4 The social drivers of AMR

In this section you will explore equity in AMR and link this to a people-centred approach to health.

While AMR is a natural process that happens over time, its emergence and spread is accelerated by human activity or caused by non-completion or non-recommended use of antimicrobials to treat, prevent or control infections in humans, animals and plants.

Please note: In this course the term ‘misuse’ of antibiotics, which puts blame on individuals, has been avoided. This course hopes to demonstrate that non-completion or non-recommended use of antibiotics is largely due to harmful power structures that affect the decisions that individuals can make when accessing treatment for themselves or their animals.

Socioeconomic challenges and inequities affect people’s experience of AMR, from exposure to infection to diagnosis and treatment. This is illustrated in Table 2, which shows the World Health Organization’s (WHO) people-centred approach to addressing AMR in human health (WHO, 2023). A focus on the social determinants of health is important because it enables an understanding of the AMR-specific health challenges that people face.

Many of these social challenges are equally relevant to animal health, for example in how they affect access to vaccines for animals and animal health worker training on AMR.

Table 2 Challenges faced on the AMR people journey (adapted from WHO, 2023).
Challenge System challenges People’s challenges
Prevention of infection
  • Limited health worker education on AMR
  • Poor water, sanitation and safe waste management
  • Poor IPC programmes and practices
  • Weak immunization programmes
  • Poor health education
  • No access to clean water or sanitation
  • Poor adherence to practices to prevent transmission of infection
  • Poor access or missed vaccinations and vaccine hesitancy
Access to health services
  • Limited health service coverage and lack of financial protection for the entire population
  • Lack of or insufficient healthcare services, diagnostics and antimicrobials and trained health workers
  • Use of substandard or falsified diagnostics and antimicrobials
  • Weak referral systems
  • Catastrophic out of pocket spending on health services, diagnostics or medicines
  • Poor access to and lack of awareness of available local health services
  • Loss to follow-up
Diagnosis
  • Limited laboratory capacity
  • Limited health worker education in appropriate diagnostics and in interpreting or using results
  • Poor diagnostic services
  • Incorrect or delayed diagnosis
  • Poor access to local diagnostic services
  • Limited awareness of the importance of timely, accurate diagnosis
Treatment
  • Weak regulation of over-the-counter (OTC) medicines
  • No quality-assured treatment, standardised treatment guidelines or stewardship
  • Inappropriate prescribing of antimicrobials
  • Inappropriate self-medication (eg. use of OTC or leftover antimicrobials, incomplete treatment cycle)
  • Increased risk of suboptimal treatment, leading to complications or longer recovery
  • Higher risk of morbidity or mortality due to infections that are difficult to treat or untreatable

Footnotes  

Infection prevention is important in both communities and healthcare facilities and continues throughout the journey. Treatment includes the continuous care that might be required for an AMR infection. The list of challenges may not be exhaustive or applicable to all countries. OTC = over-the-counter; IPC = infection, prevention and control.

The impact of the inequities illustrated in Table 2 can be seen in the global inequitable burden of AMR. Up to 90% of deaths from AMR occur in the Global South (Mendelson et al., 2024). These contexts often experience high rates of infectious disease, challenges in access to healthcare and global inequities relating to the supply of vaccines and antimicrobials.

For example, in sub-Saharan Africa nearly 1 in 1000 deaths are already associated with bacterial AMR, compared with only half as many in high-income countries (Antimicrobial Resistance Collaborators, 2022). Within countries, the AMR burden is also unequally distributed – but there is no detailed data on how due to the absence of analysis of AMR data disaggregated by gender and other equity-related factors at a national level.

You can learn more about the burden of AMR and how it is measured in the course The health and economic burden of AMR.

3.2 Intersectionality

5 AMR, sex and gender