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Prevalence and determinants of
antibiotics self-­medication among
indigenous people of Bangladesh: a
cross-­sectional study

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Adnan Mannan ‍ ‍,1,2 Kallyan Chakma ‍ ‍,1,2 Gourab Dewan ‍ ‍,3 Ayan Saha ‍ ‍,4
Naim Uddin Hasan A Chy,5 H M Hamidullah Mehedi ‍ ‍,6 Amzad Hossain ‍ ‍,7
Jannatun Wnaiza ‍ ‍,8 Md Tanveer Ahsan,9 Md Mashud Rana ‍ ‍,2,10
Nazmul Alam ‍ ‍11

To cite: Mannan A, Chakma K, ABSTRACT

Dewan G, et al. Prevalence and Objectives Self-­medication with antibiotics (SMA)
STRENGTHS AND LIMITATIONS OF THIS STUDY
determinants of antibiotics self-­ contributes significantly to the emergence of antimicrobial ⇒ This study is the first qualitative study of its kind
medication among indigenous to assess antibiotic self-­medication and its determi-
resistance (AMR), especially in low-­income countries
people of Bangladesh: a cross-­ nants among indigenous people in Bangladesh.
sectional study. BMJ Open including Bangladesh. This study aimed to generate
evidence on the self-­reported prevalence of antibiotic ⇒ This study included a robust sample with variables
2024;14:e071504. doi:10.1136/
bmjopen-2022-071504 self-­medication and its determinants among indigenous and indigenous people from three different districts.
people residing in Bangladesh’s Chittagong Hill Tracts ⇒ This study will guide the development of nation-
► Prepublication history al policies and guidelines for addressing the self-­
(CHT) districts.
and additional supplemental medication of antibiotics.
material for this paper are Design This study used a cross-­sectional design with
⇒ The study’s main weakness is that it is cross-­

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available online. To view these data collected through a survey using a semi-­structured
questionnaire. sectional, meaning that only associations can be
files, please visit the journal
online ([Link] Setting This study was conducted from late January inferred and causality cannot be determined.
bmjopen-2022-071504). to early July 2021; among different indigenous group
populations aged 18 years or more olders residing in the
Received 02 January 2023
three districts of CHT. Conclusion Male gender, family income, place of
Accepted 14 February 2024
Participants A total of 1336 indigenous people residing in residence and knowledge of antibiotics were the
Bangladesh’s CHT districts were included. significant predictors of antibiotic self-­medication. Hence,
Primary outcome and explanatory variables The it is important to streamline awareness-­raising campaigns
primary outcome measure was SMA while explanatory at the community level to mitigate the practice of SMA in
variables were socio-­demographic characteristics, health indigenous people and ultimately address the devastating
status of participants, and knowledge of antibiotics usage effects of Antimicrobial resistance (AMR) in Bangladesh.
and its side effects.
Results Among the study participants, more males
(60.54%) than females (51.57%) reported using INTRODUCTION
antibiotics. The SMA rate was high among individuals While the discovery of antibiotics has mark-
with education levels below secondary (over 50%) and edly influenced treatment methods against
those in the low-­income group (55.19%). The most infectious diseases, unfortunately, most
common diseases reported were cough, cold and fever, available antibiotics are gradually becoming
with azithromycin being the most frequently used ineffective at a higher rate.1 Antimicrobial
antibiotic. Levels of education, family income, having a resistance (AMR) is presently a significant
© Author(s) (or their
employer(s)) 2024. Re-­use chronic illness and place of residence were found to be concern of the World Health Organization
the significant predictors of having good knowledge of
permitted under CC BY-­NC. No (WHO),2 accounting for thousands of deaths
commercial re-­use. See rights antibiotic use as found in the ordered logit model. Findings
and permissions. Published by
annualy. In Europe, the number of deaths
from a logistic regression model revealed that men had
BMJ. from AMR is 33 000 per year,3 while in the
1.6 times higher odds (adjusted OR (AOR) 1.57; 95% CI
For numbered affiliations see 1.12 to 2.19) of SMA than women. Participants with USA, AMR causes as many as 35 900 deaths
end of article. ≥US$893 per month family income had lowest odds (AOR per year.4 The fatality is even worse in low-
0.14; 95% CI 0.03 to 0.64) of SMA than those who earned and middle- income countries (LMICs).5 6
Correspondence to
<US$417. Participants living in Rangamati districts had a The emergence of AMR occurs due to
Dr Ayan Saha;
​ayan.​saha.​bd@​gmail.c​ om and lower risk of SMA (…) than those in Bandarban district. evolutionary selective pressure exerted on
Dr Adnan Mannan; rate of SMA (AOR 0.52; 95% CI 0.30 to 0.90) than those in the bacterial population due to the irrational
​adnan.​mannan@​cu.​ac.b​ d Bandarban district. use of antibiotics, causing the bacteria to

Mannan A, et al. BMJ Open 2024;14:e071504. doi:10.1136/bmjopen-2022-071504 1

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circumvent the drug action and multiply.7 Treatment of consequence, their overall health status remains poorer
highly prevalent diseases such as pneumonia, cholera, compared with non-­ indigenous people.34–36 There is
tuberculosis, and malaria has become difficult due to the not sufficient information regarding antibiotics usage,
emergence of AMR.8 including SMA, among this community of more than
Although the mechanism of AMR develops in bacteria 2 million people. It is possible that the indigenous popu-
naturally, human activities can accelerate the emergence lation’s limited access to resources resulting from social,
and spread of the process. Previous studies have iden- cultural, geographical, and financial abilities contributes
tified both high consumption of antibiotics and irra- to their increasing use of SMA.34
tional consumption of the drug as contributing factors This study was conducted among the indigenous
to AMR.9 A study has reported that approximately 50% people of Chittagong to generate evidence on the self-­

