AMR was linked to approximately 4.95\u0026nbsp;million deaths worldwide [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Africa bears a disproportionate burden due to high infectious disease prevalence and limited resources [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. AMR arises from multifaceted factors, including inherent traits of the microbes themselves and human-related factors, such as how drugs are prescribed, accessed, and used [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. While AMR is a global issue, its consequences are particularly pronounced in developing countries [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Subnational data from Ghana and South Africa highlight high antibiotic rates in PHC [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn many low- and middle-income countries (LMICs), primary health care centres are the first point of contact for people seeking medical attention and the backbone of healthcare services in Africa [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. However, these centres face a range of challenges that hinder their ability to effectively combat antimicrobial resistance (AMR). In Africa, primary health care settings are uniquely vulnerable to AMR due to a high burden of infectious diseases, inadequate health education for providers and patients, and the misuse of antibiotics for conditions like viral infections. These challenges are further worsened by poor prescription practices, limited .diagnostic tools, weak regulation, and widespread misuse of antimicrobials in both human and non-human sectors [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Consequently, AMR spreads unchecked, posing a significant threat to public health and limiting the ability of health systems to effectively respond to emerging infectious diseases. In this review, primary health care (PHC) is defined as a holistic approach to health that prioritizes accessible, integrated services - including primary care and public health functions - delivered through community-based clinics, health centers, and tailored to local needs and empowering communities [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite these challenges, primary health care remains one of the most strategic points to fight antimicrobial resistance. Because PHC workers are usually the first to see and treat infections in their communities, they are in a strong position to shape how antibiotics are used. But for any intervention to work, it has to fit the systemic realities on ground, including how the local health system works, the cultural beliefs people hold, and the common illnesses found in the local communities. Despite PHC’s strategic role in shaping antibiotic use, few reviews have synthesized context-specific strategies for AMR control in African PHC system, unlike hospital-focused studies [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. This review aims to address a critical evidence gap by examining education and intervention strategies for tackling AMR in primary health care settings across Africa. It explores the effectiveness of current approaches, identifies key barriers to implementation, and highlights practical, system specific solutions offering actionable insights to strengthen AMR control efforts at the community level.\u003c/p\u003e \u003cp\u003eWe seek to answer the following questions:\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat types of education and intervention strategies have been implemented to promote antimicrobial stewardship and rational use of antibiotics in primary care or community settings in Africa?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWho are the key actors involved in implementing these interventions, and in what settings?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat are the common barriers and facilitators to effective implementation of these strategies?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat outcomes or impacts have been reported from these interventions?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eHow are these interventions monitored and sustained?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003cp\u003e\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eThis review was guided by the five stages described in Arksey \u0026amp; O\u0026rsquo;Malley\u0026rsquo;s framework for scoping reviews [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist for presenting the results [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSearch strategy and study selection\u003c/p\u003e \u003cp\u003eA comprehensive search for peer-reviewed articles published between January 1, 2015 and April 11, 2025 was conducted using 4 databases: PubMed, Google Scholar, SCOPUS and African Journals Online (AJOL). The search query for each database is presented in Additional File 1. The search results were imported into Zotero where duplicates were removed. Title and abstract screening was carried out in Raayan. Each title and abstract was independently screened by two reviewers. In case of disagreement, a third reviewer was consulted and consensus was reached. Full text was assessed by six reviewers using predefined inclusion/exclusion criteria. A manual search was conducted to identify articles that fit our inclusion criteria and might have been missed. The search and selection process is summarised in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eCriteria for study inclusion and exclusion\u003c/p\u003e \u003cp\u003eStudy eligibility was determined using the PCC (Population\u0026ndash;Concept\u0026ndash;Context) framework (Table\u0026nbsp;1).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePCC Component\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStudy Criteria\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePopulation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePHC workers (e.g., doctors, nurses, CHWs), patients, community members accessing PHC services\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eConcept\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAMR strategies/interventions such as training, policy implementation, stewardship, education, behavioral change\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eContext\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary health care or community-based settings in Africa (2015\u0026ndash;2025)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eStudies with strategic components targeting AMR in Africa\u0026rsquo;s PHC system were also included. This includes evaluation of AMR-related programs and structured assessments identifying needs or barriers in AMR control relevant for planning interventions. Education and intervention strategies in this study encompass targeted actions with feedback mechanisms to improve antibiotic use, including health worker training, antimicrobial stewardship (AMS) programs, diagnostic testing, and public education campaigns. Only primary peer reviewed studies published in the English language were included as this was the language reviewers were fluent in. However, studies that focused exclusively on hospitals with no linkage to PHC or the community were excluded. Also studies conducted in veterinary or agricultural settings, those that only assessed knowledge, awareness, or prescribing practices without any intervention or strategic component targeting AMR, case reports, comments, and editorials were excluded.\u003c/p\u003e \u003cp\u003eData extraction and synthesis\u003c/p\u003e \u003cp\u003eData was extracted into a predefined data extraction form using Google Sheets. Extracted information included study characteristics (e.g., authorship, publication year, study design, country), population details, intervention details (e.g., Type of intervention, implementers of intervention and mode of delivery), information on outcome (e.g., main finding, impact on AMR, barriers and enablers), key gaps and lesson learned. A narrative synthesis was done due to the heterogeneity of outcomes and methodology in included studies. Characteristics and recurring themes in included studies were descriptively summarised by using frequency and percentages.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThe search yielded 514 records (with duplicates removed). Title and abstract screening left 80 articles for full text assessment (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). On assessment of full-text, 17 papers met inclusion criteria and 3 papers were added from manual searching. A total of 20 studies met the inclusion criteria and were included in this review, providing evidence on education and intervention strategies aimed at addressing antimicrobial resistance (AMR) in primary health care (PHC) settings across Africa.