{
  "abstract": "BackgroundAntimicrobial resistance (AMR) strategies frequently emphasize provider knowledge and public awareness, but prescribing behavior can also reflect practice routines, information sources, and facility context. We examined these relationships in a pluralistic primary-care system in three districts of Chhattisgarh, India.\n\nMethodsWe analysed three independently sampled cross-sectional components: a provider knowledge, attitudes, and practices (KAP) survey (n=171), a WHO/International Network for Rational Use of Drugs (WHO/INRUD) prescribing assessment (600 encounters from 20 government facilities), and 371 patient exit interviews. For providers, proportional-odds logistic regression modelled ordered cold/sore-throat antibiotic provision (none, some, most, all), adjusting for provider cadre, work setting, and years in practice; binary any-versus-none models were sensitivity analyses. We summarized WHO/INRUD indicators overall and by facility, and examined exploratory encounter-level antibiotic correlates with unadjusted and facility-adjusted models. We analysed patient satisfaction using multivariable binary logistic regression and perceived clarity using proportional-odds logistic regression.\n\nResultsProvider AMR awareness was 91.4% (149/163), 95.8% (160/167) agreed that antibiotics were overused nationally, and 58.3% (95/163) reported guideline familiarity. Guideline familiarity was not associated with lower cold/sore-throat antibiotic frequency (adjusted common OR 1.13, 95% CI 0.57-2.24; p=0.725). Each additional 5 years in practice was associated with greater odds of being in a higher prescribing-frequency category (adjusted common OR 1.36, 95% CI 1.09-1.70; p=0.006 before multiplicity correction). Medical-representative literature was a routine information source for 39.6% (65/164); its association with prescribing frequency was directionally positive but imprecise (adjusted common OR 1.89, 95% CI 0.88-4.07; p=0.104). In government facilities, 54.8% (329/600) encounters included an antibiotic, ranging from 16.7% to 80.0% by facility. Antibiotic-containing encounters had more drugs (2.88 vs 2.47; p<0.001), lower generic proportions (73.6% vs 80.7%; p=0.003), lower Essential Drugs List concordance (48.9% vs 63.8%; p<0.001), and more co-prescribed injections (15.2% vs 7.7%; p=0.007); several associations attenuated after accounting for facility. In exit interviews, 92.3% (131/142) of informal-provider encounters involved a reported injection, and informal providers accounted for 72.4% (131/181) of all reported injections. Clear/very clear instructions were strongly associated with satisfaction (adjusted OR 13.66, 95% CI 6.73-27.71; p<0.001; n=369).\n\nConclusionsIn these three districts, high provider AMR awareness coexisted with prescribing patterns not explained by awareness or guideline familiarity alone. The findings support prospective evaluation of point-of-care decision support, independent drug information, facility audit and feedback, targeted informal-provider engagement, and communication-focused stewardship. Generalization beyond the study districts requires caution.",
  "abstract_shown": true,
  "affiliations": [
    "Jan Swasthya Sahyog, Bilaspur, India"
  ],
  "article_type": "PUBLISHAHEADOFPRINT",
  "arxiv": null,
  "author_total": 5,
  "authors": [
    {
      "affs": [
        0
      ],
      "name": "D. Konar"
    },
    {
      "name": "D. Singh"
    },
    {
      "name": "G. A. Patil"
    },
    {
      "name": "I. Pradhan"
    },
    {
      "name": "R. Kataria"
    }
  ],
  "bibtex": "https://research.draconitic.com/paper/30p2k3nn66z1c.bib",
  "cited_by": 0,
  "doi": "10.64898/2026.09.24.26363886",
  "fulltext_url": "https://www.medrxiv.org/content/10.64898/2026.09.24.26363886v1.full",
  "id": "30p2k3nn66z1c",
  "issns": [],
  "landing_url": "https://www.medrxiv.org/content/10.64898/2026.09.24.26363886v1",
  "language": null,
  "licence": "CC-BY-NC-ND",
  "licence_label": "CC BY-NC-ND",
  "licence_source": "article",
  "licence_url": "https://creativecommons.org/licenses/by-nc-nd/4.0/",
  "metadata_licence": null,
  "native_subjects": [
    [
      "medrxiv",
      "health systems and quality improvement"
    ],
    [
      "openalex",
      "2402|Antibiotic Use and Resistance"
    ]
  ],
  "openalex": "W7214456523",
  "pdf_url": "https://www.medrxiv.org/content/10.64898/2026.09.24.26363886v1.full.pdf",
  "pmcid": null,
  "pmid": null,
  "published": "2026-09-24",
  "publisher": null,
  "ris": "https://research.draconitic.com/paper/30p2k3nn66z1c.ris",
  "sources": [
    {
      "first_seen": "2026-10-30T12:19:29Z",
      "native_id": "10.64898/2026.09.24.26363886",
      "source": "medrxiv",
      "url": "https://www.medrxiv.org/content/10.64898/2026.09.24.26363886v1"
    }
  ],
  "subjects": [
    {
      "field": "medicine",
      "origin": "medrxiv:health systems and quality improvement",
      "subfield": "epidemiology-public-health"
    }
  ],
  "title": "Diagnosing antimicrobial stewardship needs in a pluralistic health system in India: Why Local Evidence Must Guide Implementation",
  "title_text": "Diagnosing antimicrobial stewardship needs in a pluralistic health system in India: Why Local Evidence Must Guide Implementation",
  "type": "preprint",
  "updated_at": "2026-10-30T12:19:29Z",
  "url": "https://research.draconitic.com/paper/30p2k3nn66z1c",
  "venue": "medRxiv",
  "versions": []
}