Exploring Factors Influencing Antibiotic Dispensing Among Informal Healthcare Providers in Patna, India: A Theory-Informed Qualitative Exploration Using the COM-B Model and Theoretical Domains Framework

Antimicrobial resistance is a major global public health challenge, driven in part by inappropriate antibiotic use in community settings. In India, informal healthcare providers (IPs) frequently serve as the first point of contact for care, particularly in rural and peri-urban regions, and routinely dispense antibiotics despite lacking formal medical qualifications. While prior research has documented high levels of antibiotic use among this provider group, there remains a limited understanding of the behavioural, social, and contextual factors that shape antibiotic dispensing decisions in everyday practice. This qualitative study aims to explore the behavioural, social, and contextual determinants of antibiotic dispensing among IPs in Patna, India, using a theory-informed approach. Building on a WHO AWaRe Antibiotic Handbook–based training intervention conducted in 2024, the study seeks to move beyond knowledge-based explanations and examine how broader behavioural and contextual influences shape antibiotic dispensing practices. The study is informed by the Theoretical Domains Framework and the Capability, Opportunity, Motivation–Behaviour model, which together provide a structured lens for understanding the multiple drivers influencing provider behaviour and for generating theory-informed insights relevant to antibiotic stewardship. The study will employ an exploratory qualitative design grounded in a constructivist paradigm, recognizing that knowledge and meaning are co-constructed through interactions between participants and researchers. The study will be conducted in Patna, Bihar, India, in collaboration with a local non-governmental organization that supported the earlier intervention. Approximately 30 IPs who previously participated in the AWaRe training intervention will be purposively sampled to capture variation in age, years of practice, education, daily patient load, and level of uptake of the training content. Data will be collected through in-depth, semi-structured interviews conducted in Hindi by a trained qualitative researcher familiar with the local context. Interviews will last approximately 60 to 90 minutes and will take place in private locations convenient to participants. The interview guide will be informed by the Theoretical Domains Framework and insights from prior work and will include vignette-based scenarios designed to reflect common clinical situations, such as diagnostic uncertainty, patient expectations, and resource constraints. These vignettes will be used to elicit detailed accounts of decision-making processes related to antibiotic dispensing. All interviews will be audio-recorded with participant consent and transcribed for analysis. Data analysis will follow a framework analysis approach, involving familiarisation, coding, charting, and interpretation. Deductive coding will be guided by the domains of the Theoretical Domains Framework to systematically categorize behavioural determinants, while inductive coding will allow new themes to emerge from the data. Analysis will be iterative and ongoing, with regular discussion among the research team to refine codes and interpretations. Following thematic development, findings will be mapped onto the Capability, Opportunity, Motivation–Behaviour model to identify the underlying behavioural components that enable or constrain appropriate antibiotic dispensing practices. The expected outcomes of this study include an in-depth understanding of the behavioural mechanisms and contextual realities influencing antibiotic dispensing among IPs in rural and peri-urban settings in India. By applying the Theoretical Domains Framework and the Capability, Opportunity, Motivation–Behaviour model, the study will generate theory-informed insights to support the design of context-appropriate antibiotic stewardship interventions. Findings will be disseminated through peer-reviewed publications, conference presentations, and stakeholder engagement activities, with the longer-term aim of supporting rational antibiotic use and strengthening community-level antimicrobial stewardship efforts.