Primary caregivers’ practices and perceptions on antibiotic use and resistance: a one health qualitative study in rural South India

OBJECTIVES: Antimicrobial resistance is a growing global public health threat driven by interactions between human, animal and environmental factors. Rural settings in low- and middle-income countries may face increased risk due to unregulated antibiotic use, close human-animal interactions, and environmental contamination. This study explored community-level knowledge, attitudes and practices related to antibiotic use and resistance among caregivers of children in rural South India using a One Health perspective. DESIGN: Qualitative study using focus group discussions and thematic analysis. SETTING: Four rural villages in Tirunelveli district, Tamil Nadu, India. PARTICIPANTS: Seventy-seven primary caregivers of children aged 2-12 years from households with backyard animals, purposively selected from a rural cohort study. RESULTS: Three themes emerged. First, human health practices included reliance on home remedies, reuse of prescriptions, self-medication and incomplete antibiotic courses alongside misconceptions about antibiotics. Second, environmental factors such as untreated water consumption, open defecation, poor drainage and improper waste disposal were perceived to increase infection risks. Third, animal-related pathways included close child-animal contact, antibiotic use in livestock and unsafe disposal of animal waste. Limited healthcare access and transport costs influenced treatment-seeking behaviour. CONCLUSIONS: Interconnected caregiver practices, environmental conditions and animal husbandry behaviours create multiple pathways for antimicrobial resistance transmission. Integrated, community-based interventions addressing behaviour change, healthcare access and environmental management are essential to support antibiotic stewardship within a One Health framework.