Motivating antibiotic stewardship in Bangladesh: identifying audiences and target behaviours using the behaviour change wheel

Abstract

Background South Asia is a hotspot for antimicrobial resistance due largely to over-the-counter antibiotic sales for humans and animals and from a lack of policy compliance among healthcare providers. Additionally, there is high population density and high infectious disease burden. This paper describes the development of social and behavioural change communication (SBCC) to increase the appropriate use of antibiotics. Methods We used formative research to explore contextual drivers of antibiotic sales, purchase, consumption/use and promotion among four groups: 1) households, 2) drug shop staff, 3) registered physicians and 4) pharmaceutical companies/medical sales representatives. We used formative research findings and an intervention design workshop with stakeholders to select target behaviours, prioritise audiences and develop SBCC messages, in consultation with a creative agency, and through pilots and feedback. The behaviour change wheel was used to summarise findings. Results Workshop participants identified behaviours considered amenable to change for all four groups. Household members and drug shop staff were prioritised as target audiences, both of which could be reached at drug shops. Among household members, there were two behaviours to change: suboptimal health seeking and ceasing antibiotic courses early. Thus, SBCC target behaviours included: seek registered physician consultations; ask whether the medicine provided is an antibiotic; ask for instructions on use and timing. Among drug shop staff, important antibiotic dispensing practices needed to change. SBCC target behaviours included: asking customers for prescriptions, referring them to registered physicians and increasing customer awareness by instructing that they were receiving antibiotics to take as a full course. Conclusions We prioritised drug shops for intervention delivery to all drug shop staff and their customers to improve antibiotic stewardship. Knowledge deficits among these groups were notable and considered amenable to change using a SBCC intervention addressing improved health seeking behaviours, improved health literacy on antibiotic use, and provision of information on policy governing shops. Further intervention refinement should consider using participatory methods and address the impact on profit and livelihoods for drug shop staff for optimal compliance.

Factors Driving Antimicrobial Resistance in Rural Bangladesh: A Cross-Sectional Study on Antibiotic Use-Related Knowledge, Attitude, and Practice Among Unqualified Village Medical Practitioners and Pharmacy Shopkeepers

“…However, another study found that institutional training provided to medical students might not effectively raise sufficient awareness [ 38 ]. In a 2021 study [ 39 ], experts suggested that improving awareness and practices, primarily among households and pharmacy shopkeepers, are expected to bring the highest impact, secondary to targeting behaviors of physicians and pharmaceutical companies.…”

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

“…Alongside, this instigates antimicrobial stewardship programs (ASPs) in ambulatory care similar to other important antibiotics in Bangladesh where there are concerns about resistance development [107][108][109][110]. This includes ASPs among community pharmacists and drug sellers building on ASPs in other sectors in Bangladesh [52,111].…”

“…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].…”

Public knowledge, attitudes, and practices (KAP) regarding antibiotics use and antimicrobial resistance (AMR) in Bangladesh

“…Globally, the misuse and overuse of antibiotics are two major causes contributing to the development of antibiotic-resistant pathogens [ 13 ]. Bangladesh, as a densely populated country with a high burden of infectious diseases, faces substantial challenges in managing AMR [ 14 ]. All the main factors contributing to the emergence of AMR in Bangladesh can be categorized into the supply and demand sides.…”