Gender and equity within antimicrobial resistance: a scoping review of evidence and policy in Bangladesh and Sri Lanka.

Antimicrobial resistance (AMR) is a significant public health concern, disproportionately affecting Low-and-Middle-Income countries (LMICs) across Southeast Asia, including Bangladesh and Sri Lanka. This WHO region faces a high burden of AMR, which is driven by social, biological, and structural factors. Social determinants such as poverty, education, healthcare access, and gender roles and norms contributed significantly to the non-recommended use of antimicrobials. Despite this growing burden, there is limited research on the social dimensions of AMR, including how gender norms and disparities shaped AMR in Bangladesh and Sri Lanka. This scoping review investigated how gender and equity interact with intersectional factors, including biology, age, and socioeconomic status, as well as complex power structures shaping AMR in Bangladesh and Sri Lanka, and assessed gender and equity inclusion within AMR national policy, guidelines, reports, and the National Action Plan. PubMed, Scopus, Google Scholar, and Index Medicus for South-East Asia Region (IMSEAR) were searched for peer-reviewed articles, and institutional websites were searched for grey literature published in English between 2014 and 2024. Data was extracted, charted, and analyzed through a thematic framework by using an intersectional lens and WHO Gender-responsive Assessment Scale. Our review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol (PRISMA-P) and its Extension for Scoping Reviews (PRISMA- ScR) checklist. This review identified 60 studies (38 from Bangladesh, 22 from Sri Lanka) and 30 grey documents; including policy, National Action Plans (NAPs), guidelines, and reports. Of the empirical studies, 53 (88%) used quantitative methods, 5 were qualitative, and 2 used mixed methods, with 47 studies (78%) focused on human health. Among the included studies, 70% (42) reported gender-related differences in AMR knowledge, attitudes, practices, exposure, or access, and 45% (27 studies) highlighted reliance on informal drug sellers. Using an intersectional lens, this study revealed a significant impact of the complex interplay between gender, social determinants, and structural inequalities. Women's AMR exposure and barriers to recommended antimicrobial use were shaped by their high biological susceptibility, limited healthcare access, financial dependency, limited decision-making autonomy, caregiving roles, and reliance on informal providers. Men's AMR risk and barriers to recommended antimicrobial use were influenced by their occupational exposure, over-reliance on informal providers, past experience, social-network influence, and easy access with financial and decision-making autonomy. Additionally, this review identified critical gaps, including a lack of gender-disaggregated data and the absence of gender and equity dimensions in national documents and policies. The findings highlighted the importance of incorporating gender-responsive indicators in surveillance systems, and targeted context-specific awareness campaigns must be integrated into AMR research, policy, and healthcare systems to identify inequities and effective implementation.