Assessing Antimicrobial Stewardship in a Rural Veterinary Practice Network

Thesis Abstract

The emergence of antimicrobial resistance within livestock populations and the broader ecosystem poses an escalating threat to animal and human health, necessitating robust antimicrobial stewardship (AMS) practices in rural veterinary networks where access to diagnostics and regulation varies. This study addresses the gap in understanding how rural veterinary practice networks implement AMS, and how organizational, practitioner, and client factors influence antimicrobial prescribing, usage patterns, and stewardship outcomes. The aim is to assess the effectiveness, drivers, and gaps of AMS within a representative rural veterinary practice network, with specific objectives (i) to quantify antimicrobial prescribing patterns and compliance with guidelines across twenty-five geographically dispersed clinics over a 12-month period; (ii) to identify perceptions, knowledge, and attitudes of veterinarians and clients toward AMS using a semi-structured interview approach; (iii) to evaluate the influence of diagnostic access, record-keeping quality, and feedback mechanisms on stewardship behavior; (iv) to examine the association between practice-level governance, continuing education, and prescribing quality; and (v) to develop a contextually grounded model of AMS implementation suitable for replication in similar rural settings. The study employs a mixed-methods design anchored in the Capability, Opportunity, Motivation-Behavior (COM-B) model and the Theory of Planned Behavior to elucidate behavioural determinants of AMS practices. The population comprises all veterinarians and support staff (n=120) across the network and their client cattle, small ruminant, and companion-animal cases (estimated n=4,500 patient encounters) recorded between January and December of the study year. A stratified random sample of clinics (n=25) will provide quantitative data on antimicrobial prescriptions, withdrawal intervals, and diagnostic test utilization, complemented by qualitative data from purposive samples of veterinarians (n=30) and clients (n=25) for in-depth interviews. Data collection instruments include (i) standardized audit forms capturing antimicrobial classes, indications, dosage, duration, and compliance with national guidelines; (ii) a validated AMS knowledge and attitudes questionnaire administered to veterinarians and clinic staff; (iii) semi-structured interview guides exploring decision-making processes, client expectations, and barriers to stewardship; and (iv) organizational assessment checklists evaluating governance, record-keeping, feedback loops, and access to diagnostic tests. Validity and reliability will be ensured through pilot testing, triangulation of prescription data with medical records, and inter-rater reliability checks for chart audits. Quantitative analysis will involve descriptive statistics to profile prescribing patterns, chi-square tests to examine guideline concordance by clinic type, and multilevel logistic regression to identify factors associated with appropriate antimicrobial use, accounting for clustering at the clinic level. Time-series analyses will assess trends in prescribing before and after targeted stewardship interventions. Qualitative data will be analyzed with thematic analysis, following Braun and Clarke's framework, and coded using NVivo to identify recurrent themes related to capability, opportunity, and motivation. Integration of quantitative and qualitative findings will occur through a convergent mixed-methods approach, with joint displays illustrating concordance and divergence between prescribed practices and respondent narratives. A conceptual map will be developed to illustrate the interplay of structural, educational, and behavioural determinants underpinning AMS in rural networks. Key expected findings include (i) variable adherence to AMS guidelines across clinics, with higher compliance in clinics with structured prescribing audits and diagnostic support; (ii) limited diagnostic access correlating with broader-spectrum empiricism and longer treatment durations; (iii) positive associations between ongoing professional development, feedback mechanisms, and prudent antimicrobial use; (iv) client expectations and economic constraints emerging as significant barriers to optimal stewardship; and (v) a contextualized AMS implementation model incorporating governance, data feedback loops, and community engagement strategies. The study contributes to knowledge by providing empirically grounded insights into how rural veterinary practice networks operationalize AMS, identifying lever points for intervention, and offering a scalable framework informed by COM-B and the Theory of Planned Behavior. The main conclusion is that AMS effectiveness in rural networks hinges on integrated governance, readily accessible diagnostics, continuous education, and participatory engagement with clients. Recommendations include implementing standardized prescribing audits, expanding point-of-care diagnostics, establishing monthly stewardship feedback sessions, and co-developing client education materials to align expectations with responsible antimicrobial use. Further research should test the proposed implementation model across diverse rural settings and evaluate long-term outcomes on antimicrobial resistance indicators.