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Rousham et al. BMC Public Health (2023) 23:229
https://doi.org/10.1186/s12889-023-15155-3 BMC Public Health
*Correspondence:
Emily K. Rousham
E.K.Rousham@lboro.ac.uk
Full list of author information is available at the end of the article
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.
Gender and urban-rural inuences
on antibiotic purchasing and prescription use
in retail drug shops: a one health study
Emily K. Rousham1*, Papreen Nahar2, Mohammad Rofi Uddin3, Mohammad Aminul Islam4, Fosiul Alam Nizame3,
Nirnita Khisa5, S. M. Salim Akter3, Mohammad Saeed Munim3, Mahbubur Rahman3 and Leanne Unicomb3
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Rousham et al. BMC Public Health (2023) 23:229
Background
Drug shops are recognised as an important source of
access to medicines including antibiotics [1, 2]. In low-
and middle-income countries (LMICs), drug shops offer
affordable and accessible healthcare and fill an important
gap in under-resourced public healthcare systems [3, 4].
Drug shop staff have been described as ‘de facto’ primary
health care providers [4]. Whilst there is global emphasis
on reducing the inappropriate use of antibiotics, retail
pharmacies and informal drug shops continue to play a
major role in healthcare provision and form an essential
component of Universal Health Coverage [3].
Over-the-counter provision of antibiotics leads
to inappropriate use of antibiotics which, in turn, is
considered a key driver of the emergence of antibiotic
resistance worldwide [5]. Over-the counter sales lead to
overuse of antibiotics for mild or non-bacterial infections
and are more likely to be of inappropriate dose, duration
and more likely to use higher generation antibiotics for
humans [6]. Studies across south and south-east Asia
reveal a high proportion of antibiotics sold without
prescription. In Vietnam, 88% (urban) and 91% (rural)
of sales in a survey of 17 pharmacies were without
prescription [7]. A study in Bangalore, India, found
66.7% of pharmacies (174 out of 261 observed) sold
antimicrobial drugs without a prescription [8], although
another urban survey in urban Bengaluru, India,
reported lower rates of 33% of chain stores and 42% of
independent pharmacies selling antibiotics without
a prescription [9]. In Sri Lanka, 1 in 3 community
pharmacies dispensed antibiotics without prescription
[10]. A scoping review of antibiotic use in south-east Asia
found that research on gender differences is scarce, but
suggested that these will intersect with contextual factors
such as education and socioeconomic status [11]. Studies
of prescribing and dispensing practices for humans have
frequently employed mystery shoppers or simulated
clients [9, 12–15]. However, such studies do not provide
insights into the attributes and purchasing practices of
genuine customers.
Bangladesh, an upper-middle income country based
on the human development index [16], has a thriving
market economy of retail drug shops. Many drug shops
operate without a license and staff have minimal training
[17]. In a study of antibiotic sales in six countries,
Bangladesh and Vietnam had the highest proportion of
non-licensed antibiotic dispensing outlets [18]. Over
half (52%) of 156 surveyed antibiotic suppliers in a rural
site in Matlab, southern Bangladesh, were not licensed
[18, 19]. In Bangladesh, government policy prohibits
the sale of antibiotics without a prescription [20] and
the legal requirement is for staff in drug shops to have a
minimum Grade C (certificate) pharmacist qualification.
In 2016, the government introduced a pilot initiative to
register model pharmacies (requiring a minimum Grade
A pharmacist MPharm or BPharm qualification), and
model medicine shops (minimum Grade C pharmacy
qualification), known as the Bangladesh Pharmacy
Model Initiative (BPMI), however this did not progress to
national roll out.
