The reality of embedded drug purchasing practices: Understanding the sociocultural and economic aspects of the use of medicines in Bangladesh

Background Purchasing drugs with or without prescription from retail drug shops is common practice in Bangladesh. However, what actually takes place between the drug seller and customer during the transaction is under-researched. This study explores the drug purchasing practices which underlie the socio-cultural and economic aspects of a Bangladeshi city. Methods Adopting ethnographic methods, we conducted thirty in-depth interviews (IDIs) with customers, patients, and sales assistants, and ten key informant interviews (KIIs) with drug sellers, experienced sales assistants and pharmaceutical company representatives. Thirty hours were spent observing drug sellers’ and buyers’ conversations and interactions for medicine. A total of 40 heterogeneous participants were purposively selected from three drug stores. Transcribed data were coded, and analyzed thematically. Results We found through thematic analysis that some individuals visited the drug store with fixed ideas about the name, brand, and dose of the drugs they wanted. Among the 30 IDIs participants, most individuals come without any preconceived ideas, describe their symptoms, and negotiate purchases with the expectation of quick remedies. Cultural practices of buying medicines in full or partial course of doses, with or without prescription, trust in sellers, and positive previous experiences of medications shape the drug purchasing behavior, regardless of any preconceived ideas concerning brand name, and dose. Few customers (n = 7) sought drugs by trade name, but most drug sellers often offered a generic substitute because selling non-brand drugs is more profitable. Notably, many of the clients (n = 13) bought drugs through installment payments and with loans. Conclusion Community people choose and purchase the most necessary medicines in a self-medicated way from shortly trained drug sellers that can harm individuals’ health and reduce the effectiveness of medication. In addition, the results of buying medicine through installments and loans suggest further research on the financial burden of consumers’ purchasing behavior. Policymakers, regulators, and healthcare professionals might implicate the study findings to deliver practical information on the rational use of medicines to sellers and customers.


Unfunded studies
Enter: The author(s) received no specific funding for this work.   If the data are held or will be held in a public repository, include URLs, accession numbers or DOIs. If this information will only be available after acceptance, indicate this by ticking the box below. For example: All XXX files are available from the XXX database (accession number(s) XXX, XXX.).
• If the data are all contained within the manuscript and/or Supporting Information files, enter the following: All relevant data are within the manuscript and its Supporting Information files.
• If neither of these applies but you are able to provide details of access elsewhere, with or without limitations, please do so. For example: Data cannot be shared publicly because of [XXX]. Data are available from the XXX Institutional Data Access / Ethics Committee (contact via XXX) for researchers who meet the criteria for access to confidential data.
The data underlying the results presented in the study are available from (include the name of the third party

27
Results revealed that some individuals visited the drug store with fixed ideas about the name, 28 brand, and dose of the drugs they wanted. In contrast, others come without any preconceived ideas, 29 describe their symptoms and negotiate purchases with the expectation of getting well quickly. 30 Cultural beliefs, trust in sellers, and positive previous experience of using medicines influence the 31 drug purchasing behavior, regardless of any preconceived ideas concerning brand name, and dose. 32 Furthermore, customers sought drugs by trade name but the drug seller often offered a generic 33 substitute because selling non-brand drugs is more profitable. Notably, drugs are bought by 34 installment payments and with loans. Global drug purchasing patterns and the way drugs are used in response to illness changed 45 significantly with access to services, the availability of medicines, and aggressive competition 46 among the drug firms [1]. The World Health Organization (WHO) reported that resilient healthcare 47 systems are intrinsically linked to improved access to medication by ensuring rational selection, 48 affordable prices, reliable supply systems, and sustainable financing [2]. One-third of the world's 49 population lacks regular access to essential drugs; 50% of whom are in Asia and Africa [3]. In the 50 South-East Asian Region, at least 65 million people are underprivileged in terms of access to 51 essential medicines and vaccines [4]. Moreover, every year, US$ 42 billion is spent on the 52 inappropriate use of drugs globally [5]. The severity of adverse reactions in low-and-middle-53 income countries (LMICs) was alarming, with 134 million adverse reactions occurring annually, 54 resulting in 2.6 million deaths [6]. Therefore, WHO launched its third Global Patient Safety 55 Challenge to reduce the level of severe, preventable harm related to medication by 50% over the 56 next five years [5].

