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Categories of customer attending drug shops and the number of men and women within categories (n = 582 observations) *Not ascertained: denotes cases where information was not obtained
Source publication
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...
Citations
... Notably, women exhibited a higher prevalence of residual antibiotics (16.1%) compared to men (12.4%), a finding that aligns with a meta-analysis conducted in nine high-income countries [45]. A similar pattern was observed in Bangladesh, where women were more likely to receive antibiotic prescriptions than men (OR = 4.04, 95% CI 1.55, 10.55) [46]. This discrepancy can be attributed to the fact that women are more prone to infections, such as urinary or gynecological conditions, which often result in higher antibiotic prescriptions [47]. ...
Background: Inappropriate antibiotic use drives antimicrobial resistance and remains a global concern. Evidence suggests antibiotic use may be higher among malaria-negative patients compared to malaria-positive ones, but uncertainty persists, particularly in regions with varying malaria prevalence. This study measured antibiotic residuals in three Tanzanian regions with varying malaria epidemiology and analyzed factors influencing their presence. Methods: A cross-sectional household survey was conducted in 2015, covering a population of 6000 individuals across three regions of Tanzania. Dried blood spot samples from a subset of participants were analyzed using broad-range tandem mass spectrometry to detect residual antibiotics. Risk factors associated with antibiotic presence, including household healthcare-seeking behaviors, malaria testing, and other relevant variables, were evaluated. Results: The overall prevalence of residual antibiotics in the study population was 14.4% (438/3036; 95% CI: 11.4–15.8%). Stratified by malaria transmission intensity, antibiotic prevalence was 17.2% (95% CI: 12.9–17.2%) in Mwanza (low), 14.6% (95% CI: 10.6–15.0%) in Mbeya (moderate), and 11.2% (95% CI: 7.9–11.6%) in Mtwara (high). Trimethoprim was the most frequently detected antibiotic (6.1%), followed by sulfamethoxazole (4.4%) and penicillin V (0.001%). Conclusions: Residual antibiotic prevalence did not directly correlate with malaria endemicity but was influenced by healthcare practices, including co-prescription of antibiotics and antimalarials. The higher antibiotic use in malaria-negative cases highlights the need for improved diagnostics to reduce unnecessary use and mitigate antimicrobial resistance in malaria-endemic areas.
... However, many of these socioeconomic factors interact with both forces simultaneously and separately. Persons living in urban areas may for instance enjoy higher access to healthcare and thus antibiotics than their rural counterparts [96], but may also be subjected to higher population density and thus higher risk of contagion [97]. The independent relationship that each of these two forces has with each socioeconomic factor helps explain some of the complexities and incongruences noted in the data summarised in this review. ...
Introduction
Antimicrobial resistance (AMR) is one of the biggest public health challenges of our time. National Action Plans have failed so far to effectively address socioeconomic drivers of AMR, including the animal and environmental health dimensions of One Health.
Objective
To map what socioeconomic drivers of AMR exist in the literature with quantitative evidence.
Methods
An umbrella review was undertaken across Medline, Embase, Global Health, and Cochrane Database of Systematic Reviews, supplemented by a grey literature search on Google Scholar. Review articles demonstrating a methodological search strategy for socioeconomic drivers of AMR were included. Two authors extracted drivers from each review article which were supported by quantitative evidence. Drivers were grouped thematically and summarised narratively across the following three layers of society: People & Public, System & Environment, and Institutions & Policies.
Results
The search yielded 6300 articles after deduplication, with 23 review articles included. 27 individual thematic groups of drivers were identified. The People & Public dimensions contained the following themes: age, sex, ethnicity, migrant status, marginalisation, sexual behaviours, socioeconomic status, educational attainment, household composition, maternity, personal hygiene, lifestyle behaviours. System & Environment yielded the following themes: household transmission, healthcare occupation, urbanicity, day-care attendance, environmental hygiene, regional poverty, tourism, animal husbandry, food supply chain, water contamination, and climate. Institutions & Policies encompassed poor antibiotic quality, healthcare financing, healthcare governance, and national income. Many of these contained bidirectional quantitative evidence, hinting at conflicting pathways by which socioeconomic factors drive AMR.