\u003c/p\u003e \u003cp\u003e3.1 Characteristics of Included Studies\u003c/p\u003e \u003cp\u003eThe included studies spanned 12 African countries, with the majority conducted in Ghana and South Africa (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Figure\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the timeline of the studies between 2015\u0026ndash;2025. None of the included studies were from 2015, 2016 and 2025. The included studies employed a range of designs. Four used qualitative approaches, four used pre\u0026ndash;post intervention designs, three were mixed-methods, three were retrospective analyses, two were randomized controlled trials (RCTs), and four were cross-sectional studies.This distribution illustrates highlights the dominance of descriptive and observational research over experimental approaches. The majority of interventions (n\u0026thinsp;=\u0026thinsp;14, 67%) were conducted in primary health care facilities, often in public-sector clinics or health centres. A smaller number of studies were situated in combined primary and intermediate-level services (n\u0026thinsp;=\u0026thinsp;3, 14%), and others in community-based or outreach settings (n\u0026thinsp;=\u0026thinsp;2, 10%). One study incorporated a multi-setting approach involving PHC facilities, pharmacies, informal providers, and correctional centers. Another focused on community drug outlets. Detailed study characteristics are summarised in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of Included Studies\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReferences\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCountry\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStudy Design\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSetting\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAMR Focus\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eIntervention Type\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eKey Outcomes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAfari-Asiedu et al., 2021 [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGhana\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQualitative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCommunity-Based / Outreach Setting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eKnowledge/attitude/practice changes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHealth worker training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eWhile some institutions supported the suggestion that training of unqualified drug sellers was enough for them to prescribe antibiotics, another institution opposed it\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEngler et al., 2021 [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSouth Africa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMixed-Methods\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimary Health Care Facility (PHC)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eKnowledge/attitude/practice changes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSurveillance systems\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIt was discovered that many prescribing health care providers have little knowledge on AMR and that not all health care provider was included in trainings which shouldn't be so\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKiemde et al., 2023 [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBurkina Faso\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRandomized Controlled Trial (RCT)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimary Health Care Facility (PHC)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCompliance with guidelines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAntimicrobial stewardship (AMS)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eThe study found that seasonal malaria chemoprevention (SMC) with sulfadoxine\u0026ndash;pyrimethamine plus amodiaquine (SPAQ) remains effective in reducing malaria incidence among children under five years of age in Burkina Faso, despite the presence of molecular markers of resistance. However, the paper emphasizes the need for continuous monitoring of the efficacy and safety of SMC due to increasing resistance levels.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKaawa-Mafigiri et al., 2023 [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUganda\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQualitative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimary Health Care Facility (PHC)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eChanges in antibiotic use/prescription\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eThis study demonstrated that the T\u0026amp;C package can be useful in bringing about behavior change and improving adherence to prescriptions among both healthcare workers and their patients\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNyamu et al., 2021 [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKenya\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePre-Post Interventional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimary Health Care Facility (PHC)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCompliance with guidelines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHealth worker training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eThe findings suggest that education and participatory discussion that sought to influence the knowledge and prescribing behaviour of health personnel, had a positive effect on antibiotic stewardship and resulted in a reduction in AM prescription post-intervention.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOwusu et al., 2022 [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGhana\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRetrospective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimary Health Care Facility (PHC)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCompliance with guidelines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSurveillance systems\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eThe study from a primary health facility of Ghana showed that about nine in ten patients with uncomplicated UTIs were prescribed an empirical antibiotic, of whom 60% were as recommended in the STGs\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOpoku et al., 2020 [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGhana\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRetrospective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimary Health Care Facility (PHC)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eKnowledge/attitude/practice changes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDiagnostic/testing interventions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eThe rate of antibiotic prescription for febrile outpatients is high so, to reduce this advocacy for the increased use of laboratory testing before prescribing antibiotics is recommended\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSefah et al., 2024 [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGhana\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCross-Sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimary and Intermediate Levels Healthcare Services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eKnowledge/attitude/practice changes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAntimicrobial stewardship (AMS)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eThere was sub-optimal performance for almost all the core elements of antimicrobial stewardship programs in the public hospitals\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKandeel et al., 2019 [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEgypt\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePre-Post Interventional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimary and Intermediate Levels Healthcare Services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eChanges in antibiotic use/prescription\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePublic/community education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAntibiotics prescription for ARIs decreased and the knowledge and attitude scores regarding appropriate use among physicians, pharmacists, and patients improved compared to the surveys conducted pre-intervention.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKorom et al., 2017 [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKenya\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePre-Post Interventional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimary Health Care Facility (PHC)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCompliance with guidelines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHealth worker training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eThe study showed a series of brief educational interventions that were associated with significant improvement on appropriate antibiotic prescribing for urinary tract infections.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMokwele et al., 2022 [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSouth Africa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCross-Sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCommunity Pharmacy / Drug Outlet\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCompliance with guidelines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePolicy/guideline development\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eThis study shows that dispensing antibiotics without prescription for managing UTIs appears to be common practice among privately owned pharmacies.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmg\u0026aring;rd et al., 2021 [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTanzania\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQualitative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimary Health Care Facility (PHC)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUnderstanding of antibiotic resistance and prescribing practices\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAntimicrobial stewardship (AMS)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eThis study shows that primary healthcare workers in Northern Tanzania often rely on clinical judgment and parental input to prescribe antibiotics for children, but have limited understanding of antibiotic resistance as a public health threat, viewing it mainly as an individual concern.