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Table 2 Summary of findings of included studies measuring changes behavioral outcomes

From: Public target interventions to reduce the inappropriate use of medicines or medical procedures: a systematic review

First author, year Study design Study population Study sample size Primary outcome(s) Change in intervention group Change in control group Effect size (95% CI) P value Effective in changing public behaviors Quality appraisal
Belongia, 2001 NCT Longitudinal Physicians and public 111 facilities, 664 children Pediatric antibiotic prescribing in child care facilities Baseline: 57.6%; post-intervention: 59.5% of initial visits Baseline: 60.1%; post-intervention 61.5% of initial visits NR Baseline: P = 0.56; post-intervention: P = 0.66 No Weak
Belongia, 2005 CPP Longitudinal Parents and primary care clinicians 4115 primary care physicians Change in annual antimicrobial prescribing rate − 20.4% − 19.8% − 0.6% NR No Moderate
Bernier, 2014 ITS Longitudinal French citizens covered by NHI Not reported Change in antimicrobial prescribing rate NA NA − 30% (− 36.3 to − 23.8%) P < 0.001 Mixed Strong
Cebotarenco, 2008 CPP Cross-sectional Students and parents ~6302 people No antibiotic use for cold and flu Students: a 33.7% net increase in no antibiotic use; Adults: a 38.0% net increase in no use Students − 0.4%; adults +0.1% Students 3.694 (CI 2.516 to 5.423); adults 5.541 (CI 4.559 to 6.733) P < 0.0001 Yes Weak
Finkelstein, 2001 RCT Longitudinal Physicians and parents 8815 children Antibiotics dispensed per person-year of observation among children 3 to < 36 months (− 18.6%), 36 to < 72 (− 15.0%) 3 to < 36 months (− 11.5%), 36 to < 72 (− 9.8%) 3 to < 36 monnths (− 16%), 36 to < 72 (− 12%) 3 to < 36 months (P < 0.001), 36 to < 72 (P < 0.001) Yes Strong
Finkelstein, 2008 RCT Longitudinal Physicians and parents 223,135 person/years Antibiotics dispensed per person-year of observation among children 3 to < 24 months (− 20.7%), 24 to < 48 (− 10.3), 48 to < 72 (− 2.5) 3 to < 24 months (− 21.2), 24 to < 48 (− 14.5), 48 to < 72 (− 9.3) 3 to < 24 months (− 0.5), 24 to < 48 (− 4.2), 48 to < 72 (− 6.7) 3 to < 24 months (P = 0.69), 24 to < 48 (P < 0.01), 48 to < 72 (P < 0.0001) Mixed Strong
Formoso, 2013 NCT Longitudinal Modena and Parma, Emilia-Romagna region 1,150,000 residents Antibiotic prescription rate − 11.9 − 7.4 − 4.3% (− 7.1 to − 1.5%) P = 0.008 Yes Strong
Fuertes, 2010 ITS Longitudinal Population in British Columbia, Canada Not reported Antibiotic utilization rate − 5.8% NA NR NR No Strong
Gonzales, 2004 NCT Longitudinal Medicare enrollees with acute respiratory tract infections (ARIs) 4270 patient visits Decreased antibiotic prescription rates − 5% − 2% NR P = 0.79 No Moderate
Gonzales, 2005 NCT Longitudinal Children with pharyngitis and adults with acute bronchitis Baseline: 10128 patients
Study: 9586 patients
Decreased antibiotic prescription rates Children: − 4%
Adults: − 24%
Children: − 2% at local control; 1% at distant control;
Adults: − 10% at local control; − 6% at distant control
NR Children: P = 0.18, P = 0.48 compared with distant and local control; Adults: P < 0.002 and P = 0.006, for distant and local control Mixed Moderate
Gonzales, 2008 NCT Longitudinal Mothers of young children and primary care physicians 922 households, 1.38+ million antibiotic prescriptions Net change in antibiotic dispensed per 1000 persons − 3.8% in retail pharmacy antibiotic dispenses and − 8.8% in managed care organization (MCO)-associated dispenses P = 0.30 for public, P = 0.03 for MOC members Mixed Strong