Conclusion
This umbrella review maps socioeconomic drivers of AMR with quantitative evidence, providing a macroscopic view of the complex pathways driving AMR. This will help direct future research and action on socioeconomic drivers of AMR.
... 55 Evidence from Bangladesh shows that there are wider gender disparities in access to pharmacies in rural areas. 56 Norms surrounding women's paid and unpaid labour, job characteristics and motherhood can also impact their access to prompt and accurate medical diagnoses. 9 The double burden of paid and unpaid work leaves no time for women to seek timely and accurate diagnoses. ...
Antimicrobial resistance (AMR) poses a critical public health threat, with gendered implications that are often overlooked. Key drivers of bacterial AMR include the misuse of antibiotics, inadequate water, sanitation and hygiene infrastructure and poor infection control practices. Persistent gender discrimination exacerbates these issues, resulting in disparities in healthcare access and outcomes. This review explores how biological, sociocultural and behavioural factors contribute to the differential incidence of AMR in women. We present a conceptual framework to understand how gender norms influence antibiotic use and AMR. Differences in infection susceptibility, health-seeking behaviours, the ability to access and afford essential antibiotics and quality healthcare and appropriate diagnosis and management by healthcare providers across genders highlight the necessity for gender-sensitive approaches. Addressing gender dynamics within the health workforce and fostering inclusive policies is crucial for effectively mitigating AMR. Integrating intersectional and life course approaches into AMR mitigation strategies is essential to manage the changing health needs of women and other vulnerable groups.
... Antibiotic use was higher in males than in females. These gender variations in antibiotic prescriptions have been documented by studies conducted outside of Sierra Leone [43]. Therefore, it is important to disaggregate AMR and AMU datasets based on gender or sex. ...
Introduction
Antimicrobial resistance (AMR) is a global public health concern and irrational use of antibiotics in hospitals is a key driver of AMR. Even though it is not preventable, antimicrobial stewardship (AMS) programmes will reduce or slow it down. Research evidence from Sierra Leone has demonstrated the high use of antibiotics in hospitals, but no study has assessed hospital AMS programmes and antibiotic use specifically among children. We conducted the first-ever study to assess the AMS programmes and antibiotics use in two tertiary hospitals in Sierra Leone.
Methods
This was a hospital-based cross-sectional survey using the World Health Organization (WHO) point prevalence survey (PPS) methodology. Data was collected from the medical records of eligible patients at the Ola During Children’s Hospital (ODCH) and Makeni Regional Hospital (MRH) using the WHO PPS hospital questionnaire; and required data collection forms. The prescribed antibiotics were classified according to the WHO Access, Watch, and Reserve (AWaRe) classification. Ethics approval was obtained from the Sierra Leone Ethics and Scientific Review Committee. Statistical analysis was conducted using the SPSS version 22.
Results
Both ODCH and MRH did not have the required AMS infrastructure; policy and practice; and monitoring and feedback mechanisms to ensure rational antibiotic prescribing. Of the 150 patients included in the survey, 116 (77.3%) were admitted at ODCH and 34 (22.7%) to MRH, 77 (51.3%) were males and 73 (48.7%) were females. The mean age was 2 years (SD=3.5). The overall prevalence of antibiotic use was 84.7% (95% CI: 77.9% – 90.0%) and 77 (83.8%) of the children aged less than one year received an antibiotic. The proportion of males that received antibiotics was higher than that of females. Most (58, 47.2 %) of the patients received at least two antibiotics. The top five antibiotics prescribed were gentamycin (100, 27.4%), ceftriaxone (76, 20.3%), ampicillin (71, 19.5%), metronidazole (44, 12.1%), and cefotaxime (31, 8.5%). Community-acquired infections were the primary diagnoses for antibiotic prescription.
Conclusion
The non-existence of AMS programmes might have contributed to the high use of antibiotics at ODCH and MRH. This has the potential to increase antibiotic selection pressure and in turn the AMR burden in the country. There is need to establish hospital AMS teams and train health workers on the rational use of antibiotics.