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAltaye et al., 2024 [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEthiopia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMixed-Methods\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimary Health Care Facility (PHC)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eKnowledge/attitude/practice changes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDeselect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eThis study shows that antibiotic prescribing at primary healthcare facilities in Addis Ababa is influenced by a mix of factors including prescribers' lack of up-to-date knowledge and attention to resistance, patient pressure, resource shortages, and systemic issues such as lack of lab reagents and AMR data, pointing to an urgent need for targeted interventions to improve rational antibiotic use\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSambakunsi et al., 2019 [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMalawi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMixed-Methods\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCommunity-Based / Outreach Setting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eKnowledge/attitude/practice changes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePublic/community education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eThe study found that self-medication with antimicrobials is widespread in Lilongwe, Malawi, largely due to poor knowledge, misconceptions, and limited access to healthcare. Most participants could not correctly identify antimicrobials or understood their proper use, and many believed they were effective for conditions like fever and the common cold. Stocking antibiotics at home was linked to increased self-medication, while awareness of antimicrobial resistance reduced it.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBessat et al., 2019 [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBurkina Faso\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQualitative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimary Health Care Facility (PHC)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eChanges in antibiotic use/prescription\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFindings showed that the use of an electronic device to guide the clinician\u0026rsquo;s daily practice might have potentially positive impacts on several aspects of the health care system, which go beyond the quality of the care and the decrease of unnecessary antibiotic prescriptions.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdegbite et al., 2022 [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGabon\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCross-Sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimary and Intermediate Levels Healthcare Services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eKnowledge/attitude/practice changes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHealth worker training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePrescribers in Lambar\u0026eacute;n\u0026eacute; recognise the AMR as a public health challenge in health facilities and in Gabon. Prescribers strongly believed that antimicrobial stewardship should be implemented in their health facilities to reduce the spread of AMR.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdjei et al., 2023 [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGhana\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRandomized Controlled Trial (RCT)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimary Health Care Facility (PHC)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eChanges in antibiotic use/prescription\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDiagnostic/testing interventions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eThe intervention package of POCTs, diagnostic algorithms, and behavioral change communication for healthcare workers can reduce antibiotic prescriptions.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGasson et al., 2018 [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSouth Africa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRetrospective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimary Health Care Facility (PHC)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eChanges in antibiotic use/prescription\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHealth worker training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eThe intervention achieved: 1) 28-percentage-point increase in guideline adherence (19% to 47%), 2) 19% reduction in antibiotic consumption (12.9 fewer DDDs/100 prescriptions), and 3) sustained improvement over 24 months, proving peer audits effectively combat AMR drivers in resource-limited settings.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ede Vries et al., 2022 [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSouth Africa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePre-Post Interventional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimary Health Care Facility (PHC)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eChanges in antibiotic use/prescription\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eThe study revealed critically low antibiotic guideline adherence (45.1%) in Cape Town clinics, with 68.7% of patients receiving antibiotics\u0026thinsp;\u0026minus;\u0026thinsp;30.5% lacking diagnosis documentation and 21.6% prescribed unnecessarily, exposing systemic AMR risks in primary care prescribing practices.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBrinkmann \u0026amp; Kibuule, 2019 [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNamibia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCross-Sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimary Health Care Facility (PHC)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eChanges in antibiotic use/prescription\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAntimicrobial stewardship (AMS)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAwareness of AMS policies was high (90%); Compliance with AMS practices was suboptimal (30.8% in health centers; 9.1%\u0026ndash;36.4% in clinics)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e3.2 Typology of Interventions to Tackle AMR in PHC\u003c/p\u003e \u003cp\u003eSeveral intervention methods were noted from the studies considered, and they have been grouped into seven main categories in this review as seen in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTypes of Interventions and Educational Strategies for AMR in PHC\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterventions\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescription of intervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eComparative Analysis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSource Study\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAntimicrobial stewardship (AMS)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe intervention involved the evaluation of the several methods that are involved in curbing AMR such as AMS policies and training with the barriers and enablers that impact them.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAMS programs implemented were conducted in majorly health facilities (facility- based), short term, pilot scaled, and the adaptation is not specifically tailored to a local context, as the utilized tools were adapted from already existing organizations\u0026rsquo; toolkit or framework such as WHO. Some of the interventions were a multi-component assessment. The government systems (Ghana) facilitated the intervention due to implementation of the stewardship program into its National action plan to fight AMR. Some negative government effects were noted in Namibia such as weak implementation and inadequate facilities.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSefah et al., 2024 [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eBrinkmann \u0026amp; Kibuule, 2019 [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurveillance systems[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe intervention entails examination of cases of diagnosed patients in relation to Antimicrobial prescription and from these results, seeks to suggest and ensure the adherence of health workers to prescription guidelines.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntervention was done across multiple PHCs (facility-based), a pilot study aimed at providing a basis for future improvement by assessing the baseline situation, and a multicomponent assessment (including a mixed-methods and a retrospective prescription audit.) The government systems (Ghana and South Africa) of the country had a significant involvement in the intervention due to the development or provision of framework and guidelines needed for the intervention, though certain negative influences (such as poor infrastructure and systemic failures) were noted.The duration is variable (short-term or sustained)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOwusu et al., 2022 [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eEngler et al., 2021 [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth worker training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe intervention assessed a variety of health workers on their knowledge of and educated them on AMR regulation and prevention strategies. The intervention majorly employed coordinated monitoring and active physical facilitation.