Pathways to antibiotics in Bangladesh: a qualitative study investigating how and when households access medicine including antibiotics for humans or animals when they are ill

Background To understand how to reduce antibiotic use, greater knowledge is needed about the complexities of access in countries with loose regulation or enforcement. This study aimed to explore how households in Bangladesh were accessing antimicrobials for themselves and their domestic animals. Methods In-depth interviews were conducted with 48 households in one urban and one rural area. Households were purposively sampled from two lower income strata, prioritising those with under 5-year olds, older adults, household animals and minority groups. Households where someone was currently ill with a suspected infection (13 households) were invited for a follow-up interview. Framework analysis was used to explore access to healthcare and medicines. Findings People accessed medicines for themselves through five pathways: drugs shops, private clinics, government/charitable hospitals, community/family planning clinics, and specialised/private hospitals. Drug shops provided direct access to medicines for common, less serious and acute illnesses. For persistent or serious illnesses, the healthcare pathway may include contacts with several of these settings, but often relied on medicines provided by drug shops. In the 13 households with an unwell family member, most received at least one course of antibiotics for this illness. Multiple and incomplete dosing were common even when prescribed by a qualified doctor. Antibiotics were identified by their high cost compared to other medicines. Cost was a reported barrier to purchasing full courses of antibiotics. Few households in the urban area kept household animals. In this rural area, government animal health workers provided most care for large household animals (cows), but drug shops were also important. Conclusions In Bangladesh, unregulated drug shops provide an essential route to medicines including those prescribed in the formal sector. Wherever licensed suppliers are scarce and expensive, regulations which prohibit this supply risk removing access entirely for many people

What contributes to inappropriate antibiotic dispensing among qualified and unqualified healthcare providers in Bangladesh? A qualitative study

Background Over-prescribing and inappropriate use of antibiotics contributes to the emergence of antimicrobial resistance (AMR). Few studies in low and middle-income settings have employed qualitative approaches to examine the drivers of antibiotic sale and dispensing across the full range of healthcare providers (HCPs). We aimed to explore understandings of the use and functions of antibiotics; awareness of AMR and perceived patient or customer demand and adherence among HCPs for human and animal medicine in Bangladesh. Methods We used an ethnographic approach to conduct face-to-face, in-depth interviews with 46 community HCPs in one urban and one rural area (Gazipur and Mirzapur districts respectively). We purposefully selected participants from four categories of provider in human and veterinary medicine: qualified; semi-qualified; auxiliary and unqualified. Using a grounded theory approach, thematic analysis was conducted using a framework method. Results Antibiotics were considered a medicine of power that gives quick results and works against almost all diseases, including viruses. The price of antibiotics was equated with power such that expensive antibiotics were considered the most powerful medicines. Antibiotics were also seen as preventative medicines. While some providers were well informed about antibiotic resistance and its causes, others were completely unaware. Many providers mistook antibiotic resistance as the side effects of antibiotics, both in human and animal medicine. Despite varied knowledge, providers showed concern about antibiotic resistance but responsibility for inappropriate antibiotic use was shifted to the patients and clients including owners of livestock and animals. Conclusions Misconceptions and misinformation led to a wide range of inappropriate uses of antibiotics across the different categories of human and animal healthcare providers. Low awareness of antibiotic action and antibiotic resistance were apparent among healthcare providers, particularly those with little or no training and those in rural areas. Specific and targeted interventions to address AMR in Bangladesh should include educational messages on the rational use of antibiotics and how they work, targeting all types of healthcare providers. While tailored training for providers may increase understanding of antibiotic action and improve practices, more far-reaching structural changes are required to influence and increase responsibility for optimising antibiotic dispensing among all HCPs

Designing a handwashing station for infrastructure-restricted communities in Bangladesh using the integrated behavioural model for water, sanitation and hygiene interventions (IBM-WASH).