... The study finds that gender and age are significantly associated with the use of antibiotics without a prescription. Younger people aged [18][19][20][21][22][23][24] (both male and female) are more likely to use unprescribed antibiotics than older people. The paper proposes that gender needs to be integrated into One Health approaches to understand and address the risk of AMR in pastoralist settings. ...
... However, few studies have focussed on how gender determines the availability, access, and use or misuse of antimicrobials. Limited evidence from Bangladesh and Nepal shows that more men than women purchase antibiotics without a prescription, although women are more likely to be prescribed antibiotics by clinicians than men, and women are more likely to use a prescription than men (20,21). ...
... As Figure 3 above illustrates, young men aged between 18 and 24 who are mostly unmarried boy herders purchased and ingested unprescribed amoxicillin the most, while young women of the same age, who were all married to an older male used amoxicillin slightly less than their male counterparts but their numbers were still Age difference in antibiotic use among older participants aged 24-65 did not vary significantly observations corroborated this finding as younger men (18)(19)(20)(21)(22)(23)(24) were the most frequent customers who purchased amoxicillin from the local shop, whereas older participants were more likely to visit the healthcare dispensary when they deemed an illness too severe to treat at home. These instances involved children's health and the elderly. ...
Introduction
Inappropriate use of antimicrobials is a major driver of AMR in low-resource settings, where the regulation of supply for pharmaceuticals is limited. In pastoralist settings in Tanzania, men and women face varying degrees of exposure to antibiotics due to gender relations that shape access and use of antimicrobials. For example, critical limitations in healthcare systems in these settings, including inadequate coverage of health services put people at risk of AMR, as families routinely administer self-treatment at home with antimicrobials. However, approaches to understanding AMR drivers and risk distribution, including the One Health approach, have paid little attention to these gender considerations. Understanding differences in access and use of antimicrobials can inform interventions to reduce AMR risk in community settings. This paper focuses on the gendered risk of AMR through a study of gender and social determinants of access to and use of antimicrobials in low-resource pastoralist settings in Tanzania.
Methods
A mixed methods approach involving household surveys, interviews and ethnographic participant observation in homes and sites of healthcare provision was used, to investigate access and administration of antibiotics in 379 adults in Naiti, Monduli district in northern Tanzania. A purposive sampling technique was used to recruit study participants and all data was disaggregated by sex, age and gender.
Results
Gender and age are significantly associated with the use of antibiotics without a prescription in the study population. Young people aged 18-24 are more likely to use unprescribed antibiotics than older people and may be at a higher risk of AMR. Meanwhile, although more men purchase unprescribed antibiotics than women, the administration of these drugs is more common among women. This is because men control how women use drugs at the household level.
Discussion
AMR interventions must consider the critical importance of adopting and implementing a gender-sensitive One Health approach, as gender interacts with other social determinants of health to shape AMR risk through access to and use of antimicrobials, particularly in resource-limited pastoralist settings.
... This is important in Bangladesh, given extensive colistin-resistant Escherichia coli in broiler meat and chicken feces [39][40][41] exacerbating resistance among patients to colistin in Bangladesh [42][43][44][45]. Over-the-counter dispensing of antibiotics is also common in Bangladesh and is a concern, especially when this involves 'Reserve' antibiotics [46][47][48][49] The use of colistin as an antibiotic of last resort is greatly threatened by its overuse and the associated rise of plasmid-borne mobile colistin resistance genes [50][51][52], spreading rapidly via horizontal gene transfer [53]. Resistance to colistin is generated by the chromosomally mediated modification of lipopolysaccharide (LPS) [54]. ...
