Deconstructing antimicrobial resistance national action plans: A gender-perspective driven mixed-methods analysis

INTRODUCTION: Antimicrobial resistance (AMR) is a major global health threat addressed through National Action Plans (NAPs) aligned with the WHO Global Action Plan. Despite evidence that women are disproportionately affected - receiving 27% more antibiotic prescriptions than men - gender considerations remain largely absent from AMR policies. METHODS: We conducted a mixed-methods analysis of 132 NAPs published before December 2023. A two-stage approach was used: quantitative keyword frequency analysis of 10 gender-related terms (e.g., sex, gender, women), followed by a qualitative thematic analysis of top-tier NAPs, defined as those scoring ≥3 gender-related terms on a 10-point frequency scale derived from the former quantitative analysis. We also examined the gender composition of NAP curators and assessed correlations between gender representation and keyword inclusion. RESULTS: Only 14 NAPs (11%) mentioned the term 'gender'. The most frequent gender-related term was 'urinary tract infection' (UTI), appearing in 33% of NAPs. High-scoring NAPs were predominantly from low-income countries (mean score 2.4, SD = 2.2), especially in Africa (mean 2.5, SD = 2.3), compared to upper-middle-income countries (mean 1.1, SD = 1.07) and the Pan-American region (mean 1.0, SD = 0.9). Women were underrepresented among NAP curators: 47 NAPs were led entirely by men, while only 14 were led by women. No significant correlation was found between women's participation and gender keyword inclusion (β ≈ 0.11, P = 0.449). CONCLUSION: Gender remains insufficiently integrated into AMR NAPs. The findings highlight the need for gender awareness policy development and the adoption of an intersectional framework to address overlapping social determinants that shape AMR vulnerability and response.