Article Information

Matteo Maria Cati

Adjunct Professor, Department of Economics, University of Bologna, Italy

*Corresponding author: Matteo Maria Cati, Adjunct Professor, Department of Economics, University of Bologna, Italy.

Received: 31 January 2023; Accepted: 07 February 2023; Published: 29 February 2024

Citation: Matteo Maria Cati. Advancing Behavioral Dynamics in Health Policy Decision-Making: Integrating Insights for Effective Vaccination Policy and Addressing AMR. Archives of Microbiology and Immunology. 8 (2024): 44-50.

Abstract

Keywords

Behavioral dynamics, Vaccination policy, Antimicrobial resistance, Tragic choices theory, Economic consequences, Health system implications

Article Details

1. Introduction

The increasing prevalence of antimicrobial resistance (AMR) poses a significant threat to global health. As the effectiveness of antibiotics declines, infectious diseases are becoming increasingly difficult to treat, leading to higher mortality rates, longer hospital stays, and increased healthcare costs. In this context, the role of behavioral science in shaping individual and collective responses to AMR becomes paramount. The concept of "tragic choices", introduced by eminent scholar Prof. Guido Calabresi [1-5], offers valuable insights into the complex decision-making processes that underpin public health policy. Tragic choices arise when policymakers are faced with dilemmas involving trade-offs between competing values or interests, often with no clear-cut solutions. In the context of AMR, policymakers grapple with difficult decisions, such as balancing the need to promote vaccination to protect public health with the potential risks associated with overusing antibiotics. Understanding the concept of tragic choices is crucial for crafting effective AMR mitigation strategies. By recognizing the inherent complexities and trade-offs involved in these decisions, policymakers can develop more nuanced and effective approaches that consider both the immediate and long-term consequences of their actions. In addition to the insights provided by Prof. Calabresi, the work of Nobel Laureate Prof. Vernon Smith offers valuable perspectives on behavioral dynamics and their relevance to public health policy. Prof. Smith's research has demonstrated that individuals often make decisions based on incomplete information and heuristics, rather than relying on rational cost-benefit analysis. This understanding is crucial for designing effective interventions to influence human behavior in the context of AMR, such as vaccination campaigns and antibiotic stewardship programs.

2. Methodology

This policy analysis utilizes an integrated behavioral framework encompassing a multi-step process to derive tailored interventions for improving vaccine uptake and antimicrobial stewardship. First, a systematic review of existing literature on behavioral barriers to infection control behaviors was conducted, identifying key decision-making biases including overconfidence, omission bias, risk compensation and distrust in health authorities that undermine compliance. Next, an ethical analysis was undertaken based on the "tragic trade-offs" framework elucidated by Guido Calabresi, weighing medical, economic and social considerations in public health policymaking. Finally, a set of behavioral interventions were formulated targeting individual, community and organizational levels, using incremental nudging approaches grounded in principles of libertarian paternalism while seeking to balance utilization of cognitive biases and preservation of autonomy. Interventions were selected based on demonstrated cost-effectiveness and scalability based on reviews of empirical evidence. This analytical approach combining policy analysis and behavioral decision science offers a novel paradigm for developing context-sensitive interventions while addressing ethical tensions.

2.2 Prof. Vernon Smith's Contributions to Behavioral Economics and Public Health Policy

Nobel Laureate Prof. Vernon Smith [6-10] is a pioneer in the field of behavioral economics, a branch of economics that explores how psychological, social, and cognitive factors influence individual and collective decision-making. His work has significantly enriched our understanding of human behavior and its implications for various domains, including public health policy. One of Prof. Smith's key contributions is his emphasis on the role of bounded rationality in economic decision-making. Bounded rationality acknowledges that individuals often make choices based on incomplete information, heuristics (rules of thumb), and emotions, rather than adhering to perfect rationality. This insight has significant implications for public health policy, as it suggests that traditional approaches, which often assume rational decision-making, may not be effective in influencing individual behaviors that contribute to public health outcomes.

For instance, vaccination campaigns often focus on providing detailed information about the risks and benefits of vaccination, assuming that individuals will make rational decisions based on this information. However, Prof. Smith's work suggests that individuals may not process or weigh this information in a purely rational manner. Instead, they may be influenced by factors such as social norms, the perceived risks of vaccination, and the convenience of getting vaccinated. Recognizing the limitations of bounded rationality, Prof. Smith advocates for using behavioral insights to design more effective public health interventions. This involves understanding the psychological and social factors that influence individual decisions and tailoring interventions to address these factors. For example, vaccination campaigns could incorporate social norms marketing, which highlights the fact that most people in a community are vaccinated, to encourage individuals to follow suit.