e WHO recommends that gender and equity
considerations are included in National Action Plans
on antibiotic resistance to strengthen actions to prevent
AMR [21]. ere is limited evidence, however, on
differences between men and women on antibiotic
use and consumption, and ‘even less in terms of a
comprehensive gender analysis of how gender norms,
roles and relations affect antibiotic use’ [21]. Health
systems research can also be better informed on
uptake of drug shop services and patterns of antibiotic
purchasing and prescription use through use of a
gender lens [22]. However, data from LMICs are mostly
lacking. In this study, we consider gender, a socially
constructed identity, as encompassing the social norms,
roles, behaviours and attributes of men and women
[23] in the context of Bangladesh. is study therefore
aimed to examine the use of drug shops for antibiotic
purchasing and prescription use by men and women in
urban and rural settings. is formed part of a wider
study that examined healthcare seeking behaviours for
antibiotics and dispensing of antibiotics for humans and
animals by qualified and unqualified prescribers [24, 25],
To incorporate a One Health perspective which is an
integrated, unifying approach that aims to sustainably
balance and optimize the health of people, animals
and ecosystems [26], we included drug shops that sold
antibiotics for humans, for animals and shops selling
medicines for both humans and animals.
Methods
Study site and recruitment
We conducted the study in a rural area of Mirzapur
sub-district (Upazila) in Tangail district and the urban
town centre in Tongi sub-district, Gazipur district. In
both locations, we selected areas that had not been
part of previous community-based interventions or
health surveys. Both areas were served by public health
facilities (community clinics) but only the urban area
had a government hospital. Private healthcare providers
(qualified and unqualified) and diagnostic centres
Keywords Drug resistance, Antibiotics, Community health services, Low income and middle-income countries,
Pharmacy, Observation, Gender equality and social inclusion (GESI), Prescription, Drug shop
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Rousham et al. BMC Public Health (2023) 23:229
were also common in both the rural and urban area.
Drug shops were available throughout the study areas
in local shopping areas and markets [25, 27]. Prior to
data collection, the study team visited the two areas
for familiarisation with the community leaders and
stakeholders. e research team visited key personnel
and government authorities (local government health
complex and local government livestock office in the
rural site, and government health department in the city
corporation of the urban site) to explain the purpose of
the study and seek agreement for the study to go ahead.
e observation process was piloted in one rural drug
shop (for human medicine) for training purposes and
to refine the data collection tool. e first phase of data
collection took place from October-November 2017 (8
shops). A second period of fieldwork was conducted in
September 2019 (12 shops) to increase the number of
customer interactions that were observed across the
different types of drug retail shops. e time interval
between the two rounds of data collection were due to
staffing constraints while processing and analysis of other
components of the research project took place [25, 27].
Training and recruitment
Prior to data collection, team members were trained
through a 14day classroom and field training workshop
on qualitative research methods and AMR including
customer observations by an experienced medical
anthropologist (PN). e field team comprised one
female and two male researchers at icddr,b, who had
relevant Masters’ training and fieldwork experience in
Bangladesh. Data collection, fieldwork, data entry and
cleaning were overseen by the research manager (FN)
[25].
We recruited drug shops purposively using snowball
sampling. Research staff started the selection of drug
shops by conducting a transect walk and noting the
available drug shops along the roads leading away from
the government health facility (sub-district health
complex) in both the rural and urban site. Word-of-
mouth recommendations from local residents were
used to ask which drug shops were either popular or
were considered to have experienced/knowledgeable
staff, or shops that residents would recommend in their
area. Using these suggestions, recruitment took place by
the researchers approaching drug shop owners directly.
As formative research, we did not conduct a power
calculation. We used quota sampling to recruit an equal
number of shops in the urban and rural area (50% of
the total in each area). We also aimed to purposefully
recruit up to five shops in each area selling both human
and animal medicine or animal medicine only but
were unable to meet this target in the urban site. e
drug shop owners were approached prior to any data
collection to ask whether they would be willing to take
part in the study. If they agreed, a date was arranged for
the observations to take place in their shop. Of all the
shop owners approached to participate, one rural shop
declined due to concerns that there was insufficient
space, and that business would be adversely affected.
Ethical approval
Ethical approval for the study was granted by the
Institutional Review Board at icddr,b (PR-16,100) and
Loughborough University (R17-P081). Participants
were provided with a written participant information
sheet in Bengali which was read aloud to them, and
they were given an opportunity to ask questions before
signing a written informed consent form in Bengali. All
participation was voluntary.
