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Toolbox  –  Raise Awareness

How do people change?

Behavioral change theories are something to consider when doing an intervention and raising awareness on antibiotic resistance.

When working to raise awareness, evidence suggests that incorporating behavioral change theories into interventions can increase their effectiveness. The World Health Organization has identified several benefits in applying behavioral change theories into health initiatives; a behavioral change theory can be seen as a:

  • Compass to help stakeholders identify target audiences and outcomes for evaluation
  • Road map for studying problems and identifying indicators and bottlenecks
  • Foundation for programming planning and development
  • Guide to help understand the processes of changing health behavior and its effect on social and physical environment
  • Toolkit to evaluate health interventions that are based on the understanding why people engage in a certain behavior

The success of interventions depends on a variety of factors that extends beyond the mere provision of information. A key message from behavioral sciences is that passing information from ‘teacher’ to ‘student’ as an approach for sustainable behavior change is insufficient but requires a consideration of broader social, cultural, economic and institutional factors. Moreover, it is crucial that interventions identify barriers to change, which is complex and may vary between different settings, e.g. between providers and consumers. The better an intervention is tailored to a specific target group, the greater is its chance of initiating sustainable behavior change.

Understanding and changing human behavior in relation to antibiotics

Lundborg and Tamhankar draw a helpful analogy to ‘the transtheoretical model’ of behavior change, which is a model that recognizes change as a process that unfolds over time, involving five different stages:

  • Precontemplation
  • Contemplation
  • Preparation
  • Action
  • Maintenance

The authors suggest that persons who are at different stages of behavior change may respond to different intervention programmes. Awareness of the problem of antibiotic resistance is a precondition for initiating lasting behavior change. As a result, formal education programmes are important for changing prescriber and consumer behavior in settings where knowledge about antibiotic resistance remains limited.

Another framework that can be applied for prescribing is the ‘social learning theory’. The theory explains human behavior as a continuous reciprocal interaction between personal, behavioral, and environmental influences. A basic principle is that people make decisions about health-related behavior based on outcome expectancy. This for instance could apply to a prescriber’s expectations about implementing an antibiotic stewardship in the workplace. The theory also emphasizes the importance of self-efficacy, that is, the belief a person has in his/her own ability to complete tasks and attain goals. To create conditions for an open dialogue about perceived barriers linked to the new behavior and to provide support along the process is according to this theory crucial. Further, it asserts that learning occurs in a social context where people adopt new behaviors not only from their own experiences but also by observing and imitating others who are similar to you. A recent study showed that the use of peer comparison as a behavioral intervention (“top performers” were announced through monthly e-mails) among primary care clinicians resulted in lower rates of inappropriate antibiotic prescribing for acute respiratory tract infections.

Influencing conditions in society

Both the transtheorethical model and the social learning theory explain changes in health-related behaviors and lifestyles by influencing individual behavior. Other theories focus on influencing conditions in the society. For example, the ‘Diffusion of innovation theory’ discusses how, why and how quickly change spreads through cultures. It outlines five elements of the process that can influence a person’s attitude to change:

  • Relative advantage – what are the unique benefits of the change?
  • Compatibility – does the change align with existing values and experiences?
  • Complexity – is the new behavior too complicated for adaption?
  • Trialability – is the person able to try out the new behavior before committing to it?
  • Observable – is it possible to see the tangible benefits of the change?

Academic detailing in health care

A model that appears more successful than others is the process of ‘academic detailing’. This concept was introduced in the 1980s to foster improved clinical decision-making (for example antibiotic prescribing) and includes elements of all the above-mentioned theories. The following eight steps are recommended to be incorporated into academic detailing:

  1. Assess baseline knowledge and motivations for current prescribing patterns and barriers to change
  2. Focus interventions on specific groups of prescribers and opinion leaders
  3. Develop clear educational and behavioral objectives (e.g. principles of antibiotic stewardship)
  4. Establish credibility through a respected organizational identity, referencing authoritative and unbiased sources of information and presenting both sides of controversial issues
  5. Stimulate active participation throughout the educational intervention
  6. Use concise educational materials
  7. Emphasize and repeat key messages
  8. If possible, provide reinforcement of improved prescribing practices during follow-up visits

Implementing theory into practice

Once decided what kind of theory should be used to raise awareness in a specific context, it is important to decide how to implement it. The following implementation strategies give examples what needs to be considered when implementing an initiative to raise awareness for antibiotic resistance.

