Introduction
Antimicrobial resistance (AMR) refers to the reduced effectiveness of antimicrobial agents, such as antibiotics, antivirals, antifungals, and antiparasitics, against infections caused by bacteria, viruses, fungi, and parasites [
1]. This phenomenon makes infections harder to treat and increases the risk of disease spread, severe illness, and death. Misuse and overuse of these agents in humans, animals, and plants are key contributors to the development of AMR. AMR is a natural process that occurs gradually over time through genetic changes in microorganisms, but human activities, particularly the improper use of antimicrobials, significantly speed up this process. Veterinarians play a vital role in managing AMR, as they frequently prescribe antimicrobials to protect animal health. However, overprescription and misuse of antimicrobials in veterinary practice contribute to the development of AMR in humans. AMR presents a substantial challenge to global public health and economic stability. If left unchecked, AMR will lead to increased healthcare costs, decreased productivity, and potentially millions of avoidable deaths annually. To combat AMR, governments, healthcare providers, and researchers must collaborate to implement policies promoting judicious antimicrobial use, invest in innovative therapies, and foster educational initiatives to empower individuals to understand the importance of responsible antimicrobial stewardship [
2].
AMR is an increasingly global issue that needs to be settled cooperatively. Resistant organisms exist in animals, humans, the environment, the food, and the main cause of this, is antimicrobial usage. AMR will become a leading cause of mortality in the world in the near future. As reported by some studies, by 2050, AMR will be the main cause of death on a global scale, which surpasses cancer deaths [
3,
4].
The mortality rate caused by microbial resistance is higher than the total number of deaths induced by cancer worldwide. Yet, the former has been largely neglected and, instead, issues such as cancer and how to treat it have been addressed more [
5‐
7].
Unintentional antibiotic ingestion occurs frequently due to the widespread use of antibiotics in society. According to a report from 2010, approximately 10 pills, capsules, or teaspoons of antibiotics are taken annually by every person on Earth, which suggests a high degree of accidental consumption. Healthy individuals who consume significant amounts of antibiotics unintentionally may experience negative impacts on their health, particularly concerning the disturbance of the normal microbiome. This disturbance can lead to long-term complications, such as an increased risk of developing conditions like type 1 and 2 diabetes, inflammatory bowel diseases, celiac disease, allergies, and asthma [
8]. Additionally, antibiotic exposure can contribute to the emergence of antibiotic-resistant strains, posing a challenge to public health. It is essential to note that antibiotics are necessary and lifesaving medicines when used appropriately under medical supervision. However, excessive or unnecessary use of antibiotics can pose risks to individual and population health [
9,
10].
According to the report of the World Health Organization, half of the antibiotics produced in the world are used in medicine and the other half in veterinary, agriculture and aquaculture [
11]. In general, there is no difference between antibiotics used in veterinary medicine and antibiotics used in medicine. These drugs are used to prevent and treat diseases and promote growth in animal farms (pigs and poultry), unfortunately, the use of antibiotics in veterinary medicine leads to leaving residues in meat, milk and eggs [
12]. Drug residues in food have adverse effects such as antibiotic resistance in humans, allergies, and inhibition of bacterial starter cultures used in dairy fermentation industries [
13]. Despite the beneficial effects of antibiotics on the treatment of livestock infectious diseases, the presence of their residues in milk and animal meat, as well as their transfer to the human body have adverse effects on health, industry, and economics. As reported by the National Center for Rational Prescription of Antibiotics, consuming antibiotics in Iran is 16 times as high as the global standard. Some researchers believe that the spread of microbial resistance to antibiotics results not only from the unnecessary prescription and use of these compounds in humans but also from the widespread use of antimicrobial drugs in veterinary medicine. It has caused the transfer of such pathogenic bacteria from animals to human pathogens. The main difference between microbial resistance to antimicrobial drugs in humans and animals is that microbial resistance in humans affects the individual, whereas microbial resistance in livestock affects a large population due to the consumption of raw animal products by humans. Exposure to both resistant bacteria and antibiotic compounds prescribed for the treatment of infectious diseases for livestock through transmission causes the accumulation of drugs and drug residues in raw livestock products. It seems that attempts to prevent the occurrence of microbial resistance in livestock and its consequences for humans are effective and can be implemented efficiently by veterinarians and those active in this domain. What veterinarians can do with this respect is wide-ranging.
