Antimicrobial resistance (AMR) is rising to dangerously high levels in all parts of the world and presents a threat to public health, food security, and (economic) development [1]. Currently, AMR is presented as being responsible for 700,000 deaths per year and could result in 10 million annual deaths per year by 2050 if no action is taken [1]. As new resistance mechanisms are emerging and spreading globally, the ability to treat common infectious diseases and enable chemotherapies, operations, and many other activities is threatened [2,3]. It is acknowledged as an urgent global problem that concerns every country irrespective of its level of income and development, but effects are hypothesized to be even more significant in low- and middle-income countries (LMIC) [1,4]. In social sciences, however, experts highlight how AMR can be exploited for political ends [5], the invisibility of several causes of AMR [6], and significant scientific knowledge gaps on this subject [7]. Legido-Quigley et al [8] described AMR as a “wicked problem,” as it encompasses complex networks of different stakeholders with incompatible interests.

AMR is spread via diverse agents including humans, animals, alimentation, soil, and water. Although resistance can emerge naturally through evolutionary processes [9,10], it can also occur through anthropogenic pressure resulting from an overreliance on antibiotics. Infections in humans and animals caused by extended-spectrum beta-lactamase (ESBL)–producing Escherichia coli and Klebsiella pneumoniae are increasingly resistant to most antibiotics globally due to their high diversity and rapid mutation [11,12]. The evaluation of these two gram-negative bacteria could serve as an important indicator for the prevalence of AMR in local settings.

It is critical to recognize how human practices interact with natural microbial ecology in compounding AMR risks. Within the human health sector, the reliance on broad-spectrum antibiotics, especially in the absence of diagnostics, has been identified as a major contributor to the emergence of AMR [13]. The widespread use of antibiotics in livestock exceeds direct human consumption and is driven by economic imperatives to maximize production, prevent disease, and enhance growth [7,14,15]. As most of these antibiotics are not fully metabolized but released into the environment as waste products, misguided antibiotic use has a concurrent ecological impact by affecting wild bacteria populations and promoting further antibiotic resistance development [16]. This highlights the ecological consequences of antibiotic misuse and the entangled nature of environmental, agricultural, and health systems. Additionally, the soil contains microorganisms with naturally occurring genes that can facilitate the development of AMR in the natural environment [3,7].

The relevance of this research project is multifaceted: First, the availability of information on AMR in Africa is limited. This stems from weak laboratory and surveillance systems and processes, where only a small fraction of facilities conducts bacteriological testing and the microbiological data that do exist are often of poor quality [4,17,18]. Similarly, more data on antibiotic consumption and access to health care in animal and human health are needed [19]. In addition, a One Health approach should be implemented in future studies to develop efficient interventions on AMR and improve AMR surveillance and control in Africa [19,20]. Second, the rates of AMR are higher in certain LMIC, while individual antibiotic consumption is lower in comparison with high-income countries, indicating that other factors are influencing the prevalence of AMR [9]. Third, the effects of AMR on various societal sectors, including health and economic consequences, risk being more significant in African countries due to predominant livelihoods and living conditions [21,22]. In recent years, the use of antibiotics in LMIC has increased substantially both for humans and animals because of economic growth and changes in diet [23]. At the same time, antibiotic policies concerning manufacture, dispensation, and prescription in many LMIC are often missing or lacking regulatory enforcement due to socioeconomic challenges, large population size, and challenged health care systems [24]. Fourth, the current body of literature “has created little clarity about what interventions are best suited to achieve AMR goals across contexts, cultures and health systems” [25]. The need to act on AMR at a global level is well-known and agreed upon; however, an implementation gap of action and interventions can be observed [26]. Evidence of effective and feasible multifaceted interventions in sub-Saharan African countries is limited, and studies show that challenges for implementation of interventions are numerous. Nevertheless, several initiatives at international and local levels have demonstrated that effective interventions are feasible in LMIC and that contextualization is essential [27].

