Antimicrobial resistance in the Northern Territory, Australia: insights from a systems thinking approach to human health

BACKGROUND: Antimicrobial resistance (AMR) is a complex global health threat, contributing to an estimated 4.95 million deaths worldwide with disproportionate impacts across regions. In Australia, the burden varies geographically with up to 50% of infections resistant to antibiotics in northern Australia. This qualitative study engaged stakeholders across One Health sectors to explore the dynamics influencing AMR in the Northern Territory. METHODS: Thirty-five participants across human, animal, environmental and cross-sectoral systems were consulted through interviews and focus groups. Thematic analysis informed the development of a causal loop diagram, grounded in systems thinking, to illustrate complex interactions among factors driving AMR. This paper focuses on key factors and feedback loops influencing AMR in human health. RESULTS: The causal loop diagram revealed dynamic, interconnected factors driving AMR through reinforcing and balancing feedback loops. Key drivers included antibiotic prescribing and use across human and animal health, as well as antimicrobial residues in the environment. Crucially, broader structural determinants, such as geographical isolation, health system limitations and social inequities, also shaped AMR dynamics. Consequently, reducing antibiotic use alone is unlikely to be sufficient to control AMR. While antimicrobial stewardship and infection prevention and control remain critical, additional leverage points for intervention were identified. These include culturally safe care, healthcare workforce training and retention, improved AMR awareness among professionals and communities, and investment in upstream determinants of health, such as functional housing and access to essential infrastructure. CONCLUSIONS: In regions with a high infectious disease burden, addressing AMR requires a shift from reactive, clinical models to proactive, community-based strategies. Given its systemic complexity, AMR and similar health challenges cannot be addressed by health systems alone or through siloed interventions. Coordinated, multi-sectoral and systems-informed approaches are essential to achieve sustainable impact.