Sociocultural Determinants of Antimicrobial Resistance in the Islamic Republic of Iran: A Qualitative Study

doi:10.21203/rs.3.rs-5319044/v1

Download PDF

Research Article

Sociocultural Determinants of Antimicrobial Resistance in the Islamic Republic of Iran: A Qualitative Study

https://doi.org/10.21203/rs.3.rs-5319044/v1

This work is licensed under a CC BY 4.0 License

You are reading this latest preprint version

Introduction:

Addressing antimicrobial resistance (AMR) requires consideration of the One Health approach and the sociocultural context unique to each country. This study aimed to examine the sociocultural factors influencing the development of AMR in Iran.

Methods

This qualitative study employed in-depth, face-to-face interviews. A total of 57 policymakers, managers, and service providers from both human and animal health sectors were interviewed using purposive and snowball sampling methods. The data were analyzed using framework analysis.

Findings

The study identified several factors contributing to the development of AMR, including demographic changes, improper drug use by the public, cultural challenges for service providers, lack of awareness and knowledge among livestock farmers, and general public attitudes toward drug use.

Conclusion

Sociocultural factors in both the human and animal health sectors significantly influence the use of antimicrobial drugs and the escalation of AMR across different ecosystems. The wide range of sociocultural influences among various stakeholders—such as service providers (physicians and veterinarians), the general public, and livestock farmers—highlights the necessity for policymakers to consider these groups when planning interventions to control AMR.

Sociocultural factors

Antimicrobial resistance

Antimicrobial overuse

Antimicrobial resistance (AMR) has emerged as a growing public health threat, raising widespread global concern. AMR jeopardizes the achievements of modern medicine, and countries are increasingly paying more attention to this issue. The post-antibiotic era—where common infections and minor injuries could become fatal—is not a dystopian fantasy but a realistic possibility for the 21st century(1). World Bank research indicates that AMR could reduce the GDP of low-income countries by more than 5% and push 28 million people, primarily in developing countries, into poverty by 2050(2). Without serious interventions to control AMR, it is projected that by 2050, there could be 10 million deaths annually, along with a financial and human cost of $100 trillion (3).

The World Health Organization, in its Global Action Plan on Antimicrobial Resistance, places significant emphasis on adopting the "One Health" approach and garnering support from all sectors and disciplines (4). However, countries in the Eastern Mediterranean Region, including Iran, face challenges in controlling AMR, such as a lack of coordination and integration among various sectors, resource shortages, a fragmented healthcare system, weak surveillance, and gaps in knowledge and health literacy among the population(5). According to national data, Iran is among the countries reporting high levels of multidrug resistance to seven bacteria that are of the greatest international concern (1). Various studies conducted in Iran over time indicate a high rate of irrational antimicrobial use, which is the most significant risk factor for AMR(6–8).

Over the years, Iran has implemented several interventions, such as establishing the National Committee for Rational Drug Use, setting up hospital infection control committees, developing a hospital infection surveillance system, drafting a national action plan to control AMR, and conducting various awareness-raising campaigns(5, 9). The process of AMR development and its spread across different ecosystems—human, animal, and environmental—is influenced by the complex and dynamic interplay of environmental, biological, technological, economic, and sociocultural factors. Efforts to control AMR are unlikely to be effective without understanding the sociocultural context, including public beliefs and patient-doctor relationships(10).

The overuse, misuse, and underuse of antimicrobial agents are major contributors to the development of AMR (3, 4, 11). In Iran, factors such as low professional competence among physicians, limited informational resources and practice guidelines, ineffective oversight of rational prescribing, and an unsuitable context for rational drug use have been identified as barriers to appropriate antimicrobial prescribing. Misconceptions about antimicrobials among the public, the insistence by patients on irrational antimicrobial prescriptions, and the over-the-counter purchase of these drugs by the public are key sociocultural factors contributing to the inappropriate prescribing context(12).

Other sociocultural factors influencing irrational drug use in Iran include a tendency towards self-medication, low patient awareness of the dangers of irrational drug use, improper drug consumption by patients (e.g., altering dosages, self-initiated discontinuation, or changing the timing of medication), the influence of others' recommendations on drug use, and the excessive consumption of herbal and traditional medicines(13). Behavioral issues among all stakeholders—from the public to physicians and livestock breeders—play a significant role in the emergence of AMR. Some aspects of AMR are behaviorally driven and must be examined within the specific context of each country(14). Therefore, this study aimed to examine the sociocultural factors contributing to the development of AMR in Iran.

Study Design

This study employed a qualitative research design using in-depth interviews to identify, understand, and explore the sociocultural factors influencing antimicrobial resistance (AMR) in Iran.

Sample

Participants were selected through purposive and snowball sampling methods. Initially, key informants were identified within relevant organizations and institutions, such as the Ministry of Health and the Veterinary Organization. At the end of each interview, participants were asked to recommend other experts they knew. To ensure comprehensive coverage of all issues related to the study, efforts were made to include participants from various organizations and stakeholders with diverse perspectives and roles.

