Pharmacists and Antimicrobial Stewardship in Belize: Understanding Awareness, Attitudes, and Barriers

Background: In Belize, nearly half of community pharmacies dispense antibiotics without a prescription, and over 70% of hospitalized patients receive prescribed antibiotics, rates that substantially exceed regional averages. While pharmacists serve as the country’s most accessible source of antibiotics, research has not formally documented their understanding of Antimicrobial Stewardship (AMS) or the factors influencing its implementation.
Objectives: This study examined how practicing pharmacists in Belize perceive their stewardship role, what barriers and facilitators shape their AMS practice, what behavioral factors drive antimicrobial use, and whether AMS awareness differs across workforce subgroups.
Methods: Virtual focus groups were held with registered pharmacists in Belize, spanning community, hospital, regulatory, and academic settings, all six districts, and varied experience levels and generations, using a semi-structured interview guide and each lasting 60-90 minutes. Transcripts were analyzed using Braun and Clarke's reflexive thematic analysis.
Results: Eleven focus groups were conducted with a total of 64 pharmacists. Participants were predominantly female (68.8%), concentrated in the 25–44 age range (79.7%), and practiced primarily in community settings (43.8%). Only 21.9% had received formal AMS training, yet 90.6% routinely dispensed antibiotics and counseled patients. The first theme revealed a strong professional commitment to pharmacists’ stewardship identity and role, which was enacted very differently across settings: hospital pharmacists worked within structured clinical teams, whereas community pharmacists relied on personal relationships and carried the burden of enforcement alone. The second theme, structural barriers and facilitators to AMS practice, traced this uneven enactment to specific systemic failures. Pharmacists in border districts described cross-border antibiotic purchasing that rendered domestic prescription controls futile. Across all settings, the absence of a national antibiogram left pharmacists clinically blind at the point of dispensing, and a well-designed regulatory framework in statute proved weakly enforced in practice. The third theme, socioeconomic realities, cultural beliefs, and patient-driven demand, identified social and commercial pressures that normalized inappropriate use. The emergence of AI-assisted self-diagnosis presented challenges at the pharmacy counter with algorithm-generated, drug-specific requests that bypassed the pharmacist's clinical role. Across all three themes, AMS awareness and practice differed by setting, experience, geography, and generation.
Conclusion: Belize's pharmacists lacked neither the will nor the capacity to practice stewardship. They were held back by structural, geographic, resource-bound, and motivational conditions that prevented them from acting on the knowledge they already possessed. Each gap requires a different response, and uniform interventions have predictably failed. As the first pharmacist-centered account of AMS in Belize, this study delivers evidence for the National AMR Strategic Plan and transferable lessons for other low- and middle-income countries.