Prof. Smith's work also highlights the importance of considering ethical considerations when designing public health interventions. He emphasizes that interventions should respect individual autonomy and minimize unintended consequences. For instance, while incentives may be effective in increasing vaccination rates, they should be carefully designed to avoid potential coercion or exploitation. In conclusion, Prof. Vernon Smith's contributions to behavioral economics have significantly advanced our understanding of human behavior and its implications for public health policy. Furthemore fake news [11] may play a relevant role in deviating public opinion toward unsafe vaccine choices. By recognizing the limitations of bounded rationality and emphasizing the importance of behavioral insights and ethical considerations, policymakers can develop more effective and sustainable strategies to address public health challenges such as antimicrobial resistance (AMR).

2.3 Behavioral Dynamics in Decision-Making During Crises

Crises, such as the COVID-19 pandemic and the rising threat of AMR, pose significant challenges to health policy decision-making. As pointed out by Professor Calabresi many times Governments face ‘tragic chocies’ [12] when making decisions that involve trade-offs between competing values or interests, true dilemmas that have often relevant costs for the society. While scientific expertise is crucial, it is equally important to consider the behavioral dynamics that influence individual and collective responses to these challenges. Behavioral insights can provide valuable guidance for crafting effective and humane health policies in the context of vaccine uptake and AMR mitigation.

2.4 Understanding Behavioral Dynamics

Human behavior is complex and often influenced by cognitive biases, heuristics, and psychological factors. These factors can lead to a variety of decision-making biases, such as overconfidence [13-14], risk aversion, and social conformity. In times of crisis, these biases can be amplified, making it even more difficult for individuals and communities to make informed decisions about their health and well-being.

2.5 Overconfidence

Overconfidence [15, 16] is the tendency to overestimate one's own abilities, knowledge, or judgment. During a health crisis, overconfidence can lead individuals to believe they are less susceptible to the virus or the threat of AMR, or that they are able to handle the situation on their own, even when medical advice advises otherwise. This can lead to risky behaviors such as not seeking medical attention early enough, refusing to take necessary preventive measures, or delaying treatment for AMR infections.

2.6 Risk Aversion

Risk aversion [17-19] is the tendency to prefer options with known outcomes over options with unknown outcomes. During a health crisis, risk aversion can lead individuals to avoid taking necessary preventive measures, such as vaccination or seeking early treatment for AMR infections, out of fear of the unknown consequences [20]. This can be especially prevalent in individuals who have a history of negative experiences with vaccines or other medical procedures.

2.7 Social Conformity

Social conformity [21] is the tendency to conform to the beliefs and behaviors of one's peers. During a health crisis, social conformity [22-25] can lead individuals to follow the lead of their social circles, even if those behaviors are not in line with scientific recommendations. This can be seen in situations where individuals avoid wearing masks in public or refuse to get vaccinated because their friends or family are also not doing so.

2.8 Strategies to Mitigate the Impact of Behavioral Biases

In order to mitigate the impact of these biases and promote more effective public health outcomes, it is important to consider the following strategies:

1. Clear and consistent messaging [11, 26]: Provide clear and consistent messaging from trusted sources, emphasizing the importance of scientific evidence and debunking misinformation.
2. Focus on individual risk: Tailor messaging to highlight the personal risks associated with non-compliance, rather than focusing on societal risks.
3. Address social norms: Use social norms marketing to encourage behaviors that are seen as being socially acceptable.
4. Provide incentives: Offer incentives or rewards for complying with public health guidelines.
5. Promote education and awareness: Increase public awareness of the risks of AMR and the importance of vaccination.
6. Support research and development: Invest in research and development of new antibiotics and other antimicrobial treatments.

2.9 Implications of AMR for the Economic System

AMR [27] poses a significant economic threat to society. The World Health Organization (WHO) [28] estimates that AMR could cost the global economy up to $1 trillion by 2050. This includes the costs of increased healthcare expenditures, lost productivity, and premature deaths.

