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

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posted on 26.05.2021, 16:09 authored by Leanne E. Unicomb, Fosiul Alam Nizame, Mohammad Rofi Uddin, Papreen Nahar, Patricia J. Lucas, Nirnita Khisa, S. M. Salim Akter, Mohammad Aminul Islam, Mahbubur Rahman, Emily RoushamEmily Rousham
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.

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.

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.

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.


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

Economic and Social Research Council

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Antimicrobial Resistance Cross-Council Initiative supported by the seven UK research councils in partnership with the Department of Health, the UK Department of Environment Food and Rural Affairs and the Global Challenges Research Fund (Economic and Social Research Council grant ES/ P004563/1).



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BMC Public Health




BioMed Central


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This is an Open Access Article. It is published by BioMed Central under the Creative Commons Attribution 4.0 International Licence (CC BY 4.0). Full details of this licence are available at: https://creativecommons.org/licenses/by/4.0/

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Dr Emily Rousham. Deposit date: 26 May 2021

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