BACKGROUND: In Bangladesh diarrhoeal disease and respiratory infections contribute significantly to morbidity and mortality. Handwashing with soap reduces the risk of infection; however, handwashing rates in infrastructure-restricted settings remain low. Handwashing stations--a dedicated, convenient location where both soap and water are available for handwashing--are associated with improved handwashing practices. Our aim was to identify a locally feasible and acceptable handwashing station that enabled frequent handwashing for two subsequent randomized trials testing the health effects of this behaviour. METHODS: We conducted formative research in the form of household trials of improved practices in urban and rural Bangladesh. Seven candidate handwashing technologies were tested by nine to ten households each during two iterative phases. We conducted interviews with participants during an introductory visit and two to five follow up visits over two to six weeks, depending on the phase. We used the Integrated Behavioural Model for Water, Sanitation and Hygiene (IBM-WASH) to guide selection of candidate handwashing stations and data analysis. Factors presented in the IBM-WASH informed thematic coding of interview transcripts and contextualized feasibility and acceptability of specific handwashing station designs. RESULTS: Factors that influenced selection of candidate designs were market availability of low cost, durable materials that were easy to replace or replenish in an infrastructure-restricted and shared environment. Water storage capacity, ease of use and maintenance, and quality of materials determined the acceptability and feasibility of specific handwashing station designs. After examining technology, psychosocial and contextual factors, we selected a handwashing system with two different water storage capacities, each with a tap, stand, basin, soapy water bottle and detergent powder for pilot testing in preparation for the subsequent randomized trials. CONCLUSIONS: A number of contextual, psychosocial and technological factors influence use of handwashing stations at five aggregate levels, from habitual to societal. In interventions that require a handwashing station to facilitate frequent handwashing with soap, elements of the technology, such as capacity, durability and location(s) within the household are key to high feasibility and acceptability. More than one handwashing station per household may be required. IBM-WASH helped guide the research and research in-turn helped validate the framework

Motivating antibiotic stewardship in Bangladesh:identifying audiences and target behaviours using the behaviour change wheel

BACKGROUND: South Asia is a hotspot for antimicrobial resistance due largely to over-the-counter antibiotic sales for humans and animals and from a lack of policy compliance among healthcare providers. Additionally, there is high population density and high infectious disease burden. This paper describes the development of social and behavioural change communication (SBCC) to increase the appropriate use of antibiotics.METHODS: We used formative research to explore contextual drivers of antibiotic sales, purchase, consumption/use and promotion among four groups: 1) households, 2) drug shop staff, 3) registered physicians and 4) pharmaceutical companies/medical sales representatives. We used formative research findings and an intervention design workshop with stakeholders to select target behaviours, prioritise audiences and develop SBCC messages, in consultation with a creative agency, and through pilots and feedback. The behaviour change wheel was used to summarise findings.RESULTS: Workshop participants identified behaviours considered amenable to change for all four groups. Household members and drug shop staff were prioritised as target audiences, both of which could be reached at drug shops. Among household members, there were two behaviours to change: suboptimal health seeking and ceasing antibiotic courses early. Thus, SBCC target behaviours included: seek registered physician consultations; ask whether the medicine provided is an antibiotic; ask for instructions on use and timing. Among drug shop staff, important antibiotic dispensing practices needed to change. SBCC target behaviours included: asking customers for prescriptions, referring them to registered physicians and increasing customer awareness by instructing that they were receiving antibiotics to take as a full course.CONCLUSIONS: We prioritised drug shops for intervention delivery to all drug shop staff and their customers to improve antibiotic stewardship. Knowledge deficits among these groups were notable and considered amenable to change using a SBCC intervention addressing improved health seeking behaviours, improved health literacy on antibiotic use, and provision of information on policy governing shops. Further intervention refinement should consider using participatory methods and address the impact on profit and livelihoods for drug shop staff for optimal compliance.</p

Gender and urban-rural influences on antibiotic purchasing and prescription use in retail drug shops: a One Health study

Introduction Few studies have reported antibiotic purchases from retail drug shops in relation to gender in low and middle-income countries (LMICs). Using a One Health approach, we aimed to examine gender dimensions of antibiotic purchases for humans and animals and use of prescriptions in retail drug shops in Bangladesh. Methods We conducted customer observations in 20 drug shops in one rural and one urban area. Customer gender, antibiotic purchases, and prescription use were recorded during a four-hour observation (2 sessions of 2 hours) in each shop. We included drug shops selling human medicine (n = 15); animal medicine (n = 3), and shops selling both human and animal medicine (n = 2). Results Of 582 observations, 31.6% of drug shop customers were women. Women comprised almost half of customers (47.1%) in urban drug shops but only 17.2% of customers in rural drug shops (p < 0.001). Antibiotic purchases were more common in urban than rural shops (21.6% versus 12.2% of all transactions, p = 0.003). Only a quarter (26.0%) of customers who purchased antibiotics used a prescription. Prescription use for antibiotics was more likely among women than men (odds ratio (OR) = 4.04, 95% CI 1.55, 10.55) and more likely among urban compared to rural customers (OR = 4.31 95% CI 1.34, 13.84). After adjusting for urban-rural locality, women remained more likely to use a prescription than men (adjusted OR = 3.38, 95% CI 1.26, 9.09) but this was in part due to antibiotics bought by men for animals without prescription. Customers in drug shops selling animal medicine had the lowest use of prescriptions for antibiotics (4.8% of antibiotic purchases). Conclusion This study found that nearly three-quarters of all antibiotics sold were without prescription, including antibiotics on the list of critically important antimicrobials for human medicine. Men attending drug shops were more likely to purchase antibiotics without a prescription compared to women, while women customers were underrepresented in rural drug shops. Antibiotic stewardship initiatives in the community need to consider gender and urban-rural dimensions of drug shop uptake and prescription use for antibiotics in both human and animal medicine. Such initiatives could strengthen National Action Plans

