Constructing a Theoretical Framework for Community-Level Antimicrobial Resistance Stewardship in Northern Nigeria: A Grounded Theory Investigation

Community-level antimicrobial stewardship in low- and middle-income countries requires contextually grounded theoretical frameworks that go beyond hospital-based models developed for high-income settings, yet no grounded theory of community stewardship has been constructed for Northern Nigeria's unique socioeconomic, cultural, and health system context. This qualitative grounded theory study, conducted across six communities in Kaduna, Sokoto, and Bauchi States, in the North West and North East geopolitical zones, aimed to generate a substantive theory of how community members, patent medicine vendors, community health workers, and local leaders conceptualize and navigate antibiotic use decisions. Forty-eight in-depth interviews, 12 focus group discussions, and six months of participant observation in market and community health settings were conducted. Data were analyzed using Charmaz's constructivist grounded theory approach with concurrent memo writing and theoretical sampling. The emerging theoretical framework, termed the Negotiated Access Model of Community Antibiotic Use, centers on the concept of situational antibiotic rationality, wherein cost, social trust, symptom urgency, and perceived treatment potency mediate antibiotic decision-making independent of formal medical advice. The model identifies three core processes: barrier navigation, social legitimation of self-treatment, and affordance exploitation of unregulated supply chains. This original theoretical contribution provides actionable design principles for contextually adapted community stewardship interventions across Northern Nigeria and provides a transferable qualitative framework for similar settings across sub-Saharan Africa. Keywords: antimicrobial stewardship, grounded theory, community antibiotic use, Northern Nigeria, qualitative research.