Antimicrobial Resistance in Refugee Settings : Cultural and Operational Barriers to Stewardship and Implications for Humanitarian Health Systems

Antimicrobial resistance (AMR) is an urgent and growing threat to global and humanitarian health systems, particularly in refugee settings where overcrowding, poverty, and fragile infrastructure accelerate the spread of resistant infections. This thesis explores the cultural and operational barriers to antimicrobial stewardship (AMS) in these contexts through a thematic synthesis of existing qualitative research and grey literature. Guided by the WHO health systems building-blocks framework and informed by a people-centred health perspective, the analysis identifies four key barriers that undermine stewardship efforts: gaps in community knowledge and health beliefs, systemic limitations in the health workforce, restricted access to healthcare services, and governance failures. The study reveals how social determinants of health, such as education, living situations and legal status, shape both access to antibiotics and patterns of use. The thesis argues that humanitarian actors have a pivotal role in adapting AMS strategies to the realities of displacement. This includes developing culturally appropriate health education tools, supporting task-sharing within overstretched health workforces and integrating AMS with broader health interventions. It calls for renewed urgency and cross-sector collaboration to prevent AMR from evolving into a widespread humanitarian crisis, especially in already marginalised populations.