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

Antimicrobial 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 18–74% 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.