A Codesigned Approach to Develop Tailored Antimicrobial Stewardship Strategies in Bangladesh: A Social-Ecological Systems Framework Analysis.

backgroundMultistakeholder collaboration and codesign are increasingly recognized as effective approaches for addressing complex public health challenges such as antimicrobial resistance (AMR), yet stewardship efforts in low- and middle-income countries remain fragmented and are often limited to education-focused interventions with minimal community engagement. This study used a codesign approach to develop context-specific antimicrobial stewardship (AMS) strategies for community pharmacies in rural Bangladesh, where over-the-counter antibiotic sales are common and pharmacy-led care is limited.

methodsSeparate codesign workshops were conducted in two rural regions of Bangladesh with stakeholders involved in antibiotic marketing, prescribing, dispensing, and use. Guided by the Social Ecological Systems Framework, participants identified priorities and feasible interventions at the systemic, organizational, community, and individual levels.

resultsStakeholders proposed a comprehensive, interconnected package of strategies spanning all system levels to strengthen AMS and promote appropriate antibiotic use. System-level priorities included improving access to public healthcare, strengthening diagnostic and referral systems, promoting guideline adherence, clarifying informal providers' roles, engaging pharmacy associations, and strengthening regulation of antibiotic sales and unlicensed practice, though constrained by limited resources, political inertia, conflicts of interest, and policy gaps. At the organizational level, recommendations included antibiotic-specific packaging and labelling, physician counselling on treatment completion, and reinforcement of stewardship messages by drug-sellers, though implementation may be limited by commercial interests, workforce shortages, affordability concerns, and drug-sellers' limited AMR knowledge. At the community level, stakeholders emphasized public awareness campaigns, school-based education, and engagement of nongovernmental and community organizations, noting that awareness alone is unlikely to succeed without enforcement. At the individual level, patients were encouraged to seek advice on appropriate antibiotic use, though participants noted that sustained behaviour change would require broader system reforms, and that isolated interventions were unlikely to succeed without coordinated action across multiple health system levels.

conclusionsEffective AMR mitigation requires coordinated, multisectoral action integrating policy reform, regulatory enforcement, community engagement, and contextually appropriate stewardship interventions. These findings highlight the value of codesign in identifying feasible strategies that address both structural and behavioural drivers of antibiotic use, considering the local social and economic realities. PATIENT OR PUBLIC CONTRIBUTION: Patients, community members, community-pharmacy drug-sellers, pharmaceutical sales representatives, and registered physicians from both public and private facilities, along with local health authorities, actively contributed to this study through workshops. They shared lived experiences from their respective roles and provided contextual insights that informed the design and interpretation of the findings. Their involvement ensured that the stewardship strategies were relevant and appropriate for rural community-pharmacy settings in Bangladesh.