What is the benefit of visiting a doctor, if we cannot afford a diagnostic test or buy medicine? An exploratory study of equity in antimicrobial resistance among the urban informal settlements of Dhaka.

Introduction: Antimicrobial resistance (AMR) is a critical health problem worldwide. In low and middle-income countries, over-the-counter sales of antibiotics occur at the patient's request or on the recommendation of a community service provider. This qualitative study explored how social, structural and behavioural determinants among the population and informal providers contribute to AMR risk in urban informal settlements in Bangladesh. Methods: We conducted focus group discussions and in-depth interviews (25 IDIs and 6 FGDs; 31 in total) with community people and informal healthcare providers from two settlements in Dhaka North and South City Corporations, following a thematic analysis of coded transcripts according to predetermined themes of 'healthcare access' and 'challenges', 'autonomy', 'gendered roles and norms' in urban low-income communities. Results: In both settlements, year-round respiratory and water-borne diseases were common, such as diarrheal episodes, jaundice and influenza. Children frequently suffered respiratory infections, while the elderly grappled with chronic diseases. Readymade garment factory workers, mostly women, regularly developed urinary tract infections and physical injuries from long-seated shifts and minimal health breaks (water intake, bathroom breaks and movement), leading to repeated antibiotic courses. Women, financially dependent and resource-constrained, often engaged in non-recommended use of antibiotics (using leftover antibiotics and self-regulating doses and courses), except when in their caregiving role. Men generally controlled household spending but postponed seeking formal care and consulted unqualified providers for affordability and convenience. Both discontinued antibiotics when they felt slightly better. For working men and women, rigid facility hours that coincided with work schedules and a lack of gender-sensitive services were cited as barriers. Widespread non-recommended antibiotic use was reported by both community members and informal providers. Conclusions: Our study highlights the importance of gender norms and behaviours, gendered livelihoods and the role of informal service providers in managing AMR in Bangladesh.