Reframing and unpacking 'irrational' antibiotic use: a structural and socio-ecological perspective on antibiotic resistance in India

The overuse of antibiotics is often deemed as an "irrational" practice that limits the effectiveness of antibiotics by contributing to antimicrobial resistance (AMR), especially in emerging economies or low-and-middle-income countries such as India. This thesis examines the discrepancy between knowledge or attitudes towards appropriate antibiotic use and practices, and critically analyses interventions to improve antibiotic misuse. This thesis finds that multi-faceted bundle interventions that address the socio-ecological context and limitations regarding access to care are more effective at curbing antibiotic misuse compared to educational interventions that improve solely knowledge. This thesis also explores the limited engagement of diverse healthcare practitioners in interventions in a limited-resource setting like India, and finds that national and state policies do not address the diverse cadre of healthcare practitioners in the formal and informal sectors in India. Additionally, interventions and policies focus exclusively on “irrational” use, rather than understanding the nuanced decision-making processes that contribute to antibiotic misuse, including but not limited to a desire for quick cures in the absence of employment leave or social safety nets; inadequate hygiene, infection control and prevention policies; and a lack of diagnostic testing.