Healthcare providers’ knowledge, attitude, and practice of antibiotic use and antimicrobial resistance in Southern Pakistan: a qualitative study

Healthcare providers’ knowledge, attitude, and practice of antibiotic use and antimicrobial resistance in Southern Pakistan: a qualitative study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Healthcare providers’ knowledge, attitude, and practice of antibiotic use and antimicrobial resistance in Southern Pakistan: a qualitative study Sohail Ahmed, Najma Iqbal Malik, Razia Anjum, Inam Ullah Leghari, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7329893/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background: Antimicrobial resistance (AMR) is a serious global health concern. In Pakistan, the unregulated sale of antibiotics and socioeconomic challenges compound the issue, driving high rates of drug-resistant infections. This study examines the knowledge, attitudes, and practices of healthcare providers regarding unregulated antibiotic use in Pakistan. Methods: Using purposive sampling, nearly 20 respondents were selected, and qualitative data were collected through semi-structured interviews and field notes with doctors, quacks, and pharmacists. Results: Five significant themes in Pakistan's healthcare system that propel antibiotic abuse were revealed through thematic analysis. The first theme is on administrative and structural vulnerabilities, including political influence, weak regulation, and a lack of monitoring and audit. The second theme identifies the unrestricted power of pharmaceutical businesses and drug stores, which promotes non-prescriptive sale of antibiotics and money-motivated recommending. The third theme reveals critical shortages in competent and skilled health practitioners and diagnostic services, leading to dependence on unqualified practitioners and the application of practical antibiotics. Theme four reveals practitioners' ethical practices and restricted information and skills in rational prescribing. The final theme documents financial limitations that hinder diagnostic testing of infections and drive patient pressure for quick antibiotic interventions. Conclusion: All these themes collectively represent the entrenched systemic, economic, and professional issues that lead to antibiotic abuse. The study advocates for a more effective and comprehensive approach to mitigating AMR by addressing these structural inequalities. antimicrobial resistance antibiotic misuse healthcare regulation Pakistan Figures Figure 1 Introduction The World Health Organization (WHO) characterized AMR as a global health threat and warned that, if left unaddressed, it could lead to a post-antibiotic era in which common bacterial infections might once again become fatal ( 1 ). In 2019 alone, drug-resistant infections caused 1.95 million lives, with ~ 1.1 million of these deaths occurring among children below the age of five ( 2 ). Pakistan faces a grave AMR crisis, with 59,200 deaths associated with antimicrobial resistance in 2019, ranking 176th out of 204 countries in age-standardized AMR mortality rates ( 2 ). The efficiency of Paki-stan’s healthcare system is entirely neglected with a lack of regulation, and rough handling of patients, which has tremendously contributed to antibiotic misuse ( 3 ) and the spread of drug-resistant infections ( 4 ). Factors that lead to patients' noncompliance with antibiotics are a leading concern for the public health system. Pharmaceutical companies encourage general practitioners (GPs) to prescribe medications based on financial incentives, and their healthcare representatives promote prescriptions driven by profit motives. Most of the time, antibiotics are unnecessarily prescribed to meet sales targets rather than clinical needs ( 5 ). Such prescribing is highly patient-dependent, where many patients come to the GPs expecting antibiotics for self-limited conditions, adding pressure on the GPs to comply ( 5 ). This cultural belief leads to the misuse of antibiotics, resulting in antimicrobial resistance. A major reason behind the spread of AMR in Pakistan is the over-prescription of antibiotics in government hospitals. This problem includes inadequate medical diagnostics, insufficient staff members of skilled healthcare workers, and political interference ( 6 ). However, the role of informal providers further complicates the situation. As such, these providers prescribe antibiotics indiscriminately ( 7 , 8 ) without proper regulation or oversight. Besides that, the problem of available unqualified practitioners also provisioning antibiotics constitutes a public health threat, in particular, 'quacks,' who indiscriminately prescribe antibiotics while pretending to provide healthcare services ( 9 ). For instance, Pakistan has over 600,000 quacks, creating a genuine need for a holistic understanding of the landscape of healthcare ( 10 ). Exploitative prescribing practices take advantage of regulatory loopholes in the pharmaceutical market, undermining patient safety ( 5 ). To encourage responsible prescribing, these regulatory frameworks must be significantly strengthened. Additionally, socio-economic factors play a critical role; many patients who lack access to formal healthcare services turn to informal providers instead ( 11 ). Furthermore, cultural beliefs and perceptions of illness significantly influence patient behavior, particularly in the context of antibiotic usage ( 12 ). Antibiotic resistance in Pakistan has been driven by inadequate regulatory frameworks, leading to under-regulation, over-prescription, and self-medication ( 13 ). Socio-economic factors significantly contribute to the misuse of antibiotics, with patients often obtaining these medications without prescriptions, reflecting systemic weaknesses in healthcare practices ( 14 ). Additionally, the COVID-19 pandemic has exacerbated these issues by promoting unregulated antibiotic usage as a common treatment response, emphasizing the need for heightened awareness and stewardship ( 13 , 15 ) Drawing upon a robust critical public health lens ( 16 ), our study explores the systemic causal factors that have led to antimicrobial resistance in Sindh province of Pakistan. This framework is built on a critical perspective that examines how socio-economic structures, power dynamics, and political processes shape healthcare outcomes ( 16 ). The discussion also shows how health disparities are inconceivably embedded in economic exploitation, as well as unequal distribution of resources and profit-making over public welfare, hence would be particularly relevant to AMR in low-income settings like Pakistan. This deconstructs how structural inadequacies (weak healthcare infrastructure, weak regulation, and systemic corruption) directly lead to AMR. Political interference, inadequate diagnostic facilities, and cases of poor governance in Sindh province of Pakistan lead to abuse of antibiotics, overprescription, and unregulated sales. Navarro’s ( 16 ) assertion reflects on these conditions that socio-political structures are characterized by economic gain that seldom yields health equity. AMR is likewise critically driven by economic incentives. Aggressive marketing and practitioner incentivization by pharmaceutical companies have contributed to profit-driven antibiotic prescribing, in many cases, unnecessarily clinically. Informal healthcare providers, who typically deal with a marginalized population constrained by poverty and sometimes also limited healthcare access and limited health literacy, perpetuate antibiotic misuse. These socioeconomic constraints reflect Navarro's ( 16 ) argument that health is a function of broader social forces in that the economically disadvantaged are overly burdened by systemic health issues, including AMR ( 16 – 18 ). Using the critical public health framework to understand AMR makes it clear that systemic reforms, such as stricter regulation and equitable healthcare policies or public health campaigns that address the social, political, and economic determinants, are needed to implement AMR interventions effectively. By tackling structural inequalities, this approach might be a pathway to sustainable AMR mitigation through a more just and health-oriented economic order ( 16 ). Keeping in view this gap in literature, the present study investigates the sociocultural and politico-economic factors fueling AMR, focusing on regulatory gaps, the role of informal healthcare providers, and the economic motivations behind antibiotic overuse. Methods Data Collection The country's southern parts, such as most districts in Sindh, are severely marginalized because of the unavailability of hospitals, diagnostic centers, and trained medical staff. The people in these communities also lack basic facilities such as clean drinking water and sanitation, leading to regular infections among children and mothers. Consequently, antibiotics are often employed as a first-line treatment. The sample for this study was chosen based on direct involvement or experience with the use of antibiotics and antimicrobial resistance (AMR). In the local setting, healthcare providers include formally trained personnel and informal healers, such as unlicensed healers and vendors who usually provide antibiotics without a medical prescription. Data collection was done through semi-structured interviews and field notes. A semi-structured interview guide was developed to explore antibiotic prescribing patterns, healthcare regulations, diagnostic barriers, and positive and negative awareness of AMR (see supplementary file). Participants could offer detailed insights with open-ended questions, but probing questions provided a further exploration of our key themes. A standardized set of questions was used to ensure uniformity of data collection. Interview responses were cross-verified with the triangulation of observations and available secondary data. To validate responses, member-checking was used, where participants were requested to verify and review their statements. Interview data was backed up by observational notes, validating the data further. A sample of nearly 20 healthcare providers was gathered. Our participants included 9 medical doctors, 6 druggists, and 5 quack practitioners. (Table 1 ). Table 1 Details about the Respondents (n = 20). Details of Interviews No of Informants ( n ) Interviews with formal healthcare providers and professional 9 Interviews with quacks 5 Interviews of pharmacy staff 6 We used audio recorders with their permission. Some participants allowed, but some did not allow recording; therefore, we had to take fieldnotes, keeping in mind the respondents ' comfort. The semi-structured interviews were in a flexible format, which usually lasted 1 hour, and in the local (Sindhi) language. Sociodemographic characteristics show that respondents were practitioners, including doctors, quacks, and pharmacists. (Table 2 ). Data Analysis The data analysis process was guided by Braun and Clarke's six-stage thematic analysis approach ( 43 ). Steps involved becoming familiar with the data, creating initial codes, looking for patterns, reviewing and narrowing themes, and synthesizing. Data were collected through semi-structured interviews and field notes using purposive sampling, which were translated into English from the local language. Two researchers (SA, FA) thoroughly read the transcripts repeatedly in order to attain a rich level of familiarity. They carried out line-by-line coding to find substantial units of meaning and bundled them into emerging themes. These were purified by continuous discussion among the researchers. Themes were finally validated with reference to the raw data, and disagreement was resolved by consensus. Thematic structuring was guided by an interpretive qualitative perspective rooted in the participants' narratives (Fig. 1 ). Ethical/IRB Considerations Before the study was undertaken, ethical approval had been obtained from the Department of Anthropology and the Institutional Bioethical Committee of Quaid-i-Azam University, Islamabad (Number: QAU-IBC-3006; Date of Approval: 21 October 2024). All participants were informed of the study’s purpose, voluntary participation, and right to withdraw at any time, without loss of penalty, and gave informed consent. No real names were used for all participants in the study to protect participants’ confidentiality. Access to such data was restricted to the principal researcher to protect privacy and confidentiality, and the data was securely stored. When discussing personal or professional challenges related to antibiotic use, all interactions were made with respect and sensitivity. Results Sociodemographic characteristics show that the majority of formal healthcare providers were doctors, along with informal professionals, including pharmacists and quacks (Table 2 ). Table 2 Sociodemographic Characteristics of Respondents (n = 20) Respondent Gender Age Profession Respondent 1 M 53 Public Sector Doctor Respondent 2 M 39 Private Doctor Respondent 3 M 45 Doctor Respondent 4 F 33 Public Doctor Respondent 5 M 32 Public Sector at the sub-district Hospital Respondent 6 M 67 Retired public doctor practicing in a private clinic Respondent 7 M 38 Child specialist at the Medical College Respondent 8 F 49 District Health Officer Respondent 9 M 22 Medical doctor Respondent 10 F 32 Quack - practicing in a private clinic Respondent 11 M 23 Quack - practicing in a private clinic Respondent 12 M 47 Quack - practicing in a private clinic Respondent 13 M 39 Quack - practicing in a private clinic Respondent 14 M 29 Pharmacist Respondent 15 M 28 Pharmacist Respondent 16 M 27 Pharmacist Respondent 17 M 35 Pharmacist Respondent 18 M 27 Pharmacist Respondent 19 M 43 Pharmacist Respondent 20 M 49 Pharmacist 3.1. Theme One. Structural and Administrative Challenges in Antibiotic Misuse 3.1.1. Political and Administrative Issues and Prescription Practices Pressure from local political figures often results in compromised healthcare delivery, including the overprescription of antibiotics. The political position often leads most health administrators to fall back on connections rather than promote quality patient care. A physician working at a tertiary Hospital noted: “Sometimes we’re instructed to write prescriptions as per the directives of influential local figures, regardless of medical necessity. It’s challenging to refuse under such circumstances.” (R5, Age 32) “All of the senior positions in here are filled, more or less, according to political backing, and, frankly, merit is not a criterion. Consequently, much administrative effort is geared to contributing to political favor rather than enforcing healthcare guidelines.” (R6, Age 67, Medical Superintendent) These systemic weaknesses highlight a broader need for reforms in public healthcare management, emphasizing resource allocation, stricter monitoring, and improved training for staff at all levels. 3.1.2. Absence of Consistent Monitoring, Reporting, and Accountability There are inconsistent monitoring and reporting mechanisms to measure antibiotic use. Also, a lack of regular training programs, evaluations, or workshops restricts antibiotic stewardship. This lack of accountability creates a permissive environment for the inappropriate use of antibiotics; physicians, unaccountable for their actions, are allowed to deviate from recommended practice with impunity. “We have guidelines from health authorities, but they are limited to paper. There is no structured system to make these guidelines work or to monitor antibiotic use.” (R4, Age 33) “We do not have the resources or the training to do regular auditing or to enforce compliance. In reality, AMR policies are often overlooked simply because our focus is more on immediate patient care.” (R8, Age 49, District Health Officer) ‘I have never seen any training or evaluation for AMR. Sometimes, we are not so focused on meeting sales quotas; it is more about ensuring the rational use of antibiotics.” (R2, Age 39). 