Most of the studies conducted in Iran in the field of antimicrobial resistance were in the medical and human fields, and the studies conducted in the veterinary field were mostly quantitative. A systematic review and meta-analysis showed a high level of antibiotic resistance in Staphylococcus aureus bovine mastitis in Iran. This pathogen is the common and main cause of bovine bacterial mastitis, which leads to high economic losses and can easily lead to the transmission of these treatment-resistant bacteria to humans [
14]. In a qualitative study, which is one of the few qualitative and phenomenological studies conducted in Iran in the field of AMR, the lived experience of livestock breeders, their role and views in this field has been investigated. The results of this study have confirmed the importance of antibiotic resistance in Iran and the lack of existing research in this field, especially with a qualitative approach [
15]. In another study that was conducted with semi-structured interviews with key stakeholders in Iran, including managers of the Ministry of Health, Iran Veterinary Organization, national professional associations and researchers through thematic analysis, the international enabling and predisposing factors related to It identified the control of AMR in Iran. The enabling factors that have been highlighted in this review were discussed in general, and more attention was paid to political factors such as formulation and implementation processes, and AMR surveillance, and challenges such as the smuggling of infected animals and antimicrobial drugs and livestock from neighboring countries and the impact of imposed sanctions. The review emphasizes the global nature of AMR as a challenge that requires consensus and international cooperation to effectively deal with this issue, but it does not specifically and specifically deal with why and analyze how AMR occurs and examine ways to prevent it, and only generally with the approaches Emphasizes political, including health diplomacy, to strengthen national efforts in the fight against AMR [
16]. However, the present study, in an interdisciplinary manner, has specifically addressed one of the most important fields involved in the occurrence of AMR in human societies, and a field similar to it has received less attention before.
Yet, it is hard to make interventions with veterinarians directly involved because they are not easily available for research; therefore, veterinary students are the best and closest population for interventional studies. If this population adequately understand the principles of prescribing antibiotics, this successful learning will be productive in practice too [
17].
Overcoming this problem will be possible with an One health approach, taking into account humans, animals, and environmental health altogether [
18‐
20].
Today, AMR occurs in humans, wildlife, domestic animals, plants, and our environment directly by using antibiotics, and there is a risk on a much larger and more significant scale in animal-source foods consumed by humans indirectly. So it is logical to take a multidisciplinary health approach to solve this problem by eliminating the inappropriate use of antibiotics [
21,
22].
In the medical domain, extensive research has been done to examine physicians’ beliefs about prescribing antibiotics [
23]. Many interventions have been made to reduce physicians’ over-prescription. The various aspects of antibiotic prescription have been extensively investigated so far in medical and clinical sciences. However, these interventions alone have not managed to prevent the occurrence of this important event. Thus, resolving this problem needs a multidimensional approach [
24] .
Moreover, veterinarians prescribing drugs without using paraclinical services and selling over-the-counter (OTC) drugs are very common in several countries including Iran. In many stockbreeding industries, antibiotics are widely used not only for medical purposes but also as growth stimulants. There has been a serious lack of effective monitoring of these patterns of use. Similarly, there has scarcely been any strict preventive rule for this. Thus, it is likely that the AMR incidence rate is high in countries such as Iran [
25,
26].
A vast majority of research so far on the effect of AMR has only addressed this issue in human health [
16,
24]. In veterinary medicine, the body of existing literature has been limited to laboratory research and animal health. Veterinarians’ role in integrated health, especially AMR has not been adequately addressed. Therefore, there is no complete and clear understanding of veterinarians’ mental patterns and perceived social barriers to their decisions during diagnosis and treatment [
27].
The over-prescribing of drugs is very common in animal products and animal-source foods (to be consumed by humans) in Iran. Moreover, each of these foods contains antimicrobial residues. Thus, it can be conjectured that people ingest significant amounts of antibiotics every day unintentionally without suffering from any infectious disease. Therefore, veterinarians must pay adequate attention to AMR in human health [
28].