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe intervention was a facility based, pilot program (which was either a single site or multi site). The intervention is short term, either adapted to a local context or not. The intervention was single component (diagnostic/descriptive) and in some cases multi component to include an audit component to track change post intervention. The impact of government systems is not extensively outlined, and in some cases noted, they were negative (Kenya.)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eKorom et al., 2017 [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eNyamu et al., 2021 [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePublic or community education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe intervention was aimed at the general population including the pharmacists, NGOs, seeking to enlighten them on AMR and how to mitigate its advancement. Several means to implement this intervention were put to use, including social media networking platforms, group discussions, and distribution of AMR-related materials.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe intervention was hybrid (facility and community based). Other notable analytical features of the intervention include, pilot study, short term, multi-component, adapted to the local context, and government's influence (Egypt) was strong and positive on the intervention (through the involvement of the government health sector.)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eKandeel et al., 2019 [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePolicy or guideline development\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe intervention sought to address AMR through implementation of directives concerning AMR prescription by physicians and enforcement of adherence to dispensing guidelines by pharmacists and drug sellers.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe intervention was a community based pilot study. The other features of the intervention include short term, adapted to a local context, single component (observational), Government's influence (South Africa) was not pronounced but negative due to failure of the government to enforce existing regulations.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMokwele et al., 2022 [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiagnostic or testing interventions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe intervention exploited the use of digitalized health tools and programmes, enabling specific PHC workers to properly diagnose, adhere to guidelines, prescribe appropriately, thus limiting AMR.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe intervention was a facility-based pilot program.\u003c/p\u003e \u003cp\u003eOther features include short term, adapted to a local context, multi-component. (In some cases, it was a sustained large-scale implementation across multiple PHCs in a country, e.g Burkina Faso.)\u003c/p\u003e \u003cp\u003eThe government's influence (Ghana and Burkina Faso) on the intervention was positive and facilitating (the country's health authorities and research centers were collaborated with.)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdjei et al., 2023 [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBessat et al., 2019 [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTraining and Communication (T\u0026amp;C) package\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe T\u0026amp;C package was for both health workers and patients. This had strategies targeted at reducing AMR prescription or adherence to prescription guidelines by health workers.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe intervention was a facility based pilot, short term (precursor to a randomized trial), and multi-component with significant governmental influence (Uganda). Some of the interventions were tailored to a local context.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eKaawa-Mafigiri et al., 2023 [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eMost studies targeted primary healthcare workers (n\u0026thinsp;=\u0026thinsp;9). Several studies focused on patients (n\u0026thinsp;=\u0026thinsp;4) and community members (n\u0026thinsp;=\u0026thinsp;2), while others addressed general populations (n\u0026thinsp;=\u0026thinsp;2) or specific informal providers such as drug shop operators (n\u0026thinsp;=\u0026thinsp;1). Some studies featured a mixed population approach (e.g., involving both patients and healthcare providers). This reflects a broad interest in addressing both provider-side prescribing behavior and community-level knowledge, attitudes, and practices related to antimicrobial use. While the interventions were directed to certain groups, the implementers varied; health workers and public health authorities were the top implementers (35% and 20% respectively), 25% did not specify the implementers, 10% were academics, while NGOs and government were acknowledged as implementers (5% each). Public health authorities such as national health service and pharmacy councils were instrumental in the implementation of intervention [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Some studies noted the involvement of ministries of health in establishing regulatory guidelines for antibiotic dispensing and in the implementation of AMS initiatives [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMany of the interventions\u0026rsquo; modes of delivery included an element of physical in-person training including discussions and inspections, especially those directed at the health workers.Training of healthcare workers and diagnostic testing in laboratories were the most common interventions implemented. It was found that educational programs to improve clinicians\u0026rsquo; knowledge, communication training for health facility staff, audits on prescription practices, and sensitization of health workers on the dangers of antimicrobial resistance (AMR) were necessary [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The feasibility of training over-the-counter medicine sellers (OTCMS) and Community-based Health Planning and Services (CHPS) workers for the appropriate prescription of antibiotics was also considered in order to improve antibiotic access and use at the community level [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Diagnostic tests conducted on febrile outpatients could further reduce the irrational dispensing of antibiotics, as patients were less likely to be wrongly prescribed antibiotics following laboratory investigations [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Several other methods such as the use of social media, infographics, and public campaigns were exploited for the delivery of the information, majorly those aimed at the education of the general public.\u003c/p\u003e \u003cp\u003e3.4 Barriers and Enablers to Effective Intervention\u003c/p\u003e \u003cp\u003eEfforts to curb antimicrobial resistance (AMR) are often hindered by challenges. Some of the studies highlighted challenges and facilitators of the strategies employed to tackle AMR in PHCs.\u003c/p\u003e \u003cp\u003e \u003cb\u003eBarriers\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePolicy and regulatory limitations: Several regulatory policies by institutions such as pharmacy councils inhibited the widespread adoption of educational intervention strategies due to skepticism on the ability (knowledge base) of unqualified drug sellers to receive the training, which is quite unique in the tackling of AMR [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Other policy limitations included the lack of AMS policies that promote intervention in PHCs.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eHealth workers resistance: Some privately owned pharmacies were unsupportive to the intervention by inconsistent compliance to the dispensing guidelines given [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Also, a limitation in communication/counseling skills leading to prescribing inertia [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eHuman resource limitation: The lack of adequate and required resources for public awareness AMR-intervention, limited funding and insufficient necessary health facilities at PHC for implementation of intervention strategies have been linked to the barriers hampering AMR intervention [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eOther barriers to AMR related intervention observed include prescribers poor compliance to prescription guidelines and their lack of sufficient awareness on AMR [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Also, drug stock outs at the health facilities made patients to be influenced by dispensers at the drug shops [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Further specific barriers such as competing clinical priorities with respect to intervention and seasonal prescription variation were highlighted [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. However, it is important to note that some of these barriers do not exist in isolation; they intersect to create a more challenging environment, especially for PHC facilities. For example, the lack of microbiology laboratory support (Weak Infrastructure) prevents facilities from having local AMR surveillance data. Without this data, Continuous Education is hindered, making AMS programs \"blind\" and ineffective, which in turn necessitates more human effort [7]. Furthermore, the \u003cb\u003ehigh patient workload\u003c/b\u003e (Human resource limitations) creates time pressure on health workers. This pressure, combined with \u003cb\u003edifficulties in addressing patient concerns\u003c/b\u003e and managing expectations, incentivizes the quick, default action of \u003cb\u003eover-prescribing antibiotics\u003c/b\u003e (Health Workers Resistance) rather than engaging in time-consuming communication or adherence to guidelines [10].