Abstract
<title>Abstract</title> <p>Background Antimicrobial resistance (AMR) poses an accelerating global health threat, with low- and middle-income countries (LMICs) bearing a disproportionate burden. Traditional antimicrobial stewardship (AMS) programs often fail to address the behavioral and financial drivers underlying inappropriate antibiotic use. Understanding the drivers of misuse is essential for designing interventions that strengthen stewardship and improve patient outcomes Methods A two-month prospective study was conducted in Dakar, Senegal, and Dar es Salaam, Tanzania, to understand key drivers for antimicrobial misuse among different groups. Semi-structured surveys on were administered to 287 participants (patients, clinicians, pharmacists, laboratory technicians) across public and private healthcare facilities. Additional interviews with key stakeholders supplemented survey data. Mixed methods data analysis mapped findings to a six-step antibiotic delivery pathway and seven recognized drivers of misuse. Results Approximately 50% of patients reported consideration of pharmacy-first access to antibiotics. Significant access barriers were identified for patients, who traveled three to five times farther to reach public versus private care. 18.5% of patients in Tanzania reported waiting over 60 minutes for care, compared to a median willingness to wait of 17.5 minutes. Only 43.2% of patients expected diagnostic testing before receiving a prescription, while 86.2% of clinicians reported prescribing antibiotics without test results. Less than 6% of pharmacists were found referring patients without prescriptions to clinicians. In Tanzania's private sector, only 38% of prescribed antibiotics were Access-category as defined by the WHO AWaRe prescribing framework. Conclusions Antibiotic misuse among patients in Senegal and Tanzania is associated with health system barriers, including long wait times, high costs, limited diagnostics, and inconsistent enforcement, that appear to normalize empirical prescribing and pharmacy-first care. Strengthening stewardship will likely require multi-faceted interventions that address financial incentives and access frictions across the care pathway.</p>