Overall, the world is faced with increasing availability and misuse of antibiotics in veterinary medicine, which threatens public health. There is a significant increase in AMR on a global scale, and there is a threat of increasing infections that do not respond well to treatment. It is essential to take appropriate measures and plan to prevent the over-prescription of antibiotics by veterinarians. There is an increasing need for education and empowerment policies, all deemed impossible unless the barriers facing veterinarians are recognized in appropriate prescribing. In other words, to deal with the AMR issue, the first step is to identify the causes and underlying contributing factors to this event in veterinary medicine and the disastrous conditions veterinarians face in Iran and the world. It is not possible to adequately approach what veterinarians go through and how they perceive the existing context only through quantitative research. A qualitative approach is needed to explore all aspects of this problem. Therefore, the present study employed this approach to explore the Iranian veterinarians’ perceptions of barriers to AMR prevention. We hope that the results generated from this study will help promote programs to curb slow down and the development of AMR in Iran and the world. The present findings can be used to make new social, economic, and even political decisions.
Materials and methods
Research design
This research was conducted with a qualitative approach and qualitative content analysis method from three cities of Iran: Kerman (with a large population of large and small livestock), Bandar Abbas (a fishing and aquaculture hub), and Tehran (with a large population of pets and industrial poultry). The present qualitative study used semi-structured interviews with veterinarians who had experience in treating and prescribing antibiotics or office work in veterinary medicine, or those with sufficient experience and knowledge of issues in veterinary diagnosis and treatment. The interviews were held face-to-face from May 3, 2021 to August 13, 2021. In this study, theme analysis was used, which is a common type of qualitative content analysis. It seeks a deep understanding of the complexity, details, and embedded context of a given phenomenon. In this type of analysis, interviews with individuals provide a better understanding and richer information about participants’ experiences and perspectives. This research approach allows for an in-depth and rich exploration of participants’ experiences.
The panel of experts offering advice on research questions and reviewing the transcripts for reliability consisted of one epidemiologist, three health education and health promotion specialists, and two veterinary professors collaborating with three organizations: (Hormozgan University of Medical Sciences, Veterinary Department of Kerman University and Iranian Veterinary Organization). The present participants were selected through maximum variation and snowball sampling.
Participants
The research population consisted of veterinarians from three cities (Tehran, Kerman, and Bandar Abbas) in Iran, all dealing with a large population of livestock, poultry, and aquatic animals in 2021. The inclusion criteria were: veterinary work experience at least three years, the experience of therapeutic clinical work or working as a veterinary administrative and supervisory staff, willingness to participate (in the research), and ability to answer the questions. The exclusion criteria were unwillingness to participate and withdrawal from the interview. Purposive sampling was used with maximum variation (in terms of the province of work, age, sex, the field of work in a clinic or pharmacy, and affiliation with the public or private sector) at first steps and snowball sampling methods In the following. That means some veterinarians were concerned about expressing their opinions or reporting any illegal case they had dealt with. Therefore, they had to be selected through snowball sampling. After reaching the first participant and holding the interview, s/he was asked to suggest the next veterinarian who was aware of or was experienced in prescribing antibiotics against paraclinical rules. Therefore, each participant connected and introduced us to the next participant. Interviews were held in a public place at the interviewee’s convenience. In some cases, the interview was held in the clinic, and in others in the interviewee’s office. The data were collected and analyzed simultaneously. The interviews continued until the data were saturated (i.e. when no new information was obtained) and until all the extracted themes were sufficiently supported by the data. After the 17th interview, no new data were collected, but to be on the safe side, another interview was also conducted, and after the interview with the 18th participant, the sampling was stopped.
Data collection
Guided questions and semi-structured interviews were used for data collection. The interviews were held face-to-face and video calls. When required, a trained research assistant conducted a qualitative interview to increase the accuracy and speed of data collection. The interview questions were derived from a review of the existing literature on AMR with a focus on the underlying causes and also the comments made by a panel of experts. At the beginning of the interview, the purpose of the study was revealed to the participants and they were assured of the confidentiality of the information they provided and the anonymity of their responses. The interviewees were ensured they could withdraw from the study upon their will. Then, an informed letter of consent was signed. The required permission was gained to record all the conversations. The main focus of the questions included:
1.
What are the barriers to veterinarians’ prevention of increased AMR? Explain.
2.
What do you know about the causes and precursors of AMR occurrence in Iran?
3.
What are the determinants of prescribing and using antibiotics in veterinary medicine in Iran in your opinion? Explain.
4.
What are the determinants of the increased AMR in your opinion as a veterinarian?