3.2. Theme Two. Role of Pharmaceutical Companies and Medical Drug Stores A cycle of excessive and unwarranted use of antibiotics continues, where unnecessary antibiotic use is based on commercial considerations rather than patient interest. Pharmaceutical companies can operate as freely as they wish, marketing without considering public health and without oversight. 3.2.1. Non-Prescription Dispensing of Antibiotics The findings reveal a prevalent culture of over-the-counter antibiotic sales, where antibiotics are often sold without the need for a prescription. A pharmacist candidly described the situation: “Most customers come in asking for antibiotics by name. If we do not sell to them, they will just go to another store. No one asks for a prescription; it is not the norm here.” (R15, Age28, Medical store owner) This illustrates how people often disregard prescriptions that require antibiotics. While most drugstore employees lack formal pharmaceutical training, they often remain unaware of the negative consequences of unregulated antibiotic use. Nevertheless, antibiotics are usually administered according to the patient's description of symptoms or the medications they have already been taking. Additionally, observational data show that drugs prescribed in the previous year are reused, and antibiotics are bought in response to suggestions from friends or family members. One respondent explained: “We simply cannot go to the doctor for every illness and have to rely on things that worked before. We end up buying the same antibiotics we used the last time.” (R19, age 43) 3.2.2. Influences of the Pharmaceutical Companies The practitioners confirmed the role of pharmaceutical representatives in propagating specific antibiotics, who say they offer incentives like bonuses, trips, or gifts. A doctor practicing privately shared: “There are a lot of pharmaceutical companies coming by, and they offer free samples, free stuff, and commission. When they offer things that help sustain the clinic, it’s hard to say no.” (R6, Age 67) Our findings indicate that commercial interests rather than medical necessity spearhead a cycle of antibiotic overuse in private healthcare practices. Furthermore, there are no regulatory checks, as many private clinics work without supervision. Antibiotic sales patterns, not surprisingly, are largely influenced by pharmaceutical companies that often bribe medical drug stores to promote specific brands. Store owners who were interviewed shared that sales reps often offer things like financial incentives, free samples, and even commissions to sway people to buy antibiotics. A retired public-sector doctor now in private practice shared his experience: “Pharmaceutical reps come around every month demanding we stock and sell their antibiotics. They may even push us to recommend particular brands to the patient and offer bonuses based on sales targets.” (R6, Age 67) Most of the time, these financial incentives result in biased promotion of some antibiotics, regardless of clinical suitability for patients. Some drugstore owners admitted to pitching higher-priced antibiotics rather than more affordable options because pharmaceutical companies pay more and provide better incentives. A pharmacist also confirmed this trend: "Almost every week, we are approached by company reps. If we meet their sales targets, they give us gifts and commissions. So, when it is a good deal for us, we try to sell more of their products.” (R14, Age 29) 3.3. Theme Three. Lack of Healthcare Providers, Laboratories, and Diagnostic Gaps 3.3.1. Absence of Formal Healthcare Providers and Practices of Quacks A major cause of the growing problem of antimicrobial resistance (AMR) is given by unqualified quacks. The absence of formal training among quacks means that they lack awareness of dosage guidelines, side effects, and the risks of antibiotic resistance. “Over the last few years, there has been a steep rise in quacks, especially in rural areas where doctors are limited. They prescribe antibiotics for almost every ill, the viral infections to body aches, and without diagnostic tests. (R6, Age 67) “I make a diagnosis just from what I've learned and what I have seen over the years. If a person gets a layer on the tongue, bitter taste, pain in the backbone, joint pain, and high temperature or fever at midnight, he is diagnosed as a typhoid patient. Similarly, if a person has small dots on the tongue, vomits, body pain, and weakness diagnosed as a malaria patient. However, a patient with a normal fever does not get all these types of symptoms.” (R 11, Age 23, Quack) While the health department has tried over and over to eliminate quackery, enforcement is weak, and these practitioners can run around freely, sometimes with the support of local influencers or politicians. The prevalence of quack practitioners represents a significant barrier to effective antibiotic stewardship. Without immediate and rigorous regulation, the misuse of antibiotics will likely continue, fueled by unqualified practices and unchecked prescribing habits. 3.3.2. Lack of Functional Laboratories & Diagnostic Facilities The findings show a substantial shortage of available and functioning diagnostic laboratories within Sindh, affecting the correct diagnosis of illnesses and facilitating the abuse of antibiotics. Only a few laboratories were found operating in the district, including unregistered laboratories with inadequate diagnostic equipment. Also, most medical clinics do not have an in-house laboratory facility, which limits diagnostic opportunities. A medical professional emphasized the issue: “Without reliable labs, we have often had to prescribe antibiotics for symptoms. As we do not have the luxury of waiting for lab results that may never come, we have no choice but to act quickly on what we suspect.” (R16, Age 27) A frequent result of this situation is cases of 'blind prescribing'– giving antibiotics without ‘vetting’ the diagnosis. The dearth of functioning labs not only undermines the elegance of treatment but also prolongs the chasm of antibiotic misuse – patients receive antibiotics as a preventive measure rather than targeted treatment. However, the issue is compounded further by the fact that diagnostic tools are hard to come by, and lab personnel are not trained enough. One employee at a private laboratory admitted: “We do not have any formal training and often rely on the owner, who is not a certified lab technician either. Due to a lack of proper equipment, many tests cannot be conducted.” (R 17, Age 35) This deficiency of trained professionals, together with the absence of equipment at diagnostic centers, results in misdiagnoses requiring the use of empirical treatment methods by healthcare providers irresponsibly. “The diagnostic facilities here are minimal—often, doctors prescribe antibiotics based on symptoms alone because tests aren’t always available, or results take too long. We’re trying to treat patients as quickly as possible, given the high patient load.” (R1, Age 53) “Patients are diagnosed and treated by lower-tier staff, especially in rural government hospitals. For the last six months, there hasn’t been an MBBS doctor at the clinic, so unqualified practitioners often help with diagnosing patients and handing out antibiotics.” (R 13, Age 39) 3.4. Theme Four. Healthcare Providers’ Diagnostic Proficiency and Skill Development 3.4.1. Awareness Levels among Practitioners The majority of the respondents admitted to having limited knowledge about AMR protocols and rational prescribing, with some attributing this gap to insufficient training opportunities. A Health Officer offered a telling perspective: "Most of the doctors here do not even know what AMR is. It is rarely discussed in our training sessions, and it is usually more about treating symptoms quickly, often with antibiotics." (R4, Age 33) The resultant impact is compounded by the lack of continuous medical education programs aimed at combating AMR. While medical colleges teach basic pharmacology, real life differs from the recommended guidelines. For example, using broad-spectrum antibiotics generally as first-line therapy in infections, regardless of etiology, is an example of a non-evidence-based practice. A pediatrician emphasized: "Doctors here cannot even be trained about AMR. It is not a lack of awareness; it is a lack of enforcement of guidelines that it perpetuates." (R7, Age 38) The practitioners dispense large amounts of broad-spectrum antibiotics without regard to any form of training for conditions likely managed by viral or nonbacterial infections. Often, their practices provide patients immediate relief with little thought of diagnostic accuracy and the appropriate drug choice. These findings underscore the importance of specialized AMR education programs on effective antibiotic prescribing and revised treatment regimens. 3.4.2. Ethical and Professional Gaps The findings suggest important ethical and professional gaps in the behavior of healthcare providers and their prescription of antibiotics. Many practitioners admit that having an open prescription of antibiotics is not required for clinical reasons, financial incentives, or because of the patient's demands. Many ethical concerns arise because needs are sacrificed for convenience or personal gain rather than for patient well-being. A respondent illustrated this issue: "I often see doctors prescribing cefixime for children suffering from diarrhea because it was available right there. It seemed like meeting sales targets rather than treating the patient effectively." (R9, Age 22) This is not only a problem in private clinics, but public healthcare settings also have the same problems. A retired public-sector doctor observed: “While many practitioners let their relatives or uncertified assistants prescribe antibiotics in their absence, many inappropriate and sometimes harmful practices take place under these circumstances.” (R6, Age 67) More rigorous enforcement of ethical standards and systematic auditing to comply with AMR guidelines is necessary, the findings show. In anticipation of these professional gaps, AMR awareness can be integrated into medical training, which can also improve the ethical framework of medical training by bringing in mindfulness about patient-centered care. 3.5. Theme Five: Financial Constraints in Diagnostic and Demand for Antibiotics 3.5.1. Financial Barriers to Testing The long-term overprescription of antibiotics is primarily driven by financial constraints that make patients unable to access diagnostic services. Frequent staff absences, as well as equipment shortages, have left most government laboratories closed, forcing patients to count on private labs that charge significantly more. These services are too expensive for many patients, so they rely on symptomatic treatment. This serves as an economic barrier to accurate diagnosis because lab fees are high, and patients cannot afford to pay. Doctors and patients consider broad-spectrum antibiotics a low-cost and cost-effective solution instead of pursuing expensive diagnostic procedures. A healthcare professional noted: “Many patients complain about the cost when we recommend tests. ‘It’s better to take medicine directly than to test unnecessarily,' they say.” (R3, Age 45) The financial barriers reinforce the practice of the blind prescription of antibiotics in the absence of diagnostic confirmation due to doctors’ preferences. Economic pressures combined with scarce financial resources, insufficient lab infrastructure, and little access to services all lessen the chance that antibiotics will be spent appropriately, which increases the likelihood of creating drug-resistant infections. 3.5.2. Patient Demand for Antibiotic Prescriptions The results indicate that many antibiotics are prescribed without corresponding diagnostic tests, and two main drivers are patient pressure and profit motives in healthcare providers. For example, one respondent observed: "What we see is many patients walking in expecting antibiotics. They believe that antibiotics are magic bullets. They lose faith in our treatment if we do not prescribe antibiotics." (R 5, Age 32 years, doctor) It emphasizes the high relevance that patient expectations exert on prescription behavior. Similarly, a private practitioner admitted: "We give them antibiotics because patients expect them, and also, private practice is competitive and profit-driven." (R11, Age 23, Quack) "Customers ask for antibiotics, and we give them; no one checks to see if a prescription was given. They [regulatory authorities] only come here for the bribes, not for monitoring." (R15, Age 28 years, a medical store owner). “Private clinics are businesses, and staying on top of patient satisfaction is extremely important for their survival. Patients can ask for antibiotics for faster relief, and refusing them can cost you the client.” (R10, age 32) Discussion Thematic analysis of the qualitative data revealed five major themes with corresponding subthemes that highlight the multifaceted drivers of antibiotic misuse in the healthcare system. Together, these themes underscore the systemic, professional, and socio-economic factors that fuel inappropriate antibiotic use in Pakistan. 4.1. Structural and Administrative Challenges First theme, "structural and administrative challenges in antibiotic misuse," comprises issues of 1) political and administrative limitations imposed on prescription behavior and 2) the lack of regular monitoring, reporting, and accountability systems, which destabilize the application of stewardship measures. Due to a systemic gap between governance, administrators often do not regularly use assessments, monitoring, and reporting for antibiotic use ( 19 ). The findings show that the power-oriented role plays a bigger role in the healthcare industry than patient care when administrators do not prioritize the evaluation of antibiotics as part of their core responsibility. Consequently, institutions are held accountable for little. Moreover, relying on regional networks or political connections to appoint administrators fosters a culture where personal influence outweighs professional qualifications and genuine healthcare priorities ( 20 ). The environment of poor assessment, weak reporting systems, and minimal surveillance means that clinics, hospitals, and medical stores seldom face any repercussions for misuse. This regulatory gap, which is quite broad and represents a public health governance challenge for the system to regulate the use of antibiotics and address emerging threats, is justified. These findings are corroborated by Afzal et al. ( 21 ) and Mustafa et al. ( 22 ), who state that all antibiotic prescriptions at secondary care public hospitals in Pakistan are made because of the absence of antibiotic guidelines and poor diagnostic abilities of the public health sector. In addition, the results suggest socio-political dynamics that enable unqualified drug companies to prosper even with the support of such politicians and bureaucrats. The availability of inappropriate medications that result from this influence is a significant contributor to making antimicrobial resistance management a challenging task. These findings echo Pearson and Chandler's ( 23 ) multi-country analysis of how healthcare professionals navigate antimicrobial resistance in practice, particularly their observation that structural constraints and profit motives often override clinical best practices in prescribing decisions. 