Risk Perception and Psychosocial Factors Influencing Exposure to Antimicrobial Resistance through Environmental Pathways in Malawi

Antimicrobial-resistant (AMR) bacteria are prevalent in household and environmental settings in low-income locations. However, there are limited data on individuals' understanding of AMR bacteria exposure risks in these settings. A cross-sectional study was conducted to identify individual risk perception of AMR bacteria and its associated behavioral determinants at the household level in urban, peri-urban, and rural Malawi. We conducted interviews with 529 participants from 300 households (n = 100 households/site). The risk, attitude, norms, ability, and self-regulation model was used to assess psychosocial factors underlying AMR bacteria exposure through animal feces, river water, and drain water. Analysis of variance was used to assess the difference between doers and non-doers of the three targeted behaviors: use and contact with river water, contact with drain water, and contact with animal feces. There was limited understanding regarding human-environmental interactions facilitating AMR bacteria transmission across all sites, and as such, the perceived risk of contracting AMR infection was low (41%; P = 0.189). Human contact with animal feces was seen as risky (64%) compared with contact with river and drain water (17%). Urban participants perceived that they were at greater risk of AMR bacteria exposure than their rural counterparts (P = 0.001). The perception of social norms was favorable for the targeted behaviors (P = 0.001), as well as self-reported attitude and ability estimates (self-efficacy; P = 0.023), thus indicating the role of psychosocial factors influencing the human-environment interaction in AMR bacteria transmission. Our findings underscore the need for combined infrastructural improvements and behavior-centered AMR bacteria education to drive behavioral changes, benefiting both AMR infection mitigation and broader One Health initiatives.