1. Increased Healthcare Expenditures: AMR is forcing hospitals and other healthcare providers to spend more money on treating infections, as existing antibiotics are becoming less effective. This is putting a strain on healthcare budgets and is making it more difficult to provide care to all patients.
2. Lost Productivity: AMR is costing the global economy billions of dollars in lost productivity each year. This is due to the fact that people with AMR-resistant infections are often sicker for longer periods of time and are more likely to miss work.
3. Premature Deaths: AMR is estimated to cause over 700,000 deaths each year worldwide. This is expected to increase to 10 million deaths per year by 2050 if nothing is done to address the problem.
4. Agriculture and Food Production: AMR is also a threat to agriculture and food production. As antibiotics become less effective, farmers will need to use more antibiotics to raise livestock and grow crops. This can lead to the development of antibiotic-resistant bacteria in food animals and plants, which can then be passed on to humans.
5. Travel and Trade: AMR can also make it more difficult and expensive to travel and trade internationally. Countries may restrict the movement of people and goods to prevent the spread of AMR-resistant bacteria.

2.10 Implications of AMR for the Health System

AMR is a major threat to the health system [29, 30]. It is making it increasingly difficult to treat common infections, and it is increasing the risk of death from these infections. AMR is also contributing to the rise of superbugs, which are bacteria that are resistant to all known antibiotics.

1. Increased Treatment Costs: AMR is making it more expensive to treat infections. This is because new antibiotics are expensive to develop and produce, and they are often only effective against a limited number of bacteria.
2. Increased Length of Stay: AMR is also increasing the length of stay in hospitals. This is because people with AMR-resistant infections are often sicker for longer periods of time and require more intensive care.
3. Increased Healthcare Worker Infections: AMR is also increasing the risk of healthcare worker infections. This is because healthcare workers are exposed to a wide variety of bacteria, including those that are resistant to antibiotics.
4. Increased Risk of Epidemics: AMR could also make it more difficult to control epidemics of infectious diseases. This is because antibiotics are an important tool for controlling the spread of disease, and their effectiveness is being eroded by AMR.

In summary AMR poses a significant threat to the health system [31], with its costs projected to reach $1 trillion by 2050. This is due to the increased cost of developing new antibiotics, the prolonged length of stay in hospitals for patients with AMR-resistant infections, the increased risk of healthcare worker infections, and the difficulty of controlling epidemics of infectious diseases.

2.11 Implications of AMR for the Economic System

Antimicrobial resistance (AMR) poses a significant economic threat [32-34] to societies worldwide, exerting pressure on healthcare systems, diminishing productivity, and inflating healthcare expenditures. The World Health Organization (WHO) estimates that AMR could incur global economic losses of up to $1 trillion by 2050, encompassing heightened healthcare costs, reduced productivity, and premature mortality.

Increased Healthcare Expenditures: AMR strains healthcare budgets as hospitals and medical facilities incur greater expenses in treating infections. With existing antibiotics losing efficacy, healthcare providers are compelled to resort to costlier treatments and novel therapies, exacerbating financial strains on healthcare systems globally. The escalation of healthcare expenditures further challenges equitable access to quality healthcare, underscoring the urgency of mitigating AMR's proliferation.

Lost Productivity: AMR-induced illnesses contribute to substantial productivity losses, impairing workforce efficiency and economic output. Individuals afflicted with AMR-resistant infections often experience prolonged illness durations, necessitating extended periods of absence from work. As a consequence, businesses endure diminished productivity, compromised operational efficiency, and elevated absenteeism rates, impeding economic growth trajectories.

Premature Deaths: AMR's toll extends beyond healthcare systems, manifesting in significant human losses and premature deaths. Annually, AMR-related infections claim over 700,000 lives worldwide, a figure projected to surge to 10 million fatalities annually by 2050 without decisive interventions. Premature mortality exacts immeasurable social and economic costs, depriving communities of productive contributors, exacerbating socioeconomic disparities, and impeding sustainable development efforts.

Agriculture and Food Production: AMR infiltrates agricultural ecosystems, engendering challenges in food production, animal husbandry, and crop cultivation. As antibiotics lose effectiveness, farmers resort to heightened antibiotic usage to mitigate disease outbreaks among livestock and enhance crop yields. However, indiscriminate antibiotic usage fosters the emergence of drug-resistant bacteria in agricultural settings, engendering food safety concerns, compromising animal welfare standards, and constraining international trade relations.

Travel and Trade: AMR imposes formidable impediments on global travel and trade dynamics, amplifying logistical complexities and economic inefficiencies. Nations institute stringent regulations and trade embargoes to contain the spread of AMR-resistant pathogens across borders, impeding the free flow of goods, services, and labor. Enhanced surveillance measures, quarantine protocols, and border controls further inflate operational costs and disrupt international trade networks, underscoring the imperative of collaborative, multilateral interventions to address AMR's ramifications.

