Antimicrobial resistance (AMR) occurs when ‘bacteria, viruses, fungi and parasites change over time and no longer respond to medicines making infections harder to treat and increasing the risk of disease spread, severe illness and death’ (1). Globally, bacterial AMR was estimated to be associated with 4·95 million deaths in the year 2019 (2). This is predicted to increase to 10 million deaths per year by 2050 with a cumulative cost of 100 trillion USD if no action is taken (3). This global catastrophe demands immediate attention.

Healthcare professionals (HCPs) including doctors, nurses, pharmacists, and other licenced individuals trained to prescribe, dispense, administer, and/or monitor antimicrobials are uniquely positioned to reduce AMR. Although regulations regarding prescribing practises vary for different countries (4). There is a growing emphasis on patient-centred care, which encourages shared decision-making between HCPs and patients (5, 6). Research has identified numerous mechanisms that facilitate HCPs in embracing shared decision-making practises, part of which involves enhancing HCPs skills and confidence in engaging patients in decision-making (7). Interventions have been implemented and evaluated with the aim of empowering HCPs to interact effectively with patients about the appropriate use of antimicrobials in different health conditions (8, 9). These interventions encompass a range of approaches, such as communication skills training, patient information leaflets, multicomponent toolkits and point-of-care C reactive protein (CRP) testing, each showing varying success (8). Despite the availability of such interventions, various challenges, such as time constraints and concerns about potential complications, may hinder HCPs and patients from making the right decisions regarding antimicrobial use (8). Recognising and addressing these barriers is crucial for optimising the use of exiting interventions and improving interactions between HCPs and patients to tackle antimicrobial resistance.

A significant aspect of interventions to tackle AMR focus on improving and maintaining individual antimicrobial prescribing and antimicrobial use behaviour, though the wider use of targeted behaviour change interventions is still emerging (10). Many theories of understanding behaviour and behaviour change have been identified to have potential relevance in designing and evaluating public health interventions (11). One of such is the Capability, Opportunity, Motivation, Behaviour (COM-B) model, the core model of behaviour in the Behaviour Change Wheel (BCW) (12). The COM-B model proposed that behaviour is influenced by the interaction of the three components and changing behaviour will involve changing one or more of the three components: capability, opportunity, and motivation (12). Capability refers to psychological and physical capacity of the individual to exhibit the relevant activity/behaviour (12). Capability can be psychological (knowledge or psychological skills, knowledge or stamina) or physical (physical skills, strength or stamina). Opportunity refers to external factors that that make the behaviour possible or prompt the behaviour (12). Opportunity can be physical (that is, opportunity afforded by the environment) or social (opportunity afforded by interpersonal influences, social cues and cultural norms). Motivation includes all cognitive processes that energise and direct the behaviour, which can be automatic (emotion) or reflective (beliefs, intentions) (12). Various primary studies have used the BCW and COM-B model to develop interventions and to understand factors influencing behaviour relating to AMR and infection control (13–16). This includes, for example, development of antibiotic review toolkit (13), understanding how antimicrobial stewardship education and training are implemented (15), understanding hand hygiene (16) among others. BCW and COM-B model are now often used in evidence synthesis to facilitate the identification of areas of improvement and potential interventions (17, 18), By applying the COM-B model to existing studies that explore the barriers and facilitators of utilising the available interventions that aimed at improving HCPs interaction with patients and of appropriate antimicrobial use, we can develop a thorough understanding of areas of improvement and strategies to achieve them.

This review aimed to identify AMR interventions which focus on improving HCPs’ interactions with patients. It also aimed to use the COM-B framework to group the evidence collated concerning the barriers and facilitators associated with the utilisation of such interventions and appropriate antimicrobial use among both HCPs and patients.

The electronic database search yielded 9,172 citations of which 4,979 remained after removing duplicates. After screening titles and abstracts, we retained 167 studies of which 43 were included (see Appendix 2 for excluded studies). Additional 16 papers were identified from other sources (such as Google search, citation search). In total 59 articles were included in the review and 24 contributed to the synthesis of barriers and facilitators. An overview of the study selection is presented in Figure 1. The characteristics of included studies are presented in Table 1. The studies were conducted across more than 13 countries, with the majority (n = 17 studies) conducted in United Kingdom (25, 28, 32, 37, 40, 41, 43, 44, 48–51, 53, 63, 67, 76, 77), followed by 13 studies from the United States (23, 24, 35, 42, 46, 47, 52, 62, 65, 68, 69, 71, 75), six studies from the Netherlands (33, 34, 38, 39, 70, 78), three studies each from Canada (36, 54, 64) and Germany (72–74), two each from Australia (29, 30), Spain (60, 61), Belgium (55, 56), and China (79, 80), and single study each from France (45), Sweden (66), Russian federation (26), and Latvia (57). Five studies recruited participants from multiple countries (27, 31, 58, 59, 81). Most studies (n = 46) were conducted in primary care settings, seven were in secondary care, two included both secondary and primary care, three in community pharmacies and one in nursing homes. There were a range of study designs, although most were randomised controlled trials (n = 25), followed by quantitative non-randomised (n = 12) and qualitative studies (n = 10). Most of the HCP-patient interaction was by general practitioners/family physicians/doctors except for three, where explicitly the pharmacist played the significant role (25, 28, 77).

