Confronting antimicrobial resistance in Jordan: regulatory, economic, and behavioral determinants of non-prescription antibiotic dispensing in community pharmacies—a mixed-methods study

Abstract

Background: Over-the-counter (OTC) antibiotic dispensing remains a persistent challenge in many low- and middle-income countries despite the implementation of antimicrobial stewardship (AMS) policies. Jordan's community pharmacies represent a critical interface between public health and antimicrobial resistance (AMR) control. This study aimed to examine the determinants, barriers, and enabling factors influencing AMS adherence among Jordanian community pharmacists, and to integrate quantitative and qualitative evidence to develop a contextual framework for sustainable stewardship implementation. Methods: A convergent mixed-methods design was employed between March and August 2025. The quantitative phase comprised a cross-sectional survey of 348 community pharmacists recruited through stratified random sampling across five Jordanian governorates. A validated Arabic questionnaire assessed perceived barriers, determinants, and enabling factors related to AMS. Descriptive, non-parametric, and multivariate ordinal logistic regression analyses were conducted, with diagnostic checks for model assumptions, multicollinearity, and goodness-of-fit. The qualitative phase involved 24 semi-structured interviews analyzed using Braun and Clarke's thematic approach with NVivo version 14. Data integration followed Creswell and Plano Clark's parallel design to identify convergence, complementarity, and divergence across datasets. Results: Pharmacists demonstrated strong awareness of AMS principles, yet significant barriers persisted at structural, social, and economic levels. The most commonly reported barriers included patient pressure for antibiotics, weak regulatory enforcement, and economic dependency on sales. Predictors of higher perceived barriers included working in independent pharmacies, having less than 5 years of experience, and practicing in rural settings. Attendance at AMS or continuing professional development training was protective. Qualitative findings reinforced these results, revealing five themes: regulatory and enforcement gaps, patient-driven and cultural pressures, economic constraints, limited AMS training, and policy improvement recommendations. Integration of both components (qualitative and quantitative) highlighted that pharmacists' willingness to comply with AMS is constrained by system-level weaknesses rather than attitudinal deficits. Conclusion: Antimicrobial stewardship in Jordan's community pharmacies is hindered primarily by inconsistent enforcement and economic pressures rather than lack of professional awareness. Strengthening regulatory oversight, implementing digital prescription verification, and integrating AMS education into continuing professional development and pharmacy curricula are essential to achieve sustained behavioral change. The integrated conceptual model proposed by this study offers a policy-informed roadmap to strengthen community-based stewardship within similar health system contexts.