Do socio-cultural contexts drive antimicrobial resistance?

A novel research study, led by the University of Cape Town’s (UCT) Associate Professor Esmita Charani, aims to expand researchers’ understanding on what drives antimicrobial resistance (AMR). Associate Professor Charani, who’s part of a team of researchers based in UCT’s Wellcome Centre for Infectious Diseases in Africa, has a theory of her own.

She believes that patients’ socio-cultural contexts give impetus to AMR, which is why she plans to study patients and healthcare workers in South Africa and India – two of the most unequal societies in the world – to prove or disprove this theory.

AMR poses a giant threat to modern medicine globally. It occurs when micro-organisms such as bacteria, viruses, fungi and parasites change in ways that render ineffective the medications (antimicrobials) used to treat and cure the infections they cause. In South Africa, this type of drug resistance impacts tuberculosis (TB), HIV, malaria, and fungal infections.

“In this research study I will investigate the influence of social determinants on how patients seek and experience healthcare, and how healthcare workers provide care for bacterial infection, prevention and control (IPC) and antibiotic use,” she said.

“This work builds on existing research in both South Africa and India that has previously shown that power dynamics and gendered hierarchies influence health-seeking and health-providing behaviours.”

“This work builds on existing research in both South Africa and India that has previously shown that power dynamics and gendered hierarchies influence health-seeking and health providing behaviours. By building on this, I will broaden the study of culture in healthcare by describing how relative power, hierarchies and structures can be predictors of health-providing and health-seeking behaviours.”

The UCT newsroom caught up with Charani to unpack her latest research study.

Niémah Davids (ND): What motivated your latest work?

Esmita Charani (EC): I have been studying team dynamics and hierarchies in relation to antibiotic use for several years now and I’ve been working alongside colleagues in South Africa and India.

What has emerged as a recurring theme is how much the concept of power manifests in various layers of our identities. So, I want to better understand how we work together as teams and how much our socio-cultural identities shape our lived experiences as healthcare users and healthcare providers.

ND: Why South Africa and India in particular, and how does AMR impact patients and healthcare workers in both countries?

ES: I’ve been working with UCT and the Amrita Institute of Medical Sciences in Kerala in India since 2019. Since then, we’ve mapped out the socio-cultural behaviours related to antibiotic use in both countries. And it’s critical that we consider important issues like these in two countries that experience such high levels of inequality, and where managing infections and AMR is often done with different cultural lenses, and therefore it manifests differently. So, we will work in different communities in both countries, from rural to urban areas such as Khayelitsha in the City of Cape Town, South Africa, as well as Kerala, Chandigarh, and Himachal Pradesh in India.

“This study aims to bridge the gap in existing literature by identifying communities in low- and middle-income countries (LMIC) who are most affected by AMR.”

When it comes to impact, it’s not the same for everyone because different cultural groups face different risks of exposure. Some patients face challenges with accessing, using and benefiting from information related to AMR, or solutions to tackle it. This is why we need to study how different social constructs, hierarchies and inequalities create axes of power, which influence behaviours and ultimately impact the way patients experience care and the way healthcare workers provide care. In fact, our recent series published in the Lancet, has highlighted and identified how existing interventions such as providing access to clean water, vaccines, and infection prevention have the potential to save many lives by averting the risks of AMR in under-resourced settings.

ND: What’s your objective with this research?

ES: This study aims to bridge the gap in existing literature by identifying communities in low- and middle-income countries (LMIC) who are most affected by AMR. Generally, those living in LMICs face a high burden of infection and these often go untreated. Sadly, their socio-economic conditions, which include a lack of clean water and sanitation and access to proper disease prevention programmes, don’t make things easier and actually promote the spread of AMR. This is in addition to interrupted, inadequate and inappropriate treatment and dependence on antibiotics through informal structures without the necessary prescription.

The idea is that this research helps us to better understand their exposure to AMR from both a healthcare access and health-providing perspective; the challenges they face and to come up with interventions to assist.

ND: Unpack what you’re hoping to achieve with this work.

ES: I am hoping to achieve five interrelated things:

• provide a novel understanding of how economic, racial, ethnic, gender and cultural determinants intersect with one another, shape health systems and impact IPC practices and antibiotic use
• generate empirical data that identifies healthcare workers, patients and carer groups whose needs are accounted for – this will help us leverage the strengths of different groups of people to learn how, for example, healthcare workers champion positive practices related to infection management and what we can learn from leadership models fostered by women surgeons
• implement lessons learned during the COVID-19 pandemic on how to sustain infection control behaviours across cultural groups
• provide the necessary tools to reframe entrenched systems and hierarchies to enable greater inclusion, diversity, and interdisciplinarity with interventions
• develop AMR research through an effective means of communication and language for people who are currently disengaged from interventions.

ND: How do you plan to reach your conclusions?

ES: Ethnographic research, sociograms and semi-structured interviews with healthcare workers, patients and their carers are a few ways of getting the answers we need, as well as through quantitative analysis of hospitals’ bedside observational data to study various predictors of AMR using bivariable and multivariable analyses.

ND: Tell us about your long-term plans with this work.

ES: Long-term, I hope to provide a toolkit for advocacy aimed at role players who work in this field, to assist them to promote policy dialogue on this global challenge. This work will directly benefit the target population and inform healthcare services and practices across participating countries, with potential for wider reach.

ND: Why is this all so important?

EC: We already know that the socio-cultural contexts including gender, ethnicity and race, religion and socio-economic backgrounds impact health and disease.

It is no different with AMR, which is a multifaceted global health challenge, and the drivers and consequences manifest socially. Single interventions like evidence-based guidelines, better diagnostics and new antibiotic agents do not account for the structural and social determinants of health. And we know that healthcare workers, patients and carers are at risk of infection and are at risk of being potential carriers of infection, so they can easily spread AMR. To optimise care, we must look at collective and individual behaviours to improve outcomes for our patients, their families, as well as healthcare workers.