The interviewees included managers and policymakers working in the Deputy of Treatment, the Deputy of Health, the Food and Drug Administration, the Health Insurance Organization, members of the Health Commission of the Islamic Consultative Assembly, managers from the Veterinary Organization and the Veterinary System, members of the Supreme Council of Health and Food Security, microbiology associations, infectious disease specialists, managers and technical experts from the Communicable Diseases Control Center, infection control specialists, researchers in the field of antimicrobial resistance, and faculty members and experts in health policy and food safety.

In total, 57 individuals were interviewed, comprising 36 men and 21 women, with an average of 18 years of work experience among the interviewees.

Data Collection

Before the face-to-face interviews, participants were sent research information and consent forms via email. Only one person declined to participate. One of the researchers conducted the interviews individually, with all but one being recorded with the participant's consent and transcribed verbatim. In the one case where recording was not possible, detailed notes were taken. Two participants were interviewed twice, resulting in a total of 59 interviews, with an average duration of 55 minutes each

Data Analysis

Data analysis began concurrently with data collection and continued until data saturation was achieved, meaning no new codes emerged. Saturation occurs when no new information is obtained. The interviews were analyzed using the Ritchie and Spencer framework analysis method(15), which involves five stages: familiarization, identifying a thematic framework, indexing, charting, and interpretation. To enhance the generalizability and validity of the study, measures such as maximum variation sampling, peer debriefing, conducting pilot interviews, and obtaining feedback from participants were implemented.

Findings

The findings related to sociocultural factors were categorized into five main themes: demographic changes, incorrect public drug use culture, cultural barriers among service providers, lack of awareness and knowledge among livestock farmers, and general public culture. (Table 1)

Table 1

findings
Theme	Sub-theme
General Public Culture	• Lack of Effective Public Education Policies • Reliance on Ineffective Treatments and Self-Medication • Skepticism Towards Industrial Products • Demand for Heavier Chickens • Lack of Public Awareness of Patient Rights • Public Desire for Quick Treatments
Public Drug Use Culture	• Pressure on Service Providers to Prescribe Antibiotics • Pressure from Peers for Irrational Use • Misconceptions About Antibiotics • Incomplete Adherence to Treatment Regimens • Negative Influence of Social Media • Storing Medication at Home • Lack of Commitment to Timely Medication • Easy access to antibiotics
Cultural Barriers Related to Service Providers	• Weak Teamwork in Service Delivery • Physicians’ Fear of Bad Reputation and Over-Prescribing • Negative Impact of Medical Authority on Adherence to Guidelines • Lack of Professional Ethics • Lack of Positive Attitude Toward Hand Hygiene • Unawareness of the Problem by Veterinarians • Perception of Veterinary Antimicrobials as Less Important than Human Antimicrobials • Physicians’ Preference for New Antimicrobials • Neglect of Sexually Transmitted Diseases by Policymakers
Lack of Awareness and Knowledge Among Livestock Farmers	• Low Literacy Levels Among Livestock Farmers • Poor Awareness About Medications
Demographic Changes	• The Role of Development and Population Growth in Increased Antimicrobial Consumption • Impact of Population Aging • Urban Marginalization and Limited Access to Adequate Services

1.1. Lack of Effective Public Education Policies

Interviewees expressed concerns about the absence of targeted and ongoing public education programs on antimicrobial resistance, the rational use of antimicrobials, and the characteristics of healthy food. They believe these programs have failed to effectively engage other organizations, such as media or municipalities, due to insufficient quality and quantity. One participant remarked: "The media demands payment for broadcasting information. Their programs are more focused on treatment rather than prevention and awareness. How often have you seen the media produce and broadcast good content about antimicrobial resistance in popular programs?" (P.10).

1.2. Reliance on Ineffective Treatments and Self-Medication

The prevalence of unscientific treatment methods often leads to delayed or ineffective care. Recently, skepticism about scientific prevention strategies, such as vaccination, has grown. Many charlatans promote these proven scientific interventions as conspiracies from external enemies. A physician noted: "Even educated doctors exaggerate and claim that these drugs and vaccines are brought by enemies to harm our people. Such beliefs arise due to political and religious issues" (P.33). Another physician added: "Traditional medicine has turned into charlatanism in our country. I had a patient who consulted charlatans, and by the time he came to me, his disease had progressed" (P.40). another participant noted: "Self-medication with antibiotics is relatively prevalent, and one of the main reasons for this is people's reluctance to pay for doctors' consultation fees" (P.9).

1.3. Skepticism Towards Industrial Products

Skepticism towards industrially produced food has led to the popularity of traditional products. These traditional products may be sold outside the regulatory framework of responsible organizations, increasing the risk of consuming food with antibiotic residues. A participant mentioned: "The culture of consuming pasteurized milk hasn’t caught on in our country. There’s a belief that anything nostalgic is healthier. Some people think pasteurized milk is full of chemicals to preserve it for months" (P.29).