Drug shop observations
Two observation periods per shop took place, each of
2hours’ duration. One session took place in the morning
(approximate timing 9-11am or 10-12am, depending on
the shop opening times) and one in the late afternoon or
early evening period (approximately 4-6pm) to capture
variability at different times of day. Shops and market
stalls commonly closed in the middle of the day hence no
observations were scheduled at this time.
e researcher sat in the shop where they could
observe without intruding in normal business.
Observations of transactions were recorded on a data
collection sheet which included structured sections
for completion (observed gender of customer, use of
a doctor’s prescription, names of medicines including
antibiotics purchased) and blank spaces to supplement
this information with explanatory or supplementary
notes. Before leaving, the researcher asked the customer
whether they were the patient or whether the medicines
were bought for another person/patient (by proxy) or
for an animal or livestock. Activities were recorded
in real time. If more than one customer was being
served simultaneously, the objective was to follow one
transaction from start to finish rather than to observe all
transactions taking place.
Data analysis
Data were recorded by hand then entered into a database
in Microsoft Excel, cleaned and coded. Original written
notes were referred to for clarification regarding the
nature of the shops or transactions. Medicines were
identified from the brand name on the packaging which
were then checked by a clinically trained researcher who
converted to generic names based on the details provided
on the relevant pharmaceutical company websites.
Customers were categorised as purchasing medicine
for themselves (patient), a family member or an animal.
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Rousham et al. BMC Public Health (2023) 23:229
Some customer purchases were made by a neighbouring
drug shop seller, or healthcare provider (e.g., rural
medical practitioner (RMP) or doctor) and were coded as
such.
We report frequencies of prescription use for
antibiotics as number (n) and percentages and compared
these for gender (male, female) or urban versus rural
location. Descriptive statistics are presented using chi-
square tests and the likelihood of prescription use was
estimated with adjusted and unadjusted odds ratios (OR)
with 95% confidence intervals (CI) from univariable and
multivariable logistic regression analyses respectively.
Statistical analyses were conducted using IBM SPSS
Version 27.0.
Results
Characteristics of drug shops and sta qualications
Twenty shops were included in the survey, 10 from the
rural area and 10 from the urban area. Fifteen shops sold
human medicine only, 3 sold animal medicine only and
2 sold medicines for both humans and animals, both of
which were in the rural area (Supplementary Table 1).
In the urban area we were unable to identify any shops
that sold human and animal medicines and recruited
one shop selling animal medicine. All the dispensers that
participated were male except one rural shop that had a
female dispenser/owner.
Over-the-counter sales of antibiotics without a
prescription were observed in 90% (18 out of 20) of the
shops. Four shops met the requirement of staff having a
Pharmacy Grade C qualification, all of which were in the
urban site. Ten shop staff had undertaken rural medical
practitioner (RMP) training which is not a recognised
qualification for dispensing prescription medicines.
ree shop staff had other qualifications (livestock
artificial insemination technician, local medical assistant
and family planning training, paramedic training) and
three shop staff had no qualifications (two urban, one
rural). Supplementary Table1 presents the qualifications
of drug shop staff in each shop type.
Five urban shops and one rural shop had a chamber
(room) where a registered private doctor (MBBS)
attended on a part-time basis (Supplementary Table1).
ese doctors’ chambers were independent businesses
that charged a consultation fee, with a separate shop
sign and different opening times to the drug shop but the
co-location with a drug shop was of mutual benefit. e
study observation periods took place at times when the
doctors’ chambers were closed.
Shops ranged in size, construction materials and
storage facilities. All shops had an electricity supply. All
of the urban shops had refrigerators, whereas six of the
ten rural shops did not have any refrigerated storage. e
most informal shops were small market stalls or sheds
with corrugated iron roofing and a shop front open to the
external environment. e more formal shops had glass
doors and a shop front with concrete or ceramic floors
situated in single story or multi-story buildings.
