Factors influencing antimicrobial resistance in the European food system and potential leverage points for intervention: A participatory, One Health study

PLoS One. 2022 Feb 22;17(2):e0263914. doi: 10.1371/journal.pone.0263914. eCollection 2022.


Introduction: Antimicrobial resistance (AMR) is a global crisis that evolves from a complex system of factors. Understanding what factors interact is key to finding solutions. Our objective was to identify the factors influencing AMR in the European food system and places to intervene.

Materials and methods: We conducted two workshops involving participants with diverse perspectives to identify the factors influencing AMR and leverage points (places) to target interventions. Transcripts were open coded for factors and connections, then transcribed into Vensim 8.0.4 to develop a causal loop diagram (CLD) and compute the number of feedback loops. Thematic analysis followed to describe AMR dynamics in Europe's food system and places for intervention. The CLD and themes were confirmed via participant feedback.

Results: Seventeen participants representing human, animal and agricultural sectors identified 91 CLD factors and 331 connections. Seven themes (e.g., social and economic conditions) describing AMR dynamics in Europe's food system, five 'overarching factors' that impact the entire CLD system (e.g., leadership) and fourteen places for intervention (e.g., consumer demand) emerged from workshop discussions. Most leverage points fell on highly networked feedback loops suggesting that intervening at these places may create unpredictable consequences.

Conclusions: Our study produced a CLD of factors influencing AMR in Europe's food system that implicates sectors across the One Health spectrum. The high connectivity between the CLD factors described by participants and our finding that factors are connected with many feedback mechanisms underscores the complexity of the AMR problem and the challenge with finding long-term solutions. Identifying factors and feedbacks helped identify relevant leverage points in the system. Some actions, such as government's setting AMU standards may be easier to implement. These actions in turn can support multi-pronged actions that can help redefine the vision, values and goals of the system to sustainably tackle AMR.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Community-Based Participatory Research / standards
  • Drug Resistance, Microbial*
  • Europe
  • Food Quality*
  • Humans
  • Quality Control*

Grant support

This study is funded through an operating grant of the 5th Joint Programming Initiative on Antimicrobial Resistance (JPIAMR 2017). Funding was provided by an operating grant from the Canadian Institutes for Health Research (Institute of Infection and Immunity, Institute of Population and Public Health: https://cihr-irsc.gc.ca/e/193.html) (PI: SEM, grant number 155210); a Swedish Research Council grant (https://www.vr.se/english.html) (PI and project consortium coordinator: PSJ, grant number 2017-05981); and an operating grant from the Swiss National Science Foundation (https://www.snf.ch/en) (PI: DW, grant number 40AR40_180189). The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.