1.4. Demand for Heavier Chickens

Due to low awareness, heavier chickens are more popular in the market. This demand encourages producers to keep chickens in farms longer, increasing the risk of disease and the use of antimicrobials. This, in turn, raises the risk of drug residues. One participant explained: "People usually want chickens over two kilograms. The producer has to keep them for over 45 days, increasing the risk of diseases. Therefore, they use antibiotics in the last days as prophylaxis or treatment, adding it to their water and food until the last night before sending them to the slaughterhouse" (P.55).

1.5. Lack of Public Awareness of Patient Rights

When patients are unaware of their rights, they remain a silent group with no demand for improved infection control and rational use of antimicrobials. Interviewees believed that if a patient contracts a hospital-acquired infection, they are unlikely to follow up on complaints or seek improvements in infection control and prevention. One participant commented: "Patients often don’t know their rights or those of their caregivers. If an infection occurs, there’s little follow-up, and patients don’t advocate for better infection prevention and control, believing it’s just part of hospital life" (P.49).

1.6. Public Desire for Quick Treatments

Some patients believe that rapid recovery requires antibiotic use and reject recommendations for rest or non-drug treatments. They also lack patience for diagnostic tests and antibiotic sensitivity testing. An Iranian Health Insurance Organization manager said: "Why isn’t an antibiogram done? Patients are impatient. If you send them to the lab, it takes time, and they think the lab is colluding with the doctors. They believe the process shouldn’t take so long" (P.17).

2.1. Pressure on Service Providers to Prescribe Antibiotics

Interviewees from both human and animal health sectors indicated that people and food producers often make irrational requests for antimicrobial drugs, pressuring service providers such as physicians, pharmacists, or veterinarians to comply. One member of the National Committee for Rational Drug Use described the situation: "Patients are insistent on getting antibiotics, even if they just have a cold. We say it's not necessary, but they go to the pharmacy and insist on getting it without a prescription" (P.9). Similarly, a manager from the Veterinary Organization noted a recurring issue in animal health: "Unfortunately, clients believe that a veterinarian who prescribes more antibiotics is better. They are not interested in hearing about hygiene measures or preventive guidelines. If the veterinarian says a certain drug is not needed, they insist on obtaining it anyway" (P.19).

2.2. Pressure from Peers for Irrational Use

Recommendations from non-experts regarding the use or non-use of antimicrobial drugs were frequently mentioned in the interviews. One participant noted: "Non-specialist opinions are rampant. If I improved with an antibiotic, I prescribe it to others as well. Our view of antibiotics is like candy" (P.48). In some cases where a patient should use an antimicrobial drug, inappropriate advice leads to its non-use, which is also an example of irrational consumption. An infectious disease specialist explained: "Sometimes people swing to the other extreme. We prescribe medication and tell them they have a urinary infection and need to take antibiotics, but then their relatives like aunts and uncles say that antibiotics are harmful to the child and they shouldn't use them. After a few days, we see the problem has worsened" (P.39).

2.3. Misconceptions About Antibiotics

Interviewees in this study pointed out several misconceptions that lead people to irrationally use antimicrobial drugs (Table 2).

Table 2

Misconceptions About Antibiotics
Misconception	Sample Quotation (Participant Number) (Organizational Affiliation)
Antibiotics are safe and strengthen the body against microbes	People often don't see immediate and severe side effects from the drug, which leads to a lack of awareness about its consequences, resulting in reckless usage. They believe it doesn't harm and think it kills all the microbes. (P.3), (Health Ministry Administrator)
Injectable antibiotics are always preferable	Many people think that using injectable antibiotics is better than oral forms. They often request their doctors to prescribe these antibiotics and, if the doctor refuses, they consider them less competent and may not visit them again. (P.9), (Administrator from the Rational Drug Use Committee)
Antibiotics are effective for colds and allergies	Someone catches a cold and says, 'I won't get better until I take an injection.' It's a mistaken belief that for a viral cold, one needs antibiotics. Even if the doctor hasn't prescribed it, they'll find a way to get it. (P.33), (Infectious Diseases Society Administrator
Specific antibiotics can treat all diseases	A patient says, 'Whenever I get an infection, I must take the 500mg capsule.' Whether it's an ear infection, sore throat, a wound on the leg, or diarrhea, they take the same thing. They have a strong belief in it. Whether it's ampicillin or amoxicillin" (P.33), (Infectious Diseases Society Administrator)
Insistence on prescribing newer and more expensive drugs as more effective	A person comes in with strep throat or a urinary tract infection, which could be treated with a simple first-line antibiotic. They believe that if you give them an antibiotic that costs 100,000 Toman, it's more effective. Or they suggest the newest drug that just hit the market" (P.51), (Infectious Disease Specialist)
The belief that antibiotics reduce fever	It often happens that a patient says, 'I took antibiotics as soon as I had a slight fever to bring it down; otherwise, my fever would have been much higher by now'" (P.51), (Infectious Disease Specialist)

2.4. Incomplete Adherence to Treatment Regimens

Not completing the full course of treatment is a common issue due to a lack of awareness about proper medication practices. This behavior contributes to antimicrobial resistance. One participant noted: "People, due to ignorance, stop taking antibiotics after their symptoms improve, thinking that continuing the medication is harmful to their body" (P.51).