Based on the participants’ previous answers, more exploratory questions were asked and, as a result, we extracted the main reasons why veterinarians over-prescribed drugs and why antibiotics were overconsumed in the animal source food industry. The sample size was determined by the theoretical data saturation criterion. In other words, during the data collection, when we concluded that more interviews and observations could not add any new information and only led to repeated findings, we stopped the data collection. Therefore, 18 active veterinarians in clinical, medical, educational and administrative fields were interviewed in Tehran, Kerman and Hormozgan (provinces). Individual interviews lasted between 42 and 57 min.
Data analysis
The process of data analysis was done using Granheim and Lundman method [
29,
30] and with the help of MAXQDA-2010 software by the first and second authors of the article. The first and second authors listened to recorded interviews and transcribed them into a written format in Word 2017 software immediately after every interview and on the same day with the help of other research colleagues. In the second step, the text of the interviews was read by the researchers very carefully to get a general view of their text. In the third stage, all the texts of the interviews were read line by line and very carefully, and the initial codes were started.
In the fourth step, the researchers placed the codes that were similar in terms of meaning and concept and were placed in a category in a subcategory and determined the relationship between them. In the fifth step, the codes and categories were placed in the main categories, which were conceptually more comprehensive and abstract [
31]. Finally, in a joint meeting, the entire process of data analysis was shared and conflicting opinions on the content of a topic were discussed by a research team with two qualitative health researchers and two veterinarians.
Rigor
Guba and Lincoln evaluation criteria [
32] were used to check the trustworthiness of the findings. To substantiate the validity of the findings, the researcher’s self-review technique was used in data collection and analysis as well as a peer check during which the codes were provided to two participants to resolve misunderstandings. To substantiate the reliability of findings, intra- and inter-rater reliability tests were used. To this aim, the recorded and transcribed conversations were given to several experts for review. After analyzing the data, they were re-analyzed by colleagues. The next step was documentation to test the accuracy and comprehensibility of the procedures, and the underlying mechanisms of errors.
Ethical considerations
This research was approved by the Ethics Committee of Hormozgan University of Medical Sciences (IR.HUMS.REC.1400.207). In the interviews, the researcher, by introducing herself and also explaining the purposes of the study, tried to create an amicable atmosphere for the interview. The participants were also ensured of the confidentiality of the information they provided, the anonymity of recorded conversations, and also why they were selected. They consented to their voice being recorded. The participants were free to withdraw or leave the interview any time they requested.
Discussion
The present study aimed to explore the barriers faced by Irainian veterinarians against preventing Antimicrobial resistance. A few qualitative studies have been conducted on AMR, which dealt with the causes of progress and the obstacles faced by those involved in this problem, especially in the veterinary profession [
33,
34]. The results showed that different educational, legal/administrative and veterinarian-related factors account for the increased AMR in Iranian society. The first category included factors related to the educational system, such as the lack of any specialized training course for veterinary students, those in charge of monitoring veterinary practice, veterinary departments, and ranchers struggling with educational problems who may all be implicated in increasing AMR. In Iran, various educational initiatives have been implemented, such as the publication of a book on rational prescription principles, academic papers, and reports from the National Committee on Prescribing and Rational Drug Use. Despite these efforts, there are numerous educational obstacles in veterinary colleges in Iran when it comes to instructing students on prescription fundamentals and the rational utilization of medications.
The required material has been also developed; training and retraining programs have been planned based on eclectic drug use criteria; workshops, conferences, and seminars have been held too. A prescription can simply be representative of a whole nation’s sociocultural values and medical conditions. Many studies have been conducted worldwide to improve rational drug prescription and consumption [
35]. The effects of educational interventions on the improved prescription pattern have been reported in Iranians and other studies too [
36,
37]. Continued training on rational drug prescription and pharmacy education has been recommended to doctors in the existing literature [
38,
39].
In Zareh’s study, the most commonly prescribed drugs were injections and antibiotics. The research findings showed that, after the training, there was an increase in the rational prescriptions for most prescribed drugs [
40]. As for teaching strategies, the WHO has published The Guide to Good Prescribing for medical students. This guidebook contains six rational steps that can significantly reduce the irrational prescription of drugs: 1- defining the patient’s problem 2- defining the goals of treatment 3- ensuring that the treatment is appropriate for the patient. 4 – initiating the therapeutic measure 5 - providing information, instructions and warnings (if any) 6 - monitoring and ceasing the treatment [
41]. Outdated education was a sub-category found in this study. Different studies showed that dentists often, due to a lack of knowledge about the side effects of improper prescribing of antibiotics, tend to over-prescribe them [
42,
43].
