Bridging the knowledge gap: capacity building and education on antimicrobial resistance (AMR)

While higher education has been outlined as key in sustainability educational efforts, including sustainable health, and for achieving the sustainable development goals (SDGs) (Sachs et al., 2019), a recurring challenge is how to realise this potential through clear educational objectives and effective strategies as highlighted by Isac et al. (2022) and Muchira et al. (2023) and referenced in Xiaojing and Chinaza (2024). Competence-centred education has been identified as crucial for enabling students to engage with sustainability challenges (including sustainable health) and the SDGs and to relate these wicked problems to their everyday lives by understanding and critically analysing key concepts in an effort to inform practice (Olsson et al., 2020; Xiaojing and Chinaza, 2024). Meanwhile, discussions of the transformative potential of competences have rarely included sustainable health challenges. As interdisciplinary collaborations are argued to be a condition for establishing holistic approaches to address sustainability challenges (Isac et al., 2022), competence-centred education faces challenges from the traditional disciplinary silos of higher education as well as the lack of resources and programs supporting educators to develop interdisciplinary skills and engagements around sustainability (Goller and Rieckmann, 2022).

Antimicrobial resistance (AMR) is a growing sustainable health challenge with serious implications for public health, food security and health-care systems, emerging when microbes develop resistance to antimicrobial pharmaceuticals due to overuse of antimicrobials in medicine, veterinary practice, agriculture and livestock raising (Jasovský et al., 2016). AMR poses a risk to modern medicine, with higher mortality and morbidity and increased pressures on healthcare systems (O'Neill, 2016; Laxminarayan et al., 2016). The World Health Organization (WHO) identifies AMR as a major health threat, predicting that by 2050, mortality will increase to 10 million deaths annually unless addressed comprehensively (WHO, 2021; Jonas et al., 2017; Murray et al., 2022). AMR poses a significant risk to multiple SDGs, undermining effective treatment of infections and common diseases (SDG 3: Good Health and Well-being) and threats to food security and safety of resistant infections in livestock (SDG 2: Zero Hunger) (UN, 2021). While AMR is increasingly recognised as a sustainability challenge, educational efforts have predominantly focused on individual behaviour and compliance in human health, with less attention given to structural aspects of AMR (Dixon et al., 2021; Mickelsson and Simbini, 2025). The prevalence of antimicrobial stewardship, prescription and public awareness campaigns are examples of this tendency. This creates a knowledge gap in terms of the potential role of sustainability competencies in AMR education and an implementation gap in how AMR policy is connected to educational practice. Comprehensive efforts are thus needed globally and nationally to address AMR, including education, working with health practitioners and communities based on a One Health approach interconnecting human, animal and environmental health (WHO, 2021; Velazquez-Meza et al., 2022). Educational efforts drawing on a One Health framework have leaned towards coordination and knowledge sharing between different health sectors and knowledge dissemination, while not fully exploring the potential of how to develop competencies of critical reflection and joint action across sectors. Focus has often been on the educational content with less emphasis on how learning can happen ways to support agency to realise change. This paper addresses the identified knowledge and implementation gaps through the integration of transformative learning theory (TLT) with UNESCO's eight sustainability competencies as part of how AMR education can enable the translation of policy objectives into practice.

There is a need to adapt AMR policy and relevant health education to local contextual conditions and needs, particularly in low-resource settings (Chandler et al., 2016). In Southern Africa, antimicrobial resistance is disproportionate to actual use and driven by the spread of resistant microbes through underwhelming water and sanitation infrastructure, further exacerbated by the use of antimicrobials in farming, such as small-scale poultry (Murray et al., 2022; Moyo et al., 2023; Mshana et al., 2021). In response to these challenges and calls from the WHO expressed in the Global Action Plan on AMR (WHO, 2015), national action plans have been developed in many countries (ZMHCC, 2017). To implement key objectives of these plans, educational efforts are a foundational pillar for other efforts in addressing AMR, promoting awareness, behaviour changes and equipping societal actors with the knowledge and skills needed to address AMR. Developing competencies among health practitioners and communities to understand, critically engage with and address sustainability challenges is a key part of AMR education and the successful implementation of AMR policies in diverse cultural, economic and infrastructural contexts (Pacis and VanWynsberghe, 2020). There is thus a need to move research on AMR education beyond descriptive accounts, including investigating how sustainability competencies can enable bridging the implementation gap between AMR awareness and action (Mickelsson and Oljans, 2025b; Oljans and Mickelsson, 2025).