2.5. Negative Influence of Social Media

Instead of relying on official sources, people sometimes trust incorrect and misleading information from social media. This misinformation can lead to the avoidance of necessary antimicrobial medications. For example, one participant mentioned: "We face this issue a lot with pregnant women. When a doctor prescribes an antibiotic, they ensure it doesn't negatively affect the fetus. We now have flu vaccinations that we advise pregnant women to use, but they still avoid it because they've seen negative information on Telegram and similar platforms" (P.39).

2.6. Storing Medication at Home

Interviewees described the irrational practice of keeping medications, often referred to as "fridge pharmacy," "home pharmacy," or "personal pharmacy." Storing unnecessary medications, especially antibiotics, facilitates easy access and often leads to irrational use based on previously mentioned misconceptions. One participant noted: "In Iranian households, the fridge often contains various classes of antibiotics, which leads individuals to start self-medicating and often using multiple types of antibiotics before they come to the clinic" (P.10).

2.7. Lack of Commitment to Timely Medication

Interviewees highlighted a lack of commitment to timely medication as another cultural issue related to irrational antimicrobial use. They believe that, in many cases, patients do not adhere to prescribed medication schedules, especially when repeated doses are required, due to work-related or lifestyle challenges.

2.8. Easy access to antibiotics

People can now easily obtain antibiotics from pharmacies, a practice that needs to be reformed. One of the Ministry of Health officials, while emphasizing the need for public awareness on the proper use of antibiotics, stressed the importance of cultural education in society. He stated, "To better control antimicrobial resistance, we need collaboration and planning from the Food and Drug Organization, as unfortunately, we also witness the overuse of antibiotics in food products at times." (P.3)

3.1. Weak Teamwork in Service Delivery

Both managers and policymakers, as well as operational staff, see the management of antimicrobial resistance as a challenge requiring collaboration across different levels, from hospitals to policy-making. However, they view serious deficiencies in teamwork as a barrier to achieving this collaboration. One health ministry manager stated: "Coordinating different groups in our society is challenging because teamwork is a cultural weakness. We have experienced this lack of teamwork in old programs like HIV/AIDS. Antimicrobial resistance, which receives less attention, will also suffer if different groups don't engage in effective teamwork" (P.5).

3.2. Physicians’ Fear of Bad Reputation and Over-Prescribing

Interviewees believed that a significant amount of medication prescribed, such as excessive prophylaxis during surgeries, is driven by defensive medicine practices aimed at preventing patient complaints and avoiding damage to physicians' reputations. One participant explained: "Doctors lack trust in hospital infection control and fear being easily penalized. To reduce risk, they over-prescribe as a way to compensate for their uncertainty, which also helps them maintain patient numbers and avoid complications" (P.3).

3.3. Negative Impact of Medical Authority on Adherence to Guidelines

Interviewees identified the culture of medical authority as a factor affecting physicians' adherence to infection control guidelines and standards in hospitals. A manager from an infectious disease specialist association commented: "There is a belief among some doctors that they know everything. This mindset is prevalent among doctors. Physicians should always learn from infection control nurses and accept their expertise, rather than relying solely on their own judgments" (P.32).

3.4. Lack of Professional Ethics

Non-compliance with professional ethics among service providers, such as physicians, veterinarians, and pharmacists, contributes to the excessive use of antimicrobials. Prioritizing economic interests over professional ethics can diminish ethical standards. One participant noted: "Pharmacists have not yet reached an ideal level of professional ethics. Often, pharmacists' economic interests jeopardize ethical practices, and some pharmacists easily ignore regulations and professional ethics" (P.5).

3.5. Lack of Positive Attitude toward Hand Hygiene

Participants mentioned that a lack of positive attitude toward hand hygiene among healthcare workers is common, which can lead to the spread of resistant microorganisms in service environments. One participant said: "There is a hand sanitizing solution above each bed now. Why isn't it used? Not just by doctors, but by all staff. It’s a matter of habit. Knowledge is important, but so is attitude and performance. I don't think it's a lack of knowledge" (P.41).

3.6. Unawareness of the Problem by Veterinarians

Many veterinarians do not recognize the importance of antimicrobial resistance, which contributes to the irrational use of antimicrobials in animal farms. One food safety expert and media activist mentioned: "Veterinarians responsible for dairy, meat, and poultry farms still don't acknowledge the issue. When I ask why they prescribe so many antibiotics, they respond that if they don’t, clients will go to another vet. They don’t see the problem with resistance" (P.55).

3.7. Perception of Veterinary Antimicrobials as Less Important than Human Antimicrobials

Managers in the veterinary field expressed concerns about the lower emphasis placed on the quality of veterinary medicines compared to human medicines. An experienced veterinary manager commented: "Some people in veterinary medicine believe that the sensitivity required for human medicines is greater than for veterinary ones. They argue that since human medicines are for humans, there should be more rigor in their production, distribution, and use. However, the impact of veterinary medicines is significant because a large segment of the population is affected" (P.23).

