In 2024, the European Centre for Disease Prevention and Control (ECDC) launched RespiCompass, a scenario modelling hub for infectious respiratory diseases. The hub uses an ensemble approach, whereby projections from models developed by separate groups are combined to obtain mid-to-long term scenario-based projections. RespiCompass provides outputs designed to help public health experts and authorities assess respiratory virus risks and evaluate the potential impact of interventions, including vaccination. In building RespiCompass, ECDC has convened modelling teams, disease experts, and policymakers to work together in identifying policy-relevant questions, designing scenario rounds, and interpreting multi-model outputs. Drawing on lessons from other modelling hubs, RespiCompass successfully navigated the complex challenges of its first year, fostering cross-sector collaboration and delivering timely insights for the 2024/25 respiratory virus season. This article describes RespiCompass and distils key operational, technical, and collaborative lessons to inform future initiatives; the quantitative results from the first round are reported separately. 1

Background Understanding the causes of death is essential for implementing evidence-based strategies to reduce child mortality. In light of this, the present study assessed the causes of under-five child mortality using verbal autopsy methods in the Tigray Region, Northern Ethiopia. Methods A retrospective cross-sectional study was conducted in six districts of the Tigray Region. Health extension workers administered verbal autopsy interviews for all under-five child deaths that occur between May 1, 2013, and July 31, 2013. The 2014 WHO standardized verbal autopsy questionnaires were utilized for data collection. The causes of death were determined using the InterVA-4 algorithm, and cause-specific mortality proportions were calculated using SPSS software. Result A total of 469 under-5 child deaths were reported, and verbal autopsy data was collected for 393 (87.0%) deceased children. Infectious disease attribute for (80.4%) in the post neonatal deaths, including diarrheal disease (23.0%), malaria (20.0%), acute respiratory infection (18.5%), severe malnutrition (9.1%) and HIV/AIDS (8.7%) were the major causes of death. While neonatal pneumonia (35.9%), neonatal sepsis (25.0%), prematurity (18.8%), and birth asphyxia (12.5%) were of the major causes of death attributing to 92.2% neonatal deaths. Conclusion The study has provided reliable estimates of the common causes of under-five child deaths, emphasizing the potential to deliver valuable information for decision-making at district and regional levels. It also enhances coordination and data sharing with the vital events registration system to improve the accuracy and timeliness of child mortality data.

BACKGROUND One Health (OH) is a multisectoral approach that aims to optimise health of people, animals and the environment, recognising their interconnection. Despite gaining political support in recent years, examples of successful OH implementation among governmental institutions across the European Union/European Economic Area (EU/EEA) remain limited. AIM To identify key enablers and barriers to collaboration across human, animal and environmental health sectors, and provide a framework to support national OH operationalisation in the EU/EEA. METHODS Semi-structured interviews were conducted with 26 experts from national public health institutes in 15 EU/EEA countries, recruited through European Centre for Disease Prevention and Control networks. Transcripts were analysed through qualitative content analysis. RESULTS Collaborations between human and animal health sectors were reported, but greater integration of the environmental sector is needed to strengthen OH partnerships. Analysis of opportunities and challenges highlighted key interlinked elements that can facilitate sustainable OH implementation. Strong political leadership emerged as pivotal to drive policy coherence in nexus areas, embed collaborative activities within core funding, and facilitate cross-sectoral partnerships at the technical level. CONCLUSION This qualitative study provides an overview of enablers and barriers to OH collaboration at the national level. The findings constitute the basis for an empirically derived framework emphasising the cyclical relationship between political leadership and cross-sectoral technical collaboration. Incremental steps, starting with strengthening existing cross-sectoral relationships, have the potential to generate self-reinforcing progress and enhance emergency preparedness. These empirical insights provide a foundation for developing and evaluating OH policies in EU/EEA countries, complementing existing international guidelines.