4.2. Role of Pharmaceutical Companies and Medical Drug Stores Theme 2 reflects the strong control pharmaceutical corporations have over prescribing habits, which is often based more on financial returns than on clinical requirements. The complex interplay between public and private healthcare providers in our study site exemplifies what Lock and Nguyen ( 24 ) term 'medical pluralism under market conditions.' The prevalence of dual practice among government doctors and the flourishing of unqualified practitioners mirror what João Biehl ( 25 ) observed in his study of pharmaceutical governance in Brazil, where market forces reshape healthcare delivery in ways that prioritize profit over patient care. The commodification of antibiotics in both sectors demonstrates what Biehl terms the “Pharmaceuticalization of public health”, where drugs become market commodities rather than therapeutic tools. Market forces reshape antibiotic prescribing practices in ways that often prioritize economic interests over clinical necessity. This is consistent with a recent study ( 21 ) that suggests that “Medicine availability significantly influences prescribing decisions, often taking precedence over clinical needs.” The limited presence of the Drug Regulatory Authority suggests that inspections of their medical stores are rare and often compromised. There is weak regulatory oversight regarding the distribution of antibiotics, and medical stores can sell them freely with few consequences when these antibiotics are not distributed properly. Prescribing 2–3 antibiotics in a single prescription exposes the normalization of excessive antibiotic use, which has been facilitated by patients reusing old prescriptions owing to financial constraints or time limitations. The role played by the pharmaceutical companies in the dispensing of antibiotics cannot be overlooked. These companies fund and incentivize medical stores and then encourage informal agreements with healthcare professionals to market their products. In this commercialized approach, antibiotics are viewed as commercial commodities and not as resources for healthcare. The data also show that self-medication is a common practice, as there is easy access to antibiotics from medical stores. Patients often go by past experience, suggestions from non-medical acquaintances, or out of convenience. The direct delivery of medications to customers, even without prescriptions, and the informal and transactional nature of the practice of healthcare to its personnel demonstrate how healthcare is practiced at the community level. Customers also view these stores as a convenient substitute to formal healthcare facilities, which is compounded by the loose regulatory enforcement and unacknowledged alliances between local doctors and store owners. The results also suggest that medical store owners are unaware of antimicrobial resistance. They had never been assessed or monitored by health authorities, and most of them were unaware of related policies or guidelines. To a large extent, the knowledge gap and the profit-driven motives of pharmaceutical companies highly contribute to the use of antibiotics in communities ( 26 ). In sum, for medical stores, we argue that they are informal but essential components of healthcare, providing informal services where formal systems have failed. Nevertheless, the unregulated sale of antibiotics plays their crucial role in the spread of antimicrobial resistance, influenced by a lack of regulation, economic incentives, and, in general, a culture of self-medication ( 27 ). This dynamic mirrors patterns documented by Haenssgen et al. ( 28 ) in their study of antibiotic distribution networks, where medical stores serve as crucial but problematic nodes in the informal circulation of antibiotics, especially in areas with limited formal healthcare access. 4.3. Lack of Healthcare Providers, Laboratories, and Diagnostic Gaps Theme 3 discussed the shortage of qualified providers, dependence on unqualified practitioners, also known as quacks, and the insufficiency of diagnostic structure, which causes empirical antibiotic use without proper investigations. The lack of sufficient laboratory infrastructure exacerbates the problem. This pattern aligns with Chandler's ( 29 ) analysis of how antimicrobial resistance becomes embedded within healthcare infrastructure in resource-limited settings, where systemic inadequacies create conditions that normalize antibiotic misuse. The findings show that the functionality and accessibility of laboratory services influence antibiotic prescription patterns in Pakistan. Staff protests and other administrative disruptions often cause government laboratories to remain non-functional. As a result, most patients end up using private laboratories, which are much more expensive and thus unaffordable for the lower-income population. The lack of access to affordable diagnostic services is another reason for relying heavily on empirical treatment, in which the patient is prescribed antibiotics without having the diagnosis confirmed ( 30 ). Findings indicate that there are not enough qualified staff in most private laboratories and that the majority of them work without regulatory control. Lack of professional expertise leads to insufficient implementation of protocols for the diagnosis of infections, which are essential for appropriate antibiotic use. The findings show a saddening increase in quack practitioners who are often unaware of proper drug dosages or antibiotic side effects, especially in lower-income regions where formal healthcare access is virtually non-existent. The emergence of this trend is fraught with particular risks to vulnerable groups such as the poor, elderly, women, and children ( 31 ). The results suggest that these practitioners account for a large proportion of such misuse of antibiotics by prescribing antibiotics for conditions that do not require them. 4.4. Practitioners' Ignorance and Training Gaps Theme four revealed a scarcity of knowledge of health providers about the rational use of antibiotics and incompetence in professional and ethical education, leading to irrational prescribing behaviors. 3rd generation antibiotics are prescribed countless times for conditions that do not require antibiotics, as countless practitioners routinely do. This typically means that paying attention to caring for patients is not as important as being able to output high-speed results for personal financial gain, typically. Shaikh et al. ( 14 ) note that physicians often prescribe antibiotics without adequate knowledge of antimicrobial guidelines. Many receive information from pharmaceutical representatives, leading to biased prescribing practices ( 14 , 32 ). Literature suggests that resistance data from provinces could be a guiding tool for correct empirical therapy and current resistance trends ( 33 , 34 ). This gap between knowledge and practice aligns with Tarrant et al.'s ( 35 ) analysis of how contextual factors shape antibiotic prescribing decisions, often leading practitioners to prioritize immediate patient demands over long-term stewardship concerns. Contrary to the claim of Pakistan’s National Action Plan on AMR, standardized treatment guidelines (STGs) for antibiotic prescribing were absent, necessitating a localized antibiotic prescribing policy to promote more suitable empirical prescribing ( 36 ). Although WHO warned that antimicrobial resistance is a grave public health threat, this information is not being shared widely or effectively across the system ( 37 , 38 ). 4.5. Financial Constraints in Diagnostic and Demand for Antibiotics Theme five conveyed financial barriers that dissuade diagnostic testing, burdened with patient-initiated requests for antibiotics as a perceived fix-all, coercing providers to needlessly write prescriptions. The economic constraints that limit access to true diagnostics are also seen in different views of doctors and patients on the utility of laboratory testing. These barriers to diagnostic testing reflect broader patterns identified by Charani et al. ( 39 ) in their analysis of antimicrobial stewardship across different income settings, where limited laboratory infrastructure systematically undermines evidence-based prescribing. The reasons doctors choose to prescribe antibiotics are both patient financial constraints combined with limited resources to ensure patient recovery, leaving little choice. Antimicrobial stewardship problems are not limited to LMIC. In the United States, one-third of outpatient antibiotics are considered unnecessary ( 40 ), and Southern Europe reports high non-prescription sales ( 41 ). Overprescribing continues even with hospital programs, displaying that antibiotic resistance is a global problem demanding synchronized action ( 42 ). 4.6. Limitations and Strengths of the Study The current exploratory study has limitations. First, it has used a small sample size, and most respondents were male healthcare providers. Then, this study is conducted in only Sindh province, and does not claim to be longitudinal or nationally representative research. Third, it gives only healthcare providers' perspectives on unregulated use and excludes other relevant stakeholders. The study has some strengths as well. First, it focuses on how excessive use of antibiotics worsens the conditions of not only a patient but also the healthcare system. Second, taking the meager socio-economic conditions of the people into account, research analyses how it creates multiple financial and social burdens with its now and then use in society. Third, it points out certain policy gaps and irregularities in the country's healthcare system, which provides a window of opportunity for not only the big companies that manufacture and sell them but also those health practitioners who suggest them. Therefore, it exposes the nexus among different actors who get the shared benefit of unregulated antibiotic use. Conclusion In conclusion, this study highlights the complex socio-political and economic factors perpetuating AMR in Pakistan, particularly within the district of Sindh. The findings reveal how weak regulatory structures, pervasive quack practices, and the commodification of antibiotics by pharmaceutical companies drive widespread misuse of antibiotics. Additionally, limited diagnostic infrastructure and financial constraints force healthcare providers to rely on empirical treatments, further exacerbating AMR. Structural reforms that include stricter regulations, enhanced diagnostic facilities, and improved healthcare access for underserved populations are critical to address AMR effectively. Public awareness initiatives are essential to educate communities about the dangers of antibiotic misuse. Implementing these changes, alongside more robust oversight and targeted training for healthcare providers, can contribute to more sustainable AMR management. Such systemic interventions will not only curb antibiotic misuse but also promote more equitable healthcare practices, ultimately leading to better health outcomes and reducing the AMR burden in Pakistan. Abbreviations ASRB: Advanced Studies and Research Board; AMR: Antimicrobial Resistance; STGs: Standardized Treatment Guidelines Declarations Acknowledgments The authors are thankful to the healthcare providers for their willingness to participate in and support this study. Authors’ contributions SA, IUL, and FA conceptualized and designed the study. SA, FA, RA, and NIM were responsible for all aspects of data collection, coding, analysis, and writing of the initial manuscript draft. SA, NIM, RA, IUL, RB, MS, ZA, SZ, FA, and KT provided and interpreted the findings, reviewed the manuscript, edited drafts, and added essential intellectual content. All authors read and approved the final manuscript. Funding This research received no funding. Data Availability The original data presented in this study are included in the article. Further inquiries can be directed to the corresponding author(s). Ethical approval and consent to participate The study adhered to the guidelines of the Declaration of Helsinki. Ethical approval for the study was obtained from the Research Ethics Committee of the Quaid-i-Azam University, Pakistan (Number: QAU-IBC-3006; Date of Approval: 21 October 2024). All participants were fully informed about the nature of the study beforehand, and then they provided informed consent. Informed consent was obtained from all subjects and/or their legal guardian(s). Consent for publication Not applicable Author Details Sohail Ahmed is Research Associate at Department of Anthropology, Quaid-i-Azam University, Islamabad Pakistan. Prof. Najma Iqbal Malik is Chair of Department of Psychology at University of Sargodha, Sargodha, Punjab, Pakistan. Razia Anjum is Senior Lecturer, Department of Psychology, Bath Spa University, Ras Al Khaimah, United Arab Emirates. Inam Ullah Leghari is Associate Professor of Department of Anthropology at Quaid-i-Azam University, , Islamabad Pakistan. Rubina Bhatti is the Dean of the Faculty of Social Sciences and a Professor in the Department of Information Management at The Islamia University of Bahawalpur, Pakistan. Prof. Muhammad Saleem is Chairman of Department of Applied Psychology at The Islamia University of Bahawalpur, Bahawalpur Pakistan. Zakir Ali is Deputy Director in Department of Community Relations, Karachi Sindh, Pakistan. Farooq Ahmed, Associate Professor and Chairman of Department of Anthropology at The Islamia University of Bahawalpur, Bahawalpur Pakistan. Sidra Zia, Research Associate, Department of Anthropology, The Islamia University of Bahawalpur, Bahawalpur Pakistan. Kun Tang is professor at Vanke School of Public Health, Tsinghua University, Beijing, China. Competing interests The authors declare that they have no competing interests. Clinical trial number Not applicable. References World Health Organization. Antimicrobial resistance: global report on surveillance. Geneva: WHO; 2014. Available from: https://www.who.int/publications/i/item/9789241564748. Accessed 18 Oct 2024. Institute for Health Metrics and Evaluation. Global Burden of Disease (GBD). Seattle: IHME; 2020. Available from: https://www.healthdata.org/research-analysis/gbd. Accessed 18 Oct 2024. Tahir B. The efficacy of Pakistan's National Action Plan in addressing antimicrobial resistance [PhD Dissertation]. Doha: Hamad Bin Khalifa University; 2024. Udwadia Z, Furin J. Quality of drug-resistant tuberculosis care: gaps and solutions. J Clin Tuberc Other Mycobact Dis. 2019;16:100101. doi:10.1016/j.jctube.2019.100101. Noor MN, Liverani M, Bryant J, Rahman-Shepherd A, Sharif S, Aftab W, et al. The healthcare field as a marketplace: general practitioners, pharmaceutical companies, and profit-led prescribing in Pakistan. Health Sociol Rev. 2023;32:198-212. Salam MA, Al-Amin MY, Salam MT, Pawar JS, Akhter N, Rabaan AA, et al. Antimicrobial resistance: a growing serious threat for global public health. Healthcare. 2023;11:1946. doi:10.3390/healthcare11131946. Das J, Daniels B, Ashok M, Shim EY, Muralidharan K. Two Indias: the structure of primary health care markets in rural Indian villages with implications for policy. Soc Sci Med. 2020;256:112799. Suy S, Rego S, Bory S, Chhorn S, Phou S, Prien C, et al. Invisible medicine sellers and their use of antibiotics: a qualitative study in Cambodia. BMJ Glob Health. 2019;4:e001787. Khan M, Hasan R. The healthcare field as a marketplace: general practitioners, pharmaceutical companies, and profit-led prescribing in Pakistan. Health Sociol Rev. 2022;32:1-15. doi:10.1080/14461242.2022.2139628. Sindh HealthCare Commission. Anti-quackery. Karachi: SHCC; 2024. Available from: https://shcc.org.pk/introduction-to-anti-quackery/. Accessed 20 May 2024. Hassan A, Mahmood K, Bukhsh HA. Healthcare system of Pakistan. Int J Acad Res Plan. 2017;1:170-3. Holmes AH, Moore LS, Sundsfjord A, Steinbakk M, Regmi S, Karkey A, et al. Understanding the mechanisms and drivers of antimicrobial resistance. Lancet. 2016;387:176-87. Mirha H, Ali SH, Aamar H, Sadiq M, Tharwani ZH, Habib Z, et al. The impact of antibiotic resistance on the rampant spread of infectious diseases in Pakistan: insights from a narrative review. Health Sci Rep. 2024;7:e2050. doi:10.1002/hsr2.2050. Shaikh OA, Asghar Z, Aftab RM, Amin S, Shaikh G, Nashwan AJ. Antimicrobial resistant strains of Salmonella Typhi: the role of illicit antibiotics sales, misuse, and self-medication practices in Pakistan. J Infect Public Health. 2023;16:1591-7. Majumder MAA, Rahman S, Cohall D, Bharatha A, Singh K, Haque M, et al. Antimicrobial stewardship: fighting antimicrobial resistance and protecting global public health. Infect Drug Resist. 