Patients living in precarious circumstances are less likely to use antibiotics appropriately according to a new study from the University of Warwick, suggesting that efforts to improve conditions for those with little security in their livelihoods could have an unexpected benefit in helping to tackle antimicrobial resistance globally.

The findings add to evidence that focus should shift from influencing individuals’ efforts to combat anti-microbial resistance to supporting sustainable development policy that tackles the contributing factors.

The research, published in the journal BMJ Global Health and funded by the Economic and Social Research Council (ESRC), part of UK Research and Innovation, provides comprehensive analysis of how patients accessed and used healthcare, and is the first study to quantitatively examine the relationship between precarity and antibiotic use.

Precarity refers to personal circumstances dominated by uncertainty, whether that is in employment, your personal life or social status. Those in precarious circumstances are limited in their ability to plan ahead, and deprived of safety nets, social support, economic certainty and flexibility. It is not necessarily about being poor: although this study looked at low to middle income countries, precarity can also be a problem in higher income countries.

Using statistical analysis, the researchers were able examine the impact of socioeconomic factors, such as precarity, poverty and marginalisation, on their use of antibiotics to treat their illness. They found that patients in precarious circumstances had a chance of up to 51% of using antibiotics without advice from a medical professional or for inappropriate illnesses—compared to 17% for an average patient.

Lead author Dr. Marco Haenssgen, from the Warwick Institute of Advanced Study and the Department of Global Sustainable Development, argues that this behaviour is understandable as when living in precarious circumstances individuals are engaged in a constant balancing act.

Dr. Haenssgen, Assistant Professor in Global Sustainable Development, said: “You have to balance your health, your economic life, feed your family, go to school; these are all competing priorities.

“Antibiotics have become such a staple of healthcare that they have become what some people see as a ‘quick fix’ solution. When people are in precarious circumstances and deprived of social support, if they can find a quick fix to keep them going they will use it, and then it could become problematic.”

In many low to middle income countries, patients often have to travel long distances to access healthcare services, something they may not be able to easily arrange or afford. Even in more economically developed areas, employment can be less secure and social networks can be eroded.

Antimicrobial resistance occurs when microbes become resistant to antibiotics, threatening their effectiveness. Human antibiotic use is known to be a main driver of this process, and policies to combat anti-microbial resistance have therefore typically focused on clinical factors and promoting individual responsibilities. However, the researchers argue that the impact of socioeconomic factors such as precarity are being underestimated.

Dr. Haenssgen said: “You cannot always blame the individual for misuse of antibiotics. Often, we find ourselves in living conditions that provoke problematic behaviours, which means that if you want to improve antibiotic use you need to improve those living conditions.

“If we can improve situations of precarity then we have a good start for future interventions. We have a very substantial facet of the problem that is continuously disregarded and where potentially we have a lot of gains to realise.

“Antimicrobial resistance is a massive global health problem, it can potentially overturn what global health is. Many of the past gains that we have had in infectious disease control and prevention are potentially being undone by antimicrobial resistance.”

The study focused on five local communities across rural Thailand and Lao People’s Democratic Republic and surveyed 2066 residents on recent illnesses they had experienced and how they sought healthcare support for it. This provided the researchers with a rich dataset on 1421 illness episodes that they could analyse to determine what healthcare patients seek, if any, whether they were able to access suitable healthcare, and when these occur in the timeline of their illness.