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

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.

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.