Colistin is a last-resort antimicrobial for treating multidrug-resistant Gram-negative bacteria. Phenotypic colistin resistance is highly associated with plasmid-mediated mobile colistin resistance (mcr) genes. mcr-bearing Enterobacteriaceae have been detected in many countries, with the emergence of colistin-resistant pathogens a global concern. This study assessed the distribution of mcr-1, mcr-2, mcr-3, mcr-4, and mcr-5 genes with phenotypic colistin resistance in isolates from diarrheal infants and children in Bangladesh. Bacteria were identified using the API-20E biochemical panel and 16s rDNA gene sequencing. Polymerase chain reactions detected mcr gene variants in the isolates. Their susceptibilities to colistin were determined by agar dilution and E-test by minimal inhibitory concentration (MIC) measurements. Over 31.6% (71/225) of isolates showed colistin resistance according to agar dilution assessment (MIC > 2 μg/mL). Overall, 15.5% of isolates carried mcr genes (7, mcr-1; 17, mcr-2; 13, and mcr-3, with co-occurrence occurring in two isolates). Clinical breakout MIC values (≥4 μg/mL) were associated with 91.3% of mcr-positive isolates. The mcr-positive pathogens included twenty Escherichia spp., five Shigella flexneri, five Citrobacter spp., two Klebsiella pneumoniae, and three Pseudomonas parafulva. The mcr-genes appeared to be significantly associated with phenotypic colistin resistance phenomena (p = 0.000), with 100% colistin-resistant isolates showing MDR phenomena. The age and sex of patients showed no significant association with detected mcr variants. Overall, mcr-associated colistin-resistant bacteria have emerged in Bangladesh, which warrants further research to determine their spread and instigate activities to reduce resistance.
... 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][37][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]. ...
The misuse of antimicrobials in livestock may lead to the emergence and spread of resistant pathogens harmful to human, animal, and environmental health. Therefore, determining the behavior and practices of farmers regarding antimicrobial use (AMU) and antimicrobial resistance (AMR) is crucial for addressing the growing threat of AMR. This cross-sectional study was conducted in the Eastern Province of Rwanda on 441 participants using a structured questionnaire to determine the knowledge, attitudes, and practices (KAP) towards AMU and AMR. Frequency distributions, chi-square test of association and logistic regression model were used to analyze the data. This study showed poor biosecurity measures at the farm level with various antimicrobials used here; 83.9% of participants obtained them from friends and neighbors and 61.9% used them for growth promotion. Our assessment revealed a low level of KAP towards AMR among cattle farmers from the study districts. Our data showed that at a 69% cutoff, only 52.6% of farmers had correct knowledge, whereas 56% had good attitudes (47% cutoff). Finally, 52.8% had correct practices toward AMR based on a calculated cutoff of 50%. Positive attitudes, correct knowledge, and practices regarding AMU and AMR were associated with higher educational levels. Sex was correlated with knowledge and attitudes, whereas farm location was associated with attitudes and practices. Farmers expressed a need for more access to veterinary services and AMR-related training for themselves, the community animal health workers, and veterinarians. This study highlighted the low levels of KAP associated with using antimicrobials, which may lead to the misuse of antimicrobials and the spread of AMR. It is imperative to develop and implement cross-cutting measures to minimize antibiotic usage and reduce the risk of antibiotic resistance.
... 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]. ...
Colistin is a last-resort antimicrobial for treating multidrug-resistant Gram-negative bacteria. Phe-notypic colistin resistance is highly associated with plasmid-mediated mobile colistin resistance (mcr) genes. mcr-bearing Enterobacteriaceae have been detected in many countries, with the emergence of colistin-resistant pathogens a global concern. This study assessed the distribution of mcr-1, mcr-2, mcr-3, mcr-4, and mcr-5 genes with the phenotypic colistin resistance in isolates from diarrheal infants and children in Bangladesh. Bacteria were identified using the API-20E biochemical panel and 16s rDNA gene sequencing. Polymerase chain reac-tions detected mcr gene variants in the isolates. Their susceptibilities to colistin were determined by agar dilu-tion and E-test by minimal inhibitory concentration (MIC) measurements. Over 30.0% (69/225) of isolates showed colistin resistance by agar dilution assessment (MIC> 2.0 μg/mL). Overall, 15.5% of isolates carried mcr genes (7, mcr-1; 17, mcr-2; 13, mcr-3; and co-occurrence occurred in 2 isolates). Clinical breakout MIC val-ues (≥ 4 μg/mL) were associated with 91.3% of mcr-positive isolates. The mcr-positive pathogens include twenty Escherichia spp., five Shigella flexneri, five Citrobacter spp., two Klebsiella pneumoniae, and three Pseudo-monas parafulva. mcr-genes appeared to be significantly associated with phenotypic colistin resistance phe-nomena (p=0.000), with 100% colistin-resistant isolates showing MDR phenomena. Age and sex of patients showed no significant association with detected mcr variants. Overall, mcr-associated colistin-resistant bacte-ria have emerged in Bangladesh, which warrants further research to determine their spread and instigate ac-tivities to reduce resistance.