2020;13:4713-38. doi:10.2147/IDR.S290835. Navarro V. Medicine under capitalism. New York: Prodist; 1976. Foucault M. The birth of biopolitics. New York: Palgrave Macmillan; 2010. Singer M. The limitations of medical ecology: the concept of adaptation in the context of social stratification and social transformation. Med Anthropol. 1989;10:223-34. Zapantis A, Lacy MK, Horvat RT, Dennis G, Barnes BJ, O'Neal B, et al. Nationwide antibiogram analysis using NCCLS M39-A guidelines. J Clin Microbiol. 2005;43:2629-34. Barlam TF, Cosgrove SE, Abbo LM, MacDougall C, Schuetz AN, Septimus EJ, et al. Implementing an antibiotic stewardship program: guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis. 2016;62:e51-77. Afzal S, Bajwa M, Ahmed N, Jabeen J, Haroon MS, Mushtaq RMZ, et al. The antibiotic procurement saga: a long-neglected stewardship target to combat antimicrobial resistance in Pakistan. Antimicrob Resist Infect Control. 2025;14:7. Mustafa ZU, Salman M, Yasir M, Godman B, Majeed HA, Kanwal M, et al. Antibiotic consumption among hospitalized neonates and children in Punjab Province, Pakistan. Expert Rev Anti Infect Ther. 2022;20:931-9. Pearson M, Chandler C. Knowing antimicrobial resistance in practice: a multi-country qualitative study with human and animal healthcare professionals. Glob Health Action. 2019;12:1599560. doi:10.1080/16549716.2019.1599560. Lock MM, Nguyen VK. An anthropology of biomedicine. 2nd ed. Hoboken: Wiley-Blackwell; 2018. Biehl JG. Pharmaceuticalization: AIDS treatment and global health politics. Anthropol Q. 2007;80:1083-126. Atif M, Ihsan B, Malik I, Ahmad N, Saleem Z, Sehar A, et al. Antibiotic stewardship program in Pakistan: a multicenter qualitative study exploring medical doctors' knowledge, perception and practices. BMC Infect Dis. 2021;21:374. Drug Regulatory Authority of Pakistan. Guidelines for the responsible use of antimicrobials in human health. Islamabad: DRAP; 2021. Available from: http://www.dra.gov.pk. Accessed [DD Month YYYY]. Haenssgen MJ, Charoenboon N, Zanello G, Mayxay M, Reed-Tsochas F, Jones CO, et al. Antibiotics and activity spaces: protocol of an exploratory study of behaviour, marginalisation and knowledge diffusion. BMJ Glob Health. 2018;3:e000621. Chandler CIR. Current accounts of antimicrobial resistance: stabilisation, individualisation and antibiotics as infrastructure. Palgrave Commun. 2019;5:53. doi:10.1057/s41599-019-0263-4. Ministry of National Health Services, Regulation & Coordination. AMR Action Plan for Pakistan. Islamabad: MoNHSRC; 2017. Available from: https://www.flemingfund.org/wp-content/uploads/National-AMR-Action-Plan-for-Pakistan.pdf. Accessed [DD Month YYYY]. Pakistan Medical & Dental Council. Quackery and its impact on healthcare in Pakistan. Islamabad: PMDC; 2011. Available from: http://www.pmdc.org.pk. Accessed [DD Month YYYY]. Nahar P, Unicomb L, Lucas PJ, Uddin MR, Islam MA, Nizame FA, et al. What contributes to inappropriate antibiotic dispensing among qualified and unqualified healthcare providers in Bangladesh? A qualitative study. BMC Health Serv Res. 2020;20:656. doi:10.1186/s12913-020-05512-y. Khatri D, Falconer N, de Camargo Catapan S, Coulter S, Gray LC, Paterson DL, et al. Exploring stakeholders' perspectives on antibiogram use, development, and implementation in residential aged care settings. Res Social Adm Pharm. 2024;20:747-54. Guarascio AJ, Brickett LM, Porter TJ, Lee ND, Gorse EE, Covvey JR. Development of a statewide antibiogram to assess regional trends in antibiotic-resistant ESKAPE organisms. J Pharm Pract. 2019;32:19-27. Tarrant C, Krockow EM, Nakkawita WMI, Bolscher M, Colman AM, Chattoe-Brown E, et al. Moral and contextual dimensions of "inappropriate" antibiotic prescribing in secondary care: a three-country interview study. Front Sociol. 2020;5:7. doi:10.3389/fsoc.2020.00007. Medical Microbiology and Infectious Diseases Society of Pakistan. Antimicrobial use guidelines. Karachi: MMIDSP; 2019. Available from: https://www.mmidsp.com/wp-content/uploads/2019/09/Guidelines-for-Antimicrobial-Use-2.pdf. Accessed 24 Nov 2024. World Health Organization. UN General Assembly High-Level Meeting on Antimicrobial Resistance. Geneva: WHO; 2024. Available from: https://www.un.org/pga/wp-content/uploads/sites/108/2024/09/FINAL-Text-AMR-to-PGA.pdf. Accessed 18 Oct 2024. Butt SZ, Ahmad M, Saeed H, Saleem Z, Javaid Z. Post-surgical antibiotic prophylaxis: impact of pharmacist's educational intervention on appropriate use of antibiotics. J Infect Public Health. 2019;12:854-60. Charani E, Smith I, Skodvin B, Perozziello A, Lucet JC, Lescure FX, et al. Investigating the cultural and contextual determinants of antimicrobial stewardship programmes across low-, middle- and high-income countries—a qualitative study. PLoS ONE. 2019;14:e0209847. doi:10.1371/journal.pone.0209847. Centers for Disease Control and Prevention (CDC). Antibiotic use in the U.S. 2023. Available from: https://www.cdc.gov/antibiotic-use/stewardship-report/index.html. Accessed 15 Jul 2025. European Centre for Disease Prevention and Control (ECDC). Antimicrobial consumption in the EU/EEA. 2022. Available from: https://www.ecdc.europa.eu/en/publications-data/surveillance-antimicrobial-consumption-europe-2022. Accessed 15 Jul 2025. Organisation for Economic Co-operation and Development (OECD). Stemming the superbug tide: just a few dollars more. Paris: OECD Publishing; 2018. doi:10.1787/9789264307599-en. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3:77-101. doi:10.1191/1478088706qp063oa Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 03 Nov, 2025 Reviewers agreed at journal 22 Oct, 2025 Reviewers agreed at journal 21 Oct, 2025 Reviewers invited by journal 21 Oct, 2025 Editor assigned by journal 14 Aug, 2025 Editor invited by journal 14 Aug, 2025 Submission checks completed at journal 14 Aug, 2025 First submitted to journal 14 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7329893","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":536178861,"identity":"81856b60-0b64-43e8-abae-1a83eec24cb4","order_by":0,"name":"Sohail Ahmed","email":"","orcid":"","institution":"Quaid-i-Azam University","correspondingAuthor":false,"prefix":"","firstName":"Sohail","middleName":"","lastName":"Ahmed","suffix":""},{"id":536178863,"identity":"2e29b08c-ea92-4360-8918-d3f4b604b725","order_by":1,"name":"Najma Iqbal Malik","email":"","orcid":"","institution":"University of Sargodha","correspondingAuthor":false,"prefix":"","firstName":"Najma","middleName":"Iqbal","lastName":"Malik","suffix":""},{"id":536178865,"identity":"5f850a57-a0ac-4e20-9454-718971bf015d","order_by":2,"name":"Razia Anjum","email":"","orcid":"","institution":"Bath Spa University","correspondingAuthor":false,"prefix":"","firstName":"Razia","middleName":"","lastName":"Anjum","suffix":""},{"id":536178869,"identity":"1712d372-109f-4b04-9871-b91453e9cda0","order_by":3,"name":"Inam Ullah Leghari","email":"","orcid":"","institution":"Quaid-i-Azam University","correspondingAuthor":false,"prefix":"","firstName":"Inam","middleName":"Ullah","lastName":"Leghari","suffix":""},{"id":536178874,"identity":"17a90679-f2a8-4716-a392-a782970eb0a5","order_by":4,"name":"Rubina Bhatti","email":"","orcid":"","institution":"Islamia University of Bahawalpur","correspondingAuthor":false,"prefix":"","firstName":"Rubina","middleName":"","lastName":"Bhatti","suffix":""},{"id":536178877,"identity":"3e0151ea-123c-4962-831d-438ed43e0308","order_by":5,"name":"Muhammad Saleem","email":"","orcid":"","institution":"Islamia University of Bahawalpur","correspondingAuthor":false,"prefix":"","firstName":"Muhammad","middleName":"","lastName":"Saleem","suffix":""},{"id":536178879,"identity":"ae9858ed-d7a0-4bda-a7d6-8aa7f1310670","order_by":6,"name":"Zakir Ali","email":"","orcid":"","institution":"Government of Sindh, Pakistan","correspondingAuthor":false,"prefix":"","firstName":"Zakir","middleName":"","lastName":"Ali","suffix":""},{"id":536178881,"identity":"dea236ae-b8a8-450a-b8f5-cc2de943ea52","order_by":7,"name":"Sidra Zia","email":"","orcid":"","institution":"Islamia University of Bahawalpur","correspondingAuthor":false,"prefix":"","firstName":"Sidra","middleName":"","lastName":"Zia","suffix":""},{"id":536178882,"identity":"0bf744dd-67c9-48e9-bb5b-56aa980124b8","order_by":8,"name":"Farooq Ahmed","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA90lEQVRIiWNgGAWjYBAC9gYowwCIJT4YMCRA2Qk4tfAcQNIiOYNkLdI8DMRoYT/78MGHMgZ5c7HDB2/bFBzOY2Bv3ibBuCMNtxaedGPDGecYDHfOTku2zjE4XMzAc6xMgvFMDk4t9gxpbNK8bQyMG27nmEkDtSQ2SOSYSTC2VeC2hf8ZWIv9htv536QtQFrk3xDQIgGxJRFoC5s0A9gWHpAW3A7jkXjGDPSLRPKG22nGlj0G6cVsPGnFFoln8HifP40RGGI2thtuJz+88eOPdR4/++GNNz7uSMapBQLYJJDYICKxgYAOiDJkwEhQyygYBaNgFIwgAACLKE1wIo3OegAAAABJRU5ErkJggg==","orcid":"","institution":"Islamia University of Bahawalpur","correspondingAuthor":true,"prefix":"","firstName":"Farooq","middleName":"","lastName":"Ahmed","suffix":""},{"id":536178884,"identity":"89c4b6fb-53bf-4b1c-b730-3cb0d2e78066","order_by":9,"name":"Kun Tang","email":"","orcid":"","institution":"Tsinghua University","correspondingAuthor":false,"prefix":"","firstName":"Kun","middleName":"","lastName":"Tang","suffix":""}],"badges":[],"createdAt":"2025-08-08 19:38:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7329893/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7329893/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":94945546,"identity":"b3e31b1f-2d9c-4faf-9f53-a346e79ab070","added_by":"auto","created_at":"2025-11-02 09:23:35","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":179256,"visible":true,"origin":"","legend":"","description":"","filename":"bmcarticle82.docx","url":"https://assets-eu.researchsquare.com/files/rs-7329893/v1/1be853a7b231acc929f41a4f.docx"},{"id":94945551,"identity":"5ef615a8-fab2-4103-8f9b-e8d82e18d081","added_by":"auto","created_at":"2025-11-02 09:23:36","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":10880,"visible":true,"origin":"","legend":"","description":"","filename":"06b41e9c907b4b9591ae33ebb70c8e47.json","url":"https://assets-eu.researchsquare.com/files/rs-7329893/v1/54aa8d0d2d6638dc63509efd.json"},{"id":94945544,"identity":"845bf1d6-4758-4917-98e6-b0c2d63b4e60","added_by":"auto","created_at":"2025-11-02 09:23:35","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":116274,"visible":true,"origin":"","legend":"","description":"","filename":"InterviewGuideandConsentform.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7329893/v1/050fc33341b5812a6af885b5.pdf"},{"id":94987758,"identity":"f70850fa-89ca-4e7a-bffc-fe20e02bac3b","added_by":"auto","created_at":"2025-11-03 07:02:29","extension":"xml","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":121079,"visible":true,"origin":"","legend":"","description":"","filename":"06b41e9c907b4b9591ae33ebb70c8e471enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7329893/v1/7c66c1b1aff235a112f9d430.xml"},{"id":94945612,"identity":"f9b83ea6-024a-44c8-b5d7-3bf18a7661d9","added_by":"auto","created_at":"2025-11-02 09:23:37","extension":"jpeg","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":1329552,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7329893/v1/7ee0a42c844996574f5685f7.jpeg"},{"id":94945549,"identity":"1d707d98-331d-4621-8566-3fe873438ffa","added_by":"auto","created_at":"2025-11-02 09:23:36","extension":"jpeg","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":514820,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7329893/v1/05d1636d2f810d6bc6b83ff0.jpeg"},{"id":94945556,"identity":"4b014359-a0dd-4305-8cfb-9a8cd4d56432","added_by":"auto","created_at":"2025-11-02 09:23:36","extension":"png","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":177902,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7329893/v1/e024090f03100a184e05833d.png"},{"id":94945550,"identity":"e89f699d-ed5f-4b03-b123-6c3a470a2a2e","added_by":"auto","created_at":"2025-11-02 09:23:36","extension":"png","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":131264,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7329893/v1/ecff7a469c7b7e41c0589b14.png"},{"id":94945547,"identity":"7c3649a9-9a8e-4397-ab23-8ac105d228af","added_by":"auto","created_at":"2025-11-02 09:23:35","extension":"xml","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":118057,"visible":true,"origin":"","legend":"","description":"","filename":"06b41e9c907b4b9591ae33ebb70c8e471structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7329893/v1/ce1bc0e6b69f7daafd48cd00.xml"},{"id":94988882,"identity":"72a4eba3-0831-490f-b364-027f581946cb","added_by":"auto","created_at":"2025-11-03 07:11:16","extension":"html","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":131128,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7329893/v1/24652feef361b5c6a84ac200.html"},{"id":94945613,"identity":"67a1b2ef-c168-4d62-9ee6-7f2b85493930","added_by":"auto","created_at":"2025-11-02 09:23:38","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":236955,"visible":true,"origin":"","legend":"\u003cp\u003eUnregulated Use of Antibiotics and Antimicrobial Resistance in Pakistan\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7329893/v1/f72c59e658bfced3f7b7f1de.png"},{"id":94990995,"identity":"7f727841-82be-4186-ba75-8828766f78ec","added_by":"auto","created_at":"2025-11-03 07:18:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1430541,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7329893/v1/c0734681-54ca-4d4f-a1f8-da420d4bb838.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Healthcare providers’ knowledge, attitude, and practice of antibiotic use and antimicrobial resistance in Southern Pakistan: a qualitative study","fulltext":[{"header":"Introduction","content":"\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe World Health Organization (WHO) characterized AMR as a global health threat and warned that, if left unaddressed, it could lead to a post-antibiotic era in which common bacterial infections might once again become fatal (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). In 2019 alone, drug-resistant infections caused 1.95\u0026nbsp;million lives, with ~\u0026thinsp;1.1\u0026nbsp;million of these deaths occurring among children below the age of five (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Pakistan faces a grave AMR crisis, with 59,200 deaths associated with antimicrobial resistance in 2019, ranking 176th out of 204 countries in age-standardized AMR mortality rates (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The efficiency of Paki-stan\u0026rsquo;s healthcare system is entirely neglected with a lack of regulation, and rough handling of patients, which has tremendously contributed to antibiotic misuse (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) and the spread of drug-resistant infections (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eFactors that lead to patients' noncompliance with antibiotics are a leading concern for the public health system. Pharmaceutical companies encourage general practitioners (GPs) to prescribe medications based on financial incentives, and their healthcare representatives promote prescriptions driven by profit motives. Most of the time, antibiotics are unnecessarily prescribed to meet sales targets rather than clinical needs (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Such prescribing is highly patient-dependent, where many patients come to the GPs expecting antibiotics for self-limited conditions, adding pressure on the GPs to comply (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). This cultural belief leads to the misuse of antibiotics, resulting in antimicrobial resistance.