Behaviour change interventions to influence antimicrobial prescribing: a cross-sectional analysis of reports from UK state-of-the-art scientific conferences
Rawson et al. Antimicrobial Resistance and Infection Control
Behaviour change interventions to influence antimicrobial prescribing: a cross-sectional analysis of reports from UK state-of-the-art scientific conferences
T. M. Rawson 0
L. S. P. Moore 0 1
A. M. Tivey 2
A. Tsao 2
M. Gilchrist 1
E. Charani 0
A. H. Holmes 0 1
0 National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London , Hammersmith Campus, Du Cane Road, London W12 0NN , UK
1 Imperial College Healthcare NHS Trust, Hammersmith Hospital , Du Cane Road, London W12 0HS , UK
2 Imperial College School of Medicine, Imperial College London , South Kensington Campus, London SW7 2AZ , UK
Background: To improve the quality of antimicrobial stewardship (AMS) interventions the application of behavioural sciences supported by multidisciplinary collaboration has been recommended. We analysed major UK scientific research conferences to investigate AMS behaviour change intervention reporting. Methods: Leading UK 2015 scientific conference abstracts for 30 clinical specialties were identified and interrogated. All AMS and/or antimicrobial resistance(AMR) abstracts were identified using validated search criteria. Abstracts were independently reviewed by four researchers with reported behavioural interventions classified using a behaviour change taxonomy. Results: Conferences ran for 110 days with >57,000 delegates. 311/12,313(2.5%) AMS-AMR abstracts (oral and poster) were identified. 118/311(40%) were presented at the UK's infectious diseases/microbiology conference. 56/311(18%) AMS-AMR abstracts described behaviour change interventions. These were identified across 12/30(40%) conferences. The commonest abstract reporting behaviour change interventions were quality improvement projects [44/56 (79%)]. In total 71 unique behaviour change functions were identified. Policy categories; “guidelines” (16/71) and “service provision” (11/71) were the most frequently reported. Intervention functions; “education” (6/71), “persuasion” (7/71), and “enablement” (9/71) were also common. Only infection and primary care conferences reported studies that contained multiple behaviour change interventions. The remaining 10 specialties tended to report a narrow range of interventions focusing on “guidelines” and “enablement”. Conclusion: Despite the benefits of behaviour change interventions on antimicrobial prescribing, very few AMS-AMR studies reported implementing them in 2015. AMS interventions must focus on promoting behaviour change towards antimicrobial prescribing. Greater focus must be placed on non-infection specialties to engage with the issue of behaviour change towards antimicrobial use.
Antimicrobial Resistance; Stewardship; Quality improvement; Cross-specialty; Infection
In the United Kingdom (UK), about one third of all
hospital inpatients receive antimicrobials during their
admission with a significant proportion of these
identified as inappropriate [1–3]. This accounts for a large
amount of unnecessary antimicrobial exposure.
Antimicrobial resistance (AMR) is a leading patient safety
issue that requires urgent interventions to curb its
exponential growth. One target of interventions to
address the problem of AMR is the promotion of the
appropriate use of antimicrobials in humans, which is
thought to be a leading driver for the growth of
To address this and promote the appropriate use of
antimicrobial agents a number of national and
international antimicrobial stewardship (AMS) initiatives
have been implemented [5–8]. A key facet of these
interventions targets improving and sustaining
individual prescribing behaviours. Implementation of
AMS programmes have been demonstrated to reduce
rates of AMR and improve health and economic
outcomes [9–11]. However, despite these positive steps
forward, several challenges appear to remain in
promoting the sustainable use of antimicrobials across
clinical practice .
Firstly, there is a growing body of evidence to
describe the cultural and social factors that influence
antimicrobial prescribing across healthcare settings
as well as qualitative data that supports the role of
behaviour change interventions in improving
antimicrobial prescribing [13–16]. Despite this, very little
evidence exists to describe the current landscape of
behaviour change interventions being implemented
within this field [12, 13, 15–20]. Secondly, despite
evidence to support engagement of infection
specialists with the AMS-AMR agenda, there appears to be
poorer engagement across other clinical specialties in
terms of formal training and awareness at
state-of-theart scientific conferences [21–23]. Finally, although
there are described frameworks and taxonomy’s
available from which to begin mapping behaviour change
methods [24, 25], very little data is currently available
to describe the appropriateness of these specifically for
In this cross-sectional study we aimed to explore
antimicrobial stewardship interventions reported at
major cross specialty UK state-of-the-art scientific
conferences in 2015, which contained behaviour
change interventions. We aimed to determine the
number and type of behaviour change interventions
reported by different specialties and compare these to
currently available behaviour change taxonomies to
identify potential gaps and highlight potential targets
for future interventions.