Provision versus promotion to develop a handwashing station: the effect on desired handwashing behavior

Abstract Background Diarrhea prevalence increases from around the time that complementary foods are introduced. Improving caregiver’s hand hygiene during food preparation could reduce complementary food contamination and enteric pathogen transmission. Washing hands with soap is more common when water and soap are together at a convenient location. We conducted a three-month pilot intervention to evaluate two options for setting up handwashing stations: i) provide a handwashing station, or ii) help the family to make their own from available materials. Additionally, we assessed the feasibility of this intervention to be integrated with a child feeding program. Methods We conducted the intervention among two groups; 40 households received a free of cost handwashing station and another 40 households were motivated to place their own soap/soapy-water and water vessel near the food preparation and child feeding area. Community health workers encouraged caregivers to wash hands with soap/soapy-water before food preparation and feeding a child. They either assisted study participants to install the study-provided handwashing station at the recommended place or encouraged caregivers to develop their own. Field researchers assessed placement and composition of handwashing stations and the feasibility of integrating handwashing and nutrition messages. Results By end of the trial, 39/40 households developed their own handwashing station, comprising a bucket, mug and bar soap/soapy-water of which 60% (6/10) households were observed with a functional and complete handwashing station set. Observed handwashing with soap was detected among 8/10 households from the study-provided handwashing station group and 5/10 among households who had made their own handwashing station. Sixty-seven of the 76 caregivers recalled integrated intervention messages on social and health benefits of infant and young child feeding correctly; and all recalled key handwashing with soap times, before food preparation and feeding a child. Conclusion Encouraging households to develop their own handwashing station with soap and water to place at a food preparation/child feeding location is feasible over the short term. In the absence of large-scale provision of handwashing stations, caregivers can be encouraged to create and use their own. Integrating handwashing with soap into a nutrition intervention was feasible and acceptable and should be considered by policy makers

Pathways of antibiotic use in Bangladesh: qualitative protocol for the PAUSE study

Introduction: Global actions to reduce antimicrobial resistance (AMR) include optimising the use of antimicrobial medicines in human and animal health. In countries with weak healthcare regulation, this requires a greater understanding of the drivers of antibiotic use from the perspective of providers and consumers. In Bangladesh, there is limited research on household decision-making and healthcare seeking in relation to antibiotic use and consumption for humans and livestock. Knowledge is similarly lacking on factors influencing the supply and demand for antibiotics among qualified and unqualified healthcare providers. The aim of this study is to conduct integrated research on household decision-making for healthcare and antibiotic use, as well as the awareness, behaviours and priorities of healthcare providers and sellers of antibiotics to translate into policy development and implementation. Methods and analysis: In-depth interviews will be conducted with (1) household members responsible for decision-making about illness and antibiotic use for family and livestock; (2) qualified and unqualified private and government healthcare providers in human and animal medicine and (3) stakeholders and policy-makers as key informants on the development and implementation of policy around AMR. Participant observation within retail drug shops will also be carried out. Qualitative methods will include a thematic framework analysis. A holistic approach to understanding who makes decisions on the sale and use of antibiotics, and what drives healthcare seeking in Bangladesh will enable identification of routes to behavioural change and the development of effective interventions to reduce the health risks of AMR. Ethics and dissemination: Approval for the study has been obtained from the Institutional Review Board at the International Centre for Diarrhoeal Disease Research, Bangladesh following review by the Research and Ethics Committees (PR-16100) and from Loughborough University (R17-P081). Information about the study will be provided in a participant information letter in Bangla (to be read verbally and given in writing to participants). A written informed consent form in Bangla will be obtained and participants will be informed of their right to withdraw from the study. Dissemination will take place through a 1 day dissemination workshop with key stakeholders in public health and policy, practitioners and scientists in Bangladesh, and through international conference presentations and peer-review publications. Anonymised transcripts of interviews will be made available through open access via institutional data repositories after an embargo period