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of human and animal antibiotic usage is unreasonable.10 reported prevalence and determinants of antibiotic self-­
Often, the irrational use of antibiotics comes from several medication and its determinants. Age, gender, education
socio-­demographic determinants. Recent reports show level, occupation, income, and ethnicity are various
that people in developed countries with high educa- socio-­
demographic criteria that have been taken into
tion rates often engage in inappropriate antibiotic use consideration to examine the overall background of
through self-­ medication with antibiotics (SMA).11 12 SMA. The pattern of antibiotic usage, the reasons for
Surprisingly, students from health-­ related programs in SMA, the healthcare-­seeking practices, as well as knowl-
Malaysia showed ignorance regarding antibiotic usage.9 edge and attitudes regarding antibiotic usage have been
In LMICs, people have the same difficulties regardless of investigated in this study. The findings of this study will
their level of education or economic standing. Unfortu- help us address the knowledge gaps in the usage of non-­
nately, there is widespread ignorance among the popu- prescribed antibiotics, pharmacy regulations, availability
lation regarding the distinctions between antibiotics of antibiotics, knowledge of antibiotic use and awareness
and other types of treatment.13–15 Because of their lack of antibiotic misuse in order to recommend necessary
of knowledge, many believe antibiotics may treat any intervention and policy reform.
ailment, even viral diseases.16 In the USA, 29% of annual
antibiotic prescriptions (~11.4 million) are unnecessarily
prescribed for acute respiratory tract infections only.17 METHODS

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Sometimes, patients ask physicians to prescribe them Participants
antibiotics adamantly.18 A cross-­sectional study was conducted between January
Apart from education, age is a significant variable in 2021 and July 2021 among indigenous people residing
terms of self-­medication. Multiple studies have reported in Rangamati, Bandarban, and Khagrachari, three hill
that cases of SMA are more prevalent among adults aged districts in the CHT in Bangladesh. The indigenous popu-
18 to 45 years and older.19 20 Most studies, with a few lation was characterised per the description provided by
notable exceptions, have found that SMA is more prev- the International Work Group for Indigenous Affairs
alent in females than males.19–23 Furthermore, there is a (IWGIA).37 38 Within the study, the indigenous population
correlation between the monthly family income and the was delineated into prominent ethnic groups, including
tendency to engage in SMA.24 25 Chakma, Marma, Tripura, Bawm, Tanchangya, Chak,
Antibiotics are available without a prescription in many Rakhaine, Saotal, and Mro. The categorisation of an indi-
low- and middle-­income countries, leading to the wide- vidual’s ethnicity ensued through a systematic examina-
spread occurrence of Self-­ Medication with Antibiotics tion, integrating parameters such as self-­identification,
(SMA).26 27 In Bangladesh, the SMA prevalence among observational data, surname analysis, linguistic attributes,
the general population was reported to be 26.69%.28 cultural practices, and geographical origin. Both men
SMA was shown to be relatively frequent among the and women aged 18 years and older living in the selected
people who lived in rural parts of Dhaka, Chittagong and study sites were included in the study. The sample size
Rajshahi, according to cross-­sectional studies that were (n=383) for this study was determined using the formula
conducted among participants who lived in those loca- n=z2 p(1−p)/d2,39 taking into account a significance level
tions.29 30 An investigation in Dhaka revealed that 75% of of 0.05, a confidence level of 95%, and a prevalence rate
the people polled used over-­the-­counter drugs, of which of 26.69% obtained from a prior study in Bangladesh, a
16.90% were antibiotics.31 It is necessary to address the 5% margin of error, a 20% non-­response rate, and finally
situation in low-­income nations, including Bangladesh, to multiplied by a design effect 2 due to the cluster sampling
enhance the overall health impact, given that majority of technique.40 All the respondents gave voluntary consent
the world’s population resides in these countries.32 and agreed to participate in the study.
Bangladesh is a densely populated country where 1.8%
of the total population comprises indigenous people living Sampling
in the rural areas of Chittagong, Mymensingh, Sylhet and This study used a two-­stage cluster sampling approach in
Rajshahi.33 These ethnic groups have long maintained the districts of Bandarban, Rangamati and Khagrachari.
isolation from the general population, putting them at Six out of seven upazilas (sub-­districts) in Bandarban,
a disadvantage in obtaining healthcare facilities. As a nine out of ten in Rangamati and nine in Khagrachari

2 Mannan A, et al. BMJ Open 2024;14:e071504. doi:10.1136/bmjopen-2022-071504

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were included in the study. Two sub-­districts, Rowang- day labour, handloom, and unemployed), family income
chhari in Bandarban and Baghaichari in Rangamati, in US dollars ($US) (<US$417, US$417–893, >US$893).
were excluded due to COVID-­19 lockdown and security Additional variables considered were the prevalence of
concerns. The samples were selected in proportion to the common diseases (cough, cold and fever, headache, joint
indigenous population based on the 2011 census: 20.3% pain, diarrhoea and food poisoning, dental carries and
from Bandarban, 37.5% from Khagrachari and 42.12% toothache, irritable bowel syndrome, typhoid, malaria,
from Rangamati.41 42 In the first stage, the sampling units jaundice, roundworm/tapeworm, sinusitis, asthma, other
were the sub-­districts, and a probability proportionate to respiratory diseases, acne, skin allergies, and none) and
size method was employed. This technique ensured that types of medication concerning self-­medication associ-
sub-­districts with more households had a higher chance of ated with disease prevalence.

