Social and commercial determinants of inappropriate antibiotic use in resource-constrained settings: A...

Non-prescription antibiotic use is common in low- and middle-income countries, particularly in community-settings, yet research often overlooks social and commercial drivers beyond formal-healthcare.

This qualitative study conducted 64 in-depth interviews-16 each with pharmacy drug-sellers, pharmaceutical sales-representatives, registered-physicians, and antibiotic-users-across two urban and two rural areas in Bangladesh. Using a social-ecological systems framework, it examined how social-and-commercial determinants influence perceptions and practices in antibiotic marketing, prescription, dispensing, and use.

Public-healthcare deficiencies-long waits, medication and staff shortages, limited diagnostics, and referrals to private facilities-render services inadequate and inequitable, pushing patients toward private and informal providers. High consultation fees in private facilities and out-of-pocket costs deter low-income-groups from consulting registered-physicians for 'non-severe illnesses', driving them to seek quick recovery directly from drug-sellers and unqualified-providers. These drug-sellers and informal-providers, known as doctors for their symptomatic-treatment practices, often lead to unnecessary antibiotic use without proper assessment. Weak accountability, poor enforcement, and unregistered pharmacies staffed by untrained personnel allow unregulated sales to persist. Pharmaceutical companies heavily influence prescribing and dispensing through sales representatives, who routinely engage formal and informal providers-advising on dosages and offering financial incentives, commissions, and gifts. Companies strategically target informal-providers and drug-sellers, capitalizing on their symptomatic treatment practices to boost sales, while drug-sellers rely on physician-prescriptions and sales-representatives' guidance. To sustain business, drug-sellers often sell over-the-counter antibiotics and offer symptomatic treatments despite regulations. Patients expect fast recovery, viewing "good-doctors" as those who prescribe immediate medications empirically. Patients' prior exposure to antibiotics from informal sources influences formal providers' decisions, leading them to prescribe stronger antibiotics when first-line antibiotics or non-antibiotics would suffice. Cost barriers lead many patients to buy partial courses and stop treatment once symptoms subsite, ignoring advice to complete the regimen-further exacerbating misuse.

Effective antimicrobial stewardship requires health-system strengthening, context-specific policies, and behavior-change interventions targeting supply and demand, raising awareness, enforcing regulations, and aligning with stakeholders' economic realities.