A policy gap analysis and clinical ethnographic exploration of antimicrobial resistance among refugees and migrants in the UK and Europe

Antimicrobial resistance (AMR) (infections that are less responsive to antibiotics) is increasing rapidly around the world and is a major problem for the health service. Vulnerable groups including refugees and migrants to the UK and Europe are particularly susceptible to AMR, and we need dedicated research in this group to better address this issue. Refugees and migrants to the UK and Europe are more likely to have AMR due to higher rates in their countries of origin, liberal policies around antibiotic use, poor infection control practices in under-resourced health facilities, and increased person-to-person spread during their journeys due to living conditions or detention. Bacteria affected by AMR can cause infection or be carried by patients without causing active infection; they can spread person to person, particularly in healthcare settings and over-crowded living centres. Despite the importance of this issue and calls from WHO to take a person-centred approach to AMR, the perspectives of refugees and migrants with AMR are under-explored. This is important as this marginalised population have different challenges to accessing healthcare in the UK. This evidence gap impacts on our ability to develop bespoke strategies for this population and prevent increasing the prevalence of AMR. My overall research aim is to formulate person-centred policy recommendations for tackling AMR among refugees and migrants in the UK by identifying the gaps in policies through in-depth exploration of the perspectives of refugees, migrants, and key stakeholders like policy makers or civil society organisations (CSOs). My first objective is to review documents and policies on AMR and identify gaps in evidence or recommendations for refugees and migrants in the NHS, nationally (UK) and internationally (Europe). Relevant policy documents include National Action Plans on AMR, multidrug resistant organism (MDRO) screening, and antibiotic prescription guidelines. This will identify relevant gaps in addressing AMR among this group to be explored in subsequent objectives. The second objective is to conduct clinical ethnographic studies of the lived experiences of AMR-affected refugees and migrants in the UK. Clinical ethnography is a research methodology that uses clinically-informed and reflective immersion in patient experiences; it involves in-depth interviews with participants and observations, followed by transcription and analysis. It will provide fundamental information about patients' access to healthcare across time and geographies, social, behavioural and cultural influences on antibiotic use and their lived experiences of carriage or infection with resistant bacteria. The third objective is to conduct in-depth interviews with experts on AMR including healthcare workers, policymakers or CSOs to understand their perspectives. I will draw on findings from prior objectives to inform these discussions to begin to form potential policy changes that can be appropriate to the needs of refugees and migrants in the NHS and further afield. From this, I will synthesise findings contextually to identify local and national policy recommendations based on the experiences of refugees and migrants themselves and policy makers. These could span local policy recommendations around antibiotic prescribing and use, screening for resistant bacteria and infection control through to broader recommendations as to how to improve understanding of AMR among refugees and migrants and how we can provide improved care in the NHS. This work is of high relevance to healthcare service strategy in the UK but also internationally (including WHO), as refugees and migrants face challenges in accessing healthcare impacting the development of AMR.