  • Knowledge into Practice. This implementation method is divided into two concepts: knowledge creation and action, with each concept comprised of ideal phases or categories.
  • Quality Implementation Framework: This framework for implementation consists of four phases:
    1. Initial considerations regarding the host setting
    2. Creating structure for implementation
    3. Ongoing structure once implementation begins
    4. Improving future applications

Selected Resources

Resource Description
Antibiotic resistance: using a cultural contexts of health approach to address a global health challenge (PDF 1,1 MB) Policy brief that uses a cultural contexts of health approach to explore the effect of culture in the response to antibiotic resistance. The brief examines how the prescription and use of antibiotics, the transmission of resistance, and the regulation and funding of research are influenced by cultural, social and commercial, as well as biological and technological factors. It aims to show how culture can serve as an enabler of health and provide new options for change.
Behaviour change and antibiotic prescribing in healthcare settings: literature review and behavioral analysis Review of literature on antibiotic prescribing and behavior change in healthcare settings. By Public Health England.
Understanding and changing human behaviour–antibiotic mainstreaming as an approach to facilitate modification of provider and consumer behaviour Journal article that addresses: 1) Situations where human behavior is involved in relation to antibiotics, focusing on providers and consumers; 2) Theories about human behavior and factors influencing behavior in relation to antibiotics; 3) How behavior in relation to antibiotics can change; and, 4) Antibiotic mainstreaming as an approach to facilitate changes in human behavior as regards antibiotics.
Antimicrobials in Society (AMIS) Hub: Essential Reading Information portal. Summaries of, and links to, relevant books and journal articles on the topic of antimicrobial use in society, from a social sciences perspective.
A taxonomy of behaviour change methods: an Intervention Mapping approach Journal article. The supplementary material (provided as PDF at the top of the page) provides tables and figures with an overview of methods for use in behavior change research. Some examples include tables on methods to increase knowledge, change policy, communities and social norms.
Theory at a Glance: A Guide For Health Promotion Practice Guide that describes influential theories of health-related behaviors, process of shaping behavior, and the effects of community and environmental factors on behavior.
2014 Handwashing Behavior Change Think Tank Video (50 min). Webinar summary of discussion around handwashing. Experts were brought together to discuss latest evidence, technology, advocacy, tools to change norms and identify gaps and ways forward.
The 2015 Garrod Lecture: Why is improvement difficult? Journal article on how systems thinking can be used to achieve sustainable improvement in antimicrobial stewardship by using evidence from the social sciences on how to change behavior, improve systems and apply the findings of educational research to learning in practice. Description of successes and failures.
Ledingham, K., Hinchliffe, S., Jackson, M., Thomas, F. & Tomson, G. Antibiotic resistance: using a cultural contexts of health approach to address a global health challenge. Preprint at (2019).
Norwegian Institute of Public Health. Background document WHO member state meeting: “Commitments to Responsible Use of Antimicrobials in Humans”. Preprint at (2014).
Kok, G. et al. A taxonomy of behaviour change methods: an Intervention Mapping approach. Health Psychol Rev 10, 297–312 (2016).
London School of Hygiene & Tropical Medicine. Antimicrobials in Society (AMIS) Hub: Essential Reading.
Davey, P. et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 4, CD003543 (2013).
The Global Public-Private ashing Partnership for Handwashing. 2014 Handwashing Behavior Change Think Tank. (2015).
U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute. Theory at a Glance: A Guide For Health Promotion Practice. (2005).
Baker, R. et al. Tailored interventions to overcome identified barriers to change: effects on professional practice and health care outcomes. Cochrane Database Syst Rev CD005470 (2010)
Armstrong, D., Reyburn, H. & Jones, R. A study of general practitioners’ reasons for changing their prescribing behaviour. BMJ 312, 949–952 (1996).
Edwards, R. et al. Optimisation of infection prevention and control in acute health care by use of behaviour change: a systematic review. Lancet Infect Dis 12, 318–329 (2012).
Meeker D, Linder JA, Fox CR & et al. Effect of behavioral interventions on inappropriate antibiotic prescribing among primary care practices: A randomized clinical trial. JAMA 315, 562–570 (2016).
Davey, P. The 2015 Garrod Lecture: Why is improvement difficult? J. Antimicrob. Chemother. 70, 2931–2944 (2015).
Meyers, D. C., Durlak, J. A. & Wandersman, A. The Quality Implementation Framework: A Synthesis of Critical Steps in the Implementation Process. American Journal of Community Psychology 50, 462–480 (2012).
Prochaska, J. O., DiClemente, C. C. & Norcross, J. C. In search of how people change. Applications to addictive behaviors. Am Psychol 47, 1102–1114 (1992).
Mitic, W., Ben Abdelaziz, F. & Madi, H. Health education: theoretical concepts, effective strategies and core competencies. (World Health Organization, Regional Office for the Eastern Mediterranean, 2012).
Graham, I. D. et al. Lost in knowledge translation: time for a map? J Contin Educ Health Prof 26, 13–24 (2006).
Charani, E. et al. Behavior Change Strategies to Influence Antimicrobial Prescribing in Acute Care: A Systematic Review. Clinical Infectious Diseases 53, 651–662 (2011).
Public Health England. Behaviour change and antibiotic prescribing in healthcare settings: literature review and behavioural analysis. (2015).
Stålsby Lundborg, C. & Tamhankar, A. J. Understanding and changing human behaviour--antibiotic mainstreaming as an approach to facilitate modification of provider and consumer behaviour. Ups. J. Med. Sci. 119, 125–133 (2014).
Bandura, A. Social learning theory. (Prentice-Hall, 1977).
Soumerai, S. B. & Avorn, J. Principles of educational outreach ('academic detailing’) to improve clinical decision making. JAMA 263, 549–556 (1990).
Rogers, E. M. Diffusion of innovations. (Free Press, 1995).