Exploring the factors that contribute to the successful implementation of antimicrobial resistance interventions: a comparison of high-income and low-middle-income countries

Abstract

Introduction: Antimicrobial resistance (AMR) is a challenge to modern medicine. Interventions have been applied worldwide to tackle AMR, but these actions are often not reported to peers or published, leading to important knowledge gaps about what actions are being taken. Understanding factors that influence the implementation of AMR interventions and what factors are relevant in low-middle-income countries (LMICs) and high-income countries (HICs) were the key objectives of this exploratory study, with the aim to identifying which priorities these contexts need.

Methods: A questionnaire was used to explore context, characteristics, and success factors or obstacles to intervention success based on participant input. The context was analyzed using the AMR-Intervene framework, and success factors and obstacles to intervention success were identified using thematic analysis.

Results: Of the 77 interventions, 57 were implemented in HICs and 17 in LMICs. Interventions took place in the animal sector, followed by the human sector. Public organizations were mainly responsible for implementation and funding. Nine themes and 32 sub-themes emerged as important for intervention success. The themes most frequently reported were 'behavior', 'capacity and resources', 'planning', and 'information'. Five sub-themes were key in all contexts ('collaboration and coordination', 'implementation', 'assessment', 'governance', and 'awareness'), two were key in LMICs ('funding and finances' and 'surveillance, antimicrobial susceptibility testing and preventive screening'), and five were key in HICs ('mandatory', 'multiple profiles', 'personnel', 'management', and 'design').

Conclusion: LMIC sub-themes showed that funding and surveillance were still key issues for interventions, while important HIC sub-themes were more specific and detailed, including mandatory enforcement, multiple profiles, and personnel needed for good management and good design. While behavior is often underrated when implementing AMR interventions, capacity and resources are usually considered, and LMICs can benefit from sub-themes captured in HICs if tailored to their contexts. The factors identified can improve the design, planning, implementation, and evaluation of interventions.

Keywords: antibiotic resistance; antimicrobial resistance; global health; high and low-middle-income countries; interventions; public health; resilience; success factors.

Figure 1

Number of interventions reporting targeted microorganisms stacked by sector. Twenty-seven interventions reported specific targeted microorganisms, and they were often targeting several microorganisms in the same intervention. The most reported microorganisms were Escherichia coli, followed by Salmonella spp., and Staphylococcus aureus targeted in 22, 16, and 15 interventions, respectively.

Figure 2

Stacked number of interventions by sectors and region targeted in low-middle-income countries and in high-income countries. Each group is disclosed per World Health Organization regions. AFRO, African region; EURO, European region; HICs, high-income countries; LMICs, low-middle-income countries; PAHO, Pan-Americas region; SEARO, South-East Asian region WPRO, West-Pacific region.

Figure 3

Percentage of interventions reporting each of the nine themes that were captured to lead toward positive outcomes of interventions. Percentage of themes for all interventions, high-income countries (HICs) and low-middle-income countries (LMICs) are represented in orange, blue, and purple, respectively. AMU, antimicrobial use.

Figure 4

Percentage of sub-themes that were reported in at least one-quarter of interventions overall or by context. Key sub-themes are the ones not marked and important in all contexts, while sub-themes that were reported in a quarter of interventions for at least one of the groups are referred to as important sub-themes and are marked with (*).