In light of AMR's multifaceted economic repercussions, concerted efforts are imperative to mitigate its proliferation, foster antimicrobial stewardship, and fortify healthcare infrastructures. Effective interventions entail bolstering research and development endeavors, promoting judicious antibiotic prescribing practices, and fostering interdisciplinary collaborations across healthcare, agriculture, and policymaking domains. By prioritizing sustainable antimicrobial usage, investing in innovative therapeutic modalities, and fortifying global health systems, stakeholders can collectively mitigate the socioeconomic toll of AMR and safeguard public health on a global scale.

In summary AMR also has significant economic implications, with lost productivity estimated to reach trillions of dollars each year. This is due to the extended illness durations of patients with AMR-resistant infections and the reduced agricultural productivity caused by the use of antibiotics in livestock and crop production. According to recent reports, AMR is expected to cause a 3.8% reduction in annual global GDP by 2050 if left unchecked, amounting to approximately $3.4 trillion per year. In Europe alone, AMR could cost €1.5 trillion over the next 30 years in healthcare expenditures and productivity losses if effective interventions are not implemented. These staggering costs underscore the urgent need for evidence-based policies to curtail inappropriate antibiotic usage and promote antimicrobial stewardship across human medicine and agricultural sectors.

2.12 Concrete Examples of How Behavioral Science Has Been Used to Improve Vaccination Rates and Mitigate AMR

The use of behavioral science has been shown to be effective in improving vaccination rates [35] and mitigating AMR [36]. For example, vaccine reminders and incentives, social marketing campaigns, tailored messaging, addressing social norms, community engagement, mobile health interventions, and improving access to vaccination can all be effective strategies. In one study, researchers found that sending reminders to parents about upcoming vaccination appointments led to a 10% increase in vaccination rates. In another study, researchers found that offering incentives, such as gift cards or vouchers, for getting vaccinated led to a 40% increase in vaccination rates. Social marketing campaigns can also be effective in promoting vaccination. One study found that a social marketing campaign that used catchy slogans, testimonials from parents, and celebrity endorsements resulted in a 20% increase in vaccination rates. Tailored messaging is another effective strategy. One study found that providing parents with information about the specific benefits of vaccinating their child, such as reduced risk of serious illness, was more effective than generic messaging. Addressing social norms can also encourage people to get vaccinated. One study found that social norms marketing, which highlights the fact that most people in a community are already vaccinated, led to a 15% increase in vaccination rates. Community engagement is also important for improving vaccination rates. One study found that engaging with community leaders and organizations can help to build trust and support for vaccination programs. Mobile health interventions can be used to provide vaccination reminders, educational information, and even virtual consultations with healthcare providers. One study found that a mobile health application that provided these services led to a 25% increase in vaccination rates. Finally, improving access to vaccination can also help to increase vaccination rates. One study found that offering mobile clinics or extended hours at vaccination clinics led to a 10% increase in vaccination rates.

2.13 Limitations of Behavioral Approaches

While extant behavioral interventions provide promising strategies for shifting individual decisions related to vaccination and antimicrobial use, gaps remain in addressing organizational and systemic issues:

1. Most existing interventions focus on patients and providers, with less emphasis on influencing leadership support, institutional policies, and standard operating procedures in healthcare organizations that shape norms and decision architectures.
2. Evidence on sustainability and long-term impacts of behavioral approaches is mixed, with some studies showing attenuation after initial improvement. Evaluating enduring change merits further research.
3. Scalability has been examined only in limited trials to date; logistical complexities and costs associated with expansion to population levels are yet unknown across settings. Implementation science approaches could enhance generalizability.
4. Behavioral economics strategies derived primarily from Western cultural contexts may have variable effects in different cultural milieus due to variation in value orientations, power dynamics with health systems, and communal versus individual autonomy perspectives. More adaptable frameworks accounting for sociocultural variation should be explored through partnerships with local communities.

Expanding the evidence base around organizational-level programs, durability, scalability, and cross-cultural adaptability would accelerate progress in addressing the pressing challenges of vaccine avoidance and antibiotic overuse through behavioral science.

