Backyard poultry raising is common in rural Bangladesh and many households keep their poultry inside their houses at night. Compared to keeping poultry outside in sheds at night, this practice likely elevates children’s exposure to poultry and poultry feces and associated enteric pathogens. We conducted a two-arm (subsidy and non-subsidy) pre-post pilot study. Households in both arms received the behavior change communication and counseling intervention. Households in the subsidy arm also received ~23 USD for the construction of an improved poultry shed for nighttime housing. We administered a household survey and spot-check at baseline (February 2020) and then after intervention implementation (January-February 2021) among 37 subsidy and 42 non-subsidy households to determine the impact of the intervention on 1) confining poultry in a shed outside of the house at night, 2) poultry feces management, and 3) hand washing with soap after contacting poultry and poultry feces. A secondary aim was to investigate the effectiveness of a monetary subsidy on encouraging poultry raisers to build an improved poultry night shed. At endline, 58% of all households had an improved poultry shed (87% of subsidy and 33% of non-subsidy households). The percentage of all households confining all of their poultry outside the house the previous night was significantly higher at endline (33%) compared to baseline (2.5%) (prevalence difference: 30 percentage points [pp]; 95% confidence interval: [19, 41]). More households (both arms) had no visible poultry feces piles inside the house compared to baseline (prevalence difference: 26pp [10, 41]). Our intervention effectively encouraged households to build poultry sheds, confine poultry outside of house at night, and maintain an indoor living space free of poultry feces. Future studies should assess if housing all poultry outside the house reduces children’s exposure to poultry feces enough to mitigate health risks associated with poultry ownership.

Backyard poultry-rearing contributes to income and food security for rural households in low- and middle-income countries. However, poultry are often kept inside the household dwelling at night, posing health risks to the people raising them. Housing poultry separately from the dwelling overnight is a potential intervention to limit exposure to poultry. The aim of this study was to describe practices and determinants of overnight poultry housing in rural Bangladesh as formative research for an intervention to separate young children from poultry and poultry feces. We conducted 19 transect walks in villages across Bangladesh to document overnight housing practices among backyard poultry raisers. We then conducted 27 semi-structured interviews to explore poultry-raising practices, including housing types and materials identified during transect walks. We found overnight poultry housing both inside and separate from the dwelling and found that most poultry raisers who kept their birds separate from the dwelling overnight did so in courtyard sheds. There was a preference and willingness to house birds outside, provided a shed was available, although overnight housing practices fluctuated. Having a shed was a function of household resources, including availability and access to materials and skilled labor, available physical space, area- and village-wide trends, and the preferences and concerns of poultry raisers. We recommend that future studies measuring human exposure to poultry and poultry feces assess exposure prospectively and at regular intervals to capture variations in housing practice, and include assessments of poultry housing hygiene practices. The promotion of sheds for overnight poultry housing may be an acceptable intervention approach in this setting, though programs will need to make recommendations for housing that address the risk of zoonotic disease transmission and accommodate the preferences and constraints of poultry raisers over a one-size-fits-all approach.

The brick manufacturing industry in Bangladesh is characterized by informal inefficient coal-burning kilns that emit substantial greenhouse gases and air pollution. Despite decades of regulatory measures and the promotion of advanced kiln technologies, informal kilns persist. We employed a multiphase, interdisciplinary, mixed- methods approach to identify solutions. In this paper, we first summarize past approaches and discuss the key barriers we identified to improving the industry, then we present the design, and results of a randomized pilot energy efficiency intervention designed to overcome barriers to improved kiln operation. Our approach emphasized collaborating with informal zigzag kiln owners, who constitute the majority of brick producers, and carefully considering their incentives for changing a profitable business model. The intervention achieved high (60 %), including from non-study kilns, highlighting its appeal. Our findings provide insights into key elements for a successful intervention strategy that can be applied in larger-scale studies, not only for brick manufacturing but also for addressing broader environmental and health challenges.

