Introduction
Antibiotic resistance is a major global health threat driven by multiple interconnected factors, including inappropriate use of antibiotics, gaps in infection prevention and control, limited access to diagnostics, inadequate sanitation and vaccination coverage, healthcare-associated transmission, and environmental and agricultural contamination (Wallinga et al., Reference Wallinga, Rayner and Lang2015; Iskandar et al., Reference Iskandar, Molinier, Souheil, Sartelli, Hardcastle, Haque, Lugova, Dhingra, Sharma, Islam, Mohammed, Mohamed, Hanna, Hajj, Hayat Jamaluddin, Salameh and Roques2021). Antibiotic stewardship refers to focused initiatives aimed at optimizing appropriate antibiotic use in clinical settings to ensure that antibiotics are prescribed only when necessary, at the correct dose, and for the appropriate duration (World Health Organization, 2019). These programmes require strong leadership, system-wide commitment, and education for the patient population (Sanchez et al., Reference Sanchez, Fleming-Dutra, Roberts and Hicks2016).
In paediatric care, antibiotic stewardship efforts are complicated by a variety of factors. Clinicians and caregivers often perceive a higher level of risk when treating children compared to adults, which can influence decision-making around antibiotics (Krockow et al., Reference Krockow, Colman, Chattoe-Brown, Jenkins, Perera, Mehtar and Tarrant2019; Marsh et al., Reference Marsh, Byrne and Parsafar2023). For clinicians, clinical uncertainty in children, especially those too young to clearly articulate symptoms, can prompt a lower threshold for antibiotic prescribing (Cabral et al., Reference Cabral, Lucas, Ingram, Hay and Horwood2015). For caregivers, concern for a child’s rapid deterioration or fear of complications can create strong expectations for antibiotic treatment, even in cases where it may not be clinically indicated (Lucas et al., Reference Lucas, Cabral, Hay and Horwood2015). These dynamics highlight the need to better understand the specific context of antibiotic stewardship in paediatric care.
In South Asia, antibiotic stewardship is compromised by factors at multiple levels, including patient attitudes, provider norms and incentives, clinical resources, community structures, and policy frameworks (Murray et al., Reference Murray, Leung, Hanson, Ahmed, Pavia, Khan, Szymczak, Vaughn, Patel, Biswas and Watt2024). For caregivers of young children, barriers such as long travel distances to health facilities and healthcare costs discourage timely care-seeking from qualified clinicians. In Bangladesh, these factors often lead patients to seek antibiotics from informal healthcare settings (Mangadu et al., Reference Mangadu, Putnam, Das, Dallas, Munim, Shihab, Khan, Hanson, Khan, Islam, Biswas, Amin, Qadri, Leung, Khan and Watt2026), where inappropriate antibiotic use is driven by resource constraints, shortages of medical personnel, and the lack of robust antibiotic stewardship guidelines (Biswas et al., Reference Biswas, Watt, Mangadu, Das, Munim, Shihab, Khan, Amin, Khan, Islam, Hanson, Nelson, Qadri, Leung and and Khan2025). Without access to essential resources, such as diagnostic tests, healthcare providers often resort to prescribing antibiotics as a default treatment. Community norms further drive overuse, with antibiotics often viewed as a catch-all solution for many health concerns (Dallas et al., Reference Dallas, Mangadu, Das, Hanson, Khan, Amin, Khan, Islam, Biswas, Munim, Shihab, Alam, Shirin, Qadri, Putnam, Nelson, Leung, Khan and Watt2025). These systemic and cultural factors collectively undermine efforts to implement effective antibiotic stewardship in the region (Murray et al., Reference Murray, Leung, Hanson, Ahmed, Pavia, Khan, Szymczak, Vaughn, Patel, Biswas and Watt2024).
Promoting antibiotic stewardship in Bangladesh requires an understanding of both patient and provider perspectives on the judicious use of antibiotics. Caregivers often seek antibiotics for quick symptom relief but lack understanding of appropriate use, highlighting the need for education. Healthcare providers face systemic barriers like resource limitations, clinical uncertainty, and pressure to meet patient expectations, which hinder adherence to stewardship principles. While there is increasing attention to the public health threat of antibiotic resistance (Haenssgen et al., Reference Haenssgen, Xayavong, Charoenboon, Warapikuptanun and Zaw2018; Majumder et al., Reference Majumder, Rahman, Cohall, Bharatha, Singh, Haque and Gittens-St Hilaire2020), there is limited knowledge on the most effective strategies to engage patients and providers in stewardship efforts. To address this gap, qualitative research in Bangladesh was conducted to explore knowledge and perspectives of antibiotic stewardship principles among clinicians working in government health facilities and caregivers of paediatric patients.
