Barriers and facilitators to antibiotic stewardship in Nigeria's private healthcare sector: A qualitative interview study with national health and regulatory interest holders.

Antimicrobial resistance (AMR) poses a growing global health concern, particularly in low- and middle-income countries (LMICs) such as Nigeria, where stewardship efforts have largely overlooked the private healthcare sector. Given that most Nigerians seek care from private providers, understanding the barriers and opportunities for implementing antibiotic stewardship programs in this setting is critical. We conducted a qualitative study consisting of semi-structured interviews with 14 interest holders from national health and regulatory organizations in Nigeria. Participants were purposively selected for their expertise and leadership roles related to antibiotic use and regulation in Nigeria, ensuring representation from professional associations, federal agencies, and technical bodies. Interviews were conducted virtually between August and December 2024, transcribed verbatim, and thematically analyzed using Braun and Clarke's six-step framework. Codes were grouped into four thematic domains reflecting the roles of key actors (private sector, practitioners, government and health systems, and patients), and mapped to the Social-Ecological Model (SEM) to reflect individual, organizational, and policy-level influences. Participants identified multiple barriers to stewardship implementation in the private sector, including inconsistent prescribing practices, limited access to diagnostics, weak regulatory enforcement, and knowledge gaps among practitioners and patients. System-level constraints such as workforce shortages and fragmented AMR surveillance infrastructure were also cited. However, participants did highlight several facilitators, including licensing-linked training requirements, institutional partnerships, and openness within the private sector to adopt stewardship initiatives. Recommended strategies included standardized training programs, development of prescribing guidelines and protocols, performance-based incentives, and community-based public awareness campaigns. This study underscores the urgent need for targeted, context-sensitive stewardship strategies tailored to Nigeria's private healthcare sector. Engagement with interest holders revealed both systemic challenges and actionable opportunities to strengthen antibiotic stewardship and support broader AMR control efforts.