\u003c/p\u003e\u003cp\u003eA major reason behind the spread of AMR in Pakistan is the over-prescription of antibiotics in government hospitals. This problem includes inadequate medical diagnostics, insufficient staff members of skilled healthcare workers, and political interference (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). However, the role of informal providers further complicates the situation. As such, these providers prescribe antibiotics indiscriminately (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) without proper regulation or oversight. Besides that, the problem of available unqualified practitioners also provisioning antibiotics constitutes a public health threat, in particular, 'quacks,' who indiscriminately prescribe antibiotics while pretending to provide healthcare services (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). For instance, Pakistan has over 600,000 quacks, creating a genuine need for a holistic understanding of the landscape of healthcare (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eExploitative prescribing practices take advantage of regulatory loopholes in the pharmaceutical market, undermining patient safety (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). To encourage responsible prescribing, these regulatory frameworks must be significantly strengthened. Additionally, socio-economic factors play a critical role; many patients who lack access to formal healthcare services turn to informal providers instead (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Furthermore, cultural beliefs and perceptions of illness significantly influence patient behavior, particularly in the context of antibiotic usage (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAntibiotic resistance in Pakistan has been driven by inadequate regulatory frameworks, leading to under-regulation, over-prescription, and self-medication (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Socio-economic factors significantly contribute to the misuse of antibiotics, with patients often obtaining these medications without prescriptions, reflecting systemic weaknesses in healthcare practices (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Additionally, the COVID-19 pandemic has exacerbated these issues by promoting unregulated antibiotic usage as a common treatment response, emphasizing the need for heightened awareness and stewardship (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eDrawing upon a robust critical public health lens (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), our study explores the systemic causal factors that have led to antimicrobial resistance in Sindh province of Pakistan. This framework is built on a critical perspective that examines how socio-economic structures, power dynamics, and political processes shape healthcare outcomes (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). The discussion also shows how health disparities are inconceivably embedded in economic exploitation, as well as unequal distribution of resources and profit-making over public welfare, hence would be particularly relevant to AMR in low-income settings like Pakistan.\u003c/p\u003e\u003cp\u003eThis deconstructs how structural inadequacies (weak healthcare infrastructure, weak regulation, and systemic corruption) directly lead to AMR. Political interference, inadequate diagnostic facilities, and cases of poor governance in Sindh province of Pakistan lead to abuse of antibiotics, overprescription, and unregulated sales. Navarro\u0026rsquo;s (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) assertion reflects on these conditions that socio-political structures are characterized by economic gain that seldom yields health equity. AMR is likewise critically driven by economic incentives. Aggressive marketing and practitioner incentivization by pharmaceutical companies have contributed to profit-driven antibiotic prescribing, in many cases, unnecessarily clinically. Informal healthcare providers, who typically deal with a marginalized population constrained by poverty and sometimes also limited healthcare access and limited health literacy, perpetuate antibiotic misuse. These socioeconomic constraints reflect Navarro's (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) argument that health is a function of broader social forces in that the economically disadvantaged are overly burdened by systemic health issues, including AMR (\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eUsing the critical public health framework to understand AMR makes it clear that systemic reforms, such as stricter regulation and equitable healthcare policies or public health campaigns that address the social, political, and economic determinants, are needed to implement AMR interventions effectively. By tackling structural inequalities, this approach might be a pathway to sustainable AMR mitigation through a more just and health-oriented economic order (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Keeping in view this gap in literature, the present study investigates the sociocultural and politico-economic factors fueling AMR, focusing on regulatory gaps, the role of informal healthcare providers, and the economic motivations behind antibiotic overuse.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cb\u003eData Collection\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe country's southern parts, such as most districts in Sindh, are severely marginalized because of the unavailability of hospitals, diagnostic centers, and trained medical staff. The people in these communities also lack basic facilities such as clean drinking water and sanitation, leading to regular infections among children and mothers. Consequently, antibiotics are often employed as a first-line treatment. The sample for this study was chosen based on direct involvement or experience with the use of antibiotics and antimicrobial resistance (AMR). In the local setting, healthcare providers include formally trained personnel and informal healers, such as unlicensed healers and vendors who usually provide antibiotics without a medical prescription.\u003c/p\u003e\u003cp\u003eData collection was done through semi-structured interviews and field notes. A semi-structured interview guide was developed to explore antibiotic prescribing patterns, healthcare regulations, diagnostic barriers, and positive and negative awareness of AMR (see supplementary file). Participants could offer detailed insights with open-ended questions, but probing questions provided a further exploration of our key themes. A standardized set of questions was used to ensure uniformity of data collection. Interview responses were cross-verified with the triangulation of observations and available secondary data. To validate responses, member-checking was used, where participants were requested to verify and review their statements. Interview data was backed up by observational notes, validating the data further. A sample of nearly 20 healthcare providers was gathered. Our participants included 9 medical doctors, 6 druggists, and 5 quack practitioners. (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDetails about the Respondents (n\u0026thinsp;=\u0026thinsp;20).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDetails of Interviews\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo of Informants (\u003cem\u003en\u003c/em\u003e)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInterviews with formal healthcare providers and professional\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInterviews with quacks\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInterviews of pharmacy staff\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWe used audio recorders with their permission. Some participants allowed, but some did not allow recording; therefore, we had to take fieldnotes, keeping in mind the respondents ' comfort. The semi-structured interviews were in a flexible format, which usually lasted 1 hour, and in the local (Sindhi) language. Sociodemographic characteristics show that respondents were practitioners, including doctors, quacks, and pharmacists. (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe data analysis process was guided by Braun and Clarke's six-stage thematic analysis approach (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). Steps involved becoming familiar with the data, creating initial codes, looking for patterns, reviewing and narrowing themes, and synthesizing. Data were collected through semi-structured interviews and field notes using purposive sampling, which were translated into English from the local language. Two researchers (SA, FA) thoroughly read the transcripts repeatedly in order to attain a rich level of familiarity. They carried out line-by-line coding to find substantial units of meaning and bundled them into emerging themes. These were purified by continuous discussion among the researchers. Themes were finally validated with reference to the raw data, and disagreement was resolved by consensus. Thematic structuring was guided by an interpretive qualitative perspective rooted in the participants' narratives (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cb\u003eEthical/IRB Considerations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eBefore the study was undertaken, ethical approval had been obtained from the Department of Anthropology and the Institutional Bioethical Committee of Quaid-i-Azam University, Islamabad (Number: QAU-IBC-3006; Date of Approval: 21 October 2024). All participants were informed of the study\u0026rsquo;s purpose, voluntary participation, and right to withdraw at any time, without loss of penalty, and gave informed consent. No real names were used for all participants in the study to protect participants\u0026rsquo; confidentiality. Access to such data was restricted to the principal researcher to protect privacy and confidentiality, and the data was securely stored. When discussing personal or professional challenges related to antibiotic use, all interactions were made with respect and sensitivity.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eSociodemographic characteristics show that the majority of formal healthcare providers were doctors, along with informal professionals, including pharmacists and quacks (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSociodemographic Characteristics of Respondents (n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRespondent\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eProfession\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRespondent 1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePublic Sector Doctor\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRespondent 2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePrivate Doctor\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRespondent 3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDoctor\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRespondent 4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eF\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePublic Doctor\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRespondent 5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePublic Sector at the sub-district Hospital\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRespondent 6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRetired public doctor practicing in a private clinic\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRespondent 7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eChild specialist at the Medical College\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRespondent 8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eF\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDistrict Health Officer\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRespondent 9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMedical doctor\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRespondent 10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eF\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eQuack - practicing in a private clinic\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRespondent 11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eQuack - practicing in a private clinic\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRespondent 12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eQuack - practicing in a private clinic\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRespondent 13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eQuack - practicing in a private clinic\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRespondent 14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePharmacist\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRespondent 15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePharmacist\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRespondent 16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePharmacist\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRespondent 17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePharmacist\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRespondent 18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePharmacist\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRespondent 19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePharmacist\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRespondent 20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePharmacist\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e3.1. Theme One. Structural and Administrative Challenges in Antibiotic Misuse\u003c/h2\u003e\u003cdiv id=\"Sec6\" class=\"Section3\"\u003e\u003ch2\u003e3.1.1. Political and Administrative Issues and Prescription Practices\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003ePressure from local political figures often results in compromised healthcare delivery, including the overprescription of antibiotics. The political position often leads most health administrators to fall back on connections rather than promote quality patient care. A physician working at a tertiary Hospital noted:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Sometimes we\u0026rsquo;re instructed to write prescriptions as per the directives of influential local figures, regardless of medical necessity. It\u0026rsquo;s challenging to refuse under such circumstances.\u0026rdquo; (R5, Age 32)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;All of the senior positions in here are filled, more or less, according to political backing, and, frankly, merit is not a criterion. Consequently, much administrative effort is geared to contributing to political favor rather than enforcing healthcare guidelines.\u0026rdquo; (R6, Age 67, Medical Superintendent)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThese systemic weaknesses highlight a broader need for reforms in public healthcare management, emphasizing resource allocation, stricter monitoring, and improved training for staff at all levels.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section3\"\u003e\u003ch2\u003e3.1.2. Absence of Consistent Monitoring, Reporting, and Accountability\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThere are inconsistent monitoring and reporting mechanisms to measure antibiotic use. Also, a lack of regular training programs, evaluations, or workshops restricts antibiotic stewardship. This lack of accountability creates a permissive environment for the inappropriate use of antibiotics; physicians, unaccountable for their actions, are allowed to deviate from recommended practice with impunity.\u003c/p\u003e\u003cp\u003e\u003cem\u003e \u0026ldquo;We have guidelines from health authorities, but they are limited to paper. There is no structured system to make these guidelines work or to monitor antibiotic use.\u0026rdquo; (R4, Age 33)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We do not have the resources or the training to do regular auditing or to enforce compliance. In reality, AMR policies are often overlooked simply because our focus is more on immediate patient care.\u0026rdquo; (R8, Age 49, District Health Officer)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026lsquo;I have never seen any training or evaluation for AMR. Sometimes, we are not so focused on meeting sales quotas; it is more about ensuring the rational use of antibiotics.