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being selected. For the second stage, participants (either
the head of the household or another family member in Patient and public involvement
the absence of the head) from the chosen sub-­districts No patient was involved.
were identified using systematic random sampling. The
data were collected through face-­to-­face interviews using Statistical analysis
a semi-­ structured questionnaire consisting of 60 ques- A descriptive analysis was performed to determine the
tions arranged in four separate sections. The question- distribution of socio-­demographic variables. χ2 tests with
naire consisted of four sections; section 1 assessed the a significance threshold of 5% were used to compare
demographic details and epidemiological characteristics the prevalence of self-­ medication across the variables.
including comorbidities, lifestyle and reasons for using An ordinal logistic regression model was performed to
antibiotics. Section 2 covers the pattern of antibiotic determine the predictors of the knowledge level of antibi-
usage. Section 3 takes into account healthcare-­seeking otic self-­medication as a dependent variable. Knowledge
facilities. They were asked about hygiene, the frequency level was categorized as no knowledge, poor knowledge,
of respondents visiting physicians’ offices and the distance fair knowledge, and good knowledge. A binary logistic
from the closest pharmacy. Section 4 assessed the knowl- regression analysis was performed with ever-­ reported
edge and attitude of indigenous people toward antibiotic self-­
medication of antibiotics as a dependent variable,
usage. and independent variables included socio-­demographic
characteristics including age, gender, education, marital

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This study has recognized the self-­medication of anti-
biotics (SMA) as an irrational use of antibiotics.43 The status, occupation, family income, and home district.
WHO delineates self-­medication as ‘the use of drugs to Other independent variables included in the final model
treat self-­diagnosed disorders or symptoms, or the inter- are having suffered from any chronic illness and knowl-
mittent or continued use of a prescribed drug for chronic edge about antibiotics. The variables having a p value of
or recurrent disease or symptoms’.21 44 Survey respon- <0.25 in the univariate logistic regression analysis were
dents were asked whether they had consumed medica- included in a multivariable model to estimate the adjusted
tion during the past year without consulting a doctor or OR. Both unadjusted and adjusted OR are presented with
any healthcare professional, which was identified as the 95% CIs. In the final model, a p-­value of 0.05 or below was
primary outcome variable of this study. Interviews were considered as statistically significant. SPSS V.25.0 was used
conducted by research assistants after they had the neces- for statistical analysis. GraphPad Prism V.9.0 was used to
sary training on data collection and questionnaires. We represent the findings graphically.
recruited seven local research assistants fluent in the
indigenous tribes’ languages and provided thorough
training before data collection. The question was initially RESULT
written in English and later translated into Bengali. The Socio-demographic characteristics
questionnaire was evaluated and reviewed by a panel of A total of 1537 individuals took part in the study, of
experts, including doctors, pharmacists, epidemiologists, which 749 respondents (48.7%) used antibiotics, 587
and medical specialists. All data was initially recorded respondents (38.1%) never used antibiotics, and the
manually on paper and then entered into Google Forms remaining (13.2%) were unsure if they used antibiotics
for export and storage in Microsoft Excel 2013. (online supplemental figure 1). However, information
on antibiotic use was available for 1336 of the 1537
Explanatory variables participants. Among the 1336 individuals from distinct
Explanatory variables comprised of administrative indigenous communities who participated in the study
districts (Rangamati, Bandarban, and Khagrachari), age conducted in three hill districts of Bangladesh’s Chit-
groups (18–29, 30–39, 40–49, 50–59, and 60 years and tagong division and reported use of antibiotics, were as
above), gender (male and female), ethnicity (Chakma, follows: Rangamati (42.1%), Khagrachari (31.6%) and
Marma, Tripura, Bawm, Tanchangya, Chak, Rakhain, Bandarban (26.3%), with participation from Chakma
Saotal, and Mro), educational levels (illiterate, primary, (40.2%) and Marma (37.2%) followed by Tripura (9.4%),
secondary, higher secondary, and graduate), occupations Tanchangya (6.3%), Bawm (5.5%) and other communi-
(agricultural work, service, housewife, student, business, ties (1.4%) (table 1). The majority of the participants

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Table 1 Socio-­demographic characteristics of study participants by antibiotic use
Total (N=1336) Did not use antibiotics (N=587) Used antibiotics (N=749)
N (%) N (%) N (%)
Age group (years)
 18–29 619 (46.30) 241 (38.93) 378 (61.07)
 30–39 255 (19.10) 131 (51.37) 124 (48.63)
 40–49 207 (15.50) 100 (48.31) 107 (51.69)
 50–59 149 (11.20) 69 (46.31) 80 (53.69)

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 60 and above 106 (7.90) 46 (43.40) 60 (56.60)
Gender
 Female 667 (49.90) 323 (48.43) 344 (51.57)
 Male 669 (50.10) 264 (39.46) 405 (60.54)
Education level
 Illiterate 181 (13.60) 116 (64.09) 65 (35.91)
 Primary school 222 (16.60) 114 (51.35) 108 (48.65)
 Secondary school 221 (16.50) 98 (44.34) 123 (55.66)
 Higher Secondary 319 (23.90) 132 (41.38) 187 (58.62)
 Bachelor and above 393 (29.40) 127 (32.32) 266 (67.68)
Marital status
 Married 744 (55.70) 354 (47.58) 390 (52.42)
 Never married 547 (40.90) 207 (37.84) 340 (62.16)
 Other 45 (3.40) 26 (57.78) 19 (42.22)
Occupation

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 Agriculture 255 (19.10) 145 (56.86) 110 (43.14)
 Service 308 (23.10) 116 (37.66) 192 (62.34)
 Other 68 (5.10) 32 (47.06) 36 (52.94)
 Student 436 (32.60) 159 (36.47) 277 (63.53)
 Housewife 219 (16.40) 120 (54.79) 99 (45.21)
 Unemployed 50 (3.70) 15 (30.00) 35 (70.00)
Family income
 <US$417 1150 (86.08) 530 (46.09) 620 (53.91)
 US$417 to <US$893 161 (12.05) 52 (32.30) 109 (67.70)
 ≥US$893 25 (1.87) 5 (20.00) 20 (80.00)
Ethnicity
 Chakma 537 (40.20) 207 (38.55) 330 (61.45)
 Marma 497 (37.20) 213 (42.86) 284 (57.14)
 Tripura 126 (9.40) 70 (55.56) 56 (44.44)
 Tanchangya 84 (6.30) 41 (48.81) 43 (51.19)
 Bawm 74 (5.50) 49 (66.22) 25 (33.78)
 Other 18 (1.40) 7 (38.89) 11 (61.11)
Home district
 Bandarban 351 (26.30) 240 (68.38) 111 (31.62)
 Khagrachari 422 (31.60) 145 (34.36) 277 (65.64)
 Rangamati 563 (42.10) 202 (35.88) 361 (64.12)