This paper presents the study protocol for a multidisciplinary research project on AMR in 2 districts of Burkina Faso and Ghana using a One Health perspective and design thinking approach. The study has the following aims: (1) assessing baseline data on AMR pathogens along the food chain in the Kossi Province, Burkina Faso, and the Asante Akim North District, Ghana; (2) understanding and quantifying perceptions and use of antibiotics among health care workers, communities, and livestock farmers as well as defining patterns of access and utilization of antibiotics; and (3) defining and refining an intervention aimed at reducing the impact of AMR and improving the way this issue is addressed using a stakeholder-driven approach.

The research project will be conducted in Burkina Faso and Ghana, both located in the West African subregion. The research site in Burkina Faso is the rural Kossi Province, located in the northwest of the country and corresponding to the Nouna Health District. The population is mostly living in the semi-urban town Nouna, representing the administrative center of the province [28]. Nouna Health District has a population size of about 320,232 inhabitants and a surface area of 7464 km² [28]. The main economic activities are farming and animal breeding [29]. A Health and Demographic Surveillance System has been established in the province and is managed by the Centre de Recherche en santé de Nouna (CRSN; Nouna Health Research Center). Burkina Faso has a national human and animal surveillance system for AMR consisting of 15 designated laboratories since 2018 and is enrolled in the Global Antimicrobial Resistance and Use Surveillance System (GLASS) of the World Health Organization (WHO) but is not yet reporting data to the system [30]. Burkina Faso’s National Action Plan (NAP) was published in 2018 but has not been implemented by the government yet [30].

The research site in Ghana is in the semi-urban and rural Asante Akim North District, which is in the eastern part of the Ashanti Region. The district has a size of 1218 km² and approximately 85,788 inhabitants [31]. Approximately 72% of the district’s work force is employed in the agrarian sector [32]. Multiple health institutions are serving in the district and are constituted by private sector actors, religious missions, and public sector actors [32]. Ghana is enrolled in the WHO GLASS. However, there is no precise nationwide surveillance system on antimicrobial use and AMR prevalence, and no data were contributed in 2020 and 2021 [33-36]. The establishment of a nationwide AMR surveillance system is outlined in the NAP but has yet to be implemented [36,37]. Ghana is considered a leading country on the African continent for handling AMR due to its work and approach including the establishment, in 2011, of the Ghana National Policy Platform on AMR, which consists of various stakeholders from diverse institutions and sectors, thereby integrating the One Health approach [36]. Moreover, the NAP on AMR (2017-2021) and a policy document on antimicrobial use and resistance were officially launched in April 2018 in the country [36,38]. However, policy and project implementation is lagging due to poor coordination of the different stakeholders, insufficient financial resources and infrastructure, and enforcement of regulations [36].

Ghana and Burkina Faso are neighboring countries but different in many respects, such as the socioeconomic level, the structure of the health system, the presence of industries, and national security. Therefore, it would be of interest to contrast the information collected between the two study sites and to see the influence of these factors on AMR and what this could mean for possible interventions. In addition, through the development of a south-south collaboration between the two countries, knowledge can be shared, and synergy effects can be used for a holistic approach to AMR.

Ethical approval was obtained from the ethical committee of Heidelberg University Hospital (S-826/2021), National Ethical Committee in Burkina Faso (number 2021-12-270), Nouna Health Research Centre ethical committee (number 2021-018-MS/SG/INSP/CRSN/CIE), Kwame Nkrumah University of Science and Technology Committee on Human Research Publication and Ethics (CHRPE/AP/580/21), and Ghana Health Service Ethics Review Committee (GHS-ERC 004/11/21).

Informed consent and the ability of participants to opt out of the study at any point will be provided together with an information sheet on the project. Additionally, all data will be de-identified to ensure privacy and confidentiality. All recordings will be deleted once transcription is completed and checked. Participants of the workshops in phase 2 will receive beverages and a meal during the workshops and compensation for their attendance once the workshop has ended, as this presents a day-long commitment. Otherwise, no compensation will be provided for study participants.

