Barriers and pathways to environmental surveillance of antibiotic resistance in middle- and low-income settings: a qualitative exploratory key expert study

Figures & data

Table 1. Recruited key informants in terms of geographical origin, technical competence and LMI-related area of practical experience of ABR-related environmental surveillance.

Origin	Function	Experience from
Africa (1)	Environmental scientist	Africa
North America (1)	Environmental engineer	North America, Asia
Asia (1)	Environmental scientist	Africa, Asia
Europe (4)	Environmental chemist Environmental scientist Bioinformatician/Statistician Microbiologist	Europe, Africa, Asia

Figure 1. Thematic categories of reported barriers for ABR-related environmental surveillance, and pathways to overcome these barriers.

Table 2. Overview of reported infrastructural barriers to environmental ABR surveillance in LMI settings.

Infrastructural barriers
Lack of organized infrastructure makes representative sampling infeasible	Unreliable local equipment and facilities prevent continuous sampling and adequate analysis	Design or maintenance of physical structures prevent access to specific optimal sampling spots
Due to, e.g. very decentralized sewage and wastewater infrastructure	Due to, e.g. electricity shortage, lack of machinery, suitable labs	Due to practical infeasibility or physical danger related to risk of falling or toxic contamination

Table 3. Overview of reported institutional barriers to environmental ABR surveillance in LMI settings.

Institutional barriers
Political governance	Business and managerial interests and structures	Bureaucracy	Political and managerial priorities
Authoritarian political governance tends to impede access to sites and resources more	Due to, e.g. corruption, power relations or career-related interests	Due to difficulties of securing adequate collaboration agreements, and permissions and authorizations for sampling, analysis and international transfer of samples.	Environmental ABR-related concerns low on the agenda, often due to limited economic circumstances

Table 4. Overview of reported socio-cultural barriers to environmental ABR surveillance in LMI settings.

Socio-cultural barriers
Working culture	Knowledge and know-how	Language and communication	Corruption and sharing ethos	War and social unrest
Experts hold different expectations of performance and autonomy of local collaborators than local collaboratrs themselves	Implementation of surveillance methods impeded by lack of local knowledge and skill, and experts lack of understanding of local contexts, enhancing all other institutional and social barriers.	Language differences, related translation problems and different communication ideals impede implementation and enhance institutional and other socio-cultural barriers.	Differences between surveillance experts’ views of what is expected and unacceptable and that of local collaborators impede collaboration and enhance institutional barriers.	Unstable sociopolitical situation or outright war-like circumstances impede experts to supervise on site (due to safety issues or bans to enter areas) or to form local collaborations.

Table 5. Overview of reported grounds to avoid regions due to barriers.

Avoidance of Regions
Earlier (discouraging) experience of region	Warnings about region	Known complications in regions
The expert has tried to conduct environmental AMR surveillance in a region, and been discouraged from trying again	The expert has received intelligence about barriers that discourages from attempts at environmental AMR surveillance	The expert has foreknowledge of barriers in a region that discourages from attempts at environmental AMR surveillance in this region

Table 6. Overview of reported ways to simplify methods due to barriers.

Simplification of Methods
Managing unforeseen problems by creating an alternative, sub-optimal, methodological solution on the spot.	Planning that adapts all methods to fit local conditions before implementation
Such as sampling “as close as possible” when the optimal sampling location cannot be accessed	Trying to foresee barriers that make optimal methods infeasible, and adapt the implemented methods

Table 7. Overview of reported roles for collaborators and ways of securing them.

Local Collaboration
To manage language problems	To adjust logistics	To navigate administrative and legal barriers	Initiated by chance	Initiated by trustful relationships
A local natural language speaker acts as interpreter and translator	Someone with local knowledge about infrastructure, technical equipment, transport, etc. helps with information and solutions to manage related barriers	A local resident or knowledgeable longtime visitor helps with procedural advice and introductions to adequate administrators	Luck provides a suitable collaborator that just happens to be able to assist	Relationships can be built through local capacity building for staff, openness regarding aims of the expert and related benefit sharing

Table 8. Overview of how chosen pathways undermine aims of environmental ABR surveillance.

Counterproductive pathway choices
Avoiding regions and sites goes against the core aim of LMI environmental ABR surveillance	Adjusting methods threatens to undermine the core aim of LMI environmental ABR surveillance	Both these pathway choices threaten to maintain or worsen ABR-related global epistemic injustices
The strategy maintains both the gaps in global ABR surveillance and the local lack of surveillance data that the environmental approach is supposed improve.	The strategy undermines the chance of filling gaps in global ABR surveillance and addressing local needs of surveillance data that the environmental approach is supposed improve.	Addressing the global epistemic injustice created by lack of reliable ABR surveillance data from LMI settings is a further main rationale for addressing the lack of such surveillance data, besides global health promotion.

Table 9. Overview of how some pathways fail to adequately address barriers.

Misaligned barriers and pathways
Lack of systematic strategy for establishing local collaboration	Lack of strategy to make collaborators benefitting partners	Lack of strategy for local capacity building
Despite local collaborators pointed to as primary way to manage barriers without avoiding regions	Despite observation that benefit sharing could aid in establishing trustful local collaboration	Despite observation that local capacity building could aid in establishing trustful local collaboration

Table 10. Overview of sense of disempowerment interplay with structiural factors.

Structurally embedded self-inefficacy
Unmotivated sense of powerlessness in the face of barriers	Structural factors do limit feasible options of researchers and experts	Researchers and experts could initiate structural action and reform
Researchers and experts could probably do more to overcome hurdles for productive pathways around barriers than what they project themselves	Several structural factors, from war to existing socio-economic contexts, are out of reach for researchers and experts to influence.	Institutional global actors within and outside the research community could be prompted to take action to prevent barriers and better support researchers and experts to implement more productive pathways.