A summary of the quality of the studies is presented in Figure 2 and details for individual studies are presented in Appendix 3. We consider most of the studies to be of good quality as 15 studies fulfilled 100% of the relevant quality criteria, 19 studies fulfilled between 80–90% and 13 fulfilled 60%. Although the remaining 12 studies fulfilled less than 50%, this was mostly due to not clearly reporting information related to the criteria concerning intervention effectiveness (Figure 2; Appendix 3).

Various types of interventions were evaluated (Appendix 4). Some were established strategies, such as Treat Antibiotics Responsibly; Guidance, Education (TARGET) (28, 41, 53), antibiotics review kit (ARK) (37), Health Alliance for Prudent Prescribing, Yield and Use of Antimicrobial Drugs in the Treatment of Respiratory Tract Infections (HAPPY AUDIT) (60, 61), Genomics to combat Resistance against Antibiotics in Community-acquired LRTI in Europe Internet TRaining for antibiOtic use (GRACE INTRO) (27, 81) and Converting Habits of Antibiotic Use for Respiratory Tract Infections in German Primary Care (CHANGE-3) (72, 74), while some were bespoke antimicrobial stewardship programmes (23, 26, 30, 34, 35, 38, 42, 46, 47, 49, 52, 58, 59, 62–66, 68, 69, 77–80). C-reactive protein point-of-care testing was often reported (26, 27, 33, 34, 40, 50, 51, 56–59, 70, 76, 81). The majority of the studies (n = 51) reported that interventions include a patient interactive component in the form of posters, leaflet, videos, interactive decision support tools (Table 1; Appendix 4).

In the following section, we describe the barriers and facilitators based on the capability, opportunity, and motivation components of COM-B (see Figure 3 for barriers and Figure 4 for facilitators), starting with the provider level factors and then patient level factors. In Appendix 5, we present further details on the factors, including examples of types of interventions to mitigate the barriers based on the BCW.

This review consolidates existing evidence on the interventions supporting HCPs in their interaction with patients/public, employing a theoretical framework to group the barriers and facilitators of appropriate behaviour. We identified various interventions. Despite the availability of interventions, our findings show factors that impede or enhance the ability of both HCPs and patients to utilise/benefit from the interventions and make informed decisions about antimicrobial use. We grouped these barriers and facilitators into capability, opportunity, and motivation, providing a foundation for future work to tackle AMR.

One of the most frequently reported issues relating to capability is both HCPs and patient’s knowledge/awareness and understanding of AMR, antimicrobials and the impact of AMR, which varied across studies with no clear pattern (23, 28, 29, 36, 43, 53, 77). This suggests the need for strategies to improve knowledge among both HCPs and patients (45, 53, 67). Studies have shown that current AMR campaigns, including World Antimicrobial Awareness Week, do not result in significant public awareness or behaviour change (82, 83). Despite understanding the importance of not prescribing antibiotics unnecessarily, some HCPs reported difficulty persuading patients leading to inappropriate prescribing (28, 73). Several studies indicated that training could enhance clinicians’ ability to avoid inappropriate prescriptions and improve consulting styles (40, 43, 79). There are various resources available to support but lack of awareness of available resources or forgetting about them is reported in several studies (50, 53, 63, 72, 74, 76, 77). This underscores the need for immediate action from healthcare leaders and policymakers to devise strategies addressing these challenges that impact on capability. These strategies should extend beyond education or training initiatives and incorporate measures to ensure the sustained implementation of any positive changes.

In terms of opportunity, time constraints is a frequent issue among HCPs (23, 27–29, 36, 40, 41, 44, 45, 50, 51, 53, 63, 72, 74, 76). As shown in the findings, various resources such as posters, decision aids, and leaflets were available, and patients reported their potential usefulness (30). However, HCPs are often under pressure to manage consultations efficiently and in many contexts, time is often strictly restricted. This may hinder their ability to thoroughly assess the necessity of antimicrobials or to effectively communicate to patients why antimicrobials are unnecessary. Some HCPs are able to effectively use patient information sheets to reinforce discussions and provide self-help advice to patients (25, 27, 29, 30, 41, 43, 67, 77). Care must be taken to avoid inconsistencies between clinician’s treatment plans and messages in the leaflets (43). Improved accessibility of interventions, including providing simple, visually appealing materials is important as these aspects were considered beneficial (40, 44, 51, 63, 76). Having a variety of tools to accommodate different communication styles or patient preferences/needs was considered useful (29, 30). Research highlighted uncertainties regarding who will be responsible to take action and the absence of effective monitoring of antimicrobial stewardship programmes (53, 80). Clarifying the roles of individuals and the role of various organisations, in tackling AMR would be helpful (84). In one study in Australia, it was reported that some childcare centre regulations allow children with certain symptoms return to the setting if they are on antibiotics, this may drive parents to desire antibiotics (29). This is also true in the United Kingdom (85). This exemplifies the need to review policies and factors that may impact on antimicrobial use across various sectors.