5. Conclusion

In conclusion, this paper has provided a comprehensive examination of the critical intersection between behavioral dynamics, health sciences, and policy, particularly in the context of addressing the threat of antimicrobial resistance (AMR). By drawing upon the profound insights of Nobel Laureate Prof. Vernon Smith and the nuanced "tragic choices" theory developed by eminent scholar Prof. Guido Calabresi, the study has sought to deepen our understanding of the intricate interplay between human behavior and effective health policy decision-making, with a specific focus on vaccination policy and AMR mitigation. The analysis has demonstrated that behavioral dynamics play a pivotal role in shaping individual and collective responses to public health crises, highlighting the need for policymakers to consider these factors when crafting and implementing interventions.

The paper has further emphasized the economic and health system implications of AMR, highlighting the substantial costs associated with increased healthcare expenditures, lost productivity, premature deaths, and the potential disruption of global travel and trade. These implications underscore the urgent need for concerted efforts to mitigate AMR's proliferation and foster antimicrobial stewardship. In recognition of the complexities surrounding AMR, the paper has advocated for a multi-pronged approach that integrates behavioral insights, scientific knowledge, and ethical considerations. This approach should prioritize strategies such as:

1. Clear and consistent messaging that emphasizes the importance of scientific evidence and debunks misinformation
2. Tailored messaging that highlights the personal risks associated with non-compliance, rather than focusing on societal risks
3. Social norms marketing that encourages behaviors seen as being socially acceptable
4. Incentives and rewards for complying with public health guidelines
5. Education and awareness campaigns that increase public awareness of the risks of AMR and the importance of vaccination
6. Research and development of new antibiotics and other antimicrobial treatments

By embracing a comprehensive approach that incorporates behavioral science, we can effectively address the challenges posed by AMR and safeguard public health for generations to come. While promising, behavioral science strategies have limitations that warrant further research. Most behavioral interventions for improving infection control and prevention behaviors focus on individual decision-making at the patient or provider level (Meeker et al., 2020). Less emphasis has been placed on organizational, institutional and health system levels. Future studies should adopt a socioecological perspective and evaluate multi-level interventions encompassing individual, community, organizational and public policy components (Meeker et al., 2020).

Furthermore, more rigorous study designs and impact evaluations are needed to strengthen the evidence base for behavioral approaches to tackling AMR and improving vaccine uptake. Areas such as cost-effectiveness, intervention scalability and sustainability, and applicability across diverse socioeconomic and cultural settings remain open research questions. Addressing these gaps through robust research partnerships, advanced analytics, and increased funding commitments will accelerate progress against one of the most formidable global health challenges of our time.

Acknowledgements:

I express my sincere gratitude to the Nobel Laureate Prof. Vernon Smith for his invaluable contributions and profound insights shared during our recent email exchange. His expertise in Experimental Sciences significantly influenced the development of this research. I also acknowledge the enlightening conversations with Prof. Guido Calabresi, whose legendary insights have left an indelible mark on my understanding of Tragic Choices eventually made by Governemtns in times of health crisis during the Covid-19 pandemic. The synergy of Prof. Calabresi's and Prof. Smith's perspectives shaped the intellectual foundation of this work. Their generosity in sharing time and expertise is genuinely appreciated and resonates throughout this article.