Methods
This qualitative study included individual interviews with 18 clinicians and 36 caregivers of children presenting to the hospital with a primary complaint of paediatric diarrhoea. The study received ethical approval from the Research Review Committee at the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), and the Institutional Review Board at the University of Utah. Written informed consent was obtained from all participants prior to their participation in the study.
Study setting and population
In collaboration with the Institute for Epidemiology, Disease Control and Research and the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), participants were recruited from three government health facilities in Bangladesh: 1) Patuakhali District Hospital, an urban site located in the south that serves approximately 191,000 patients annually with around 22 registered doctors; 2) Chatak Upazila Health Complex, a sub-district rural facility in the northeast, with an annual patient volume of approximately 86,500 and around five registered doctors; and 3) the Bangladesh Institute of Tropical and Infectious Diseases, a specialized urban referral hospital in Dhaka that treats roughly 57,800 patients per year with around 40 registered doctors. The study sites were purposively selected to represent diverse healthcare settings in Bangladesh, including urban and rural locations, different tiers of the public health system, and varying patient loads. Inclusion of a district hospital, an upazila health complex, and a specialized referral hospital enabled exploration of antibiotic stewardship perspectives across a range of clinical contexts and resource settings.
At each of the study sites, study staff collaborated with clinic and hospital leadership to identify all eligible medical doctors who regularly treat emergency and outpatient cases of paediatric diarrhoea. From this eligible pool, purposive sampling was used to ensure inclusion of clinicians with diverse years of experience and specialties. Six clinicians were enrolled from each clinical site, for a total of 18 clinicians across the three study sites.
To recruit caregivers, purposive sampling was used to identify parents or caregivers of children under 59 months of age presenting with diarrhoea as the primary concern. The under-five-year age cutoff aligns with the World Health Organization’s definition of the key demographic priority for diarrhoea-related mortality. During designated emergency and outpatient clinic days, research staff approached all eligible families to ensure broad representation and reduce selection bias. At each clinical site, 12 patient caregivers were recruited, for a total of 36 caregiver participants.
Procedures
From July to September 2023, individual in-depth interviews were conducted with providers and caregivers at clinical sites by a member of icddr,b’s qualitative research team. Interviews were conducted in a private room of the clinic in Bangla and lasted 30–60 minutes. Study staff, a multi-national and multi-disciplinary team, developed semi-structured interview guides for each participant group. The guide for clinician interviews (Supplement 1) included questions about their understanding of antibiotic stewardship, how this concept influences their clinical practice, the culture of antibiotic stewardship at their clinical practice facility, and challenges associated with antibiotic stewardship. The guide for caregiver interviews (Supplement 2) included questions about caregivers’ expectations related to antibiotics, their understanding and familiarity with appropriate antibiotic use, and their opinions on their personal role in antibiotic stewardship. All interviews were audio-recorded, transcribed verbatim in Bangla, and subsequently translated into English by trained fluent research staff at icddr,b. All team members held Master’s degrees in Anthropology and possessed an average of six years of experience in qualitative research. Translations were reviewed for accuracy and consistency by senior Bangladeshi investigators who were deeply familiar with the cultural context, with particular attention to terms related to medicines, antibiotics, and antibiotic stewardship that may not have direct conceptual equivalents across languages.
Qualitative data analysis
Data analysis was conducted using an applied thematic analysis framework, allowing for a comprehensive and detailed exploration of clinicians’ and caregivers’ perspectives on antibiotic stewardship (Ayton, Reference Ayton, Tsindos and Berkovi2023). A comprehensive codebook was created where the following domains served as deductive codes: 1) understanding and familiarity of antibiotic stewardship, 2) local- and facility-level antibiotic stewardship practices, and 3) challenges associated with ensuring judicious antibiotic use. Coding was conducted by independent researchers with training in public health and qualitative research methods. Coders independently reviewed transcripts and generated inductive codes using a coding framework that was iteratively refined during analysis. Any discrepancies in coding were resolved through discussion and, when required, by consultation with a senior researcher experienced in qualitative methods. The codebook was revised as needed to capture emerging themes.
Following coding, analytic memos were written to synthesize emerging themes across the three domains, leading to the creation of data visualizations (see Figure 1). Representative quotations were selected based on their relevance, clarity, and ability to illustrate key themes, ensuring balanced representation across participant groups (clinicians and caregivers).
Summary of Qualitative Findings on Antibiotic Stewardship Perspectives Among Clinicians and Caregivers in Bangladesh.
Figure 1. Long description
A table summarizing qualitative findings on antibiotic stewardship perspectives among clinicians and pediatric caregivers in Bangladesh. The table is divided into three main columns: Understanding, Culture, and Challenges, each with rows for Pediatric Caregivers and Clinicians. The Understanding column describes the limited understanding of antibiotic stewardship among caregivers and their willingness to engage, while clinicians are familiar with the concept but not the term. The Culture column highlights that caregivers try to avoid pressuring clinicians and want to understand how antibiotics work, whereas clinicians make conscious efforts to prescribe antibiotics only when necessary and desire formal education on antibiotic stewardship. The Challenges column notes that caregivers sometimes expect antibiotics and have beliefs about their use, while clinicians face issues like antibiotic dispensing by informal providers, staffing shortages, and pressure to maintain patient satisfaction.
Results
Description of the sample
The 18 clinician participants were mostly male (n = 13) with a mean age of 39 years (range: 30–57). On average, the clinicians had 11.3 years of experience (range: 0.25–26 years). The 36 patient caregivers were mostly mothers (n = 25) with a mean age of 27 years (range: 18–43 years). Only two caregivers had completed secondary school. The findings from the qualitative data are summarized in Figure 1.
Understanding and familiarity of antibiotic stewardship
Only a few clinicians (4/18) reported being familiar with the term ‘antibiotic stewardship’. However, after discussing the concept and its principles during the interview, most clinicians demonstrated an understanding of appropriate and judicious antibiotic use.
‘Though I was not familiar with the term, what I understand is that is using antibiotics when it is required.’ (Urban site, medical officer, 4 months of practice)
None of the patient caregivers had heard the specific term ‘antibiotic stewardship’, and only a small number (6/36) demonstrated an understanding of the concept. A few caregivers (11/36) said that they had heard about the importance of limiting use of antibiotics from people in their community.
‘We should reduce antibiotic use. Sometimes we even need to change antibiotics… It is not needed to prescribe antibiotics if it is not required.’ (Rural site, caregiver 16, mother of a 26-month-old child)
‘I have heard it from our landlord of our residents particularly… She said that the antibiotics should be taken when it is necessary. Particularly when anyone has occasional weakness, occasional illness, coughing, headaches, fever, pain, or rash then he/she need not take the antibiotics.’ (Urban site, caregiver 34, mother of a 13-month-old child)
Local and facility level antibiotic stewardship culture
Fifteen out of 18 clinicians described that the facilities where they worked made efforts to promote antibiotic stewardship. However, these activities varied by site, reflecting differences in institutional context, with more research-active or training-oriented settings having more formalized antibiotic stewardship efforts. Around 14 clinicians noted that their facilities were cognizant of the challenges of antibiotic resistance, raised awareness on the topic among the clinic team, and emphasized the importance of practising appropriate use of antibiotics.
‘There is a lot of research on antibiotics in this hospital. We found resistance of antibiotics. That’s why we are regularly informed about antibiotic resistance through seminars or meetings.’ (Urban site, assistant surgeon, 17 years in practice)
Seven of eighteen clinicians noted that they incorporated stewardship principles into their clinical practice. They described conscious efforts to only prescribe antibiotics when clinically necessary, consider guideline-concordant or narrower-spectrum antibiotics when appropriate, and avoid unnecessary antibiotic use, particularly with paediatric patients.
‘I usually don’t prescribe antibiotics to all children. For no sign of dehydration or some sign, we don’t prescribe antibiotics. We can follow it properly. We are careful about antibiotic prescribing.’ (Urban site, medical officer, 18 years in practice)
However, clinicians acknowledged that antibiotic stewardship had not fully permeated the culture within their facilities, as many healthcare providers continued to rely on personal or patient preferences when prescribing antibiotics. A medical officer (four years in clinical practice) explained that in the treatment of respiratory tract infections, the preferred antibiotic is based on a fixed protocol, but in the case of paediatric diarrhoea, antibiotics are typically chosen ‘due to personal choice’.
Given the relatively weak culture of antibiotic stewardship within some of these facilities, clinicians suggested educational initiatives to improve awareness and uptake of antibiotic stewardship practices.
‘You can arrange a workshop for the emergency doctors. If they become aware of antibiotic use, the load of antibiotics will be reduced.’ (Urban site, assistant professor, paediatrics, 22 years in government job practice)
Several caregivers stated that they felt they had a personal role in promoting antimicrobial stewardship by becoming educated, staying informed about the proper use of antibiotics, and being willing to try alternatives to antibiotics.
‘I can try not to take antibiotics. I can try my best for that… I can take alternative medicines in this regard. We can try with normal medicines and subsequently with antibiotics if required.’ (Rural site, caregiver, 17, mother of a 10-month-old child)
Challenges associated with ensuring judicious antibiotic use
While clinicians pointed to some efforts to promote antibiotic stewardship in their hospitals, they noted several challenges to reducing the inappropriate use of antibiotics, namely: unrestricted availability of antibiotics in the community, desire to meet patient expectations, and resource constraints.
Unrestricted availability of antibiotics in the community
Clinicians described a context where patients have unhampered access to antibiotics in the community through pharmacists and informal healthcare providers. By the time patients present to the formal healthcare system, the majority have already started a course of antibiotics. Clinicians noted that they then felt obligated to maintain the patients on antibiotics.
‘95% patient came here after taking one antibiotic. I don’t get the opportunity to stop antibiotics. If any patient came after taking one or two doses of antibiotics, then we stop it. But if he came after taking antibiotics two or three days, then we let him take antibiotics two days more.’ (Urban site, assistant surgeon, 17 years in practice)
Desire to meet patient expectations
Clinicians felt that antimicrobial stewardship efforts are hampered by the expectations of patient caregivers who sometimes have unrealistic expectations related to antibiotics.
‘In the case of antibiotics, first of all, the parent is actually responsible. They want the patient to recover within an hour. That is actually not possible’ (Rural site, medical officer, 4 years in practice)
Clinicians described that patient expectations, and the desire to meet those expectations to maintain satisfaction, significantly influenced their decisions about prescribing antibiotics.
‘The patient’s caregiver wants the antibiotics, and after getting the antibiotics, they get more relaxed in their mind.’ (Rural site, resident medical officer, 1.5 years in practice)
Patient demand for antibiotics also emerged during caregiver interviews, as some caregivers noted that they expected to be given medications (typically antibiotics) to help resolve their child’s diarrhoea.
‘It is very important to use medicines. For that reason, I have brought my child here… There is no reason not to give any medicine. If my child is ill, they will surely give us medicines.’ (Urban site, caregiver, 1, mother of a 13-month-old child)
Resource constraints
Clinicians expressed that staffing shortages made it difficult to adhere to the principles of antibiotic stewardship. They stated that although other healthcare providers such as nurses are available, these personnel may not understand when antibiotics are indicated. Clinicians emphasized the need for clearer guidelines, ongoing training, supervision, and promotion of antibiotic stewardship across all levels of healthcare staff.
‘We have a lack of mid-level doctors. We have consultants who are not available all the time. Diarrhea patients require continuous follow-up. The nurses working in the diarrhea ward know and understand dehydration status. They understand which patients require ORS (oral rehydration solution) and IV (intravenous) saline. However, there is confusion about antibiotic use.’ (Urban site, paediatrician, 23 years in practice)
Discussion
These findings suggest that while clinicians in Bangladesh are generally familiar with the principles of antibiotic stewardship, and many reported integrating stewardship principles into their clinical practice, they do not feel part of a broader culture of antibiotic stewardship in their facilities. Among caregivers, only a few participants understood the principles of appropriate antibiotic use. Challenges to effective antibiotic stewardship included the unrestricted availability of antibiotics in the community, pressure to meet expectations for quick symptom relief for the child, and resource constraints.
Best practices of antibiotic stewardship include regular audits of antibiotic use and the development of guidelines tailored to local resistance patterns. These guidelines should be formally implemented at clinical practice sites with an assigned coordinator monitoring guideline adherence. For paediatric care, these practices should also be accompanied with patient communication training, as antibiotic decisions can be influenced by the knowledge and attitudes of paediatric caregivers (Gerber et al., Reference Gerber, Jackson, Tamma and Zaoutis2021). In many low- and middle-income countries (LMICs), implementing stewardship programmes has been challenging due to resource constraints, limited access to diagnostic tools, and a lack of trained personnel (Iskandar et al., Reference Iskandar, Molinier, Souheil, Sartelli, Hardcastle, Haque, Lugova, Dhingra, Sharma, Islam, Mohammed, Mohamed, Hanna, Hajj, Hayat Jamaluddin, Salameh and Roques2021). Given these challenges, it is important to consider low-cost interventions that can serve as important first steps toward more comprehensive stewardship programmes. This may include practical measures such as diarrhoea treatment algorithms, periodic prescription reviews, targeted feedback to clinicians, and caregiver education on appropriate antibiotic use (Iskandar et al., Reference Iskandar, Molinier, Souheil, Sartelli, Hardcastle, Haque, Lugova, Dhingra, Sharma, Islam, Mohammed, Mohamed, Hanna, Hajj, Hayat Jamaluddin, Salameh and Roques2021; Abo et al., Reference Abo, Freyne, Kululanga and Bryant2022; Otieno et al., Reference Otieno, Campbell, Maley, Arunga and Okumu2022). Maintaining and expanding these efforts requires sustained funding, continuous training, close monitoring, and commitment from healthcare administrators to implement comprehensive stewardship guidelines.
Antibiotic dispensing from informal healthcare providers and community-based drug vendors was identified as a barrier to antibiotic stewardship efforts. These stakeholders play a prominent role in Bangladesh’s rural healthcare system, often serving as the first point of care for many individuals due to their enhanced accessibility and lower cost (Hanson et al., Reference Hanson, Khan, Khan, Amin, Biswas, Islam, Nelson, Ahmed, Brintz, Hegde, Qadri, Watt, Leung and Khan2024). However, they frequently lack formal medical training and rely on informal sources of knowledge, contributing to antibiotic overuse (icddr,b, 2009; Shen et al., Reference Shen, Wang, Yin, Sun and Dyar2023; Zhou et al., Reference Zhou, Wei, Wu, Deng, Xu, Shang, Fenfen, Song, Zhu, Yang and Li2024). Previous work has shown that village doctors often dispense antibiotics empirically without proper diagnosis or adherence to clinical guidelines, driven by patient demand, limited access to diagnostics, and financial incentives (Hanson et al., Reference Hanson, Khan, Khan, Amin, Biswas, Islam, Nelson, Ahmed, Brintz, Hegde, Qadri, Watt, Leung and Khan2024). Their practices exacerbate antibiotic misuse and accelerate antimicrobial resistance in resource-limited settings, making informal healthcare providers important stakeholders in antibiotic stewardship efforts (Bepari et al., Reference Bepari, Rabbi, Shaon, Khan, Zahid, Dalal and Reza2023). To advance stewardship in this area, it is important to strengthen and enforce regulations governing antibiotic dispensing, including restrictions on non-prescription antibiotic sales and improved oversight of community drug vendors. Simultaneously, it is important to train, engage, and educate community drug vendors so that they can provide high-quality care in their scope of practice while promoting appropriate antibiotic use in the community.
Caregivers prioritized effective treatment for their children’s illness, with some explicitly pointing to antibiotics as an expected component of comprehensive care. As observed in other research (Krockow et al., Reference Krockow, Colman, Chattoe-Brown, Jenkins, Perera, Mehtar and Tarrant2019; Datta et al., Reference Datta, Kiwak, Fried, Benjamin, Iannone, Krein, Carter and Cohen2024), caregivers typically lacked awareness about the risks associated with unnecessary antibiotics. However, there was some indication that public perception of antibiotics was changing, as some caregivers noted that they had heard from their peers about the importance of limiting antibiotic use. These findings highlight the importance of targeted educational interventions to enhance caregiver awareness about the risks of inappropriate antibiotic use. Stewardship initiatives in India and Nepal have succeeded by combining hospital-based interventions like antibiotic prescription audits with community outreach activities to promote antibiotic resistance knowledge (Chandy et al., Reference Chandy, Mathai, Thomas, Faruqui, Holloway and Lundborg2013; Foxlee et al., Reference Foxlee, Townell, Heney, McIver and Lau2021; Khanal et al., Reference Khanal, Acharya, Trotter, Tripathi, Koirala, Pahari and Acharya2023). Recent evidence from South Africa suggests that healthcare personnel’s awareness alone is insufficient to reduce inappropriate antibiotic use, underscoring the need for multilevel stewardship strategies that are tailored to local healthcare contexts and cultural factors (Maluleke et al., Reference Maluleke, Maluleke, Jelić, Campbell, Marković-Peković, Schellack, Ramdas, Godman and Meyer2025).
Clinicians demonstrated a generally cautious approach to antibiotic prescribing, aligning with antibiotic stewardship principles. Many described guideline-consistent decision-making based on the patient’s clinical presentation, with a priority to avoid unnecessary antibiotics. However, challenges remain, particularly with patients arriving at healthcare facilities having already initiated antibiotics purchased from informal healthcare providers or community pharmacies without a prescription (Bepari et al., Reference Bepari, Rabbi, Shaon, Khan, Zahid, Dalal and Reza2023). This situation complicates clinical decision-making and underscores the broader issue of antibiotic misuse at the community level. The practice of continuing antibiotics prescribed elsewhere, even when not clinically indicated, is a significant concern (Reynolds and McKee, Reference Reynolds and McKee2009; Magin et al., Reference Magin, Davey and Davis2022).
Although these findings may echo known challenges to antibiotic stewardship in LMICs, the urgency of addressing antimicrobial resistance in low-resource settings reinforces the importance of this study. Through eliciting experience and views from both providers and caregivers, this work clarifies practical impediments to rational use of antibiotics and reveals important areas where providers and outpatient facilities can be involved in stewardship activities. That said, the findings need to be interpreted in the context of the limitations of the research. First, the research may not fully represent the diversity of healthcare practices across Bangladesh, as this sample was limited to three clinical settings. Second, the small sample size limits the ability to make robust comparisons across participant groups, facility types, or geographic locations. Third, social desirability bias could affect the validity of participants’ responses, as they might modify answers to meet societal expectations. Recognizing these limitations is essential for a nuanced understanding of the study’s results. Lastly, the study did not include prescription audits, direct observation, microbiological data, or critical clinical settings like intensive care. Therefore, findings may not fully capture real-world prescribing practices across all care levels.
Conclusion
Antibiotic stewardship is a critical strategy for combatting antimicrobial resistance and preserving the effectiveness of life-saving antibiotics. This study contributes to a systems-level understanding of antibiotic stewardship in LMICs, where formal stewardship programmes are often limited. These findings highlight the interconnectedness of formal and informal health sectors and frame informal providers as critical stakeholders in antibiotic stewardship efforts for paediatric care. These findings suggest the need for a dual approach that combines institutional capacity-building (e.g., establishing facility-level stewardship committees and improving diagnostic infrastructure) with rigorous, community-level regulatory enforcement to limit the unrestricted availability of antibiotics. Furthermore, these findings underscore the importance of designing multilevel, context-specific interventions that are informed by the lived experiences of clinicians, patients, and caregivers. Advancing antibiotic stewardship in resource-constrained settings will require targeted investment in research, policy, and capacity-building to implement and sustain effective, locally appropriate strategies.
Supplementary material
The supplementary material for this article can be found at https://doi.org/10.1017/S0021932026100674.
Data availability statement
Given the nature of the qualitative data, the research team has decided not to release the data on a public repository. Please contact the corresponding author with any inquiries.
Acknowledgements
The icddr,b is grateful to the Governments of Bangladesh and Canada for providing core/unrestricted support toward our mission of solving public health problems through innovative scientific research.
Funding statement
This work was supported by the National Institutes of Health in the United States (R01AI35114 to DTL). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests
The authors affirm that the research was carried out without any commercial or financial associations that could be seen as a possible conflict of interest.
Ethical standard
This study was approved by the Institutional Review Boards (Research Review Committee and Ethical Review Committee) of the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) and the University of Utah. Written informed consent was obtained from all participants prior to their participation in the study. Participants were adequately informed about the study objectives, procedures, confidentiality, voluntary participation, and monetary compensation for transportation cost was provided for their participation.
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