Barriers and facilitators to adherence to national drug policies on antibiotic prescribing and dispensing in Bangladesh

Background: The National Drug Policy in Bangladesh prohibits the sale and distribution of antibiotics without prescription from a registered physician. Compliance with this policy is poor; prescribing antibiotics by unqualified practitioners is common and over-the-counter dispensing widespread. In Bangladesh, unqualified practitioners such as drug shop operators are a major source of healthcare for the poor and disadvantaged. This paper reports on policy awareness among drug shop operators and their customers and identifies current dispensing practices, barriers and facilitators to policy adherence.  Methods: We conducted a qualitative study in rural and urban Bangladesh from June 2019 to August 2020. This included co-design workshops (n = 4) and in-depth interviews (n = 24) with drug shop operators and customers/household members, key informant interviews (n = 12) with key personnel involved in aspects of the antibiotic supply chain including pharmaceutical company representatives, and model drug shop operators; and a group discussion with stakeholders representing key actors in informal market systems namely: representatives from the government, private sector, not-for-profit sector and membership organizations.  Results: Barriers to policy compliance among drug shop operators included limited knowledge of government drug policies, or the government-led Bangladesh Pharmacy Model Initiative (BPMI), a national guideline piloted to regulate drug sales. Drug shop operators had no clear knowledge of different antibiotic generations, how and for what diseases antibiotics work contributing to inappropriate antibiotic dispensing. Nonetheless, drug shop operators wanted the right to prescribe antibiotics based on having completed related training. Drug shop customers cited poor healthcare facilities and inadequate numbers of attending physician as a barrier to obtaining prescriptions and they described difficulties differentiating between qualified and unqualified providers.  Conclusion: Awareness of the National Drug Policy and the BPMI was limited among urban and rural drug shop operators. Poor antibiotic prescribing practice is additionally hampered by a shortage of qualified physicians; cultural and economic barriers to accessing qualified physicians, and poor implementation of regulations. Increasing qualified physician access and increasing training and certification of drug shop operators could improve the alignment of practices with national policy.</p

Piloting a low-cost hardware intervention to reduce improper disposal of solid waste in communal toilets in low-income settlements in Dhaka, Bangladesh

Abstract Background Bangladesh faces daunting challenges in addressing the sanitation needs of its urban poor. Maintaining the cleanliness and functionality of communal toilets is dependent upon periodic emptying of fecal sludge, and cooperation between users of communal toilets. Trash disposal into latrines can block the outflow pipes, rendering the toilets non-functional. Methods Pre-intervention: We conducted in-depth interviews with five operators of fecal sludge emptying equipment and five adult residents who were also caregivers of children. We identified factors contributing to improper disposal of trash into communal toilets, a barrier to operation of the equipment, in low-income communities of Dhaka, Bangladesh. Intervention design: We developed behavior change communication materials to discourage waste disposal in toilets, and promote use of waste bins. We conducted six focus group discussions with adult male, female, landlord and children to select the preferred design for waste bins to be placed inside toilets, and finalize communication materials. Post-intervention: We then pilot-tested an intervention package to promote appropriate trash disposal practices and thus facilitate periodic removal of fecal sludge when the latrine pits become full. We conducted 20 in-depth interviews and four focus group discussions with community residents, landlords and cleaners of communal toilets. Results Barriers to appropriate waste disposal included lack of private location for disposal of menstrual hygiene products, limited options for formal trash collection and disposal, and the use of plastic bags for disposing children’s feces. A pilot intervention including behavior change communication and trash bins was implemented in two urban slum communities. Spot checks confirmed that the bins were in place and used. Respondents described positive improvements in the appearance of the toilet and surrounding environment. Conclusion The current practice on the part of local residents of disposing of waste into toilets impedes the safe removal of fecal sludge and impairs toilet functionality. Residents reported positive changes in toilet cleanliness and usability resulting from this intervention, and this both improves the user experience with toilets, and also promotes the sustainability of the entrepreneurial model of Vacutug operators supported by WSUP