\u0026rdquo; (R2, Age 39).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e\u003cb\u003e3.2. Theme Two. Role of Pharmaceutical Companies and Medical Drug Stores\u003c/b\u003e\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eA cycle of excessive and unwarranted use of antibiotics continues, where unnecessary antibiotic use is based on commercial considerations rather than patient interest. Pharmaceutical companies can operate as freely as they wish, marketing without considering public health and without oversight.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec9\" class=\"Section3\"\u003e\u003ch2\u003e3.2.1. Non-Prescription Dispensing of Antibiotics\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe findings reveal a prevalent culture of over-the-counter antibiotic sales, where antibiotics are often sold without the need for a prescription. A pharmacist candidly described the situation:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Most customers come in asking for antibiotics by name. If we do not sell to them, they will just go to another store. No one asks for a prescription; it is not the norm here.\u0026rdquo; (R15, Age28, Medical store owner)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThis illustrates how people often disregard prescriptions that require antibiotics. While most drugstore employees lack formal pharmaceutical training, they often remain unaware of the negative consequences of unregulated antibiotic use. Nevertheless, antibiotics are usually administered according to the patient's description of symptoms or the medications they have already been taking. Additionally, observational data show that drugs prescribed in the previous year are reused, and antibiotics are bought in response to suggestions from friends or family members. One respondent explained:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We simply cannot go to the doctor for every illness and have to rely on things that worked before. We end up buying the same antibiotics we used the last time.\u0026rdquo; (R19, age 43)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section3\"\u003e\u003ch2\u003e3.2.2. Influences of the Pharmaceutical Companies\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe practitioners confirmed the role of pharmaceutical representatives in propagating specific antibiotics, who say they offer incentives like bonuses, trips, or gifts. A doctor practicing privately shared:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;There are a lot of pharmaceutical companies coming by, and they offer free samples, free stuff, and commission. When they offer things that help sustain the clinic, it\u0026rsquo;s hard to say no.\u0026rdquo; (R6, Age 67)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eOur findings indicate that commercial interests rather than medical necessity spearhead a cycle of antibiotic overuse in private healthcare practices. Furthermore, there are no regulatory checks, as many private clinics work without supervision.\u003c/p\u003e\u003cp\u003eAntibiotic sales patterns, not surprisingly, are largely influenced by pharmaceutical companies that often bribe medical drug stores to promote specific brands. Store owners who were interviewed shared that sales reps often offer things like financial incentives, free samples, and even commissions to sway people to buy antibiotics. A retired public-sector doctor now in private practice shared his experience:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Pharmaceutical reps come around every month demanding we stock and sell their antibiotics. They may even push us to recommend particular brands to the patient and offer bonuses based on sales targets.\u0026rdquo; (R6, Age 67)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eMost of the time, these financial incentives result in biased promotion of some antibiotics, regardless of clinical suitability for patients. Some drugstore owners admitted to pitching higher-priced antibiotics rather than more affordable options because pharmaceutical companies pay more and provide better incentives. A pharmacist also confirmed this trend:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"Almost every week, we are approached by company reps. If we meet their sales targets, they give us gifts and commissions. So, when it is a good deal for us, we try to sell more of their products.\u0026rdquo; (R14, Age 29)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e3.3. Theme Three. Lack of Healthcare Providers, Laboratories, and Diagnostic Gaps\u003c/h2\u003e\u003cdiv id=\"Sec12\" class=\"Section3\"\u003e\u003ch2\u003e3.3.1. Absence of Formal Healthcare Providers and Practices of Quacks\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eA major cause of the growing problem of antimicrobial resistance (AMR) is given by unqualified quacks. The absence of formal training among quacks means that they lack awareness of dosage guidelines, side effects, and the risks of antibiotic resistance.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Over the last few years, there has been a steep rise in quacks, especially in rural areas where doctors are limited. They prescribe antibiotics for almost every ill, the viral infections to body aches, and without diagnostic tests. (R6, Age 67)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I make a diagnosis just from what I've learned and what I have seen over the years. If a person gets a layer on the tongue, bitter taste, pain in the backbone, joint pain, and high temperature or fever at midnight, he is diagnosed as a typhoid patient. Similarly, if a person has small dots on the tongue, vomits, body pain, and weakness diagnosed as a malaria patient. However, a patient with a normal fever does not get all these types of symptoms.\u0026rdquo; (R 11, Age 23, Quack)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eWhile the health department has tried over and over to eliminate quackery, enforcement is weak, and these practitioners can run around freely, sometimes with the support of local influencers or politicians. The prevalence of quack practitioners represents a significant barrier to effective antibiotic stewardship. Without immediate and rigorous regulation, the misuse of antibiotics will likely continue, fueled by unqualified practices and unchecked prescribing habits.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section3\"\u003e\u003ch2\u003e3.3.2. Lack of Functional Laboratories \u0026amp; Diagnostic Facilities\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe findings show a substantial shortage of available and functioning diagnostic laboratories within Sindh, affecting the correct diagnosis of illnesses and facilitating the abuse of antibiotics. Only a few laboratories were found operating in the district, including unregistered laboratories with inadequate diagnostic equipment. Also, most medical clinics do not have an in-house laboratory facility, which limits diagnostic opportunities. A medical professional emphasized the issue:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Without reliable labs, we have often had to prescribe antibiotics for symptoms. As we do not have the luxury of waiting for lab results that may never come, we have no choice but to act quickly on what we suspect.\u0026rdquo; (R16, Age 27)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eA frequent result of this situation is cases of 'blind prescribing'\u0026ndash; giving antibiotics without \u0026lsquo;vetting\u0026rsquo; the diagnosis. The dearth of functioning labs not only undermines the elegance of treatment but also prolongs the chasm of antibiotic misuse \u0026ndash; patients receive antibiotics as a preventive measure rather than targeted treatment. However, the issue is compounded further by the fact that diagnostic tools are hard to come by, and lab personnel are not trained enough. One employee at a private laboratory admitted:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We do not have any formal training and often rely on the owner, who is not a certified lab technician either. Due to a lack of proper equipment, many tests cannot be conducted.\u0026rdquo; (R 17, Age 35)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThis deficiency of trained professionals, together with the absence of equipment at diagnostic centers, results in misdiagnoses requiring the use of empirical treatment methods by healthcare providers irresponsibly.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The diagnostic facilities here are minimal\u0026mdash;often, doctors prescribe antibiotics based on symptoms alone because tests aren\u0026rsquo;t always available, or results take too long. We\u0026rsquo;re trying to treat patients as quickly as possible, given the high patient load.\u0026rdquo; (R1, Age 53)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Patients are diagnosed and treated by lower-tier staff, especially in rural government hospitals. For the last six months, there hasn\u0026rsquo;t been an MBBS doctor at the clinic, so unqualified practitioners often help with diagnosing patients and handing out antibiotics.\u0026rdquo; (R 13, Age 39)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003e3.4. Theme Four. Healthcare Providers\u0026rsquo; Diagnostic Proficiency and Skill Development\u003c/h2\u003e\u003cdiv id=\"Sec15\" class=\"Section3\"\u003e\u003ch2\u003e3.4.1. Awareness Levels among Practitioners\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe majority of the respondents admitted to having limited knowledge about AMR protocols and rational prescribing, with some attributing this gap to insufficient training opportunities. A Health Officer offered a telling perspective:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"Most of the doctors here do not even know what AMR is. It is rarely discussed in our training sessions, and it is usually more about treating symptoms quickly, often with antibiotics.\" (R4, Age 33)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe resultant impact is compounded by the lack of continuous medical education programs aimed at combating AMR. While medical colleges teach basic pharmacology, real life differs from the recommended guidelines. For example, using broad-spectrum antibiotics generally as first-line therapy in infections, regardless of etiology, is an example of a non-evidence-based practice. A pediatrician emphasized:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"Doctors here cannot even be trained about AMR. It is not a lack of awareness; it is a lack of enforcement of guidelines that it perpetuates.\" (R7, Age 38)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe practitioners dispense large amounts of broad-spectrum antibiotics without regard to any form of training for conditions likely managed by viral or nonbacterial infections. Often, their practices provide patients immediate relief with little thought of diagnostic accuracy and the appropriate drug choice.\u003c/p\u003e\u003cp\u003eThese findings underscore the importance of specialized AMR education programs on effective antibiotic prescribing and revised treatment regimens.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section3\"\u003e\u003ch2\u003e3.4.2. Ethical and Professional Gaps\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe findings suggest important ethical and professional gaps in the behavior of healthcare providers and their prescription of antibiotics. Many practitioners admit that having an open prescription of antibiotics is not required for clinical reasons, financial incentives, or because of the patient's demands. Many ethical concerns arise because needs are sacrificed for convenience or personal gain rather than for patient well-being. A respondent illustrated this issue:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"I often see doctors prescribing cefixime for children suffering from diarrhea because it was available right there. It seemed like meeting sales targets rather than treating the patient effectively.\" (R9, Age 22)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThis is not only a problem in private clinics, but public healthcare settings also have the same problems. A retired public-sector doctor observed:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;While many practitioners let their relatives or uncertified assistants prescribe antibiotics in their absence, many inappropriate and sometimes harmful practices take place under these circumstances.\u0026rdquo; (R6, Age 67)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eMore rigorous enforcement of ethical standards and systematic auditing to comply with AMR guidelines is necessary, the findings show. In anticipation of these professional gaps, AMR awareness can be integrated into medical training, which can also improve the ethical framework of medical training by bringing in mindfulness about patient-centered care.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003e3.5. Theme Five: Financial Constraints in Diagnostic and Demand for Antibiotics\u003c/h2\u003e\u003cdiv id=\"Sec18\" class=\"Section3\"\u003e\u003ch2\u003e3.5.1. Financial Barriers to Testing\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe long-term overprescription of antibiotics is primarily driven by financial constraints that make patients unable to access diagnostic services. Frequent staff absences, as well as equipment shortages, have left most government laboratories closed, forcing patients to count on private labs that charge significantly more. These services are too expensive for many patients, so they rely on symptomatic treatment. This serves as an economic barrier to accurate diagnosis because lab fees are high, and patients cannot afford to pay. Doctors and patients consider broad-spectrum antibiotics a low-cost and cost-effective solution instead of pursuing expensive diagnostic procedures. A healthcare professional noted:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Many patients complain about the cost when we recommend tests. \u0026lsquo;It\u0026rsquo;s better to take medicine directly than to test unnecessarily,' they say.\u0026rdquo; (R3, Age 45)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe financial barriers reinforce the practice of the blind prescription of antibiotics in the absence of diagnostic confirmation due to doctors\u0026rsquo; preferences. Economic pressures combined with scarce financial resources, insufficient lab infrastructure, and little access to services all lessen the chance that antibiotics will be spent appropriately, which increases the likelihood of creating drug-resistant infections.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section3\"\u003e\u003ch2\u003e3.5.2. Patient Demand for Antibiotic Prescriptions\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe results indicate that many antibiotics are prescribed without corresponding diagnostic tests, and two main drivers are patient pressure and profit motives in healthcare providers. For example, one respondent observed:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"What we see is many patients walking in expecting antibiotics. They believe that antibiotics are magic bullets. They lose faith in our treatment if we do not prescribe antibiotics.\" (R 5, Age 32 years, doctor)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eIt emphasizes the high relevance that patient expectations exert on prescription behavior. Similarly, a private practitioner admitted:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"We give them antibiotics because patients expect them, and also, private practice is competitive and profit-driven.\" (R11, Age 23, Quack)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"Customers ask for antibiotics, and we give them; no one checks to see if a prescription was given. They [regulatory authorities] only come here for the bribes, not for monitoring.\" (R15, Age 28 years, a medical store owner).