Veterinarians also are central to antimicrobial stewardship on farms, with their prescribing decisions significantly impacting AMR.A study on Canadian dairy cattle veterinarians’ revealed factors influencing their antimicrobial prescribing, attitudes towards reducing antimicrobial use, awareness of AMR, and perceived barriers to improving stewardship [
44]. In addition educational resources have been developed to enhance veterinarians’ understanding of AMR and promote rational antimicrobial use. Online courses such as “Antimicrobial stewardship in veterinary practice” and “Farmed Animal Antimicrobial Stewardship Initiative” aim to educate veterinarians on responsible antimicrobial use [
45,
46].
What we need is a high-quality time management element added to the existing curricula so that students can be well-equipped with whatever they need to act professionally. Excessive imitation of medical sciences in specialized courses can only lower the efficiency of a vet’s profession. Rather, there is a need for incorporating courses on different animal species both at the general practitioner’s level and the specialized doctorate degrees [
47].
There is also the issue of time management in the curriculum. Decreasing the quantity of content and increasing the quality (by adding more useful content) can better reform the veterinary curriculum. Goal-setting in veterinary sciences has already been revolutionized, and veterinary universities cannot ignore it. Thus, it is essential to consider the present and future needs in defining the required specialties to handle the existing national health issues, each of which can impose a loss of millions of dollars nationally. For many years, curricula have been developed in the European Union to achieve the necessary specializations by the existing needs, at least in the cattle breeding industry [
48]. A deficient educational system is one factor that increases the overuse of antibiotics. Therefore, it is necessary to take basic measures based on the macro-planning of students’ knowledge and increase the quality of internships. In a study by Wushouer et al. in China, it was observed that an increasing awareness was followed by a decreasing rate of antibiotic administration [
49]. Therefore, it is necessary to increase knowledge through a different approach in the educational system. Most experts believe that education in medical sciences should follow a different approach than other fields of study because knowledge construction in these fields of study (i.e., medicine, veterinary medicine) affects the content that students receive and the experiences they gain [
50].
Failure to hold training courses for producers of raw animal products and unsystematic student internships can significantly lower the quality of education. Raising the study index in AMR and modeling on successful examples can be considered in curriculum design. Moreover, all departments of the veterinary faculties should cooperate and the heavy burden of teaching AMR should be removed from the bacteriology department only, and be shared by all basic sciences and clinical courses. Only then can we hope to see improved practice in students’ learning experiences and professional life in the near future.
The present findings showed that currently in our country, the educational system needs to be seriously reformed by appropriate training programs and pre-employment awareness-raising programs for veterinarians and ranchers [
51]. People working in this field should be more empowered, better aware, and skilled enough at a correct diagnosis or proper functioning [
52]. Only then we can hope that their self-efficacy is increased and they can learn to act more responsibly. These can help to prevent the occurrence of AMR and to begin to resolve it rather than worsening the issue.
