Poverty and drug resistance: the context needs to change, not the understanding of patients

16th June 2020

While stewardship programmes have some impact on antimicrobial resistance, hardship, particularly in low- and middle-income countries, means traditional awareness-raising campaigns are likely to fail. Is it time for a new approach, focused on community-building?

“Despite the fact that behavioural sciences routinely argue that as little as 20% of our decisions are driven by the reflective evaluation of factual information, the global response to antimicrobial resistance (AMR) still emphasises individual responsibility and knowledge. The UK Review on Antimicrobial Resistance names as first global intervention to reduce antibiotic demand “a massive global public awareness campaign,” the World Health Organization’s Global Action Plan on Antimicrobial Resistance states its first objective to be “improve awareness and understanding” of AMR, and a wide range of global and national surveys are aimed at populations’ antibiotic knowledge and attitudes.

Recent research across Asia, however, has exposed the limitations of the conventional information, education, and communication approach to improve people’s medicine use and health behaviours. Representative survey data from rural Thailand and Laos revealed linguistic challenges of seemingly simple messages like “only take antibiotics when prescribed to you by a healthcare worker,” but it also showed how people with more confident knowledge and seemingly more positive attitudes tended to overconsume antibiotics or even sell them informally. Studies from other research teams in China found that more educated people were also more likely to stockpile antibiotics and self-medicate at home.

The limitations of AMR education and awareness require us to consider other explanations for people’s health behaviour. For example, our current work in progress, using data from Thailand and Laos, shows that life at the economic, social, and geographic margins of society can raise barriers to accessing regulated doctors and nurses, while precarious work and living arrangements can foster toxic self-dependence and drive people into “quick fix” solutions that are personally and societally harmful in the long term – even among populations who are not normally considered “poor.” Such self-dependence can arise from rigid employment structures, insecure income, or from a lack of support structures in people’s community, consequently limiting one’s ability to respond to crises flexibly.

In the presence of widespread and dynamic hardship in low- and middle-income countries, well-meaning education and awareness messages are likely to remain ineffective. Rather than declaring antibiotic overuse and other forms of problematic behaviour to be “lazy” or “irrational,” we should consider whether people may in fact be coping with adversity – in which case we need to change the context, not the patient.

The recent emphasis on “AMR-sensitive” development policy by our research team and by the World Bank responds to this need to consider the broader livelihoods in which people use antibiotics and other antimicrobials. Behavioural interventions based on this logic would include for instance social and labour protection schemes, community building initiatives, or financial inclusionto reduce precarity and barriers to healthcare. But context-sensitive policy also requires us to make health policy differently – in intersectoral collaboration (crossing the conventional boundaries of public health) and with close attention to local voices and realities (e.g. through patient-public involvement and collaboration with local social and development workers).

And yet, our knowledge in this area remains rather circumstantial and so far we understand little about “what works” in tackling AMR. Broadening our policy knowledge for more effective interventions will require an interdisciplinary and diverse range of research designs, spanning:

Clearly knowledge is not unimportant and the international efforts to raise awareness about drug resistance are commendable. However, the development towards broader contextual responses will help to maximise the value of education and awareness campaigns, while also making global health policy more responsive to the broader sustainable development agenda.”

Dr Marco J Haenssgen is Assistant Professor in Global Sustainable Development at the University of Warwick

@HaenssgenJ

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