Determinants of antimicrobial resistance occurrence in animal‐based food, perceived by livestock farmers: A qualitative phenomenological study

Abstract Background and Purpose of the Study The determinants of antimicrobial resistance in human medicine have been copiously explored. On the other hand, the existing research in veterinary medicine and animal husbandry is in its infancy. The present qualitative study used the one‐health approach to explore farmers’ attitudes toward antimicrobial use and antimicrobial stewardship. Methodology The present qualitative study was phenomenological in type. It was conducted in 2022 in the two cities of Kerman and Bandar Abbas in Iran. The data were collected through in‐depth interviews by semistructured interviews with 17 livestock, poultry, and aquatic animal breeders selected through purposive sampling. The interviews lasted between 35 and 65 min in the Farsi language. The data were analyzed using conventional qualitative content analysis and Colaizzi's seven‐step analysis technique. Results The open coding was done in MAXQDA 10 and the results of data analysis were classified into five main themes and 17 subthemes subcategories. The main categories include personal determinants, contextual determinants, legal and regulatory determinants, social determinants, and economic determinants. Conclusion Considering the increasing use of antibiotics among livestock farmers and breeders of animals used as human food, different measures such as educational, regulatory, social, and even cultural interventions may be able to control and prevent antimicrobial resistance.

animals and humans alike at risk of death. 29 Most population-based studies of AMR and medical decisions have mainly used questionnaires and mostly followed a quantitative approach. Although surveys may analyze factors that may influence medical decisions based on qualitative research, it is possible to explore why and how various factors influence people's decisions.
Qualitative approaches allow participants to freely and deeply explore their experiences, and decisions and share thoughts.
However, so far only a few qualitative studies have explored farmers' and ranchers' experience of antimicrobial treatments but only in limited and specific contexts. [30][31][32] Very little research has been conducted on health promotion in social sciences regarding antimicrobial stewardship among veterinarians and ranchers. 33,34 Recognizing the important role of scientists in health promotion and social sciences in dealing with AMR can be effective. 35  unique to each group, and the use of qualitative research to examine the experiences of these people will reveal more features. 32 This study aims to fill the gaps using a qualitative approach to discover the lived experiences of livestock farmers in the use of antibiotics on the farm, or in livestock, poultry and aquatic breeding centers. It aims to explore their attitude toward AMR and how this attitude may or may not help antimicrobial stewardship. Considering the significant role of ranchers and producers of raw food of animal origin, their lived experience is explored in the present study.

| Participants and sampling
The present qualitative study adopted a phenomenological approach.
Phenomenology is the study of lived experiences of people facing a special phenomenon. Phenomenology seeks to reveal meanings as they are lived in everyday life. 31 The phenomenological approach was justified by the fact that, logically, individuals are the best source of describing feelings, experiences, and situations when expressing themselves in words. The present participants are 17 livestock farmers that have experience in using antibiotics in Kerman and Bandar Abbas cities in Iran in 2022, selected through purposive sampling. All participants were literate. We first selected a number of breeders and livestock farmers who visited the two main veterinary pharmacies in Kerman and Bandar Abbas to buy antibiotics. They were invited to participate in the study. Each interviewee suggested the next one be interviewed. The inclusion criteria were being a breeder of livestock, poultry, and aquatic animals, as well as having the experience of self-administration of antibiotics in animals under their care and willingness to participate in the research. The interviews continued until data saturation. 36 When no new code was extracted from an interview, the sampling was stopped and the data saturation occurred. All the interviewers and the interviewees were Persian speakers.

| Data collection and procedure
The interview guide was developed for this study. The guide included two parts: the first part asked for demographic information, including sex, marital status, education, socioeconomic status, residence status and type of work, and so on. The second part included semistructured open-ended questions that were pilot tested with a scientist experienced in qualitative research.
The interviews were held face-to-face. The research questions dealt with the experience of livestock, poultry, and aquatic breeders in using antibiotics for livestock. The interview was in Farsi language and followed an exploratory approach. The purpose of the semistructured interview was to allow the interviewees to talk about their experiences easily and make it easy for the participants to Immediately completing each interview, it was transcribed and coded.
When each interview was analyzed, the next interview followed. In the case of any ambiguity in content, another interview was held to solve the ambiguities. The interviews lasted between 35 and 65 min, depending on the participant's interest in continuing the interview.
Immediately after each interview, all the interviews were transcribed in Microsoft Word.

