Healthcare providers' perspectives on antimicrobial resistance in Northwest Syria: an exploratory qualitative study.

Background: Armed conflict contributes to the development and spread of antimicrobial resistance (AMR). Understanding healthcare providers' perceptions is essential for identifying key determinants and developing contextualised recommendations. This study explored perceptions of AMR among healthcare providers in northwest Syria - a conflict-affected area- before the fall of the Syrian regime in December 2024. Methods: A qualitative study was conducted using semi-structured interviews with healthcare providers who had worked in northwest Syria within the previous five years. Seventeen interviews were conducted remotely in Arabic in July-August 2023. Participants were identified through purposive and snowball sampling. Transcriptions were analysed using deductive thematic analysis. Results: Of the 17 key informants, (11 doctors, 6 pharmacists); most were from Idlib governorate. Emerging themes included healthcare professionals' understanding of AMR, perceived drivers, conflict- and disaster-related influences, and examples of good practice. Frequently cited drivers of AMR were over-the-counter availability of antimicrobials, pharmacy-led dispensing, and community insistence on antibiotics. Inadequate microbiology diagnostic capacity was also highlighted as a key factor. Conclusion: Interviews highlighted perceived contributors to AMR in northwest Syria, including ineffective or absent policies regulating antibiotic dispensing, lack of antimicrobial guidelines or poor enforcement, and limited access to diagnostics. These findings support the development of contextualised recommendations during the transition of Syria's health system.