Utilising health education in developing sustainability competencies (UNESCO, 2015) among health practitioners and communities becomes key in contextually relevant implementation of AMR policies in diverse cultural, economic and infrastructural conditions (Sartelli et al., 2020). Such health educational efforts come to encompass the raising of awareness among communities to the risk of antimicrobial abuse and the need for preventive practices and strengthening the understanding among health practitioners and policy makers regarding the importance of proper use of antimicrobials in human and animal health as well as the need for water and sanitary infrastructure in limiting the spread of resistance (Rocha et al., 2022). Without health education, even the most well-designed AMR action plans risk failing, as the success of AMR action plans hinges on education being fully integrated into the implementation, as educational programs help translate scientific guidelines into practical actions through higher education and social institutions into the everyday practices of health practitioners and communities (WHO, 2015; Fletcher-Miles et al., 2020). As such, education as a key component in AMR policy implementation highlights the relevance of SDG 4, Quality education, for addressing AMR as a sustainability challenge (United Nations, 2021). This paper seeks to contribute with a framework that connects AMR educational efforts to sustainability competencies as a comprehensive way to integrate knowledge, critical skills and value reflections to enable engagement with AMR as a complex sustainability challenge.

Key for AMR policy is to strengthen knowledge and agency around sustainability challenges on the part of health practitioners and communities, which can be achieved through education. To make progress towards the policy objectives of addressing the sustainability challenge, AMR education, as health education, focuses on the challenge of AMR need to equip health practitioners and communities with competencies to contribute to addressing AMR in their everyday practices (Glasser and Hirsh, 2016; Sterling et al., 2017). Our understanding of competencies draws on Glasser and Hirsh (2016), as constellations of values, skills and knowledges that provide societal actors with needed understandings and abilities to be active participants in critical and futures-oriented transformations in a more sustainable world. These knowledges, skills and values developed as part of such competencies are thus key for societal actors to become drivers and “change agents” in addressing the sustainability challenge of AMR (Wiek et al., 2011).

There is thus a gap in how change can be enacted, especially in contexts of limited resources and prevalent structural barriers, making AMR educational policy implementation complex (Mickelsson and Oljans, 2025b). Drawing on sustainability education research and particularly sustainability competencies, we seek to contribute to AMR education, which supports critical reflection and transformative change.

The aim of this paper is to explore how the development of sustainability competences as key components in AMR education can contribute to the implementation of AMR policies in practice. Two research questions are formulated,

1. What aspects of sustainability competencies are highlighted in workshop participants' discussions on AMR?

2. How could these competencies, as key components of AMR education, contribute to the implementation of AMR policies in practice?

In framing the paper, we draw on TLT (Mezirow, 1997, 2000), which provides a robust framework for understanding how individuals develop the competencies necessary for sustainable development. The WHO's sustainability competencies, such as systems thinking, normative competence and self-awareness, are not only outcomes of transformative learning (TL) but also serve as catalysts for deep personal and societal change. By aligning these competencies with the phases of TL, this study situates and orders them within a progressive pedagogical process that fosters critical reflection, dialogue and strategic action. Such integration is essential for equipping learners to navigate the complexities of global health and sustainability challenges. This framework details how critical reflection can enable deep perspective shifts in learners and provides key tools for engaging with challenging topics (Mezirow, 1997, 2000). Taking TLT further, Clark and Wilson (1991) and Scott (2003) argue for the need to consider how TL occurs in context. The behavioural change thus goes beyond the acquisition of new knowledge to include fundamental revisions of beliefs, attitudes and perceptions on the part of the learner, changing how they act based on these transformed understandings of themselves and the world (Merriam, 2004).

As highlighted by Alam (2021), TLT can contribute with insights regarding the design and implementation of educational interventions and evaluations of learning towards sustainability through the analysis of learning processes, results, and contextual conditions. TL becomes the process of facilitating learners to engage in deep changes to thinking, behaviour and practice that are essential for achieving sustainable development. Learners go from understanding sustainability challenges to taking practical actions that contribute to real-world sustainability. Through developing competencies such as critical reflection, ethical decision-making and collaborative problem-solving, learners are empowered to engage in behavioural change towards more sustainable behaviours, making decisions that are aligned with the SDGs (United Nations, 2015; UNESCO, 2017). These competencies are supported by TL as it enables learners to reflect on deeply held beliefs and adapt them in line with sustainable thinking (Mezirow, 2000; Merriam, 2004; Alam, 2021). To this end, TLT offers an analytical approach to understand how critical reflections can support AMR education and policy implementation, as part of examining how individuals and communities can adopt new practices and attitudes towards the conditions that drive the emergence and spread of resistance as a global health crisis (WHO, 2015; UNESCO, 2017; WHO, 2023).

TLT, coupled with UNESCO's key competences for sustainable development, provides a theoretically deep, critical and action-oriented framing for AMR education and policy implementation. Facilitating the development of competencies, such as critical reflection, systems thinking, collaboration and futures thinking, health practitioners and communities are able to shift their perspectives, generating transformative practices that contribute to addressing AMR. This framework thus links theory and practice through the use of competence-based TL.

