Exploring behavioral determinants of antimicrobial dispensing in drug retail outlets of Addis Ababa, Ethiopia: a mixed methods study

Abstract Antimicrobial resistance (AMR) is a critical global health threat, exacerbated by inappropriate dispensing practices. Despite efforts to improve antimicrobial stewardship, behavioral determinants influencing antimicrobial dispensing remain understudied, particularly in low-resource settings like Ethiopia. This study was aimed to explore the behavioral drivers of antimicrobial dispensing among pharmacy professionals working at community drug retail outlets of Addis Ababa. This convergent, parallel mixed-methods study was conducted in three randomly selected sub-cities of Addis Ababa from March to May 2025. The quantitative component addressed the prevalence and predictors of dispensing behavior, surveying 240 pharmacy professionals selected via multi-stage sampling from 120 drug retail outlets. Data were collected using digital (Google Forms) and paper-based questionnaires, measuring TDF-based behavioral determinants and dispensing behavior. Participants were pharmacists and druggists with at least three months of dispensing experience, selected from private pharmacies and drug stores. Hierarchical multiple regression and confirmatory factor analysis were performed using SPSS and AMOS. The qualitative component explored contextual nuances through in-depth interviews with 16 professionals until thematic saturation, analyzed using Dedoose software with a thematic approach, without a predefined framework to allow free expression of feelings. Data quality was ensured through pre-testing, digital validation, and transcription cross-checking. Quantitative findings revealed inappropriate dispensing in 53.75% of cases (129/240). One-sample t-tests showed significant positive deviations for most TDF domains (p < .001), except environmental context (p = .642). Hierarchical regression indicated demographic and behavioral factors explained 62% of dispensing behavior variance, with age (β = 0.630, p < .001), female gender (β = 0.343, p < .001), and behavioral factors; (Professional Role and Self-Regulation: β = 0.456, p < .001; Emotional and Social Dynamics: (β = 0.359, p < .001)) as positive predictors, while Skills and Belief Systems (β=-0.431, p < .001) and experience (≥ 5 years) negatively predicted appropriate dispensing (β=-0.304, p < .001). Qualitative insights highlighted systemic barriers, including patient pressure, profit motives, and weak regulatory enforcement, which often overrode professional knowledge. Triangulation revealed that while pharmacists understood guidelines, workplace pressures and financial incentives drove non-compliance. Inappropriate antimicrobial dispensing was prevalent and significantly influenced by key determinants: longer experience negatively predicted appropriate dispensing, while female gender positively predicted it. Behavioral factors, particularly social and commercial pressures like patient demand and competition, were stronger drivers than knowledge alone.