Beyond Prescriptions: How Behaviour Science Is Revolutionizing Our Fight Against Superbugs
Exploring how behaviour change interventions are transforming antimicrobial prescribing practices to combat the global threat of antimicrobial resistance.
Introduction: The Silent Pandemic and Our Prescribing Problem
Imagine a world where a simple scratch could be deadly, where routine surgeries become life-threatening gambles, and where modern medicine's greatest achievements crumble beneath the weight of relentless superbugs. This isn't science fiction—it's the looming reality of antimicrobial resistance (AMR), declared by the World Health Organization as one of the top 10 global health threats facing humanity 1 .
Did You Know?
In the UK, about one-third of all hospital inpatients receive antimicrobials during their admission, with a significant proportion identified as inappropriate 2 .
Prescribing Problem
Most antibiotics are prescribed in primary care settings, often for conditions where they offer little benefit 5 .
The COVID-19 pandemic unfortunately exacerbated this problem, with early practices involving prescription of broad-spectrum antibiotics and increased self-medication 1 . But how do we change deeply ingrained prescribing habits? The answer may lie not in developing newer, stronger drugs, but in understanding and reshaping human behavior through scientifically-designed interventions.
The Science of Changing Minds: Key Concepts and Theories
Understanding the Behavioural Puzzle
Antimicrobial prescribing is not simply a clinical decision—it's a complex human behavior influenced by multiple factors. Prescribers must navigate diagnostic uncertainty, patient expectations, time constraints, organizational culture, and ingrained habits 5 .
Behaviour change interventions are systematic approaches designed to influence these prescribing patterns through targeted strategies based on scientific principles.
The COM-B Framework
This model identifies three essential components that interact to produce behaviour:
- Capability - the knowledge and skills needed
- Opportunity - environmental and social factors
- Motivation - cognitive processes that direct behavior
Based on Michie and colleagues' work 6
Behaviour Change Wheel
The COM-B framework forms part of the broader Behaviour Change Wheel, which helps intervention designers select appropriate strategies based on the identified barriers and enablers 5 .
Visual representation of the Behaviour Change Wheel framework
The UK Conference Study: A Snapshot of Behaviour Change Science
Methodology: Scanning the Scientific Landscape
To understand how behaviour change science was being applied to antimicrobial prescribing in the UK, researchers conducted a fascinating cross-sectional analysis of reports presented at major UK scientific conferences in 2015 2 .
The research team identified 30 specialty conferences and screened 12,313 abstracts, of which 311 (2.5%) focused on antimicrobial stewardship or resistance 2 .
Results: A Landscape of Missed Opportunities
The findings revealed both progress and concerning gaps in behaviour change approaches to antimicrobial stewardship. Of the 311 AMS-AMR abstracts identified, only 56 (18%) described behaviour change interventions 2 .
Perhaps most strikingly, behaviour change interventions were not equally distributed across specialties. Half of all behaviour change interventions (50%) were presented at the infectious diseases/microbiology conference 2 .
Most concerning was the finding that 10 of the 12 specialties reporting behaviour change interventions focused on a narrow range of strategies, primarily "guidelines" and "enablement" 2 .
| Conference Specialty | Total Abstracts | AMS-AMR Abstracts | Percentage |
|---|---|---|---|
| Infectious Diseases/Microbiology | 375 | 144 | 38.4% |
| Genitourinary Medicine | 299 | 26 | 8.7% |
| Orthopaedics | 96 | 8 | 8.3% |
| Plastic Surgery | 78 | 6 | 7.7% |
| All Other Specialties | 11,465 | 127 | <5% |
Table 1: Conference Types and AMS-AMR Abstract Representation 2
The Intervention Gap: Why Weren't We Using Behaviour Science?
The UK conference study revealed a startling paradox: despite evidence supporting the effectiveness of behaviour change interventions in improving antimicrobial prescribing, very few AMS-AMR studies actually reported implementing them in 2015 2 . This implementation gap suggests a concerning delay in translating behavioural science evidence into practical interventions.
Limited Awareness
Limited awareness of behavioural science among infection specialists might have limited its application 2 .
Complexity
The complexity of behavioural interventions might deter time-pressed clinicians from implementing them 2 .
Publication Bias
Publication biases where behaviour change interventions were under-reported in conference abstracts due to word limitations or perceived lack of scientific rigor 2 .
Narrow Understanding
The limited range of behaviour change functions being employed suggested a narrow understanding of behavioural science 2 .
"The study highlighted significant disparities in engagement across specialties. While infectious disease specialists had embraced behaviour change approaches, other specialties where antibiotics are frequently prescribed lagged behind." 2
What Works? Effective Behaviour Change Strategies
Multifaceted Approaches Show Greatest Promise
A systematic review of community-based behaviour change interventions to improve antibiotic use found positive emerging evidence of benefits, with multifaceted interventions offering the highest benefit 1 .
These successful interventions often combine educational aspects with persuasion, proving more effective than solely educational interventions 1 .
The Power of Participatory Design
Effective behaviour change interventions often employ participatory approaches that engage end-users in the design process. This inclusive participation leads to greater public ownership and use of community channels 1 .
The Tailoring Antimicrobial Resistance Programmes (TAP) and the more broadly applied Tailoring Health Programmes (THP) developed by WHO/Europe provide step-by-step tools for applying behavioural and cultural insights 6 .
Targeting the Right Behavioural Components
Successful interventions carefully diagnose which aspects of behaviour need changing before selecting appropriate techniques. Using frameworks like COM-B helps designers match interventions to specific barriers 5 .
- Capability deficits: education, training
- Opportunity barriers: environmental restructuring, enablement
- Motivation issues: persuasion, incentivization, modelling
| Intervention Function | Number Reported | Percentage |
|---|---|---|
| Guidelines | 16 | 22.5% |
| Service Provision | 11 | 15.5% |
| Enablement | 9 | 12.7% |
| Environmental Restructuring | 9 | 12.7% |
| Persuasion | 7 | 9.9% |
| Education | 6 | 8.5% |
| Other Functions | 13 | 18.3% |
Table 2: Types of Behaviour Change Functions Identified 2
Conclusion: The Future of Antimicrobial Stewardship
The silent pandemic of antimicrobial resistance continues to accelerate, threatening to undo decades of medical progress. As the UK conference study revealed, we have been slow to harness the power of behavioural science in addressing this crisis 2 . However, the emerging evidence provides cause for cautious optimism.
"The future of antimicrobial stewardship likely lies in embedding behavioural science more deeply into intervention design, implementation, and evaluation."
This will require greater collaboration between infection specialists, behavioural scientists, implementation researchers, and healthcare professionals across all specialties. It will also require addressing the significant gaps in our current approach—particularly the limited engagement of non-infection specialties and the narrow range of behaviour change techniques being employed.
The Ultimate Goal
By learning how to change minds, we might just preserve the medicines that save bodies. The fight against superbugs isn't just a medical battle—it's a behavioural one, and it's one we cannot afford to lose.