Resumo Profissionais de saúde constituem uma categoria fundamental para orientar a população sobre diversos problemas de saúde e medidas eficazes de prevenção. Apesar disso, até o momento não foram identificados estudos no Brasil que analisem conhecimentos e orientações realizadas sobre o vírus Zika por profissionais de saúde. Objetivou-se compreender as percepções, os conhecimentos e as orientações desenvolvidas por profissionais de saúde de Salvador-Bahia sobre o vírus Zika no contexto pós-epidemia. Trata-se de um estudo qualitativo, desenvolvido através de 13 entrevistas semiestruturadas. Os dados demonstraram que os profissionais de saúde tinham a percepção de não estar adequadamente preparados, mesmo no pós-epidemia, para o enfrentamento do vírus Zika. Situação evidenciada por insuficiências no conhecimento sobre aspectos importantes desta arbovirose. Ademais, as orientações no curso da epidemia responsabilizaram a população por mitigar o risco de infecção, restringindo-se à reprodução dos discursos das autoridades sanitárias, desconsiderando as vulnerabilidades socioambientais. Para além da capacitação dos profissionais e das recomendações apropriadas em saúde, é necessário que os determinantes sociais que propiciam distintos níveis de suscetibilidade ao adoecimento sejam efetivamente transformados.

Abstract Background Since February 2022, millions of Ukrainian women and children have fled their home country. Evidence suggests that vaccination coverage among Ukrainian refugee children is sub-optimal. We therefore tested the effect of three messages on mothers’ intention to vaccinate their children, and on scheduling a vaccination appointment. Methods The UNICEF-funded project (SBC office) 'Say Yes to Vaccinations’ conducted an online randomized controlled trial among Ukrainian refugee mothers residing in Poland who had at least one child under 7 years of age. Participants were randomized to 1 of 3 intervention groups or to the control group. Intervention messages encouraged vaccination with a specific frame: 1) trust in the Polish healthcare system, 2) ease of access to vaccination, 3) risk aversion (highlighting the vulnerability to diseases due to emergency). Primary outcomes included intention to get a child vaccinated in Poland and clicking on a link to schedule a vaccination appointment. Results 3,282 women entered the survey, 1,233 did not meet the inclusion criteria. A total of 1,910 Ukrainian mothers completed the study, 33% had fully vaccinated children. The mothers who read the risk aversion message were significantly more likely to intend to get their children vaccinated in Poland (AOR 2.35; 95% CI 1.25-4.42). 31% of the participants in the risk aversion intervention groups clicked on the link to make the appointment compared with 25% in the control group, which translated into an AOR of 1.53 (95% CI 1.12-2.09). The messages focused on trust and ease of access did not result in increased vaccination intention or clicking on the link. Getting vaccination information from social media was associated with increased vaccination intention (AOR 1.91; 95% CI 1.21-3.00), not trusting anyone for vaccination information, however, was associated with decreased vaccination intentions (AOR 0.34; 95% CI 0.11-1.00). Conclusion We found that framing a pro-vaccination message around risk aversion resulted in increased intention to vaccinate and more clicks on a vaccination scheduler. Health workers who interact with Ukrainian refugees could use the risk aversion frame when communicating around vaccination, highlighting the vulnerable situation faced by refugees. Disclosures Saad Omer, MBBS MPH PhD, Meta: Advisor/Consultant|Meta: Grant/Research Support

Health professionals are a fundamental category to guide the population about various health problems and effective prevention measures. Despite this, so far, no studies have been identified in Brazil that analyze knowledge and guidance given about the zika virus by health professionals. The objective was to understand the perceptions, knowledge and guidelines developed by health professionals in Salvador-Bahia about the zika virus in the post-epidemic context. This is a qualitative study, developed through 13 semi-structured interviews. The data showed that health professionals had the perception of not being adequately prepared, even in the post-epidemic, to face the zika virus. Situation evidenced by insufficiencies in knowledge about important aspects of this arbovirus. Furthermore, guidelines in the course of the epidemic made the population responsible for mitigating the risk of infection, restricting themselves to the reproduction of the speeches of health authorities, disregarding socio-environmental vulnerabilities. In addition to professional training and appropriate health recommendations, it is necessary that the social determinants that provide different levels of susceptibility to illness are effectively transformed.

Background: Since February 2022, the start of the fullscale war in Ukraine, millions of women and children have fled the country. Vaccination of refugee children is important to protect this vulnerable population from disease. Aim: We investigate the determinants of vaccination intention in refugee mothers from Ukraine residing in Poland and test the effect of three message frames. Methods: Participants were randomised into either a control group or one of three intervention groups encouraging vaccination using a specific frame: (i) trust in the Polish health system, (ii) ease of access to vaccination or (iii) risk aversion. Primary outcomes were intention to vaccinate a child in Poland and clicking on a vaccination scheduling link. Results: The study was completed by 1,910 Ukrainian refugee mothers. Compared with the control group, the risk aversion message significantly increased vaccination intention (adjusted odds ratio (AOR): 2.35, 95% confidence interval (CI): 1.25-4.42) and clicking on the vaccine scheduling link (AOR: 1.53, 95% CI: 1.12- 2.09). Messages around trust and ease of access did not have an effect. Important determinants of vaccination intention were perceived importance of vaccination (AOR: 1.12 95% CI: 1.01-1.25) and trusting vaccination information official health institutes (AOR: 1.40 95% CI: 1.06-1.83) and social media (AOR: 2.09 95% CI: 1.33-3.27). Discussion: Using a risk aversion frame highlighting the vulnerability to infection that refugees face resulted in increased vaccination intention and clicks on a vaccination scheduler. Health workers who interact with Ukrainian refugees could use this frame in their vaccination communication.

