Pathways of antibiotic use in Bangladesh: a qualitative protocol for the PAUSE study

Introduction: Global actions to reduce antimicrobial resistance include optimising the use of antimicrobial medicines in human and animal health. In countries with weak healthcare regulation, this requires a greater understanding of the drivers of antibiotic use from the perspective of providers and consumers. In Bangladesh, there is limited research on household decision-making and healthcare seeking in relation to antibiotic use and consumption for humans and livestock. Knowledge is similarly lacking on factors influencing the supply and demand for antibiotics among qualified and unqualified healthcare providers. The aim of this study is to conduct integrated research on household decision-making for healthcare and antibiotic use, as well as the awareness, behaviours and priorities of healthcare providers and sellers of antibiotics to translate into policy development and implementation. Methods and analysis: In-depth interviews will be conducted with i) household members responsible for decision-making about illness and antibiotic use for family and livestock; ii) qualified and unqualified private and government healthcare providers in human and animal medicine and iii) stakeholders and policy makers as key informants on the development and implementation of policy around antimicrobial resistance (AMR). Participant observation within retail drug shops will also be carried out. Qualitative methods will include a thematic framework analysis. A holistic approach to understanding who makes decisions on the sale and use of antibiotics, and what drives healthcare seeking in Bangladesh will enable identification of routes to behaviour change and the development of effective interventions to reduce the health risks of antimicrobial resistance. Ethics and Dissemination Approval for the study has been obtained from the Institutional Review Board at the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) following review by the Research and Ethic committees (PR-16100) and from Loughborough University (R17-P081). Dissemination will take place through stakeholder workshops, international conferences and publication.