Abstract identification & screening
All major medical specialties recognised by the Royal
College of Physicians, London, UK, were identified and
included alongside major surgical specialties identified by the
intercollegiate surgical curriculum programme. Psychiatric,
paediatric, and obstetrics and gynaecology specialties were
also included. UK specialists (specialist trainees or
consultants) in each of the defined fields were consulted by email
to determine the largest clinical scientific/research
conference within the UK in 2015. Two specialists from each
field, who were based in the North West London area were
contacted for their opinions. Where there was
disagreement, the authors opted for the conference with the largest
attendance. Educational, continuing professional
development and sub-specialty conferences were not considered
for inclusion given their often focused agendas, which may
have biased our findings.
Each major conference per specialty was identified and
abstract booklets extracted and interrogated. Conference
characteristics collated included; location, conference
dates, estimated attendance and total number of
abstracts accepted (either as oral, poster or publication
only). Accepted conference abstracts (invited, oral,
poster and publication only) were then identified and
interrogated using a previously validated search criterion to
identify all abstracts relating to AMS and AMR. [21, 22]
All identified oral, poster, or published only abstracts
from the search were then anonymously reviewed by
two out of three authors (TMR, AMT, & AT). Abstracts
were included if they were deemed to be describing an
aspect of AMS  or AMR  in terms of direct
effect on patients. In vitro studies with no translational
benefit to individual patients were excluded. For the
purpose of our investigation we focused on bacterial
resistance and stewardship, abstracts relating solely to
antiviral, antifungal, antiprotozoal or antimycobacterial
resistance were excluded. This focus was selected given
that anti-bacterial agents make up over 93% of all
antimicrobials prescribed for systemic use .
Furthermore, the large variation in prescribing of other
antimicrobial classes across different specialties may have
influenced our results. When there was disparity
between the opinions of reviewers’ a fourth independent
reviewer (LSPM) was consulted to reach consensus.
Characterising behaviour change interventions
Once all AMS-AMR abstracts had been identified the
rates of AMS-AMR coverage between specialty
conferences was assessed. Abstracts were then re-read by at
least two of four researchers (TMR, AMT, AT, & LSPM)
and categorised into types of intervention reported in
the abstracts. To categorise the types of interventions
reported a modified version of intervention and policy
framework definitions provided by Michie and
colleagues for the construction of their behaviour change
wheel were used (Additional file 1: Table S1) . In the
original behaviour change wheel, three layers (policy,
intervention, and behaviour systems are described).
Within the classification used in this study, behaviour
systems were not included (capability, opportunity,
motivation, and behaviour; COM-B) as reported
interventions were focused on the two levels of the
framework above this, which aim to directly influence COM-B
. Researchers attempted, where possible, to
categorise reported behaviour change interventions into one or
more of the sixteen functions (split into policies and
interventions) described within this framework. Although
the framework is designed to provide flexibility and
accommodate multiple interventions/policy combinations,
Table 1 UK state-of-the-art scientific conference summary
researchers attempted to strictly categorise reported
interventions into the fewest number of categories
possible. When there was discrepancy the group discussed
these issues until consensus was reached. Descriptive
statistics was performed in SPSS 22.0 (IBM, Chicago, IL)
with Chi-squared with Yates correction. Ethics approval
was not required for this observational study.
AMS-AMR coverage at UK state-of-the-art scientific
conferences in 2015
Thirty specialty state-of-the-art scientific conferences
abstract booklets were identified and extracted for analysis.
These conferences ran over >110 days with >57,000
delegates estimated to of attended them in 2015 (Table 1). In
total, 12,313 abstracts were extracted for analysis with 311
Breast Surgery 
Emergency Medicine 
Primary Care 
General Surgery 
Surgery (ASiT) 
Genitourinary Medicine 
Intensive Care 
Neuro surgery 
Obstetrics & Gynaecology 
Paediatric surgery 
Plastic surgery 
Transplant surgery 
Vascular surgery 
(2.5%) identified as related to AMS-AMR (Fig. 1). Of
these, 118/311 (38%) were presented at the UK’s infectious
diseases/microbiology conference . This made up 38%
(144/375) of all conference abstracts reported at this
conference. Genitourinary medicine  had the second
highest coverage with 9% (26/299), orthopaedics  third and
plastic surgery  fourth with 8% of abstracts related to
AMS-AMR each (8/96 & 6/78, respectively). All other
specialty’s had <5% AMS-AMR coverage with neurology
, emergency medicine , psychiatry , geriatrics
, and endocrinology  not having any AMS-AMR
related coverage at their 2015 conferences. Compared to
published data on conference coverage in the UK in 2014
 there was no significant difference in the level of
AMS-AMR reporting (311/12,313, 2.5%, in 2015 & 221/
7843, 2.8%, in 2014; p = 0.22). Infection/microbiology had
a significantly larger proportion of AMS-AMR abstracts
compared to all other specialties reviewed within this
study (p < 0.01).
