Advising the Development of Public Health Guidelines to Delay Antimicrobial Resistance

European Antibiotic Awareness Day campaign poster for National Health Service

NHS campaign ad for European Antibiotic Awareness Day


Antimicrobial resistance (AMR) poses a serious and growing threat to public health as infections from resistant strains of microbials are becoming increasingly more difficult and expensive to treat. Strategies are needed that encourage more responsible antimicrobials use to safeguard human health. This includes awareness campaigns targeting the public to raise the profile of the issue and induce societal and cultural change, and promote more careful use of antimicrobials.

The Department of Health asked the National Institute for Health and Care Excellence (NICE) to develop a public health guideline aimed at delaying antimicrobial resistance. To inform the development of the guidelines, RAND Europe was commissioned to review the evidence of effectiveness, cost effectiveness, and qualitative evidence on changing risk related behaviours pertaining to antimicrobial use.


Our review centred on educational interventions including media campaigns as well as campaigns delivered by health care providers, aimed at the general public, focusing on:

  • the importance of using antimicrobials correctly;
  • the dangers associated with their overuse and misuse;
  • suitable alternatives to antimicrobials;
  • changes in individual understanding in order to ensure they are informed about the type of healthcare they should ask for;
  • changes in behaviour that can avert the problems associated with the misuse of antimicrobials, such as infection prevention measures.

In particular this review sought to answer two research questions:

  1. Which educational interventions are effective and cost-effective in changing people’s behaviour to ensure they only ask for antimicrobials when appropriate and use them correctly?
  2. Which educational interventions are effective and cost-effective in changing the public’s behaviour to prevent infection and reduce the spread of antimicrobial resistance?

The scope of the review is outlined in the NICE public health guideline scope document Antimicrobial resistance – changing risk-related behaviours in the general population.

The results of the review will inform the development of public health guidelines aimed at delaying AMR.


The team undertook a systematic review following guidance presented in Developing NICE guidelines: the manual (PDF) to collect and summarise all relevant published and unpublished evidence on this topic area.


Overall, 60 studies met the inclusion criteria; 29 related to research question 1, and 36 related to research question 2 (five studies were applicable to both). There was significant heterogeneity among studies, in terms of the intervention evaluated; setting; participants/target audience; and reporting of results (for example, questions evaluating hand hygiene behaviour ranged from ‘Do you need to wash your hands after playing in the garden?’ to ‘Do you need to wash your hands after coughing?’; also, some studies presented results for individual questions posed while others compiled an overall score). This heterogeneity, alongside the poor quality rating of the majority of studies, limits the interpretation of the results.

In general, education interventions were more likely to lead to improvements in knowledge of appropriate use of antimicrobials, rather than improvement in knowledge of antimicrobial resistance. Also, interventions delivered in person appear to be more effective, but given there are no head-to-head studies that compare the impact of mode of delivery, it is not known if this is a real difference. There is inconsistent evidence concerning whether education interventions improve knowledge of appropriate hand hygiene or lead to improvements in hand hygiene, but weak evidence to suggest that it results in improvements to food safety practices and behaviour.


Project Team

Josephine Exley
Sarah King
Jirka Taylor
Mafalda Pardal
Kristy Kruithof