The study operationalised participatory research workshops as its principal method (Ørngreen and Levinsen, 2017) and used case vignettes as the tool to structure the discussions and promote interdisciplinary collaboration within the workshops.

Working with case vignettes selected for their narrative potential in exploring dimensions of AMR and AMR policy implementation, participants engaged in interdisciplinary knowledge co-creation (Converse et al., 2015; Payton and Gould, 2022). Vignettes drew on relevant research and real-world experiences with antimicrobial use and resistance in Zimbabwe, with initial drafts of the vignettes being shared with interdisciplinary colleagues familiar with AMR in Zimbabwe. Their feedback was used to improve the vignettes for greater contextual relevance and linguistic clarity. The case vignettes focused on the impacts on health and food security from the usage of antibiotics (AB) and antiretrovirals (ARV) in beef cattle and poultry raising (See Mickelsson and Oljans, 2025a). As such, the two case vignettes addressed different aspects of the intersections between health, food and AMR, highlighting the use of antibiotics and antiretroviral drugs respectively by small-scale farmers in the line of food production and their impact on the health of humans, animals and ecosystems. The vignettes were closely aligned with the aim of the study, as it facilitated discussion around the complexity of sustainability challenges related to AMR. By presenting case scenarios, the vignettes enabled participants to reflect on and explore how key competencies in AMR education could contribute to the practical implementation of AMR policies.

Two one-day participatory research workshops were held at the Midlands State University, Gweru (provincial capital) and the University of Zimbabwe, Harare (national capital). The study involved 60 interdisciplinary participants, with 10 university lecturers and 20 university students conveniently and purposively sampled from each university (Bryman, 2017). They were recruited based on their experiential encounters from being part of physical, social and institutional environments across such diverse fields as education, veterinary science, medicine, pharmacy, agriculture and environmental science. The selection of participants was considered representative, as it included individuals from institutions and faculties relevant to food safety and public health in relation to AMR. Participants brought expertise from fields such as nutrition, microbiology, veterinary medicine, food technology and public health, ensuring a diverse and thematically appropriate range of perspectives. The selection of participants was based on a holistic understanding of sustainability and health, and encompassing participants from a range of departments and academic disciplines, all sharing an interest in the intersections of health, food, food security, sustainability and antimicrobial resistance. The development and organisation of the workshops focusing on exploring AMR education as a sustainability challenge was built on previous use of the participatory research workshop in research (Mickelsson et al., 2019). The authors co-facilitated the workshops, with note-taking to support transcription provided by colleagues from the respective universities. The vignettes were in the form of written stories that the participants listened to, while the text was displayed on a screen. The workshops followed a protocol of first introducing an overview of AMR as a wicked problem, followed by a first discussion where participants in small groups analysed the vignettes using guiding questions. During a second discussion, participants in the same groups revisited the vignettes using ethical/policy questions, including ethical considerations, responsibility, trade-offs and opportunities for systemic actions to identify interdependencies enacted in the vignettes. The workshops were audio-recorded and transcribed by the authors, supplemented by contemporaneous notes to support the transcription process and enhance the depth and accuracy of the transcripts.

As part of strengthening reliability, both authors coded the transcripts independently using the same analytical framework, supported in transcription and analysis by the contemporaneous notes taken during the workshops. This was followed by joint sessions in which coding was compared, and any differences were discussed with the aim of reaching an agreement for the analysis. Through this process the themes and especially sub-themes were provided further analytical nuance and clarity. To ground the analysis and interpretations in the empirical data, illustrative quotes were used for each theme and sub-theme.

The analysis utilised a combined deductive-inductive approach, where the deductive top-down approach was used in analysing the collected data, guided by the eight UNESCO key competences for sustainability (UNESCO, 2017), to explore how the development of sustainability competences can contribute to AMR education and policy implementation. Deductive qualitative content analysis is a theory-driven approach, starting with a pre-existing framework which is applied systematically to the data, allowing for the exploration of specific, predefined themes (Elo and Kyngäs, 2008; Lundy, 2007). In studying the interview transcripts, the analysis draws on previous knowledge and conceptual frameworks, identifying key concepts. In this case, the analysis is grounded in the eight UNESCO sustainability competencies, providing a structured lens through which to examine how participants discuss aspects of these key competencies in developing and implementing AMR policies. Simultaneously, to avoid limiting the analysis to just pre-defined categories, we used an inductive approach to capture unexpected insights in the data. This included conditions specific to the Zimbabwean context that were not accounted for by the sustainability competencies, including concepts of responsibility and gaps between AMR policy and everyday experiences and practices in engaging with AMR. Through the inductive analysis, we were able to characterise partially unexpected aspects as outlined in the 12 sub-themes in Table 2, which provides further nuance to the main themes of the sustainability competences. The UNESCO competencies are interrelated and cut across the SDGs, allowing citizens to interconnect the SDGs as part of efforts in the 2030 Agenda for sustainable development, and encompassing what citizens need in dealing with current complex sustainability challenges (UNESCO, 2017). Through our analysis, we identify aspects of the UNESCO key sustainability competencies, Systems thinking, Anticipatory, Normative, Strategic, Collaboration, Critical thinking, Self-awareness, Integrated problem-solving, including inductive sub-themes relevant to developing and implementing AMR policies (see Table 2). This combination of deductive and inductive analysis ensures that the analysis remains focused on understanding how aspects of these competences become key parts in AMR education while at the same time identifying unexpected, contextually relevant aspects of AMR education and meaningful implementation of AMR policies. By applying this framework, the analysis seeks to identify both the strengths and gaps in current AMR-related education and policy implementation, offering insights into areas where further development of aspects of these key competences is needed.

