19th January 2022

To celebrate our 50th anniversary, we’re inviting a select number of experts to share what they see as being the 21st-century solutions to one of the biggest and most complex challenges of our generation: antimicrobial resistance (AMR). In this post, Dr Alix Brazier, Sarah Merriam and David Halpern, of the UK’s Behavioural Insights Team (BIT), explore how applying behavioural science can impact AMR…

AMR already causes 700,000 deaths every year around the world. This number could increase to 10 million by 2050 if no action is taken.[1] This is more than we record today from cancer,[2] and forty times the estimated number of deaths that will be attributable to climate change by 2050.[3]

There are two key recommendations for tackling AMR: increase the number of effective antimicrobials available, and reduce demand for existing antibiotics.[4] While we depend on scientists to find new antimicrobials, reducing demand for antibiotics largely relies on human behaviour change and involves improving hygiene, preventing infection spread, reducing agricultural antibiotic use, and developing and using diagnostics, vaccines and alternatives to reduce unnecessary use.

Given the importance of human behaviour in AMR, applying behavioural sciences can help reduce its development.

In this blog, we focus on three areas where we see the greatest potential for behavioural science interventions: (1) ‘Nudging’ antimicrobial stewardship; (2) Building good hygiene habits; and (3) Leveraging market forces.

Nudging antimicrobial stewardship

In the absence of a strong pipeline of new antimicrobials, we must take steps to protect the ones we have. In healthcare, this can be achieved by clinicians making correct diagnoses and prescribing appropriate treatments, and patients following the recommendations of their doctors. In this area, even low-cost ‘nudge’-style interventions can have big impacts when implemented at scale.[5]

How can we do this?

In 2014, BIT sent a letter, signed by England’s Chief Medical Officer, which provided social norm feedback to high-prescribing GPs in England. The feedback highlighted that 80% of practices in their area prescribed fewer antibiotics than theirs. This simple intervention led to a 3.3% reduction in antibiotics dispensed over the following 6 months, equating to a 0.85% reduction in England’s antibiotic prescribing rate if all trial participants had received the letter.[6] For context, the NHS England Quality Premium at the time rewarded a 1% reduction in antibiotic items prescribed.[7] This proved to be the first in a series of trials showing it is possible to ‘nudge’ down the number of unnecessary antibiotics prescriptions. Subsequent trials have built on this work to deliver larger effect sizes,[8] [9] including a 2019 trial led by BIT’s New Zealand team that led to a 9.2% reduction in prescriptions.[10]

Nudge-style approaches could also be applied to optimising patient behaviours: encouraging patients to take antibiotics at the right dose and frequency for the right duration. For example, pill packets could be designed to optimise prescription adherence, similar to combined oral contraceptive pill packets, which indicate the day of the week to help keep track of pill-taking.

Building good hygiene habits

Behavioural science can also be applied to promote good hygiene practices, to minimise the spread of infection and reduce the need for antibiotics. Improving hygiene standards in many countries requires structural intervention, such as investment in sanitation and clean water supply. However, even simple hygiene behaviours like handwashing can have a big impact. The evidence for this dates back as far as 1847, when handwashing was seen to reduce maternal deaths from puerperal fever in Vienna.[11] Behavioural science can help promote uptake of simple hygiene behaviours, or optimise how they are performed.

How can we do this?

In a 2020 trial with BRAC, the Department for International Development and Unilever,[12] [13] BIT showed over 2,000 adults in Bangladesh one of four handwashing posters, which would be placed above sinks in new public handwashing stations being installed across Bangladesh (e.g. outside mosques, markets, and bus stands). BIT found that step-by-step guides improved recall of handwashing steps, but too many additional details crowded out the main handwashing messages.

Offering ‘timely’ feedback can also optimise hygiene behaviours. The ‘Together for Infection Prevention’ programme, in which hygiene experts offer intensive care clinicians feedback on hygiene practices at patients’ bedsides, has been made available to hospitals throughout Germany after it was seen to increase hand hygiene compliance from 72% to 85% (and from 57% to 84% in units that previously had difficulties complying with hygiene standards).[14]

Organising the choice architecture (the environment in which behaviours occur) can also have a powerful effect on hygiene behaviours. A large-scale trial conducted in a hospital in Denmark found that varying the placement and salience of a free-standing hand sanitiser dispenser increased hand hygiene compliance among hospital visitors from 0.43% to 19.66%.[15]

Leveraging market forces

One of the challenges to addressing AMR is that it falls victim to ‘temporal discounting’: our tendency to value rewards in the present more than those in the future.[16] This is particularly true in agriculture, where use of antibiotics appears to have only upsides in the present (increased productivity, lower risk), and the costs of resistance will largely materialise years down the line. The EU is leading the way by banning the use of antibiotics in farming for anything other than therapeutic purposes from 2022.[17] In countries where governments are reluctant to introduce an outright ban, increasing the immediate ‘costs’ associated with these drugs, or making the benefits of reduced antibiotic use in farming more immediate, could reduce unnecessary use.