(46.3%) in this study were young (18–29 years), and the and female (49.9%) populations in this study was nearly
prevalence of using antibiotics was comparatively higher similar among the study participants, and the male popu-
in this age group (table 1). The ratio of the male (50.1%) lation (60.5%) reported using antibiotics more than

4 Mannan A, et al. BMJ Open 2024;14:e071504. doi:10.1136/bmjopen-2022-071504

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Table 2 Comparison of respondents by antibiotic usage with and without prescription
Total Self-­medication Prescription
(N=742) (N=382) (N=360)
N (%) N (%) N (%) P value
Age group (years) >0.05
 18–29 375 (50.54) 204 (54.40) 171 (45.60)
 30–39 123 (16.58) 58 (47.15) 65 (52.85)
 40–49 107 (14.42) 55 (51.40) 52 (48.60)
 50–59 77 (10.38) 34 (44.16) 43 (55.84)

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 60 and above 60 (8.09) 31 (51.67) 29 (48.33)
Gender <0.01
 Female 340 (45.82) 153 (45.00) 187 (55.00)
 Male 402 (54.18) 229 (56.97) 173 (43.03)
Education level <0.05
 Illiterate 65 (8.76) 38 (58.46) 27 (41.54)
 Primary school 107 (14.42) 68 (63.55) 39 (36.45)
 Secondary school 121 (16.31) 66 (54.55) 55 (45.45)
 Higher Secondary 184 (24.80) 91 (49.46) 93 (50.54)
 Bachelor and above 265 (35.71) 119 (44.91) 146 (55.09)
Marital status >0.05
 Married 388 (52.29) 194 (50.00) 194 (50.00)
 Never married 336 (45.28) 179 (53.27) 157 (46.73)
 Other 18 (2.43) 9 (50.00) 9 (50.00)
Occupation <0.01

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 Agriculture 110 (14.82) 70 (63.64) 40 (36.36)
 Service 187 (25.20) 79 (42.25) 108 (57.75)
 Other 36 (4.85) 23 (63.89) 13 (36.11)
 Student 275 (37.06) 141 (51.27) 134 (48.73)
 Housewife 99 (13.34) 47 (47.47) 52 (52.53)
 Unemployed 35 (4.72) 22 (62.86) 13 (37.14)
Family income <0.001
 <US$417 616 (83.02) 340 (55.19) 276 (44.81)
 US$417 to <US$893 106 (14.29) 40 (37.74) 66 (62.26)
 ≥US$893 20 (2.70) 2 (10.00) 18 (90.00)
Chronic condition <0.01
 No 296 (39.89) 171 (57.77) 125 (42.23)
 Yes 446 (60.11) 211 (47.31) 235 (52.69)
Ethnicity <0.05
 Chakma 326 (43.94) 164 (50.31) 162 (49.69)
 Marma 281 (37.87) 148 (52.67) 133 (47.33)
 Tripura 56 (7.55) 19 (33.93) 37 (66.07)
 Tanchangya 43 (5.80) 30 (69.77) 13 (30.23)
 Bawm 25 (3.37) 15 (60.00) 10 (40.00)
 Other 11 (1.48) 6 (54.55) 5 (45.45)
Home district <0.05
 Bandarban 111 (14.96) 71 (63.96) 40 (36.04)
 Khagrachari 273 (36.79) 133 (48.72) 140 (51.28)
 Rangamati 358 (48.25) 178 (49.72) 180 (50.28)
2
*P values were analysed using χ tests, and p<0.05 was considered statistically significant.

Mannan A, et al. BMJ Open 2024;14:e071504. doi:10.1136/bmjopen-2022-071504 5

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females (51.57%). More than half of the participants behind antibiotic use (figure 1B). The most commonly
had higher secondary or higher education, with major prescribed antibiotics for the above-­mentioned disease
occupations including students (32.6%) and salaried job behind the use of antibiotics were azithromycin (27.0%),
holders (23.1%). Diabetes and hypertension stand out as amoxicillin (20.0%), metronidazole (18.0%), followed by
the most prevalent comorbidities within the SMA popula- ciprofloxacin, cefixime, tetracycline, etc (figure 1C).
tion (online supplemental figure 2).
Determinants of antibiotic self-medication
Pattern of self-medication of antibiotics usage The male gender was 1.6 times more likely to self-­
Only 7 of the 749 participants were excluded from the medicate with antibiotics compared with females (AOR
study because it was unclear whether they used antibiotics 1.57; 95% CI 1.23 to 2.19). Participants with high income

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that had been prescribed by a doctor. Approximately 382 were significantly less likely to use self-­medicating antibi-
respondents (51.4% of 742) who used antibiotics did not otics (AOR 0.14; 95% CI 0.03 to 0.64). Those who knew
have prescriptions. Self-­medication for antibiotic usage the difference between antibiotics and other drugs were
was significantly different by gender, education level, significantly less likely to self-­medicate antibiotics (AOR
occupation, and family income (table 2). The SMA rate 0.45; 95% CI 0.34 to 0.74). Indigenous people living in the
was higher than 50% in the illiterate (58.46%), primary Rangamati districts were less likely to self-­medicate with
school (63.55%) and secondary school (54.55%) groups. antibiotics (AOR 0.52; 95% CI 0.30 to 0.90) compared
The low-­income group (55.19%) also had a higher SMA with the residents from Bandarban (table 4). There was
rate. no statistically significant difference in antibiotic self-­
medication across ethnic groups among the indigenous
Knowledge of the use of antibiotics population that participated in the study.
The results reported that education level, occupation, Most (12.5%) of the self-­prescribed antibiotic users had
family income, chronic morbidity, and home district diabetes (online supplemental figure 3). Other chronic
significantly predict the knowledge level (no, poor, fair, diseases reported were hypertension (8.0%), anxiety
or good) (p≤0.001) (table 3). The participants having (7.0%), eye problems (6.5%), heart disease (5.0%), and
highest level of education had the best likelihood of respiratory disease (5.0%).
having good knowledge of antibiotic use compared to the

