Applying a gender and equity matrix for a contextualized antimicrobial stewardship intervention in Pakistan

Antimicrobial resistance (AMR) is a growing global health threat that extends beyond biomedical dimensions, as it is profoundly shaped by social and structural determinants such as gender, socioeconomic status, and access to care. However, research exploring these factors remains limited. This study adapts and applies a gender and equity matrix to examine how these factors intersect to affect AMR risks in rural Pakistan. We synthesized literature on antibiotic prescription and use in Pakistan and similar sociocultural and economic context settings, focusing on upper respiratory tract and diarrhoeal infections. We then integrated these findings with insights from a structured consultation with gender and public health experts. The gender and equity matrix mapped inequities across three topic-specific domains-susceptibility/vulnerability to infection, care provision (during facility visits), and care uptake (before and after facility visits)-cross-referenced with biological and social stratifiers along with gender analysis domains. Findings were synthesized into cross-cutting themes to identify actionable drivers of AMR. The context analysis highlighted persistent gender- and equity-related barriers in access to care, including women's limited mobility, lower health literacy, and restricted decision-making autonomy. We also identified structural constraints, including limited household financial resources that result in women being deprioritized for care, alongside gender-insensitive health care service delivery. In rural low- and middle-income countries' settings, addressing these barriers requires gender-responsive health system design, equitable provider-patient communication, and interventions that reduce economic and physical barriers to care uptake. The gender and equity matrix offers a structured approach to reveal how social and structural determinants interact to drive AMR risks, providing a practical tool for systematically integrating gender and equity considerations into AMR policy and programming.