Objectives To assess completeness and accuracy of the family folder in terms of capturing community-level health data.Study design A capture–recapture method was applied in six randomly selected districts of Tigray Region, Ethiopia.Participants Child health data, abstracted from randomly selected 24 073 family folders from 99 health posts, were compared with similar data recaptured through household survey and routine health information made by these health posts.Primary and secondary outcome measures Completeness and accuracy of the family folder data; and coverage selected child health indicators, respectively.Results Demographic data captured by the family folders and household survey were highly concordant, concordance correlation for total population, women 15–49 years age and under 5-year child were 0.97 (95% CI 0.94 to 0.99, p<0.001), 0.73 (95% CI 0.67 to 0.88) and 0.91 (95% CI 0.85 to 0.96), respectively. However, the live births, child health service indicators and child health events were more erratically reported in the three data sources. The concordance correlation among the three sources, for live births and neonatal deaths was 0.094 (95% CI −0.232 to 0.420) and 0.092 (95% CI −0.230 to 0.423) respectively, and for the other parameters were close to 0.Conclusion The family folder system comprises a promising development. However, operational issues concerning the seamless capture and recording of events and merging community and facility data at the health centre level need improvement.

The capacity to deliver programmes that prevent and control infectious diseases is a key public health function. The European Centre for Disease Prevention and Control (ECDC) aims to support and strengthen this capacity in European Union/ European Economic Area (EU/EEA) countries as part of its 2021-27 strategy which includes explicit attention to social and behavioural aspects of disease prevention. To achieve its strategic goals, it is important that ECDC improves its knowledge of prevention strategies, actors and activities in EU/EEA countries. In this Perspective, we summarise three challenges to implementing the prevention framework proposed by ECDC: (i) defining, recognising and identifying with 'prevention', (ii) integrating new understandings into established ways of thinking, and (iii) the need for more attention to prevention in governance. These challenges are derived from the findings of a project which conducted a preliminary mapping of prevention actors, networks and activities in four EU countries to support the development of a community of practice within the new ECDC prevention framework. This Perspective serves to draw attention to this prevention framework and the three identified challenges for those working on its implementation.

Behavioural sciences have complemented medical and epidemiological sciences in the response to the SARS-CoV-2 pandemic. As vaccination uptake continues to increase across the EU/EEA - including booster vaccinations - behavioural science research remains important for both pandemic policy, planning of services and communication. From a behavioural perspective, the following three areas are key as the pandemic progresses: (i) attaining and maintaining high levels of vaccination including booster doses across all groups in society, including socially vulnerable populations, (ii) informing sustainable pandemic policies and ensuring adherence to basic prevention measures to protect the most vulnerable population, and (iii) facilitating population preparedness and willingness to support and adhere to the reimposition of restrictions locally or regionally whenever outbreaks may occur. Based on mixed-methods research, expert consultations, and engagement with communities, behavioural data and interventions can thus be important to prevent and effectively respond to local or regional outbreaks, and to minimise socioeconomic and health disparities. In this Perspective, we briefly outline these topics from a European viewpoint, while recognising the importance of considering the specific context in individual countries.

