Antibiotic dispensing practices and determinants among informal healthcare providers in low- and middle-income countries: a mixed-methods scoping review

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Although IPs frequently dispense antibiotics, their practices remain poorly researched and excluded from surveillance systems. Guided by the Joanna Briggs Institute methodology, this scoping review examined antibiotic dispensing and its determinants among IPs in LMICs. Nine databases were searched, identifying 10,109 records, of which 31 met the inclusion criteria. Twenty-seven studies reported wide variation in antibiotic dispensing, ranging from 18–74% in standardised studies, 5–100% in provider-reported studies, and 11–86% in consumer-reported studies. Six qualitative studies identified key behavioural and contextual determinants, including limited knowledge of appropriate antibiotic use, learning through experience, patient expectations, peer influence, perceived consequences of not prescribing, and incentives. Antibiotic dispensing by IPs is widespread and represents a critical blind spot in antimicrobial resistance interventions. Health sciences/Diseases Health sciences/Health care Health sciences/Medical research Figures Figure 1 Figure 2 Figure 3 Introduction Antibiotic consumption is surging globally, with low- and middle-income countries (LMICs) experiencing the steepest increases, raising alarms about the growing threat of antimicrobial resistance (AMR) in regions least equipped to manage it 1,2 . Recent analyses show a 16.3% global increase in antibiotic use between 2016 and 2023, driven mainly by LMICs (+ 18.6%), while high-income countries reported a modest decline of 4.9% 3 . The overuse and misuse of antibiotics remain major challenges, particularly within primary care, where more than half of outpatient consultations in LMICs result in an antibiotic prescription, often without a clinical justification 4 . In most LMICs, a substantial proportion of primary healthcare is provided by informal healthcare providers (IPs), who offer significant frontline care (between 9% and 90%) depending on the local context, particularly in underserved and rural communities 5 – 9 . The term “ informal healthcare providers” encompasses a diverse group of practitioners, including drug sellers, village doctors (a locally used term for informally trained rural practitioners), medicine vendors, traditional healers, and birth attendants, who operate outside formal health system structures. IPs typically lack formal medical qualifications, professional registration, and operate outside regulatory or institutional frameworks 5 , 9 , 10 . Antibiotic abuse by primary care providers, especially IPs, is a recognized blind spot in the global AMR response 11 . The World Health Organization (WHO) Global Antimicrobial Resistance and Use Surveillance System (GLASS) report does not include AMR data from the informal healthcare sector 12 , and information on antibiotic dispensing by IPs is also not systematically captured at the national level across LMICs. However, several regional and country-level studies have documented antibiotic dispensing practices among IPs. A critical aspect of their practice is the frequent sale and provision of antibiotics, as consistently demonstrated in studies from countries such as Bangladesh, India, Vietnam, Ghana, Zambia, and the Democratic Republic of Congo, where a substantial proportion of antibiotic dispensing occurs through informal channels, including IPs 13 – 19 . To address this evidence gap and better understand the extent of antibiotic dispensing among IPs, as well as to consolidate evidence on factors influencing these practices, we conducted a scoping review guided by a published protocol in BMJ Open 20 . The review aimed to 1) examine the reported extent of antibiotic dispensing among IPs, disaggregated by the methods used to assess antibiotic use; 2) describe dispensing patterns, including the types of antibiotics and the clinical conditions involved; and 3) identify the main factors influencing antibiotic dispensing practices among these providers. Methods This scoping review followed the Joanna Briggs Institute (JBI) methodology for scoping reviews 21 and is reported in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist 22 , Supplementary File 1. The review protocol was published in BMJ Open in 2024 20 . Eligibility criteria The inclusion criteria for this review was developed according to the Population-Concept-Context (PCC) framework, in accordance with the JBI guideline 21 . Population Population eligibility criteria were defined a priori and are detailed in the published review protocol 20 , which also provides further specifications on inclusion and exclusion parameters, including the distinction between IPs and other community-based cadres. For this review, IPs were defined as individuals who met one or more of the following criteria: (i) were not registered with or affiliated to government or recognised private institutions, (ii) had independently established community-based practices, and (iii) lacked formal medical qualifications to prescribe or dispense modern (biomedical) medicines, including antibiotics. Practitioners formally recognised under traditional or alternative systems of medicine, such as Ayurveda, Yoga and Naturopathy, Unani, Siddha, and Homeopathy (AYUSH) systems in India, were excluded. During full-text screening, minor clarifications to the protocol were required. Some studies classified pharmacists and nurses as informal providers; although their antibiotic dispensing may be restricted under national regulations, these cadres were excluded in line with this review’s stricter definition, which applied only to unregistered providers without formal medical qualifications. Concept Two core concepts guided this review. The first was antibiotic dispensing practices, encompassing the extent of dispensing, types of antibiotics used, and the conditions for which they were provided. The second was the identification of factors influencing antibiotic dispensing among IPs. Although the protocol initially included an assessment of routes of administration 20 , this was not undertaken due to data limitations. For clarity, prescription refers to the formal act of ordering antibiotics by a qualified healthcare professional, whereas dispensing refers to the direct supply or sale of antibiotics to patients by IPs during consultations. Therefore, the term “ dispensing ” is used throughout this review to describe these practices. Context and design The review focused on studies conducted in low, lower-middle, and upper-middle-income countries, as defined by the World Bank classification system. No restrictions were applied to study design, publication year, or language to ensure comprehensive inclusion of empirical evidence. As described in the published protocol 20 , non-empirical publications, such as reviews, editorials, commentaries, protocols, conference abstracts, and multiple outputs from the same study, were excluded. One non-English article was translated using machine translation. Search strategy A comprehensive search was conducted on June 11, 2024, by an experienced research librarian (GG) across nine electronic databases: MEDLINE (Ovid), EMBASE (Ovid), SCOPUS, Global Health (Ovid), CINAHL, Web of Science, LILACS (GIM), African Journals Online via Africa-Wide Information (EBSCOhost), and Index Medicus for the South-East Asia Region (IMSEAR) (GIM). The search combined two core concepts: “antibiotics” and “informal healthcare providers”. The complete search strategies are available in Supplementary File 2. In addition, the reference lists of all studies selected for full-text review were manually searched for additional relevant literature; however, no new studies were identified. Study review and selection All records were imported into Covidence systematic review software (Veritas Health Innovation, Melbourne, Australia), and duplicates were removed automatically. Screening was conducted in two stages. In the first stage, five reviewers (DT, ST, AB, SB, MA) independently screened titles and abstracts against predefined inclusion criteria following a pilot of ten records. Each record was assessed by two reviewers, and any study deemed potentially relevant by at least one was advanced to full-text screening. In the second stage, the same five reviewers independently screened full-text articles, again with two reviewers per study. Reasons for exclusion were systematically documented in Covidence. Discrepancies were resolved through discussion, with arbitration by the first author (PT) when consensus was not reached. Assessment of methodological quality The protocol included an assessment of methodological quality 20 ; however, this was not undertaken. The included studies demonstrated substantial heterogeneity in outcome definitions, measurement approaches, and data sources, which made formal quality appraisal impractical. This approach aligns with the JBI guidance 21 , which does not require critical appraisal for scoping reviews and recommends its inclusion only when it contributes to contextual interpretation rather than exclusion or weighting of evidence. Data extraction Data extraction was performed using a standardized form developed in Covidence. For the first two review objectives, information was collected on study title, publication year, objectives, design, setting, sampling strategy, data sources, terminology, definitions used for IPs, methods of assessing antibiotic dispensing, and details of dispensing practices, including prevalence estimates, types of antibiotics, clinical indications, and patient characteristics where available. Two reviewers independently extracted data, and all entries were verified by the first author (PT) for accuracy and completeness. For the third objective, textual information on factors associated with antibiotic dispensing was extracted separately into a Microsoft Word file. In studies involving multiple interest holder groups such as IPs, patients, or policy decision-makers, only data specific to IPs were retained for analysis. Data synthesis Data synthesis followed the approach outlined in the published protocol 20 . Findings were summarised using descriptive tables, visuals, and narrative synthesis, in accordance with scoping review guidance 23 , 24 . Basic study characteristics, including title, year of publication, objective, design, sample size, and terminology used for IPs, were tabulated by country. Antibiotic dispensing practices were described narratively without quantitative aggregation owing to the diversity of assessment methods across studies. Findings were organised into three categories: (i) studies using standardised methods such as standardised patients, prescription reviews, or direct observation of provider and patient interactions; (ii) provider-reported studies based on surveys or interviews with IPs; and (iii) client or consumer-reported studies using household or patient surveys. This categorisation of studies also provided an indication of relative methodological robustness, with studies employing standardised methods generally considered to yield higher-quality evidence than those based on provider- or consumer-reported data. Dispensing estimates were summarised in descriptive tables and illustrated in a forest plot-style visual to depict the range of reported estimates. Conditions treated and antibiotics dispensed were described narratively, and individual agents, if reported, were classified according to the WHO AWaRe framework 25 . To ensure readability, percentages reported in the narrative text were rounded to the nearest whole number. Original values, including decimals as reported in the source studies, are retained in the manuscript tables. Factors influencing antibiotic dispensing were analysed through deductive content analysis guided by the Theoretical Domains Framework (TDF) 26 . The unit of analysis in this qualitative synthesis was a discrete statement describing a determinant of IP dispensing behaviour. Textual data were first coded manually in Word documents and later transferred to Microsoft Excel to facilitate organisation, comparison, and synthesis. A domain-specific codebook was developed a priori using TDF definitions, with child codes consolidated under parent domains such as knowledge, social influence, reinforcement, and beliefs about consequences. The distribution of excerpts across domains was summarised as counts and presented in a figure, with one representative quotation for each domain included in a table. Although the Rodrigues et al. framework 27 was initially planned, the TDF was adopted for its greater conceptual granularity and capacity to capture interacting behavioural and contextual determinants. Results The study selection process is summarised in the PRISMA flow diagram (Figure 1). The database searches identified 10,109 records. After removal of duplicates, 5,672 records remained for title and abstract screening. Of these, 194 were retained for full-text review. Following full-text assessment, 31 studies met the inclusion criteria and were included in the review. The major reasons for exclusion were an ineligible study population (n = 80), an ineligible outcome (n = 34), and an ineligible study design (n = 20). Out of the 31 studies included in this review, 27 addressed the first research aim of examining antibiotic dispensing practices among IPs. For the second aim, which explored dispensing patterns in greater detail, 27 studies (22 quantitative and 5 qualitative) contributed data on illnesses or conditions treated by IPs, and 16 studies (12 quantitative and 4 qualitative) provided details on the types or classifications of antibiotics dispensed. Finally, 6 studies addressed the third aim of examining factors influencing antibiotic dispensing practices among IPs. Research aims 1 & 2: Antibiotic dispensing practices and patterns among IPs in LMICs Characteristics of included studies The 27 studies included in this review for our first and second research aims were published between 1999 and 2023 and together represented data from eight countries: India (n = 9/27, 33.3%), Bangladesh (n = 8/27, 29.6%), Nigeria (n = 4/27, 14.8%), Ghana (n = 2/27, 7.4%), and one study each from Cambodia, Chad, Pakistan, and the Central African Republic (3.7% each). The included studies used varied designs, comprising cross-sectional quantitative surveys (n = 17/27, 63.0%), qualitative studies (n = 5/27, 18.5%), and mixed methods approaches (n = 2/27, 7.4%), while one study each (3.7%) used secondary data analysis, a prospective cohort design, or a quasi-experimental approach. Among quantitative studies, provider-based studies enrolled between 21 and 1,751 providers, prescription or patient record review-based studies included between 117 and 15,322 records, and consumer-reported studies surveyed between 13 households and 2,784 individuals. Most studies employed a convenience (10/27, 37.0%) or purposive (9/27, 33.3%) sampling strategy. Terminology used to describe IPs varied widely, including “village doctors,” “drug sellers,” “rural medical practitioners,” “quacks,” and “patent medicine vendors.” In several cases, definitions were context-specific and varied within countries. A detailed summary of study characteristics is presented in Table 1, and study-specific definitions of IPs are provided in Table 1 of the Supplementary File 3. Extent of antibiotic dispensing practices by IPs In the quantitative analysis (n = 22 