A Framework for Integrating One Health in Antimicrobial Stewardship Programs

Thesis Abstract

This study investigates how a One Health framework can be operationalized within antimicrobial stewardship programs (ASPs) to optimize antimicrobial use across human, animal, and environmental sectors. The problem addressed is the persistent fragmentation between sectors that undermines stewardship efficacy, enabling antimicrobial resistance (AMR) progression. The aim is to develop and validate a comprehensive integrative framework that aligns governance, surveillance, and practice across sectors to enhance ASP performance. Specific objectives include (1) mapping current ASP architectures across human and veterinary health and environmental interfaces; (2) identifying determinants that facilitate or hinder cross-sector collaboration; (3) developing a theoretically grounded framework that specifies roles, processes, and indicators for One Health–oriented ASP implementation; (4) testing the framework's predictive validity against AMR trends and antibiotic use metrics; and (5) generating actionable recommendations for policy and practice. A mixed-methods design is employed, combining qualitative and quantitative strands to ensure depth and generalizability. The qualitative component uses purposive sampling to select 40 stakeholders across tertiary hospitals, veterinary clinics, agricultural settings, and environmental monitoring programs in three metropolitan regions. In-depth interviews (n=30) and focus groups (n=10) are analyzed using thematic analysis underpinned by the Institutional Theory and the Social Ecological Model to identify governance mechanisms, communication pathways, and operational barriers. The quantitative component collects cross-sectional survey data from a broader sample of 300 clinicians, veterinarians, farm managers, and environmental health professionals, and aggregates antimicrobial usage and resistance indicators from 24 facilities over a 24-month period. Instrument validity and reliability are established through content validity indices, Cronbach’s alpha, and pilot testing. Data integration employs a convergent parallel design with joint display matrices to triangulate qualitative themes with quantitative indicators. Analytical techniques include thematic analysis for interview transcripts, descriptive statistics and cluster analysis to profile ASP maturity, multiple regression to assess predictors of cross-sector collaboration, and time-series analysis (ARIMA) on AMR and antibiotic consumption data to evaluate framework impact. The analytical model integrates components from the One Health Systems Framework and the Capability, Opportunity, Motivation–Behavioral (COM-B) model to define indicators of institutional readiness, stakeholder engagement, and behavioral change in prescribing and dispensing practices. Model specification entails specifying endogenous variables representing cross-sector communication quality, integrated surveillance capacity, and policy alignment, with exogenous controls for region, facility type, and baseline AMR prevalence. Ethical approvals are obtained from institutional review boards, with informed consent, data anonymization, and cross-sector data-sharing agreements strictly observed. Key expected findings include (i) a diagnostic map of existing silos and enablers across human, animal, and environmental health sectors; (ii) a set of core process indicators and governance mechanisms that reliably predict improved antimicrobial use and reduced AMR trajectories; (iii) a validated One Health ASP framework comprising governance structures, integrated surveillance protocols, joint education and training modules, and standardized data-sharing procedures; and (iv) demonstration of the framework’s explanatory power for observed variations in AMR trends across settings. The study anticipates identifying context-specific adaptations required for different regional ecologies and stakeholder configurations. Contribution to knowledge centers on providing a theoretically informed, practically implementable framework that bridges One Health theory and antimicrobial stewardship practice, enabling systematic cross-sector collaboration and harmonized surveillance. The research advances methodological approaches to framework development in transdisciplinary health, combining Institutional Theory, COM-B, and integrated time-series analytics within a robust mixed-methods design. The main conclusion expected is that an operationalized One Health framework substantially enhances ASP effectiveness by institutionalizing cross-sector governance, shared surveillance data, and coordinated intervention strategies. Recommendations include policy directives for mandatory intersectoral antimicrobial surveillance data sharing, capacity-building programs for joint stewardship education, development of interoperable information systems, and phased scale-up plans tailored to regional AMR profiles.