Objective The World Health Organization declared a Public Health Emergency of International Concern following the rapid emergence of neonatal microcephaly in Brazil during the 2015-2016 Zika virus (ZIKV) epidemic. In response, a national campaign sought to control Aedes mosquito populations and reduce ZIKV transmission. Achieving adherence to vector control or mosquito-bite reduction behaviours, including the use of topical mosquito repellents, is challenging. Coproduction of research at the community level is needed to understand and mitigate social determinants of lower engagement with Aedes preventive measures, particularly within disempowered groups. Design In 2017, the Zika Preparedness Latin America Network (ZikaPLAN) conducted a qualitative study to understand individual and community level experiences of ZIKV and other mosquito-borne disease outbreaks. Presented here is a thematic analysis of 33 transcripts from community focus groups and semistructured interviews, applying the Health Belief Model (HBM) to elaborate knowledge, attitudes and perceptions of ZIKV and vector control strategies. Participants 120 purposively sampled adults of approximate reproductive age (18-45); 103 women participated in focus groups and 17 men in semistructured interviews. Setting Two sociopolitically and epidemiologically distinct cities in Brazil: Jundiai (57 km north of Sao Paolo) and Salvador (Bahia state capital). Results Four key and 12 major themes emerged from the analysis: (1) knowledge and cues to action; (2) attitudes and normative beliefs (perceived threat, barriers, benefits and self-efficacy); (3) behaviour change (household prevention and community participation); and (4) community preferences for novel repellent tools, vector control strategies and ZIKV messaging. Conclusions Common barriers to repellent adherence were accessibility, appearance and effectiveness. A strong case is made for the transferability of the HBM to inform epidemic preparedness for mosquito-borne disease outbreaks at the community level. Nationally, a health campaign targeting men is recommended, in addition to local mobilisation of funding to strengthen surveillance, risk communication and community engagement.

Many countries, including some within the EU/EEA, are in the process of transitioning from the acute pandemic phase. During this transition, it is crucial that countries' strategies and activities remain guided by clear COVID-19 control objectives, which increasingly will focus on preventing and managing severe outcomes. Therefore, attention must be given to the groups that are particularly vulnerable to severe outcomes of SARS-CoV-2 infection, including individuals in congregate and healthcare settings. In this phase of pandemic management, a strong focus must remain on transitioning testing approaches and systems for targeted surveillance of COVID-19, capitalising on and strengthening existing systems for respiratory virus surveillance. Furthermore, it will be crucial to focus on lessons learned from the pandemic to enhance preparedness and to enact robust systems for the preparedness, detection, rapid investigation and assessment of new and emerging SARS-CoV-2 variants. Filling existing knowledge gaps, including behavioural insights, can help guide the response to future resurgences of SARS-CoV-2 and/or the emergence of other pandemics. Finally, 'vaccine agility' will be needed to respond to changes in people's behaviours, changes in the virus, and changes in population immunity, all the while addressing issues of global health equity.

Introduction: The Västerbotten Intervention Programme (VIP) in the Region Västerbotten Sweden is one of the very few cardiovascular disease (CVD) prevention programmes globally that is integrated into routine primary health care. The VIP has been shown as a cost-effective intervention to significantly reduce CVD mortality. However, little is known about the effectiveness of a digital solution to tailor risk communication strategies for supporting behavioral change. STAR-C aims to develop and evaluate a technical platform for personalized digital coaching that will support behavioral change aimed at preventing CVD. Methods: STAR-C employs a mixed-methods design in seven multidisciplinary projects, which runs in two phases during 2019–2024: (i) a formative intervention design and development phase, and (ii) an intervention implementation and evaluation phase. In the 1st phase, STAR-C will model the trajectories of health behaviors and their impact on CVDs (Project 1), evaluate the role of the social environment and social networks on behavioral change (Project 2) and assess whether and how social media facilitates the spread of health information beyond targeted individuals and stimulates public engagement in health promotion (Project 3). The findings will be utilized in carrying out the iterative, user-centered design, and development of a person-tailored digital coaching platform (Project 4). In the 2nd phase, STAR-C will evaluate the implementation of the coaching programme and its effectiveness for promoting behavioral change and the spreading of health information across social networks and via social media (Project 5). The cost-effectiveness (Project 6) and ethical issues (Project 7) related to the coaching programme intervention will be evaluated. Discussion: The STAR-C research programme will address the knowledge and practice research gaps in the use of information technologies in health promotion and non-communicable disease (NCD) prevention programmes in order to narrow the health inequality gaps. Ethics: STAR-C has received approval from the Swedish Ethical Review Authority (Dnr. 2019-02924;2020-02985). Dissemination: The collaboration between Umeå University and Region Västerbotten will ensure the feasibility of STAR-C in the service delivery context. Results will be communicated with decision-makers at different levels of society, stakeholders from other regions and healthcare professional organizations, and through NGOs, local and social media platforms.

