Who gets what and when? Pathways of antibiotic use among people and animals in Bangladesh

Lead Research Organisation: Loughborough University
Department Name: Sch of Sport Exercise & Health Sciences


Bangladesh is a low-income country with an estimated 40% of the population living in extreme poverty. Against this background of poverty, Bangladesh is internationally recognised for achieving 'good health at low cost' through community-based interventions to improve the health of the most disadvantaged. However, antibiotic resistant bacteria are known to be present in drinking water, wastewater and in patient samples, and the availability of over-the-counter, inexpensive antibiotics means that there is a high risk of a rapid and uncontrolled spread of antibiotic resistance throughout the population. Studies in Bangladesh suggest that 63% of prescriptions for antibiotics are from practitioners with no qualifications, and antibiotics are prescribed in nearly half (44%) of all consultations in primary health care. Tackling antibiotic resistance is essential for the long term economic development and welfare of the country.
In order to slow the spread of antibiotic resistance, there are complexities around balancing the need for access to health for the disadvantaged, at the same time as introducing greater regulation around the prescribing and ready availability of antibiotics. Research is required to better understand the needs of households and individuals for antibiotic treatment for their family and livestock, as well as understanding the prescribing behaviours of qualified and unqualified practitioners.
We will study the pathways of antibiotic use 1) from the perspective of lay people who buy or consume antibiotics either for themselves, family members or for livestock and 2) from the perspective of the healthcare practitioners, including qualified and unqualified providers (market sellers, unqualified drug shop owners and untrained 'doctors'). Through in-depth interviews in urban and rural Bangladesh, we will gain a better understanding of behaviours around antibiotic prescribing and consumption as well as establishing whether there is an awareness of antibiotic resistance among healthcare practitioners, or their patients and clients. By interviewing practitioners across the whole range of formal and informal outlets we will assess the potential for practitioners to change prescribing practices or act as agents of change. The third aim of the study is to work with government and non-government agencies to inform the development of interventions to reduce antibiotic use. We will use the formative research from interviews to work with a professional communication team to develop culturally appropriate messages and materials for awareness-raising and communication campaigns on antibiotic resistance. These materials will be pre-tested with lay people, healthcare providers and drug shop owners to establish the acceptability of messages, who should be targeted, and what potential there is for the users and stakeholders in antimicrobial resistance to develop national awareness-raising or behaviour change interventions.
The benefits of this research are to shed light on the behaviours around antibiotic treatment seeking behaviour and prescribing, the relationships between lay people and their local healthcare practitioner, motivations for seeking or selling antibiotics for people and animals; who and what the antibiotic treatment is sought for; what happens to antibiotics after prescription or purchase, and on the perceived effects of antibiotics on the resolution of symptoms. The findings will provide formative data on which to identify pathways for behaviour change.
Our international partner, the International Centre for Diarrhoeal Disease Research Bangladesh (ICDDR, B), is internationally recognised for the development and delivery of low-cost, scalable solutions to major health problems. Capacity-building in Bangladesh and establishing a leading centre for research on antimicrobial resistance are integral parts of this pump-priming initiative.