Reported behaviour change interventions for
Of the 311 AMS-AMR abstracts identified 56 (18%)
described behaviour change interventions (Table 2). Of
these, 28/56 (50%) were reported at the
infection/microbiology conference with general surgery conferences
reporting the second largest proportion with 7/56 (13%).
In total, behaviour change interventions were reported
Fig. 1 Selection method to identify antimicrobial stewardship/
antimicrobial resistance abstracts among state-of-the-art
conferences in 2015
across 12/30 (40%) specialty state-of-the-art conferences
with infection/microbiology reporting a significantly
greater amount that all other conferences (p < 0.01). The
commonest abstracts reporting behaviour change
interventions were quality improvement projects accounting
for 44/56 (79%) of all reported behaviour change
interventions. However, this represented a minority of all
AMS-AMR quality improvement projects identified with
80/124 (65%) either not reporting any intervention or
not reporting a specific behaviour change intervention.
The remainder of behaviour change interventions
included were found to be reported within observational
studies (12/56; 21%). This also represented a minority of
observational studies reporting AMS-AMR topics across
clinical specialties (12/54; 22%).
In total, 71 unique behaviour change functions were
identified across the 56 abstracts reported behaviour
change interventions (Table 2). Eight abstracts were
deemed to describe multiple behaviour change
interventions with six of these being reported at the infectious
diseases/microbiology conference  and two at the
primary care conference . Policy categories;
“guidelines” (16/71) and “service provision” (11/71) were the
most frequently reported. Intervention functions;
“education” (6/71), “persuasion” (7/71), “enablement” (9/71),
and environmental restructuring (9/71) were also
common. Intervention categories “incentivisation” and
“coercion” and policy categories “fiscal” and “legislation” were
not reported in any interventions. However, only
infection/microbiology and primary care tended to report a
broad variety of interventions, with the majority of
interventions reported in the remaining ten specialties
tending to focus on enablement (intervention) and guidelines
or service provision (policy). The types of functions
reported in abstracts that described multiple behaviour
change interventions (8/56; 14%) are highlighted in
Table 3. In abstracts reporting multiple behaviour
change intervention functions there was a mix of policy
and intervention targets with guidelines featuring in 6/8
(75%), environmental restructuring, education and
persuasion all featuring in 4/8 (50%), and service provision
in 3/8 (38%) of the abstracts.
Clinical state-of-the-art conferences provide an
opportunity for medical professionals to participate in research
and reporting. They also allow us to gain an insight into
different levels of research being undertaken within the
field; from small scale research undertaken at the local
level, to large scale studies being performed by key
opinion leaders and organisations. This provides a
window into the activities within specialties that is less
influenced by publication bias than can often be
observed through systematically reviewing peer-reviewed
Table 3 Outline of intervention functions reported in abstracts
reporting multiple behaviour change interventions
Guideline, persuasion & environmental
Guideline, persuasion, & modelling
Education, persuasion & environmental
Guideline, persuasion & service provision
Guideline, environmental restructuring,
Guideline, education, service provision,
Guideline & service provision
Education & environmental restructuring
publications. Within this study, we observed a low rate
of behaviour change intervention reporting across the
majority of specialty state-of-the-art conferences in
2015. Infection specialties reported a significantly greater
number and broader variety of AMS-AMR interventions
with the majority of interventions reported by
noninfection specialties falling into a narrow band of
intervention and policy based functions.
These observations are concerning given the recent
focus placed upon the need for cross-specialty
engagement with AMS-AMR and behaviour change
interventions. This has been supported broadly in the literature
[4, 13, 16, 21, 22, 39]; by national organisations including
Public Health England (PHE) , the British Society for
Antimicrobial Chemotherapy (BSAC), and government
; and major international governments and
organisations [6, 7]. These findings highlight the need to broaden
the focus of AMS campaigns beyond infection specialties
to promote leadership from within cohorts, which can
drive behaviour change towards antimicrobial use.
This must be supported by clear and defined tools to
help specialties engage and design AMS-AMR behaviour
change interventions and assess the impact of these on
patient outcomes. Whilst the use of behaviour change
taxonomies allows content of interventions to be coded and
categorised, facilitating the analysis of behaviour change
interventions [24, 41], they are not appropriate for
determining the effectiveness of interventions. Furthermore, for
the field of AMS-AMR there remains no definition on
what an appropriate behaviour change intervention is.