The second category of the determinants of increased AMR was administrative and legal factors. Problems with the law, monitoring, and selling OTC drugs are important issues that can increase the costs of treatment too. This finding is consistent with several studies. For example, it is estimated that about 100,000 people in the United States die every year from the adverse effects of drugs [
53]. In the United Kingdom, problems in 11% of prescriptions cost over € 400 million in loss, and about 16% of these problems harm patients [
54]. Most of these errors are preventable, including drugs prescribed heedless of contraindications, those taken incorrectly, or those not having been properly monitored. The WHO, along with other relevant international organizations, proposed certain criteria to evaluate the quality of prescriptions to prevent the occurrence of problems and lower treatment costs [
55,
56]. A useful way of evaluating the prescription pattern in a country is to evaluate the doctors’ prescriptions. A simple prescription can represent the current state of medical education in a country, how laws and regulations affect the medical community, socio-cultural beliefs, and the medical condition [
36]. Based on WHO guidelines use of medically important antimicrobials in food-producing animals, any level of restriction in antibiotic prescription should be considered, including a complete cessation of the use of one or more antibiotics. Examples of restrictions that WHO considered are: any prohibition on the use of antibiotics, such as but not limited to the prohibited use for specific indications (e.g., for prophylaxis of disease or growth promotion), the requirement of a prescription by a veterinarian for the use of antibiotics, voluntary restrictions on farms or organic interventions [
55]. Drugs that need confirmation from a specially qualified person or organization should not be sold over the counter. Prescribed drugs are regulated by the US Food and Drug Administration (FDA). Having a federal license with a medical leaflet is a prerequisite for the packing of any drug. A medical leaflet usually consists of four parts: indications, contraindications, warnings, and dosage [
57]. He who writes out a prescription decides who can consume the drug. A pharmacist can buy drugs, but he should sell them only to those authorized by a legally qualified person. Thus, a prescribed drug has 3 parts [
58]: (1) The doctor’s prescription, (2) The pharmacist’s written prescription while delivering the drug, and (3) the drug package with a label on it. That is why officials are expected to always think about formulating new and public policies to implement correct and new strategies for the use of antibiotics [
59]. Educational and political interventions, establishing and implementing laws regarding AMR stewardship may be effective and acceptable either before or during the livestock and poultry breeding programs, even for pet owners [
60]. Success in the coordinated implementation of related laws is not possible without the advocacy of various stakeholders, including policymakers, veterinarians and ranchers, pet owners, public sector employees, farmers, and consumers [
51]. It seems that the use of effective legislation, contractual requirements, professional obligations and the distribution of suitable facilities in more distant areas makes the implementation of this plan possible [
21,
22].
The third category was the client-related factors. Quick response and arbitrary drug use were among the sub-categories. With the expansion of public access to the internet system, people may want to refer less to vets and, instead, self-medicate or they may expect a quick response and begin to use antibiotics. In their research, Hofmeister et al. investigated veterinary visitors and found the internet connection speed as the third most important source of retrieving pet health information after GPs and specialized vets and before family and friends and other mass media [
61]. Kogan et al. maintained that internet-based sources are considered an extra source of information about pet health for pet owners besides visiting vets for consultation [
62]. Volk et al. reckoned that the internet and online health information could replace veterinarians and lead to fewer pet owners visiting veterinary clinics [
63]. Thus, since some clients do not want to pay the visit and para clinic fees, by searching on the Internet and cyberspace, or based on their previous experience or else, they prescribe and take antibiotics arbitrarily before any visit to vets. If they do not find some proper treatment, they try other antibiotics, which leads to the problem of changing or stopping the antibiotics early before the end of the treatment period.
Some other poultry or aquatic breeders who have farms of several thousand pieces are very worried about the loss of their livestock, poultry and the aquatic population at the beginning of the disease. Since there may be a large population of their herd while waiting for the antibiogram test, they prefer to use a broad-spectrum and preferably cheaper antibiotic (for large-scale use for a large herd) to begin with and prevent their economic loss to a large extent [
60]. Therefore, both in the producers and breeders of animal-origin food and in the owners of pets, the customer’s demand needs quick response and the customer’s demand should be prioritized [
22].
In addition, a person who once used a broad-spectrum antibiotic without a prescription and got a response, suggests that to his/her colleagues or other breeders, and by promoting social learning, this behavior promotes the progress of antimicrobial resistance. In addition, many of these people are unaware of antibiotic residues and abstinence intervals, and currently do not feel threatened about the future of antimicrobial resistance. When they go to the vet, they prefer to go to a vet who prescribes some antibiotics to return home without any drug prescribed [
33].
Another subcategory extracted from the present findings was the use of antibiotics as growth stimulants by poultry farmers. The use of antibiotics, both as a treatment in humans and as a therapeutic measure or growth stimulant in animals, has a great effect on the microbial flora of the intestine and also induces resistant strains in these animals [
64]. When used as a growth stimulant, antibiotics can have adverse effects on humans and animals [
65].
The fourth category was the veterinarian-related factors. The lack of an inter-sectoral approach was one subcategory extracted from the findings. Foreign studies mentioned a multi-sectoral approach and knowledge sharing in educational environments [
66]. There seems to be a need for all institutions to have the required knowledge about the use of antibiotics through shared efforts between universities, the government, and the various professions. One subcategory was the insignificance of antimicrobial resistance to veterinarians. Antibiotic-containing products have harmful effects and there is a significant increase in the resistance of different types of infectious bacteria [
67] besides the important role that antibiotic-containing animal products play in this process. Thus, global efforts are needed to reduce antibiotic use and attempt to control it. More control is needed over veterinary drugs and their use in livestock and poultry farms [
68].
