Background: Antimicrobial resistance (AMR) is a major global health concern, especially in low- and middle-income countries. One primary cause of AMR is low-value use of antibiotics (LVUA), which refers to uses of antibiotics that do not significantly benefit the individual and may instead cause harm or lead to unnecessary healthcare expenditures. Antimicrobial stewardship programmes (ASPs) have proven effective in tackling AMR. However, understanding the factors driving LVUA is important for guiding effective ASP strategies. This study aimed to understand factors influencing LVUA in Jordan, exploring the broader context of pharmaceutical policy and regulation to inform ASP strategies aimed at reducing LVUA. Method: Three studies were conducted to achieve this aim. Study One, guided by the Socioecological Model (SEM) and Implementation Research (IR) framework, employed a qualitative approach involving document review and semi-structured interviews to understand policymaker views on LVUA and AMR. Interviews were analysed using a combination of inductive and deductive approaches. Study Two, used the SEM to frame focus group discussions (FGDs) exploring beliefs and factors influencing LVUA among community members. Study Three, informed by the findings of focus group discussions, employed a quantitative approach using the theoretical domains framework (TDF) in a cross-sectional survey to identify predictors of LVUA among community members. The survey was analysed employing descriptive, bivariate, and multivariate analyses. Results: Study One, which involved 17 interviews, revealed inconsistencies and suboptimal implementation of LVUA control strategies, particularly highlighting a disconnect between strategic intentions and practical applications. This gap was evident in the emphasis on hospital settings over community pharmacies, which are the primary source of antibiotics for community members. Through the lens of the IR framework, these findings highlighted systemic challenges in aligning policy with practice. Policymakers identified public expectations, insurance coverage, health infrastructure, and pharmaceutical company incentives as key influences on LVUA, reflecting the broader systemic perspective as explained by the SEM. In addition, Study Two, using the SEM framework, captured the community's perspective through six FGDs involving a total of 48 participants. This study revealed the complexity of LVUA, with community members pointing to the healthcare system's structure, easy access to community pharmacies, issues of availability and affordability, weak enforcement of antibiotic laws, and social and cultural norms as key contributors to LVUA. Study Three, which employed the TDF in a survey of 513 participants, further confirmed the community's perspective as represented by the individual levels of the SEM. The findings highlighted social influences as the strongest predictors of LVUA and emphasised the impact of community beliefs and knowledge about antibiotics. The SEM framework helped elucidate how these individual, community, and systemic factors influence LVUA. Conclusion: This research program identified factors influencing LVUA across multiple levels, as outlined by the SEM. Based on these insights, recommendations are made for improving health policy and LVUA strategies in Jordan, with a central focus on ensuring accessible, affordable and available healthcare services for community members. Future interventions should prioritise bridging the gap between policy and practice while actively involving the community to ensure that their needs and challenges are adequately addressed.
Date of Award | 6 Jan 2025 |
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Original language | English |
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Awarding Institution | - The University of Manchester
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Supervisor | Ellen Schafheutle (Supervisor) & Sarah Willis (Supervisor) |
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Access to and Regulation of Antibiotics in Jordan
Alqudah, R. (Author). 6 Jan 2025
Student thesis: Phd