Research has shown that “magic bullet” approaches to AMR focusing on highly technological and biomedical approaches such as surveillance and the development of new antibiotics will not be sufficient to combat the global and multifactorial problem of AMR [13,45]. Even though we currently do not have much data on the prevailing situation in the regions we will be studying, we know that the irrational use of antibiotics in humans and animals significantly contributes to AMR [3,10,26]. Policies and underlying infrastructure of antibiotics, perceptions, understanding, and knowledge of stakeholders and community members need to be understood to develop sustainable and effective solutions while considering their social and economic capital as well as behavioral, ethical, political, and cultural factors [4,15,26,45]. Therefore, the multifactorial nature of AMR, the diverse reasons and drivers underlying the use of antibiotics, and the local contexts and constraints need to be considered and integrated into all efforts.

The first phase of the research project will add to the field of One Health by examining the issue of AMR from microbiology, anthropology, and socioepidemiology perspectives. Therefore, this study will address the challenge of disciplinary silos through close multidisciplinary collaboration. It stands out in the combination of different disciplinary and epistemological perspectives through multilateral collaboration between the Burkinabe, Ghanaian, German, and French research institutions. Microbiological data will contribute to a clear picture of prevalent resistance in animals and improve the biomedical understanding of AMR in the study sites. Generally, both AMR surveillance and data on AMR are limited in western sub-Saharan Africa [46]. Furthermore, available studies are mostly done at the health care level, investigating resistance levels in ESBL-producing E. coli and Klebsiella spp. isolates [46] or in febrile children younger than 5 years [47]. Few studies exist on ESBL-producing E. coli and Klebsiella spp. in livestock; however, these have been conducted in urban settings such as Ouagadougou in Burkina Faso [48]. Data on AMR bacteria and their genotype distribution in meat are still scarce especially in rural areas of Ghana and Burkina Faso, for example. In our study, strains will be genotyped to describe phylogenies, mechanisms of resistance, and virulence. Data collected from livestock can also be compared with a human strain collection of an ongoing AMR surveillance system in the 2 districts where the study is implemented in order to describe transmission reservoirs in these parts of Africa.

Anthropological studies will add to the understanding of antibiotic access and utilization patterns, perceptions, and uses of antibiotics among human and animal health care workers, communities, livestock farmers, medicines suppliers, and institutional actors. It will also identify and outline the constraints and enablers of these actors and how these factors influence their behavior. The socioepidemiology data collected among health care workers will generate knowledge on their perception of AMR and the logic of their prescription patterns, while the household survey will quantify community members’ knowledge of antibiotics, AMR, and antibiotic consumption practices. The anthropology and socioepidemiology perspectives will enable a description of the underlying infrastructure and the social, cultural, economic, and political structures that impact the development and spread of AMR. Thereby, this study will add to available literature on health care–seeking behaviors outside of health care facilities, antibiotic use across different levels of health care providers, and access among community members in Burkina Faso [49-51]. Furthermore, by combining the microbiological data on AMR with the perception of institutional actors at different levels, community members, and farmers, we will be able to develop a holistic description of the situation in the 2 study sites. This will represent a necessary step to develop an intervention reflecting the local context and needs.

The second phase of the project will result in the development of an intervention using the design thinking approach, which is increasingly used in global health to apply social innovation for diverse health issues representing “both a social need and a social problem” [52]. A scoping review indicated that design thinking is used within various initiatives of different organizations and institutions to improve human health [52]. Design thinking is iterative, measurable, and result-driven and places the people being served in the center of the design, innovation, and implementation process [42,43]. Therefore, stakeholders’ actual needs and expectations are met, and acceptable, equitable, effective, and sustainable health solutions can be developed through this active engagement [53-55]. Design thinking consists of stakeholder and cross-disciplinary collaboration and a multistep approach to gain an understanding of the situation and context, brainstorm, test, and revise the best solution in a collaborative process [53]. Therefore, the following steps are repeated over time: define, ideate, prototype, test, and implement [41].