Characteristics of drug shop customers
A total of 582 customers were observed; 31.6% of
customers were women. In urban drug shops, women
comprised almost half of all customers (47.1%) whereas
in the rural shops only 17.2% of customers were women
(p < 0.001) (Table 1). When broken down by shop type,
the proportion of women customers was highest in shops
selling human medicine (37.4%) compared to shops
selling human and animal medicine (15.8%), and shops
selling animal medicine only (14.0%) (Table2).
Table 1 Customer prescription use and antibiotic purchasing by gender and location (urban or rural) from retail drug shop
observations in Bangladesh
Total
n (%)
Urban
n (%)
Rural
n (%)
p *
Customers purchasing antibiotics (n = 574) 96 (16.7) 60 (21.6) 36 (12.2) 0.003
Customers purchasing antibiotics with prescription (n = 96) 25 (26.0) 21 (35.0) 4 (11.1) 0.01
Proportion of women and men costumers (n = 582) Women 184 (31.6) 132 (47.1) 52 (17.2) < 0.001
Men 398 (68.4) 148 (52.9) 250 (82.8)
Observations with complete purchase data (n = 574) Women 183 (31.9) 132 (47.5) 51 (17.2) < 0.001
Men 391 (68.1) 146 (52.5) 245 (82.8)
Customers with prescription by gender (all observations) (n = 78) Women 37 (47.4) 34 (52.3) 3 (23.1) 0.002
Men 41 (53.6) 31 (47.7) 10 (76.9)
Customers without prescription by gender (all observations) (n = 496) Women 146 (29.4) 98 (46.0) 48 (17.0)
Men 350 (70.6) 115 (54.0) 235 (83.0)
Customers purchasing antibiotics with prescription by gender (n = 25) Women 14 (56.0) 12 (57.1) 2 (50.0) 0.03
Men 11 (44.0) 9 (42.9) 2 (50.0)
Customers purchasing antibiotics without prescription by gender (n = 71) Women 17 (23.9) 12 (30.8) 5 (15.6)
Men 54 (76.1) 27 (69.2) 27 (84.4)
*using chi-square analysis
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Customers bought medicines for themselves, the
patient (50.0% of all customers), a family member (34.4%),
an animal or livestock (10.0%), or as a practitioner or
drug shop owner (3.4%). In a small number of cases
this information was not ascertained (2.7%) (Table 2).
Customers seeking medicines for animals included cows,
goats, hens, ducks and pigeons.
Fig.1 shows the number of customers buying medicines
for themselves (patient), another family member, for an
animal or for other purposes with the breakdown of men
and women in each category. Women were represented
in all customer categories, but relatively few customers
seeking animal medicine were women (10.9%). Further
information on the types of medicine purchased in the
urban and rural shops is summarised in Supplementary
Table2.
Use of prescriptions and antibiotic purchases by gender
and locality
Antibiotics were purchased in 16.7% of observations, with
more antibiotic purchases in urban than in rural shops
(21.6% versus 12.2% of observations, chi-square = 8.07,
p < 0.003) ( Table 1). Use of prescriptions for antibiotics
was also more common in the urban compared to
rural shops; 35.0% versus 11.1% used prescription for
antibiotics respectively, p = 0.01. e proportion of
customers purchasing antibiotics in different shop types,
irrespective of prescription use, was highest in animal
medicine shops (42.0%), followed by human medicine
shops (15.0%) and human and animal medicine shops
(11.4%) (Table2). For all customer observations, women
were more likely than men to have a prescription
(unadjusted OR = 2.16, 95% CI 1.33, 3.51, p < 0.002),
however, after adjusting for location (urban or rural),
Table 2 Customer characteristics according to type of retail drug shop (selling human medicine, animal medicine or both human and
animal medicine) from observations in Bangladesh
Shop type
Human
medicine
n (%)
Human
and animal
medicine
n (%)
Animal
