Exploring the association between multi-dimensional poverty and antibiotic resistance: findings from a mixed-methods study in Pakistan.

Background: Poverty is a potential contributor to antibiotic resistance; however, the previous studies have not adequately addressed the role of poverty in shaping antibiotic resistance through social inequalities. Considering this, the current study evaluated the role of multi-dimensional poverty in antibiotic resistance. Methods: A mixed-method study was conducted in three provinces of Pakistan using multistage sampling to recruit physician-confirmed urinary tract infection (UTI) patients from public laboratories. Antibiotic resistance data were collected from susceptibility reports, while poverty was measured using the multi-dimensional poverty index (MPI). Water, sanitation and hygiene (WASH) practices were assessed through a self-developed, validated questionnaire. Survey-weighted logistic regression analysis examined the association between MPI and antibiotic resistance. Findings: A total of 698 patients were recruited, with more than half being in some level of deprivation (total = 413, vulnerable: 117, deprived: 76, severely deprived: 220). Multidimensional poverty was independently associated with increased odds of multidrug resistance (MDR). The risk of MDR was significantly increase across the deprivation level in unadjusted analysis (vulnerable; OR: 1.94, 95% CI 1.11-3.39, deprived; OR: 2.05, 95% CI 1.06-3.98, and severely deprived: OR: 1.80, 95% CI 1.04-3.09). After adjusting for antibiotics misuse and poor WASH practices, the association persisted. In the fully adjusted model, the risk of MDR was further increased in the poorer-subgroups, (vulnerable; aORs: 3.03, 95% CI 1.33-6.73, deprived; aOR: 3.01, 95% CI 1.26-7.15, and severely deprived; aOR: 4.28 95% CI 1.74-10.49). The qualitative interviews (n = 34) from patients highlighted that financial barriers drove self-medication with leftover antibiotics and treatment non-adherence. Poor WASH infrastructure was described as a systemic contributor to infection spread. In addition, patients in the poorer subgroups were presented with delayed treatment seeking. Interpretation: The risk of antibiotic resistance increases with the increasing levels of deprivation; however, we should not assume that higher deprivation directly drives antibiotic resistance. Instead, structural barriers such as limited healthcare access, poor WASH infrastructure, and financial constraints create an environment where self-medication, treatment non-adherence, and infection transmission occur across all poverty levels, not just because of individual choices. These findings emphasize the need for interventions that address healthcare inequities, improve WASH infrastructure, and regulate antibiotic access, combined with behavior-changing interventions. Funding: This work was funded by the "Young Talent Support Plan" of the Health Science Center, Xi'an Jiaotong University, and the National Natural Science Foundation of China (grant number 72274150).