Community identity, poverty, and antimicrobial discontinuation in a Particularly Vulnerable Tribal Group in central India: a cross-sectional study of healthcare choice and differentiated stewardship

Background Antimicrobial stewardship in many settings assumes that community antimicrobial misuse reflects low awareness, and favours education-based interventions. Population-level evidence on healthcare seeking and antimicrobial practices in marginalised indigenous groups in low-income and middle-income countries is limited. We examined socioeconomic and identity-related determinants of healthcare-provider choice, antimicrobial awareness, and harmful antimicrobial practices in a tribal population in central India. Methods We did a cross-sectional survey of 1146 adults in the catchment area of Jan Swasthya Sahyog (JSS), a non-profit community health organisation, in Bilaspur and Mungeli districts, Chhattisgarh, India (January, 2021-April, 2022). Healthcare-provider choice was modelled with binary and multinomial logistic regression (government as reference), and antimicrobial awareness and ten harmful practices with logistic regression, applying Benjamini-Hochberg false discovery rate (FDR) correction within each family. A 30-day treatment-recall sub-study (n=284) assessed actual treatment location and out-of-pocket cost. Models with rare events or separation were refitted with Firth penalised regression. Findings Median per capita income was INR 8000 per year. Baiga identity was associated with higher odds of using informal (odds ratio 2.58) and private (2.55) providers rather than government facilities, but not JSS (1.36). Awareness of antimicrobials was 7.6% and was associated mainly with education (primary-or-less vs college 0.04). Baiga identity was independently associated with premature discontinuation (4.77), stopping for perceived intolerance (4.43), and financial discontinuation (6.81, 95% CI 3.51-13.25), but with lower odds of stopping because of perceived recovery (0.12). In the sub-study, predicted government-facility use was 1.6% for Baiga versus 18.1% for non-Baiga individuals. Findings were robust to Firth penalisation. Interpretation In this population, antibiotic non-completion was associated with poverty and access constraints rather than only with awareness, and a non-profit provider appeared to reach groups more equitably. Affordability-oriented, differentiated stewardship merits prospective evaluation. Findings are from a single catchment, are associational, and should be interpreted with the study's sampling in mind.