How can we do this?

We can leverage market forces to drive changes in the use of antimicrobials in agricultural settings. For example, food labelling enables consumers to make informed choices about the provenance or content of what they eat, and has been shown to help consumers make healthier food purchases.[18] Introducing front-of-pack labelling indicating the extent of antibiotic use in animal rearing, or incorporating this element into other food product or restaurant labels, could drive a market for meat produced with the minimum antibiotic intervention. In turn, this would encourage farmers to change their production behaviours.

The examples above are just a few ways in which we think behavioural science could help tackle AMR. These interventions show huge promise and should be pursued alongside medical research to find new effective antimicrobials. Get in touch with the Behavioural Insights Team to find out more.


[1] https://cdn.who.int/media/docs/default-source/documents/no-time-to-wait-securing-the-future-from-drug-resistant-infections-en.pdf?sfvrsn=5b424d7_6&download=true
[2] https://amr-review.org/sites/default/files/160518_Final%20paper_with%20cover.pdf
[3] https://www.who.int/news-room/fact-sheets/detail/climate-change-and-health
[4] https://amr-review.org/sites/default/files/160518_Final%20paper_with%20cover.pdf
[5] https://www.bi.team/publications/east-four-simple-ways-to-apply-behavioural-insights/
[6] https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)00215-4/fulltext
[7] https://www.prescqipp.info/umbraco/surface/authorisedmediasurface/index?url=%2fmedia%2f3541%2f2018091112-amr-qp-poster-phe-conference-2018-v2.pdf
[8] https://www.health.gov.au/sites/default/files/documents/2021/05/nudge-vs-superbugs-report.pdf
[9] https://academic.oup.com/jac/article-abstract/74/9/2797/5492366
[10] Chappell, N., Gerard, C., Gyani, A., Hamblin, R., Jansen, R. M., Lawrence, A., … & White, J. (2021). Using a randomised controlled trial to test the effectiveness of social norms feedback to reduce antibiotic prescribing without increasing inequities. The New Zealand medical journal, 134(1544), 13-34.
[11] https://www.nationalgeographic.com/history/article/handwashing-once-controversial-medical-advice
[12] https://www.brac.net/
[15] https://www.journalofhospitalinfection.com/article/S0195-6701(21)00333-9/fulltext
[16] https://journals.sagepub.com/doi/10.1111/j.1467-9280.1994.tb00610.x
[18] https://onlinelibrary.wiley.com/doi/10.1111/obr.12364


Dr Alix Brazier

Alix is a Senior Advisor in the Health team at BIT. She currently leads the team’s work applying behavioural insights to improve healthcare and mental health, and has worked on a range of projects relating to these subjects. Before joining BIT, Alix spent two years working as a junior doctor in the NHS. Alix holds a Bachelor of Arts, a Bachelor of Medicine and a Bachelor of Surgery from the University of Oxford. She is currently working towards her PhD at Imperial College London.

Sarah Merriam

Sarah is a Senior Advisor in the Health team at BIT. She currently leads the team’s work applying behavioural insights to reduce the emergence and transmission of infectious diseases. Prior to joining BIT, Sarah completed a Masters in Epidemiology at the London School of Hygiene and Tropical Medicine.

David Halpern

David Halpern is the Chief Executive of the Behavioural Insights Team. David has led the team since its inception in 2010. Prior to that, David was the first Research Director of the Institute for Government and between 2001 and 2007 was the Chief Analyst at the Prime Minister’s Strategy Unit. David was also appointed as the What Works National Advisor in July 2013. He supports the What Works Network and leads efforts to improve the use of evidence across government. Before entering government, David held tenure at Cambridge and posts at Oxford and Harvard.


Additional Reading


Initial response from BSAC

This blog echoes Esmita Charani’s Vanguard article in addressing the vexed issued of how we change professional and public perception and opinion about AMR and how we can get people to do what we want them to do.

Nudging them in the right direction is one option. One nudge is unlikely to be enough though and repeated pokes will be required until the modified behaviour is normalised. Particularly where established practice has been to do something else. There are numerous analogies in everyday life – the use of seat belts or cycle helmets, for example, or drink driving. In each case, the challenge is to make the right thing to do the accepted norm.

Not only this, but make the right thing the easiest thing to do. For example, by placing hand hygiene facilities in accessible places. Going forward, it will be interesting to see how changes in attitude as a consequence of the COVID pandemic will influence behaviours. Will these be of long term benefit to the AMR agenda? Will positive attitudes to vaccination, or the use of hand sanitisers at the entrance to shops and restaurants persist, for example?


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