System Mapping of Antimicrobial Resistance to Combat a Rising Global Health Crisis

Abstract

Antimicrobial resistance (AMR) decreases the effectiveness of antimicrobials to treat bacterial infections in humans and animals. The increased occurrence of AMR in bacterial population in humans, animals, and the environment requires the measures to combat a rising global health crisis. The aim of this research was to present current knowledge on AMR in a system map and to identify potential explanations of former identified variables significantly associated with AMR. This study applies a systems thinking approach and uses feedback loops to visualize the interconnections between human, animal, and environmental components in a circular AMR system map model. First, a literature review focusing on AMR and socioeconomic factors, wicked problem, and system change was carried out, which was then processed in a system map to conceptualize the present core challenges of AMR via feedback loops. Second, to investigate possible underlying values of the society and those that influence humans' behavior in the present AMR system, an iceberg model was established. Third, leverage points were assessed to estimate which kinds of interventions would have the greatest effect to mitigate AMR in the system. The present AMR system map implies the potential to identify and visualize important risk factors that are direct or indirect drivers of AMR. Our results show that the tool of system mapping, which interconnects animals, humans, and environment in one model, can approach AMR holistically and be used to assess potential powerful entry points for system wide interventions. This study shows that system maps are beneficial as a model to predict the relative effect of different interventions and adapt to rapidly changing environments in a complex world. Systems thinking is considered as a complementing approach to the statistical thinking, and further research is needed to evaluate the use of such tools for the development and monitoring of interventions.

Keywords: antimicrobial resistance (AMR); antimicrobial stewardship (AMS); leverage points; sustainability transition; system change; systems thinking; transformation; wicked problem.

Figure 1

Flowchart of study design using a systems thinking approach. In terms of the system mapping and identification of leverage points following Meadows (13) and Abson et al. (11) and in terms of the Iceberg Model following Monat and Gannon (12).

Figure 2

The iceberg model of a human-designed system. The model consists of two visible components above the water surface and two hidden components beneath the water surface. Repeated events demolish the patterns of the system, which are influenced by system structures. Mental models are people's behavior that is shaped by the system structures. Drawing inspired by (12).

Figure 3

Present antimicrobial resistance (AMR) system map created in Kumu.io (27) https://www.kumu.io/LeaMat20/amr-system-map#untitled-map. The internal system elements (blue) are connected with arrows indicating the negative (balancing) and the positive (reinforcing) feedback loops. These interconnections are based on the hard variables (i.e., physical flows) and soft variables (i.e., information flows). The breaks in the arrows, which are leading to “AMR,” indicate a time delay. The three yellow circles (i.e., policies, natural environment, and treatment method) depict the external elements that affect the internal objects. The two green elements (i.e., transportation network and wastewater treatment) symbolize systems outside of the system boundaries.

Figure 4

A section of Figure 3: causal loops in present antimicrobial resistance (AMR) system map between “antimicrobial usage” (AMU) and “AMR” created in Kumu.io (27).

Figure 5

Iceberg model of present AMR system. On the top, visibly, the events and patterns of the present AMR system. Under the water surface, hidden, the system structure and on the bottom peoples' underlying assumptions, beliefs, and values (mental model). The upper part is supposed to be influenced by the one below, meaning the system structure is caused by the mental models. The model is applied lightly in this context to give an overview of the different levels and to provide a contextual application of the system map around the “water level.” To truly see the depth of the AMR problem, the iceberg model could be explored much more deeply to enter into the mental models that undercut all of society as we know it (e.g., life and death). However, this becomes a philosophical exercise and is outside of the focus of this research.

Figure 6

A section of Figure 3: causal loops in present antimicrobial resistance (AMR) map of “infection and malnutrition” (IM) created (2021) in Kumu.io.

Figure 7

A section of Figure 3: causal loops in present antimicrobial resistance (AMR) system map of “available resources” created in Kumu.io (27).