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

孟加拉国是一个低收入国家，估计有40%的人口生活在极端贫困中。在这种贫困的背景下，孟加拉国通过以社区为基础的干预措施改善最弱势群体的健康，以低成本实现了“良好的健康”，这一点得到了国际认可。然而，已知抗生素耐药性细菌存在于饮用水、废水和患者样本中，非处方、廉价抗生素的可用性意味着抗生素耐药性在整个人群中快速和不受控制地传播的风险很高。孟加拉国的研究表明，63%的抗生素处方来自没有资格的从业人员，在初级卫生保健的所有咨询中，抗生素处方占近一半（44%）。解决抗生素耐药性问题对国家的长期经济发展和福利至关重要。为了减缓抗生素耐药性的传播，在平衡弱势群体获得健康的需求方面存在复杂性，同时对抗生素的处方和现成可用性进行更严格的监管。需要开展研究，以更好地了解家庭和个人对其家人和牲畜的抗生素治疗需求，并了解合格和不合格从业人员的处方行为。我们将研究抗生素使用的途径：1）从为自己，家庭成员或牲畜购买或消费抗生素的外行人的角度，2）从医疗保健从业人员的角度，包括合格和不合格的提供者（市场销售商，不合格的药店老板和未经培训的“医生”）。通过在孟加拉国城市和农村的深入访谈，我们将更好地了解抗生素处方和消费行为，并确定医疗保健从业人员或其患者和客户是否意识到抗生素耐药性。通过采访从业者在整个范围内的正式和非正式的网点，我们将评估从业者改变处方做法或作为变革的代理人的潜力。该研究的第三个目的是与政府和非政府机构合作，为制定减少抗生素使用的干预措施提供信息。我们将利用访谈中的形成性研究，与专业的沟通团队合作，为提高对抗生素耐药性的认识和沟通活动开发文化上适当的信息和材料。这些材料将由非专业人士、医疗保健提供者和药店老板进行预先测试，以确定信息的可接受性、目标人群以及抗菌素耐药性的使用者和利益相关者制定国家提高认识或行为改变干预措施的潜力。这项研究的好处是阐明抗生素治疗寻求行为和处方的行为，外行人和他们当地的保健医生之间的关系，寻求或出售抗生素的人和动物的动机;谁和抗生素治疗是寻求什么;处方或购买后抗生素会发生什么，以及抗生素对症状的解决的感知效果。我们的国际合作伙伴，孟加拉国国际腹泻病研究中心（ICDDR，B），在为主要健康问题开发和提供低成本、可扩展的解决方案方面获得国际认可。孟加拉国的能力建设和建立一个主要的抗菌素耐药性研究中心是这一启动倡议的组成部分。

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.