This makes evaluating behaviour change challenging as
certain functions of any framework used may be irrelevant
or actually have a negative impact on behaviours within
this context. [24, 41, 42] Kok and colleagues argue that as
behavioural determinants are often specific to behaviours,
populations, and contexts characterisations should thus
be individualised and tailored for such [24, 41]. This will
require engagement and drive from within clinical
specialties to review current practices, define the context in
which AMS-AMR interventions need to be implemented,
and then tailor behaviour change interventions to
optimise their effect within their local environment.
Finally, in a previous study “high risk” specialties were
identified that currently use large amounts of
antimicrobials and also experience high levels of healthcare
associated infections . This study reported that certain
“high risk” specialties such as infection and intensive
care had relatively high levels of engagement with
AMSAMR, whilst other specialties such as haematology and
nephology tended to have a low apparent engagement at
scientific conferences . Within this study, we have
observed an overall low rate of behaviour change
interventions across all high risk specialties reported
previously with only infection  and nephrology 
reporting any behaviour change interventions in 2015.
Furthermore, specialties with relatively high coverage of
AMS-AMR at scientific conferences, such as
Genitourinary Medicine, failed to report on behaviour change
interventions despite having 9% coverage of AMS-AMR
topics in 2015. This highlights the need for greater
panspecialty promotion of behaviour change interventions
for AMS-AMR given the significant lack of focus on
reporting such interventions currently.
There are several limitations to this study. Firstly, we
only selected one leading state-of-the-art conference for
each major clinical specialty in the UK. This makes our
findings difficult to generalise across other countries and
also may have introduced bias through excluding smaller,
conferences and meetings, where specialties may have had
more of an AMS-AMR focus. However, this method was
selected as we aimed to generate a representative picture
of current behaviour change interventions and the
importance placed upon this by different specialties. By selecting
leading state-of-the-art conferences we hoped that this
would reflect the current overall importance of this subject
within the specialty as well as allow for a more
representative view of work being undertaken in the field. Secondly,
we did not review invited talks and seminars provided by
conferences given that they often were not presenting
original data or results. Furthermore, as the taxonomy
used to describe behaviour change does not allow for
evaluation of the effectiveness of interventions it is not
possible to evaluate whether interventions described were
“appropriate” for the context in which they were described.
Finally, as only a relatively small number of specialists from
a specific geographical area were contacted to seek opinions
on defining the largest UK conference in their field this
may have introduced bias in our conference selection. To
address this we ensured that two specialists from each field
were contacted for their opinions. When there was
discrepancy in responses from the individuals, conference
attendance size was considered as the determinant with the
conference with the largest attendance selected.
In conclusion, despite evidence to support the role of
behaviour change interventions for improving
antimicrobial prescribing, very few studies reported implementing
them at UK state-of-the-art conferences in 2015. Future
research must focus on providing appropriate
frameworks and mechanisms to allow clinical specialties to
engage with AMS-AMR and design and evaluate the
impact of behaviour change interventions within their
Additional file 1: Table S1. Behaviour change taxonomy used for
classification of interventions reported in state-of-the-art scientific conference
abstracts in 2015. (DOC 36 kb)
The authors would like to thank members of Imperial College NHS
Healthcare Trust who participated in the study. The authors would also like
to acknowledge the National Institute of Health Research Imperial
Biomedical Research Centre and the National Institute for Health Research
Health Protection Research Unit (NIHR HPRU) in Healthcare Associated
Infection and Antimicrobial Resistance at Imperial College London in
partnership with Public Health England and the NIHR Imperial Patient Safety
Translational Research Centre. The views expressed in this publication are
those of the authors and not necessarily those of the NHS, the National
Institute for Health Research or the UK Department of Health.
This report is independent research funded by the National Institute for
Health Research Invention for Innovation (i4i) programme, Enhanced,
Personalized and Integrated Care for Infection Management at Point of Care
(EPIC IMPOC), II-LA-0214-20008.
Availability of data and materials
Datasets analysed during the current study are available from the
corresponding author (TMR ) on reasonable request, as long
as this meets local ethics and research governance criteria.
TMR, LSPM, & AH conceived the study design. TMR, EC, ANT, AT, & LSMP
extracted and analysed the data. TMR drafted the initial manuscript. All
authors (TMR, LSPM, EC, AT, ANT, MG, & AH) reviewed and contributed
significantly to revision of the manuscript, agreeing on the final format for
submission to ARIC.
The authors declare that they have no competing interests.
Consent for publication
Ethics approval and consent to participate
No ethics or consent was required from this study using publically available
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