Building behaviour change systems for antimicrobial resistance response in Nigeria by leveraging insights from mass gatherings awareness efforts (2017–2023)

Introduction: The Stages of Change model describes how individuals move through different levels of new behaviour adoption, supported by internal cognitive processes and external infrastructure. In Nigeria, mass gatherings were leveraged to raise awareness about antimicrobial resistance (AMR). We aimed to review the use of mass gatherings for AMR awareness in Nigeria from 2017 to 2022, describe the 2023 Joint External Evaluation (JEE) AMR findings, and propose a SoC model for sustainable behaviour change. Methods: A desk review of AMR awareness initiatives from 2017 to 2022 was conducted. Additionally, secondary analyses of a 2018 U-report survey and a 2021 qualitative study on antibiotic use and AMR were conducted. Further, the 2023 JEE-AMR findings for the country were reviewed. Frequencies and proportions were generated, and co-occurrence network analysis and thematic coding were performed for qualitative data. Results: Overall, 125 AMR awareness activities were documented, mostly in 2019 (44%). Fifteen methods were used to engage stakeholders, including mass gatherings and social media. Behaviour change efforts occurred mainly in healthcare settings. Nigeria leveraged mass gatherings to launch a national Antibiotic Guardian Pledge Campaign virtually and to establish a hybrid multisectoral Community of Practice. A 2018 national poll showed that 49% of Nigerians had heard of AMR, while stating that taking antibiotics prevented AMR. A study in the Federal Capital Territory found that rural residents were unfamiliar with the term "AMR," while urban residents linked drug resistance to improper medicine use. Many respondents obtained antibiotics from pharmacies without a prescription. In selecting antibiotics, rural residents prioritised affordability, while urban residents focused on drug authenticity. The JEE-AMR score was 2.4/5 in 2023, with a multisectoral coordination mechanism for AMR response in place. However, the response was still mainly reliant on donor funding, and the enforcement of antibiotics being prescription-only was weak despite sustained awareness. Conclusion: Widespread practice of self-medication and purchasing antibiotics without prescriptions remains a significant challenge in Nigeria, driven by regulatory weaknesses and high healthcare costs. The SoC model emphasises the need for structural enablers to drive consistent behaviour change to combat AMR in Nigeria namely improving appropriate antibiotic use by strengthening the national antimicrobial stewardship programme and expanding access to health insurance .