3.8. Physicians’ Preference for New Antimicrobials

Similar to the public's preference for new and expensive antibiotics, some infectious disease specialists believe this issue also exists among physicians. They think that when new drugs are introduced, some doctors prefer to prescribe these new medications despite existing guidelines. One participant noted: "For a simple sore throat that can be treated with a cheap, basic drug, new-generation drugs are often prescribed unnecessarily. These should be reserved for resistant microorganisms where the new antibiotics are our last resort" (P.33).

3.9. Neglect of Sexually Transmitted Diseases by Policymakers

Another issue in managing infectious diseases, particularly in human health, is the stigmatization of patients with sexually transmitted infections (STIs). This stigma affects diagnosis, treatment, follow-up, and data recording for conditions such as tuberculosis and STIs. One participant stated: "STIs have always been stigmatized and neglected. This affects funding, public awareness, and patient management. Even in universities, they haven't received adequate attention. We don’t have accurate statistics on these diseases in our country" (P.5). Another added: "Patients with STIs often go to private clinics to avoid being noticed, and many skip lab tests and follow-ups, seeking a quick cure" (P.5).

4.1. Low Literacy Levels Among Livestock Farmers

Veterinary officials point to low literacy among livestock farmers as a key factor behind the overuse of antimicrobial drugs and difficulties in implementing AMR policies. Many farmers rely on traditional practices and lack training in animal care, feed, and biosecurity, making it challenging to address issues like antimicrobial resistance.

4.2. Poor Awareness About Medications

Farmers have a limited understanding of medications, their side effects, and withdrawal periods. One expert stated: "Farmers view antibiotics as vaccines to boost production"(P.21).

The lack of education and awareness among farmers is a major factor contributing to the excessive use of antimicrobials. This issue undermines educational policies and creates conditions where farmers view medications as tools for profit and increased production. For instance, "Some farmers see antimicrobials as vaccines that provide immunity to their herds" (P.21). Additionally, "Some farmers use human antibiotics, such as human ceftriaxone, without proper knowledge about its use and side effects" (P.19).

5.1. The Role of Development and Population Growth in Increased Antimicrobial Consumption

Economic development and improved conditions in the country have enhanced access to healthcare services and improved health indicators. However, this improved access has been accompanied by the inappropriate and irrational use of antimicrobials, which can accelerate the development of antimicrobial resistance. Additionally, population growth has increased the demand for animal protein production, leading to the use of antimicrobials as growth promoters. One participant highlighted this by stating: "To ensure food security by 2050, we need to increase our animal protein supply by more than 50% in addition to what we currently have... With the increased demand for food, the use of antibiotics as growth promoters in livestock, poultry, and plants has risen" (P.25).

5.2. Impact of Population Aging

A health policymaker from the Ministry of Health observed that improved health indicators and increased life expectancy among Iranians have led to a rise in the use and misuse of antimicrobial drugs. He illustrated this with an example involving tuberculosis (TB) patients: "About 30% of our TB patients are elderly, due to the successful control of TB in the country over past decades. Managing TB in the elderly is particularly challenging because it’s difficult for them to follow all treatment protocols on time and in full" (P.6).

5.3. Urban Marginalization and Limited Access to Adequate Services

Urban marginalization and the development of informal settlements, coupled with the lack of health centers and poor sanitary conditions, have limited access to basic healthcare, negatively impacting the health of marginalized populations. A member of the Rational Drug Use Committee noted: "In areas with higher population density, naturally, there are more visits to doctors. The time that doctors and pharmacists can spend with each patient is reduced, leading to irrational prescribing. Moreover, many people in these areas don't visit doctors at all; they resort to self-medication, traditional remedies, or even various forms of folk healing" (P.7).

In the present study, factors such as demographic changes, incorrect drug culture among the public, cultural challenges among service providers, lack of awareness and knowledge among livestock owners, and the general public's culture were identified as underlying contributors to the development of antimicrobial resistance (AMR). Additionally, some of these cultural factors pose challenges to policymaking efforts aimed at combating AMR.

Participants identified increasing population growth as a factor contributing to the heightened demand for animal protein, which in turn drives the increased use of antimicrobials in Iran. Globally, it is estimated that antibiotic use for animal food production will rise by up to 67% by 2030 (16). This creates a dilemma between short-term benefits and long-term consequences; while the use of antimicrobials in animal production can boost livestock output in the short term, it also exacerbates selective pressure and the spread of microbial resistance, which threatens food production in the long run. Resistance indefinitely impacts animal morbidity and mortality rates (17), decreasing the effectiveness of treatments and leading to increased infection spread. Ultimately, reduced livestock production and trade will lead to higher prices for protein sources such as meat, eggs, and milk (2).

The study also highlighted that increased marginalization and reduced access to quality health services are social factors contributing to the irrational use of antimicrobials. Living conditions are a determining factor in infection rates and access to healthcare, as evidenced by the association of treatment-resistant tuberculosis in Europe with factors such as inadequate home ventilation systems and overcrowding in prisons(18). The high population density in marginalized areas is also a crucial factor, as a high patient-to-doctor ratio prevents effective patient-provider interactions and examinations, significantly affecting prescription practices (11). Policymakers should implement equity-focused interventions to provide better services for vulnerable groups, such as marginalized populations, which would also contribute to controlling AMR. Vulnerable populations, due to higher exposure to infections and less access to quality healthcare, including vaccination and treatment, are at greater risk for microbial resistance and its consequences(19).