Hennessy, 2002 NCT Longitudinal Medical providers and community 10,809 Antibiotic utilization − 31% (P ≤ 0.01) − 10% (P ≥ 0.05) − 21% NR Mixed Moderate
Kliemann, 2016 ITS Longitudinal Residents of Sao Paulo 41,262,199 Antibiotic utilization − 1.616 DID NA NR P = 0.002 Yes Moderate
Lambert, 2007 CPP Longitudinal Communities in North East of England Not reported Per person, per clinic visit Initial: − 31% Expanded: − 35% NA NR P < 0.01 Mixed Weak
Lee, 2017 RCT Cross-sectional Adult patients 914 patients Antibiotic prescriptions 20.6% 17.7% 1.20 (0.83–1.73) P = 0.313 No Weak
Mainous, 2009 QE (controlled post-test) Cross-sectional Latino adults 500 adults Use of non-prescription antibiotics 1.3% 3.2% NR P = 0.90 No Weak
McNulty, 2010 CPP Cross-sectional Adult ≥ 15 Pre= (1999); post (1830) Antibiotic use without professional advice − 0.5% 0% NR NR No Weak
Perz, 2002 CPP Longitudinal Children < 15 464200 person-years Antibiotic prescription rates Year 3:19% Year 1: 8% 11% (8–14%) P < 0.001 Yes Moderate
Sabuncu, 2009 ITS Longitudinal French citizens covered by NHI Not reported Change in winter antibiotic prescribing rate (Oct to Mar) NA NA − 26.5% (− 33.5 to − 19.6%) <  0.0001 Yes Strong
Santa-Ana-Tellez, 2013 ITS Longitudinal Populations in Mexico and Brazil Not reported OTC antibiotics consumption Brazil = − 1.35; Mexico = − 1.17 NA NR Brazil P < 0.01; Mexico P < 0.001 Mixed Strong
Santa-Ana-Tellez, 2015 ITS Longitudinal Populations in Mexico and Brazil Not reported Seasonal variation in total Penicillin use Brazil = 0.077; Mexico = − 0.359 NA Brazil = 0.077 (-1.142 to 1.297); Mexico = -0.359 (-0.613 to -0.105) Brazil P > 0.05; Mexico P < 0.01 Mixed Strong
Taylor, 2005 RCT Cross-sectional Parent/child dyads 499 children Total no. of prescriptions for antibiotics 2.2 ± 2.6 2.5 ± 2.9 NR P = 0.23 No Weak
Trepka, 2001 CPP Cross-sectional Physicians and public 365 children Expected an antibiotic for their child and did not receive one and brought their child to another physician because they did not receive an antibiotic Expected an antibiotic for their child and did not receive one: − 5.1% brought their child to another physician because they did not receive an antibiotic: − 2.9% Expected an antibiotic for their child and did not receive one: 3.2% brought their child to another physician because they did not receive an antibiotic: 1.6% Expected an antibiotic for their child and did not receive one: − 8.4% (− 13.9 to − 2.8); brought their child to another physician because they did not receive an antibiotic: − 4.5% (− 8.0 to – 0.9), they did not receive an antibiotic: 1.6% Expected an antibiotic for their child and did not receive one: P = 0.003 brought their child to another physician because they did not receive an antibiotic: P = 0.02 Yes Weak
Wirtz, 2013 ITS Longitudinal Chile, Colombia, Venezuela, Brazil Not reported OTC antibiotics consumption Colombia: − 2.4DID; Chile: − 3.8 DID; Venezuela: + 5.39DID and Mexico: − 2.4DID NA Colombia: − 1.00; Chile: − 5.56; Venezuela: opposite impact; Mexico: no difference Colombia: P = 0.001; Chile: P < 0.05 Mixed Moderate
Wutzke, 2007 ITS Longitudinal Australian community Not reported Change in use of antibiotics − 3.40% NA 1.3–5.5 < 0.05 Yes Moderate
Beshears, 2013 RCT Cross-sectional union members 5498 adults Conversion rate to lower-cost alternatives Unaffiliated testimonial group 11.3%; Affiliated testimonial group 11.7% 12.20% NR NR (insignificant) No Moderate