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Private clinics are businesses, and staying on top of patient satisfaction is extremely important for their survival. Patients can ask for antibiotics for faster relief, and refusing them can cost you the client.\u0026rdquo; (R10, age 32)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThematic analysis of the qualitative data revealed five major themes with corresponding subthemes that highlight the multifaceted drivers of antibiotic misuse in the healthcare system. Together, these themes underscore the systemic, professional, and socio-economic factors that fuel inappropriate antibiotic use in Pakistan.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003e4.1. Structural and Administrative Challenges\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eFirst theme, \"structural and administrative challenges in antibiotic misuse,\" comprises issues of 1) political and administrative limitations imposed on prescription behavior and 2) the lack of regular monitoring, reporting, and accountability systems, which destabilize the application of stewardship measures. Due to a systemic gap between governance, administrators often do not regularly use assessments, monitoring, and reporting for antibiotic use (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). The findings show that the power-oriented role plays a bigger role in the healthcare industry than patient care when administrators do not prioritize the evaluation of antibiotics as part of their core responsibility. Consequently, institutions are held accountable for little. Moreover, relying on regional networks or political connections to appoint administrators fosters a culture where personal influence outweighs professional qualifications and genuine healthcare priorities (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe environment of poor assessment, weak reporting systems, and minimal surveillance means that clinics, hospitals, and medical stores seldom face any repercussions for misuse. This regulatory gap, which is quite broad and represents a public health governance challenge for the system to regulate the use of antibiotics and address emerging threats, is justified. These findings are corroborated by Afzal et al. (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) and Mustafa et al. (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), who state that all antibiotic prescriptions at secondary care public hospitals in Pakistan are made because of the absence of antibiotic guidelines and poor diagnostic abilities of the public health sector.\u003c/p\u003e\u003cp\u003eIn addition, the results suggest socio-political dynamics that enable unqualified drug companies to prosper even with the support of such politicians and bureaucrats. The availability of inappropriate medications that result from this influence is a significant contributor to making antimicrobial resistance management a challenging task. These findings echo Pearson and Chandler's (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) multi-country analysis of how healthcare professionals navigate antimicrobial resistance in practice, particularly their observation that structural constraints and profit motives often override clinical best practices in prescribing decisions.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003e4.2. Role of Pharmaceutical Companies and Medical Drug Stores\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eTheme 2 reflects the strong control pharmaceutical corporations have over prescribing habits, which is often based more on financial returns than on clinical requirements. The complex interplay between public and private healthcare providers in our study site exemplifies what Lock and Nguyen (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) term 'medical pluralism under market conditions.' The prevalence of dual practice among government doctors and the flourishing of unqualified practitioners mirror what Jo\u0026atilde;o Biehl (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) observed in his study of pharmaceutical governance in Brazil, where market forces reshape healthcare delivery in ways that prioritize profit over patient care. The commodification of antibiotics in both sectors demonstrates what Biehl terms the \u0026ldquo;Pharmaceuticalization of public health\u0026rdquo;, where drugs become market commodities rather than therapeutic tools. Market forces reshape antibiotic prescribing practices in ways that often prioritize economic interests over clinical necessity. This is consistent with a recent study (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) that suggests that \u0026ldquo;Medicine availability significantly influences prescribing decisions, often taking precedence over clinical needs.\u0026rdquo;\u003c/p\u003e\u003cp\u003eThe limited presence of the Drug Regulatory Authority suggests that inspections of their medical stores are rare and often compromised. There is weak regulatory oversight regarding the distribution of antibiotics, and medical stores can sell them freely with few consequences when these antibiotics are not distributed properly. Prescribing 2\u0026ndash;3 antibiotics in a single prescription exposes the normalization of excessive antibiotic use, which has been facilitated by patients reusing old prescriptions owing to financial constraints or time limitations.\u003c/p\u003e\u003cp\u003eThe role played by the pharmaceutical companies in the dispensing of antibiotics cannot be overlooked. These companies fund and incentivize medical stores and then encourage informal agreements with healthcare professionals to market their products. In this commercialized approach, antibiotics are viewed as commercial commodities and not as resources for healthcare.\u003c/p\u003e\u003cp\u003eThe data also show that self-medication is a common practice, as there is easy access to antibiotics from medical stores. Patients often go by past experience, suggestions from non-medical acquaintances, or out of convenience. The direct delivery of medications to customers, even without prescriptions, and the informal and transactional nature of the practice of healthcare to its personnel demonstrate how healthcare is practiced at the community level. Customers also view these stores as a convenient substitute to formal healthcare facilities, which is compounded by the loose regulatory enforcement and unacknowledged alliances between local doctors and store owners.\u003c/p\u003e\u003cp\u003eThe results also suggest that medical store owners are unaware of antimicrobial resistance. They had never been assessed or monitored by health authorities, and most of them were unaware of related policies or guidelines. To a large extent, the knowledge gap and the profit-driven motives of pharmaceutical companies highly contribute to the use of antibiotics in communities (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn sum, for medical stores, we argue that they are informal but essential components of healthcare, providing informal services where formal systems have failed. Nevertheless, the unregulated sale of antibiotics plays their crucial role in the spread of antimicrobial resistance, influenced by a lack of regulation, economic incentives, and, in general, a culture of self-medication (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). This dynamic mirrors patterns documented by Haenssgen et al. (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e) in their study of antibiotic distribution networks, where medical stores serve as crucial but problematic nodes in the informal circulation of antibiotics, especially in areas with limited formal healthcare access.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec23\" class=\"Section2\"\u003e\u003ch2\u003e4.3. Lack of Healthcare Providers, Laboratories, and Diagnostic Gaps\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eTheme 3 discussed the shortage of qualified providers, dependence on unqualified practitioners, also known as quacks, and the insufficiency of diagnostic structure, which causes empirical antibiotic use without proper investigations. The lack of sufficient laboratory infrastructure exacerbates the problem. This pattern aligns with Chandler's (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) analysis of how antimicrobial resistance becomes embedded within healthcare infrastructure in resource-limited settings, where systemic inadequacies create conditions that normalize antibiotic misuse.\u003c/p\u003e\u003cp\u003eThe findings show that the functionality and accessibility of laboratory services influence antibiotic prescription patterns in Pakistan. Staff protests and other administrative disruptions often cause government laboratories to remain non-functional. As a result, most patients end up using private laboratories, which are much more expensive and thus unaffordable for the lower-income population. The lack of access to affordable diagnostic services is another reason for relying heavily on empirical treatment, in which the patient is prescribed antibiotics without having the diagnosis confirmed (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eFindings indicate that there are not enough qualified staff in most private laboratories and that the majority of them work without regulatory control. Lack of professional expertise leads to insufficient implementation of protocols for the diagnosis of infections, which are essential for appropriate antibiotic use.\u003c/p\u003e\u003cp\u003eThe findings show a saddening increase in quack practitioners who are often unaware of proper drug dosages or antibiotic side effects, especially in lower-income regions where formal healthcare access is virtually non-existent. The emergence of this trend is fraught with particular risks to vulnerable groups such as the poor, elderly, women, and children (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). The results suggest that these practitioners account for a large proportion of such misuse of antibiotics by prescribing antibiotics for conditions that do not require them.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\u003ch2\u003e4.4. Practitioners' Ignorance and Training Gaps\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eTheme four revealed a scarcity of knowledge of health providers about the rational use of antibiotics and incompetence in professional and ethical education, leading to irrational prescribing behaviors. 3rd generation antibiotics are prescribed countless times for conditions that do not require antibiotics, as countless practitioners routinely do. This typically means that paying attention to caring for patients is not as important as being able to output high-speed results for personal financial gain, typically. Shaikh et al. (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) note that physicians often prescribe antibiotics without adequate knowledge of antimicrobial guidelines. Many receive information from pharmaceutical representatives, leading to biased prescribing practices (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Literature suggests that resistance data from provinces could be a guiding tool for correct empirical therapy and current resistance trends (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThis gap between knowledge and practice aligns with Tarrant et al.'s (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) analysis of how contextual factors shape antibiotic prescribing decisions, often leading practitioners to prioritize immediate patient demands over long-term stewardship concerns. Contrary to the claim of Pakistan\u0026rsquo;s National Action Plan on AMR, standardized treatment guidelines (STGs) for antibiotic prescribing were absent, necessitating a localized antibiotic prescribing policy to promote more suitable empirical prescribing (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Although WHO warned that antimicrobial resistance is a grave public health threat, this information is not being shared widely or effectively across the system (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec25\" class=\"Section2\"\u003e\u003ch2\u003e4.5. Financial Constraints in Diagnostic and Demand for Antibiotics\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eTheme five conveyed financial barriers that dissuade diagnostic testing, burdened with patient-initiated requests for antibiotics as a perceived fix-all, coercing providers to needlessly write prescriptions. The economic constraints that limit access to true diagnostics are also seen in different views of doctors and patients on the utility of laboratory testing. These barriers to diagnostic testing reflect broader patterns identified by Charani et al. (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e) in their analysis of antimicrobial stewardship across different income settings, where limited laboratory infrastructure systematically undermines evidence-based prescribing. The reasons doctors choose to prescribe antibiotics are both patient financial constraints combined with limited resources to ensure patient recovery, leaving little choice. Antimicrobial stewardship problems are not limited to LMIC. In the United States, one-third of outpatient antibiotics are considered unnecessary (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e), and Southern Europe reports high non-prescription sales (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). Overprescribing continues even with hospital programs, displaying that antibiotic resistance is a global problem demanding synchronized action (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec26\" class=\"Section2\"\u003e\u003ch2\u003e4.6. Limitations and Strengths of the Study\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe current exploratory study has limitations. First, it has used a small sample size, and most respondents were male healthcare providers. Then, this study is conducted in only Sindh province, and does not claim to be longitudinal or nationally representative research. Third, it gives only healthcare providers' perspectives on unregulated use and excludes other relevant stakeholders. The study has some strengths as well. First, it focuses on how excessive use of antibiotics worsens the conditions of not only a patient but also the healthcare system. Second, taking the meager socio-economic conditions of the people into account, research analyses how it creates multiple financial and social burdens with its now and then use in society. Third, it points out certain policy gaps and irregularities in the country's healthcare system, which provides a window of opportunity for not only the big companies that manufacture and sell them but also those health practitioners who suggest them. Therefore, it exposes the nexus among different actors who get the shared benefit of unregulated antibiotic use.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eIn conclusion, this study highlights the complex socio-political and economic factors perpetuating AMR in Pakistan, particularly within the district of Sindh. The findings reveal how weak regulatory structures, pervasive quack practices, and the commodification of antibiotics by pharmaceutical companies drive widespread misuse of antibiotics. Additionally, limited diagnostic infrastructure and financial constraints force healthcare providers to rely on empirical treatments, further exacerbating AMR. Structural reforms that include stricter regulations, enhanced diagnostic facilities, and improved healthcare access for underserved populations are critical to address AMR effectively. Public awareness initiatives are essential to educate communities about the dangers of antibiotic misuse. Implementing these changes, alongside more robust oversight and targeted training for healthcare providers, can contribute to more sustainable AMR management. Such systemic interventions will not only curb antibiotic misuse but also promote more equitable healthcare practices, ultimately leading to better health outcomes and reducing the AMR burden in Pakistan.