\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e\n\u003ch3\u003eEnablers\u003c/h3\u003e\n\u003cp\u003eMost studies reviewed did not clearly specify an enabler towards the intervention strategies. However, three studies attributed the availability of enabling tools (guidelines, diagnostics, IT) as a facilitator for the intervention implementation. Four studies mentioned funding as an enabler, as the availability of funds promoted the specific intervention strategies such as formal training on antimicrobial stewardship programs, laboratory infrastructure and point-of-care testing (it is to be noted that the infrastructure mentioned refers to but not limited to diagnostics test because while establishing full labs is difficult, expanding POCT use is a more practical and scalable approach for AMR interventions in PHC) [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Importantly, certain study noted the government as an enabler for the intervention, for example, the government's role is described through the \u003cb\u003eGhana National Action Plan to fight antimicrobial resistance\u003c/b\u003e, which identifies the Antimicrobial Stewardship Program (ASP) as one of its five strategic areas [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e3.5 Reported Outcomes and Impact on AMR\u003c/p\u003e\n\u003ch3\u003eChanges in Prescribing Practices\u003c/h3\u003e\n\u003cp\u003ePrescription practices by the primary health workers was highlighted as one of the major drivers of AMR. The practices include inappropriate prescription of medicines in healthcare settings and prescription without proper diagnosis [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. This was attributed to lack of knowledge as some primary health workers do not recognise AMR as a problem in their health facilities [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Some other primary health workers knew little about practices that contribute to the spread of AMR, due to lack of training in this aspect [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. There was also the case of self medication and inappropriate use of antibiotics amongst community members which was due to Inappropriate access of drugs from improper providers e.g drug shops [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. This is further worsened by weak implementation of regulations. Although only a few studies addressed regulations, most of them sought to address knowledge which was found to positively change prescription practices in studies that reported it as an outcome.\u003c/p\u003e\n\u003ch3\u003eImprovements in Awareness and Knowledge\u003c/h3\u003e\n\u003cp\u003eImprovement in awareness and knowledge of AMR can serve as a good solution in reducing the use and inappropriate dispensing of antibiotics and this can be achieved through pharmacist and pharmacy assistant education programs, enforcement of regulations by authorities and regular inspections [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Also, some other points were raised in improving awareness and knowledge across reviewed studies. There should be several methods put in place for community awareness such as social media campaigning targeted towards the general public, training of physicians and pharmacists, and multiple focus group discussions were conducted targeted at physicians, pharmacists, NGOs and the general public [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Prescribers should be equipped with the right knowledge on antimicrobial prescription and use [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Primary health professionals must be empowered through formal training and certificate programs in infectious disease management and antimicrobial stewardship principles and strategies [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eKaawa-Mafigiri et al. (2023) through a baseline assessment conducted between 23rd of February and 12th of March 2010, demonstrated that the training and communication (T\u0026amp;C) package can be useful in bringing about behavior change and improving adherence to prescriptions among both healthcare workers and their patients [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].This findings also suggests that education and participatory discussion can influence the knowledge and prescribing behaviour of health personnel and have a positive effect through antibiotic stewardship which would resulted in a reduction in antimicrobial prescription post-intervention [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Findings also showed that the use of an electronic device to guide the clinician\u0026rsquo;s daily practice might have potentially positive impacts on several aspects of the healthcare system, which go beyond the quality of the care and the decrease of unnecessary antibiotic prescriptions [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e3.6 Sustainability and Scalability of Strategies\u003c/p\u003e \u003cp\u003eMost of the interventions reported in the reviewed studies were implemented on a small scale without clear plans for long-term sustainability or integration into national health systems [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Kaawa-Mafigiri et al. (2023), Kandeel et al. (2019) and Mokwele et al. (2022) were pilot studies [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In several cases, the interventions were conducted solely for the purpose of the study, with no structured mechanisms to maintain them beyond the project period [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Only a few studies, such as those supported by external funders including the Swiss Agency for Development and Cooperation (SDC), the Federal Ministry of Economic Cooperation and Development (BMZ), and the UK Department for International Development (DFID) demonstrated more structured implementation efforts and hinted at potential for scale-up or adoption by national ministries of health [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. However, even in these cases, sustainability was not guaranteed, and long-term scalability remained uncertain.Sustainability was however supported by encouragement of pharmaceutical governance at multiple levels, particularly through leadership in implementing Antimicrobial stewardship programs in hospitals [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The regular updating of guidelines with clear, practical instructions was also key as it enabled health workers to avoid unnecessary use of antibiotics [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Policies developed on the basis of before-and-after intervention surveys encouraged the scaling of interventions [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis review revealed that educational programs to improve primary healthcare workers\u0026rsquo; knowledge, audits on prescription practices and sensitization of health workers on the dangers of AMR are necessary to curb AMR. The feasibility of training over-the-counter medicine sellers on dispensing of antimicrobials and other community-based educational interventions were considered. Conducting diagnostic tests before prescription of antimicrobials was also highlighted as a strategy to reduce the irrational dispensing of antimicrobials as patients were less likely to be prescribed antibiotics following laboratory investigations.\u003c/p\u003e \u003cp\u003eTo better explain how these interventions influence behavior, the COM-B (Capability, Opportunity, Motivation\u0026ndash;Behavior) model was integrated into our analytical framing.[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] This framework illustrates that effective antimicrobial interventions require not only improved capability through knowledge and skills, but also enabling opportunities such as diagnostic access and supportive institutional environments and sustained motivation including supervision, feedback, and cultural reinforcement.[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] Applying this lens clarifies how interventions such as health worker training (Nyamu et al., 2021), educational campaigns (Kandeel et al., 2019), and peer audit programs (Gasson et al., 2018) function to influence prescribing and community antibiotic-use behavior. These studies collectively demonstrate that knowledge interventions alone are insufficient unless supported by opportunity and motivation-enabling systems within PHC contexts.