References

1. Calabresi G, and Philip Bobbit, Tragic Choices (New York, NY: W.W. Norton and Company) (1978).
2. Calabresi G. The Pointlessness of Pareto: Carrying Coase Further," The Yale Law Journal 100 (1991): 1211–1237.
3. Calabresi G. The Future of Law and Economics – Essays in Reform and Recollection (New Haven and London, UK: Yale University Press) (2016).
4. Calabresi G. The Future of Law and Economics: Comments and Reflections, Jerusalem Review of Legal Studies, 16 (2017): 167–178.
5. Calabresi G, and Douglas Melamed A. "Property Rules, Liability Rules, and Inalienability: One View of the Cathedral," Harvard Law Review 85 (2007): 1089–1128.
6. Vernon L. Smith Nobel Prize Lecture Constructivism and ecological rationality in economics December 8, (2002).
7. Vernon L. Smith The Economy Will Survive the Coronavirus Don’t despair. Even amid the doom and gloom there are many things to be glad about. Wall Street journal – Opinion Commentary – April 5 (2020).
8. Vernon L. Smith Rational choice: The contrast between economics and psychology, Journal of Political Economy 99 (1991): 877-897.
9. Vernon L. Smith Experiments with a decentralized mechanism for public good decisions The American Economic Review 70 (1980): 584-599.
10. Vernon L. Smith Experimental methods in economics, Behavioural and experimental economics (2010): 120-136.
11. Matteo Maria Cati. Scientific Communication in the Storm: the War against the Fakedemic on COVID-19 Vaccines. Archives of Microbiology and Immunology 6 (2022): 171-187.
12. Matteo Maria Cati. Tragic Choices, Government Actions and the „domino effect?, the case of the COVID – 19 Syndemic and the Italian scenario. Journal of Pharmacy and Pharmacology Research 6 (2022): 15-24.
13. Salgado S, Berntsen D. It Won’t Happen to Us: Unrealistic Optimism Affects 571 COVID-19 Risk Assessments and Attitudes Regarding Protective Behaviour. Journal of 572 Applied Research in Memory and Cognition 10 (2021): 368–80.
14. Dolinski D, Dolinska B, Zmaczynska-Witek B, Banach M, Kulesza W. Unrealistic 538 Optimism in the Time of Coronavirus Pandemic: May It Help to Kill, If So—Whom: 539 Disease or the Person? JCM 9 (2020): 1464.
15. Weinstein, Neil D. Unrealistic Optimism About Future Life Events. Journal of Personality and Social Psychology, November 39 (1980): 806-20.
16. Taylor, Shelly E and Brown JD. "Illusion and Well-Being: A Social Psychological Per- spective on Mental Health." Psychological Bulletin, March 103 (1988): 193- 210.
17. Rabin M, Thaler RH. Anomalies, Risk Aversion.  Econ. Perspect15 (2001): 219–232.
18. Kahneman D. Maps of Bounded Rationality: Psychology for Behavioral Economics.  Econ. Rev93 (2003): 1449–1475.
19. Kahneman D, Knetsch JL, Thaler RH. Anomalies: The Endowment Effect, Loss Aversion, and Status Quo Bias.  Econ. Perspect5 (1991): 193–206.
20. Molins F, Sahin F, Serrano MÁ. The Genetics of Risk Aversion: A Systematic Review. Int J Environ Res Public Health 19 (2022): 14307.
21. Salali GD, Uysal MS, Bozyel G, Akpinar E, Aksu A. Does social influence affect COVID-19 vaccination intention among the unvaccinated? Evolutionary Human Sciences 4 (2022): e32.
22. Eva Vriens, Luca Tummolini, Giulia Andrighetto, Vaccine-hesitant people misperceive the social norm of vaccination, PNAS Nexus 2 (2023): 132.
23. Germar M, Albrecht T, Voss A, Mojzisch A. Social conformity is due to biased stimulus processing: electrophysiological and diffusion analyses. Soc Cogn Affect Neurosci 11 (2016): 1449-59.
24. Zaki J, Schirmer J, Mitchell JP. Social influence modulates the neural computation of value. Psychological Science22 (2011): 894–900.
25. Schnuerch R, Gibbons H. A review of neurocognitive mechanisms of social conformity. Social Psychology45 (2014): 466–78.
26. Thompson J, Bujalka H, McKeever S, Lipscomb A, Moore S, Hill N, et al. Educational strategies in the health professions to mitigate cognitive and implicit bias impact on decision making: a scoping review. BMC Med Educ 23 (2023): 455.
27. World Health Organization (WHO) World AMR Awearness Week. From 18 to 24 November (2023).
28. World Health Organization (W.H.O.) Antimicrobial resistance. Nov. 21 (2023).
29. Walsh TR, Gales AC, Laxminarayan R, Dodd PC. Antimicrobial Resistance: Addressing a Global Threat to Humanity. PLoS Med 20 (2023): e1004264.
30. Antimicrobial Resistance Collaborators Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis Lancet 399 (2022): 629–55.
31. World Health Organization. 10 global health issues to track in 2021 (2020).
32. Poudel AN, Zhu S, Cooper N, Little P, Tarrant C, Hickman M, Yao G. The economic burden of antibiotic resistance: A systematic review and meta-analysis. PLoS One 18 (2023): e0285170.
33. World Bank Group Final Report Drug-Resistant Infection A Threat to our Economic Future March (2017).
34. Porooshat Dadgostar (2019) Antimicrobial Resistance: Implications and Costs, Infection and Drug Resistance (2019): 3903-3910.
35. Michie S. Encouraging vaccine uptake: lessons from behavioural science. Nat Rev Immunol22 (2022): 527–528.
36. British Society for Antimicrobial Chemotherapy Vanguard Report: Behavioral Science and AMR (2022).