A community health worker led approach to cardiovascular disease prevention in the UK-SPICES-Sussex (scaling-up packages of interventions for cardiovascular disease prevention in selected sites in Europe and Sub-saharan Africa): an implementation research project.

Background: This paper describes a UK-based study, SPICES-Sussex, which aimed to co-produce and implement a community-based cardiovascular disease (CVD) risk assessment and reduction intervention to support under-served populations at moderate risk of CVD. The objectives were to enhance stakeholder engagement; to implement the intervention in four research sites and to evaluate the use of Voluntary and Community and Social Enterprises (VCSE) and Community Health Worker (CHW) partnerships in health interventions. Methods: A type three hybrid implementation study design was used with mixed methods data. This paper represents the process evaluation of the implementation of the SPICES-Sussex Project. The evaluation was conducted using the RE-AIM framework. Results: Reach: 381 individuals took part in the risk profiling questionnaire and forty-one women, and five men participated in the coaching intervention. Effectiveness: quantitative results from intervention participants showed significant improvements in CVD behavioural risk factors across several measures. Qualitative data indicated high acceptability, with the holistic, personalised, and person-centred approach being valued by participants. Adoption: 50% of VCSEs approached took part in the SPICES programme, The CHWs felt empowered to deliver high-quality and mutually beneficial coaching within a strong project infrastructure that made use of VCSE partnerships. Implementation: Co-design meetings resulted in local adaptations being made to the intervention. 29 (63%) of participants completed the intervention. Practical issues concerned how to embed CHWs in a health service context, how to keep engaging participants, and tensions between research integrity and the needs and expectations of those in the voluntary sector. Maintenance: Several VCSEs expressed an interest in continuing the intervention after the end of the SPICES programme. Conclusion: Community-engagement approaches have the potential to have positively impact the health and wellbeing of certain groups. Furthermore, VCSEs and CHWs represent a significant untapped resource in the UK. However, more work needs to be done to understand how links between the sectors can be bridged to deliver evidence-based effective alternative preventative healthcare. Reaching vulnerable populations remains a challenge despite partnerships with VCSEs which are embedded in the community. By showing what went well and what did not, this project can guide future work in community engagement for health.

The Pre-Implementation Phase of a Project Seeking to Deliver a Community-Based CVD Prevention Intervention (SPICES-Sussex): A Qualitative Study Exploring Views and Experience Relating to Intervention Development.

BACKGROUND.: Community-led health care interventions may be an effective way to tackle cardiovascular disease (CVD) risk factors, especially in materially deprived communities where health care resources are stretched and engagement with institutions is often low. To do so effectively and equitably, interventions might be developed alongside community members through community engagement. OBJECTIVES.: The aim of this project was to carry out stakeholder mapping and partnership identification and to understand the views, needs, experiences of community members who would be involved in later stages of a community-based CVD prevention intervention's development and implementation. METHODS.: Stakeholder mapping was carried out to identify research participants in three communities in Sussex, United Kingdom. A qualitative descriptive approach was taken during the analysis of focus groups and interviews with 47 participants. FINDINGS.: Three themes were highlighted related to intervention design (a) Management: the suitability of the intervention for the community, management of volunteers, and communication; (b) Logistics: the structure and design of the intervention; and (c) Sociocultural issues, the social and cultural expectations/experiences of participants and implementers. CONCLUSIONS.: Study participants were open and willing to engage in the planned community-based intervention, particularly in elements of co-design and community-led delivery. They also highlighted the importance of sociocultural factors. Based on the findings, we developed recommendations for intervention design which included (but were not limited to): (a) a focus on a bottom-up approach to intervention design, (b) the recruitment of skilled local volunteers, and (c) the importance of fun and simplicity.

Gender and urban-rural influences on antibiotic purchasing and prescription use in retail drug shops: a one health study.

INTRODUCTION: Few studies have reported antibiotic purchases from retail drug shops in relation to gender in low and middle-income countries (LMICs). Using a One Health approach, we aimed to examine gender dimensions of antibiotic purchases for humans and animals and use of prescriptions in retail drug shops in Bangladesh. METHODS: We conducted customer observations in 20 drug shops in one rural and one urban area. Customer gender, antibiotic purchases, and prescription use were recorded during a four-hour observation (2 sessions of 2 hours) in each shop. We included drug shops selling human medicine (n = 15); animal medicine (n = 3), and shops selling both human and animal medicine (n = 2). RESULTS: Of 582 observations, 31.6% of drug shop customers were women. Women comprised almost half of customers (47.1%) in urban drug shops but only 17.2% of customers in rural drug shops (p < 0.001). Antibiotic purchases were more common in urban than rural shops (21.6% versus 12.2% of all transactions, p = 0.003). Only a quarter (26.0%) of customers who purchased antibiotics used a prescription. Prescription use for antibiotics was more likely among women than men (odds ratio (OR) = 4.04, 95% CI 1.55, 10.55) and more likely among urban compared to rural customers (OR = 4.31 95% CI 1.34, 13.84). After adjusting for urban-rural locality, women remained more likely to use a prescription than men (adjusted OR = 3.38, 95% CI 1.26, 9.09) but this was in part due to antibiotics bought by men for animals without prescription. Customers in drug shops selling animal medicine had the lowest use of prescriptions for antibiotics (4.8% of antibiotic purchases). CONCLUSION: This study found that nearly three-quarters of all antibiotics sold were without prescription, including antibiotics on the list of critically important antimicrobials for human medicine. Men attending drug shops were more likely to purchase antibiotics without a prescription compared to women, while women customers were underrepresented in rural drug shops. Antibiotic stewardship initiatives in the community need to consider gender and urban-rural dimensions of drug shop uptake and prescription use for antibiotics in both human and animal medicine. Such initiatives could strengthen National Action Plans.

Protocol for integrating mental health services into primary healthcare facilities: a qualitative study of the perspectives of patients, family members and healthcare providers in rural Bangladesh.

INTRODUCTION: In Bangladesh, Non-communicable diseases (NCDs) account for 67% of all deaths. Mental health services are not available in routine healthcare at the primary facilities in Bangladesh. The protocol is for a qualitative study that seeks to understand the perceptions, beliefs and norms regarding common mental disorders (CMDs) among patients with NCD with and without CMDs to identify barriers to accessing mental health services in rural communities in Bangladesh. We also aim to explore the feasibility of integrating mental healthcare into routine NCD services at primary health facilities in rural Bangladesh. METHODS AND ANALYSIS: This study will be conducted at the outpatient departments in two subdistrict hospitals and one district hospital in Munshiganj district in Bangladesh. We will purposefully select patients with hypertension and diabetes from the patient inventory generated from a recently completed randomised control trial titled 'Control of Blood Pressure and Risk Attenuation Bangladesh, Pakistan, Sri Lanka' in two subdistricts in Munshiganj district in Bangladesh. The selected participants will be screened for CMD using the Depression, Anxiety and Stress Scale - 21 Items (DASS-21) over the telephone. Sixty in-depth interviews with patients and family members, 8-10 key informant interviews with healthcare providers and 2 focus group discussions with community health workers will be held following consent.The study is conceptualised under Levesque et al's framework. Thematic analysis will be applied following the study objectives and key issues, and commonly emerging topics generated by the data. The findings will be presented anonymously to corroborate the interpretation. ETHICS AND DISSEMINATION: Approval has been obtained from the Institutional Review Board at icddr,b (PR-19108) and the University of York (HSRGC/2020/382/F). Written informed consent or audio recording consent form in Bangla will be obtained. For dissemination, we will invite representatives of the collaborating institutions to share the findings in national or international conferences and peer-reviewed journals.

Early life, life course and gender influences on levels of C-reactive protein among migrant Bangladeshis in the UK.

BACKGROUND AND OBJECTIVES: Humans co-evolved with pathogens, especially helminths, that educate the immune system during development and lower inflammatory responses. The absence of such stimuli in industrialized countries is associated with higher baseline levels of C-reactive protein (CRP) among adults who appear at greater risk for inflammatory disorders. This cross-sectional study examined effects of early life development on salivary CRP levels in 452 British-Bangladeshis who spent varying periods growing up in Bangladesh or UK. We also analyzed how gender and central obesity modulate effects on CRP. We hypothesized that: (i) first-generation Bangladeshis with higher childhood exposure to pathogens would have chronically lower CRP levels than second-generation British-Bangladeshis; (ii) effects would be greater with early childhoods in Bangladesh; (iii) effects by gender would differ; and (iv) increasing obesity would mitigate early life effects. METHODOLOGY: Saliva samples were assayed for CRP using ELISAs, and anthropometric data collected. Participants completed questionnaires about demographic, socioeconomic, lifestyle and health histories. Data were analyzed using multiple linear regression. RESULTS: First-generation migrants who spent early childhoods in mostly rural, unhygienic areas, and moved to UK after age 8, had lower salivary CRP compared to the second-generation. Effects differed by gender, while waist circumference predicted higher CRP levels. CRP increased with years in UK, alongside growing obesity. CONCLUSIONS AND IMPLICATIONS: Our study supports the hypothesis that pathogen exposure in early life lowers inflammatory responses in adults. However, protective effects differed by gender and can be eroded by growing obesity across the life course which elevates risks for other inflammatory disorders. Lay Summary: Migrants to the UK who spent early childhoods in less hygienic environments in Bangladesh that help to educate their immune systems had lower levels of the inflammatory marker, C-reactive protein (CRP) compared to migrants who grew up in UK. Both gender and increasing obesity were associated with increased levels of CRP.

Co-designing new tools for collecting, analysing and presenting patient experience data in NHS services: working in partnership with patients and carers.

BACKGROUND: The way we collect and use patient experience data is vital to optimise the quality and safety of health services. Yet, some patients and carers do not give feedback because of the limited ways data is collected, analysed and presented. In this study, we worked together with researchers, staff, patient and carer participants, and patient and public involvement and engagement (PPIE) contributors, to co-design new tools for the collection and use of patient experience data in multiple health settings. This paper outlines how the range of PPIE and research activities enabled the co-design of new tools to collect patient experience data. METHODS: Eight public contributors represented a range of relevant patient and carer experiences in specialist services with varied levels of PPIE experience, and eleven members of Patient and Participation Groups (PPGs) from two general practices formed our PPIE group at the start of the study. Slide sets were used to trigger co-design discussions with staff, patient and carer research participants, and PPIE contributors. Feedback from PPIE contributors alongside verbatim quotes from staff, patient and carer research participants is presented in relation to the themes from the research data. RESULTS: PPIE insights from four themes: capturing experience data; adopting digital or non-digital tools; ensuring privacy and confidentiality; and co-design of a suite of new tools with guidance, informed joint decisions on the shaping of the tools and how these were implemented. Our PPIE contributors took different roles during co-design and testing of the new tools, which supported co-production of the study. CONCLUSIONS: Our experiences of developing multiple components of PPIE work for this complex study demonstrates the importance of tailoring PPIE to suit different settings, and to maximise individual strengths and capacity. Our study shows the value of bringing diverse experiences together, putting patients and carers at the heart of improving NHS services, and a shared approach to managing involvement in co-design, with the effects shown through the research process, outcomes and the partnership. We reflect on how we worked together to create a supportive environment when unforeseen challenges emerged (such as, sudden bereavement).

The way we collect and use patient experience data is important because of concern that patients and carers may be excluded by the limited ways it is currently done in NHS services. In this study, we worked in partnership with researchers, staff, patient and carer participants, and patient and public involvement and engagement contributors, to co-design new tools for the collection, analysis and presentation of patient experience data. We focused on services for people with musculoskeletal conditions and services for people with severe mental health conditions. Our PPIE group, formed at the start of the study, represented a range of relevant and diverse health experiences from patients and carers of specialist services, and primary care. The aim of this paper is to share our experiences from working in partnership with our PPIE contributors on the co-design work of the study. Illustrations of how the PPIE activities added crucial insights in the shaping of the tools are given alongside the research data from patients, carers and staff participants. We experienced some challenges during the project. We discuss how we managed to work together to create a supportive environment when unforeseen challenges emerged (such as, sudden bereavement). Our experiences of developing multiple components of PPIE work for this study demonstrates the importance of tailoring PPIE to suit different settings, and to complement people's strengths and capacity. It also shows the value of bringing diverse experiences together enabling a shared approach to co-design. Researchers and PPIE contributors wrote this paper jointly.

Motivating antibiotic stewardship in Bangladesh: identifying audiences and target behaviours using the behaviour change wheel.

BACKGROUND: South Asia is a hotspot for antimicrobial resistance due largely to over-the-counter antibiotic sales for humans and animals and from a lack of policy compliance among healthcare providers. Additionally, there is high population density and high infectious disease burden. This paper describes the development of social and behavioural change communication (SBCC) to increase the appropriate use of antibiotics. METHODS: We used formative research to explore contextual drivers of antibiotic sales, purchase, consumption/use and promotion among four groups: 1) households, 2) drug shop staff, 3) registered physicians and 4) pharmaceutical companies/medical sales representatives. We used formative research findings and an intervention design workshop with stakeholders to select target behaviours, prioritise audiences and develop SBCC messages, in consultation with a creative agency, and through pilots and feedback. The behaviour change wheel was used to summarise findings. RESULTS: Workshop participants identified behaviours considered amenable to change for all four groups. Household members and drug shop staff were prioritised as target audiences, both of which could be reached at drug shops. Among household members, there were two behaviours to change: suboptimal health seeking and ceasing antibiotic courses early. Thus, SBCC target behaviours included: seek registered physician consultations; ask whether the medicine provided is an antibiotic; ask for instructions on use and timing. Among drug shop staff, important antibiotic dispensing practices needed to change. SBCC target behaviours included: asking customers for prescriptions, referring them to registered physicians and increasing customer awareness by instructing that they were receiving antibiotics to take as a full course. CONCLUSIONS: We prioritised drug shops for intervention delivery to all drug shop staff and their customers to improve antibiotic stewardship. Knowledge deficits among these groups were notable and considered amenable to change using a SBCC intervention addressing improved health seeking behaviours, improved health literacy on antibiotic use, and provision of information on policy governing shops. Further intervention refinement should consider using participatory methods and address the impact on profit and livelihoods for drug shop staff for optimal compliance.

Severely stigmatised skin neglected tropical diseases: a protocol for social science engagement.

More than one billion people are affected by neglected tropical diseases (NTDs) and many of these diseases are preventable. While the grouping of these conditions as NTDs has generated vast mapping, mass drug administration and surveillance programmes, there is growing evidence of gaps and weaknesses in purely biomedical approaches, and the need for responses that also recognise the social determinants of health. In order to unpack the social and political determinants of NTDs, it is important to view the problem from a social science perspective. Given this background, the Social Sciences for Severe Stigmatizing Skin Diseases (5S) Foundation has recently been established by the Centre for Global Health Research at Brighton and Sussex Medical School. The broad aim of the 5S Foundation is to incorporate social science perspectives in understanding and addressing the problems around three NTDs, namely, podoconiosis, mycetoma and scabies. This protocol paper sets out the aims and approaches of the 5S Foundation while activities such as research, public engagement, training and capacity building get underway.

Integrating depression care within NCD provision in Bangladesh and Pakistan: a qualitative study.

BACKGROUND: Co-morbidity of depression with other non-communicable diseases (NCDs) worsens clinical outcomes for both conditions. Low- and middle-income countries need to strengthen mechanisms for detection and management of co-morbid depression within NCDs. The Behavioural Activation for Comorbid Depression in Non-communicable Disease (BEACON) study explored the acceptability and feasibility of integrating a brief depression intervention (behavioural activation, BA) into NCD services in healthcare facilities in Bangladesh and Pakistan. METHODS: Face-to-face qualitative interviews were conducted with 43 patients and 18 health workers attending or working in NCD centres in four healthcare facilities in Bangladesh and Pakistan, and with three policy makers in each country. The interviews addressed four research questions (1) how NCD care is delivered, (2) how NCD patients experience distress, (3) how depression care is integrated within NCD provision, and (4) the challenges and opportunities for integrating a brief depression intervention into usual NCD care. The data were analysed using framework analysis, organised by capability, opportunity and motivation factors, cross-synthesised across countries and participant groups. RESULTS: Patients and health workers described NCD centres as crowded and time pressured, with waiting times as long as five hours, and consultation times as short as five minutes; resulting in some patient frustration. They did not perceive direct links between their distress and their NCD conditions, instead describing worries about family and finance including affordability of NCD services. Health worker and policy maker accounts suggested these NCD centres lacked preparedness for treating depression in the absence of specific guidelines, standard screening tools, recording systems or training. Barriers and drivers to integrating a brief depression intervention reflected capability, opportunity and motivation factors for all participant groups. While generally valuing the purpose, significant challenges included the busy hospital environment, skill deficits and different conceptions of depression. CONCLUSIONS: Given current resource constraints and priorities, integrating a brief psychological intervention at these NCD centres appears premature. An opportune first step calls for responding to patients' expressed concerns on service gaps in provisioning steady and affordable NCD care. Acknowledging differences of conceptions of depression and strengthening psychologically informed NCD care will in turn be required before the introduction of a specific psychological intervention such as BA.

What contributes to inappropriate antibiotic dispensing among qualified and unqualified healthcare providers in Bangladesh? A qualitative study.

BACKGROUND: Over-prescribing and inappropriate use of antibiotics contributes to the emergence of antimicrobial resistance (AMR). Few studies in low and middle-income settings have employed qualitative approaches to examine the drivers of antibiotic sale and dispensing across the full range of healthcare providers (HCPs). We aimed to explore understandings of the use and functions of antibiotics; awareness of AMR and perceived patient or customer demand and adherence among HCPs for human and animal medicine in Bangladesh. METHODS: We used an ethnographic approach to conduct face-to-face, in-depth interviews with 46 community HCPs in one urban and one rural area (Gazipur and Mirzapur districts respectively). We purposefully selected participants from four categories of provider in human and veterinary medicine: qualified; semi-qualified; auxiliary and unqualified. Using a grounded theory approach, thematic analysis was conducted using a framework method. RESULTS: Antibiotics were considered a medicine of power that gives quick results and works against almost all diseases, including viruses. The price of antibiotics was equated with power such that expensive antibiotics were considered the most powerful medicines. Antibiotics were also seen as preventative medicines. While some providers were well informed about antibiotic resistance and its causes, others were completely unaware. Many providers mistook antibiotic resistance as the side effects of antibiotics, both in human and animal medicine. Despite varied knowledge, providers showed concern about antibiotic resistance but responsibility for inappropriate antibiotic use was shifted to the patients and clients including owners of livestock and animals. CONCLUSIONS: Misconceptions and misinformation led to a wide range of inappropriate uses of antibiotics across the different categories of human and animal healthcare providers. Low awareness of antibiotic action and antibiotic resistance were apparent among healthcare providers, particularly those with little or no training and those in rural areas. Specific and targeted interventions to address AMR in Bangladesh should include educational messages on the rational use of antibiotics and how they work, targeting all types of healthcare providers. While tailored training for providers may increase understanding of antibiotic action and improve practices, more far-reaching structural changes are required to influence and increase responsibility for optimising antibiotic dispensing among all HCPs.

Implementing a digital patient feedback system: an analysis using normalisation process theory.

BACKGROUND: Patient feedback in the English NHS is now widespread and digital methods are increasingly used. Adoption of digital methods depends on socio-technical and contextual factors, alongside human agency and lived experience. Moreover, the introduction of these methods may be perceived as disruptive of organisational and clinical routines. The focus of this paper is on the implementation of a particular digital feedback intervention that was co-designed with health professionals and patients (the DEPEND study). METHODS: The digital feedback intervention was conceptualised as a complex intervention and thus the study focused on the contexts within which it operated, and how the different participants made sense of the intervention and engaged with it (or not). Four health care sites were studied: an acute setting, a mental health setting, and two general practices. Qualitative data was collected through interviews and focus groups with professionals, patients and carers. In total 51 staff, 24 patients and 8 carers were included. Forty-two observations of the use of the digital feedback system were carried out in the four settings. Data analysis was based on modified grounded theory and Normalisation Process Theory (NPT) formed the conceptual framework. RESULTS: Digital feedback made sense to health care staff as it was seen as attractive, fast to complete and easier to analyse. Patients had a range of views depending on their familiarity with the digital world. Patients mentioned barriers such as kiosk not being visible, privacy, lack of digital know-how, technical hitches with the touchscreen. Collective action in maintaining participation again differed between sites because of workload pressure, perceptions of roles and responsibilities; and in the mental health site major organisational change was taking place. For mental health service users, their relationship with staff and their own health status determined their digital use. CONCLUSION: The potential of digital feedback was recognised but implementation should take local contexts, different patient groups and organisational leadership into account. Patient involvement in change and adaptation of the intervention was important in enhancing the embedding of digital methods in routine feedback. NPT allowed for a in-depth understanding of actions and interactions of both staff and patients.

A protocol paper: community engagement interventions for cardiovascular disease prevention in socially disadvantaged populations in the UK: an implementation research study.

Background: Cardiovascular disorders (CVD) are the single greatest cause of mortality worldwide. In the UK, the National Health Service (NHS) has launched an initiative of health checks over and above current care to tackle CVD. However, the uptake of Health Checks is poor in disadvantaged communities. This protocol paper sets out a UK-based study (Sussex and Nottingham) aiming to co-produce a community delivered CVD risk assessment and coaching intervention to support community members to reduce their risk of CVD.The overall aim of the project is to implement a tailored-to-context community engagement (CE) intervention on awareness of CVD risks in vulnerable populations in high, middle and low-income countries. The specific objectives of the study are to enhance stakeholder' engagement; to implement lifestyle interventions for cardiovascular primary prevention, in disadvantaged populations and motivate uptake of NHS health checks. Methods: This study uses both qualitative and quantitative methods in three phases of evaluation, including pre-, per- and post-implementation. To ensure contextual appropriateness the 'Scaling-up Packages of Interventions for Cardiovascular disease prevention in selected sites in Europe and Sub-Saharan Africa: An implementation research' (SPICES) project will organize a multi-component community-engagement intervention. For the qualitative component, the pre-implementation phase will involve a contextual assessment and stakeholder mapping, exploring potentials for CVD risk profiling strategies and led by trained Community Health Volunteers (CHV) to identify accessibility and acceptability. The per-implementation phase will involve healthy lifestyle counselling provided by CHVs and evaluation of the outcome to identify fidelity and scalability. The post-implementation phase will involve developing sustainable community-based strategies for CVD risk reduction. All three components will include a process evaluation. A stepped wedge cluster randomised trial of the roll out will focus on implementation outcomes including uptake and engagement and changes in risk profiles. The quantitative component includes pre and post-intervention surveys. The theory of the socio-ecological framework will be applied to analyse the community engagement approach. Discussion: Based on the results ultimately a sustainable community engagement-based strategy for the primary prevention of CVD risk will be developed to enhance the performance of NHS health care in the UK. The Trial Registration number is ISRCTN68334579.

Pathways to antibiotics in Bangladesh: A qualitative study investigating how and when households access medicine including antibiotics for humans or animals when they are ill.

BACKGROUND: To understand how to reduce antibiotic use, greater knowledge is needed about the complexities of access in countries with loose regulation or enforcement. This study aimed to explore how households in Bangladesh were accessing antimicrobials for themselves and their domestic animals. METHODS: In-depth interviews were conducted with 48 households in one urban and one rural area. Households were purposively sampled from two lower income strata, prioritising those with under 5-year olds, older adults, household animals and minority groups. Households where someone was currently ill with a suspected infection (13 households) were invited for a follow-up interview. Framework analysis was used to explore access to healthcare and medicines. FINDINGS: People accessed medicines for themselves through five pathways: drugs shops, private clinics, government/charitable hospitals, community/family planning clinics, and specialised/private hospitals. Drug shops provided direct access to medicines for common, less serious and acute illnesses. For persistent or serious illnesses, the healthcare pathway may include contacts with several of these settings, but often relied on medicines provided by drug shops. In the 13 households with an unwell family member, most received at least one course of antibiotics for this illness. Multiple and incomplete dosing were common even when prescribed by a qualified doctor. Antibiotics were identified by their high cost compared to other medicines. Cost was a reported barrier to purchasing full courses of antibiotics. Few households in the urban area kept household animals. In this rural area, government animal health workers provided most care for large household animals (cows), but drug shops were also important. CONCLUSIONS: In Bangladesh, unregulated drug shops provide an essential route to medicines including those prescribed in the formal sector. Wherever licensed suppliers are scarce and expensive, regulations which prohibit this supply risk removing access entirely for many people.

Pathways of antibiotic use in Bangladesh: qualitative protocol for the PAUSE study.

INTRODUCTION: Global actions to reduce antimicrobial resistance (AMR) include optimising the use of antimicrobial medicines in human and animal health. In countries with weak healthcare regulation, this requires a greater understanding of the drivers of antibiotic use from the perspective of providers and consumers. In Bangladesh, there is limited research on household decision-making and healthcare seeking in relation to antibiotic use and consumption for humans and livestock. Knowledge is similarly lacking on factors influencing the supply and demand for antibiotics among qualified and unqualified healthcare providers.The aim of this study is to conduct integrated research on household decision-making for healthcare and antibiotic use, as well as the awareness, behaviours and priorities of healthcare providers and sellers of antibiotics to translate into policy development and implementation. METHODS AND ANALYSIS: In-depth interviews will be conducted with (1) household members responsible for decision-making about illness and antibiotic use for family and livestock; (2) qualified and unqualified private and government healthcare providers in human and animal medicine and (3) stakeholders and policy-makers as key informants on the development and implementation of policy around AMR. Participant observation within retail drug shops will also be carried out. Qualitative methods will include a thematic framework analysis.A holistic approach to understanding who makes decisions on the sale and use of antibiotics, and what drives healthcare seeking in Bangladesh will enable identification of routes to behavioural change and the development of effective interventions to reduce the health risks of AMR. ETHICS AND DISSEMINATION: Approval for the study has been obtained from the Institutional Review Board at the International Centre for Diarrhoeal Disease Research, Bangladesh following review by the Research and Ethics Committees (PR-16100) and from Loughborough University (R17-P081). Information about the study will be provided in a participant information letter in Bangla (to be read verbally and given in writing to participants). A written informed consent form in Bangla will be obtained and participants will be informed of their right to withdraw from the study. Dissemination will take place through a 1 day dissemination workshop with key stakeholders in public health and policy, practitioners and scientists in Bangladesh, and through international conference presentations and peer-review publications. Anonymised transcripts of interviews will be made available through open access via institutional data repositories after an embargo period.

mHealth and the management of chronic conditions in rural areas: a note of caution from southern India.

This article examines challenges facing implementation of likely mHealth programmes in rural India. Based on fieldwork in Andhra Pradesh in 2014, and taking as exemplars two chronic medical 'conditions' - type 2 diabetes and depression - we look at ways in which people in one rural area currently access medical treatment; we also explore how adults there currently use mobile phones in daily life, to gauge the realistic likelihood of uptake for possible mHealth initiatives. We identify the very different pathways to care for these two medical conditions, and we highlight the importance to the rural population of healthcare outside the formal health system provided by those known as registered medical practitioners (RMP), who despite their title are neither registered nor trained. We also show how limited is the use currently made of very basic mobile phones by the majority of the older adult population in this rural context. Not only may this inhibit mHealth potential in the near future; just as importantly, our data suggest how difficult it may be to identify a clinical partner for patients or their carers for any mHealth application designed to assist the management of chronic ill-health in rural India. Finally, we examine how the promotion of patient 'self-management' may not be as readily translated to a country like India as proponents of mHealth might assume.

At the margins of biomedicine: the ambiguous position of 'Registered Medical Practitioners' in rural Indian healthcare.

This analysis challenges a tendency in public health and the social sciences to associate India's medical pluralism with a distinction between biomedicine, as a homogeneous entity, and its non-biomedical 'others'. We argue that this overdrawn dichotomy obscures the important part played by 'informal' biomedical practice, an issue with salience well beyond India. Based on a qualitative study in rural Andhra Pradesh, South India, we focus on a figure little discussed in the academic literature - the Registered Medical Practitioner (RMP) - who occupies a niche in the medical market-place as an informal exponent of biomedical treatment. We explore the significance of these practitioners by tracking diagnosis and treatment of one increasingly prominent medical 'condition', namely diabetes. The RMP, who despite the title is rarely registered, sheds light on the supposed formal-informal sector divide in India's healthcare system, and its permeability in practice. We develop our analysis by contrasting two distinctive conceptualisations of 'informality' in relation to the state in India - one Sarah Pinto's, the other Ananya Roy's.