O'Malley, 2006 QE
(matched controlled)
Longitudinal Adult patients 9790064 claims Generic dispensing rate Mailing: − 4.94; Advertising: − 0.13; Generic sampling: − 0.02; physician incentive: − 0.33 Doubling co-payment for brand-name drugs: 8.60 NR P > 0.05 No Moderate
Sedjo, 2009 QE Longitudinal Consumer-directed health care enrolees 4026 people Conversion rate to lower-cost alternatives 0.30% 9.30% 29.82 (4.41–201.93) P < 0.05 Yes Moderate
Vallès, 2003 RCT Longitudinal Patients taking medications for chronic disorders 4620 patients Evolution of the percentage of generic prescribing 5.10% (1999–2000) 1.90% (1999–2000) NR P < 0.001 Yes Strong
Hasak 2018 QE Cross-sectional Postoperative patients 258 patients Self-reported proper opioid disposal 28 (22) 14 (11) NR P = 0.02 Yes Weak
Lawrence, 2019 RCT Cross-sectional Parents of postoperative patients 202 caregivers Self-reported proper opioid disposal 66 (71.7) 50 (56.2) 15.5 (1.7 to 29.3) P = 0.03. Yes Moderate
Maughan, 2016 RCT Cross-sectional Postoperative patients 79 patients Self-reported proper opioid disposal 52% (16/31) 30% (8/27) NR P = 0.11. No Weak
Rose, 2016 QE Cross-sectional Postoperative patients 87 patients Self-reported proper opioid disposal 12 (27%) 2 (5%) 22% (5 to 38) P = 0.005 Yes Weak
Spoth, 2008 RCT Longitudinal Late adolescents and young adults 2651 (study 2 on prescription drugs) Self-reported lifetime prescription drug misuse overall 11th graders: 3.9%;
12th graders: 7.7%
11th graders: 7.7%;
12th graders: 10.5%
NR 11th graders: P < 0.01;
12th graders: P < 0.1
Yes Weak
Spoth, 2013 RCT Longitudinal Late adolescents and young adults Study 1: 667 students; Study 2: 2127 students Self-reported lifetime prescription drug misuse overall Study 1- 5.4;
Study 2- 2.5 in age 21, 4.4 in age 22, 6.3 in age 25.
Study 1- 15.5;
Study 2- 6.5 in age 21, 8.9 in age 22, 9.4 in age25.
Study 1: 65%;
Study 2: 62% in age 21, 51% in age 22, 33% in age 25.
Study 1-P < 0.01;
Study 2- age 21, P = 0.015, age 22, P = 0.019, age 25, P = 0.064
Yes Weak
Eden, 2014 RCT Cross-sectional Pregnant women with previous cesarean 131 women MoD (vaginal) 41% 37% NR P = 0.724 No Weak
Fraser, 1997 RCT Cross-sectional Pregnant women with previous cesarean section 1275 women MoD (vaginal) 53% 49% 1.1 (1.0 to 1.2) P > 0.05 No Weak
Hassani, 2016 QE Cross-sectional Primiparous women 60 women MoD (vaginal) 30% 10% NR NR Yes Weak
Montgomery, 2007 RCT Cross-sectional Pregnant women with previous cesarean section 742 women MoD (vaginal) Decision analysis group: 37%; Info: 29% Usual care: 30% Info v. usual care: 0.93 (0.61,1.41)
Decision v. usual care: 1.42 (0.94,2.14)
P > 0.9
P = 0.22
No Strong
Navaee, 2015 RCT Cross-sectional Primiparous women 67 women MoD (vaginal) 62.9% 43.8% NR P = 0.117 No Weak
Sharifirad, 2013 RCT Cross-sectional Pregnant women and partners 88 women and partners MoD (vaginal) 71.5% 50.0% NR P < 0.05 Yes Weak
Shorten, 2005 RCT Cross-sectional Pregnant women with previous cesarean section 227 women MoD (vaginal) VD: 49.2% CS: 50.8% NR NR No Weak
Valiani, 2014 RCT Cross-sectional Pregnant women and partners 180 women and partners MoD (vaginal) Mothers alone intervention = 60%; Couples = 56.7% 26.7% NR P = 0.017 Yes Weak
  1. Notes: CS elective cesarean section, CPP controlled pre- and post-study, NA not applicable, NR not reported, PDMO prescription drug misuse overall, NCT nonrandomized controlled trial, OTC over-the-counter purchases, MoD mode of delivery, RCT randomized controlled trial, VD normal vaginal delivery