medicine
n (%)
Total
n (%)
All observations Women 161 (37.4) 16 (15.8) 7 (14.0) 184 (31.6)
Men 270 (62.6) 85 (84.2) 43 (86.0) 398 (68.4)
Customers with prescription (all observations) No 357 (83.4) 88 (91.7) 48 (96.0) 493 (85.9)
Yes 71 (16.6) 8 (8.3) 2 (4.0) 81 (14.1)
Customers purchasing antibiotics No 364 (85.0) 85 (88.6) 29 (58.0) 478 (83.3)
Yes 64 (15.0) 11 (11.4) 21 (42.0) 96 (16.7)
Customers purchasing antibiotics with a prescription No 42 (63.6) 9 (81.8) 20 (95.2) 71 (74.0)
Yes 22 (34.3) 2 (18.8) 1 (4.8) 25 (26.0)
Medicine sought for (all observations) Patient (human) 239 (55.4) 49 (48.5) 3 (6.0) 291 (50.0)
Family member 169 (32.9) 29 (28.7) 2 (4.0) 200 (34.4)
Animal 3 (0.7) 10 (9.9) 45 (90.0) 58 (10.0)
Practitioner or drug shop
owner
12 (2.8) 8 (7.9) 0 20 (3.4)
Not stated/missing 11 (2.6) 5 (5.0) 0 16 (2.7)
Total observations 431 101 50 582
Table 3 Unadjusted and adjusted odds ratios of prescription use by gender and location (urban vs. rural) in retail drug shops in
Bangladesh
Prescription use
Unadjusted OR
(95% CI)
pAdjusted OR (95% CI) p
All customers (n = 582) Gender Men (ref ) 1.00 1.00
Women 2.16 (1.33, 3.51) 0.002 1.34 (0.81, 2.22) 0.26
Location Rural (ref) 1.00 1.00
Urban 5.91 (3.28, 10.62) < 0.001 5.41 (2.95, 9.93) < 0.001
Customers who purchased antibiotics (n = 96) Gender Men (ref ) 1.00 1.00
Women 4.04 (1.55, 10.55) 0.004 3.38 (1.26, 9.09) 0.016
Location Rural (ref) 1.00 1.00
Urban 4.31 (1.34, 13.84) 0.014 3.53 (1.06, 11.71) 0.039
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Rousham et al. BMC Public Health (2023) 23:229
the gender difference was not statistically significant
(adjusted OR = 1.34, 95% CI 0.81, 2.22, p = 0.26) (Table3).
Among observations resulting in an antibiotic
purchase, prescription use was more likely in women
than men (unadjusted OR = 4.04, 95% CI 1.55, 10.55,
p < 0.004) and in urban shops compared to rural shops
(unadjusted OR = 4.31, 95% CI 1.34, 13.84, p < 0.014)
(Table3). e effect of gender remained significant after
controlling for location (adjusted OR = 3.38, 95% CI 1.26,
9.09, p = 0.016) but the confidence intervals were wide.
Fig.2 shows the classes of antibiotics for the observed
antibiotics sold, and the percentage sold with or without
a prescription. Cephalosporins were the most commonly
dispensed antibiotic (20.8% of all antibiotics sold)
followed by penicillin (16.6%) and fluoroquinolones
(14.5%). Non-prescription purchases were made for
all classes of antibiotics including third generation
cephalosporins (ceftriaxone, cefixime, cefuroxime);
penicillin (amoxycillin; flucloxacillin); fluoroquinolones
(ciprofloxacin), tetracyclines (gentamycin, doxycycline,
oxytetracycline); sulphonamides; macrolides
(azithromycin); nitroimidazoles (metronidazole). e
category of ‘other’ antibiotics included aminoglycosides,
quinolone and mupirocin (topical antibiotic). Specific
antibiotic classes sold with or without prescription were
not broken down further by location or gender due to the
overall sample size.
Discussion
is study aimed to examine gender dimensions of
drug shop attendance, antibiotic purchasing, and use
of prescriptions in rural and urban areas, taking a One
Health perspective by including shops for human and
animal medicine. Almost all shops (90%) in the study
sold antibiotics without a prescription, and only a
quarter (26%) of all customers used a prescription to
buy antibiotics, contrary to government regulations
[20]. Although the study was limited to two study
areas, findings are likely to be similar in other areas
of Bangladesh. A recent study reported 100% of 189
registered retail drug shops in north and south Dhaka
supplied antibiotics without prescription on request [28].
