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