... In the LMICs' pharmaceutical sector, approximately two-thirds of antibiotics are used for self-medication (WHO, 2015). Selfmedication 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). Despite antibiotics being prescriptiononly medicines in these countries, they are still available and purchased in local drug stores and accessed through informal networks. ...
... 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). Men also have higher rates of noncompliance with antibiotic treatment, which can expose them to higher rates of AMR. ...
Different sexes and genders experience differentiated risks of acquiring infections, including drug-resistant infections, and of becoming ill. Different genders also have different health-seeking behaviours that shape their likelihood of having access to and appropriately using and administering antimicrobials. Consequently, they are distinctly affected by antimicrobial resistance (AMR). As such, it is crucial to incorporate perspectives on sex and gender in the study of both AMR and antimicrobial use in order to present a full picture of AMR's drivers and impact. An intersectional approach to understanding gender and AMR can display how gender and other components 'intersect' to shape the experiences of individuals and groups affected by AMR. However, there are insufficient data on the burden of AMR disaggregated by gender and other socio-economic characteristics, and where available, it is fragmented. For example, to date, the best estimate of the global burden of bacterial AMR published in The Lancet does not consider gender or other social stratifiers in its analysis. To address this evidence gap, we undertook a scoping review to examine how sex and gender compounded by other axes of marginalization influence one's vulnerability and exposure to AMR as well as one's access to and use of antimicrobials. We undertook a gendered analysis of AMR, using intersectionality as a concept to help us understand the multiple and overlapping ways in which different people experience exposure vulnerability to AMR. This approach is crucial in informing a more nuanced view of the burden and drivers of AMR. The intersectional gender lens should be taken into account in AMR surveillance, antimicrobial stewardship, infection prevention and control and public and professional awareness efforts, both donor and government funded, as well as national and international policies and programmes tackling AMR such as through national action plans.
Background: There are global concerns about the rising rates of antimicrobial resistance (AMR), particularly in low- and middle-income countries (LMICs). AMR is driven by high rates of inappropriate prescribing and dispensing of
antibiotics, particularly Watch antibiotics. To develop future interventions, it is important to document current knowledge, attitudes, and practices (KAP) among key stakeholder groups in LMICs.
Methods: We undertook a narrative review of published papers among four WHO Regions, including African and Asian countries. Relevant papers were sourced from 2018 to 2024 and synthesized by key stakeholder group, country, WHO Region, income level and year. The findings were summarized to identify pertinent future activities
for all key stakeholder groups.
Results: We sourced 459 papers, with a large number coming from Africa (42.7%). An appreciable number dealt
with patients’ KAP (33.1%), reflecting their influence on the prescribing and dispensing of antibiotics. There was
marked consistency of findings among key stakeholder groups across the four WHO Regions, all showing concerns with high rates of prescribing of antibiotics for viral infections despite professed knowledge of antibiotics
and AMR. There were similar issues among dispensers. Patients’ beliefs regarding the effectiveness of antibiotics
for self-limiting infectious diseases were a major challenge, although educational programmes did improve
knowledge. The development of the AWaRe (Access, Watch and Reserve) system, including practical prescribing
guidance, provides a future opportunity for the standardization of educational inputs.
Conclusions: Similar KAP regarding the prescribing and dispensing of antibiotics across LMICs and stakeholder
groups presents clear opportunities for standardization of educational input and practical training programmes
based on the AWaRe system