Planned Impact

Impact activities are an integrated component of this two year project. A key objective of the study is to inform government policy and identify pathways to behaviour change. We will collaborate and engage with organisations and researchers that have carried out preliminary work on the regulation and licensing of drug shops in Bangladesh (School of Public Health, BRAC University and Systems for Improved Access to Pharmaceuticals and Services). The likely end-users of this research are the Directorate General of Drug Administration, the Bangladesh Chemist and Druggist Association, and Directorate General of Health Services. We will ensure that they are involved at the beginning of the research process to facilitate the translation of research findings into knowledge sharing, policy development and interventions.
Beneficiaries of the research
The beneficiaries of the research include: 1. Patients and lay people in Bangladesh who may benefit from improved prescribing practices across government and private healthcare providers; 2. Pharmacists and drug shop owners, if accreditation schemes or financial incentives are provided for adhering to appropriate prescribing practices; 3. Government ministries and non-government organisations that are developing national antibiotic policies, training or accreditation schemes for healthcare practitioners; 4. International policy makers, donors and advisory groups, particularly in the South East Asia region.
Project development
In the first three months of the study, we will engage with organisations that are working in the field of antibiotic use, and who have experience working with healthcare providers and drug shops in Bangladesh (as above) and connect with organisations that will drive knowledge translation and implementation. To avoid duplication of any previous work, we will ensure that our sampling frame and data collection is designed to fill the gaps in knowledge.
Mid-term impact
At the end of Year 1 we will employ a professional communications team to develop materials for potential interventions based on aware-raising and key messages for behaviour change around antibiotic prescribing and consumption. This will be achieved through a one day intervention development workshop where the findings will be presented to stakeholders and users from the Government of Bangladesh, local government officials and non-government organisations (NGOs).
End of project impact activities
We will organise workshops for impact activities in the UK and in Bangladesh. We will also seek to work with government and non-government organisations in the UK in the use of behaviour change messages relating to AMR (e.g. Public Health England). Change implementation projects would require follow-on funding. In order to develop such projects we will forge collaborations with implementation organisations for feasibility and pilot studies.
Benefits of the research
The findings of the qualitative research with laypeople and health practitioners will provide formative knowledge on antibiotic prescribing practices, reasons for seeking antibiotic treatment and the extent of knowledge and awareness of causes of antibiotic resistance. There is a recognised need for training for drug shop owners; our findings can suggest further mechanisms to influence the relevant bodies on appropriate training and opportunities to develop accreditation schemes. These findings will identify pathways to improve the prescription and consumption of antibiotics and reduce the spread of antibiotic resistance.
Stakeholder Engagement and Dissemination: Throughout the two year project we will be involved in knowledge exchange and dissemination activities. The findings of the proposed study will feed directly to UK AMR stakeholders through the advisory board members of the AMR Bridging the Gaps network at Loughborough University (EP/M027341/1) and dedicated website.


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Description Our preliminary findings from qualitative interviews suggest that the term antibiotic is not widely recognised among households and caregivers in rural Bangladesh. Households will seek medicine from formal and informal drug sellers and healthcare practitioners but they may not necessarily be aware of whether they are being prescribed antibiotics, or what distinguishes antibiotics from other types of medicine. Costs, convenience and trust in local providers all play an important role around healthcare decision making and behaviours. We have also interviewed formal and informal healthcare practitioners to understand the use of antibiotics from their perspective to understand the demands from customers and the constraints imposed by running a profitable enterprise.
Exploitation Route Our intervention development workshop was a valuable opportunity to engage with users and stakeholders in the research. We have discussed our work and preliminary findings with representatives from the Bangladesh Ministry of Health, Families and Welfare in relation to a government initiative to develop model pharmacies. We hope that our research will also inform the future development of the model pharmacy programme in Bangladesh as it is rolled out.
Sectors Communities and Social Services/Policy,Healthcare,Pharmaceuticals and Medical Biotechnology

Description Collaboration partnership with BRAC JPG School of Public Health, BRAC University, Dhaka, Bangladesh 
Organisation BRAC University
Country Bangladesh 
Sector Academic/University 
PI Contribution We are pooling expertise from UK research institutions (Loughborough University, Durham University and University of Bristol), along with international co-investigators at icddr,b and collaborators in health policy and universal access to healthcare at BRAC JPG School of Public Health, BRAC University.
Collaborator Contribution Research collaborators at BRAC University will be conducting key informant interviews with stakeholders involved in antimicrobial resistance policy (e.g. National Action Plan on AMR), multi-sectoral government committees, private providers and industry.
Impact A desk based policy review has been carried out and will be developed for publication.
Start Year 2017
Description Intervention Development Workshop with Users and Stakeholders 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact We invited external opinion leaders, experts and users of the research to an intervention development workshop. This was an interactive forum to present some preliminary qualitative findings from our research. In small group discussions we asked groups to highlight behaviours to avoid, behaviours to encourage and which target audience was the priority for behaviour change messages and materials. A local design agency with experience in behaviour change communication captured the facilitated discussion and key behaviours of different target audiences. This workshop will lead to early development of key messages to reduce inappropriate antimicrobial use.
Year(s) Of Engagement Activity 2018