In line with the qualitative study in the UK, this study showed various behavioral and contextual factors involved in the participants’ beliefs about AMR stewardship and their responsibilities in the right direction [
33]. One of these issues is the lack of experience in writing correct prescriptions among novice vets who prescribe several antibiotics at the same time in the hope that at least one works. This finding is in line with some studies that acknowledged that, when uncertain, most new clinicians tend to over-treat with antimicrobial drugs instead of refraining from treatment [
1,
69‐
71]. They prescribe several antibiotics in the hope that one works. The other extreme case is also possible when experienced veterinarians prescribe drugs based on their long-held experience. These clinicians have more faith in a series of antibiotics. On the other hand, the diagnosis of the disease and the prescription are dependent n each other. When they are told about the laboratory evidence, they react as if their credibility has been damaged. Therefore, they provide waves of unprincipled recommendations and increase antimicrobial resistance. If a veterinarian intends to prescribe antibiotics based on the principles and guidelines, s/he will face other problems, including the fear of losing clients because, as mentioned earlier, if the prescription is not in accordance with the client’s wishes or the urgency of responding to it, the client will prefer to go to another vet, and this issue will endanger the job security even more.
Another sub-category is lacking self-efficacy in dealing with different visits.In other words, the approach of veterinarians to prescribing antibiotics is to a great extent pre-established and classified. For example, oxytetracycline is the preferred antibiotic for most respiratory diseases. Any cause of disease that requires more attention to the self-efficacy of veterinarians and clinicians can be improved by training methods and participation in appropriate courses. Diminishing moral values becomes important in cases where full-time monitoring of antibiotic residues in animal products and their transfer to society and the environment is not possible, and where the government and regulatory agencies fail due to poor enforcement of laws. The regulatory forces cannot monitor and take care of the veterinary private sector employees and breeders. We can only hope that the vets will feel committed enough in their acts of diagnosis and prescription and the resultant effect on antimicrobial resistance. In the end, it is possible to recommend the modification of the appearance of prescriptions as a solution, because most of the headers of the veterinarians’ prescriptions in Iran are designed in a large way, which encourages the person to fill most of the prescription with writing the unnecessary drugs, so maybe it is recommended to design and implement a single protocol in limiting the written space of the prescriptions, we can take a step in reducing the obstacles facing the control of antimicrobial resistance.
Limitations, strengths and future directions
There were certain limitations in this study. As the interviews were face-to-face, participants might have been tempted to provide socially acceptable answers. Also, some veterinarians showed concerns about the illegal cases they were aware of and reported. So, they were selected through snowball sampling. In addition, selecting interviewees with work experience and an adequate understanding of the relevant problems and interviewing them in a private place were somehow difficult.
As in other qualitative studies, researchers’ beliefs may have influenced the study procedure from conceptualization to interaction with participants and data interpretation [
72].There were chances that the interviewees’ comments did not cover all factors possibly because of the limited sample size. Sampling in qualitative studies continues until the saturation happens. Thus, in this study also the interviews continued until the data were saturated (i.e., when no new information was obtained) and until all the extracted themes were sufficiently supported by the data. No formula was included.
It is possible that besides the factors mentioned by the present participants, other experiences are gained in other parts of the country that cannot be subsumed under the present categories.
Despite the potential limitations, the present study has several strengths. The first is the sampling method with maximum variation (in terms of the province of work, age, sex, and work in the clinic or drug supply or employed in public and private sectors). The next strength is that during the interviews, some participants were dissatisfied with the current conditions, and this study provided an opportunity for them to find solutions. Moreover, there has been extensive research on AMR, but the vast majority of them are quantitative. Few have explored AMR determinants in society. The present study goes beyond the laboratory work, and with the One Health approach, using numerous interviews, it gains a deep understanding of work experience, and comprehensive and valid data to solve the AMR issue. The authors of this study intend to use the data from this study or at least part of the data for future educational interventions. A focus on the categories extracted from these studies helps to plan effective multidimensional interventions. This study can also guide future lines of research.