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group who were illiterate (p≤0.05). Among the various
occupation groups, job holders or students had good DISCUSSION
knowledge about antibiotic use than those who work This study showed that more than half of the antibiotic
in agriculture (p≤0.01). Compared with the individuals users from the indigenous population in the Chittagong
who earned <US$417 had a higher likelihood of having Hill Tracts (CHT) practiced self-­medication. This propor-
good knowledge of antibiotic use than those who earned tion was noticeably higher than other studies conducted
≥US$893 (p<0.05). In addition, patients who suffered in Dhaka and Rajshahi.40 45 The contrasting SMA preva-
from chronic ailments were more likely to deeper lence within the country could be due to different target
comprehension of the use of antibiotics (p<0.001). Resi- populations, cultural diversities, and socio-­ economic
dents from Rangamati districts had the highest likelihood status. This deviation from intra-­country variation high-
of knowing the use of antibiotics compared with those lights the need to monitor the legislation of drug prescrip-
who live in Bandarban (p<0.001). tion, delivery and consumption, even in the remote areas
of Bangladesh to fight the baneful spread of AMR. These
Reasons and antibiotics usage among the participants statistics of SMA are also higher than other countries—
The top three reasons for SMA were previous experi- South-­ western India (18.0%), Nepal (26.2%), Turkey
ence (36.5%), the urgency of the problem (22.6%) and (19.0%), Ethiopia (22.7%), and Greece (20.0%).39 46–50
economic constraints (16.9%) in this study (figure 1A). Within the sample population, the socio-­demographic
Around 43% of the individuals took antibiotics as advised factors that are associated with SMA were explored as part
by the pharmacies, while 38% followed written prescrip- of the current study. The low-­income group (<US$417)
tions for using antibiotics. For taking antibiotics without a has a higher level of SMA practice. People in this poor
prescription, participants in the study population demon- economic condition rarely visit qualified doctors at a
strated that using previous experience was the most government health centre as it requires transport costs
common reason for SMA practice (36.54%) (figure 1A). and time expenditure, leading to SMA.51 Additionally,
Long distances between home and facilities (22.66%), owing to a high prevalence of poverty, many individuals
high consultation fees, and the urgency to treat symp- within these communities are unable to purchase the
toms were reasons for using antibiotics without a valid complete course of antibiotics, driving an inclination
prescription. Other sources include advice without a towards non-­prescription antibiotic use. The easy accessi-
prescription from primary care physicians, previous bility of certain over-­the-­counter antibiotics also contrib-
prescriptions, experience and more. Cough, cold, and utes to SMA.32
fever (70.1%); headache (13.8%); dysentery, diarrhoea In our study, we found that many of the respondents
and food poisoning (11.8%) were the top three diseases consumed antibiotics previously prescribed by doctors

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Table 3 Ordered logit estimates for knowledge level on antibiotic use
Not at all Poor Fair Good Knowledge level
(N=478) (N=577) (N=394) (N=88) (N=1537)
 
  N (%) N (%) N (%) N (%) (Ordered logit)
Age group (years)
 18–29 145 (20.00) 294 (40.55) 236 (32.55) 50 (6.90) Reference
 30–39 106 (36.55) 108 (37.24) 60 (20.69) 16 (5.52) 0.9171
 40–49 90 (38.63) 98 (42.06) 39 (16.74) 6 (2.58) 0.8268

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 50–59 68 (40.96) 49 (29.52) 38 (22.89) 11 (6.63) 0.9732
 60 and above 69 (56.10) 28 (22.76) 21 (17.07) 5 (4.07) 0.9167
Gender
 Female 266 (35.23) 254 (33.64) 196 (25.96) 39 (5.17) Reference
 Male 212 (27.11) 323 (41.30) 198 (25.32) 49 (6.27) 0.8899
Education level
 Illiterate 147 (73.50) 45 (22.50) 8 (4.00) 0 (0.00) Reference
 Primary school 145 (57.77) 77 (30.68) 25 (9.96) 4 (1.59) 2.1251***
 Secondary school 90 (35.43) 116 (45.67) 38 (14.96) 10 (3.94) 4.1917***
 Higher Secondary 64 (16.71) 165 (43.08) 131 (34.20) 23 (6.01) 8.6442***
 Bachelor and above 32 (7.13) 174 (38.75) 192 (42.76) 51 (11.36) 15.8541***
Marital status
 Married 339 (40.36) 295 (35.12) 169 (20.12) 37 (4.40) Reference
 Never married 110 (17.05) 268 (41.55) 218 (33.80) 49 (7.60) 0.9076
 Other 29 (55.77) 14 (26.92) 7 (13.46) 2 (3.85) 0.7553
Occupation

