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

Abstract

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.

Evaluation of cattle farmers’ knowledge, attitudes, and practices regarding antimicrobial use and antimicrobial resistance in Rwanda

“…This concords with the study that showed that sex differences are contextual and correlate with other sociodemographic factors especially education level and socioeconomic levels, with females having relatively more knowledge than their counterparts [ 35 ]. This also coincides with the study from Bangladesh that revealed that men leaned more towards buying unprescribed animal drugs compared to women; similarly, women-owned farms were also more likely to use fewer antimicrobials in farms compared to men-owned ones [ 36 – 38 ]. This discrepancy could be attributed to factors such as: i) women have more access to information; a cross-sectional study in Thailand showed that women had 1.8 times more odds of accessing information on AMR than men [ 39 ], ii) women have more knowledge on antibiotics because they tend to use prescribed medicines and are more aware of efficacy of medicine compared to men [ 40 ].…”

Using intersectionality to study gender and antimicrobial resistance in low- and middle-income countries

“…On the one hand, as shown in Uganda’s low-income regions, men tend to have higher rates of self-medication, due to greater purchasing power that enables them to obtain medication from the private sector, a more expensive option unavailable to women ( Ocan et al , 2014 ). Other studies have also shown that men are more likely to buy antibiotics without a prescription, compared with women ( Jones et al , 2022 ; Rousham et al. , 2023 ).…”

“…In the LMICs’ pharmaceutical sector, approximately two-thirds of antibiotics are used for self-medication ( WHO, 2015 ). Self-medication is prevalent in some sub-Saharan countries such as Tanzania, Cameroon and Namibia, ranging from 50% to 60% in some regions ( Simon and Kazaura, 2020 ), as well as in other LMICs such as India, with around three-quarters of antibiotics bought without prescriptions in some areas ( Rousham et al. , 2023 ).…”

Mobile Colistin-Resistant Gene; mcr-1, mcr-2, mcr-3 Identified in Diarrheal Pathogens among Infants, Children, and Adults in Bangladesh: Implications for the Future

“…This is important in Bangladesh, given extensive colistin-resistant Escherichia coli in broiler meat and chicken feces [44][45][46], exacerbating resistance among patients to colistin in Bangladesh [47][48][49][50]. Over-the-counter dispensing of antibiotics is also common in Bangladesh and a concern, especially when this involves 'Watch' and 'Reserve' antibiotics [51][52][53][54] Overall, activities to enhance the appropriate use of colistin in both animals and humans are essential as colistin still remains the antibiotic of choice for multiple drug-resistant gram-negative bacterial infections (MDR-GNB). This includes carbapenem-resistant Acinetobacter baumannii (CRAB) as well as other pathogens resistant to the new antimicrobial agents [55][56][57].…”