Findings indicated that behaviors related to seeking and utilizing services play a critical role in the irrational use of antimicrobials. A study conducted in Qom province on students found that over half cited the lack of necessity for a doctor as a primary reason for self-medication (20). The public's perception of doctors and belief in their efficacy significantly influences this behavior. Understanding patient expectations and perceptions by healthcare providers can improve doctor-patient relationships.

A sociocultural study comparing penicillin-resistant pneumococcus prevalence of 43% in France with 7% in Germany revealed that treatment-seeking behaviors are a cultural determinant. In France, people sought antibiotics after coughing and increased mucus, whereas many Germans considered this unnecessary. Additionally, the doctor-patient relationship and patient pressure for medication in France impacted antibiotic use, while Germans, due to higher awareness, were less demanding of antibiotics. Other social factors, such as maternal employment rates and the use of daycare centers for children, also affected antibiotic consumption. For example, lower rates of breastfeeding among French infants increased the risk of pneumococcal infections and, consequently, higher antibiotic use (21).

The present study identified practices such as keeping medications at home, prescribing drugs without a prescription, especially new and expensive antibiotics, and not taking medications on time and completely as contributing factors to the development of AMR. Such beliefs and behaviors, including misinformation and misconceptions about antibiotics, self-medication during common colds, excessive storage of medications at home, and efforts to obtain drugs without prescriptions, were also confirmed in a study conducted in Syria (22). Participants in the study identified social pressure and online media influence as significant factors contributing to irrational drug use. This issue is prevalent not only in human health but also in animal health, where livestock owners have reported being influenced by more experienced colleagues to use a variety of antibiotics extensively to prevent greater losses and herd mortality (23). The study showed that the preference for new and expensive drugs is common both among the public and healthcare providers. Similarly, in India, doctors tend to prefer prescribing imported and more expensive brands (24).

The study revealed that doctors' fear of legal repercussions and damage to their reputation, combined with maintaining patient satisfaction, are reasons for their over-prescription of medications. This finding is corroborated by another study (12). ). Furthermore, this issue is not limited to doctors; pharmacists also tend to satisfy patients by over-prescribing and selling unauthorized medications (13). Therefore, the development of clinical guidelines and adherence to their implementation could support more rational prescribing practices among physicians.

Our findings indicate that a weak team culture is a challenge for controlling AMR; this aligns with studies (12, 13) That cited insufficient interaction and lack of effective collaboration among pharmacists, microbiologists, physicians, and infectious disease specialists as barriers to rational prescribing in hospitals. The study by Attar-Schaye and colleagues attributed medical paternalism to the lack of team collaboration (13), and our study identified medical paternalism in the healthcare system as a barrier to adherence to guidelines and protocols in service settings.

Participants believed that despite knowing the importance of hand hygiene, doctors do not consistently practice it and lack the necessary attitude to apply it continuously in their daily practice. Sami and colleagues also noted that inadequate belief and attitude among some physicians regarding rational drug prescribing lead to reduced commitment and sensitivity to AMR (12). Our study showed that a lack of true understanding of the looming crisis caused by AMR leads to non-compliance with drug tiering and unnecessary prescription of last-resort antimicrobials. Similarly, other researchers (13) have expressed concerns about physicians’ preferences for testing new drugs and over-prescribing as worrying trends.

To overcome cultural barriers among service providers, particularly physicians, educational interventions should be planned from student years through initial and continuing professional education. Previous studies (12) have shown that limited access to high-quality educational materials, inadequate continuing education, and a lack of locally adapted clinical guidelines are significant challenges for Iranian physicians in the rational prescribing of antimicrobials. Training pharmacists to engage constructively with other healthcare providers and offer effective pharmaceutical counseling to the public can also help reduce irrational drug use (13).

Livestock owners, as consumers of antimicrobials, must also be addressed. The findings of the present study indicate that their low literacy and limited awareness about antimicrobials can lead to irrational use. Increasing awareness among livestock owners about the dangers of irrational drug use and antimicrobial resistance could lead to better cooperation and more effective participation in consumption reduction policies. Farmers’ beliefs, attitudes, and expertise in disease management influence their use of antimicrobials. When a disease occurs, livestock owners evaluate the costs and benefits of using antimicrobials based on their technical expertise, age, education level, and experience, which influences many of their behaviors (25). A study among Iranian livestock owners indicated that low health literacy, limited access to veterinary services, insufficient support from the government, and economic considerations are factors impacting irrational antibiotic use (23).