studies) (Figure 2 and Table 2), we observed variability in antibiotic dispensing practices across the three assessment methods described earlier in the methods section. This categorisation provides a broad indication of study quality, as studies using standardised methods, such as the standardised patient method, prescription reviews, are generally more robust than those based on provider- or consumer-reported data. Among the six studies that used standardized methods, including one standardized patient study, four prescription reviews, and one direct observation of patient–provider interactions, antibiotic dispensing ranged from 18% (10/57 simulated visits) to 74% (11,336/15,322 prescriptions). The single direct-observation study reported an average of 1.19 and 0.94 antibiotics per consultation across two study sites, although limited data precluded recalculating the percentages 29 . Denominators varied across studies: three used the total number of patients, two the total number of medicines per prescription, and one the average number of antibiotics per consultation. Twelve studies relied on providers’ self-reports of their dispensing practices, with estimates ranging from 5% (12/247 enrolled providers) to 100% (an estimated 14,590 patients with diarrhea or dysentery receiving antibiotics). Denominators differed substantially across studies, including the number of providers enrolled (n = 8), the number of patients treated by the providers (n = 3), and the number of medicines dispensed by the providers (n = 1). Four studies drew on consumer or client reporting to estimate antibiotic dispensing by IPs. These studies reported dispensing rates ranging from 11% (52/472 individuals seeking care) to 86% (694/807 of total antibiotic courses prescribed across both formal and informal providers). Denominators included the number of patients who sought care from informal providers (n = 3) and the total number of antibiotic courses prescribed by all providers in the study (n = 1). The findings from five qualitative studies (n=5 studies) were consistent with those from the quantitative analysis, confirming the widespread dispensing of antibiotics by IPs. For instance, Sizear et al. (2019) reported that 62% (8/13) of IPs admitted dispensing antibiotics for diarrhea from the first day of illness, and many also initiated antibiotic treatment for pneumonia immediately after symptom onset 37 . Similarly, Ntim-Amponsah et al. (2005) documented that all 21 chemical shop attendants included in their study dispensed antibiotic eye drops as the first-line treatment for any eye condition encountered 45 . Detailed findings from all five qualitative studies are presented in Table 2. Illnesses/conditions treated This sub-analysis included 27 studies, comprising 22 quantitative and 5 qualitative studies (Table 2). IPs dispensed antibiotics for a range of health problems, most commonly acute respiratory infections (n = 11), gastrointestinal infections (n = 11), and febrile illnesses (n = 9). General illnesses (n = 5) and presumptive tuberculosis (n = 3) were also frequently reported, while skin infections, eye conditions, sexually transmitted infections, and lymphatic filariasis were mentioned in a smaller number of studies. Types of antibiotics dispensed IPs dispensed a wide range of antibiotics (Table 2). Out of the total studies (n = 27), 16 studies (12 quantitative and 4 qualitative) (included in this sub-analysis) provided details on the type or classification of antibiotics dispensed by IPs. All antibiotics mentioned in these 16 studies were listed, yielding 110 reported instances. The most frequently reported antibiotics were amoxicillin (n = 11), azithromycin (n = 8), ciprofloxacin (n = 8), ampicillin (n = 7), and cefixime (n = 5). The majority belonged to the Access (n = 52) and Watch (n = 42) categories of the WHO AWaRe classification, while one antibiotic was classified as Reserve. Some studies also reported combination antibiotics (n = 5) and class-level mentions (n = 5), including a few used for tuberculosis treatment (n = 5) that are not included in the WHO AWaRe classification system. Research aim 3 : Factors associated with antibiotic dispensing by IPs A total of six 17,19,37,51-53 qualitative studies contributed evidence on the factors influencing antibiotic dispensing by IPs. These studies were conducted in India (n = 3), Bangladesh (n = 2), and Cambodia (n = 1), and together involved 110 IPs. Sampling approaches included purposive sampling (n = 5) and snowball sampling (n = 1). Data were collected primarily through in-depth interviews (n = 4), with two studies using focus group discussions. Most applied thematic analysis (n = 5), while one study employed framework analysis. Additional details on definitions of IPs are provided in Table 2 of the Supplementary File 3. Analysis of these studies using the TDF highlighted several domains shaping antibiotic dispensing practices among IPs (Table 3, Figure 3). Across all studies (n=6), seventy-nine coded excerpts were analyzed. Knowledge (This domain relates to IPs’ understanding and awareness of antibiotics and their appropriate use) : This domain was consistently identified (22 excerpts) across the six studies [1, 3–7] . Across India, Bangladesh, and Cambodia, IPs commonly believed that antibiotics were essential or compulsory for treatment 17,51 , effective for any condition 53 , and acted as “sure-shot drugs” 37 or as medicines to “boost up the body” 52 . Some classified antibiotics as mild (“halka phulka” in Hindi) 51 or judged their strength based on price 17 . Pharmaceutical representatives were reported as the primary source of information on antibiotics 37,51 . IPs also referred to books and guidelines, though English-language materials limited their understanding. 37 . Others relied on trial-based experience 19,52 or informal learning through apprenticeships with qualified doctors and short training sessions 19,52 . Social influences (This domain captures the social and interpersonal pressures shaping IPs’ dispensing behaviour) : This domain 19,37,51-53 was the second most frequently reported driver of antibiotic dispensing (15 excerpts). Across studies from India, Bangladesh, and Cambodia, patient expectations strongly influenced IPs’ behavior, as many patients insisted on shorter courses 51 , requested antibiotics based on their ability to pay 51 , or viewed antibiotics as the default treatment option 51-53 . IPs also perceived pressure to meet expectations for quick symptomatic relief or cure 37,51,52 . Interactions with pharmaceutical representatives (drug detailers) were another key influence, as representatives often introduced or promoted new antibiotics and encouraged their sale 19,51 . Additionally, informal mentorship from qualified doctors who advised IPs on antibiotic use further shaped dispensing practices 19 . Beliefs about consequences (This domain concerns IPs’ perceptions of the outcomes of dispensing or withholding antibiotics) : This domain was reported across all studies (14 excerpts) 17,19,37,51-53 . Limited understanding of antibiotic indications shaped dispensing practices, as IPs perceived antibiotics as necessary to ensure recovery. Rather than relying on clinical indications, their decisions were guided by perceived consequences, viewing antibiotics as essential or powerful medicines 19,37,51-53 and as necessary to prevent treatment failure 51 . Antibiotics were also regarded as an essential part of first aid or early treatment 51,52 . Fear of adverse outcomes further influenced dispensing behavior, as IPs believed that not giving antibiotics could result in patients not recovering, seeking care elsewhere, or harming their business reputation 19,51 . Reinforcement (This domain reflects the rewards or pressures that sustain antibiotic dispensing behaviour) : This domain had nine excerpts across three studies 19,51,52 . Antibiotics were perceived as part of routine care and a therapeutic necessity 19,51 . Their sale also contributed significantly to IPs’ income 19 , and financial incentives from pharmaceutical representatives further reinforced dispensing practices 19 . Fear of patients seeking care from competing providers acted as a negative reinforcer of continued antibiotic dispensing 19,51,52 . Additionally, patients’ limited knowledge about antibiotics created demand for rapid relief, and when such expectations were not met, IPs feared patient dissatisfaction and loss of clientele 52 . Social and professional role, and identity (This domain represents how IPs view their role, reputation, and legitimacy as care providers) : This domain was represented by seven excerpts across three studies 19,51,53 . IPs’ conceptualization of their professional role and image as effective practitioners, measured through patient retention and perceived ability to cure, influenced their antibiotic dispensing practices. They believed antibiotics were necessary to control disease 51 and formed part of the basic treatment 19 . IPs described their role within a collaborative formal–informal care network, emphasizing their legitimacy as key actors in the broader healthcare ecosystem 51 . In a study in Cambodia, an IP stated that dispensing antibiotics fell within their comfort zone and self-defined scope of practice, whereas others perceived dispensing as an entitlement based on informal training and accumulated experience 53 . Environmental context and resources (This domain relates to external and system-level factors influencing dispensing practices) : This domain had seven excerpts 17,19,37,51,52 . IPs described their role in patient care as an opportunity to fill service gaps, enabled by systemic deficiencies in healthcare access and delivery 51,52 . A study in Bangladesh found that the lack of clinical guidelines in local languages contributed to knowledge gaps in antibiotic use 37 . IPs also reported that incomplete antibiotic courses and the selection of specific drugs were often determined by patients’ financial constraints, shaping dispensing decisions based on affordability and access 17,19,51 . Beliefs about capabilities (This domain reflects IPs’ confidence in their ability to dispense antibiotics appropriately) : Three excerpts 51-53 reflected IPs’ confidence in dispensing antibiotics, which was primarily rooted in experiential learning and peer validation 51,52 . In a study from Cambodia, one provider described antibiotic use as comfortably within their scope of practice, reflecting a broader perception among IPs that practical experience alone was sufficient to guide antibiotic use 52,53 . Discussion This scoping review consolidates evidence from 31 studies across 8 LMICs. Twenty-seven studies reported on dispensing practices of IPs, showing consistently high levels of antibiotic dispensing ranging from 5 to 100% depending on setting and assessment method. We found six qualitative studies that examined factors influencing dispensing, identifying influences mapped mainly to the TDF domains of knowledge, social influences, beliefs about consequences, and reinforcement, reflecting limited knowledge, patient expectations, financial dependence, experience-based learning, and peer influence. Collectively, these findings provide a comprehensive overview of the extent, nature, and underlying drivers of antibiotic dispensing by IPs across LMICs. In this review, 27 studies reported on antibiotic dispensing practices, with proportions ranging from approximately 18 to 74% in studies using standardised methods, 5 to 100% in provider-reported studies, and 11 to 86% in consumer-reported studies. These consistently high estimates in this review indicate an existing gap in current global and national surveillance systems in quantifying antibiotic dispensing by IPs and, consequently, estimating their contribution to the overall burden of AMR 12 . When these estimates are viewed alongside the findings from a systematic review by Sudhinaraset et al., which showed that IPs deliver a substantial share of primary healthcare, between 9 and 90%, in LMICs 5 , they collectively highlight the scale and public health significance of antibiotic dispensing by this large provider group. Antibiotics dispensed by IPs likely represent one of the largest unmeasured components of global antibiotic use. Integrating these providers into antibiotic use surveillance programs through national surveys, community-based monitoring, or prescription audits within their clinics will be essential to produce more accurate estimates and to inform stewardship strategies. The qualitative analysis in this review, guided by the TDF, revealed that multiple interrelated factors influence antibiotic dispensing by IPs. Several of these qualitative insights were corroborated by dispensing-related data from studies included in the review (in research aim 1). Limited knowledge and misconceptions about antibiotic use emerged as dominant themes, with IPs often perceiving antibiotics as essential for treatment and effective for almost any illness. These perceptions were reflected in quantitative findings: 76.8% (284/370) of providers in Nigeria sold antibiotics for fever 42 , and 61.5% (8/13) of interviewed providers in Bangladesh dispensed antibiotics for diarrhoea at the first visit 37 . Other domains, such as social pressures, perceived consequences, and capability, further reinforced these behaviours, contributing to shorter, unnecessary, or excessive treatment regimens and the use of antibiotics as a default treatment option. For example, in Bangladesh, 84.3% (498/591) of antibiotics were dispensed in inadequate doses 35 , and in another study, 14.2% (35/247) of providers dispensed antibiotics even when not indicated 39 . In Ghana, all 21 (100%) chemical shop attendants sold antibiotic eye drops as first-line treatment for any eye complaint 45 , while in India, dispensing rates were higher among children under 5 years (85%) than among adults (71%) 16 . Collectively, these integrated findings illustrate how diverse and interacting factors sustain inappropriate antibiotic use among IPs, echoing patterns previously documented among formal and primary care providers 54 , 55 . These qualitative findings also suggest that while training to improve knowledge is important for antibiotic stewardship among IPs, education alone is insufficient to modify entrenched dispensing behaviours. This was evident in our recent study in Patna city, India, where a one-time training based on the WHO AWaRe Antibiotic Handbook led to moderate improvements in knowledge for only selected clinical conditions 56 . Evidence from other settings indicates that multifaceted interventions combining behavioural, social, and structural components achieve greater effectiveness than single strategies. Such approaches include training combined with an audit and feedback and support system, peer engagement, digital reminders, and community education with extended follow-up 55,57,58 . Some studies were excluded from this review due to methodological and reporting limitations that prevented the extraction of reliable data specific to IPs. In some cases, aggregated data were reported, combining formal and informal providers, for example, physicians with IPs or licensed pharmacists with unqualified drug sellers 59 , 60 . Another major challenge was the absence of a clear definition of IPs in several excluded studies. Some grouped heterogeneous provider categories, such as shops, churches, traditional practitioners, drug sellers, friends, relatives, and supermarkets, while others combined multiple