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

Abstract

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.

Motivating antibiotic stewardship in Bangladesh: Identifying audiences and target behaviours using the Behaviour Change Wheel

“…Travel costs and distance to health facilities or clinics were barriers to seeking earlier consultation with qualified professionals [12]. However, doctors were reported to give little time during consultation, prescribe drugs including antibiotics over the telephone and patients perceived that the additional costs of consulting a doctor or undergoing recommended tests were to enhance profits and were often viewed as unnecessary [22].…”

“…Formative data collection provided information for step 1 [12,22] on current key behaviours. Following the formative research, steps 2 through 4 were undertaken through an intervention design workshop and the co-creation of intervention resources with a creative agency.…”

“…Access to registered physicians is not currently possible for large sectors of the population because the number of qualified doctors is insufficient to meet demand [30,31]. Cost and convenience are also important barriers for patients to seek care from qualified physicians [12,22], echoed in the findings from piloting the SBCC materials. These challenges are similar in other settings with over the counter provision of antibiotics [32,33].…”

“…Understanding the behaviours, service and economic priorities of healthcare providers, and the needs of consumers is therefore central to developing an effective strategy to engage in antimicrobial stewardship to reduce antibiotic resistance [12,22]. This study is part of a larger project that aimed to inform government policy and identify pathways to behaviour change among groups from the antibiotic supply and demand sides [23].…”

“…Contextual drivers of antibiotic use among household members, and inappropriate prescribing and dispensing practices of healthcare professionals and drug shop staff have been published[12,22]. Among household members, an important contextual driver was that most did not what know an antibiotic was or what antibiotics were for.…”