General subcultures formed within the community, stemming from the absence of successful educational policies, have been identified as determining factors in increased irrational use. Sweden’s successful experience shows that to change people's behaviors, education on the negative impacts of inappropriate antibiotic use, such as common upper respiratory infections, is essential. Continuous education and awareness campaigns, for example on national or local television, about the economic consequences for health and antimicrobial resistance trends are necessary. Additionally, summary guidelines on common infections for prescribers are well-received(26). In Sweden, annual data on antibiotic consumption and resistance is published for the public. National treatment guidelines are updated and available for download. Informational guides on common infections are published in six languages, and web-based educational content is provided for clinicians and the general public (26). The lack of community demand due to insufficient awareness and sensitization has led to the issue not being addressed seriously at higher levels. This issue has been highlighted in other studies as a "missed opportunity" for raising public awareness about antimicrobial resistance and the need for cautious use of antibiotics (27).

Social and cultural factors play a crucial role in the use of antimicrobials, the proliferation and transmission of resistant microorganisms, and their impact across various ecosystems, including both human and animal health sectors. These factors influence all stakeholders involved in antimicrobial resistance, including the public (as consumers of healthcare services and animal-derived food products), physicians, pharmacists, livestock owners, and food producers. Therefore, these determinants are fundamental in shaping the levels of antimicrobial use in the country and must be considered by policymakers to ensure the success of interventions. It is essential to address this phenomenon not only from a clinical and microbiological perspective but also through an understanding of these social and cultural factors.

This study provides insights into the social and cultural factors that policymakers can use to design effective interventions for various stakeholders in this field. It is recommended that public awareness campaigns focus on reducing the irrational use of antimicrobials, respecting physicians' diagnoses, adhering to prescribed treatment regimens, and completing antimicrobial courses. Additionally, there should be a push for clinical guidelines, increased oversight, and enhanced capacity by insurance providers, as well as the development of laboratory capabilities and the use of rapid diagnostic tests to differentiate and diagnose microbial infections in outpatient and inpatient settings to reduce the prescription of antimicrobials. Service providers, including physicians, pharmacists, and veterinarians, should collaborate in a coordinated team effort, playing a protective role for antimicrobials, and incorporate considerations of microbial resistance into all their daily practices rather than viewing it as a distant challenge.

antimicrobial restriction =AMR

Ethics approval and consent to participate

The study was approved by the Ethics Committee of Tehran University of Medical Sciences. Ethics code: IR.TUMS.REC.1397.173. Written informed consent was obtained from participants, and they had the right to withdraw from the study at any stage upon request.

Consent for publication

Not applicable

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

This research is part of a PhD thesis in health policy, which benefited from the financial support provided by Tehran University of Medical Sciences. The registration code is 9421460003. The funder had no role in the study design, data collection, data analysis, data interpretation, or the writing of results and the final text.

Authors' contributions

MM and EJP contributed to the study's conception and design. MM and EJP conducted data collection. ZN and MM conducted data analysis. MM and ZN drafted the manuscript. All authors provided critical revisions and approved the final manuscript.

Acknowledgments

The authors would like to express their gratitude to those who contributed to this research project.