The deductive-inductive analysis follows six consecutive steps outlined in Table 1, providing a systematic, theory-driven and contextually relevant analysis. This meant that results are both linked to the global context through the deductive use of the UNESCO sustainability competencies and grounded in the Zimbabwean AMR education context through the inductive analysis.

Ethical approval for the study was received from the Medical Research Council of Zimbabwe (MRCZ/A/2920). Principles of informed consent and voluntary participation were adhered to by seeking permission from researchers and students at respective universities, providing them with a consent form and information sheet. These outlined the purpose of the study and workshop as well as the workshop process, including how research data would be collected, documented and managed after the workshop. Furthermore, the voluntary nature of the workshop and study was emphasised, giving the participants the freedom to leave at any point without having to justify their decision. Before signing the consent form, participating researchers and students were provided opportunities to raise questions regarding the research and workshop, with further opportunities offered during the workshop. The study adheres to the global code of conduct for research in resource-poor settings (TRUST, 2018). To provide confidentiality, no participant names were recorded as part of data collection and participant codes were used instead.

With ESD requiring more than the transmission of knowledge and transformation needed in how individuals perceive, reflect and act upon complex global challenges, our analytical framework enabled us to operationalise TLT as a powerful pedagogical lens for the progressive cultivation of sustainability competencies. This included emphasising the progress from disorienting dilemmas, critical reflection and dialogic learning to perspective transformation that can lead to meaningful action and reintegration. Drawing from WHO, UNESCO and Wiek et al. (2011), the progressive and integrated order of sustainability competencies set by UNESCO was used to analyse workshop discussions on how participants identified and discussed what is needed for developing and implementing AMR in local contexts. Competencies are progressive in the sense that they are mutually supportive and part of an integrated whole, enabling educators to design for pedagogical progression moving from understanding, comprehension, through evaluation, collaboration towards action. The analysis, structured around the eight sustainability competencies, resulted in the categorisation of a main theme, eight primary themes and twelve sub-themes providing further depth and highlighting contradictions and tensions emerging in the discussions (see Table 2). This meant that participants articulated certain competencies as more foundational for AMR education, while others were more linked to specific contextual conditions. As highlighted by the sub-themes, participants highlighted emerging tensions of AMR education and policy implementation, such as between short-term individual needs and long-term communal sustainability and unexpected synergies between conventional and traditional medicine. These competencies are not isolated skills but transformative capacities that enable learners to engage with sustainability challenges in holistic, ethical and future-oriented ways. Transformative learning unfolds through a series of phases that align with the development of sustainability competencies.

In the participants' discussions, systems thinking was one of the more recurring competencies. A theme related to systems thinking emerging from the participants' discussions is the understanding of relationships in AMR. The quote below highlights how the impact of antimicrobial use in livestock and small-scale farming needs to be understood in terms of how it affects the ecosystem as a whole.

As seen in the quotes, there is a need to understand relationships between the animals that are given antimicrobials and the environments they are part of. As these are closely linked, the use of antimicrobials affects more than the animals; it impacts the soil, the water and rivers and by extension the communities where the farmers live. Participants emphasised how antimicrobial use in animals could not be understood in isolation but must be analysed in relation to the ecosystem, water environments, human health and community livelihoods. To this end, developing and implementing AMR policies were framed as requiring the ability to identify and understand these interconnections and how actions and behaviours have results for human, animal and environmental health.

Another theme from the discussion related to the UNESCO competency of systems thinking is complex AMR systems analysis. These reflections illustrate how the participants went beyond recognising AMR as a complex systemic challenge to reflect on this complexity and engage with the resulting uncertainty. While participants identified what they perceived as resistance pathways between livestock and humans, they also acknowledged that changes in practices could impact resistance in unexpected ways. As highlighted in the quote below, AMR education for effective policy implementation needs to consider the complexity of the sustainability challenges, which are both intersectoral, including management of healthcare, agriculture and environment, and multileveled, encompassing local, regional and global considerations.

