# Culture and Antimicrobial Consumption: Sector- and Class-Specific Differences in Country-Level Associations Across Europe

## TL;DR

This study shows that cultural values like power distance and uncertainty avoidance are more strongly linked to community antibiotic use than hospital use in Europe.

## Contribution

The study reveals that cultural associations with antimicrobial consumption differ by sector and antimicrobial class.

## Key findings

- Cultural values like PDI and UAI are more strongly associated with community antibiotic use than hospital use.
- The associations are specific to antibacterials for systemic use (J01) in the community sector.
- Findings were robust across sensitivity analyses and statistical methods.

## Abstract

Background: Antimicrobial consumption (AMC) varies widely across European countries, and cross-national studies have linked this variation to cultural values. However, two critical gaps remain: it is unclear whether these associations differ between community and hospital sectors or across antimicrobial classes. This study directly tests these differences. Methods: We analysed country-level AMC data from the European Centre for Disease Prevention and Control for EU/EEA countries, combining sector-specific (community, hospital) and Anatomical Therapeutic Chemical (ATC) group-specific data. Spearman’s rank correlation coefficients (ρ) were calculated between Hofstede’s cultural dimensions and AMC. We compared correlations across sectors within ATC groups, and between community antibacterials for systemic use (J01) and other community medicine classes, using differences in correlations (Δρ). Uncertainty was assessed with non-parametric bootstrap 95% confidence intervals and paired-label permutation tests, with false discovery rate control. Sensitivity analyses included leave-one-country-out checks and replication using Kendall’s τ-b. Results: Cultural values, especially Power Distance Index (PDI) and Uncertainty Avoidance Index (UAI), were more strongly associated with community antibiotic use than with hospital antibiotic use or other community medicine groups. PDI and UAI showed significantly stronger correlations with community J01 use than with hospital J01 use and with several other community ATC groups. These patterns were robust in sensitivity analyses. Conclusions: The national cultural context appears more closely related to community antibiotic use than to hospital use or other community medicines, particularly for PDI and UAI. This demonstrates that cultural drivers of AMC are context-specific, necessitating stewardship strategies tailored to community settings to address norms around hierarchy and uncertainty.