Uniting the disciplines to understand behaviour and influence change.

Combating antimicrobial resistance: An interdisciplinary approach

To effectively address the growing threat of antimicrobial resistance (AMR), when microbes develop ways to resist the drugs traditionally used to treat them, it’s crucial to understand and influence the behaviours of a broad range of interlinking - yet often disparate - communities.  

To make progress in combating AMR, a truly interdisciplinary approach is needed. Exeter’s One Health ethos unites social scientists, humanities specialists, microbiologists, mathematicians and many more, taking a holistic approach to influencing policy and behaviours, such as public understanding, clinician prescribing behaviour, political action, and the complex interactions of far-flung global communities.

Beyond medical practices, addressing AMR requires a broader understanding of the cultural, societal, and economic factors that influence antibiotic use. Judith Green, Professor of Sociology at the University of Exeter, said she is seeing an increasing recognition of the importance of the social sciences and humanities in global health issues. 

Professor Green argues that "The big challenges of healthcare are no longer solely technological but involve the complex interplay of culture, human behaviour, ecological and global systems. AMR is not merely an individual issue, but a systemic problem rooted in societal attitudes, historical practices, and economic structures. You can’t just take one policy and apply it to different areas, without understanding local contexts. To overcome that, we need collaboration between science, social science and humanities to develop effective interventions."

The economics of AMR presents significant challenges. At Exeter, we're working to understand and influence economic policy related to the development and use of antimicrobial drugs. A major global focus area involves regulating the use of new antibiotics because over-prescribing accelerates resistance to these vital new drugs. 

Pricing is also an issue. Most bacterial infections can be treated with inexpensive antibiotics, meaning there is little profit potential for large pharmaceutical companies, and many have stopped their antibiotic development work.

Antibiotic use in farming is another major contributor to AMR and can lead to the development of resistant bacteria that can spread to humans. Approximately one-third of global antibiotic use over the next two decades is expected to be in Chinese pork and chicken farming. In a country with food security concerns and relatively little land for its vast population, joined up working to find sustainable solutions is crucial.

The complexity is further compounded by the lack of regulation in many parts of the world regarding antibiotic use, allowing for unscrupulous practices from the companies that market antibiotics. 

The cultural context of AMR is also critical, as the challenges and solutions to AMR often vary significantly between locations and communities. Different societies have varying attitudes and practices regarding antibiotic use. Understanding these cultural factors is essential for designing effective interventions that are tailored to specific communities. To put this on the agenda, the Exeter team compiled a WHO report on the cultural aspects of AMR globally, arguing that neglecting this issue is a major barrier to change.

For example, in Spain, the Exeter team reported that high levels of injury and sexually transmitted diseases after the Spanish Civil War led to General Franco ensuring penicillin was freely available, so people in the Catholic country did not have to admit to their priest why they needed medication, leading to a culture of over-the-counter antibiotic use. “The Spanish are used to buying antibiotics over the counter, like any supermarket product.” Professor Hinchliffe explained. “It takes time to change that culture of expectation.”

The path to combating AMR can also be complex, with unexpected challenges. In the UK poultry industry, antibiotics are often the first line of defence against disease in chickens. While one recommendation to address this is pen-side tests, to establish if the infection would respond well to an antibiotic, replacing the nuanced decision-making of veterinarians with technology could inadvertently increase antibiotic use.

“Sometimes you think you’ve got an easy technical solution, but if you lose those layers of knowledge, you can actually end up medicalising a problem and having the opposite effect than what was intended. We need to be really careful that we value the knowledge and practices of farmers and vets.” - Professor Stephen Hinchliffe

Solutions can also stem from a better understanding of how farmers have adapted their practices to live with disease, rather than eradicating it. A tenth of the world’s population lives along the rivers that flow through Bangladesh, and fish farming is vital for rural development and of nutritional importance. However, high disease levels and low water quality necessitate antibiotic use. Here, Exeter’s research focuses on how farmers manage disease outbreaks, and the role of markets, economic pressures, and agricultural practices in influencing the health of fish farming ecosystems.

Professor Hinchliffe highlights an overemphasis on behaviour change as the primary solution to AMR, and the idea that education holds the answer. “But look at smoking – we all knew it was bad for us years before many people quit.” He points out that cultural factors, legislation, and the influence of retail sectors are equally important and that simply informing people about the negative consequences of antibiotic overuse may not be sufficient to drive meaningful change. Instead, we must consider a broader range of strategies to address the multifaceted challenges of AMR. By working together, researchers, policymakers, healthcare professionals, and communities can develop effective solutions to this global health crisis.