Highlighted by the quotes, the key for AMR education and policy implementation is the ability to analyse the different levels of the intersectoral challenge while accounting for what is not yet known, i.e. new practices involving antimicrobials in humans or animals resulting in the emergence and spread of resistance. Participants framed systems thinking as foundational in the sense that without engaging with these interconnections, new practices and efforts to address AMR risked lacking contextual relevance. Simultaneously, for the participants, the competence also encompassed an emerging tension between acknowledging complexity in AMR education and the need for clear and practice-oriented recommendations for small-scale farmers, communities and policymakers.

Anticipatory competence was in the participants' discussions often linked to risk assessment and envisioning futures, forming the theme AMR Risk Assessment in Future Scenarios. As illustrated by the quote, participants discussed how ongoing practices, including antimicrobial overuse in animals, could be envisioned as creating long-term health risks through the spread of resistant microbes in the local community.

As highlighted, these futures must then be assessed in terms of risks for health and sustainability. A second theme, identified in the participants' discussions, is AMR envisioning where communities are empowered to envision situations in which AMR has been successfully addressed.

In line with the quote, such a competence encompasses identifying how education is likely to lead to certain desirable outcomes and developing strategies to work towards this vision of sustainable health. Importantly, participants highlighted how envisioning could encompass both futures of risk and futures of possibilities, including using education to empower farmers and communities to become healthier and take a greater role in antimicrobial stewardship. Meanwhile, the discussions highlighted how these more positive visions of the future existed in tension with the immediate conditions of economic pressure and food insecurity, constraining future possibilities. While not as key as systems thinking, participants framed anticipatory competence as necessary to avoid AMR education becoming reactive.

In the participants' discussions, a theme related to normative competence was mentioned in the form of reflections on norms and negotiating sustainability values in AMR. The quote below highlights the need to be able to reflect on norms and navigate value trade-offs between long-term health risks and immediate food security, with participants emphasising competing priorities:.

As seen above, negotiating between norms regarding the emergence and spread of resistance (AMR) and the economic benefits of increased livestock growth or cheap meat becomes crucial for AMR education in effective policy implementation in context. This includes setting sustainability goals that are fair and understanding the ethical implications of practices and behaviours, and how different, sometimes conflicting, values are expressed through these practices and behaviours. Therefore, it becomes key to grasp conflicting interests and negotiate between these in situations of uncertainty to make AMR policy contextually relevant. Normative competence thus became, in the participants' discussions, more about ongoing value negotiation rather than specific skills, prompting AMR educational engagements to go beyond individual farmers to consider consumer practices, markets and social values.

Strategic competence was in the participants' discussions connected to the theme of developing and implementing innovative AMR actions. Illustrated by the quote below, participants saw potential for integrating traditional medicine with conventional medical approaches to AMR in creating contextually relevant approaches. Importantly, this did not represent a shift to traditional medicine but rather an effort to generate innovative and sustainable solutions adapted to community needs.

As seen, such innovative AMR actions respect and draw on the strengths of cultural practices in terms of healthcare access and trust for the community to address AMR. This highlights the necessity to engage and work with local communities in developing and implementing AMR policy to promote sustainable actions locally and nationally as part of AMR efforts. A further theme identified in the participants' discussions is AMR action at local levels. As seen in the following quote, AMR education and effective policy implementation involves the ability to act locally.

The quotes show that reducing antimicrobial use in livestock animals can be a key local action that contribute to addressing the challenge of AMR both locally and as part of broader mitigation efforts. Strategic competence around AMR was thus more than abstract planning, including identifying practice pathways to enable communities in connecting their ongoing activities to national and global AMR educational goals.

Critical AMR thinking competence emerging from the participants' discussions in reflecting on AMR perceptions and practices. As illustrated by the quote below, participants view the ability to question the shared information, status quo and routine practices while reflecting on the broader impacts of these practices and being able to push for change when required as important.

Highlighted is how the use of antimicrobials in healthy animals often have broader implications, making it essential to reflect on how we view the use of antimicrobials and their benefits and risks for not just ourselves but the communities we are part of. As such, being able to reflect on perceptions and practices is, according to the participants, key for both the effectiveness and the ethical soundness of AMR education and policy implementation. Critical thinking becomes highly relevant because it involves the ability to question assumptions, evaluate evidence and make balanced judgments in complex and uncertain situations. It illustrates not only the intellectual skill of problem analysis but also the practical competence of making responsible, informed choices in situations where the consequences extend beyond the individual to national or even global health.

Collaboration competence was discussed by the workshop participants as encompassing learning and empathy for AMR action. As seen in the following quotes, they emphasised the necessity to engage diverse stakeholders, farmers, health practitioners, interdisciplinary academics, communities and government officials as part of AMR education and policy implementation.