58
The pharmacy is the one place where drug purchasing and pharmaceutical procedures are 59 discussed and negotiated by pharmacists and customers [7] Chemist and Druggist Association grade pharmacists "A" for bachelor's degrees, "B" for diplomas, 81 and "C" for three months of training. Notably, 95% of drug sellers are not concerned about the 82 possible side effects of drugs that their patients/customers may suffer [14]. There is plenty of 83 opportunity to prescribe, dispense, and take non-essential and unsafe drugs because of the lack of 84 professional education and training, the desire for profit, and because they are easy prey for the 85 drug firms. There is little research into whether the purchase of drugs might be influenced by 86 sociocultural and economic factors that contribute to irrational drug buying. Thus, this study set 87 out to understand the sociocultural and economic aspects of drug purchasing in a drug store setting. 88 It is hoped that our finding will aid policymakers in reinforcing the rational use of medicines in In order to recruits study participants, the author (SM) spent time at the drug store to observe and 109 meet the customers who visited for the purpose of seeking primary healthcare and buying 110 medication. During the first week of fieldwork, the researcher used to wait at the front counter to 111 observe because the sellers would not allow him to sit inside, possibly because there are sensitive

112
The author may clarify if there were any criterion for selecting study site?
The author did not mention anything about sociocultural and economic aspects rather than general description of qualitative analysis in the methodology. It may be mentioned how the author assessed these two aspects which are the prime focus of this manuscript? issues around the selling and buying of drugs. However, the researchers' previous qualitative 113 research experiences, student identity, and official letter from Mahidol University confirming that 114 they were collecting data for research purposes, helped to build a good relationship with the drug 115 seller and customers. A week later, the sellers voluntarily invited them to sit in and observe some 116 initial conversations with customers. We purposively recruited participants from three-drug stores 117 who were private retailers, primary healthcare providers and customers. Of the various drug 118 sellers, some of were sellers with limited training (three months), some were rural medical 119 practitioners (RMP) cum drug seller, and some were trainee sales assistants. The customers who 120 visited these drug shops did so either for their own health needs or for those of family members 121 and relatives, and they came with or without any preconceived ideas about the name, brand and 122 dose of the medicines they wanted. Before recruiting participants for interview, we made a note of 123 the customer's visits with the nature of their health problem, and whether they were asking for 124 medicines with or without a prescription. The participants were invited for interview at a time 125 convenient to them after observing the interaction which took place when they purchased their 126 drugs. We recruited 40 participants following the principles of sampling parameters of settings, 127 actors, events, and processes in line the research questions and objectives [23]. We carried out a 128 total of thirty in-depth interviews (IDIs) with lay patients, customers, trainee sales assistants, and 129 ten key informant interviews (KIIs) with primary healthcare providers with drug sellers, very 130 experienced sales assistants, medical representatives and regular customers in order to get a deeper 131 understanding and collect contextualized data (Table 1). In addition, it has been noted that carrying

171
This section sets out the demographic profiles of the study participants ( Table 1). The mean age   We found various types of drug shops in the study areas considering the location, sellers training 186 and the client flow. We purposively selected three drug stores located in three different settings.

187
The first was located on a commercial road side and was operated by a seller with limited training  it is unclear how the authors concluded these findings? Where is the data? How many of the respondents mentioned these aspects? How the authors measured their cultural beliefs?
It may be but would be strong to say that a drug store being in a affluent area, their clients will be from higher income group. Did the authors analyzed the characteristics of the respondents who visited these drug stores ? There might be several factors for a client to visit a drug store, one of them is drugs availability. Poor people may also visit to drug seller in the affluent area as they might sell drugs which are not available in other place or may be there are other factors, easy to reach, give discounts.
Drug store ?
In the following sections, we categorized three key themes of drug purchasing interactions: the 211 purchasing practices, sociocultural and economic reasons of medicine tradeoff discussed below.  is the name of the drug, they are the same as two brothers with the same mother."

285
Data also identified that if customers want to go to another drug store if they do not agree to the 286 alternative offered, the seller asked them to wait and got the desired brand from another drug shop. and expiry date because of they trusted the seller. One drug seller stated in KII:

296
"The medical representative offers more profit and a higher commission on the non-brand 297 products. As we do not take a consultation fee and have no other source of income, except 298 the profit from drug selling, we tried to sell these drugs to the customer who asked us for 299 medicines, especially the rickshaw pullers and daily laborers". It is the availability of healthcare services and information at drug store that attracts customers. One medical representative shared the fact that drug sellers competed among themselves to build 368 a good reputation in the community that would help to maintain their drug business.

369
"There is competition to create a good reputation for curing disease as quickly as possible.

370
They do not think about the side effects of the drugs, and even the buyer wants to get well 371 quickly. There is competition to provide antibiotics in every case."  community, not only to the drug store but also to the drug seller who will go to the patient's home.