How women in Bangladesh confront the stigma of childlessness: agency, resilience, and resistance.

In a context where motherhood is an integral part of a woman's stereotype, being childless is a devastating experience. We explore how these so-called deviant women manage this situation. The objective of this article is to contribute to the debate regarding infertile women's agency, resilience, and resistance. This article is based on anthropological fieldwork among urban middle-class and rural poor women. Their life histories reveal that childless women in Bangladesh, a pro-natalist, patriarchal society, are not passive victims, but rather actively fight their stigmatization and manage to survive. The childless women follow overt and covert strategies to overcome their stigmatized identity and create space for themselves in various innovative ways. The women do not resist in a coordinated way as a group, but do so individually. Given the collective nature of a society like rural Bangladesh, we believe that the women's individual acts will eventually have collective effects.

The importance of a positive approach to sexuality in sexual health programmes for unmarried adolescents in Bangladesh.

This article explores the mismatch that exists between what unmarried adolescents in Bangladesh experience, want and need in regard to their sexuality and what they receive from their society, which negatively impacts on their understanding of sexuality and their well-being. The findings provide a picture of Bangladeshi adolescents' (12-18 years) sexual feelings, experiences, behaviours, anxieties and concerns - in particular in relation to desire, pleasure, sexual power, masturbation, virginity, romantic love and dating, and arranged marriage - and how socio-sexual norms and taboos influence these. Curiosity of boys and girls about sex was driven by a need and desire to know and understand, but also because it was exciting to read about and talk about sex. Young people are not just passive recipients of adult norms and messages around sexuality, but agents who actively construe meanings and navigate between what is expected from them and what they want, need and feel themselves. Adolescents have a need for information and support - long before they ever have sex. We call for a positive, rights-based approach to sexuality education for adolescents and a focus beyond health outcomes alone to support adolescents and young people to make sense of the multiplicity of messages they encounter and reduce unnecessary feelings of guilt and anxiety.

Contextualising sexual harassment of adolescent girls in Bangladesh.

Violence against women is a social mechanism confirming women's subordination in many societies. Sexual violence and harassment have various negative psychological impacts on girls, including a persistent feeling of insecurity and loss of self-esteem. This article aims to contextualize a particular form of sexual harassment, namely "eve teasing", experienced by Bangladeshi adolescent girls (12-18 years) which emerged from a study of adolescent sexual behaviour carried out by young people. The study used qualitative methods and a participatory approach, including focus group discussions, key informant interviews and observation. Despite taboos, unmarried adolescents actively seek information about sex, erotic pleasure and romance. Information was easily available from videos, mobile phone clips and pornographic magazines, but reinforced gender inequality. "Eve teasing" was one outlet for boys' sexual feelings; they gained pleasure from it and could show their masculinity. The girls disliked it and were afraid of being blamed for provoking it. Thus, "eve teasing" is a result of socio-cultural norms relating to sexuality, as well as a lack of access to sexual and reproductive health information and services in Bangladesh. These findings underscore the importance of comprehensive sexuality education that goes beyond a mere health focus and addresses gender norms and helps youth to gain social-sexual interaction skills.

The link between infertility and poverty: evidence from Bangladesh.

The link between high fertility and poverty is well established. However, this paper shows how infertility may also generate poverty among childless families in Bangladesh. An ethnographic study was conducted, involving various qualitative research methods that revealed economic consequences to be one of the crucial sequelae of childlessness in Bangladesh. This paper details how the poverty/fertility relationship is dependent on social and institutional characteristics, including patriarchal values, education, urban-rural location and health services. Empirical data show that childlessness generates poverty in various ways, including the deprivation of children's earnings, decline in women's mobility, demoralisation of men to earn an income, marriage devaluation by the husband, disbursements for treatment and denial of microcredit (very small loans to those in poverty, which support them to become self-employed to generate income). The current study shows that the infertility/poverty relationship is mostly contingent upon class and gender. It is therefore the rural poor childless women who are most badly affected economically in Bangladesh rather than the urban middle class childless women. In other words, this study reveal that along with gender, class plays a dominant role in terms of the economic consequences of childlessness in Bangladesh. It sheds light on a different and unusual aspect of poverty and aims to contribute to the gender discussion of livelihood and poverty.