Highlighted by the quotes, stakeholder engagements should be characterised by collaboration and mutual respect and empathy to be able to understand and integrate the different stakeholders' perspectives and needs regarding addressing AMR. Collaboration thus encompasses both co-learning among stakeholders and the facilitation of participatory knowledge creation and problem-solving to address AMR. However, in the emphasis on collaboration, there was also tensions as participants highlighted how uneven power relations between farmers, communities, academics and government officials impact collaboration on equal terms.

A second theme emerging in the discussion was AMR conflict resolution. As highlighted by the quote, to develop and implement AMR policy requires the ability to manage conflicts between more short-term individual needs for economic and food security and the longer-term health interests of both the individual and the community.

As seen above, this illustrates an recurring tension with the immediate pressures of having food on the table and sending children to school, risking to crowd out the more societal challenge of reducing antimicrobial use and avoiding the emergence and spread of resistance. Based on participants’ discussions, it is thus key for collaboration to include joint dialogues and negotiating trade-offs to find common ground, while simultaneously acknowledging that addressing AMR in ways that consider all stakeholders equally will sometimes be a challenge.

Self-awareness competence was expressed by the workshop participants as a theme related to reflecting on roles and responsibilities in addressing AMR. Showcased by the following quote, participants highlighted the key importance of understanding what one's own role is in driving resistance and responsibility to address AMR. From the discussion, this includes recognising the impact of decisions and practices beyond immediate surroundings.

As seen above, participants emphasised a central tension in the need to weigh the immediate economic gains from giving antimicrobials to farming animals against long-term health risks associated with AMR for both the individual and society. This raised questions regarding accountability and shared responsibilities in AMR education. While it is important to recognise individual roles and responsibilities in addressing AMR, participants also brought attention to the role of communities and systemic factors to contextualise self-awareness and make it meaningful in relation to AMR. AMR self-awareness as a competence thus requires us all to engage in evaluation of our decisions and practices and to motivate ourselves to align these decisions and practices with the common good of addressing AMR.

A theme related to critical thinking competence emerging from the participants' discussions is integrated AMR solutions. As highlighted in the following quote, the ability to integrate multiple ways of knowing AMR becomes key in AMR education and policy implementation

Participants emphasise the need to combine traditional and conventional medical knowledge and practice as the basis for collaborative approaches to address AMR and provide viable and sustainable solutions. Linked is the theme of locally adapted AMR approaches, which the participants express as considering community conditions, needs and priorities, illustrated in the quote below.

As seen, such approaches become important to AMR education and policy implementation as they offer holistic perspectives on problem-solving that consider the contextual conditions of communities in promoting effective AMR management. This theme can be described as the competence to connect knowledge across disciplines, stakeholders and levels of action in order to address the complexity of antimicrobial resistance. Furthermore, it highlights the ability to synthesise diverse sources of information, navigate conflicting interests and co-create strategies that are both scientifically sound and socially feasible. This competence illustrates not only technical problem-solving skills but also systems thinking and the capacity to collaborate across sectors, which is essential in tackling a “One Health” challenge such as antimicrobial resistance.

The paper sought to explore how the development of sustainability competences as key components in AMR education can contribute to the implementation of AMR policies in practice. We operationalised TLT to bridge the implementation gap between knowing and doing through the developing of a sustainability competence-based framework for AMR education.

The results outline a multifaceted approach to AMR education and policy implementation, built on interdisciplinary collaborations and deeply rooted in communities' contextual conditions and needs. Through the developing an understanding of how sustainability competencies can be integrate in AMR education the identified knowledge gap is addressed, while illustrating how these competencies, operationalised using TLT to support educational practice contributes to the closing the implementation gap. This was key for the paper intention to provide a framework that integrate TLT and UNESCO sustainability competencies. The paper thus makes a conceptual contribution in linking TL with sustainability competencies while also providing an framework for AMR education as a practical contribution. TL provides a pedagogical framework through which sustainability competencies can be cultivated. As learners encounter disorienting dilemmas and engage in critical reflection and dialogue, they begin to internalize sustainability values and develop the capacity to act strategically. As such, TLT guides the bringing of the knowledge gap by connecting AMR awareness and understanding with abilities of context-relevant and reflective decision-making. Each competency aligns with a phase of TL, reinforcing the need for educational approaches that foster deep, value-driven change. The paper is thus providing an framework for educators to use in operationalising sustainability competencies as part of transformative AMR education. Through the papers’ framework, a structured approach is outlined which shifts AMR education towards competence building, emphasising how competences are build on the basis of systems thinking, collaboration and self-reflection while AMR policies are contextually adapted to educational practices through strategic and normative competencies. Three main outcomes from the results include a) the development of a competence-based framework for transformative AMR education and b) highlighting the possibilities of drawing on interdisciplinary collaborations and co-creation to bridge the implementation gap between knowledge and practice. While explorative, the results highlight how AMR education policies are shaped by contextual conditions, including water and sanitation and economic pressures. This indicates that these conditions need to be considered as part of developing sustainability competencies and interdisciplinary collaborations. Interdisciplinary collaborations throughout higher education, from medicine and veterinary sciences, through agriculture and dietetics, to education are thus all components of sustainable, effective and ethical AMR education and policy implementation (Wallace et al., 2016; Chandler et al., 2016; Rawson et al., 2020; Velazquez-Meza et al., 2022; WHO, 2021).

