An application of COM-b model to explore factors influencing veterinarians’ antimicrobial prescription behaviors: Findings from a qualitative study in Bangladesh

The integration of behavioral theories in designing antimicrobial stewardship (AMS) interventions aimed at optimizing the antimicrobial prescription in veterinary practice is highly recommended. However, little is known about the factors that influence veterinarians' antimicrobial behavior for food-producing animals in lower- and middle-income settings like Bangladesh. There is a large body of research on the factors that influence veterinarian behavior of prescribing antimicrobials, however, there is a need for more studies that use comprehensive behavior change models to develop and evaluate interventions. Applying the Capability, Opportunity, and Motivation for Behavior (COM-B) model, this qualitative study attempted to address this gap by conducting 32 one-on-one semi-structured interviews with registered veterinarians in Bangladesh. In alignment with COM-B constructs and the theoretical domain framework (TDF), thematic analysis (both inductive and deductive inferences) was performed to analyze the data and identify underlying factors that influence veterinarians' antimicrobial prescription behavior. We found that under "Capability," factors such as knowledge of antimicrobial resistance (AMR); ability to handle complex disease conditions; ability to identify the appropriate antimicrobial type, routes of administration, and potential side effects influence prescription behavior by veterinarians. Under "Opportunity," veterinarians' prescription behavior was influenced by lack of laboratory testing facilities, poor farm biosecurity, farm management and location, farming conditions, impacts of climate change, the clinical history of animals and social influence from different actors including senior figures, peers, farmers, and other informal stakeholders. Under "Motivation," national laws and guidelines serve as catalysts in reducing antimicrobial prescriptions. However, perceived consequences such as fear of treatment failure, losing clients, farmers' reliance on informal service providers, and economic losses demotivate veterinarians from reducing the prescription of antimicrobials. Additionally, veterinarians feel that reducing the burden of AMR is a shared responsibility since many informal stakeholders are involved in the administration and purchase of these medicines. Based on our results, this study recommends incorporating the factors we identified into existing or novel AMS interventions. The behavior change wheel can be used as the guiding principle while designing AMS interventions to increase capability, opportunity and motivation to reduce antimicrobial over-prescription.