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

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 ...