Insecure livelihoods hindering efforts to combat anti-microbial resistance globally

• Researchers led by University of Warwick find that precarity - in employment, personal circumstances, social status - is among the biggest factors in affecting whether patients use antibiotics correctly
• Whereas poverty did not have an impact, precarity pushed up to 1 in 2 people into inappropriate antibiotic use, suggesting that this could be a challenge in higher income as well as in developing countries
• Research demonstrates that individuals cannot always be blamed for misuse of antibiotics, and that better sustainable development policy is needed
• Efforts to improve security of livelihoods globally could also help tackle anti-microbial resistance as a side-effect

Patients living in precarious circumstances are less likely to use antibiotics appropriately according to a new study from the University of Warwick, suggesting that efforts to improve conditions for those with little security in their livelihoods could have an unexpected benefit in helping to tackle antimicrobial resistance globally.

The findings add to evidence that focus should shift from influencing individuals' efforts to combat anti-microbial resistance to supporting sustainable development policy that tackles the contributing factors.

The research, published in the journal BMJ Global Health and funded by the Economic and Social Research Council (ESRC), part of UK Research and Innovation, provides comprehensive analysis of how patients accessed and used healthcare, and is the first study to quantitatively examine the relationship between precarity and antibiotic use.

Precarity refers to personal circumstances dominated by uncertainty, whether that is in employment, your personal life or social status. Those in precarious circumstances are limited in their ability to plan ahead, and deprived of safety nets, social support, economic certainty and flexibility. It is not necessarily about being poor: although this study looked at low to middle income countries, precarity can also be a problem in higher income countries.

Using statistical analysis, the researchers were able examine the impact of socioeconomic factors, such as precarity, poverty and marginalisation, on their use of antibiotics to treat their illness. They found that patients in precarious circumstances had a chance of up to 51% of using antibiotics without advice from a medical professional or for inappropriate illnesses - compared to 17% for an average patient.

Lead author Dr Marco Haenssgen, from the Warwick Institute of Advanced Study and the Department of Global Sustainable Development, argues that this behaviour is understandable as when living in precarious circumstances individuals are engaged in a constant balancing act.

Dr Haenssgen, Assistant Professor in Global Sustainable Development, said: "You have to balance your health, your economic life, feed your family, go to school; these are all competing priorities.

"Antibiotics have become such a staple of healthcare that they have become what some people see as a 'quick fix' solution. When people are in precarious circumstances and deprived of social support, if they can find a quick fix to keep them going they will use it, and then it could become problematic."

In many low to middle income countries, patients often have to travel long distances to access healthcare services, something they may not be able to easily arrange or afford. Even in more economically developed areas, employment can be less secure and social networks can be eroded.

Antimicrobial resistance occurs when microbes become resistant to antibiotics, threatening their effectiveness. Human antibiotic use is known to be a main driver of this process, and policies to combat anti-microbial resistance have therefore typically focused on clinical factors and promoting individual responsibilities. However, the researchers argue that the impact of socioeconomic factors such as precarity are being underestimated.

Dr Haenssgen said: "You cannot always blame the individual for misuse of antibiotics. Often, we find ourselves in living conditions that provoke problematic behaviours, which means that if you want to improve antibiotic use you need to improve those living conditions.

"If we can improve situations of precarity then we have a good start for future interventions. We have a very substantial facet of the problem that is continuously disregarded and where potentially we have a lot of gains to realise.

"Antimicrobial resistance is a massive global health problem, it can potentially overturn what global health is. Many of the past gains that we have had in infectious disease control and prevention are potentially being undone by antimicrobial resistance."

The study focused on five local communities across rural Thailand and Lao People's Democratic Republic and surveyed 2066 residents on recent illnesses they had experienced and how they sought healthcare support for it. This provided the researchers with a rich dataset on 1421 illness episodes that they could analyse to determine what healthcare patients seek, if any, whether they were able to access suitable healthcare, and when these occur in the timeline of their illness.

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* 'Precarity and clinical determinants of healthcare-seeking behaviour and antibiotic use in rural Laos and Thailand' will be published in BMJ Global Health, DOI: 10.1136/bmjgh-2020-003779

Notes to editors:

Images available to download at the links below, credits must be included:

Picture 1 caption: A Thai villager studying a formulary for herbal medicine. Photo credits: Patthanan Thavethanutthanawin

https://warwick.ac.uk/services/communications/medialibrary/images/december_2020/picture5.jpg

Picture 2 caption: Pills and capsules of medicine. Photo credits: Patthanan Thavethanutthanawin.

https://warwick.ac.uk/services/communications/medialibrary/images/december_2020/picture6.jpg

For interviews or a copy of the paper contact:

Peter Thorley
Media Relations Manager (Warwick Medical School and Department of Physics) | Press & Media Relations | University of Warwick
Email: peter.thorley@warwick.ac.uk
Mob: +44 (0) 7824 540863

The study data is publicly available at the UK Data Service:

Haenssgen, M. J., Ariana, P., Wertheim, H. F. L., Greer, R. C., Jones, C., Lubell, Y., et al. (2019). Antibiotics and activity spaces: rural health behaviour survey in Northern Thailand and Southern Laos 2017-2018 [data set]. Colchester: UK Data Service. doi:10.5255/UKDA-SN-853658. Available at http://reshare.ukdataservice.ac.uk/853658/

The Department for Global Sustainable Development was founded in 2015 with a remit to deliver a suite of innovative degree courses which take on the challenge of engaging with the UN's Sustainable Development Goals in a multi-disciplinary and intellectually enriching environment. The department has grown to encompass 12 undergraduate degree courses and the Institute for Global Sustainable Development which was established in 2017 to foster research that contributes to the sustainable development agenda across the global north and global south.

The Economic and Social Research Council (ESRC) is part of UK Research and Innovation, a non-departmental public body funded by a grant-in-aid from the UK government. For more information visit http://www.ukri.org.

The ESRC is the UK's largest funder of research on the social and economic questions facing us today. It supports the development and training of the UK's future social scientists and also funds major studies that provide the infrastructure for research. ESRC-funded research informs policymakers and practitioners and helps make businesses, voluntary bodies and other organisations more effective.

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