Sponsored .
 Agriculture 170 (60.93) 86 (30.82) 17 (6.09) 6 (2.15) Reference
 Service 65 (19.35) 125 (37.20) 121 (36.01) 25 (7.44) 1.8889**
 Other 31 (38.27) 36 (44.44) 11 (13.58) 3 (3.70) 1.2036
 Student 66 (12.52) 219 (41.56) 192 (36.43) 50 (9.49) 1.6798***
 Housewife 123 (49.80) 85 (34.41) 36 (14.57) 3 (1.21) 0.9769
 Unemployed 23 (34.33) 26 (38.81) 17 (25.37) 1 (1.49) 0.8305
Family income
 <US$417 456 (34.29) 519 (39.02) 294 (22.11) 61 (4.59) Reference
 US$417 to <US$893 18 (10.11) 48 (26.97) 95 (53.37) 17 (9.55) 1.9034***
 ≥US$893 4 (13.79) 10 (34.48) 5 (17.24) 10 (34.48) 2.2534**
Chronic condition
 No 284 (35.90) 296 (37.42) 169 (21.37) 42 (5.31) Reference
 Yes 194 (26.01) 281 (37.67) 225 (30.16) 46 (6.17) 1.4551***
Ethnicity
 Chakma 156 (24.19) 218 (33.80) 215 (33.33) 56 (8.68) Reference
 Marma 197 (34.62) 230 (40.42) 123 (21.62) 19 (3.34) 0.9112
 Tripura 44 (32.84) 42 (31.34) 40 (29.85) 8 (5.97) 1.3464
 Tanchangya 35 (36.08) 48 (49.48) 10 (10.31) 4 (4.12) 0.9263
 Bawm 34 (45.95) 36 (48.65) 4 (5.41) 0 (0.00) 1.1154
 Other 12 (66.67) 3 (16.67) 2 (11.11) 1 (5.56) 0.5065
Home district
 Bandarban 168 (46.15) 155 (42.58) 30 (8.24) 11 (3.02) Reference
 Khagrachari 164 (33.40) 137 (27.90) 148 (30.14) 42 (8.55) 1.7414***
 Rangamati 146 (21.41) 285 (41.79) 216 (31.67) 35 (5.13) 2.5839***

*p<0.1; **p<0.05; ***p<0.001.

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Sponsored .
Figure 1 Characteristics of self-­prescribed antibiotic usage and common disease that antibiotic was used for. (A) The reason
behind the use of self-­prescribed antibiotics. (B) Common diseases behind antibiotics. (C) Mostly self-­prescribed antibiotics
where the X-­axis represents the antibiotics name and the Y-­axis represents the percentage of antibiotics usages.

for the treatment of a different disease. In some cases, a group as the largest antibiotic consumer in the rural
positive outcome in terms of recovery influenced them to non-­indigenous population of Bangladesh.53 Conversely,
continue using the same antibiotic to treat similar symp- non-­indigenous young people in urban areas do not use
toms, even if it is a simple cough and cold (figure 1B). antibiotics at that level.54 This could be explained by the
This fact is in concordance with non-­indigenous Bangla- fact that adults who become independent are more likely
deshi people.40 Depending on past experience, it may to make self-­ decisions rather than relying on a physi-
not be a rational approach if the antibiotic was previ- cian’s decision regarding SMA.40 Early health education
ously used to treat a different type or severity of infec- about the proper use of antibiotics and personal hygiene
tion, particularly in terms of the dosage and duration of can help the group develop lifelong healthy habits. By
treatment. To prevent unnecessary prescriptions of anti- focusing on them, we also have a chance of reaching
biotics and promote adherence to guidelines, physicians other family members to convey the message.47
should restrict the issuance of excessive prescriptions, as In line with past studies in Bangladesh, socio-­
many patients rely on prior prescriptions for information demographic analysis of the sample population revealed
regarding medications.19 that men consume more antibiotics than women do.40 55 56
Previous studies have highlighted a higher prevalence However, these findings deviate from most of the results
of SMA in older people compared with the younger age found in a similar study in Ethiopia, where the prevalence
cohort.52 The higher incidence of SMA in elders may of SMA was 54.6% among female participants.48 The
be due to the accumulation of illness episodes and/ difference in results also indicates that females are more
or previous experiences with SMA, which are factors cautious about health decisions than males. The gender
that contribute to the development of SMA.52 This disparity in SMA may stem from the fact that women, in
study found that the 18–29 year-­old cohort of indige- general, in LMICs do not have equal access to healthcare
nous people residing in the CHT were the largest anti- compared with men.57 The determination of whether
biotic consumers. A similar study reported the same age males or females possess more knowledge and exhibit

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Table 4 Multivariate analysis of factors associated with self-­medication with antibiotics
Unadjusted OR (95% CI) P value Adjusted OR (95% CI) P value
Age group (years)
 18–29 (ref.)
 30–39 0.66 (0.35 to 1.24) 0.197 0.63 (0.33 to 1.20) 0.159
 40–49 0.75 (0.386 to 1.48) 0.412 0.71 (0.36 to 1.41) 0.326
 50–59 0.54 (0.26 to 1.12) 0.099 0.57 (0.27 to 1.21) 0.143
 60 and above 0.69 (0.0307 to 1.54) 0.364 0.72 (0.31 to 1.64) 0.433

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Gender
 Female (ref.)
 Male 1.60 (1.15 to 2.22) 0.005 1.57 (1.13 to 2.14) 0.008
Education level
 Illiterate (ref.)
 Primary school 1.27 (0.64 to 2.52) 0.485 1.32 (0.66 to 2.63) 0.429
 Secondary school 0.86 (0.43 to 1.73) 0.670 0.98 (0.48 to 1.99) 0.948
 Higher Secondary 0.67 (0.32 to 1.41) 0.293 0.86 (0.40 to 1.85) 0.701
 Bachelor and above 0.57 (0.27 to 1.17) 0.126 0.76 (0.35 to 1.63) 0.482
Marital status
 Married (ref.)
 Never married 0.85 (0.46 to 1.56) 0.595 0.83 (0.44 to 1.55) 0.554
 Other 1.29 (0.46 to 3.61) 0.624 1.22 (0.43 to 3.44) 0.704
Occupation