supplementary file

supplementary file.docx

Organization WH. Antimicrobial resistance: global report on surveillance: World Health Organization; 2014.
Bank W. Drug-resistant infections: a threat to our economic future. World Bank. 2017.
O'Neill J. Tackling drug-resistant infections globally: final report and recommendations. 2016.
Organization WH. Global action plan on antimicrobial resistance. 2015.
Nashwan AJ, Barakat M, Niaz F, Tariq S, Ahmed SK. Antimicrobial resistance: stewardship and one health in the Eastern Mediterranean region. Cureus. 2024;16(4).
Amidi S, Solter S, Rashidian B, Zokaian A-R, Razmjoian F. Antibiotic use and abuse among physicians in private practice in Shiraz, Iran. Medical care. 1975;13(4):341-5.
Hosseinzadeh K, Azimian J. Iranians’ self-report knowledge and practice about arbitrary use of antibiotics. Journal of clinical and diagnostic research: JCDR. 2017;11(8):FC06.
Hashemi S, Nasrollah A, Rajabi M. Irrational antibiotic prescribing: a local issue or global concern? Excli j. 2013;12:384-95.
Iran I. The antimicrobial resistance situation in Iran: the national initiative and R&D to face AMR. AMR CONTROL 2018. 2018:20.
Ledingham K, Hinchliffe S, Jackson M, Thomas F, Tomson G. Antibiotic resistance: using a cultural contexts of health approach to address a global health challenge. 2019.
Ayukekbong JA, Ntemgwa M, Atabe AN. The threat of antimicrobial resistance in developing countries: causes and control strategies. Antimicrobial Resistance & Infection Control. 2017;6:1-8.
Sami R, Salehi K, Sadegh R, Solgi H, Atashi V. Barriers to rational antibiotic prescription in Iran: a descriptive qualitative study. Antimicrob Resist Infect Control. 2022;11(1):109.
Eteraf-Oskouei T, Mohammadi Y, Najafi M. Evaluating the causes of non-standard prescription and drug use in Iran and its improvement strategies from the viewpoint of pharmacy students of Tabriz University of Medical Sciences. Depiction of Health. 2019;10(3):180-8.
Wallinga D, Rayner G, Lang T. Antimicrobial resistance and biological governance: explanations for policy failure. Public Health. 2015;129(10):1314-25.
Ritchie J, Spencer L. Qualitative data analysis for applied policy research. Analyzing qualitative data: Routledge; 2002. p. 173-94.
Van Boeckel TP, Glennon EE, Chen D, Gilbert M, Robinson TP, Grenfell BT, et al. Reducing antimicrobial use in food animals. Science. 2017;357(6358):1350-2.
Hao H, Cheng G, Iqbal Z, Ai X, Hussain HI, Huang L, et al. Benefits and risks of antimicrobial use in food-producing animals. Frontiers in microbiology. 2014;5:288.
Farmer P. Pathologies of power: Health, human rights, and the new war on the poor: Univ of California Press; 2004.
Charani E, Mendelson M, Ashiru-Oredope D, Hutchinson E, Kaur M, McKee M, et al. Navigating sociocultural disparities in relation to infection and antibiotic resistance—the need for an intersectional approach. JAC-antimicrobial resistance. 2021;3(4):dlab123.
Alipour Z, Eskandari N, Izadi Tamhe A, Faezipour A, Abedini Z, Khoramirad Rad A. Relationship between personality characteristics and use of antibiotics. Journal of Holistic Nursing And Midwifery. 2015;25(3):46-54.
Harbarth S, Albrich W, Brun-Buisson C. Outpatient antibiotic use and prevalence of antibiotic-resistant pneumococci in France and Germany: a sociocultural perspective. Emerging infectious diseases. 2002;8(12):1460.
Barah F, Morris J, Goncalves V. Irrational use and poor public beliefs regarding antibiotics in developing countries: a pessimistic example of Syria. International journal of clinical practice. 2009;63(8):1263-4.
Toghroli R, Aghamolaei T, Hassani L, Sharifi H, Jajarmi M. Determinants of antimicrobial resistance occurrence in animal‐based food, perceived by livestock farmers: A qualitative phenomenological study. Health Science Reports. 2023;6(3):e1160.
Patel V, Vaidya R, Naik D, Borker P. Irrational drug use in India: a prescription survey from Goa. Journal of postgraduate medicine. 2005;51(1):9-12.
Lhermie G, Gröhn YT, Raboisson D. Addressing antimicrobial resistance: an overview of priority actions to prevent suboptimal antimicrobial use in food-animal production. Frontiers in Microbiology. 2017;7:2114.
Mölstad S, Löfmark S, Carlin K, Erntell M, Aspevall O, Blad L, et al. Lessons learnt during 20 years of the Swedish strategic programme against antibiotic resistance. Bulletin of the World Health Organization. 2017;95(11):764.
Dreser A, Vázquez-Vélez E, Treviño S, Wirtz VJ. Regulation of antibiotic sales in Mexico: an analysis of printed media coverage and stakeholder participation. BMC public health. 2012;12(1):1051.

No competing interests reported.

supplementaryfile.docx

Download PDF

Editor assigned by journal
25 Oct, 2024
Submission checks completed at journal
25 Oct, 2024
First submitted to journal
23 Oct, 2024

You are reading this latest preprint version

Sociocultural Determinants of Antimicrobial Resistance in the Islamic Republic of Iran: A Qualitative Study

Status:

Version 1

Abstract

Introduction

Methods

Study Design

Sample

Data Collection

Data Analysis

Findings

General Public Culture

1.1. Lack of Effective Public Education Policies

1.2. Reliance on Ineffective Treatments and Self-Medication

1.3. Skepticism Towards Industrial Products

1.4. Demand for Heavier Chickens

1.5. Lack of Public Awareness of Patient Rights

1.6. Public Desire for Quick Treatments

Public Drug Use Culture

2.1. Pressure on Service Providers to Prescribe Antibiotics

2.2. Pressure from Peers for Irrational Use

2.3. Misconceptions About Antibiotics

2.4. Incomplete Adherence to Treatment Regimens

2.5. Negative Influence of Social Media

2.6. Storing Medication at Home

2.7. Lack of Commitment to Timely Medication

2.8. Easy access to antibiotics

Cultural Barriers Related to Service Providers

3.1. Weak Teamwork in Service Delivery

3.2. Physicians’ Fear of Bad Reputation and Over-Prescribing

3.3. Negative Impact of Medical Authority on Adherence to Guidelines

3.4. Lack of Professional Ethics

3.5. Lack of Positive Attitude toward Hand Hygiene

3.6. Unawareness of the Problem by Veterinarians

3.7. Perception of Veterinary Antimicrobials as Less Important than Human Antimicrobials

3.8. Physicians’ Preference for New Antimicrobials

3.9. Neglect of Sexually Transmitted Diseases by Policymakers

Lack of Awareness and Knowledge among livestock farmers

4.1. Low Literacy Levels Among Livestock Farmers

4.2. Poor Awareness About Medications

Demographic Changes

5.1. The Role of Development and Population Growth in Increased Antimicrobial Consumption

5.2. Impact of Population Aging

5.3. Urban Marginalization and Limited Access to Adequate Services

Discussion

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1