A key topic cutting across the themes identified in the results is the need for sustainable AMR efforts that take a long-term transformative perspective. TLT enables participants to shift from awareness to decision-making, fostering agency and critical reflection. Utilising a TLT framework (Mezirow, 1997, 2000), we argue that such sustainable efforts involve co-learners, academics across disciplines, critically reflecting on their knowledge and practices as part of societal norms. Transformative co-learning can thus generate shifts in perspectives on AMR and how the challenge can be addressed in practice (Clark and Wilson, 1991; Taylor, 2007; Scott, 2003). The results highlight how the implementation gap can be addressed through the integration of TL as part of AMR education, allowing the contextualisation of AMR challenges and co-creating ways to implement AMR policy. In the Zimbabwean case, the feasibility of such shifts in practice appears to rely on the ability to make affordances for structural challenges, including infrastructural limitations and resource scarcity. As highlighted in the paper, both agriculture and healthcare emerged as key in preventing the emergence and spread of resistance, addressing the underlying drivers of AMR (O'Neill, 2016). Crucially, these efforts need to go beyond prescriptive directives on minimising the use of antimicrobials by engaging communities and farmers around their everyday economic challenges (Goutard et al., 2017). The results highlights how sustainability competencies when integrated with TLT can contribute to bridging the implementation gap between knowledge and practice and as a conceptual framework form the basis for developing competence-based AMR educational efforts. Systems thinking in relation to AMR thus becomes an emergent practice linking participants antimicrobial prescriptions, livestock use and the health of local water ecosystems and communities. This highlights the importance of engaging with local practices and practitioners, which form a key component of the everyday realities that form the context for AMR education. Furthermore, results suggested the value of drawing on interdisciplinary research to identify and explore alternative methods for health promotion and disease prevention in livestock animals, as well as futures thinking to envision future challenges and opportunities in addressing AMR (Littmann and Viens, 2015; Laxminarayan et al., 2016; United Nations, 2021).

Applied to health education as part of higher education, engagements beyond and across disciplinary silos and interdisciplinary collaborations could be enabled by operationalising TLand One health approaches as part of competencies-centred sustainability education, contributing to achieving SDG 2, 3 and 4 (Sachs et al., 2019; Goller and Rieckmann, 2022). As highlighted in the results, the identified aspects of the UNESCO competences provide educational objectives and effective strategies as part of the development of these competences (Isac et al., 2022; Muchira et al., 2023; Xiaojing and Chinaza, 2024). Furthermore, the results emphasise the role of competences in providing higher education students with concrete avenues for critically and reflectively engaging with AMR and how these reflections can inform their practices (Olsson et al., 2020; Xiaojing and Chinaza, 2024). While preliminary, the results illustrate the potential value of curricula that enable students to engage with structural aspects of AMR, including resource scarcity and health inequalities. As part of supporting novel cross-sectoral practices, curriculum and educational modules could be developed that connect case-vignette supported learning with interdisciplinary projects that include students from health, agriculture, veterinary sciences, as well as education. This could be productively supported by establishing interdisciplinary curriculum committees on sustainable health challenges, such as AMR, which encompasses agricultural and veterinary lecturers in addition to those working in medicine.

Related to the relevance for health education is the need for collaborative efforts where AMR education and policy implementation are a whole-society affair, involving stakeholders across disciplines and sectors. Through collaboration that is supported by the government and NGOs, AMR policies and by extension health policies, can become effective, inclusive and critically supported by the health practitioners, farmers and communities that are set to implement them (World Health Organization, 2015; Murray et al., 2022; WHO, 2021). The results indicate that policy adaptation would need to extend beyond technical solutions to developing sustainability competencies as capacity-building for health practitioners in navigating structural challenges of AMR. Based on the results, important policy contributions would include integrating sustainability competencies as part of the national AMR action plan, as well as drawing on these competencies in AMR policy implementation. In adapting policy to structural conditions in Zimbabwe, competencies could be used in training future practitioners to actively engage with the structural challenges of AMR, such as limited water and sanitation.