Sponsored .
 Agriculture (ref.)
 Service 0.67 (0.37 to 1.22) 0.189 0.75 (0.41 to 1.36) 0.344
 Other 1.37 (0.58 to 3.19) 0.470 1.31 (0.55 to 3.09) 0.545
 Student 0.98 (0.50 to 1.90) 0.952 1.05 (0.535 to 2.06) 0.895
 Housewife 0.78 (0.43 to 1.43) 0.424 0.84 (0.45 to 1.55) 0.579
 Unemployed 1.33 (0.55 to 3.21) 0.528 1.36 (0.55 to 3.34) 0.500
Family income
 <US$417 (ref.)
 US$417 to <US$893 0.64 (0.40 to 1.02) 0.062 0.70 (0.44 to 1.12) 0.139
 ≥US$893 0.11 (0.02 to 0.51) 0.005 0.14 (0.03 to 0.64) 0.011
Ethnicity
 Chakma (ref.)
 Marma 0.89 (0.61 to 1.29) 0.533 0.97 (0.66 to 1.42) 0.863
 Tripura 0.47 (0.25 to 0.91) 0.026 0.53 (0.27 to 1.02) 0.059
 Tanchangya 1.31 (0.61 to 2.81) 0.491 1.44 (0.66 to 3.11) 0.355
 Bawm 0.67 (0.24 to 1.84) 0.436 0.66 (0.24 to 1.82) 0.420
 Other 0.88 (0.25 to 3.14) 0.842 0.97 (0.27 to 3.53) 0.968
Home district
 Bandarban (ref.)
 Khagrachari 0.53 (0.30 to 0.94) 0.029 0.57 (0.32 to 1.02) 0.057
 Rangamati 0.47 (0.28 to 0.81) 0.006 0.52 (0.30 to 0.90) 0.020
Chronic condition
 No (ref.)
 Yes 0.73 (0.52 to 1.01) 0.060
Know about antibiotics
Continued

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Table 4 Continued
Unadjusted OR (95% CI) P value Adjusted OR (95% CI) P value
 No (ref.)
 Yes 0.74 (0.52 to 1.07) 0.111
Knows about antibiotics and
other drugs
 No (ref.)
 Yes 0.50 (0.34 to 0.74) 0.001

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Constant 3.62 (1.32 to 9.90) 0.012 4.33 (1.53 to 12.24) 0.006
No of observations 742 742
Pseudo r-­squared 0.073 0.095
The dependent variable ‘self-­prescription’ assumes a value of 1 if the respondent reported taking antibiotics that were self-­prescribed and
assumes a value of 0 if not.

superior practices is heavily influenced by the specific Because of this lengthy usage, their expertise regarding
situation and is contingent on several socio-­demographic this topic has increased. Even family members of just
characteristics. Consequently, it is not possible to make one or two chronic patients were found to have a better
generalisations about gender differences. Although the understanding of antibiotics than those who do not have
findings are not always consistent, the majority of studies such patients in their family.74 75
did confirm the existence of gender disparities.58 Survey respondents from Khagrachari and Rangamati
Education level is crucial in SMA; 19 59 studies in devel- exhibit better antibiotic knowledge than those from
oping and developed countries also reported family Bandarban. Such a difference might be a because of
income as a strong predictor of antibiotic knowledge.60–62 community clinic (CC) activities. The government of

Sponsored .
Regardless of education, family income also regulates the People’s Republic of Bangladesh established CCs
people’s access to information.62 However, people from in 1998.76 These CCs try to make people aware of the
both higher and lower education strata reported prac- rational use of antibiotics.76 The total number of CCs
ticing self-­prescribed antibiotics in LMICs.63–65 Illiterate in Bandarban is less in Khagrachari or Rangamati (CCs
or low-­educated people are rarely aware of health risk in Bandarban, Khagrachari and Rangamati: 92, 108 and
issues as well as SMA-­associated threats. In contrast, highly 118, respectively).77
educated people and health sector students hold false This study indicate that the study population voluntarily
confidence, which drives them to SMA.25 The present used antibiotics for cough, cold, or fever in more than
study depicts that most of the illiterate people (73.5%) 70% of cases. The use of antibiotics in such a pattern accel-
were not aware of antibiotic use at all. A correlation erated the development of AMR.9 This study revealed that
between antibiotic knowledge and educational qualifi- the most commonly used antibiotics for self-­medication
cations was reported in other countries.66 67 It is unlikely are azithromycin (27.0%), amoxicillin (20.0%), metro-
for less educated people to acquire antibiotic knowledge nidazole (18.0%), and ciprofloxacin (14.0%), which
from newspapers, magazines, and websites. Efforts must belong to the macrolides, penicillins, nitroimidazole, and
be made to reach out to these people and disseminate fluoroquinolones classes of antibiotics, respectively.78 79
antibiotic knowledge that will ultimately reduce the rate Alarmingly, most of them are broad-­spectrum in nature,
of AMR in CHT people. Antibiotic knowledge is also which poses the threat of developing a wider and more
correlated with occupation. Job holders and students varied range of antibiotic-­resistant organisms.80
had better knowledge of antibiotics, as also reported in One more crucial and essential result that came out
other studies.68–70 The segment of the study population of this research was the identification of the reasons that
that is more connected to the media, the internet, and contribute to SMA. These factors include a lack of easy
other social communication systems had better knowl- access to healthcare, high consultation costs, extensive
edge of antibiotic usage. On the contrary, farmers71 and distances between consultation centres, and prescription-­
housewives72 from CHT were either illiterate or poorly free medication sold in pharmacies. One of the most
educated and demonstrated no understanding of the far-­ effective ways to address these issues is to increase the
reaching consequences of SMA. number of CCs that are staffed full-­time by appropri-
Patients with chronic diseases had better understanding ately trained medical professionals. At the same time, it
of antibiotic usage (table 3). Antibiotics are adminis- is imperative that pharmacies ban the practice of selling
tered for extended courses of treatment for patients with antibiotics to customers without a prescription. It may
chronic disease. They are forced to use these medicines be helpful to reduce the rate of SMA by counselling
to a significant extent throughout this time period.73 people to help them understand that previous usage

