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

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