\u003c/p\u003e \u003cp\u003eA number of studies highlighted the low level of public awareness about antimicrobial resistance, leading to inappropriate antimicrobial prescriptions among healthcare providers, thereby causing greater burdens, such as increased risk of death, increased cost of care and ineffectiveness of first-line treatments of common endemic diseases as a result of drug-resistant infections on the PHC system in Africa. While some healthcare providers in some places are not up-to-date concerning AMR, others are knowledgeable about it but they still inappropriately prescribe antimicrobials due to other factors such as high workload; however, in both cases, educational interventions such as regular health audits and Continuous Medical Education for healthcare providers were suggested [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In light of this, a multidisciplinary approach by healthcare professionals is needed in creating a robust public awareness of antimicrobial use and antimicrobial resistance. The leverage of public engagement facilitates behavior change leading to the perception that the AMR issue is a society-wide concern, therefore particular efforts have to be carried out by everyone [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Adequate knowledge gaps resulting in improper use and misuse of antimicrobials driving AMR was also identified among healthcare workers. In addition, there is limited awareness regarding the importance of antibiograms; there is poor hygiene, and weak infection prevention and control (IPC) measures, thereby calling for proper sensitization through education and intervention [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Based on these findings, healthcare workers should be more informed about the risks associated with inappropriate antibiotic dispensing. Additionally, antimicrobial stewardship programs should be established to promote and raise community awareness about the proper use of antimicrobials and the dangers posed by antimicrobial resistance [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In countries where unauthorized personnels like OTCMS prescribe antibiotics, they should be sensitized on the dangers and regulations against such should be enforced. On the other hand, countries should consider training healthcare workers with adequate education on prescribing some antibiotics. This was noted in Afari-Asiedu et al., 2021 where CHPS facilities with midwives in Ghana were allowed to dispense some antibiotics [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eImportantly, this review identified a critical gap regarding the paucity of evidence on strategies for curbing AMR in Africa\u0026rsquo;s primary healthcare system. Despite some studies reporting good knowledge among PHC workers, the lack of strategies such as AMS guidelines specific to PHC, presents a critical challenge [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. The limited evidence on the effectiveness of strategies to tackle AMR at this level of healthcare calls for a need for more studies tailored to finding options that work best in the African context [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e4\u003c/span\u003e presents studies conducted in district-level hospitals, which usually act as immediate referral hospitals for PHCs. These studies give more insight into possible studies that can be conducted and strategies that can be adapted for PHC settings.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of insightful studies conducted in district-level hospital settings.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePaper Title\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCountry / Setting\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFacility Type\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIntervention Focus\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMethodology\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRelevance to PHC\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eKey Takeaway\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAssessing the impact of antimicrobial stewardship implementation at a district hospital in Ghana using a health partnership model [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGhana\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ea district hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAntimicrobial Stewardship (AMS) program, which included continuous education and training for hospital staff on appropriate antibiotic use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eThe program utilized Point Prevalence Surveys (PPS) to assess antibiotic use at baseline, midpoint, and end of the project\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eThe successful elements of the intervention, such as staff training, feedback mechanisms, and the use of practical toolkits, can be adapted for PHC settings.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIt addressed the problem of excessive antibiotic use by targeting hospital staff, especially prescribers\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImproving antimicrobial stewardship in the outpatient department of a district general hospital in Sierra Leone [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSierra Leone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOutpatient department of a rural district general hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDevelopment and implementation of a full, empirical antimicrobial guideline tailored to the local context.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eA quality improvement project designed to improve the antimicrobial prescriptions\u003c/p\u003e \u003cp\u003epractices of paramedical staff. The guidelines were developed by multiple experts. It was placed in each outpatient room to ensure easy access\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePHC in low resource settings will benefit from tailored local guidelines, training of healthcare providers, regular audit, support and evaluation.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eThe intervention contextualized international guidelines (based around drug availability and cost) and was able to address the issue of inappropriate antimicrobial prescriptions.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEvaluating hospital performance in antibiotic stewardship to guide action at national and local levels in a lower-middle income setting [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKenya\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 public hospitals\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAssessment of existing antibiotic stewardship (ABS) policies and structures in the selected hospitals.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eA survey conducted in the hospitals. Included both quantitative assessments using developed indicators and qualitative data gathered from semi-structured interviews with frontline healthcare workers and hospital managers.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eThere is a significant gaps in formal ABS programs in Kenyan hospitals and lack of a coordinated approach to implement the national AMR policies at the county level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eExisting structures can be leveraged to improve antibiotic stewardship practices.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAntimicrobial Stewardship Activities in Public Healthcare Facilities in South Africa: A Baseline for Future Direction [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSouth Africa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePublic healthcare facilities (9 national central hospitals, 10 referral hospitals and 18 community health centre)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAntimicrobial Stewardship Programs (ASPs) aimed at improving antibiotic prescribing practices and adherence to the AMR framework\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eA mixed method study conducted in 2 phases. A questionnaire was first completed by healthcare professionals (HCPs), then a qualitative component involving focus group discussions and in-depth interviews.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePoints out peculiar challenges such as resource limitations in entry level primary healthcare facilities. AMS activities and ASPs were found to not yet be fully implemented at PHCs.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eImproving antibiotic prescribing practices at PHC will be an effective strategy in tackling AMR\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDevelopment of Antimicrobial Stewardship Programmes in Low and Middle-Income Countries: A Mixed-Methods Study in Nigerian Hospitals [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNigeria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTertiary and secondary care hospitals\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThe intervention was a multifaceted AMS program. It included strategies such as increasing awareness of antibiotic resistance, developing guidelines for antibiotic use and implementing local audits.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eA mixed method study was conducted in 3 stages.\u003c/p\u003e \u003cp\u003eStage 1: A survey of antibiotic use was conducted, along with interviews with prescribers\u003c/p\u003e \u003cp\u003eStage 2: An established theoretical model for behavioral change was applied to develop an AMS strategy\u003c/p\u003e \u003cp\u003eStage 3: Consultation with purposively selected stakeholders\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eIt emphasizes the importance of local data in developing tailored strategies can be more effective at the PHC-level in combating AMR and improving antibiotic use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIt highlighted the necessity of understanding local contexts when developing AMS programs.