ANTIMICROBIAL RESISTANCE AND IRRATIONAL DRUG USE: EVALUATING PRESCRIPTION PRACTICES IN PRIMARY HEALTHCARE SYSTEMS IN DEVELOPING COUNTRIES: A QUANTITATIVE CROSS-SECTIONAL STUDY USING STRUCTURAL EQUATION MODELING

Abstract

Antimicrobial resistance (AMR) poses a critical global health threat, with irrational drug use in primary healthcare (PHC) systems accelerating the emergence of resistance. This quantitative cross-sectional study examines the structural relationships among provider knowledge, institutional support, patient education access, prescribing practice quality, and irrational drug use across 37 PHC centers in four geographic regions of a developing country (N = 412 healthcare providers). Using structural equation modeling via partial least squares (SEM-PLS) in SmartPLS 4, we tested a model incorporating direct, indirect (mediated), and moderated pathways. Results demonstrate that provider knowledge (β = 0.52, p < 0.001) and institutional support (β = 0.38, p < 0.001) significantly predict prescribing practice quality, which in turn strongly reduces irrational drug use (β = −0.68, p < 0.001). Provider knowledge exerts a significant indirect protective effect through prescribing quality (indirect β = −0.35, 95% CI [−0.51, −0.18], VAF = 51%). Institutional support moderates the prescribing-to-irrational-use relationship (interaction β = 0.24, p < 0.05, f² = 0.18). Audit-based irrational prescription rates varied significantly by provider cadre (physicians 42.3%, nurses 58.6%, paramedics 71.2%) and geographic region (35.9% to 68.6%). The model explained 64% of the variance in irrational drug use (R² = 0.64, SRMR = 0.068, NFI = 0.923). We conclude that strengthening provider education alongside institutional mechanisms for antimicrobial stewardship can meaningfully reduce irrational prescribing and help contain AMR in low-resource primary care settings.