Social and commercial determinants of inappropriate antibiotic use in resource-constrained settings: A social-ecological system framework analysis

This qualitative study in Bangladesh explores the social and commercial drivers of non-prescription antibiotic use, often overlooked in AMR research. Based on 64 interviews across urban and rural areas, it reveals that inadequate public healthcare, high costs in private care, and weak regulation drive low-income populations toward informal drug sellers, who frequently dispense antibiotics without proper diagnosis. Pharmaceutical sales representatives influence both formal and informal providers through incentives, contributing to inappropriate antibiotic use. Patients expect quick recovery and often buy incomplete antibiotic courses, compounding misuse. The study concludes that effective antimicrobial stewardship must go beyond regulation—requiring health system reform, behavior change, and context-sensitive interventions that address both supply and demand factors.