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAntimicrobial stewardship in a rural regional hospital \u0026ndash;\u003c/p\u003e \u003cp\u003egrowing a positive culture [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSouth Africa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eA rural regional hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eA comprehensive antibiotic stewardship program that included audits on antibiotic use, and educational initiatives (for healthcare professionals, non-clinical staff and the public)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eA quality improvement project delivered through face-to-face training sessions for healthcare staff and development of online learning modules for new medical staff. Posters were also distributed around the hospital to educate non-clinical staff and the public\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eIt demonstrates the efficacy of tailored educational programs and community engagement initiatives\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eContinuous education and a structure that encourages staff to engage in stewardship efforts is important for the success of strategies to combat AMR\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn comparison with the World Health Organization\u0026rsquo;s Global Action Plan on Antimicrobial Resistance (2015), our study also emphasizes the critical role of public awareness and professional education in combating AMR [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Similar to the gaps identified in African primary healthcare settings, the WHO reports widespread shortcomings in AMR awareness campaigns and professional training, especially in low- and middle-income countries. Moreover, the WHO\u0026rsquo;s GLASS data underscores limited laboratory capacity, poor infection prevention and control (IPC) implementation, and scarce use of antibiograms\u0026mdash;issues echoed by this study [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. The WHO\u0026rsquo;s 2021 report also notes that despite many African countries developing National Action Plans (NAPs) for AMR, implementation remains weak due to insufficient funding, fragmented governance, and a lack of coordination between human and animal health sectors [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. These systemic gaps reinforce the current study\u0026rsquo;s findings, especially the limited integration of multisectoral approaches and poor dissemination of AMR guidelines at the primary healthcare level. The review by Huttner et al. (2010) focusing on educational interventions show that context-sensitive training programs and institutional support significantly improve antimicrobial stewardship outcomes - underscoring the need for targeted, scalable interventions in African primary care [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStrengths and Contributions of the Review\u003c/p\u003e \u003cp\u003eThis study makes a significant contribution by reviewing the education and intervention strategies that have been implemented to tackle AMR in primary care or community settings in Africa. This is an area that is often underrepresented in global AMR literature, despite its role as the first point of contact of the populace with the health system. The review included all relevant evidence found in the searched databases and employed a methodologically rigorous process. The evidence synthesized uses different methodological approaches and were conducted in different countries across the continent, thereby improving the generalizability of results reported in this review. The absence of a published framework for AMS in Africa\u0026rsquo;s PHC settings further underscores the need for a context-sensitive synthesis.\u003c/p\u003e \u003cp\u003eLimitations of the Review\u003c/p\u003e \u003cp\u003eDespite the contributions, the study is not without limitations. Included studies were limited to those published in English language and accessible through selected databases. Policy documents, national action plans (NAPs) and gray literature which could give leads on implemented strategies were not retrieved. Due to poor data infrastructure in Africa, this study might not be able to properly capture the strategies implemented to promote antimicrobial stewardship and rational use of antibiotics at the PHC-level in Africa. Additionally, determining study setting was based on the authors\u0026rsquo; report and to delineate PHC and district-level hospitals was difficult in a few studies, especially those conducted in countries where distinction between some facility levels is blurred. The heterogeneity of outcomes and varying methodological approaches in included studies made it difficult to compare the effectiveness of strategies. Also, the findings from the studies are based on the content of included studies and does not involve stakeholder engagement, which could have added more contextual relevance.\u003c/p\u003e \u003cp\u003eRecommendations for Practice and Policy\u003c/p\u003e \u003cp\u003eThe findings across our highlighted studies show that simply raising awareness among healthcare workers and the public is not enough, resource allocation, AMS tailored strategies and consistent policy enforcement are critical to shaping better antibiotic use [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. One of the identified issues is the prescribing of antibiotics by local over-the-counter drug sellers, many of whom are not qualified to do so. This reveals a systemic gap in both regulation and training, pointing to a clear role for the Ministries of Health in ensuring that only authorized personnel prescribe antibiotics [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. There\u0026rsquo;s also a strong call for regular and updated training for health workers to keep pace with evolving best practices [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In this context, tailored training packages and communication strategies should be included in the broader toolkit to curb AMR [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhen compared to global health strategies, these recommendations align with WHO\u0026rsquo;s call for improved antimicrobial stewardship (AMS) in PHC. However, the implementation in many LMICs remains suboptimal, as current AMS efforts tend to be mostly focused on healthcare facilities while often neglecting the primary care and community level. There is a growing consensus that AMS strategies need to be customized for PHC environments, accompanied by institutionalized guidelines and allocation of resources for effective implementation [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFurthermore, Family physicians and PHC workers could be central to this change. By applying Community-Oriented Primary Care (COPC) principles, they can help build awareness at the grassroots level and serve as stewards for antibiotic use [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Furthermore, expanding the use of mobile apps for prescribing guidelines and empowering pharmacists to serve as gatekeepers could improve prescription accuracy and reduce unnecessary antibiotic use. The evidence also highlights the importance of multi-sectoral collaboration. Ministries alone cannot shoulder the responsibility hence, NGOs, donors, and private sector organizations need to support funding and capacity-building initiatives for AMS programs [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite these promising approaches, there are several gaps to address. Many regions still lack formal surveillance systems for AMR, which undermines long-term monitoring and evaluation at the national level [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In addition, laboratory testing before prescribing antibiotics is still not consistently practiced, which makes it difficult to determine whether an infection is bacterial or viral [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. This further perpetuates inappropriate antibiotic use.\u003c/p\u003e \u003cp\u003eMinistries of Health, NGOs, and PHC centres should prioritize the institutionalization of AMS guidelines, fund PHC-specific stewardship programs, and promote training systems that reflect the realities of rural and under-resourced areas. Additionally, integrating community engagement and empowering healthcare professionals with the right tools and knowledge will be critical to the fight against AMR [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. There is still room and an urgent need for more tailored, inclusive, and systemic responses to safeguard the effectiveness of antibiotics for future generations.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThis review reveals a growing but still limited research on educational and intervention strategies aimed at combating antimicrobial resistance in Africa's primary health care systems. Although many recent studies demonstrate innovative approaches such as training programs for healthcare providers and community focused awareness campaigns, the majority of these approaches are small-scale interventions with limited potential for long-term impact. The persistence of inappropriate antibiotic use, particularly among primary health care providers, continues to drive resistance. Furthermore, the absence of antimicrobial stewardship guidelines tailored to PHC settings remains a significant gap. To effectively manage AMR, future s strategies sustainability, cross-sector collaboration, and strong policy enforcement must be prioritized.\u003c/p\u003e \u003cp\u003eInvestments in the health system would also strengthen this awareness particularly at the community and primary care levels,which are crucial to ensuring that interventions are not only impactful but sustainable. This calls for a shift from short-term, fragmented efforts to comprehensive, system-wide approaches that are responsive to the realities of healthcare delivery across the African continent.