https://orcid.org/0000-0003-4630-909X
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ABSTRACT
Background
The use of large quantities of antimicrobial drugs for human health and agriculture is advancing the predominance of drug resistant pathogens in the environment. Antimicrobial resistance is now a major public health threat posing significant challenges for achieving the Sustainable Development Goals. In Bangladesh, where over one third of the population is below the poverty line, the achievement of safe and effective antibiotic medication use for human health is challenging.
Objective
To explore factors and practices around access and use of antibiotics and understanding of antimicrobial resistance in rural communities in Bangladesh from a socio-cultural perspective.
Methods
This qualitative study comprises the second phase of the multi-country ABACUS (Antibiotic Access and Use) project in Matlab, Bangladesh. Information was collected through six focus group discussions and 16 in-depth interviews. Informants were selected from ten villages in four geographic locations using the Health and Demographic Surveillance System database. The Access to Healthcare Framework guided the interpretation and framing of the findings in terms of individuals’ abilities to: perceive, seek, reach, pay and engage with healthcare.
Results
Village pharmacies were the preferred and trusted source of antibiotics for self-treatment. Cultural and religious beliefs informed the use of herbal and other complementary medicines. Advice on antibiotic use was also sourced from trusted friends and family members. Access to government-run facilities required travel on poorly maintained roads. Reports of structural corruption, stock-outs and patient safety risks eroded trust in the public sector. Some expressed a willingness to learn about antibiotic resistance.
Conclusion
Antimicrobial resistance is both a health and development issue. Social and economic contexts shape medicine seeking, use and behaviours. Multi-sectoral action is needed to confront the underlying social, economic, cultural and political drivers that impact on the access and use of antibiotic medicines in Bangladesh.
Responsible Editor Stig Wall, Umeå University, Sweden
Responsible Editor Stig Wall, Umeå University, Sweden
Acknowledgments
We are most grateful to the ABACUS team and the all of the informants who freely gave of their time to participate in the FGDs and IDIs. We express our gratitude to the reviewers for their extensive commentaries. Apart from developing a much stronger manuscript we learnt a lot from their feedback.
Author contributions
The themes for the qualitative interviews were developed by JK under the guidance of HW and with support from WK and AM. Fieldwork was conducted by WAK and AM under the direction of HM as Principal Investigator for the ABACUS project. Data analysis was undertaken by MC with assistance from WAK, AM and JSW and guidance from JK. The first draft was prepared by MC. JSW developed and finalised the draft, undertook the literature review and provided critical input for the submission and subsequent revision. All authors read and approved the final version.
Disclosure statement
No potential conflict of interest was reported by the authors.
Ethics and consent
The procedures followed in this study were approved by the Oxford University Tropical Research Ethics Committee and the Ethical Review Committee of the International Centre for Diarrhoeal Disease Research, Bangladesh.
Paper context
Antimicrobial drugs (antifungals, antivirals and antimalarials) are public goods. Inappropriate use promotes the spread of resistant pathogens and reduces treatment efficacy, thereby impacting on public health. In Bangladesh, over sixty percent of patients’ total healthcare expenditure is for pharmaceuticals, over sixty percent of which is borne through out-of-pocket purchasing of antibiotics from unregulated vendors without medical prescription or advice. This study found that people in rural communities in Matlab were either not informed or knew little about appropriate access and use of antibiotic medicines. The principle means through which knowledge was available was village pharmacies.