An integrative approach to understanding antimicrobial resistance in New Zealand

Abstract

Antimicrobial resistance (AMR) occurs when micro-organisms (including bacteria, viruses, fungi and parasites) survive exposure to a medicine that would usually kill them or halt their growth. This is a natural phenomenon which is becoming much more common. AMR is a growing public health crisis both globally and in New Zealand. It limits our ability to effectively prevent and treat infectious diseases, and poses a threat to many practices and standards of modern medicine. The rapid development of bacterial resistance to antibiotics is particularly concerning.

AMR is a highly complex issue. There are human, animal and environmental reservoirs of AMR, with complex transmission pathways between them. Their relative importance is unclear and contested. There is increasing recognition of AMR as a ‘One Health’ issue at the nexus of human, animal and environmental health. Coinciding with this is the recognition that addressing AMR will require new ways of thinking that transcend disciplinary boundaries: we need to think of AMR as a ‘system’ of interconnecting components, and seek to understand the problem as a whole, and not just its component parts. However, there are few examples of such approaches being applied in practice.

This thesis describes an integrative approach to understanding AMR, which is underpinned by both One Health and EcoHealth principles. EcoHealth is a research paradigm based on the principles of systems thinking, transdisciplinary research, multi-stakeholder participation, sustainability, gender and social equity, and translating knowledge into action. The chosen method, participatory system dynamics, was used to model stakeholder understandings of the causes and effects of AMR in New Zealand, with a particular focus on identifying feedback loops that drive system behaviour over time. Feedbacks are formed by variables connecting into loops that either reinforce or balance changes happening in the system.

This research involved 27 interviews with 31 purposively selected stakeholders who have clinical, academic/research, policy, community and industry experience related to AMR. From the interviews, system dynamics modelling methods were used to build causal loop diagrams representing feedback loops involved in AMR. It is important to learn how people believe the system works and to integrate the different parts of this complex problem in order to identify key leverage points for improving policy and practice.

Many of the feedback loops arising from this research have not been previously identified in the literature. The results of this research suggest important connections between AMR and other broad issues including poverty, inequality, water quality and intensive farming practices. This is the first time that participatory system dynamics modelling has been used to integrate human, animal and environmental aspects of antimicrobial resistance. It is hoped that future work will refine and strengthen the model through workshops with stakeholders, and develop into simulation of possible policy interventions.