Regarding motivation, the perception that patients want antibiotics is a common issue which spans across various contexts (23, 40, 43, 44, 51, 53, 73). For example, in some instances where HCPs and patients have good knowledge of AMR and use available interventions HCPs frequently assume patients expect antibiotics and feel pressure to prescribe antibiotics even when they are not clinically indicated (23, 40, 43, 44, 51, 53, 73). Whereas patients do not always want antibiotics, sometimes they only want reassurance (43). The overestimation of patients’ desire for antibiotics have also been highlighted by others (86). HCPs have also reported fear of patient’s condition deteriorating and fear of litigation as a reason for prescribing antibiotics, even when they would have preferred not to (87). General practitioners viewed delayed prescribing favourably, as it offers a safety net (29, 44). Monetary incentives were suggested, however, opinions varied regarding the necessity for monetary incentives for behaviour change among HCPs (45, 50, 51). Careful considerations must be paid to incentives across different sectors to prevent propagation of inappropriate behaviours. For instance, while the health and governmental domains aim to encourage the responsible use of antibiotics, pharmaceutical companies may have incentives aligned with increased usage (88).

Overall, navigating issues related to appropriate antimicrobial behaviour is a multifaceted challenge. As a result, a multifaceted approach is necessary to tackle all the components of behaviour drivers simultaneously to make meaningful improvement in antimicrobial prescribing behaviour, as with other interventions to change behaviour. Future studies should focus on the development of suitable strategies to improve the identified behaviour drivers among HCPs and the public, while also maximising the utilisation of existing interventions. Policymakers should encourage multidisciplinary collaboration among HCPs, patients, caregivers, and various organisational sectors to address the complexities of antimicrobial stewardship. This collaborative approach can facilitate the development and implementation of effective interventions to tackle AMR. It is worth noting that tackling AMR requires a global effort but there are currently inconsistencies regarding how antimicrobial prescriptions are regulated and enforced globally (4). It is important that health organisations and policy makers globally focus on developing appropriate interventions to improve psychological (individual motivations to act), social (collective support) and structural (capability and opportunity) conditions to achieve a continuous positive change (89).

We used a preregistered protocol and performed comprehensive searches of electronic databases and grey literature to minimise the risk of publication bias. The full-text screening phase of the study selection was performed in duplicate. Data extraction was checked by a second reviewer to ensure accuracy. We also used a theoretical framework to analyse the barriers and facilitators which facilitates the identification of possible intervention types which may be used to mitigate barriers identified. These are specific strengths of this review. However, since we limited to articles published in English Language due to limited time and resources, some potentially relevant studies which are not published in English Language may have been missed. Also, a single reviewer performed title and abstract screening, although 10% were double screened, we acknowledge that some potentially relevent studies may have inadvertently been overlooked. We conducted a quality assessment of the included articles to offer an overview of their overall methodological quality. However, we acknowledge that most of the quality criteria included in the quality assessment tools that we used, particularly for randomised controlled trials, focus on effectiveness which is not the focus of this review. Furthermore, although we are interested in interventions that aim to improve HCPs’ interaction with patients, many of the interventions in included studies had several components and the findings relating to the patient interaction components are not always presented differently. Therefore, most of the issues highlighted may not necessarily pertain to the patient interaction alone. We aimed to provide a comprehensive overview of the barriers and facilitators related to the utilisation of the interventions of interest and appropriate antimicrobial use among HCPs and patients. It is important to consider contextual factors when applying the review findings. Differences in interventions, and study populations prevent us from making exhaustive comparisons across countries. We categorised barriers and facilitators under capability, opportunity, or motivation but we are aware that some of the issues identified may cut across different components. We used COM-B framework to group the barriers and facilitators and highlighted potential intervention types which may be used to target the barriers.

Future work is needed to conduct an in-depth behavioural analysis to understand the behavioural drivers, use evidence-based approaches to prioritise the key issues to be addressed, examine how existing interventions tackle these issues, and identify opportunities for improvement. This may have to focus on individual context, as demonstrated in a previous systematic review (17). Such efforts will serve as a foundation for developing targeted interventions or improving existing ones in collaboration with relevant stakeholders to enhance HCPs and patient interaction to encourage appropriate behaviour.

This review identified a range of interventions that support HCPs to improve their interaction with patients in order to promote appropriate antimicrobial use. The barriers and facilitators identified covered all components of the COM-B model, providing a wide range of avenues for improvement. These findings should be considered when developing, implementing, or improving interventions to support HCPs in interacting with patients to promote appropriate antimicrobial behaviour.

The original contributions presented in the study are included in the article/Supplementary material, further inquiries can be directed to the corresponding author.

AA: Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Validation, Writing – original draft, Writing – review & editing. IG: Data curation, Formal analysis, Funding acquisition, Methodology, Writing – review & editing. JS: Data curation, Writing – review & editing. VA: Data curation, Writing – review & editing. AB: Writing – review & editing. MJ: Writing – review & editing. EG: Methodology, Writing – review & editing. DT: Methodology, Writing – review & editing. DA-O: Methodology, Writing – review & editing.