| Rigor and trustworthiness
To estimate reliability, two methods were used, one the review of content by the participants themselves and the other the review by the field specialists. The interviews were recorded and then transcribed. The content was reviewed by several experts in health education and one expert in bacteriology. After analyzing the data, it was re-examined by the qualitative researchers. The revised manuscripts were sent to the participants to confirm the findings obtained by the researcher.
Also, to check the reliability of data, the four criteria proposed by Lincoln and Goba were used. These included: validity, reliability, verifiability, and transferability. 37 To evaluate and increase the validity of findings, the sampling continued until data saturation.
The data transfer was ensured by providing a comprehensive and complete description of the topic to the participants, with a subsequent data collection and analysis. Also, an external review was done to increase the reliability of the findings. The verifiability of findings was increased through triangulation. 38

| Data analysis
Data collection and analysis were carried out simultaneously. After the initial analysis of each interview, the next was planned. Each transcript of the interview was read three times to identify the hidden concepts in the statements of the participants. After extracting the initial codes, the codes were clustered into categories. Codes that shared similar meanings were grouped together. This process of analysis continued until the emergence of the main and subthemes. To facilitate the analysis of the qualitative data, the MAXQDA-10 was used and also the data were analyzed using Colaizzi seven-step method a content analysis, as described below: 1. Reviewing important findings and empathizing with the participants to understand them better.

| ETHICS CONSIDERATIONS
In the interviews, the researchers introduced themselves and also explained the purpose of the research. They attempted to create an amicable atmosphere for the interview. The participants were also ensured of the confidentiality of the information they provided, the anonymity of recorded conversations, and also why they were selected to be included in the study. They consented to the voice recording. The participants were free to withdraw from the interview at any time they requested.
The mean age of participants was 39.5 years. The minimum and maximum age was 26 and 53 years, respectively. Other participants' demographic characteristics are summarized in Table 1.
Five main themes and 17 subthemes were obtained from the results of the qualitative phenomenology (Table 2)

| Transportation and distance issue
The lack of transportation facilities and distance from medical centers in rural areas were mentioned among the reasons for the arbitrary use of antibiotics. Here is an excerpt: "If we decide to come to the city and see a doctor to prescribe some medicine, the animal may die" (Participant #13: cow and sheep breeder)

| Category 3: Regulatory factors
Subcategories: inefficient rules, lacking cooperation of public sector and livestock breeders, limited facilities.

| Category 5: Economic factors
Subcategories: Tendency for more production, prevention of loss, medical discount, high medical and lab costs, the threat for other livestock, and insurance issues.

| Tendency for more production
Some participants shared their experience of consuming antibiotics to increase production and livestock growth.
"Through experience, we know that antibiotics help the livestock grow better and more. The growth of the livestock is more than when it is not on antibiotics". welcome drugs that are on sale at particular times of the year. They may want to buy and store a load of the drugs, which they will use more for sure in future.
"At particular times of the year, some drugs are on sale.
We buy a lot of them at the drugstore at a lower price.
When our poultry is sick, we will benefit from a herd of 20 thousand". (Participant #17: poultry breeder)

| High medical and lab costs
Some participants mentioned such obstacles as the high diagnostic and medical costs for the antibiotic selfmedication.

| The threat for other livestock
The perceived threat of the spread of a disease from one livestock to another was among the experiences shared by the participants.
"It is a threat to a whole livestock to get sick. The one or two sick animals should be separated from others to save others". (Participant #9: sheep breeder)

| Insurance issues
The inefficiency and inadequacy of the insurance system in livestock and poultry and compensation worries most livestock farmers about livestock losses. Therefore, even though the breeders insure their livestock, they are worried about the loss of their livestock and do not hesitate to make any efforts to prevent these losses.
"After a loss, the insurance company brings a reason for not paying the compensation. Even if it decides to pay, the amount is so low that is hardly helpful. All our money will be gone. We cannot wait and do nothing. We can not take the risk. We go for self-medication hoping to lower   43,44 were consistent with the present findings. Therefore, it is recommended to take certain measures such as eliminating mediators and dealers, guaranteeing the purchase of products from ranchers, issuing grazing licenses to unlicensed ranchers, giving loans and facilities of low profit, monitoring and following up on the issues facing ranchers by an executive and regulatory bodies. Also, the lack of the required facilities, welfare and communication facilities, lack of transportation, and health services were among the other issues pinpointed by the ranchers. It is suggested that the government provide more facilities for the livestock farmers' welfare. Among the important determinants found in this study are social factors. One subcategory is the influence of important others and pharmaceutical advertisements. Ranchers' acquaintance with elders and exemplary ranchers and technical and local leaders who can play an important role in removing the obstacles and problems in ranching can be effective by sharing the information required to enhance the impression of important others. 45 To enhance the quality of communications between livestock farmers and promoters, it is recommended to provide educational courses and workshops for livestock farmers to improve their professional skills in dealing with livestock and the relevant diseases. Many pharmaceutical advertisements in the livestock industry have caused more demand than the needs of livestock farmers and are used to treat diseases or increase the growth of livestock. It can unintentionally increase the pharmaceutical residues in this category of food. 46 Baghloui et al. 47 found that out of the total number of carcasses, the amount of antibiotic injection in animal carcasses was 17.38%. Mahmoudi et al. 48 Concluded that a total of 6.3% of the carcasses contained antibiotic residues. It seems due to the breeders' deficient knowledge or to prevent any loss, many animals not recovering from a disease are transferred to the slaughterhouse, and any drug and antibiotics may be used to treat them. When companies TOGHROLI ET AL.