cadres, including NGO workers, trained and untrained traditional birth attendants, unqualified doctors, and homeopathic practitioners, into a single composite category labelled as informal healthcare source/settings 61 , 62 . These inconsistencies highlight the need for a consensus and standardized guidelines to harmonize the definition and reporting of IPs, including the separate reporting of antibiotic dispensing across distinct provider groups, to improve the accuracy and comparability of findings. Among the included studies, a major challenge was the variability in methodologies used to assess antibiotic dispensing, including standardised patient studies, prescription reviews, direct observation, and provider or consumer-reported assessments. Most studies (16 of 22 reporting dispensing) relied on provider or consumer reports, which are prone to recall, reporting, and social desirability biases. The denominators used to report outcomes also varied substantially. Across 22 studies, 6 different denominators were applied, including total patients, total medicines, total antibiotics, total providers, and total care-seeking episodes from IPs. This methodological heterogeneity, together with inconsistent denominators for outcomes, limits the comparability and synthesis of dispensing estimates. Consequently, the estimates presented in this review should be viewed as descriptive, offering a broad overview of dispensing practices among IPs rather than pooled measures. The forest-style figure was therefore used to depict the spread of reported estimates across studies, not to support statistical aggregation or meta-analysis. There was also limited reporting of details on antibiotics dispensed. Only 16 studies (out of 27; 12 quantitative and 4 qualitative) provided such information. Also, in studies that included multiple clinical conditions, antibiotics were seldom classified by condition, making it challenging to identify condition-specific dispensing patterns. Addressing this, along with the methodological and reporting gaps discussed above, will be essential to strengthen the evidence base on antibiotic dispensing by IPs and to inform context-appropriate interventions to improve antibiotic stewardship within this important provider group. Strengths and limitations This review provides the first comprehensive synthesis of antibiotic dispensing practices by IPs across LMICs, following the JBI methodological framework. Using a mixed-methods approach that combined quantitative mapping with qualitative synthesis, the review offers an integrated understanding of IPs’ dispensing practices and the behavioural and contextual factors that influence them in LMIC settings. There are several limitations to this review. We searched nine major databases; however, grey literature was not included due to time and resource constraints, and reports from national governments or international and non-governmental organisations working with IPs may have been missed. As there is no universally accepted definition of IPs and multiple terms are used across different contexts, some studies may not have been captured despite the use of broad search terms. Substantial heterogeneity was observed in study methodologies, denominators, and outcome reporting, which limited comparability across studies. In addition, many studies relied on provider- or consumer-reported assessments, which are prone to recall and social desirability biases, potentially leading to over- or under-reporting of antibiotic dispensing practices. Some studies that reported aggregated data combining formal and informal providers were excluded to avoid biased estimates; however, this may have resulted in an underestimation of the overall contribution of IPs to antibiotic dispensing. Conclusion This scoping review found that antibiotic dispensing by IPs is widespread across LMICs. Dispensing was consistently reported to be high across studies, reflecting substantial antibiotic use within this provider group. The behavioural analysis identified key domains influencing these practices, primarily knowledge, social influences, beliefs about consequences, and reinforcement, illustrating how experience-based learning, patient expectations, perceived need for antibiotics, and incentives collectively shape dispensing behaviour. Overall, this review provides a comprehensive synthesis of evidence on antibiotic dispensing practices and the factors influencing these practices among IPs in LMICs. These findings offer an evidence base to inform future research and guide the development of context-appropriate stewardship interventions for IPs. Declarations Competing Interests MP serves as an advisor to non-profits, namely the World Health Organisation, Partners in Health, and the Gates Foundation. MP serves on the editorial board of PLOS Medicine and was previously an Editor-in-Chief of PLOS Global Public Health. GS holds a Tier 2 Canada Research Chair in Communicable Diseases Epidemiology. All other authors have no financial or non-financial competing interests. Funding Statement: This project was funded by the McGill Interdisciplinary Initiative in Infection and Immunity (MI4) (Grant number: #SFG5-01). The funders had no role in study design, data collection, analysis, and interpretation of data, or the writing of the manuscript. Author Contribution PT, MT, BB, SG, MP and GS conceptualised the review. PT, MT, BB, SG, DT, ST, AB, SB, GG, COO, MA, PS, CJ, SS, MD, SAR, MP and GS contributed to developing the study design and review protocol. PT, SG, GG, MP and GS developed and conducted the search strategy. PT, MT, BB, DT, ST, AB, SB and MA screened the studies. PT, MT, BB, SG, DT, ST, AB, SB, MA, MP and GS extracted the data. PT, MT, BB, SG, DT, ST, AB, SB, GG, COO, MA, PS, CJ, SS, MD, SAR, MP and GS analysed and synthesised the evidence. PT prepared the original draft with input from SG, MP and GS. All authors contributed to the manuscript through critical review and editing, and all authors read and approved the final version. Acknowledgement PT (first author) acknowledges the support of the Fonds de recherche du Québec – Santé (FRQS) Postdoctoral Fellowship. Data Availability All data generated or analysed during this study are included in this published article and its supplementary information files. References Klein, E. Y. et al. Global increase and geographic convergence in antibiotic consumption between 2000 and 2015. Proceedings of the National Academy of Sciences 115 , E3463-E3470 (2018). https://doi.org:10.1073/pnas.1717295115 Murray, C. J. L. et al. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. The Lancet 399 , 629-655 (2022). https://doi.org:10.1016/S0140-6736(21)02724-0 Klein, E. Y. et al. Global trends in antibiotic consumption during 2016–2023 and future projections through 2030. Proceedings of the National Academy of Sciences 121 , e2411919121 (2024). https://doi.org:doi:10.1073/pnas.2411919121 Sulis, G. et al. Antibiotic prescription practices in primary care in low- and middle-income countries: A systematic review and meta-analysis. PLoS Med 17 , e1003139 (2020). https://doi.org:10.1371/journal.pmed.1003139 Sudhinaraset, M., Ingram, M., Lofthouse, H. K. & Montagu, D. What Is the Role of Informal Healthcare Providers in Developing Countries? A Systematic Review. PLOS ONE 8 , e54978 (2013). https://doi.org:10.1371/journal.pone.0054978 Sheikh, K., Josyula, L. K., Zhang, X., Bigdeli, M. & Ahmed, S. M. Governing the mixed health workforce: learning from Asian experiences. BMJ Glob Health 2 , e000267 (2017). Thapa, P. et al. Unlocking the potential of informal healthcare providers in tuberculosis care: insights from India. BMJ Glob Health 9 (2024). https://doi.org:10.1136/bmjgh-2024-015212 Oga-Omenka, C., Okafor, U. & Sulis, G. Engaging pharmacists and medicine vendors in antimicrobial stewardship in LMICs. Lancet Infect Dis 23 , 786-787 (2023). https://doi.org:10.1016/s1473-3099(23)00342-0 Thapa, P. et al. Role of informal healthcare providers in tuberculosis care in low- and middle-income countries: A systematic scoping review. PLoS One 16 , e0256795 (2021). https://doi.org:10.1371/journal.pone.0256795 Shah, N. M., Brieger, W. R. & Peters, D. H. Can interventions improve health services from informal private providers in low and middle-income countries?: a comprehensive review of the literature. Health Policy Plan 26 , 275-287 (2011). https://doi.org:10.1093/heapol/czq074 Pai, M., Gandra, S., Thapa, P. & Carmona, S. Tackling antimicrobial resistance: recognising the proposed five blind spots can accelerate progress. Lancet Microbe 6 , 100968 (2025). https://doi.org:10.1016/j.lanmic.2024.100968 World Health Organization. Global antibiotic resistance surveillance report 2025 , (2025). Ingelbeen, B. et al. Antibiotic use from formal and informal healthcare providers in the Democratic Republic of Congo: a population-based study in two health zones. Clinical Microbiology and Infection 28 , 1272-1277 (2022). https://doi.org:10.1016/j.cmi.2022.04.002 Wildbret, S. et al. Drivers of informal sector and non-prescription medication use in pediatric populations in a low- and middle-income setting: A prospective cohort study in Zambia. PLOS Glob Public Health 3 , e0002072 (2023). https://doi.org:10.1371/journal.pgph.0002072 Thapa, P. et al. What are the tuberculosis care practices of informal healthcare providers? A cross-sectional study from Eastern India. Health Policy Plan 37 , 1158-1166 (2022). https://doi.org:10.1093/heapol/czac062 Khare, S. et al. Antibiotic Prescribing by Informal Healthcare Providers for Common Illnesses: A Repeated Cross-Sectional Study in Rural India. Antibiotics (Basel) 8 (2019). https://doi.org:10.3390/antibiotics8030139 Nahar, P. et al. What contributes to inappropriate antibiotic dispensing among qualified and unqualified healthcare providers in Bangladesh? A qualitative study. BMC Health Services Research 20 , 656 (2020). https://doi.org:10.1186/s12913-020-05512-y Nair, M. et al. Knowledge, attitudes, and practices related to antibiotic use in Paschim Bardhaman District: A survey of healthcare providers in West Bengal, India. PLoS One 14 , e0217818 (2019). https://doi.org:10.1371/journal.pone.0217818 Gautham, M., Spicer, N., Chatterjee, S. & Goodman, C. What are the challenges for antibiotic stewardship at the community level? An analysis of the drivers of antibiotic provision by informal healthcare providers in rural India. Soc Sci Med 275 , 113813 (2021). https://doi.org:10.1016/j.socscimed.2021.113813 Tandan, M. et al. Antibiotic dispensing practices among informal healthcare providers in low-income and middle-income countries: a scoping review protocol. BMJ Open 14 , e086164 (2024). https://doi.org:10.1136/bmjopen-2024-086164 Micah DJ Peters, C. G., Patricia McInerney, Zachary Munn, Andrea C. Tricco, Hanan Khalil. JBI Manual for Evidence Synthesis , (2020). Tricco, A. C. et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern Med 169 , 467-473 (2018). https://doi.org:10.7326/m18-0850 Pollock, D. et al. Recommendations for the extraction, analysis, and presentation of results in scoping reviews. JBI Evidence Synthesis 21 (2023). https://doi.org:10.11124/JBIES-22-00123 South, E. & Rodgers, M. Data visualisation in scoping reviews and evidence maps on health topics: a cross-sectional analysis. Systematic Reviews 12 , 142 (2023). https://doi.org:10.1186/s13643-023-02309-y Sharland, M. et al. Encouraging AWaRe-ness and discouraging inappropriate antibiotic use-the new 2019 Essential Medicines List becomes a global antibiotic stewardship tool. Lancet Infect Dis 19 , 1278-1280 (2019). https://doi.org:10.1016/S1473-3099(19)30532-8 Thompson, W. et al. Factors associated with antibiotic prescribing for adults with acute conditions: an umbrella review across primary care and a systematic review focusing on primary dental care. J Antimicrob Chemother 74 , 2139-2152 (2019). https://doi.org:10.1093/jac/dkz152 Teixeira Rodrigues, A., Roque, F., Falcão, A., Figueiras, A. & Herdeiro, M. T. Understanding physician antibiotic prescribing behaviour: a systematic review of qualitative studies. International Journal of Antimicrobial Agents 41 , 203-212 (2013). https://doi.org:10.1016/j.ijantimicag.2012.09.003 Patnaik, S. K., Mukhopadhyay, A. K., & Dhariwal, A. C. Treatment practices for lymphatic filariasis amongst doctors of East Godavari District, Andhra Pradesh. Journal of Communicable Diseases 39 , 65-67 (2007). https://doi.org:PMID: 18338719 Gautham, M. et al. Informal rural healthcare providers in North and South India. Health Policy Plan 29 Suppl 1 , i20-29 (2014). https://doi.org:10.1093/heapol/czt050 Samal, M., Khara, N., Pati, S. & Sahoo, K. C. Treatment by untrained providers among sick infants in rural Odisha, India. Prim Health Care Res Dev 20 , e84 (2019). https://doi.org:10.1017/S1463423619000380 Khare, S. et al. Determinants and pathways of healthcare-seeking behaviours in under-5 children for common childhood illnesses and antibiotic prescribing: a cohort study in rural India. BMJ Open 11 , e052435 (2021). https://doi.org:10.1136/bmjopen-2021-052435 Gautham, M., Miller, R., Rego, S. & Goodman, C. Availability, Prices and Affordability of Antibiotics Stocked by Informal Providers in Rural India: A Cross-Sectional Survey. Antibiotics (Basel) 11 (2022). https://doi.org:10.3390/antibiotics11040523 Mamun KZ, T. S., Shears P, Hart CA. A survey of antimicrobial prescribing and dispensing practices in rural Bangladesh. Mymensingh Med J. 15 , 81-84 (2007). https://doi.org:10.3329/mmj.v15i1.9 Islam, Q. S. et al. Informal allopathic provider knowledge and practice regarding control and prevention of TB in rural Bangladesh. Int Health 6 , 225-231 (2014). https://doi.org:10.1093/inthealth/ihu025 Saha, S. & Hossain, M. T. Evaluation of medicines dispensing pattern of private pharmacies in Rajshahi, Bangladesh. BMC Health Serv Res 17 , 136 (2017). https://doi.org:10.1186/s12913-017-2072-z Lucas, P. J. et al. Pathways to antibiotics in Bangladesh: A qualitative study investigating how and when households access medicine including antibiotics for humans or animals when they are ill. PLoS One 14 , e0225270 (2019). https://doi.org:10.1371/journal.pone.0225270 Sizear, M. M. I. et al. Perceptions of appropriate treatment among the informal allopathic providers: insights from a qualitative study in two peri-urban areas in Bangladesh. BMC Health Serv Res 19 , 424 (2019). https://doi.org:10.1186/s12913-019-4254-3 Samir, N. et al. Antibiotic Use for Febrile Illness among Under-5 Children in Bangladesh: A Nationally Representative Sample Survey. Antibiotics (Basel) 10 (2021). https://doi.org:10.3390/antibiotics10101153 Bepari, A. K. et al. Factors Driving Antimicrobial Resistance in Rural Bangladesh: A Cross-Sectional Study on Antibiotic Use-Related Knowledge, Attitude, and Practice Among Unqualified Village Medical Practitioners and Pharmacy Shopkeepers. Adv Ther 40 , 3478-3494 (2023). https://doi.org:10.1007/s12325-023-02547-5 Sujon, H. et al. Beyond the regulatory radar: knowledge and practices of rural medical practitioners in Bangladesh. BMC Health Serv Res 23 , 1322 (2023). https://doi.org:10.1186/s12913-023-10317-w Okonofua FE, O. J., Omorodion FI, Temin MT, Coplan PA, Kaufman JA, Heggenhougen HK. Assessment of health services for treatment of sexually transmitted infections among Nigerian adolescents. Sex Transm Dis. 26 , 184-190 (1999). https://doi.org:10.1097/00007435-199903000-00010 Adamu, A. A., Gadanya, M. A., Jalo, R. I., Uthman, O. A. & Wiysonge, C. S. Factors influencing non-prescription sales of antibiotics among patent and proprietary medicine vendors in Kano, Nigeria: a cross-sectional study. Health Policy Plan 35 , 819-828 (2020). https://doi.org:10.1093/heapol/czaa052 Uneke, C. J. et al. An assessment of nursing mothers' and young people's access to proprietary and patent medicine vendors' services in rural communities of south-eastern Nigeria: implication for review of national drug policy. J Pharm Policy Pract 14 , 92 (2021). https://doi.org:10.1186/s40545-021-00334-7 Onah, C. K. et al. Practices toward presumptive tuberculosis clients among patent medicine vendors in Ebonyi State Nigeria. Int J Mycobacteriol 10 , 71-78 (2021). https://doi.org:10.4103/ijmy.ijmy_2_21 Ntim-Amponsah, C. T., Amoaku, W. M. K., & Ofosu-Amaah, S. Alternate eye care services in a Ghanaian district. Ghana Medical Journal 39 , 22-23 (2005). https://doi.org:10.4314/gmj.v39i1.35975 Samuel Osei-Asante, S. N. O.