402
For instance, the drug seller often made home calls to the elderly and pregnant women to carry out One limitation of our study was the time constraints as we followed the purposive sampling 434 strategy. Although, a purposive sampling strategy identified rich and informative participants, 435 building up a rapport and becoming familiar with the community was time consuming. Another

436
The author may also discuss the about the drug policy of Bangladesh and specifically where this study can contribute.
This is not clear how the patients will be aware from this findings? Should policymakers take initiatives to aware the patients?
limitation was that the study was conducted in urban areas, but healthcare beliefs, seeking medical 437 care and medicine purchasing practices might vary widely in the context of rural areas.

438
Furthermore, sensitivity about the whole issue of recommending, dispensing and selling drugs 439 meant that it was difficult for the sellers to allow us, as outsiders, into their professional space, and 440 observe the services provided at the drug store. The risk was that this might affect the customer's 441 trust. However, the reality of health and drug related practices are context bound, and so these 442 findings can be applied to other places of drug purchasing.

27
Results revealed that some individuals visited the drug store with fixed ideas about the name, 28 brand, and dose of the drugs they wanted. In contrast, others come without any preconceived ideas, 29 describe their symptoms and negotiate purchases with the expectation of getting well quickly.  inappropriate use of drugs globally [5]. The severity of adverse reactions in low-and-middle-53 income countries (LMICs) was alarming, with 134 million adverse reactions occurring annually, 54 resulting in 2.6 million deaths [6]. Therefore, WHO launched its third Global Patient Safety

55
Challenge to reduce the level of severe, preventable harm related to medication by 50% over the 56 next five years [5].

58
The pharmacy is the one place where drug purchasing and pharmaceutical procedures are 59 discussed and negotiated by pharmacists and customers [7]. In order to recruits study participants, the author (SM) spent time at the drug store to observe and  (Table 1). In addition, it has been noted that carrying

171
This section sets out the demographic profiles of the study participants ( Table 1). The mean age   We found various types of drug shops in the study areas considering the location, sellers training 186 and the client flow. We purposively selected three drug stores located in three different settings.

187
The first was located on a commercial road side and was operated by a seller with limited training  In the following sections, we categorized three key themes of drug purchasing interactions: the 211 purchasing practices, sociocultural and economic reasons of medicine tradeoff discussed below.  is the name of the drug, they are the same as two brothers with the same mother."

285
Data also identified that if customers want to go to another drug store if they do not agree to the 286 alternative offered, the seller asked them to wait and got the desired brand from another drug shop.  It is the availability of healthcare services and information at drug store that attracts customers. One medical representative shared the fact that drug sellers competed among themselves to build 368 a good reputation in the community that would help to maintain their drug business.

369
"There is competition to create a good reputation for curing disease as quickly as possible.

370
They do not think about the side effects of the drugs, and even the buyer wants to get well 371 quickly. There is competition to provide antibiotics in every case."  community, not only to the drug store but also to the drug seller who will go to the patient's home.

402
For instance, the drug seller often made home calls to the elderly and pregnant women to carry out One limitation of our study was the time constraints as we followed the purposive sampling 434 strategy. Although, a purposive sampling strategy identified rich and informative participants, 435 building up a rapport and becoming familiar with the community was time consuming. Another 436 limitation was that the study was conducted in urban areas, but healthcare beliefs, seeking medical 437 care and medicine purchasing practices might vary widely in the context of rural areas. 438 Furthermore, sensitivity about the whole issue of recommending, dispensing and selling drugs 439 meant that it was difficult for the sellers to allow us, as outsiders, into their professional space, and 440 observe the services provided at the drug store. The risk was that this might affect the customer's 441 trust. However, the reality of health and drug related practices are context bound, and so these 442 findings can be applied to other places of drug purchasing. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article's retracted status in the References list and also include a citation and full reference for the retraction notice.

Response
Thank you so much for the comment and suggestions. In response to your observation, we conducted an additional check, and the reference has been updated. At this point, it is hopefully complete and correct according to the requirements of the journal. For your kind information, in our last revised manuscript, we included some new articles according to the reviewer's comments.
That is why the reference number changed, and we apologize for not mentioning it in our last response and rebuttal letter. Once again, I would like to thank you for your comments and suggestions.

Additional Editor Comments:
Apologies for taking the time to review your paper. Unfortunately, there is a limited number of reviewers who have the expertise and interest to review this paper. We have reviewers who initially agreed but later did not complete the review on time. I reviewed your paper and have following comments: This is an interesting and important study that investigated the drug purchasing practices which underlie the socio-cultural and economic aspects of a Bangladeshi city. However, there are a few areas in the manuscripts that can be further improved considering my additional comments. I have following minor observations, please consider them while revising it: