Study design

This study is part of a larger project aimed at developing and testing a mobile health (mHealth) tool that supports village doctors in Bangladesh to use antibiotics responsibly [30]. The broader initiative includes mapping village doctors, conducting formative qualitative research to understand providers’ behavior, co-designing the tool with users, pilot testing, and evaluating its impact.

As in the formative research phase, this study utilized a qualitative descriptive design to examine the factors that influence the provision of antibiotics among village doctors in rural Bangladesh. This approach enables researchers to gather comprehensive accounts of participants’ lived experiences and viewpoints, which are essential to investigating complex behavioral patterns within specific contextual settings [31]. Through this methodology, we were able to explore the underlying motivations, beliefs, and situational factors that drive antibiotic provision decisions across different ecological levels.

Study site and population

The study was conducted in Sitakunda Upazila, a sub-district of Chattogram District in the southeastern part of Bangladesh. Sitakunda Upazila is approximately 500 square kilometers of land area and has a population of around 497,396 [32]. The literacy average rate in Sitakunda was about 54%. The primary occupations of the local population are in the service sector (28.76%), agriculture (24.12%), and commerce (21.53%). The hospitals and healthcare centers in Sitakunda include Union Health Centre and community clinics at the wards [32]. Sitakunda was selected as a study site because it has high pediatric diarrhea burden [33]. The area has a large number of informal healthcare providers in practice in areas with a broad range of healthcare access and economic conditions. Our team knows the area well and has built strong, established working relationships with members of the community through previous research.

In the first stage of the broader initiative, using a ‘snowball’ sampling method, 411 village doctors were identified and mapped across 10 unions in Sitakunda, and 371 agreed to complete a structured survey, which has been reported elsewhere [34]. From this mapping, four unions were selected for participation in the qualitative interviews based on the following criteria: (i) accessibility:- areas that could be safely reached by the research team within reasonable travel time; (ii) density of village doctors:- unions with a sufficient number of active village doctors to enable adequate participant recruitment; and (iii) healthcare needs:- areas where village doctors are mostly popular as primary source of medical care for residents. From these four unions, we used convenience sampling to approach 20 village doctors to participate in the qualitative study. We targeted recruiting 20 village doctors because prior methodological work suggests 10–17 in-depth interviews within a relatively homogeneous group are typically sufficient to reach saturation and identify major patterns [35,36]. Moreover, we interviewed village doctors only, as our research focused specifically on the perspectives and practices of village doctors since they are a first point of care in rural settings.

From the 20 village doctors who were approached, 18 agreed to participate and completed in-depth interviews. The remaining two declined due to time constraints.

Procedures

In-depth interviews (IDIs) were conducted by a team of three Bangladeshi anthropologists who were trained in qualitative research, familiar with the study objectives, and fluent in Bengali, the local language. We used in-depth interviews rather than other qualitative methods like focus group discussions due to the specific aim and context of our study. Individual interviews allow us to dive deeper into each participant’s thoughts and experiences about antibiotic prescribing practices. This was especially important given the sensitivity of the possible misuse of antibiotics. By discussing one-on-one, participants could share their opinions freely, without the pressure of a group setting [37,38]. IDIs were conducted in May 2023 at locations convenient for the participants, typically their chambers or drug shops, to ensure a comfortable and familiar environment. Each interview lasted approximately 40–60 minutes and was audio-recorded with the participant’s consent.

The team used a semi-structured interview guide (Supplement 1), developed in English and translated into Bengali. The guide covered key topics, including the role of village doctors in treating pediatric diarrhea, their knowledge of antibiotic stewardship, attitudes toward antibiotics, and practices regarding antibiotic dispensing behavior for pediatric diarrheal illness. All interviews were conducted in Bengali, audio recorded, transcribed verbatim, and then translated into English. The same three anthropologists who conducted the interviews were primarily responsible for transcription and translation, while all three team members collaboratively coded and analyzed the data to ensure consistency and rigor in interpretation.

Analysis

We conducted an inductive thematic analysis to understand antibiotic dispensing among village doctors in rural Bangladesh. Village doctors both recommend and directly supply medications to patients outside the formal regulatory framework. For this study, “antibiotic provision” refers to this combined process of clinical decision-making and medication supply, which differs from the separated prescribing and dispensing functions in formal healthcare settings.

Thematic analysis followed Braun and Clarke’s approach [39], allowing themes to emerge directly from the interview data without imposing a pre-existing framework. The research team in Bangladesh reviewed all the interview transcripts, manually coded them for concepts related to antibiotic provision, and looked for relationships between codes, and grouped codes to synthesize the emerging themes [40].

After the initial coding and theme development, we mapped the inductively derived themes onto the five domains of the Social Ecological Framework (SEF) [41] that emerged as factors of antibiotic dispensing behavior across five interconnected levels: (1) Individual level, (2) Interpersonal level, (3) Organizational level, (4) Community level, and (5) Policy or macro level. This two-step process enabled us to remain grounded in participants’ perspectives while also situating our findings within a widely recognized model for understanding multi-level influences on health behaviors. By organizing the results according to the SEF, we systematically examined the various factors influencing antibiotic provision practices for pediatric diarrhea among village doctors in rural Bangladesh, offering a comprehensive understanding of the issue within its broader socio-ecological context.

Ethical approval

The study protocol was approved by the Ethical Review Committee of the International Centre for Diarrhoeal Diseases Research, Bangladesh (icddr,b), and the Institutional Review Board of the University of Utah, USA. The investigators explained the study to each participant and obtained informed written consent before conducting the interviews.

Individual level

At the individual level, several factors shaped village doctors’ decisions to provide antibiotics for pediatric diarrhea. These included their clinical knowledge and training, personal beliefs about antibiotics, and approaches to clinical decision-making.

All participants reported having government-accredited training in medical practices, along with various short-term government and non-government training focused on the management of diarrheal diseases. However, this training did not necessarily translate into evidence-based clinical practice. Although clinical guidelines do not recommend providing antibiotics for most cases of diarrhea, most village doctors indicated that they routinely provided antibiotics to patients based on a belief that antibiotics are the best and quickest way to recover from illness.

“Antibiotics make patients recover faster, or when you have diarrhea, it works faster like magic. This is why antibiotics are being used without hesitation.” (Village doctor with 21 years of practice)

Knowledge gaps and misconceptions regarding antibiotics and antibiotic resistance were common. Many participants had limited understanding of what constitutes an antibiotic and demonstrated little awareness of antibiotic resistance as a public health concern. For example, they described giving patients metronidazole as a first line treatment but did not understand that it was an antibiotic.

“I provide ORS, metronidazole, and probiotics as the first line of medications. If the condition does not improve, then antibiotics are provided.”(Village doctor with 21 years of practice)

Misconceptions about antibiotic spectrum were also observed. While many village doctors knew antibiotics are effective against bacteria, some believed that antibiotics could treat all pathogens, including viruses.

“Antibiotics mainly work against any germs in our body. They kill the viruses that enter our bodies.” (Village doctor with 20 years of practice)

Few participants were familiar with the concept of antibiotic resistance. Although many had heard of it, none understood its precise definition or could explain the long-term consequences of antibiotic overuse or misuse. Moreover, most didn’t perceive resistance as relevant to their daily practice or as a priority compared to immediate patient satisfaction and symptom relief.

In terms of clinical decision-making, the years of experience of village doctors appeared to play a role in antibiotic dispensing practices, with more junior village doctors being more likely to prescribe antibiotics for childhood diarrhea than senior village doctors. Some participants mentioned that senior practitioners may feel more confident in their clinical decision making while junior practitioners are more likely to have lower self-confidence in their clinical judgement. This lack of confidence may push them to prescribe antibiotics as a precaution to avoid potential complications, even when not strictly necessary or clinically indicated.

“Those who are inexperienced, or those who are new, are still learning by working in a pharmacy (drug shop). They may not have any training, but they think of themselves as doctor; these junior people usually dispense more antibiotics.” (Village doctor with 21 years of practice)

Interpersonal level

At the interpersonal level, village doctors’ practices related to antibiotic provision were shaped by the expectations and demands of patients and caregivers, as well as the promotional activities of pharmaceutical companies.

Most participants explained that patients and their caregivers often expect and demand “powerful medicines” to ensure a quick recovery for their children. This expectation often centers on antibiotics, which are widely perceived as the most effective and rapid solution for pediatric diarrhea.

“I think people have a tendency to take antibiotics because they believe antibiotics are powerful drugs for quick recovery.” (Village doctor with 21 years of practice)

“Antibiotics help patients recover more quickly, especially during diarrhea. As they (caregivers/patient) asked us to provide antibiotics, we generally provide without any hesitation to make our customers happy.” (Village doctor with 21 years of practice)

All participants reported that parents typically take their child to a village doctor expecting to receive medications. In some cases, parents may even visit the village doctor without the pediatric patient to consult with the doctor and request specific medication for the sick child. Participants explained that client satisfaction with village doctors’ services is largely dependent on the receipt of antibiotics, leading participants to feel pressured to provide antibiotics, even if not clinically necessary.

“It is very common that sometimes parents come with their sick children and tell us that they saw a child with diarrhea in their neighborhood recover quickly with [Azithromycin/ Cefixime]. So, they believe their baby will have a rapid cure and thus demand [Azithromycin/Cefixime]. Sometimes, they come with old packets or syrup bottles.” (Village doctor with 15 years of practice)

In addition to client expectations, participants also spoke about the influence of pharmaceutical companies on their antibiotic providing practices. Pharmaceutical companies frequently organize or support short-term training on management of various diseases, including diarrhea. Participants noted that these programs often emphasize selling their products, rather than providing comprehensive education on the rational use of antibiotics.

“Pharmaceutical companies sometimes organize seminars to promote their medications, not arrange programs or training that could help us learn new things.” (Village doctor with 9 years of practice)

Organizational level

At the organizational level, several factors influenced the antibiotic provision practices of village doctors, including economic incentives, resource constraints, and a competitive healthcare environment.

The economic structure of village doctors’ practices contributes to the provision of antibiotics. Village doctors can earn income through both consultation fees and the sale of medications. For some, the sale of medicines was their sole source of income, as they didn’t charge for consultation. This dual role of serving as both healthcare provider and medicine seller creates inherent conflicts of interest that could influence their recommendations to patients. Some participants said they did not charge any consultation fees and instead relied solely on selling medications directly to patients for their income. This business model necessitates maintaining a stock of medications and managing operational costs, which can create pressure to sell the available stock of medication. Additionally, pharmaceutical companies offer financial and non-financial incentives to village doctors who promote their products. Since antibiotics are typically priced higher than other medications, village doctors earn larger commissions and profit margins for selling antibiotics.

“A well-known brand’s tablet has a lower profit margin. However, if you sell antibiotics from an unknown brand, you will achieve a better profit margin, even though those medicines may be less effective.” (Village doctor with 20 years of practice)

“If I sell ten boxes of antibiotics, they often reward me with two additional boxes as a gift. Sometimes they even provide gifts like utensils or fans.” (Village doctor with 21 years of practice)

Resource constraints were another organizational challenge. Most village doctors lacked access to laboratory facilities and advanced diagnostic equipment. This limitation hinders their ability to make evidence-based prescribing decisions, potentially leading them to adopt overly cautious prescribing practices. Additionally, the competitive nature of the healthcare environment in rural areas, where multiple providers vie for patients, further reinforced the tendency to prescribe antibiotics as a means of maintaining patient satisfaction and sustaining their business.

“In many cases, particularly in rural or small-town areas, pharmacies and local doctors often prescribe unnecessary antibiotics primarily for business reasons. Their motivation is not related to treating diseases but rather to profit from selling antibiotics, which can be quite lucrative.” (Village doctor with 5 years of practice)

Since village doctors had limited access to laboratory diagnostics, they relied primarily on patient history and clinical presentation, including noticeable color and odor of stool samples. Although this approach is pragmatic given the constraints, it may result in over-use of antibiotics.