-D., Emmanuel Antwi and George Owusu-Dapaah. Medicine sales by itinerant vendors at lorry stations: A case study at Kejetia Station in Kumasi, Ghana. Journal of Pharmaceutical Sciences and Research 13 , 438-443 (2021). https://doi.org:Not availabel Qidwai W, K. M., Hashmi S, Afridi M, Ali RA. Private drug sellers' education in improving prescribing practices. J Coll Physicians Surg Pak 16 , 743-746 (2006). https://doi.org:PMID: 17125630 Somsé P, M.-Y. F., Morency P, Dubois MJ, Grésenguet G, Pépin J. Quality of sexually transmitted disease treatments in the formal and informal sectors of Bangui, Central African Republic. Sex Transm Dis. 27 , 458-464 (2000). https://doi.org:10.1097/00007435-200009000-00007 Ndoutamia, G., Fissou, H. Y., Nadjilem, D. & Gatsing, D. Perception, knowledge and use of antibiotic among communities in Chad. African Journal of Pharmacy and Pharmacology 11 , 260-265 (2017). https://doi.org:10.5897/ajpp2017.4791 Om, C., Daily, F., Vlieghe, E., McLaughlin, J. C. & McLaws, M. L. Pervasive antibiotic misuse in the Cambodian community: antibiotic-seeking behaviour with unrestricted access. Antimicrob Resist Infect Control 6 , 30 (2017). https://doi.org:10.1186/s13756-017-0187-y Nair, M. et al. "Without antibiotics, I cannot treat": A qualitative study of antibiotic use in Paschim Bardhaman district of West Bengal, India. PLoS One 14 , e0219002 (2019). https://doi.org:10.1371/journal.pone.0219002 Khare, S., Pathak, A., Stalsby Lundborg, C., Diwan, V. & Atkins, S. Understanding Internal and External Drivers Influencing the Prescribing Behaviour of Informal Healthcare Providers with Emphasis on Antibiotics in Rural India: A Qualitative Study. Antibiotics (Basel) 11 (2022). https://doi.org:10.3390/antibiotics11040459 Suy, S. et al. Invisible medicine sellers and their use of antibiotics: a qualitative study in Cambodia. BMJ Glob Health 4 , e001787 (2019). https://doi.org:10.1136/bmjgh-2019-001787 Kasse, G. E., Humphries, J., Cosh, S. M. & Islam, M. S. Factors contributing to the variation in antibiotic prescribing among primary health care physicians: a systematic review. BMC Primary Care 25 , 8 (2024). https://doi.org:10.1186/s12875-023-02223-1 Wilkinson, A., Ebata, A. & MacGregor, H. Interventions to Reduce Antibiotic Prescribing in LMICs: A Scoping Review of Evidence from Human and Animal Health Systems. Antibiotics 8 (2019). 10.3390/antibiotics8010002 Thapa, P. et al. Impact of WHO AWaRe Antibiotic Handbook training on antibiotics prescribing knowledge among primary care providers: A vignette-based, pre-post pilot study in Patna, India. medRxiv , 2025.2009.2006.25335195 (2025). https://doi.org:10.1101/2025.09.06.25335195 Chalker, J., Ratanawijitrasin, S., Chuc, N. T., Petzold, M. & Tomson, G. Effectiveness of a multi-component intervention on dispensing practices at private pharmacies in Vietnam and Thailand--a randomized controlled trial. Soc Sci Med 60 , 131-141 (2005). https://doi.org:10.1016/j.socscimed.2004.04.019 Yao, L. et al. The effects of the primary health care providers' prescription behavior interventions to improve the rational use of antibiotics: a systematic review. Glob Health Res Policy 5 , 45 (2020). https://doi.org:10.1186/s41256-020-00171-2 Pathak, D., Pathak, A., Marrone, G., Diwan, V. & Lundborg, C. S. Adherence to treatment guidelines for acute diarrhoea in children up to 12 years in Ujjain, India--a cross-sectional prescription analysis. BMC Infect Dis 11 , 32 (2011). https://doi.org:10.1186/1471-2334-11-32 Das, J. et al. Use of standardised patients to assess quality of tuberculosis care: a pilot, cross-sectional study. Lancet Infect Dis 15 , 1305-1313 (2015). https://doi.org:10.1016/s1473-3099(15)00077-8 Bezie, M. M. et al. Factors associated with the use of antibiotics for children presenting with illnesses with fever and cough obtained from prescription and non-prescription sources: a cross-sectional study of data for 37 sub-Saharan African countries. BMC Public Health 24 , 1089 (2024). https://doi.org:10.1186/s12889-024-18490-1 Hassan, M. Z. et al. Antibiotic use for acute respiratory infections among under-5 children in Bangladesh: a population-based survey. BMJ Glob Health 6 (2021). https://doi.org:10.1136/bmjgh-2020-004010 Tables Tables 1 to 3 are available in the Supplementary Files section Additional Declarations Competing interest reported. MP serves as an advisor to non-profits, namely the World Health Organisation, Partners in Health, and the Gates Foundation. MP serves on the editorial board of PLOS Medicine and was previously an Editor-in-Chief of PLOS Global Public Health. GS holds a Tier 2 Canada Research Chair in Communicable Diseases Epidemiology. All other authors have no financial or non-financial competing interests. 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1","display":"","copyAsset":false,"role":"figure","size":319215,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA-ScR flow diagram showing study selection and exclusions\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8123464/v1/40a96d5a6d32800c2c8b1dd2.png"},{"id":96805944,"identity":"e0f2978c-d05c-4e2c-88d4-6d23b501a362","added_by":"auto","created_at":"2025-11-26 09:13:01","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":310560,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eForest plot–style summary of antibiotic dispensing proportions across included studies (n=20)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e*Indicates a single study has been reported multiple times, either because there was a percentage of antibiotic dispensing for multiple conditions or multiple populations\u003cbr\u003e\n**C indicates disease condition and P indicates patient population\u003c/p\u003e\n\u003cp\u003e*** Two quantitative studies \u003csup\u003e29,46\u003c/sup\u003e could not be included in the plot as the percentage estimates were reported only as descriptive statements or without sufficient numerical data to calculate proportions\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8123464/v1/b15e3e94cf757c54743cf2b0.png"},{"id":96917337,"identity":"ff30a47d-f68b-46c7-ab46-8e603b3a5a67","added_by":"auto","created_at":"2025-11-27 14:09:34","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":51436,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of excerpts across TDF domains\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8123464/v1/da4909ed98800cd686f85897.png"},{"id":97280371,"identity":"f8a135ef-a9bf-488c-9f88-0847e07767ba","added_by":"auto","created_at":"2025-12-02 16:53:24","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1578192,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8123464/v1/360fc234-e17c-4b5a-95aa-09b797fc2e7f.pdf"},{"id":96805946,"identity":"9602aed8-6ad7-4714-a74d-c520879e7926","added_by":"auto","created_at":"2025-11-26 09:13:01","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":52858,"visible":true,"origin":"","legend":"","description":"","filename":"S1PRISMAScRChecklist.docx","url":"https://assets-eu.researchsquare.com/files/rs-8123464/v1/ef337901b55b726d27bb90a4.docx"},{"id":96917232,"identity":"c49aeb5b-e197-4d27-bafd-729c3ff60c3c","added_by":"auto","created_at":"2025-11-27 14:09:25","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":28150,"visible":true,"origin":"","legend":"","description":"","filename":"S2Completesearchstrategy.docx","url":"https://assets-eu.researchsquare.com/files/rs-8123464/v1/f32a0d83cdb4dc453775ad83.docx"},{"id":96917087,"identity":"030b1115-c52c-4ed0-9bb1-9af8e154aac6","added_by":"auto","created_at":"2025-11-27 14:09:15","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":40869,"visible":true,"origin":"","legend":"","description":"","filename":"S3StudyspecificdefinitionsofIPs.docx","url":"https://assets-eu.researchsquare.com/files/rs-8123464/v1/7718b333f09a4ab1bd38ba44.docx"},{"id":96917725,"identity":"16e73477-113e-424f-a359-a53afc544cf3","added_by":"auto","created_at":"2025-11-27 14:10:27","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":128469,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-8123464/v1/f3c06a5dc3e6e718c0a0b8d1.docx"}],"financialInterests":"Competing interest reported. MP serves as an advisor to non-profits, namely the World Health Organisation, Partners in Health, and the Gates Foundation. MP serves on the editorial board of PLOS Medicine and was previously an Editor-in-Chief of PLOS Global Public Health. GS holds a Tier 2 Canada Research Chair in Communicable Diseases Epidemiology. All other authors have no financial or non-financial competing interests.","formattedTitle":"Antibiotic dispensing practices and determinants among informal healthcare providers in low- and middle-income countries: a mixed-methods scoping review","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAntibiotic consumption is surging globally, with low- and middle-income countries (LMICs) experiencing the steepest increases, raising alarms about the growing threat of antimicrobial resistance (AMR) in regions least equipped to manage it \u003csup\u003e1,2\u003c/sup\u003e. Recent analyses show a 16.3% global increase in antibiotic use between 2016 and 2023, driven mainly by LMICs (+\u0026thinsp;18.6%), while high-income countries reported a modest decline of 4.9% \u003csup\u003e3\u003c/sup\u003e. The overuse and misuse of antibiotics remain major challenges, particularly within primary care, where more than half of outpatient consultations in LMICs result in an antibiotic prescription, often without a clinical justification \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eIn most LMICs, a substantial proportion of primary healthcare is provided by informal healthcare providers (IPs), who offer significant frontline care (between 9% and 90%) depending on the local context, particularly in underserved and rural communities \u003csup\u003e\u003cspan additionalcitationids=\"CR6 CR7 CR8\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. The term \u0026ldquo;\u003cem\u003einformal healthcare providers\u0026rdquo;\u003c/em\u003e encompasses a diverse group of practitioners, including drug sellers, village doctors (a locally used term for informally trained rural practitioners), medicine vendors, traditional healers, and birth attendants, who operate outside formal health system structures. IPs typically lack formal medical qualifications, professional registration, and operate outside regulatory or institutional frameworks \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. Antibiotic abuse by primary care providers, especially IPs, is a recognized blind spot in the global AMR response \u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThe World Health Organization (WHO) Global Antimicrobial Resistance and Use Surveillance System (GLASS) report does not include AMR data from the informal healthcare sector \u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e, and information on antibiotic dispensing by IPs is also not systematically captured at the national level across LMICs. However, several regional and country-level studies have documented antibiotic dispensing practices among IPs. A critical aspect of their practice is the frequent sale and provision of antibiotics, as consistently demonstrated in studies from countries such as Bangladesh, India, Vietnam, Ghana, Zambia, and the Democratic Republic of Congo, where a substantial proportion of antibiotic dispensing occurs through informal channels, including IPs \u003csup\u003e\u003cspan additionalcitationids=\"CR14 CR15 CR16 CR17 CR18\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eTo address this evidence gap and better understand the extent of antibiotic dispensing among IPs, as well as to consolidate evidence on factors influencing these practices, we conducted a scoping review guided by a published protocol in \u003cem\u003eBMJ Open\u003c/em\u003e \u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. The review aimed to 1) examine the reported extent of antibiotic dispensing among IPs, disaggregated by the methods used to assess antibiotic use; 2) describe dispensing patterns, including the types of antibiotics and the clinical conditions involved; and 3) identify the main factors influencing antibiotic dispensing practices among these providers.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis scoping review followed the Joanna Briggs Institute (JBI) methodology for scoping reviews \u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e and is reported in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist \u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e, Supplementary File 1. The review protocol was published in \u003cem\u003eBMJ Open\u003c/em\u003e in 2024 \u003csup\u003e20\u003c/sup\u003e.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eEligibility criteria\u003c/h2\u003e\u003cp\u003eThe inclusion criteria for this review was developed according to the Population-Concept-Context (PCC) framework, in accordance with the JBI guideline \u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003ePopulation\u003c/h3\u003e\n\u003cp\u003ePopulation eligibility criteria were defined a priori and are detailed in the published review protocol \u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e, which also provides further specifications on inclusion and exclusion parameters, including the distinction between IPs and other community-based cadres. For this review, IPs were defined as individuals who met one or more of the following criteria: (i) were not registered with or affiliated to government or recognised private institutions, (ii) had independently established community-based practices, and (iii) lacked formal medical qualifications to prescribe or dispense modern (biomedical) medicines, including antibiotics. Practitioners formally recognised under traditional or alternative systems of medicine, such as Ayurveda, Yoga and Naturopathy, Unani, Siddha, and Homeopathy (AYUSH) systems in India, were excluded.\u003c/p\u003e\u003cp\u003eDuring full-text screening, minor clarifications to the protocol were required. Some studies classified pharmacists and nurses as informal providers; although their antibiotic dispensing may be restricted under national regulations, these cadres were excluded in line with this review\u0026rsquo;s stricter definition, which applied only to unregistered providers without formal medical qualifications.\u003c/p\u003e\n\u003ch3\u003eConcept\u003c/h3\u003e\n\u003cp\u003eTwo core concepts guided this review. The first was antibiotic dispensing practices, encompassing the extent of dispensing, types of antibiotics used, and the conditions for which they were provided. The second was the identification of factors influencing antibiotic dispensing among IPs. Although the protocol initially included an assessment of routes of administration \u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e, this was not undertaken due to data limitations.\u003c/p\u003e\u003cp\u003eFor clarity, prescription refers to the formal act of ordering antibiotics by a qualified healthcare professional, whereas dispensing refers to the direct supply or sale of antibiotics to patients by IPs during consultations. Therefore, the term \u0026ldquo;\u003cem\u003edispensing\u003c/em\u003e\u0026rdquo; is used throughout this review to describe these practices.\u003c/p\u003e\n\u003ch3\u003eContext and design\u003c/h3\u003e\n\u003cp\u003eThe review focused on studies conducted in low, lower-middle, and upper-middle-income countries, as defined by the World Bank classification system. No restrictions were applied to study design, publication year, or language to ensure comprehensive inclusion of empirical evidence. As described in the published protocol \u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e, non-empirical publications, such as reviews, editorials, commentaries, protocols, conference abstracts, and multiple outputs from the same study, were excluded. One non-English article was translated using machine translation.\u003c/p\u003e\n\u003ch3\u003eSearch strategy\u003c/h3\u003e\n\u003cp\u003eA comprehensive search was conducted on June 11, 2024, by an experienced research librarian (GG) across nine electronic databases: MEDLINE (Ovid), EMBASE (Ovid), SCOPUS, Global Health (Ovid), CINAHL, Web of Science, LILACS (GIM), African Journals Online via Africa-Wide Information (EBSCOhost), and Index Medicus for the South-East Asia Region (IMSEAR) (GIM). The search combined two core concepts: \u0026ldquo;antibiotics\u0026rdquo; and \u0026ldquo;informal healthcare providers\u0026rdquo;. The complete search strategies are available in Supplementary File 2. In addition, the reference lists of all studies selected for full-text review were manually searched for additional relevant literature; however, no new studies were identified.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eStudy review and selection\u003c/h2\u003e\u003cp\u003eAll records were imported into Covidence systematic review software (Veritas Health Innovation, Melbourne, Australia), and duplicates were removed automatically. Screening was conducted in two stages. In the first stage, five reviewers (DT, ST, AB, SB, MA) independently screened titles and abstracts against predefined inclusion criteria following a pilot of ten records. Each record was assessed by two reviewers, and any study deemed potentially relevant by at least one was advanced to full-text screening. In the second stage, the same five reviewers independently screened full-text articles, again with two reviewers per study. Reasons for exclusion were systematically documented in Covidence. Discrepancies were resolved through discussion, with arbitration by the first author (PT) when consensus was not reached.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eAssessment of methodological quality\u003c/h3\u003e\n\u003cp\u003eThe protocol included an assessment of methodological quality \u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e; however, this was not undertaken. The included studies demonstrated substantial heterogeneity in outcome definitions, measurement approaches, and data sources, which made formal quality appraisal impractical. This approach aligns with the JBI guidance \u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e, which does not require critical appraisal for scoping reviews and recommends its inclusion only when it contributes to contextual interpretation rather than exclusion or weighting of evidence.\u003c/p\u003e\n\u003ch3\u003eData extraction\u003c/h3\u003e\n\u003cp\u003eData extraction was performed using a standardized form developed in Covidence. For the first two review objectives, information was collected on study title, publication year, objectives, design, setting, sampling strategy, data sources, terminology, definitions used for IPs, methods of assessing antibiotic dispensing, and details of dispensing practices, including prevalence estimates, types of antibiotics, clinical indications, and patient characteristics where available. Two reviewers independently extracted data, and all entries were verified by the first author (PT) for accuracy and completeness.\u003c/p\u003e\u003cp\u003eFor the third objective, textual information on factors associated with antibiotic dispensing was extracted separately into a Microsoft Word file. In studies involving multiple interest holder groups such as IPs, patients, or policy decision-makers, only data specific to IPs were retained for analysis.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eData synthesis\u003c/h2\u003e\u003cp\u003eData synthesis followed the approach outlined in the published protocol \u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. Findings were summarised using descriptive tables, visuals, and narrative synthesis, in accordance with scoping review guidance \u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. Basic study characteristics, including title, year of publication, objective, design, sample size, and terminology used for IPs, were tabulated by country.\u003c/p\u003e\u003cp\u003eAntibiotic dispensing practices were described narratively without quantitative aggregation owing to the diversity of assessment methods across studies. Findings were organised into three categories: (i) studies using standardised methods such as standardised patients, prescription reviews, or direct observation of provider and patient interactions; (ii) provider-reported studies based on surveys or interviews with IPs; and (iii) client or consumer-reported studies using household or patient surveys. This categorisation of studies also provided an indication of relative methodological robustness, with studies employing standardised methods generally considered to yield higher-quality evidence than those based on provider- or consumer-reported data. Dispensing estimates were summarised in descriptive tables and illustrated in a forest plot-style visual to depict the range of reported estimates. Conditions treated and antibiotics dispensed were described narratively, and individual agents, if reported, were classified according to the WHO AWaRe framework \u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. To ensure readability, percentages reported in the narrative text were rounded to the nearest whole number. Original values, including decimals as reported in the source studies, are retained in the manuscript tables.\u003c/p\u003e\u003cp\u003eFactors influencing antibiotic dispensing were analysed through deductive content analysis guided by the Theoretical Domains Framework (TDF) \u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. The unit of analysis in this qualitative synthesis was a discrete statement describing a determinant of IP dispensing behaviour. Textual data were first coded manually in Word documents and later transferred to Microsoft Excel to facilitate organisation, comparison, and synthesis. A domain-specific codebook was developed a priori using TDF definitions, with child codes consolidated under parent domains such as knowledge, social influence, reinforcement, and beliefs about consequences. The distribution of excerpts across domains was summarised as counts and presented in a figure, with one representative quotation for each domain included in a table. Although the Rodrigues et al. framework \u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e was initially planned, the TDF was adopted for its greater conceptual granularity and capacity to capture interacting behavioural and contextual determinants.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe study selection process is summarised in the PRISMA flow diagram (Figure 1). The database searches identified 10,109 records. After removal of duplicates, 5,672 records remained for title and abstract screening. Of these, 194 were retained for full-text review. Following full-text assessment, 31 studies met the inclusion criteria and were included in the review. The major reasons for exclusion were an ineligible study population (n = 80), an ineligible outcome (n = 34), and an ineligible study design (n = 20).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOut of the 31 studies included in this review, 27 addressed the first research aim of examining antibiotic dispensing practices among IPs. For the second aim, which explored dispensing patterns in greater detail, 27 studies (22 quantitative and 5 qualitative) contributed data on illnesses or conditions treated by IPs, and 16 studies (12 quantitative and 4 qualitative) provided details on the types or classifications of antibiotics dispensed. Finally, 6 studies addressed the third aim of examining factors influencing antibiotic dispensing practices among IPs.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResearch aims 1 \u0026amp; 2: Antibiotic dispensing practices and patterns among IPs in LMICs\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCharacteristics of included studies\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe 27 studies included in this review for our first and second research aims were published between 1999 and 2023 and together represented data from eight countries: India (n = 9/27, 33.3%), Bangladesh (n = 8/27, 29.6%), Nigeria (n = 4/27, 14.8%), Ghana (n = 2/27, 7.4%), and one study each from Cambodia, Chad, Pakistan, and the Central African Republic (3.7% each).\u003c/p\u003e\n\u003cp\u003eThe included studies used varied designs, comprising cross-sectional quantitative surveys (n = 17/27, 63.0%), qualitative studies (n = 5/27, 18.5%), and mixed methods approaches (n = 2/27, 7.4%), while one study each (3.7%) used secondary data analysis, a prospective cohort design, or a quasi-experimental approach. Among quantitative studies, provider-based studies enrolled between 21 and 1,751 providers, prescription or patient record review-based studies included between 117 and 15,322 records, and consumer-reported studies surveyed between 13 households and 2,784 individuals. Most studies employed a convenience (10/27, 37.0%) or purposive (9/27, 33.3%) sampling strategy.\u003c/p\u003e\n\u003cp\u003eTerminology used to describe IPs varied widely, including \u0026ldquo;village doctors,\u0026rdquo; \u0026ldquo;drug sellers,\u0026rdquo; \u0026ldquo;rural medical practitioners,\u0026rdquo; \u0026ldquo;quacks,\u0026rdquo; and \u0026ldquo;patent medicine vendors.\u0026rdquo; In several cases, definitions were context-specific and varied within countries. A detailed summary of study characteristics is presented in Table 1, and study-specific definitions of IPs are provided in Table 1 of the Supplementary File 3.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eExtent of antibiotic dispensing practices by IPs\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn the quantitative analysis (n = 22 studies) (Figure 2 and Table 2), we observed variability in antibiotic dispensing practices across the three assessment methods described earlier in the methods section. This categorisation provides a broad indication of study quality, as studies using standardised methods, such as the standardised patient method, prescription reviews, are generally more robust than those based on provider- or consumer-reported data.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAmong the six studies that used standardized methods, including one standardized patient study, four prescription reviews, and one direct observation of patient\u0026ndash;provider interactions, antibiotic dispensing ranged from 18% (10/57 simulated visits) to 74% (11,336/15,322 prescriptions). The single direct-observation study reported an average of 1.19 and 0.94 antibiotics per consultation across two study sites, although limited data precluded recalculating the percentages \u003csup\u003e29\u003c/sup\u003e. Denominators varied across studies: three used the total number of patients, two the total number of medicines per prescription, and one the average number of antibiotics per consultation.\u003c/p\u003e\n\u003cp\u003eTwelve studies relied on providers\u0026rsquo; self-reports of their dispensing practices, with estimates ranging from 5% (12/247 enrolled providers) to 100% (an estimated 14,590 patients with diarrhea or dysentery receiving antibiotics). Denominators differed substantially across studies, including the number of providers enrolled (n = 8), the number of patients treated by the providers (n = 3), and the number of medicines dispensed by the providers (n = 1).\u003c/p\u003e\n\u003cp\u003eFour studies drew on consumer or client reporting to estimate antibiotic dispensing by IPs. These studies reported dispensing rates ranging from 11% (52/472 individuals seeking care) to 86% (694/807 of total antibiotic courses prescribed across both formal and informal providers). Denominators included the number of patients who sought care from informal providers (n = 3) and the total number of antibiotic courses prescribed by all providers in the study (n = 1).\u003c/p\u003e\n\u003cp\u003eThe findings from five qualitative studies (n=5 studies) were consistent with those from the quantitative analysis, confirming the widespread dispensing of antibiotics by IPs. For instance, Sizear et al. (2019) reported that 62% (8/13) of IPs admitted dispensing antibiotics for diarrhea from the first day of illness, and many also initiated antibiotic treatment for pneumonia immediately after symptom onset \u003csup\u003e37\u003c/sup\u003e. Similarly, Ntim-Amponsah et al. (2005) documented that all 21 chemical shop attendants included in their study dispensed antibiotic eye drops as the first-line treatment for any eye condition encountered \u003csup\u003e45\u003c/sup\u003e. Detailed findings from all five qualitative studies are presented in Table 2.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIllnesses/conditions treated\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis sub-analysis included 27 studies, comprising 22 quantitative and 5 qualitative studies (Table 2). IPs dispensed antibiotics for a range of health problems, most commonly acute respiratory infections (n = 11), gastrointestinal infections (n = 11), and febrile illnesses (n = 9). General illnesses (n = 5) and presumptive tuberculosis (n = 3) were also frequently reported, while skin infections, eye conditions, sexually transmitted infections, and lymphatic filariasis were mentioned in a smaller number of studies.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTypes of antibiotics dispensed\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIPs dispensed a wide range of antibiotics (Table 2). Out of the total studies (n = 27), 16 studies (12 quantitative and 4 qualitative) (included in this sub-analysis) provided details on the type or classification of antibiotics dispensed by IPs. All antibiotics mentioned in these 16 studies were listed, yielding 110 reported instances. The most frequently reported antibiotics were amoxicillin (n = 11), azithromycin (n = 8), ciprofloxacin (n = 8), ampicillin (n = 7), and cefixime (n = 5). The majority belonged to the Access (n = 52) and Watch (n = 42) categories of the WHO AWaRe classification, while one antibiotic was classified as Reserve. Some studies also reported combination antibiotics (n = 5) and class-level mentions (n = 5), including a few used for tuberculosis treatment (n = 5) that are not included in the WHO AWaRe classification system.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResearch aim 3\u003c/strong\u003e\u003cstrong\u003e: Factors associated with antibiotic dispensing by IPs\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of six \u003csup\u003e17,19,37,51-53\u003c/sup\u003e qualitative studies contributed evidence on the factors influencing antibiotic dispensing by IPs. These studies were conducted in India (n = 3), Bangladesh (n = 2), and Cambodia (n = 1), and together involved 110 IPs. Sampling approaches included purposive sampling (n = 5) and snowball sampling (n = 1). Data were collected primarily through in-depth interviews (n = 4), with two studies using focus group discussions. Most applied thematic analysis (n = 5), while one study employed framework analysis. Additional details on definitions of IPs are provided in Table 2 of the Supplementary File 3.\u003c/p\u003e\n\u003cp\u003eAnalysis of these studies using the TDF highlighted several domains shaping antibiotic dispensing practices among IPs (Table 3, Figure 3). Across all studies (n=6), seventy-nine coded excerpts were analyzed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKnowledge\u0026nbsp;\u003c/strong\u003e\u003cem\u003e(This domain relates to IPs\u0026rsquo; understanding and awareness of antibiotics and their appropriate use)\u003c/em\u003e\u003cstrong\u003e:\u003c/strong\u003e This domain was consistently identified (22 excerpts) across the six studies \u003csup\u003e[1, 3\u0026ndash;7]\u003c/sup\u003e. Across India, Bangladesh, and Cambodia, IPs commonly believed that antibiotics were essential or compulsory for treatment \u003csup\u003e17,51\u003c/sup\u003e, effective for any condition \u003csup\u003e53\u003c/sup\u003e, and acted as \u0026ldquo;sure-shot drugs\u0026rdquo; \u003csup\u003e37\u003c/sup\u003e or as medicines to \u0026ldquo;boost up the body\u0026rdquo; \u003csup\u003e52\u003c/sup\u003e. Some classified antibiotics as mild (\u0026ldquo;halka phulka\u0026rdquo; in Hindi) \u003csup\u003e51\u003c/sup\u003e or judged their strength based on price \u003csup\u003e17\u003c/sup\u003e. Pharmaceutical representatives were reported as the primary source of information on antibiotics \u003csup\u003e37,51\u003c/sup\u003e. IPs also referred to books and guidelines, though English-language materials limited their understanding. \u003csup\u003e37\u003c/sup\u003e. Others relied on trial-based experience \u003csup\u003e19,52\u003c/sup\u003e or informal learning through apprenticeships with qualified doctors and short training sessions \u003csup\u003e19,52\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSocial influences\u0026nbsp;\u003c/strong\u003e\u003cem\u003e(This domain captures the social and interpersonal pressures shaping IPs\u0026rsquo; dispensing behaviour)\u003c/em\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eThis domain\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003csup\u003e19,37,51-53\u003c/sup\u003e was the second most frequently reported driver of antibiotic dispensing (15 excerpts). Across studies from India, Bangladesh, and Cambodia, patient expectations strongly influenced IPs\u0026rsquo; behavior, as many patients insisted on shorter courses \u003csup\u003e51\u003c/sup\u003e, requested antibiotics based on their ability to pay \u003csup\u003e51\u003c/sup\u003e, or viewed antibiotics as the default treatment option \u003csup\u003e51-53\u003c/sup\u003e. IPs also perceived pressure to meet expectations for quick symptomatic relief or cure \u003csup\u003e37,51,52\u003c/sup\u003e. Interactions with pharmaceutical representatives (drug detailers) were another key influence, as representatives often introduced or promoted new antibiotics and encouraged their sale \u003csup\u003e19,51\u003c/sup\u003e. Additionally, informal mentorship from qualified doctors who advised IPs on antibiotic use further shaped dispensing practices \u003csup\u003e19\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBeliefs about consequences\u0026nbsp;\u003c/strong\u003e\u003cem\u003e(This domain concerns IPs\u0026rsquo; perceptions of the outcomes of dispensing or withholding antibiotics)\u003c/em\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eThis domain was reported across all studies (14 excerpts) \u003csup\u003e17,19,37,51-53\u003c/sup\u003e. Limited understanding of antibiotic indications shaped dispensing practices, as IPs perceived antibiotics as necessary to ensure recovery. Rather than relying on clinical indications, their decisions were guided by perceived consequences, viewing antibiotics as essential or powerful medicines \u003csup\u003e19,37,51-53\u003c/sup\u003e and as necessary to prevent treatment failure \u003csup\u003e51\u003c/sup\u003e. Antibiotics were also regarded as an essential part of first aid or early treatment \u003csup\u003e51,52\u003c/sup\u003e. Fear of adverse outcomes further influenced dispensing behavior, as IPs believed that not giving antibiotics could result in patients not recovering, seeking care elsewhere, or harming their business reputation \u003csup\u003e19,51\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReinforcement\u0026nbsp;\u003c/strong\u003e\u003cem\u003e(This domain reflects the rewards or pressures that sustain antibiotic dispensing behaviour)\u003c/em\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eThis domain had nine excerpts across three studies \u003csup\u003e19,51,52\u003c/sup\u003e. Antibiotics were perceived as part of routine care and a therapeutic necessity \u003csup\u003e19,51\u003c/sup\u003e. Their sale also contributed significantly to IPs\u0026rsquo; income \u003csup\u003e19\u003c/sup\u003e, and financial incentives from pharmaceutical representatives further reinforced dispensing practices \u003csup\u003e19\u003c/sup\u003e. Fear of patients seeking care from competing providers acted as a negative reinforcer of continued antibiotic dispensing \u003csup\u003e19,51,52\u003c/sup\u003e. Additionally, patients\u0026rsquo; limited knowledge about antibiotics created demand for rapid relief, and when such expectations were not met, IPs feared patient dissatisfaction and loss of clientele \u003csup\u003e52\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSocial and professional role, and identity\u0026nbsp;\u003c/strong\u003e\u003cem\u003e(This domain represents how IPs view their role, reputation, and legitimacy as care providers)\u003c/em\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eThis domain was represented by seven excerpts across three studies \u003csup\u003e19,51,53\u003c/sup\u003e. IPs\u0026rsquo; conceptualization of their professional role and image as effective practitioners, measured through patient retention and perceived ability to cure, influenced their antibiotic dispensing practices. They believed antibiotics were necessary to control disease \u003csup\u003e51\u003c/sup\u003e and formed part of the basic treatment \u003csup\u003e19\u003c/sup\u003e. IPs described their role within a collaborative formal\u0026ndash;informal care network, emphasizing their legitimacy as key actors in the broader healthcare ecosystem \u003csup\u003e51\u003c/sup\u003e. In a study in Cambodia, an IP stated that dispensing antibiotics fell within their comfort zone and self-defined scope of practice, whereas others perceived dispensing as an entitlement based on informal training and accumulated experience \u003csup\u003e53\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEnvironmental context and resources\u0026nbsp;\u003c/strong\u003e\u003cem\u003e(This domain relates to external and system-level factors influencing dispensing practices)\u003c/em\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eThis domain had\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eseven excerpts \u003csup\u003e17,19,37,51,52\u003c/sup\u003e. IPs described their role in patient care as an opportunity to fill service gaps, enabled by systemic deficiencies in healthcare access and delivery \u003csup\u003e51,52\u003c/sup\u003e. A study in Bangladesh found that the lack of clinical guidelines in local languages contributed to knowledge gaps in antibiotic use \u003csup\u003e37\u003c/sup\u003e. IPs also reported that incomplete antibiotic courses and the selection of specific drugs were often determined by patients\u0026rsquo; financial constraints, shaping dispensing decisions based on affordability and access \u003csup\u003e17,19,51\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBeliefs about capabilities\u0026nbsp;\u003c/strong\u003e\u003cem\u003e(This domain reflects IPs\u0026rsquo; confidence in their ability to dispense antibiotics appropriately)\u003c/em\u003e: Three excerpts \u003csup\u003e51-53\u003c/sup\u003e reflected IPs\u0026rsquo; confidence in dispensing antibiotics, which was primarily rooted in experiential learning and peer validation \u003csup\u003e51,52\u003c/sup\u003e. In a study from Cambodia, one provider described antibiotic use as comfortably within their scope of practice, reflecting a broader perception among IPs that practical experience alone was sufficient to guide antibiotic use \u003csup\u003e52,53\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis scoping review consolidates evidence from 31 studies across 8 LMICs. Twenty-seven studies reported on dispensing practices of IPs, showing consistently high levels of antibiotic dispensing ranging from 5 to 100% depending on setting and assessment method. We found six qualitative studies that examined factors influencing dispensing, identifying influences mapped mainly to the TDF domains of knowledge, social influences, beliefs about consequences, and reinforcement, reflecting limited knowledge, patient expectations, financial dependence, experience-based learning, and peer influence. Collectively, these findings provide a comprehensive overview of the extent, nature, and underlying drivers of antibiotic dispensing by IPs across LMICs.\u003c/p\u003e\u003cp\u003eIn this review, 27 studies reported on antibiotic dispensing practices, with proportions ranging from approximately 18 to 74% in studies using standardised methods, 5 to 100% in provider-reported studies, and 11 to 86% in consumer-reported studies. These consistently high estimates in this review indicate an existing gap in current global and national surveillance systems in quantifying antibiotic dispensing by IPs and, consequently, estimating their contribution to the overall burden of AMR \u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. When these estimates are viewed alongside the findings from a systematic review by Sudhinaraset et al., which showed that IPs deliver a substantial share of primary healthcare, between 9 and 90%, in LMICs \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e, they collectively highlight the scale and public health significance of antibiotic dispensing by this large provider group. Antibiotics dispensed by IPs likely represent one of the largest unmeasured components of global antibiotic use. Integrating these providers into antibiotic use surveillance programs through national surveys, community-based monitoring, or prescription audits within their clinics will be essential to produce more accurate estimates and to inform stewardship strategies.\u003c/p\u003e\u003cp\u003eThe qualitative analysis in this review, guided by the TDF, revealed that multiple interrelated factors influence antibiotic dispensing by IPs. Several of these qualitative insights were corroborated by dispensing-related data from studies included in the review (in research aim 1). Limited knowledge and misconceptions about antibiotic use emerged as dominant themes, with IPs often perceiving antibiotics as essential for treatment and effective for almost any illness. These perceptions were reflected in quantitative findings: 76.8% (284/370) of providers in Nigeria sold antibiotics for fever \u003csup\u003e\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u003c/sup\u003e, and 61.5% (8/13) of interviewed providers in Bangladesh dispensed antibiotics for diarrhoea at the first visit \u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e. Other domains, such as social pressures, perceived consequences, and capability, further reinforced these behaviours, contributing to shorter, unnecessary, or excessive treatment regimens and the use of antibiotics as a default treatment option. For example, in Bangladesh, 84.3% (498/591) of antibiotics were dispensed in inadequate doses \u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e, and in another study, 14.2% (35/247) of providers dispensed antibiotics even when not indicated \u003csup\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e. In Ghana, all 21 (100%) chemical shop attendants sold antibiotic eye drops as first-line treatment for any eye complaint \u003csup\u003e\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u003c/sup\u003e, while in India, dispensing rates were higher among children under 5 years (85%) than among adults (71%) \u003csup\u003e16\u003c/sup\u003e. Collectively, these integrated findings illustrate how diverse and interacting factors sustain inappropriate antibiotic use among IPs, echoing patterns previously documented among formal and primary care providers \u003csup\u003e\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e,\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThese qualitative findings also suggest that while training to improve knowledge is important for antibiotic stewardship among IPs, education alone is insufficient to modify entrenched dispensing behaviours. This was evident in our recent study in Patna city, India, where a one-time training based on the WHO AWaRe Antibiotic Handbook led to moderate improvements in knowledge for only selected clinical conditions \u003csup\u003e\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e\u003c/sup\u003e. Evidence from other settings indicates that multifaceted interventions combining behavioural, social, and structural components achieve greater effectiveness than single strategies. Such approaches include training combined with an audit and feedback and support system, peer engagement, digital reminders, and community education with extended follow-up \u003csup\u003e55,57,58\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eSome studies were excluded from this review due to methodological and reporting limitations that prevented the extraction of reliable data specific to IPs. In some cases, aggregated data were reported, combining formal and informal providers, for example, physicians with IPs or licensed pharmacists with unqualified drug sellers \u003csup\u003e\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e,\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e\u003c/sup\u003e. Another major challenge was the absence of a clear definition of IPs in several excluded studies. Some grouped heterogeneous provider categories, such as shops, churches, traditional practitioners, drug sellers, friends, relatives, and supermarkets, while others combined multiple cadres, including NGO workers, trained and untrained traditional birth attendants, unqualified doctors, and homeopathic practitioners, into a single composite category labelled as informal healthcare source/settings \u003csup\u003e\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e,\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e\u003c/sup\u003e. These inconsistencies highlight the need for a consensus and standardized guidelines to harmonize the definition and reporting of IPs, including the separate reporting of antibiotic dispensing across distinct provider groups, to improve the accuracy and comparability of findings.\u003c/p\u003e\u003cp\u003eAmong the included studies, a major challenge was the variability in methodologies used to assess antibiotic dispensing, including standardised patient studies, prescription reviews, direct observation, and provider or consumer-reported assessments. Most studies (16 of 22 reporting dispensing) relied on provider or consumer reports, which are prone to recall, reporting, and social desirability biases. The denominators used to report outcomes also varied substantially. Across 22 studies, 6 different denominators were applied, including total patients, total medicines, total antibiotics, total providers, and total care-seeking episodes from IPs. This methodological heterogeneity, together with inconsistent denominators for outcomes, limits the comparability and synthesis of dispensing estimates. Consequently, the estimates presented in this review should be viewed as descriptive, offering a broad overview of dispensing practices among IPs rather than pooled measures. The forest-style figure was therefore used to depict the spread of reported estimates across studies, not to support statistical aggregation or meta-analysis.\u003c/p\u003e\u003cp\u003eThere was also limited reporting of details on antibiotics dispensed. Only 16 studies (out of 27; 12 quantitative and 4 qualitative) provided such information. Also, in studies that included multiple clinical conditions, antibiotics were seldom classified by condition, making it challenging to identify condition-specific dispensing patterns. Addressing this, along with the methodological and reporting gaps discussed above, will be essential to strengthen the evidence base on antibiotic dispensing by IPs and to inform context-appropriate interventions to improve antibiotic stewardship within this important provider group.\u003c/p\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eStrengths and limitations\u003c/h2\u003e\u003cp\u003eThis review provides the first comprehensive synthesis of antibiotic dispensing practices by IPs across LMICs, following the JBI methodological framework. Using a mixed-methods approach that combined quantitative mapping with qualitative synthesis, the review offers an integrated understanding of IPs\u0026rsquo; dispensing practices and the behavioural and contextual factors that influence them in LMIC settings.\u003c/p\u003e\u003cp\u003eThere are several limitations to this review. We searched nine major databases; however, grey literature was not included due to time and resource constraints, and reports from national governments or international and non-governmental organisations working with IPs may have been missed. As there is no universally accepted definition of IPs and multiple terms are used across different contexts, some studies may not have been captured despite the use of broad search terms. Substantial heterogeneity was observed in study methodologies, denominators, and outcome reporting, which limited comparability across studies. In addition, many studies relied on provider- or consumer-reported assessments, which are prone to recall and social desirability biases, potentially leading to over- or under-reporting of antibiotic dispensing practices. Some studies that reported aggregated data combining formal and informal providers were excluded to avoid biased estimates; however, this may have resulted in an underestimation of the overall contribution of IPs to antibiotic dispensing.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis scoping review found that antibiotic dispensing by IPs is widespread across LMICs. Dispensing was consistently reported to be high across studies, reflecting substantial antibiotic use within this provider group. The behavioural analysis identified key domains influencing these practices, primarily knowledge, social influences, beliefs about consequences, and reinforcement, illustrating how experience-based learning, patient expectations, perceived need for antibiotics, and incentives collectively shape dispensing behaviour. Overall, this review provides a comprehensive synthesis of evidence on antibiotic dispensing practices and the factors influencing these practices among IPs in LMICs. These findings offer an evidence base to inform future research and guide the development of context-appropriate stewardship interventions for IPs.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eCompeting Interests\u003c/h2\u003e\u003cp\u003eMP serves as an advisor to non-profits, namely the World Health Organisation, Partners in Health, and the Gates Foundation. MP serves on the editorial board of PLOS Medicine and was previously an Editor-in-Chief of PLOS Global Public Health. GS holds a Tier 2 Canada Research Chair in Communicable Diseases Epidemiology. All other authors have no financial or non-financial competing interests.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding Statement:\u003c/h2\u003e\u003cp\u003eThis project was funded by the McGill Interdisciplinary Initiative in Infection and Immunity (MI4) (Grant number: #SFG5-01). The funders had no role in study design, data collection, analysis, and interpretation of data, or the writing of the manuscript.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003ePT, MT, BB, SG, MP and GS conceptualised the review. PT, MT, BB, SG, DT, ST, AB, SB, GG, COO, MA, PS, CJ, SS, MD, SAR, MP and GS contributed to developing the study design and review protocol. PT, SG, GG, MP and GS developed and conducted the search strategy. PT, MT, BB, DT, ST, AB, SB and MA screened the studies. PT, MT, BB, SG, DT, ST, AB, SB, MA, MP and GS extracted the data. PT, MT, BB, SG, DT, ST, AB, SB, GG, COO, MA, PS, CJ, SS, MD, SAR, MP and GS analysed and synthesised the evidence. PT prepared the original draft with input from SG, MP and GS. All authors contributed to the manuscript through critical review and editing, and all authors read and approved the final version.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003ePT (first author) acknowledges the support of the Fonds de recherche du Qu\u0026eacute;bec \u0026ndash; Sant\u0026eacute; (FRQS) Postdoctoral Fellowship.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eAll data generated or analysed during this study are included in this published article and its supplementary information files.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eKlein, E. Y.\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e Global increase and geographic convergence in antibiotic consumption between 2000 and 2015. \u003cem\u003eProceedings of the National Academy of Sciences\u003c/em\u003e \u003cstrong\u003e115\u003c/strong\u003e, E3463-E3470 (2018). https://doi.org:10.1073/pnas.1717295115\u003c/li\u003e\n \u003cli\u003eMurray, C. J. L.\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. \u003cem\u003eThe Lancet\u003c/em\u003e \u003cstrong\u003e399\u003c/strong\u003e, 629-655 (2022). https://doi.org:10.1016/S0140-6736(21)02724-0\u003c/li\u003e\n \u003cli\u003eKlein, E. Y.\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e Global trends in antibiotic consumption during 2016\u0026ndash;2023 and future projections through 2030. \u003cem\u003eProceedings of the National Academy of Sciences\u003c/em\u003e \u003cstrong\u003e121\u003c/strong\u003e, e2411919121 (2024). https://doi.org:doi:10.1073/pnas.2411919121\u003c/li\u003e\n \u003cli\u003eSulis, G.\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e Antibiotic prescription practices in primary care in low- and middle-income countries: A systematic review and meta-analysis. \u003cem\u003ePLoS Med\u003c/em\u003e \u003cstrong\u003e17\u003c/strong\u003e, e1003139 (2020). https://doi.org:10.1371/journal.pmed.1003139\u003c/li\u003e\n \u003cli\u003eSudhinaraset, M., Ingram, M., Lofthouse, H. K. \u0026amp; Montagu, D. What Is the Role of Informal Healthcare Providers in Developing Countries? A Systematic Review. \u003cem\u003ePLOS ONE\u003c/em\u003e \u003cstrong\u003e8\u003c/strong\u003e, e54978 (2013). https://doi.org:10.1371/journal.pone.0054978\u003c/li\u003e\n \u003cli\u003eSheikh, K., Josyula, L. K., Zhang, X., Bigdeli, M. \u0026amp; Ahmed, S. M. Governing the mixed health workforce: learning from Asian experiences. \u003cem\u003eBMJ Glob Health\u003c/em\u003e \u003cstrong\u003e2\u003c/strong\u003e, e000267 (2017).\u003c/li\u003e\n \u003cli\u003eThapa, P.\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e Unlocking the potential of informal healthcare providers in tuberculosis care: insights from India. \u003cem\u003eBMJ Glob Health\u003c/em\u003e \u003cstrong\u003e9\u003c/strong\u003e (2024). https://doi.org:10.1136/bmjgh-2024-015212\u003c/li\u003e\n \u003cli\u003eOga-Omenka, C., Okafor, U. \u0026amp; Sulis, G. Engaging pharmacists and medicine vendors in antimicrobial stewardship in LMICs. \u003cem\u003eLancet Infect Dis\u003c/em\u003e \u003cstrong\u003e23\u003c/strong\u003e, 786-787 (2023). https://doi.org:10.1016/s1473-3099(23)00342-0\u003c/li\u003e\n \u003cli\u003eThapa, P.\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e Role of informal healthcare providers in tuberculosis care in low- and middle-income countries: A systematic scoping review. \u003cem\u003ePLoS One\u003c/em\u003e \u003cstrong\u003e16\u003c/strong\u003e, e0256795 (2021). https://doi.org:10.1371/journal.pone.0256795\u003c/li\u003e\n \u003cli\u003eShah, N. M., Brieger, W. R. \u0026amp; Peters, D. H. Can interventions improve health services from informal private providers in low and middle-income countries?: a comprehensive review of the literature. \u003cem\u003eHealth Policy Plan\u003c/em\u003e \u003cstrong\u003e26\u003c/strong\u003e, 275-287 (2011). https://doi.org:10.1093/heapol/czq074\u003c/li\u003e\n \u003cli\u003ePai, M., Gandra, S., Thapa, P. \u0026amp; Carmona, S. Tackling antimicrobial resistance: recognising the proposed five blind spots can accelerate progress. \u003cem\u003eLancet Microbe\u003c/em\u003e \u003cstrong\u003e6\u003c/strong\u003e, 100968 (2025). https://doi.org:10.1016/j.lanmic.2024.100968\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. \u003cem\u003eGlobal antibiotic resistance surveillance report 2025\u003c/em\u003e, \u0026lt;https://www.who.int/publications/i/item/9789240116337\u0026gt; (2025).\u003c/li\u003e\n \u003cli\u003eIngelbeen, B.\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e Antibiotic use from formal and informal healthcare providers in the Democratic Republic of Congo: a population-based study in two health zones. \u003cem\u003eClinical Microbiology and Infection\u003c/em\u003e \u003cstrong\u003e28\u003c/strong\u003e, 1272-1277 (2022). https://doi.org:10.1016/j.cmi.2022.04.002\u003c/li\u003e\n \u003cli\u003eWildbret, S.\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e Drivers of informal sector and non-prescription medication use in pediatric populations in a low- and middle-income setting: A prospective cohort study in Zambia. \u003cem\u003ePLOS Glob Public Health\u003c/em\u003e \u003cstrong\u003e3\u003c/strong\u003e, e0002072 (2023). https://doi.org:10.1371/journal.pgph.0002072\u003c/li\u003e\n \u003cli\u003eThapa, P.\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e What are the tuberculosis care practices of informal healthcare providers? A cross-sectional study from Eastern India. \u003cem\u003eHealth Policy Plan\u003c/em\u003e \u003cstrong\u003e37\u003c/strong\u003e, 1158-1166 (2022). https://doi.org:10.1093/heapol/czac062\u003c/li\u003e\n \u003cli\u003eKhare, S.\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e Antibiotic Prescribing by Informal Healthcare Providers for Common Illnesses: A Repeated Cross-Sectional Study in Rural India. \u003cem\u003eAntibiotics (Basel)\u003c/em\u003e \u003cstrong\u003e8\u003c/strong\u003e (2019). https://doi.org:10.3390/antibiotics8030139\u003c/li\u003e\n \u003cli\u003eNahar, P.\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e What contributes to inappropriate antibiotic dispensing among qualified and unqualified healthcare providers in Bangladesh? A qualitative study. \u003cem\u003eBMC Health Services Research\u003c/em\u003e \u003cstrong\u003e20\u003c/strong\u003e, 656 (2020). https://doi.org:10.1186/s12913-020-05512-y\u003c/li\u003e\n \u003cli\u003eNair, M.\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e Knowledge, attitudes, and practices related to antibiotic use in Paschim Bardhaman District: A survey of healthcare providers in West Bengal, India. \u003cem\u003ePLoS One\u003c/em\u003e \u003cstrong\u003e14\u003c/strong\u003e, e0217818 (2019). https://doi.org:10.1371/journal.pone.0217818\u003c/li\u003e\n \u003cli\u003eGautham, M., Spicer, N., Chatterjee, S. \u0026amp; Goodman, C. What are the challenges for antibiotic stewardship at the community level? An analysis of the drivers of antibiotic provision by informal healthcare providers in rural India. \u003cem\u003eSoc Sci Med\u003c/em\u003e \u003cstrong\u003e275\u003c/strong\u003e, 113813 (2021). https://doi.org:10.1016/j.socscimed.2021.113813\u003c/li\u003e\n \u003cli\u003eTandan, M.\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e Antibiotic dispensing practices among informal healthcare providers in low-income and middle-income countries: a scoping review protocol. \u003cem\u003eBMJ Open\u003c/em\u003e \u003cstrong\u003e14\u003c/strong\u003e, e086164 (2024). https://doi.org:10.1136/bmjopen-2024-086164\u003c/li\u003e\n \u003cli\u003eMicah DJ Peters, C. G., Patricia McInerney, Zachary Munn, Andrea C. Tricco, Hanan Khalil. \u003cem\u003eJBI Manual for Evidence Synthesis\u003c/em\u003e, \u0026lt; https://doi.org/10.46658/JBIMES-20-12\u0026gt; (2020).\u003c/li\u003e\n \u003cli\u003eTricco, A. C.\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. \u003cem\u003eAnn Intern Med\u003c/em\u003e \u003cstrong\u003e169\u003c/strong\u003e, 467-473 (2018). https://doi.org:10.7326/m18-0850\u003c/li\u003e\n \u003cli\u003ePollock, D.\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e Recommendations for the extraction, analysis, and presentation of results in scoping reviews. \u003cem\u003eJBI Evidence Synthesis\u003c/em\u003e \u003cstrong\u003e21\u003c/strong\u003e (2023). https://doi.org:10.11124/JBIES-22-00123\u003c/li\u003e\n \u003cli\u003eSouth, E. \u0026amp; Rodgers, M. Data visualisation in scoping reviews and evidence maps on health topics: a cross-sectional analysis. \u003cem\u003eSystematic Reviews\u003c/em\u003e \u003cstrong\u003e12\u003c/strong\u003e, 142 (2023). https://doi.org:10.1186/s13643-023-02309-y\u003c/li\u003e\n \u003cli\u003eSharland, M.\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e Encouraging AWaRe-ness and discouraging inappropriate antibiotic use-the new 2019 Essential Medicines List becomes a global antibiotic stewardship tool. \u003cem\u003eLancet Infect Dis\u003c/em\u003e \u003cstrong\u003e19\u003c/strong\u003e, 1278-1280 (2019). https://doi.org:10.1016/S1473-3099(19)30532-8\u003c/li\u003e\n \u003cli\u003eThompson, W.