In this study, women constituted nearly one third
of all drug shop customers (31.6%) but this varied by
Fig. 1 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
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Rousham et al. BMC Public Health (2023) 23:229
urban-rural locality. In urban drug shops, men and
women attended in almost equal proportions, but in
rural shops women were under-represented comprising
only 17.2% of customers. ese gender dimensions of
drug shop use may relate to employment, income or
other factors influencing female status in urban and rural
areas. e urban area in this study had a high number of
garment industry employers which may have contributed
to women’s autonomy and health care seeking practices.
Urban centres in Bangladesh, particularly those with
garment industry employers, have increasing rates of
female employment [29] which is, in turn, associated
with increased decision-making powers and greater
financial independence. Labour force participation rates
for females aged over 15 years increased from 29.8%
to 2010 to 36.4% in 2020 in Bangladesh, higher than
neighbouring countries [30]. e ability of women to
access drug shops and thereby gain direct access to health
care is an important consideration of future initiatives on
antibiotic stewardship.
We also observed gender differences in prescription
use for antibiotics. Women were more likely to buy
antibiotics with a prescription than men. However,
this is in part due to the high proportion of antibiotics
bought by men for animals without prescription in rural
shops. Relatively few studies of over-the-counter sales of
antibiotics in south and south-east Asia have provided
a breakdown of customers by gender or have compared
practices in urban and rural areas. Biswas et al. [31]
surveyed pharmacies in three cities in Khulna division,
Bangladesh where 39% of customers were women, a
slightly lower proportion than we observed in urban
shops. In Kerala, India, the use of prescriptions for
antibiotics purchased from pharmacies increased with
higher income strata and more skilled occupations, but
there were no reported differences in prescription use by
gender [32].
e proportion of all transactions resulting in an
antibiotic purchase (16.7% overall, 21.6% urban, 12.2%
rural) was lower in this study compared to customer-
dispenser interactions observed in 30 pharmacies
in Vietnam where 30% of urban and 24% of rural
transactions included antibiotics [7]. e rates of
antibiotic purchase without prescription, however, were
higher in our study (74.5.%) than a survey in southern
Bangladesh which reported 45.7% antibiotic purchases
without prescription [18], the latter study was conducted
in the rural Matlab area of demographic and health
Fig. 2 Classes of antibiotics purchased, with or without a prescription, as a percentage of total observed antibiotic purchases (n = 96)
*Other classes included aminoglycosides, quinolone, mupirocin
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Rousham et al. BMC Public Health (2023) 23:229
surveillance which has had a long term influence on
healthcare provision in the community. We found non-
prescription sale of antibiotics was higher in rural than
urban shops, similar to reports elsewhere [7]. e overall
proportion of customers buying antibiotics (with and
without prescription), however, was higher in urban
compared to rural shops, which could reflect greater
financial capacity for private healthcare.
In our study, antibiotics sold from drug shops without
prescription included those which are on the list of
critically important antimicrobials for human medicine
[33] namely ceftriaxone, cefixime, ciprofloxacin and
azithromycin. e widespread and inappropriate use of
broad-spectrum and critical antibiotics for human health
is serious concern for antibiotic stewardship [34, 35].
Strengths of the study include the new insights gained
by examining gender dimensions of antibiotic purchasing
across rural and urban settings, thereby contributing to
the gender equality and social inclusion (GESI) agenda.
An innovation of this study was the inclusion of drug
shops selling medicines for humans, animals or both.
Limitations of the study include the scarcity of animal
medicine shops in the urban area, hence only one was
recruited to the study which may not be generalisable.