Background While several studies have assessed knowledge, attitudes and behaviours of the public, physicians and medical students in a number of EU/EEA countries with respect to antibiotic use and antibiotic resistance, there is a paucity of literature for other healthcare workers. This survey aimed to fill this gap. Methods A 43-item online questionnaire was developed, validated and pilot-tested through a modified Delphi consensus process involving 87 Project Advisory Group (PAG) members, including national representatives and members of European health professional groups. The survey was distributed by the PAG and via social media to healthcare workers in 30 EU/EEA countries. Results Respondents (n = 18,365) from 30 EU/EEA countries participated. Knowledge of antibiotics and antibiotic use was higher (97%) than knowledge of development and spread of antibiotic resistance (75%). Sixty percent of respondents stated they had received information on avoiding unnecessary prescribing, administering or dispensing of antibiotics. Among respondents who prescribed, administered or dispensed antibiotics, 55% had provided advice on prudent antibiotic use or management of infections to patients, but only 17% had given resources (leaflets or pamphlets). For community and hospital prescribers, fear of patient deterioration or complications was the most frequent reason (43%) for prescribing antibiotics that were considered unnecessary. Community prescribers were almost twice as likely as hospital prescribers to prescribe antibiotics due to time constraints or to maintain patient relationships. Conclusion It is important to move from raising awareness about prudent antibiotic use and antibiotic resistance among healthcare workers to designing antimicrobial stewardship interventions aimed at changing relevant behaviours.

Migrants have been disproportionately impacted by COVID-19 and emerging evidence suggests they may face barriers to COVID-19 vaccination. Participatory approaches and engagement strategies are urgently needed to strengthen uptake, alongside innovative delivery mechanisms and sharing of best practice, to ensure migrants are better consider within countries’ existing vaccine priority structures.

Background Communities affected by infectious disease outbreaks are increasingly recognised as partners with a significant role to play during public health emergencies. This paper reports on a qualitative case study of the interactions between affected communities and public health institutions prior to, during, and after two emerging tick-borne disease events in 2016: Crimean-Congo Haemorrhagic Fever in Spain, and Tick-Borne Encephalitis in the Netherlands. The aim of the paper is to identify pre-existing and emergent synergies between communities and authorities, and to highlight areas where synergies could be facilitated and enhanced in future outbreaks. Methods Documentary material provided background for a set of semi-structured interviews with experts working in both health and relevant non-health official institutions (13 and 21 individuals respectively in Spain and the Netherlands), and focus group discussions with representatives of affected communities (15 and 10 individuals respectively). Data from all sources were combined and analysed thematically, initially independently for each country and then for both countries together. Results Strong synergies were identified in tick surveillance activities in both countries, and the value of pre-existing networks of interest groups for preparedness and response activities was recognised. However, authorities also noted that there were hard-to-reach and potentially vulnerable groups, such as hikers, foreign tourists, and volunteers working in green areas. While the general population received preventive information about the two events, risk communication or other community engagement efforts were not seen as necessary specifically for these sub-groups. Post-event evaluations of community engagement activities during the two events were limited, so lessons learned were not well documented. Conclusions A set of good practices emerged from this study, that could be applied in these and other settings. They included the potential value of conducting stakeholder analyses of community actors with a stake in tick-borne or other zoonotic diseases; of utilising pre-existing stakeholder networks for information dissemination; and of monitoring community perceptions of any public health incident, including through social media. Efforts in the two countries to build on the community engagement activities that are already in place could contribute to better preparedness planning and more efficient and timely responses in future outbreaks.

Europe is in the midst of a COVID-19 epidemic and a number of non-pharmaceutical public health and social measures have been implemented, in order to contain the transmission of severe acute respiratory syndrome coronavirus 2. These measures are fundamental elements of the public health approach to controlling transmission but have proven not to be sufficiently effective. Therefore, the European Centre for Disease Prevention and Control has conducted an assessment of research gaps that can help inform policy decisions regarding the COVID-19 response. We have identified research gaps in the area of non-pharmaceutical measures, physical distancing, contact tracing, transmission, communication, mental health, seasonality and environment/climate, surveillance and behavioural aspects of COVID-19. This prioritisation exercise is a step towards the global efforts of developing a coherent research road map in coping with the current epidemic but also developing preparedness measures for the next unexpected epidemic.