\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e Factors associated with antibiotic prescribing for adults with acute conditions: an umbrella review across primary care and a systematic review focusing on primary dental care. \u003cem\u003eJ Antimicrob Chemother\u003c/em\u003e \u003cstrong\u003e74\u003c/strong\u003e, 2139-2152 (2019). https://doi.org:10.1093/jac/dkz152\u003c/li\u003e\n \u003cli\u003eTeixeira Rodrigues, A., Roque, F., Falc\u0026atilde;o, A., Figueiras, A. \u0026amp; Herdeiro, M. T. Understanding physician antibiotic prescribing behaviour: a systematic review of qualitative studies. \u003cem\u003eInternational Journal of Antimicrobial Agents\u003c/em\u003e \u003cstrong\u003e41\u003c/strong\u003e, 203-212 (2013). https://doi.org:10.1016/j.ijantimicag.2012.09.003\u003c/li\u003e\n \u003cli\u003ePatnaik, S. K., Mukhopadhyay, A. K., \u0026amp; Dhariwal, A. C. Treatment practices for lymphatic filariasis amongst doctors of East Godavari District, Andhra Pradesh. \u003cem\u003eJournal of Communicable Diseases\u003c/em\u003e \u003cstrong\u003e39\u003c/strong\u003e, 65-67 (2007). https://doi.org:PMID: 18338719\u003c/li\u003e\n \u003cli\u003eGautham, M.\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e Informal rural healthcare providers in North and South India. \u003cem\u003eHealth Policy Plan\u003c/em\u003e \u003cstrong\u003e29 Suppl 1\u003c/strong\u003e, i20-29 (2014). https://doi.org:10.1093/heapol/czt050\u003c/li\u003e\n \u003cli\u003eSamal, M., Khara, N., Pati, S. \u0026amp; Sahoo, K. C. Treatment by untrained providers among sick infants in rural Odisha, India. \u003cem\u003ePrim Health Care Res Dev\u003c/em\u003e \u003cstrong\u003e20\u003c/strong\u003e, e84 (2019). https://doi.org:10.1017/S1463423619000380\u003c/li\u003e\n \u003cli\u003eKhare, S.\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e Determinants and pathways of healthcare-seeking behaviours in under-5 children for common childhood illnesses and antibiotic prescribing: a cohort study in rural India. \u003cem\u003eBMJ Open\u003c/em\u003e \u003cstrong\u003e11\u003c/strong\u003e, e052435 (2021). https://doi.org:10.1136/bmjopen-2021-052435\u003c/li\u003e\n \u003cli\u003eGautham, M., Miller, R., Rego, S. \u0026amp; Goodman, C. Availability, Prices and Affordability of Antibiotics Stocked by Informal Providers in Rural India: A Cross-Sectional Survey. \u003cem\u003eAntibiotics (Basel)\u003c/em\u003e \u003cstrong\u003e11\u003c/strong\u003e (2022). https://doi.org:10.3390/antibiotics11040523\u003c/li\u003e\n \u003cli\u003eMamun KZ, T. S., Shears P, Hart CA. A survey of antimicrobial prescribing and dispensing practices in rural Bangladesh. \u003cem\u003eMymensingh Med J.\u003c/em\u003e \u003cstrong\u003e15\u003c/strong\u003e, 81-84 (2007). https://doi.org:10.3329/mmj.v15i1.9\u003c/li\u003e\n \u003cli\u003eIslam, Q. S.\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e Informal allopathic provider knowledge and practice regarding control and prevention of TB in rural Bangladesh. \u003cem\u003eInt Health\u003c/em\u003e \u003cstrong\u003e6\u003c/strong\u003e, 225-231 (2014). https://doi.org:10.1093/inthealth/ihu025\u003c/li\u003e\n \u003cli\u003eSaha, S. \u0026amp; Hossain, M. T. Evaluation of medicines dispensing pattern of private pharmacies in Rajshahi, Bangladesh. \u003cem\u003eBMC Health Serv Res\u003c/em\u003e \u003cstrong\u003e17\u003c/strong\u003e, 136 (2017). https://doi.org:10.1186/s12913-017-2072-z\u003c/li\u003e\n \u003cli\u003eLucas, P. J.\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e Pathways to antibiotics in Bangladesh: A qualitative study investigating how and when households access medicine including antibiotics for humans or animals when they are ill. \u003cem\u003ePLoS One\u003c/em\u003e \u003cstrong\u003e14\u003c/strong\u003e, e0225270 (2019). https://doi.org:10.1371/journal.pone.0225270\u003c/li\u003e\n \u003cli\u003eSizear, M. M. I.\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e Perceptions of appropriate treatment among the informal allopathic providers: insights from a qualitative study in two peri-urban areas in Bangladesh. \u003cem\u003eBMC Health Serv Res\u003c/em\u003e \u003cstrong\u003e19\u003c/strong\u003e, 424 (2019). https://doi.org:10.1186/s12913-019-4254-3\u003c/li\u003e\n \u003cli\u003eSamir, N.\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e Antibiotic Use for Febrile Illness among Under-5 Children in Bangladesh: A Nationally Representative Sample Survey. \u003cem\u003eAntibiotics (Basel)\u003c/em\u003e \u003cstrong\u003e10\u003c/strong\u003e (2021). https://doi.org:10.3390/antibiotics10101153\u003c/li\u003e\n \u003cli\u003eBepari, A. K.\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e Factors Driving Antimicrobial Resistance in Rural Bangladesh: A Cross-Sectional Study on Antibiotic Use-Related Knowledge, Attitude, and Practice Among Unqualified Village Medical Practitioners and Pharmacy Shopkeepers. \u003cem\u003eAdv Ther\u003c/em\u003e \u003cstrong\u003e40\u003c/strong\u003e, 3478-3494 (2023). https://doi.org:10.1007/s12325-023-02547-5\u003c/li\u003e\n \u003cli\u003eSujon, H.\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e Beyond the regulatory radar: knowledge and practices of rural medical practitioners in Bangladesh. \u003cem\u003eBMC Health Serv Res\u003c/em\u003e \u003cstrong\u003e23\u003c/strong\u003e, 1322 (2023). https://doi.org:10.1186/s12913-023-10317-w\u003c/li\u003e\n \u003cli\u003eOkonofua FE, O. J., Omorodion FI, Temin MT, Coplan PA, Kaufman JA, Heggenhougen HK. Assessment of health services for treatment of sexually transmitted infections among Nigerian adolescents. \u003cem\u003eSex Transm Dis.\u003c/em\u003e \u003cstrong\u003e26\u003c/strong\u003e, 184-190 (1999). https://doi.org:10.1097/00007435-199903000-00010\u003c/li\u003e\n \u003cli\u003eAdamu, A. A., Gadanya, M. A., Jalo, R. I., Uthman, O. A. \u0026amp; Wiysonge, C. S. Factors influencing non-prescription sales of antibiotics among patent and proprietary medicine vendors in Kano, Nigeria: a cross-sectional study. \u003cem\u003eHealth Policy Plan\u003c/em\u003e \u003cstrong\u003e35\u003c/strong\u003e, 819-828 (2020). https://doi.org:10.1093/heapol/czaa052\u003c/li\u003e\n \u003cli\u003eUneke, C. J.\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e An assessment of nursing mothers\u0026apos; and young people\u0026apos;s access to proprietary and patent medicine vendors\u0026apos; services in rural communities of south-eastern Nigeria: implication for review of national drug policy. \u003cem\u003eJ Pharm Policy Pract\u003c/em\u003e \u003cstrong\u003e14\u003c/strong\u003e, 92 (2021). https://doi.org:10.1186/s40545-021-00334-7\u003c/li\u003e\n \u003cli\u003eOnah, C. K.\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e Practices toward presumptive tuberculosis clients among patent medicine vendors in Ebonyi State Nigeria. \u003cem\u003eInt J Mycobacteriol\u003c/em\u003e \u003cstrong\u003e10\u003c/strong\u003e, 71-78 (2021). https://doi.org:10.4103/ijmy.ijmy_2_21\u003c/li\u003e\n \u003cli\u003eNtim-Amponsah, C. T., Amoaku, W. M. K., \u0026amp; Ofosu-Amaah, S. Alternate eye care services in a Ghanaian district. \u003cem\u003eGhana Medical Journal\u003c/em\u003e \u003cstrong\u003e39\u003c/strong\u003e, 22-23 (2005). https://doi.org:10.4314/gmj.v39i1.35975\u003c/li\u003e\n \u003cli\u003eSamuel Osei-Asante, S. N. O.-D., Emmanuel Antwi and George Owusu-Dapaah. Medicine sales by itinerant vendors at lorry stations: A case study at Kejetia Station in Kumasi, Ghana. \u003cem\u003eJournal of Pharmaceutical Sciences and Research\u003c/em\u003e \u003cstrong\u003e13\u003c/strong\u003e, 438-443 (2021). https://doi.org:Not availabel\u003c/li\u003e\n \u003cli\u003eQidwai W, K. M., Hashmi S, Afridi M, Ali RA. Private drug sellers\u0026apos; education in improving prescribing practices. \u003cem\u003eJ Coll Physicians Surg Pak\u003c/em\u003e \u003cstrong\u003e16\u003c/strong\u003e, 743-746 (2006). https://doi.org:PMID: 17125630\u003c/li\u003e\n \u003cli\u003eSoms\u0026eacute; P, M.-Y. F., Morency P, Dubois MJ, Gr\u0026eacute;senguet G, P\u0026eacute;pin J. Quality of sexually transmitted disease treatments in the formal and informal sectors of Bangui, Central African Republic. \u003cem\u003eSex Transm Dis.\u003c/em\u003e \u003cstrong\u003e27\u003c/strong\u003e, 458-464 (2000). https://doi.org:10.1097/00007435-200009000-00007\u003c/li\u003e\n \u003cli\u003eNdoutamia, G., Fissou, H. Y., Nadjilem, D. \u0026amp; Gatsing, D. Perception, knowledge and use of antibiotic among communities in Chad. \u003cem\u003eAfrican Journal of Pharmacy and Pharmacology\u003c/em\u003e \u003cstrong\u003e11\u003c/strong\u003e, 260-265 (2017). https://doi.org:10.5897/ajpp2017.4791\u003c/li\u003e\n \u003cli\u003eOm, C., Daily, F., Vlieghe, E., McLaughlin, J. C. \u0026amp; McLaws, M. L. Pervasive antibiotic misuse in the Cambodian community: antibiotic-seeking behaviour with unrestricted access. \u003cem\u003eAntimicrob Resist Infect Control\u003c/em\u003e \u003cstrong\u003e6\u003c/strong\u003e, 30 (2017). https://doi.org:10.1186/s13756-017-0187-y\u003c/li\u003e\n \u003cli\u003eNair, M.\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e \u0026quot;Without antibiotics, I cannot treat\u0026quot;: A qualitative study of antibiotic use in Paschim Bardhaman district of West Bengal, India. \u003cem\u003ePLoS One\u003c/em\u003e \u003cstrong\u003e14\u003c/strong\u003e, e0219002 (2019). https://doi.org:10.1371/journal.pone.0219002\u003c/li\u003e\n \u003cli\u003eKhare, S., Pathak, A., Stalsby Lundborg, C., Diwan, V. \u0026amp; Atkins, S. Understanding Internal and External Drivers Influencing the Prescribing Behaviour of Informal Healthcare Providers with Emphasis on Antibiotics in Rural India: A Qualitative Study. \u003cem\u003eAntibiotics (Basel)\u003c/em\u003e \u003cstrong\u003e11\u003c/strong\u003e (2022). https://doi.org:10.3390/antibiotics11040459\u003c/li\u003e\n \u003cli\u003eSuy, S.\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e Invisible medicine sellers and their use of antibiotics: a qualitative study in Cambodia. \u003cem\u003eBMJ Glob Health\u003c/em\u003e \u003cstrong\u003e4\u003c/strong\u003e, e001787 (2019). https://doi.org:10.1136/bmjgh-2019-001787\u003c/li\u003e\n \u003cli\u003eKasse, G. E., Humphries, J., Cosh, S. M. \u0026amp; Islam, M. S. Factors contributing to the variation in antibiotic prescribing among primary health care physicians: a systematic review. \u003cem\u003eBMC Primary Care\u003c/em\u003e \u003cstrong\u003e25\u003c/strong\u003e, 8 (2024). https://doi.org:10.1186/s12875-023-02223-1\u003c/li\u003e\n \u003cli\u003eWilkinson, A., Ebata, A. \u0026amp; MacGregor, H. Interventions to Reduce Antibiotic Prescribing in LMICs: A Scoping Review of Evidence from Human and Animal Health Systems. \u003cem\u003eAntibiotics\u003c/em\u003e \u003cstrong\u003e8\u003c/strong\u003e (2019). 10.3390/antibiotics8010002\u003c/li\u003e\n \u003cli\u003eThapa, P.\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e Impact of WHO AWaRe Antibiotic Handbook training on antibiotics prescribing knowledge among primary care providers: A vignette-based, pre-post pilot study in Patna, India. \u003cem\u003emedRxiv\u003c/em\u003e, 2025.2009.2006.25335195 (2025). https://doi.org:10.1101/2025.09.06.25335195\u003c/li\u003e\n \u003cli\u003eChalker, J., Ratanawijitrasin, S., Chuc, N. T., Petzold, M. \u0026amp; Tomson, G. Effectiveness of a multi-component intervention on dispensing practices at private pharmacies in Vietnam and Thailand--a randomized controlled trial. \u003cem\u003eSoc Sci Med\u003c/em\u003e \u003cstrong\u003e60\u003c/strong\u003e, 131-141 (2005). https://doi.org:10.1016/j.socscimed.2004.04.019\u003c/li\u003e\n \u003cli\u003eYao, L.\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e The effects of the primary health care providers\u0026apos; prescription behavior interventions to improve the rational use of antibiotics: a systematic review. \u003cem\u003eGlob Health Res Policy\u003c/em\u003e \u003cstrong\u003e5\u003c/strong\u003e, 45 (2020). https://doi.org:10.1186/s41256-020-00171-2\u003c/li\u003e\n \u003cli\u003ePathak, D., Pathak, A., Marrone, G., Diwan, V. \u0026amp; Lundborg, C. S. Adherence to treatment guidelines for acute diarrhoea in children up to 12 years in Ujjain, India--a cross-sectional prescription analysis. \u003cem\u003eBMC Infect Dis\u003c/em\u003e \u003cstrong\u003e11\u003c/strong\u003e, 32 (2011). https://doi.org:10.1186/1471-2334-11-32\u003c/li\u003e\n \u003cli\u003eDas, J.\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e Use of standardised patients to assess quality of tuberculosis care: a pilot, cross-sectional study. \u003cem\u003eLancet Infect Dis\u003c/em\u003e \u003cstrong\u003e15\u003c/strong\u003e, 1305-1313 (2015). https://doi.org:10.1016/s1473-3099(15)00077-8\u003c/li\u003e\n \u003cli\u003eBezie, M. M.\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e Factors associated with the use of antibiotics for children presenting with illnesses with fever and cough obtained from prescription and non-prescription sources: a cross-sectional study of data for 37 sub-Saharan African countries. \u003cem\u003eBMC Public Health\u003c/em\u003e \u003cstrong\u003e24\u003c/strong\u003e, 1089 (2024). https://doi.org:10.1186/s12889-024-18490-1\u003c/li\u003e\n \u003cli\u003eHassan, M. Z.\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e Antibiotic use for acute respiratory infections among under-5 children in Bangladesh: a population-based survey. \u003cem\u003eBMJ Glob Health\u003c/em\u003e \u003cstrong\u003e6\u003c/strong\u003e (2021). https://doi.org:10.1136/bmjgh-2020-004010\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 3 are available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"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":"","lastPublishedDoi":"10.21203/rs.3.rs-8123464/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8123464/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eAntimicrobial stewardship programs largely focus on qualified physicians, overlooking informal healthcare providers (IPs) who deliver much of the primary care in low- and middle-income countries (LMICs). Although IPs frequently dispense antibiotics, their practices remain poorly researched and excluded from surveillance systems. Guided by the Joanna Briggs Institute methodology, this scoping review examined antibiotic dispensing and its determinants among IPs in LMICs. Nine databases were searched, identifying 10,109 records, of which 31 met the inclusion criteria. Twenty-seven studies reported wide variation in antibiotic dispensing, ranging from 18\u0026ndash;74% in standardised studies, 5\u0026ndash;100% in provider-reported studies, and 11\u0026ndash;86% in consumer-reported studies. Six qualitative studies identified key behavioural and contextual determinants, including limited knowledge of appropriate antibiotic use, learning through experience, patient expectations, peer influence, perceived consequences of not prescribing, and incentives. Antibiotic dispensing by IPs is widespread and represents a critical blind spot in antimicrobial resistance interventions.\u003c/p\u003e","manuscriptTitle":"Antibiotic dispensing practices and determinants among informal healthcare providers in low- and middle-income countries: a mixed-methods scoping review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-26 09:12:56","doi":"10.21203/rs.3.rs-8123464/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":"eb71f37e-0aac-4aa3-94dc-30a8447f7a5f","owner":[],"postedDate":"November 26th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":58465573,"name":"Health sciences/Diseases"},{"id":58465574,"name":"Health sciences/Health care"},{"id":58465575,"name":"Health sciences/Medical research"}],"tags":[],"updatedAt":"2025-12-02T16:53:11+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-26 09:12:56","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8123464","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8123464","identity":"rs-8123464","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}