“When someone suffers from diarrhea, and has a bad odor in stool, we consider it a bacterial infection and provide antibiotics to that patient.” (Village doctor with 27 years of practice)

Community level

At the community level, cultural beliefs and expectations, healthcare seeking behaviors within the community, and antibiotic availability and accessibility play a role in shaping antibiotic provision practices. Community members believed that antibiotics are essential for a quick recovery from illness. Participants felt that many members of the community were unfamiliar with the term “antibiotic,” but they recognized the names of specific medications. Those who were aware of antibiotics often viewed them as potent and highly effective treatments for a range of diseases, particularly diarrhea.

“In Bangladesh, I don’t think any patient is satisfied without taking any antibiotic, whether its diarrhea or cough and cold with fever or any other illness. That’s what I have seen in my years of practice. Sometimes you can’t be a good doctor if you don’t give antibiotic.” (Village doctor with 5 years of practice)

Village doctors also explained that people in their community often changed village doctors if they didn’t see improvement in a short time. This further reinforces the cultural expectations of trying to minimize recovery time by prescribing antibiotics instead of taking a “wait and see” approach.

The socio-economic conditions of rural communities create additional complexities. Many village doctors mentioned that most patients were from low-income families. Some doctors take the patient’s economic situation into account when deciding which medications to sell to patients.

“If doxycycline is sufficient for my patient, I won’t prescribe ciprofloxacin. Doxycycline costs 2 takas, while ciprofloxacin costs 20 takas, so the patient would save 18 takas.” (Village doctor with 17 years of practice)

Finally, participants reported that antibiotics were widely available from multiple venues in their community. The availability and promotion of antibiotics in the community sustains the expectation that antibiotics can and should be taken to treat all common ailments.

Policy level

At the policy level, antibiotic provision among village doctors was influenced by weak regulatory frameworks, inadequate enforcement mechanisms, and broader governance challenges within Bangladesh’s healthcare system.

The most significant policy level factor was the lack of stringent regulations governing antibiotic sales and distribution. This regulatory weakness is compounded by widespread lack of awareness about prescribing authority, that is, most participants were unaware that the right to prescribe antibiotics legally belongs to registered physicians only. Current policies provide limited oversight of antibiotic sales and distribution in rural areas, with minimal monitoring of prescribing patterns. Participants also described this lack of strict guidelines for antibiotic dispensing creates an environment where antibiotics could be purchased freely from unregulated outlets, including grocery stores and stationery shops, where untrained individuals dispensed medications without proper knowledge or qualifications. This unregulated environment is exacerbated by the widespread use of counterfeit certificates by pharmacy operators, undermining the credibility and safety of healthcare services.

“Whether it is a betel leaf store or a stationery store, you can find medicines/drugs to some extent, particularly for diarrhea. Go to any stationery shop and tell them to give you something for diarrhea, then they will give you oral dehydration saline along with ‘Metronidazole’ certainly.” (Village doctor with 5 years of practice)

The weak regulatory system is further undermined by inadequate enforcement efforts. Notably, none of the participants reported any legal penalties associated with selling antibiotics, highlighting a gap in enforcement that could warn practitioners about legal risks. Instead, village doctors expressed confidence in their training and management skills, asserting they are well-equipped to treat diarrheal diseases and believe they have the authority to provide antibiotics for this illness.

“There are no real rules and regulations for selling and consumption of antibiotic, as a result of which the people of Bangladesh are suffering a lot.” (Village doctor with 5 years of practice)

The policy environment also created conditions that positioned village doctors as essential healthcare providers in rural areas, despite their lack of formal recognition. Village doctors play a crucial role in providing healthcare in rural areas, where access to formal healthcare options is often limited and challenging. Caregivers of children with diarrhea often avoid visiting government hospitals due to challenges of distance, cost, long wait time and lack of trust. Given this, parents often prefer to take their child to a village doctor for more timely treatments and cost-effective services. Although these village doctors are not officially recognized by the government, the community acknowledges them for their availability and the services they provide. This recognition allows them considerable freedom to use antibiotics for treating pediatric diarrhea.

“Most families are not willing to go to the hospital. They like to get initial treatment from their family doctor (village doctor). As they are our old patients and known people, they first come to us. Another reason is the money. Some people think about the distance to a hospital.” (Village doctor with 21 years of practice)