Furthermore, a community-centric approach is presented as crucial in AMR education and policy implementation. This includes developing an understanding of communities’ incentives, needs and priorities, and how practices contribute to the emergence and spread of resistance, for human, animal and environmental health (Bloomfield et al., 2017). Communities thus develop agency in making responsible decisions on antimicrobial use (Chandler et al., 2016). The results highlight the potential value of engaging multiple ways of knowing and doing AMR as a productive starting point for furthering AMR education. An example would be to integrate traditional practices around raising livestock and the use of traditional medicinal plants to promote health and prevent disease in animals (Lam et al., 2021). A societal implication supported by the papers’ results would be to couple sustainability competencies with community engagement approaches, to have universities working together with communities in co-developing locally relevant approaches to AMR (Khumalo et al., 2024).

From the previous cross-cutting topics, practical strategies for health policy implementation through health education focused on AMR can be outlined. Integrating traditional medical practices of health promotion and disease prevention with conventional AMR efforts in both humans and animals has the potential to constitute a comprehensive strategy for lessening the dependence on antimicrobials (Van Boeckel et al., 2019). Contextual adaptation of AMR policies in particular and health policies in general to fit the economic, social and environmental conditions of local communities would, for example, acknowledge and consider the practices of small-scale farmers and the challenges they face (Robinson et al., 2016). These can be brought together in AMR and health education and policy implementation by focusing on collaborative systems for monitoring antibiotic use and resistance patterns in local contexts, extending to traditional medical practitioners and local communities. Community-level monitoring and reporting would generate feedback loops in which information from the community level informs ongoing policy development, implementation and revisions (WHO, 2021). Such efforts could build on citizen science approaches that use low-cost digital reporting platforms (Mickelsson et al., 2024). This would enable communities, small-scale farmers and community health practitioners to document antimicrobial use, water and sanitation challenges and local cases of infections and resistance. Reporting could furthermore provide valuable input in adapting and developing national AMR efforts and priorities. These topics could provide generative avenues of further research.

To support replication and future development, the presented framework could be extended to different educational settings by mapping sustainability competencies to contextual AMR educational objectives, pedagogically designing educational activities informed by TLT and evaluating competence development among students and policy implementation as part of AMR education using participatory research methods. This approach would enable researchers and educators to adapt the framework to diverse settings thus testing the relevance of the proposed framework and further develop it.

This paper explored how the development of sustainability competencies as key components of AMR education can address identified knowledge and implementation gaps, contributing to the linking of AMR policies to practice. Drawing on the UNESCO key competencies for sustainability, the papers’ results suggest that AMR education benefits from an sustainability competences-based interdisciplinary and inter-sectoral approach, where societal actors can collaborate to address the sustainability challenge of AMR. The paper illustrates how integrating sustainability competencies with TLT could inform and structure AMR educational objectives, informing how policy can be implemented as educational practices. TL is thus connected to sustainability competencies as part of the presented through educational competence development and policy implementation. By developing comprehensive sustainability competencies, including understanding relationships, risk assessment and envisioning, and reflections on norms and values, the identified knowledge gap can be addressed by providing conceptual depth regarding how sustainability competencies can be integrated with TLT as a conceptual framework for AMR education. The paper highlights ways to develop curriculum and educational modules across disciplines that embed sustainability competencies and TLT as part of addressing AMR challenges by developing and learners' critical reflection, collaboration and context-relevant decision making. In terms of policy, the paper indicates how integrating sustainability competencies and TLT as a key part of AMR national policy and action plans could further the adaptation of education to the structural conditions and realities in Zimbabwe, strengthening adaptive AMR policy implementation. Implications for the framework also extend to economic benefit of limiting antimicrobial dependency, improving animal health and supporting sustainable practices among small-scale farmers as part of AMR management. The research can inform AMR policy implementation by highlighting the importance of cross-sectoral competencies and educational approaches that support sustainable decision-making. It can be used in teaching to develop critical thinking around AMR governance, guide policymakers in designing inclusive strategies and contribute to research by deepening understanding of the social dimensions of AMR challenges.

In terms of societal implications, linking sustainability competencies with community engagement and citizen science approaches could enable university-community partnerships to develop localised antimicrobial and AMR monitoring and reporting systems, with education facilitating action on AMR. Through explicitly outlining how transformative education centred on sustainability competencies can bridge the gap between AMR educational policy and practice, the paper outlines the potential for adaptive, contextually relevant and adaptive AMR policy implementation. These contributions suggest potential areas for further empirical and conceptual research, especially regarding how sustainability competencies are articulated in diverse contextual conditions.

We acknowledge Dr Tecklah Usai and MSc. Doroth Chinofunga for their contribution to designing the study. We would also like to acknowledge the researchers, lecturers and students from Midland State University and the University of Zimbabwe, who contributed greatly to the research through their part in the participatory research workshops.