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eASRB: Advanced Studies and Research Board; AMR: Antimicrobial Resistance; STGs: Standardized Treatment Guidelines\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors are thankful to the healthcare providers for their willingness to participate in and support this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSA, IUL, and FA conceptualized and designed the study. SA, FA, RA, and NIM were responsible for all aspects of data collection, coding, analysis, and writing of the initial manuscript draft. SA, NIM, RA, IUL, RB, MS, ZA, SZ, FA, and KT provided and interpreted the findings, reviewed the manuscript, edited drafts, and added essential intellectual content. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe original data presented in this study are included in the article. Further inquiries can be directed to the corresponding author(s).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study adhered to the guidelines of the Declaration of Helsinki.\u0026nbsp;Ethical approval for the study was obtained from the Research Ethics Committee of the Quaid-i-Azam University, Pakistan (Number: QAU-IBC-3006; Date of Approval: 21 October 2024). All participants were fully informed about the nature of the study beforehand, and then they provided informed consent. Informed consent was obtained from all subjects and/or their legal guardian(s).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSohail Ahmed is Research Associate at Department of Anthropology, Quaid-i-Azam University, Islamabad Pakistan. Prof. Najma Iqbal Malik is Chair of Department of Psychology at University of Sargodha, Sargodha, Punjab, Pakistan. Razia Anjum is Senior Lecturer, Department of Psychology, Bath Spa University, Ras Al Khaimah, United Arab Emirates. Inam Ullah Leghari is Associate Professor of Department of Anthropology at Quaid-i-Azam University, , Islamabad Pakistan. Rubina Bhatti is the Dean of the Faculty of Social Sciences and a Professor in the Department of Information Management at The Islamia University of Bahawalpur, Pakistan. Prof. Muhammad Saleem is Chairman of Department of Applied Psychology at The Islamia University of Bahawalpur, Bahawalpur Pakistan. \u0026nbsp;Zakir Ali is Deputy Director in Department of Community Relations, Karachi Sindh, Pakistan. Farooq Ahmed, Associate Professor and Chairman of Department of Anthropology at The Islamia University of Bahawalpur, Bahawalpur Pakistan. Sidra Zia, Research Associate, Department of Anthropology, The Islamia University of Bahawalpur, Bahawalpur Pakistan. Kun Tang is professor at Vanke School of Public Health, Tsinghua University, Beijing, China.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Health Organization. Antimicrobial resistance: global report on surveillance. Geneva: WHO; 2014. Available from: https://www.who.int/publications/i/item/9789241564748. Accessed 18 Oct 2024.\u003c/li\u003e\n\u003cli\u003eInstitute for Health Metrics and Evaluation. Global Burden of Disease (GBD). Seattle: IHME; 2020. Available from: https://www.healthdata.org/research-analysis/gbd. Accessed 18 Oct 2024.\u003c/li\u003e\n\u003cli\u003eTahir B. The efficacy of Pakistan\u0026apos;s National Action Plan in addressing antimicrobial resistance [PhD Dissertation]. Doha: Hamad Bin Khalifa University; 2024.\u003c/li\u003e\n\u003cli\u003eUdwadia Z, Furin J. Quality of drug-resistant tuberculosis care: gaps and solutions. J Clin Tuberc Other Mycobact Dis. 2019;16:100101. doi:10.1016/j.jctube.2019.100101.\u003c/li\u003e\n\u003cli\u003eNoor MN, Liverani M, Bryant J, Rahman-Shepherd A, Sharif S, Aftab W, et al. The healthcare field as a marketplace: general practitioners, pharmaceutical companies, and profit-led prescribing in Pakistan. Health Sociol Rev. 2023;32:198-212.\u003c/li\u003e\n\u003cli\u003eSalam MA, Al-Amin MY, Salam MT, Pawar JS, Akhter N, Rabaan AA, et al. Antimicrobial resistance: a growing serious threat for global public health. Healthcare. 2023;11:1946. doi:10.3390/healthcare11131946.\u003c/li\u003e\n\u003cli\u003eDas J, Daniels B, Ashok M, Shim EY, Muralidharan K. Two Indias: the structure of primary health care markets in rural Indian villages with implications for policy. Soc Sci Med. 2020;256:112799.\u003c/li\u003e\n\u003cli\u003eSuy S, Rego S, Bory S, Chhorn S, Phou S, Prien C, et al. Invisible medicine sellers and their use of antibiotics: a qualitative study in Cambodia. BMJ Glob Health. 2019;4:e001787.\u003c/li\u003e\n\u003cli\u003eKhan M, Hasan R. The healthcare field as a marketplace: general practitioners, pharmaceutical companies, and profit-led prescribing in Pakistan. Health Sociol Rev. 2022;32:1-15. doi:10.1080/14461242.2022.2139628.\u003c/li\u003e\n\u003cli\u003eSindh HealthCare Commission. Anti-quackery. Karachi: SHCC; 2024. Available from: https://shcc.org.pk/introduction-to-anti-quackery/. Accessed 20 May 2024.\u003c/li\u003e\n\u003cli\u003eHassan A, Mahmood K, Bukhsh HA. Healthcare system of Pakistan. Int J Acad Res Plan. 2017;1:170-3.\u003c/li\u003e\n\u003cli\u003eHolmes AH, Moore LS, Sundsfjord A, Steinbakk M, Regmi S, Karkey A, et al. Understanding the mechanisms and drivers of antimicrobial resistance. Lancet. 2016;387:176-87.\u003c/li\u003e\n\u003cli\u003eMirha H, Ali SH, Aamar H, Sadiq M, Tharwani ZH, Habib Z, et al. The impact of antibiotic resistance on the rampant spread of infectious diseases in Pakistan: insights from a narrative review. Health Sci Rep. 2024;7:e2050. doi:10.1002/hsr2.2050.\u003c/li\u003e\n\u003cli\u003eShaikh OA, Asghar Z, Aftab RM, Amin S, Shaikh G, Nashwan AJ. Antimicrobial resistant strains of Salmonella Typhi: the role of illicit antibiotics sales, misuse, and self-medication practices in Pakistan. J Infect Public Health. 2023;16:1591-7.\u003c/li\u003e\n\u003cli\u003eMajumder MAA, Rahman S, Cohall D, Bharatha A, Singh K, Haque M, et al. Antimicrobial stewardship: fighting antimicrobial resistance and protecting global public health. Infect Drug Resist. 2020;13:4713-38. doi:10.2147/IDR.S290835.\u003c/li\u003e\n\u003cli\u003eNavarro V. Medicine under capitalism. New York: Prodist; 1976.\u003c/li\u003e\n\u003cli\u003eFoucault M. The birth of biopolitics. New York: Palgrave Macmillan; 2010.\u003c/li\u003e\n\u003cli\u003eSinger M. The limitations of medical ecology: the concept of adaptation in the context of social stratification and social transformation. Med Anthropol. 1989;10:223-34.\u003c/li\u003e\n\u003cli\u003eZapantis A, Lacy MK, Horvat RT, Dennis G, Barnes BJ, O\u0026apos;Neal B, et al. Nationwide antibiogram analysis using NCCLS M39-A guidelines. J Clin Microbiol. 2005;43:2629-34.\u003c/li\u003e\n\u003cli\u003eBarlam TF, Cosgrove SE, Abbo LM, MacDougall C, Schuetz AN, Septimus EJ, et al. Implementing an antibiotic stewardship program: guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis. 2016;62:e51-77.\u003c/li\u003e\n\u003cli\u003eAfzal S, Bajwa M, Ahmed N, Jabeen J, Haroon MS, Mushtaq RMZ, et al. The antibiotic procurement saga: a long-neglected stewardship target to combat antimicrobial resistance in Pakistan. Antimicrob Resist Infect Control. 2025;14:7.\u003c/li\u003e\n\u003cli\u003eMustafa ZU, Salman M, Yasir M, Godman B, Majeed HA, Kanwal M, et al. Antibiotic consumption among hospitalized neonates and children in Punjab Province, Pakistan. Expert Rev Anti Infect Ther. 2022;20:931-9.\u003c/li\u003e\n\u003cli\u003ePearson M, Chandler C. Knowing antimicrobial resistance in practice: a multi-country qualitative study with human and animal healthcare professionals. Glob Health Action. 2019;12:1599560. doi:10.1080/16549716.2019.1599560.\u003c/li\u003e\n\u003cli\u003eLock MM, Nguyen VK. An anthropology of biomedicine. 2nd ed. Hoboken: Wiley-Blackwell; 2018.\u003c/li\u003e\n\u003cli\u003eBiehl JG. Pharmaceuticalization: AIDS treatment and global health politics. Anthropol Q. 2007;80:1083-126.\u003c/li\u003e\n\u003cli\u003eAtif M, Ihsan B, Malik I, Ahmad N, Saleem Z, Sehar A, et al. Antibiotic stewardship program in Pakistan: a multicenter qualitative study exploring medical doctors\u0026apos; knowledge, perception and practices. BMC Infect Dis. 2021;21:374.\u003c/li\u003e\n\u003cli\u003eDrug Regulatory Authority of Pakistan. Guidelines for the responsible use of antimicrobials in human health. Islamabad: DRAP; 2021. Available from: http://www.dra.gov.pk. Accessed [DD Month YYYY].\u003c/li\u003e\n\u003cli\u003eHaenssgen MJ, Charoenboon N, Zanello G, Mayxay M, Reed-Tsochas F, Jones CO, et al. Antibiotics and activity spaces: protocol of an exploratory study of behaviour, marginalisation and knowledge diffusion. BMJ Glob Health. 2018;3:e000621.\u003c/li\u003e\n\u003cli\u003eChandler CIR. Current accounts of antimicrobial resistance: stabilisation, individualisation and antibiotics as infrastructure. Palgrave Commun. 2019;5:53. doi:10.1057/s41599-019-0263-4.\u003c/li\u003e\n\u003cli\u003eMinistry of National Health Services, Regulation \u0026amp; Coordination. AMR Action Plan for Pakistan. Islamabad: MoNHSRC; 2017. Available from: https://www.flemingfund.org/wp-content/uploads/National-AMR-Action-Plan-for-Pakistan.pdf. Accessed [DD Month YYYY].\u003c/li\u003e\n\u003cli\u003ePakistan Medical \u0026amp; Dental Council. Quackery and its impact on healthcare in Pakistan. Islamabad: PMDC; 2011. Available from: http://www.pmdc.org.pk. Accessed [DD Month YYYY].\u003c/li\u003e\n\u003cli\u003eNahar P, Unicomb L, Lucas PJ, Uddin MR, Islam MA, Nizame FA, et al. What contributes to inappropriate antibiotic dispensing among qualified and unqualified healthcare providers in Bangladesh? A qualitative study. BMC Health Serv Res. 2020;20:656. doi:10.1186/s12913-020-05512-y.\u003c/li\u003e\n\u003cli\u003eKhatri D, Falconer N, de Camargo Catapan S, Coulter S, Gray LC, Paterson DL, et al. Exploring stakeholders\u0026apos; perspectives on antibiogram use, development, and implementation in residential aged care settings. Res Social Adm Pharm. 2024;20:747-54.\u003c/li\u003e\n\u003cli\u003eGuarascio AJ, Brickett LM, Porter TJ, Lee ND, Gorse EE, Covvey JR. Development of a statewide antibiogram to assess regional trends in antibiotic-resistant ESKAPE organisms. J Pharm Pract. 2019;32:19-27.\u003c/li\u003e\n\u003cli\u003eTarrant C, Krockow EM, Nakkawita WMI, Bolscher M, Colman AM, Chattoe-Brown E, et al. Moral and contextual dimensions of \u0026quot;inappropriate\u0026quot; antibiotic prescribing in secondary care: a three-country interview study. Front Sociol. 2020;5:7. doi:10.3389/fsoc.2020.00007.\u003c/li\u003e\n\u003cli\u003eMedical Microbiology and Infectious Diseases Society of Pakistan. Antimicrobial use guidelines. Karachi: MMIDSP; 2019. Available from: https://www.mmidsp.com/wp-content/uploads/2019/09/Guidelines-for-Antimicrobial-Use-2.pdf. Accessed 24 Nov 2024.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. UN General Assembly High-Level Meeting on Antimicrobial Resistance. Geneva: WHO; 2024. Available from: https://www.un.org/pga/wp-content/uploads/sites/108/2024/09/FINAL-Text-AMR-to-PGA.pdf. Accessed 18 Oct 2024.\u003c/li\u003e\n\u003cli\u003eButt SZ, Ahmad M, Saeed H, Saleem Z, Javaid Z. Post-surgical antibiotic prophylaxis: impact of pharmacist\u0026apos;s educational intervention on appropriate use of antibiotics. J Infect Public Health. 2019;12:854-60.\u003c/li\u003e\n\u003cli\u003eCharani E, Smith I, Skodvin B, Perozziello A, Lucet JC, Lescure FX, et al. Investigating the cultural and contextual determinants of antimicrobial stewardship programmes across low-, middle- and high-income countries\u0026mdash;a qualitative study. PLoS ONE. 2019;14:e0209847. doi:10.1371/journal.pone.0209847.\u003c/li\u003e\n\u003cli\u003eCenters for Disease Control and Prevention (CDC). Antibiotic use in the U.S. 2023. Available from: https://www.cdc.gov/antibiotic-use/stewardship-report/index.html. Accessed 15 Jul 2025.\u003c/li\u003e\n\u003cli\u003eEuropean Centre for Disease Prevention and Control (ECDC). Antimicrobial consumption in the EU/EEA. 2022. Available from: https://www.ecdc.europa.eu/en/publications-data/surveillance-antimicrobial-consumption-europe-2022. Accessed 15 Jul 2025.\u003c/li\u003e\n\u003cli\u003eOrganisation for Economic Co-operation and Development (OECD). Stemming the superbug tide: just a few dollars more. Paris: OECD Publishing; 2018. doi:10.1787/9789264307599-en.\u003c/li\u003e\n\u003cli\u003eBraun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3:77-101. doi:10.1191/1478088706qp063oa\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"antimicrobial resistance, antibiotic misuse, healthcare regulation, Pakistan","lastPublishedDoi":"10.21203/rs.3.rs-7329893/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7329893/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Antimicrobial resistance (AMR) is a serious global health concern. In Pakistan, the unregulated sale of antibiotics and socioeconomic challenges compound the issue, driving high rates of drug-resistant infections. This study examines the knowledge, attitudes, and practices of healthcare providers regarding unregulated antibiotic use in Pakistan.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e Using purposive sampling, nearly 20 respondents were selected, and qualitative data were collected through semi-structured interviews and field notes with doctors, quacks, and pharmacists.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Five significant themes in Pakistan's healthcare system that propel antibiotic abuse were revealed through thematic analysis. The first theme is on administrative and structural vulnerabilities, including political influence, weak regulation, and a lack of monitoring and audit. The second theme identifies the unrestricted power of pharmaceutical businesses and drug stores, which promotes non-prescriptive sale of antibiotics and money-motivated recommending. The third theme reveals critical shortages in competent and skilled health practitioners and diagnostic services, leading to dependence on unqualified practitioners and the application of practical antibiotics. Theme four reveals practitioners' ethical practices and restricted information and skills in rational prescribing. The final theme documents financial limitations that hinder diagnostic testing of infections and drive patient pressure for quick antibiotic interventions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e All these themes collectively represent the entrenched systemic, economic, and professional issues that lead to antibiotic abuse. The study advocates for a more effective and comprehensive approach to mitigating AMR by addressing these structural inequalities.\u003c/p\u003e","manuscriptTitle":"Healthcare providers’ knowledge, attitude, and practice of antibiotic use and antimicrobial resistance in Southern Pakistan: a qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-02 09:23:17","doi":"10.21203/rs.3.rs-7329893/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-11-03T15:05:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"312373783019913563318811475960012473605","date":"2025-10-22T11:13:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"192889311966150996614749883413307239987","date":"2025-10-21T22:55:04+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-21T22:39:12+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-14T13:49:14+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-14T11:50:50+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-14T10:58:17+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-08-14T10:54:52+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e5ed3510-0a5e-4137-98b5-d599feccfd98","owner":[],"postedDate":"November 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-11-02T09:23:17+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-02 09:23:17","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7329893","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7329893","identity":"rs-7329893","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}