Shops selling both human and animal medicine were only
present in the rural area and reflect the more informal
and unregulated aspects of drug shops in rural compared
to urban areas. Further, we did not have an inventory
of shops from which to select at random, but rather
selected shops through snowball sampling, giving rise to
the possibility of selection bias. Finally, the presence of
a researcher during the observations may have affected
dispensing practices or customer behaviours, due to the
Hawthorne effect [36]. We endeavoured to minimise
this effect by making the observations as unobtrusive
as possible. e effect of an observer would likely lead
to more appropriate practices (e.g. a lower rate of non-
prescription use or fewer non-prescription antibiotics
sales) and hence an underestimate of the actual rates
of over-the-counter sales of antibiotics. Nevertheless,
over-the-counter sales without prescription were very
common. Future research with a larger sample of animal
medicine shops would be a valuable addition, as well as
following animal drug shop staff who visit clients on site
or by telephone.
is study can help to identify priority audiences and
target behaviours for improving antibiotic stewardship. A
high proportion of rural drug shop owners did not have
the required pharmacy qualifications, and several had
no qualifications. In other studies, rural drug shops had
less knowledge of antibiotic generation and appropriate
prescribing, and reported less contact with medical
representatives who provide information on antibiotics,
compared to urban shop staff [25]. e common practice
of purchasing antibiotics by proxy for a patient is another
behaviour to target to prevent inappropriate antibiotic
use. Rural customers buying antibiotics for animals,
most of whom were men, were the least likely to use a
prescription and are another important target group.
e challenge for universal health coverage and
antibiotic stewardship is balancing the affordability
and accessibility of drug shops against the difficulties
of regulation, qualifications and risks of inappropriate
antibiotic dispensing. e Bangladesh National Drug
Policy aims to ensure good pharmacy practices at the
point of sale of antibiotics [20]. ese measures could
improve antibiotic stewardship, but the lack of access
to qualified healthcare professionals for those who need
antibiotics is still likely to remain for a large proportion of
the population. Future studies should incorporate gender
dimensions of antibiotic purchase and consumption
across the One Health spectrum to inform interventions
and incorporate these dimensions into National Action
Plans.
Supplementary Information
The online version contains supplementary material available at https://doi.
org/10.1186/s12889-023-15155-3.
Supplementary Material 1
Acknowledgements
Not applicable.
Authors’ contributions
EKR, PN, MAI and LU developed the concept for the paper. EKR and LU
analysed the data, prepared the first draft and led the manuscript writing.
FN, MRU, NK, SMSA, MSM conducted data collection and contributed to
preliminary analyses. MAI, PN and MR contributed to writing the paper. All
authors read and commented on drafts and approved the final manuscript.
Funding
This work was supported by the UK Antimicrobial Resistance Cross
Council Initiative in partnership with the Department of Health and Social
Care, Department for Environment Food & Rural Affairs, and the Global
Challenges Research Fund (ES/P004563/1). icddr,b is also grateful to the
Governments of Bangladesh, Canada, Sweden, and the UK for providing core/
unrestricted support. The funders had no role in the study design, conduct or
interpretation of findings.
Availability of data and materials
The datasets used and/or analysed during the current study are available from
the corresponding author on reasonable request.
Declarations
Ethical approval and consent to participate
Ethical approval for the study was granted by the Institutional Review Board
at icddr,b (PR-16100) and Loughborough University (R17-P081). All methods
were carried out in accordance with the Declaration of Helsinki. Informed
consent was obtained from all participants.
Consent for publication
Not applicable.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 9 of 9
Rousham et al. BMC Public Health (2023) 23:229
Competing interests
The authors declare no competing interests.
Author details
1School of Sport, Exercise and Health Sciences, Loughborough University,
LE11 3TU Loughborough, Leicestershire, UK
2Department of Global Health and Infection, Brighton and Sussex Medical
School, University of Sussex, Brighton and Hove, UK
3Environmental Interventions Unit, Infectious Diseases Division,
International Centre for Diarrhoeal Disease Research, Bangladesh
(icddr,b), Dhaka, Bangladesh
4Paul G. Allen School for Global Health, Washington State University,
Pullman, WA, USA
5Tarum Development Organization, Rangamati, Bangladesh
Received: 20 October 2022 / Accepted: 30 January 2023
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