6 Revisiting the social and structural drivers of AMR

As you will have come to understand from your study in the course so far, AMR drivers are about not only antimicrobial practices but also social and structural determinants of health: the underlying societal and environmental factors that create conditions conducive to the development and spread of AMR.

These are explained in Figure 5, which highlights how drivers of antibiotic resistance and barriers to managing antibiotic resistance are shaped by the socio-cultural inequities (such as gender inequity) that exist at multiple levels – from community to national and international. This includes stigma and social norms within communities, but also power structures within national health system structures and the lack of representation of communities and diverse groups in political decision-making. In this way, managing the spread of AMR needs to look beyond people’s knowledge and behaviours.

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Figure 5 An intersectional view of social constructs and antibiotic resistance (ABR) (Charani et al., 2021).
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A figure with the heading ‘Sociocultural imbalances and their effect on ABR’. On the left-hand side of the figure, under the heading ‘As drivers of ABR’, is the following list: ‘The needs and associated risks of specific populations in society not addressed’, ‘Gaps in knowledge, awareness and literacy’, ‘Attitudes towards health, disease, infection and ABR’ and ‘Lack of access to health; over-, under-, mis-use of antibiotics due to access issues’. In the centre of the figure is a series of concentric circles with various labels. The centre circle is labelled ‘Constructs of gender/class/race/caste’. The second circle is labelled ‘Residence/migrant status’. The third circle is labelled ‘Community position and culture’. The fourth circle is labelled ‘Accountability and agency’. The fifth and final circle is labelled ‘Policy and agenda/political economy’. On the right-hand side of the figure, under the heading ‘As barriers to tackling ABR’, is the following list: ‘Lack of representation in policy and decision-making’, ‘Campaigns not targeting diverse populations’, ‘Power dynamics and hierarchies influencing adherence to desired behaviours’ and ‘Lack of access to health; over-, under-, mis-use of antibiotics due to access issues’. The headings at the bottom of the figure read ‘Access to healthcare, including vaccination’, ‘Access to WASH’, ‘Education >> occupation >> wash’ and ‘Positionality: fallback position in family and society, based on gender, religion and culture’.

Figure 5 An intersectional view of social constructs and antibiotic resistance (ABR) (Charani et al., 2021).

  • Think back to Table 2, which illustrates the challenges faced on the AMR people journey. Can you see how the sociocultural imbalances illustrated in Figure 5 map onto the AMR journey?

  • Things to consider here include:

    • decision-making norms about access to healthcare, such as autonomy in decision-making
    • access to education and knowledge about AMR
    • the economic costs of diagnostic testing and the availability of diagnostic testing in countries.

Figure 5 highlights that AMR is not an issue of ‘misuse’, but rather of the structures that prevent recommended use. In fact, bans on antibiotic use are often offered as solutions to curb AMR. However, evidence from Mexico shows that these bans do not work, and people will find ways to work around them (Pérez-Cuevas et al., 2014). This is largely because in many contexts, there is an absence of holistic healthcare and antibiotics are seen as a ‘quick fix’ for the systemic disparities in power, resources and opportunities that result from institutionalised biases and practices (Willis and Chandler, 2019). Context, therefore, is critically important; this will be illustrated in the following case study on urban informal settlements.

5.2 AMR and gender differences

6.1 A case study on urban informal settlements