Ethical tensions related to over-the-counter antibiotic use in rural Cambodia: a qualitative study

Background Antimicrobial resistance (AMR) is an important health threat in Southeast Asia, where over-the-counter (OTC) antibiotic sales remain widespread. However, the ethical tensions shaping these informal dispensing practices remain underexplored. Methods Thirty in-depth interviews were conducted among community members, drug dispensers, and healthcare providers in Siem Pang district, northeast Cambodia to explore local perceptions of antibiotic use and the ethical dilemmas surrounding OTC sales. Participants were recruited through purposive and snowball sampling. Coding and thematic analysis were conducted in NVivo 15. Results Five major themes were identified. Firstly, knowledge and perceptions of antibiotics, their use, and AMR revealed a limited understanding of antibiotic mechanisms and AMR. Secondly, perceived accessibility versus perceived safety of OTC antibiotics as financial and logistical barriers to formal care made informal sources more attractive despite perceived risks. Thirdly, collective versus individual health, whereby treatment decisions prioritize the perceived immediate needs of the individual or household over public health concerns. Fourthly, patient autonomy versus professional responsibility, as an emphasis on autonomy in informal care-seeking was not matched by reliable information or professional responsibility. Finally, justification and personal moral codes, through which informal dispensers framed selling antibiotics as socially responsible or economically necessary. Conclusion Limited knowledge and financial pressures drive dispensers and consumers to prioritize individual needs over collective risk, sustaining informal OTC antibiotic use. Ethical tensions emerge within systemic constraints, highlighting that interventions must address both economic incentives and knowledge gaps.