Antibiotic consumption in post-COVID societies: comparing cultures for shaping One Health policies

Abstract Background Antibiotic (AB) misuse remains a leading lifestyle-related contributor to antimicrobial resistance (AMR) across culturally diverse Europe. This report compares Bulgaria (BG) and Finland (FIN) - two countries at opposite ends of the EU-spectrum in terms of citizen satisfaction and AB consumption, drawing on data from the World Happiness Report (WHR), ECDC, and Eurobarometer. It explores how cultural values and trust in healthcare influence alignment with One Health (OH) strategies against AMR, providing EU-wide insights through the lens of national case studies. AB use and AMR perception: FIN is the only EU country showing statistically significant declines in AB use across hospital and community settings. Conversely, BG demonstrates significant post-COVID increases in both sectors. Public engagement also varies - only 24% in BG report regularly receiving information on appropriate AB use, compared to 50% in FIN. Awareness of AMR is rising in both countries, yet gaps persist: 96% of Finns and 78% of Bulgarians agree that unnecessary AB use reduces efficacy. Cultural values and OH policies on AMR: Using Hofstede's Cultural Model (HCM) dimensions, differences in power distance (PDI), uncertainty avoidance (UA), and individualism (IDV) help explain divergent trends. FIN's low PDI and high IDV align with low AB use and strong AMR awareness. In contrast, BG's higher PDI and UA correlate with AB misuse and institutional mistrust. FIN, ranked first in WHR, contrasts with BG at 85th, marked by weaker support networks. Further, FIN adopted a national OH action plan on AMR in 2017; BG has yet to do so. Conclusions Cultural resistance may hinder the development of cohesive OH strategies. A cultural transformation in BG is vital to curb AB use, as demonstrated by FIN's inclusive, values-driven policies. Recognizing cultural dimensions can enhance the EU's OH policies aimed at reducing AB use by 20% by 2030, and at positioning the EU as a best-practice region. Key messages • Cross-cultural analysis offers transferable insights on responsible antibiotic use and should guide more effective, locally adapted AMR strategies. • Effective and sustainable One Health AMR policies rely on social trust, health literacy, and culturally tailored communication.