Gender and other intersecting factors in antimicrobial resistance for infectious diseases of poverty: a systematic evidence gap analysis in low- and lower-middle-income countries

Gender influences health outcomes by affecting exposure to risk factors, healthcare access, and health-seeking behaviours. Yet, many studies fail to consider how these gendered experiences interact with other social factors, such as age, socioeconomic status, and ethnicity. Our study systematically mapped existing research to identify gaps in understanding how these factors affect service delivery outcomes related to antimicrobial resistance (AMR) for infectious diseases of poverty. We conducted a systematic review and evidence gap map analysis following PRISMA 2020 guidelines. A comprehensive search was conducted across five major databases (MEDLINE, EMBASE, Scopus, Cochrane Library, and Web of Science) for studies published up to March 31, 2024. To synthesise the evidence, we developed and applied a specialized ‘Guide for an Intersectionality Approach’, adapted from established frameworks, to evaluate how gender identity, gender roles, and norms intersect with social factors like age, socioeconomic status, and ethnicity to influence AMR service delivery outcomes in Low- and Lower-Middle-Income Countries (LLMICs) for malaria, tuberculosis (TB) and neglected tropical diseases (NTDs). Out of 38,310 identified records, 14 studies met the inclusion criteria, all of which focused exclusively on TB; no eligible evidence was found for other infectious diseases of poverty like malaria or NTDs. While all included studies provided sex-disaggregated data, there was a significant lack of deeper intersectional analysis, with zero studies exploring non-traditional gender roles, power dynamics, or the compounded effects of intersecting social stratifiers. Findings indicated sex parity in diagnostic access but revealed male-specific vulnerabilities in treatment retention and a 4.06-fold higher risk of mortality for men. Conversely, women faced higher risks of treatment delays in certain contexts and often relied on informal antibiotic sources. There is a lack of studies evaluating how social determinants shaped by gender dynamics (roles, norms, relations, and power) influences inequities and vulnerabilities caused by AMR in LMICs. This gap limits our understanding of how these intersections affect antibiotic use, healthcare access, and treatment adherence. Future research should use intersectionality as an analytical framework and mixed-methods approaches to develop more inclusive and equitable health interventions that address the compounded inequities and vulnerabilities associated with gender and other social factors.