\u003c/p\u003e\n\n"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eABS\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAntibiotic Susceptibility\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eAJOL\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAfrican Journals Online\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eAMR\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAntimicrobial Resistance\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eAMS\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAntimicrobial Stewardship\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eASP\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAntimicrobial Stewardship Program\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eBMZ\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGerman Federal Ministry for Economic Cooperation and Development\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCHPS\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCommunity\u0026ndash;based Health Planning and Services\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCHW\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCommunity Health Worker\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCOPC\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCommunity\u0026ndash;Oriented Primary Care\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eDFID\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDepartment for International Development (UK)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eHCP\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHealth Care Provider\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eIPC\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInfection Prevention and Control\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eLMIC\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLow\u0026ndash;and Middle\u0026ndash;Income Countries\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eNAP\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNational Action Plan\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eOTCMS\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOver\u0026ndash;the\u0026ndash;Counter Medicine Sellers\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003ePPC\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePublic Primary Care\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003ePHC\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePrimary Health Care\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003ePPS\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePoint Prevalence Survey\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eRCT\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRandomized Controlled Trial\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eSDC\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSwiss Agency for Development and Cooperation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eSMC\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSeasonal Malaria Chemoprevention\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eSPAQ\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSulfadoxine\u0026ndash;Pyrimethamine and Amodiaquine\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eSMC\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSeasonal Malaria Chemoprevention\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eBecause of the nature of scoping reviews, ethical approval is not required.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eAll data and materials used for this study are publicly available online and have been properly cited in the reference list.\u003c/p\u003e\n\u003cp\u003eCompeting Interest\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThe authors received no funding for this study.\u003c/p\u003e\n\u003cp\u003eAuthors’ Contributions\u003c/p\u003e\n\u003cp\u003eTOO: Conceptualization, Methodology, Formal Analysis, Supervision, Writing - Original Draft,Writing - Review \u0026amp; Editing. TLA: Data Curation, Writing - Original Draft , Visualization. \u0026nbsp;GAO: Data Curation, Writing - Original Draft ,Writing - Review \u0026amp; Editing. ORE: Data Curation, Writing - Original Draft. IR: Data Curation, Writing - Original Draft. AOA: Data Curation, Writing - Original Draft. All authors approved the final version of the work\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;None.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eMurray CJL, Ikuta KS, Sharara F, et al. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. The Lancet 2022; 399: 629\u0026ndash;655. (accessed 7 October 2025).\u003c/li\u003e\n \u003cli\u003eThe burden of bacterial antimicrobial resistance in the WHO African region in 2019: a cross-country systematic analysis - PubMed, https://pubmed.ncbi.nlm.nih.gov/38134946/ (accessed 7 October 2025).\u003c/li\u003e\n \u003cli\u003ePrescribing indicators at primary health care centers within the WHO African region: a systematic analysis (1995\u0026ndash;2015) | BMC Public Health | Full Text, https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-016-3428-8 (accessed 7 October 2025).\u003c/li\u003e\n \u003cli\u003eSalam MdA, Al-Amin MdY, Salam MT, et al. Antimicrobial Resistance: A Growing Serious Threat for Global Public Health. Healthcare 2023; 11: 1946.\u003c/li\u003e\n \u003cli\u003eAyukekbong JA, Ntemgwa M, Atabe AN. The threat of antimicrobial resistance in developing countries: causes and control strategies. 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In: Global action plan on antimicrobial resistance. 2015.\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. Global antimicrobial resistance and use surveillance system (GLASS) report 2022. World Health Organization, 2022.\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. Global antimicrobial resistance and use surveillance system (GLASS) report 2021. Technical Report, Geneva: World Health Organization, https://apps.who.int/iris/handle/10665/341666 (2021).\u003c/li\u003e\n \u003cli\u003eHuttner B, Goossens H, Verheij T, et al. Characteristics and outcomes of public campaigns aimed at improving the use of antibiotics in outpatients in high-income countries. Lancet Infect Dis 2010; 10: 17\u0026ndash;31.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Antimicrobial Resistance (AMR), Primary Health Care (PHC), Africa, Antibiotic Stewardship, Educational Interventions","lastPublishedDoi":"10.21203/rs.3.rs-8702660/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8702660/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBACKGROUND\u003c/b\u003e\u003c/p\u003e \u003cp\u003eAntimicrobial resistance (AMR) is an increasing threat to public health systems worldwide, particularly in Africa, where primary health care (PHC) settings often serve as the initial point of interaction for the majority of the population. These settings are especially exposed to AMR due to widespread antimicrobial misuse, insufficient diagnostic tools and resources, lack of knowledge and limited understanding among health care providers and the public. This review aims to synthesize existing evidence on education and intervention strategies aimed at mitigating AMR in PHC systems across African countries.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMETHODS\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis scoping review followed the framework proposed by Arksey \u0026amp; O\u0026rsquo;Malley and PRISMA-ScR. A systematic search was conducted across four databases which are PubMed, Google Scholar, SCOPUS, and AJOL for reviewed articles published between January 1, 2015 and April 11, 2025. Studies involving AMR-related educational or interventional strategies involving PHC workers, patients, or communities in Africa were included in this review. This encompassed strategies such as antimicrobial stewardship (AMS) initiatives, diagnostic improvements, and regulatory or policy measures with defined intervention or feedback mechanisms. Data from eligible studies were analyzed and summarized.\u003c/p\u003e\u003cp\u003e\u003cb\u003eRESULT\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA total of 20 studies were included. The majority of studies originated from Ghana and South Africa. Most interventions focused on healthcare provider training, public awareness campaigns via social media, and Antimicrobial stewardship (AMS) programs. Key implementers were health workers (35%) and public health authorities (20%). Barriers included restrictive policies, resource constraints, health worker resistance, and poor guideline compliance. Enablers like diagnostics and funding supported implementation. Outcomes showed improved prescribing practices and increased AMR awareness, but sustainability was limited by short-term funding and lack of system-wide integration.\u003c/p\u003e\u003cp\u003e\u003cb\u003eCONCLUSION\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis review highlights significant efforts in recent years to address AMR in African PHC systems through education and intervention strategies. However, due to the small scale, short duration, and lack of long-term planning in many interventions there is a need for more robust, scalable, and clear solutions. Effective AMR control requires not only continuous training and public engagement but also strong policy support, adequate resources, and the integration of AMS frameworks customized to PHC settings.\u003c/p\u003e","manuscriptTitle":"Education and Intervention Strategies for Tackling Antimicrobial Resistance in Primary Health Care: Evidence from Africa","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-13 12:22:32","doi":"10.21203/rs.3.rs-8702660/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b554d903-cd67-46f2-bed1-43a43398df43","owner":[],"postedDate":"February 13th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-10T03:40:06+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-13 12:22:32","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8702660","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8702660","identity":"rs-8702660","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}