ObjectivesTo understand the barriers contributing to the more than threefold decline in the number of deaths (of all causes) reported to a national toll free telephone line (1-1-7) after the 2014–2016 Ebola outbreak ended in Sierra Leone and explore opportunities for improving routine death reporting as part of a nationwide mortality surveillance system.DesignAn exploratory qualitative assessment comprising 32 in-depth interviews (16 in Kenema district and 16 in Western Area). All interviews were audio-recorded, transcribed and analysed using qualitative content analysis to identify themes.SettingParticipants were selected from urban and rural communities in two districts that experienced varying levels of Ebola cases during the outbreak. All interviews were conducted in August 2017 in the post-Ebola-outbreak context in Sierra Leone when the Sierra Leone Ministry of Health and Sanitation was continuing to mandate reporting of all deaths.ParticipantsFamily members of deceased persons whose deaths were not reported to the 1-1-7 system.ResultsDeath reporting barriers were driven by the lack of awareness to report all deaths, lack of services linked to reporting, negative experiences from the Ebola outbreak including prohibition of traditional burial rituals, perception that inevitable deaths do not need to be reported and situations where prompt burials may be needed. Facilitators of future willingness to report deaths were largely influenced by the perceived communicability and severity of the disease, unexplained circumstances of the death that need investigation and the potential to leverage existing death notification practices through local leaders.ConclusionsSocial mobilisation and risk communication efforts are needed to help the public understand the importance and benefits of sustained and ongoing death reporting after an Ebola outbreak. Localised practices for informal death notification through community leaders could be integrated into the formal reporting system to capture community-based deaths that may otherwise be missed.

Background The outbreak of Zika virus in Brazil in 2015 followed the arrival of chikungunya in 2014 and a long history of dengue circulation. Vital to the response to these outbreaks of mosquito-borne pathogens has been the dissemination of public health messages, including those promoted through risk communication posters. This study explores the content of a sample of posters circulated in Brazil towards the end of the Zika epidemic in 2017 and analyses their potential effectiveness in inducing behaviour change. Methods A content analysis was performed on 37 posters produced in Brazil to address outbreaks of mosquito-borne pathogens. The six variables of the Health Belief Model were used to assess the potential effectiveness of the posters to induce behaviour change. Results Three overarching key messages emerged from the posters. These included (i) the arboviruses and their outcomes, (ii) a battle against the mosquito, and (iii) a responsibility to protect and prevent. Among the six variables utilised through the Health Belief Model, cues to action were most commonly featured, whilst the perceived benefits of engaging in behaviours to prevent arbovirus transmission were the least commonly featured. Conclusions The posters largely focused on mosquito-borne transmission and the need to eliminate breeding sites, and neglected the risk of the sexual and congenital transmission of Zika and the importance of alternative preventive actions. This, we argue, may have limited the potential effectiveness of these posters to induce behaviour change.

BackgroundAntimicrobial misuse is common in low-income and middle-income countries (LMICs), and this practice is a driver of antibiotic resistance. We compared community-based antibiotic access and use practices across communities in LMICs to identify contextually specific targets for interventions to improve antibiotic use practices.MethodsWe did quantitative and qualitative assessments of antibiotic access and use in six LMICs across Africa (Mozambique, Ghana, and South Africa) and Asia (Bangladesh, Vietnam, and Thailand) over a 2·5-year study period (July 1, 2016–Dec 31, 2018). We did quantitative assessments of community antibiotic access and use through supplier mapping, customer exit interviews, and household surveys. These quantitative assessments were triangulated with qualitative drug supplier and consumer interviews and discussions.FindingsVietnam and Bangladesh had the largest proportions of non-licensed antibiotic dispensing points. For mild illness, drug stores were the most common point of contact when seeking antibiotics in most countries, except South Africa and Mozambique, where public facilities were most common. Self-medication with antibiotics was found to be widespread in Vietnam (55·2% of antibiotics dispensed without prescription), Bangladesh (45·7%), and Ghana (36·1%), but less so in Mozambique (8·0%), South Africa (1·2%), and Thailand (3·9%). Self-medication was considered to be less time consuming, cheaper, and overall, more convenient than accessing them through health-care facilities. Factors determining where treatment was sought often involved relevant policies, trust in the supplier and the drug, disease severity, and whether the antibiotic was intended for a child. Confusion regarding how to identify oral antibiotics was revealed in both Africa and Asia.InterpretationContextual complexities and differences between countries with different incomes, policy frameworks, and cultural norms were revealed. These contextual differences render a single strategy inadequate and instead necessitate context-tailored, integrated intervention packages to improve antibiotic use in LMICs as part of global efforts to combat antibiotic resistance.FundingWellcome Trust and Volkswagen Foundation.