The mixed methods approach and subsequent triangulation of research results will contribute to increasing knowledge and developing a holistic understanding of AMR, which is essential for the development of appropriate interventions at the study sites. Using the One Health perspective, both human and animal health will be examined in this study. The One Health approach will allow us to gain insights into the interconnection of the 2 sectors and to develop a holistic intervention that takes different perspectives and needs into account. Therefore, to follow the One Health paradigm, collaboration across disciplines will be promoted, and actors from different professions and social levels, particularly community members, will be encouraged to bring forward their ideas for solutions. By challenging disciplinary boundaries and through the collaboration of different disciplines within the research team itself and the design teams during the intervention phase, synergy effects and strengths can be brought together to capitalize on innovative potentials. This will be facilitated by a design thinking approach to support innovative potential through the close collaboration of stakeholders and community members, both directly and indirectly affected by AMR. The stakeholder-driven and participatory bottom-up approach to the multifactorial problem of AMR has the potential to result in a common understanding of needs and problems and the subsequent development of a common solution that is tailored to the local situation, context, and needs. Furthermore, it has been shown that moving away from a traditional top-down to a value-driven and participatory bottom-up approach could lead to increased efficacy and acceptability of interventions and improved antibiotic use [26].

In addition, continuous contact with policymakers and the national AMR networks in Burkina Faso and Ghana from the beginning of the research process has the potential to increase the acceptability and scale-up of the resulting intervention that will be developed. By engaging these stakeholders, existing networks, policies, and projects will be incorporated from the first to the last phase of the design thinking approach, which will be built on existing structures and approaches to ensure acceptability, efficacy, and sustainability of the resulting intervention. Moreover, a south-south collaboration will be facilitated within the research project through sharing of competencies and technical know-how within and between the researchers and AMR networks via regular exchanges and through research and dissemination meetings.

The main limitation of this study is the limited involvement of the environmental sector. The influence of environmental factors on AMR has not been highlighted within the scope of this study. Currently no data have been collected from environmental sources to add to the human and animal data sources. However, we intend to complement this research with such data (collaborations are currently being developed to add this component). In addition, environmental stakeholders from the local and national levels will be included in the qualitative interviews and the development of interventions in the 2 countries.

A diversity of approaches to AMR exists, ranging from research and development of new antibiotics; antibiotic stewardship; improved hygiene; and infection, prevention, and control to behavior change and education of patients and health care professionals. However, social scientists have identified a problematic focus on the causes of AMR linked to the behavior of individuals, both consumers and prescribers, that depoliticizes AMR and isolates it from our modes of life and economies, thereby not acknowledging that AMR is not only a natural phenomenon but also a social fact [56]. Therefore, social scientists urge us to question our way of living in the world, caring for it, and taking care of it [56]. We acknowledge that AMR is a complex and multifaceted issue that needs to be addressed at different levels, taking social and systemic factors into account. For this study, we decided to focus on the behavioral aspects, as these are proven to be an important factor contributing to AMR and lie within the scope of our community-based and participatory approach to develop an intervention. Nonetheless, systemic challenges might become clear within the course of our project and provide important insights for future research projects and policy and decision makers.

Although this study’s multidisciplinary approach offers innovative potential through the close collaboration of different disciplines during continuous (online) meetings and design thinking workshops, it will also present a challenge due to different perspectives, epistemologies, and methodologies. Furthermore, considering current realities and power relations within science, between disciplines and institutions in the so called “Global North” and the “Global South,” we acknowledge that the approach we are promoting through this work, although bottom-up and participatory through actively including community members and other stakeholders, can be challenged from many points of view. Therefore, this study will provide useful insights on how to mitigate such challenges and ensure equitable collaboration.

The generated results will be primarily relevant to the districts of the research project. However, due to direct contact with local, regional, and national stakeholders, the developed intervention can serve as a pilot project for a subsequent scale-up within Burkina Faso and Ghana, as well as other countries. It is expected that these interventions will contribute to improving the way the issue of AMR is addressed among communities, health care providers, livestock farmers, and institutional actors in LMIC. If the interventions in Kossi Province and Asante Akim North District provide positive results, the potential scale-up will be supported by the research team. To facilitate this process, national stakeholders will be informed and engaged right from the project’s inception. The results of this study will provide rigorous scientific evidence on the prevalence of AMR along the dominant food production chains and the perspectives and understanding of AMR among community members and stakeholders from the animal, environmental, and human health sectors in the 2 districts in Burkina Faso and Ghana. Furthermore, insights will be provided regarding the development of an AMR intervention through a participatory bottom-up approach using the design thinking process and the multidisciplinary One Health perspective.