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of antibiotics should not be the basis of SMA for future Author affiliations
1
illnesses. Several questions, such as why self-­medication Department of Genetic Engineering & Biotechnology, University of Chittagong,
Chattogram, Bangladesh
is more prevalent in the Bandarban area and among the 2
Disease Biology and Molecular Epidemiology Research Group (dBme), Chattogram,
Tanchangya population, warrant further investigation Bangladesh
to identify underlying issues at the root level. Moreover, 3
Department of Medicine, Rangamati Medical College, Rangamati, Bangladesh
4
it would be beneficial to undertake additional research Department of Bioinformatics & Biotechnology, Asian University for Women,
to investigate the factors contributing to the prevalence Chattogram, Bangladesh
5
Department of Economics, University of Chittagong, Chattogram, Bangladesh
of SMA among the individual indigenous populations 6
Department of Medicine, 250 Bedded General Hospital, Chattogram, Bangladesh
under study separately. Additionally, several studies are 7
Department of Genetic Engineering & Biotechnology, Jagannath University, Dhaka,
required to obtain a complete picture of the misuse of Bangladesh

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8
antibiotics in this population. For example, what circum- Department of Biochemistry & Biotechnology, University of Science and Technology
stances cause local medicine vendors to sell antibiotics Chittagong, Chattogram, Bangladesh
9
Department of Pharmacy, University of Chittagong, Chattogram, Bangladesh
without a prescription? Is it a lack of awareness, lax law 10
Department of Pharmacology and Therapeutics, Chittagong Medical College,
enforcement, or simply taking advantage of underprivi- Chattogram, Bangladesh
leged people? Is there an alternative method that could 11
Department of Public Health, Asian University for Women, Chattogram, Bangladesh
be more effective in conveying the message that the
voluntary use of antibiotics can have potentially harmful Twitter Adnan Mannan @Adnan Mannan
consequences? Through investigation of these questions, Acknowledgements The authors would like to thank the research assistants of
it will be possible to gain a more in-­depth understanding the Disease Biology and Molecular Epidemiology Research Group, Chattogram for
their support. Special thanks to the Chittagong University Research and Higher
of the situation and find a solution to the problem of Study Society (CURHS) for their unconditional support.
AMR. These, in turn, will assist in reducing the risk of the
Contributors All authors made a substantial contribution to this work. AM, KC,
impending threat among the indigenous community of GD, AS, JW, HMHM, MMR and NA contributed to designing the study, drafting the
Bangladesh. manuscript and finalisation. NUHAC, AH and MTA contributed to data analyses
and preparing the first draft. AM, KC, AS, AH, JW and NA thoroughly reviewed the
manuscript and contributed substantially to the necessary revision. AM, GD, AS, AH
Limitations and NA finally reviewed the manuscript and prepared it for submission. AM and AS
This study has a few limitations that needs attention. This are the guarantors.
study followed a cross-­sectional design that may introduce Funding This study was funded by Ministry of Planning, Government of

Sponsored .
some level of recall bias on antibiotic usage and types of Bangladesh (20.00.0000.[Link]-­647).
antibiotics. Thus, the study findings should be interpreted Competing interests None declared.
with caution. Furthermore, a few areas of Khagrachari Patient and public involvement Patients and/or the public were not involved in
and Bandarban were excluded from the study for security the design, or conduct, or reporting, or dissemination plans of this research.
reasons, which may limit the findings being generalizable Patient consent for publication Consent obtained directly from patient(s).
across the indigenous population.
Ethics approval This study involves human participants and was approved
However, this study was unique in terms of recruiting (Ref: 1728) by the Institutional review board of 250-­bedded General Hospital,
a sample size, highlighting antibiotic self-­ medication Chattogram, Bangladesh. Participants gave informed consent to participate in the
among indigenous people in three districts in Bangladesh. study before taking part.
Study findings further highlighted that a high proportion Provenance and peer review Not commissioned; externally peer reviewed.
of antibiotic self-­medication needs immediate attention Data availability statement Data are available upon reasonable request. All data
and further confirmation by larger studies. Nevertheless, relevant to the study are included in the article. Any additional data of this study can
the evidence revealed in this study will be useful for policy be obtained from the corresponding author (AM) upon request.
formulation and raising awareness among this socially Supplemental material This content has been supplied by the author(s). It has
disadvantaged community in Bangladesh. not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been
peer-­reviewed. Any opinions or recommendations discussed are solely those
of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and
responsibility arising from any reliance placed on the content. Where the content
includes any translated material, BMJ does not warrant the accuracy and reliability
CONCLUSION of the translations (including but not limited to local regulations, clinical guidelines,
terminology, drug names and drug dosages), and is not responsible for any error
Despite antibiotics being a prescription-­ only medicine
and/or omissions arising from translation and adaptation or otherwise.
in Bangladesh, this study identified the contributing
Open access This is an open access article distributed in accordance with the
factors of self-­medication. Furthermore, various contrib- Creative Commons Attribution Non Commercial (CC BY-­NC 4.0) license, which
uting factors surfaced, such as knowledge, practices, and permits others to distribute, remix, adapt, build upon this work non-­commercially,
misconceptions about antibiotic usage among the indige- and license their derivative works on different terms, provided the original work is
nous communities of Bangladesh. These indicate a lack of properly cited, appropriate credit is given, any changes made indicated, and the use
is non-­commercial. See: [Link]
awareness and regulatory control across various sectors.
Thus, raising public awareness and enforcing regulations ORCID iDs
in Bangladesh will encourage physicians, pharmacists, Adnan Mannan [Link]
Kallyan Chakma [Link]
and patients to effectively address SMA to prevent AMR-­
Gourab Dewan [Link]
mediated clinical issues among the indigenous popula- Ayan Saha [Link]
tion in Bangladesh. H M Hamidullah Mehedi [Link]

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