Background: Backyard poultry-raising is common in rural Bangladeshi households. Raising poultry contributes to fecal contamination of the domestic environment, increasing children’s exposure to enteric pathogens, including Campylobacter, which has been associated with child stunting.   Objective: To investigate the effectiveness of a behavior change communication and counseling intervention to encourage households to confine poultry outside of the household dwelling in a shed at night and improve poultry feces management.   Methods: We conducted a two-arm pre-post pilot study. Households in both arms received the behavior change communication and counseling intervention. Households in the subsidy arm also received ~23 USD for the construction of a poultry shed for nighttime housing. We administered a household survey and spot-check before and after intervention implementation among 37 subsidy and 42 non-subsidy households.   Results: At endline, 58% of all households had a poultry shed (87% of subsidy and 33% of non-subsidy households) and the percentage of households confining all poultry outside the house the previous night was significantly higher at endline (33%) compared to baseline (2.5%) (prevalence difference [PD]: 30 percentage points [pp]; 95% CI: [19, 41]). Additionally, more households had no visible poultry feces piles inside the house compared to baseline (PD: 26pp 95% CI: [12, 41]), but there were no significant differences in the number of poultry feces piles in the courtyard or veranda.   Discussion: Our intervention effectively encouraged households to confine poultry outside of household dwellings at night and to maintain an indoor living space free of poultry feces. Households were willing and able to construct a shed even without a subsidy. Households that received a subsidy were more likely to construct a shed. Future studies should assess if housing all poultry outside the household dwelling reduces children’s exposure to poultry feces enough to mitigate health risks associated with poultry ownership. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This research was supported by USAID funding through WASHPaLS (USAID contract AID-OAA-I-14-00068/AID-OAA-TO-16-0016). This study was made possible by the support of the American People through the United States Agency for International Development (USAID). The contents of this manuscript are the sole responsibility of authors and do not necessarily reflect the views of USAID or the United States Government. The funders played no part in study design, data analysis, or publication of peer-reviewed results. The funder did require a final report and some of the content of this manuscript is similar to that presented in the final report (USAID and International Centre for Diarrhoeal Disease Research, Bangladesh 2021) all content has been used with permission. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The protocol (PR-18087) for this study was approved by the Institutional Review Board of icddr,b the IRB concluded that approval for research involving animals was not required. The enumerators collected informed written consent from the primary poultry-raiser in the study household at enrollment. This trial did not assess any health outcomes and was therefore not registered as a clinical trial. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The data that support the findings of this study can be made available upon reasonable request and approval by icddr,b.

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.

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.

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.

Observational data suggest maternal handwashing with soap prevents neonatal mortality. We tested the impact of a chlorhexidine-based waterless hand cleansing promotion on the behavior of mothers and other household members. In rural Bangladesh in 2014, we randomized consenting pregnant women to chlorhexidine provision and hand cleansing promotion or standard practices. We compared hand cleansing with chlorhexidine or handwashing with soap before baby care, among mothers and household members in the two groups, and measured chlorhexidine use in the intervention arm. Chlorhexidine was observed in the baby's sleep space in 97% of 130 intervention homes, versus soap in 59% of 128 control homes. Hand cleansing before baby care was observed 5.6 times more frequently among mothers in the intervention arm than in the controls (95% CI = 4.0-7.7). Hand cleansing was significantly more frequently observed in the intervention arm among women other than the mother (RR = 10.9) and girls (RR = 37.0). Men and boys in the intervention arm cleansed hands before 29% and 44% of baby care events, respectively, compared with 0% in the control arm. The median number of grams consumed during the neonatal period was 176 (IQR = 95-305 g), about 7.8 g/day (IQR = 4.2-13.8 g). Promotion of waterless chlorhexidine increased hand cleansing behavior among mothers and other household members. Discrepancy between observed use and measured chlorhexidine consumption suggested courtesy bias in structured observations. A waterless hand cleanser may represent one component of the multimodal strategies to prevent neonatal infections in low-resource settings.

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.