Non-prudent use of antibiotics in the European Union – turning research into action using a multidisciplinary approach


Antimicrobial resistance (AMR) is an increasing worldwide public health problem with important implications for the European Union (EU). When antibiotics become ineffective, bacterial infections lead to increased use of healthcare, morbidity, mortality, and costs. Globally, estimates suggest that AMR leads to 700 000 deaths per annum (O’Neil, 2016). For the EU, the European Centre for Disease Prevention and Control (ECDC) has estimated that AMR currently causes 25 000 deaths annually and losses of at least EUR 1.5 billion per annum in extra healthcare costs and productivity (ECDC/EMEA, 2009).  

An important driving force behind AMR is the non-prudent use of antimicrobial agents in both humans and animals. Several reports have been published in recent years (O’Neil, 2016; Paget, 2017; WHO 2015; United Nations, 2019) that outline measures to reduce the consumption of antibiotics and a variety of actions have been proposed, including global awareness campaigns, increasing financial resources for infectious diseases in the healthcare sector, the development of new antibiotics, and policies aimed at the reduction of antibiotic use in both humans and animal. 

Considering the nature of the problem, the European Commission funded the ARNA project (Antimicrobial Resistance and causes of Non-prudent use of Antibiotics in human medicine in the EU) and requested a mixed methods study that was implemented by social scientists. The core ARNA team at Nivel included two sociologists, an epidemiologist with a social science background, and a general practitioner.  

Problem setting in the European Union

Worldwide, the focus of research and policy actions has been on prescribed antibiotics, with much less attention paid to the human use of antibiotics without a prescription. The use of antibiotics without a prescription represents a non-prudent use of antibiotics because of its lack of medical guidance leading to inappropriate use and antibiotic resistance. 

Data from the 2013, 2016, and 2018 Eurobarometer surveys (Eurobarometer, 2018) suggest that the proportion of antibiotics that were used without a prescription increased from 5% of all antibiotics used in 2013 to 7% in 2016. This proportion remained stable at 7% in 2018. However, rates varied across EU Member States. The highest rates were found in Romania (20%, 2016), Greece (16%), and Cyprus (10%), both in 2013 and in 2016. In 2018 Romania was still the country with the highest proportion of self-obtained antibiotics, but the proportion decreased to 15%. Austria and Bulgaria completed the 2018 top 3 (15% and 14% respectively). The proportion of antibiotics without a prescription decreased in Greece and Cyprus. The two prevailing sources of antibiotics without a prescription were over-the-counter (OTC) selling in pharmacies and the use of leftover antibiotics.

The NIVEL ARNA project was established to:

  1. Identify key factors that drive the sales and non-prudent use of antibiotics in human medicine obtained without a prescription 
  2. Assess the level of enforcement of the legislation regarding “prescription-only” use of antimicrobial agents in the EU 
  3. Document good practices aimed at strengthening more prudent use of antibiotics
  4. Develop policy options for more prudent use of antibiotics

The focus of the ARNA study was the following seven EU Member States: Cyprus, Estonia, Greece, Hungary, Italy, Romania, and Spain. These were countries with high levels of use of antibiotics without a prescription at the time the ARNA project was conducted.

ARNA: a social science assessment of non-prudent use of antibiotics

We devised a mixed method approach to assess the non-prudent use of antibiotics in Europe (Paget et al., 2017): 

  1. Knowledge, attitude, and behaviour surveys. These were developed by NIVEL and implemented in all seven Member States to obtain detailed information about the non-prudent use of antibiotics among: 
  • General population, including detailed interviews of patients who used antibiotics without a prescription
  • Healthcare workers: general practitioners (GPs) and pharmacists. 
  1. Online survey of the key stakeholders. This survey was carried out in all EU Member States: 
  • An online survey among Ministries of Health and national experts to describe policy measures that EU Member States have taken on a healthcare-system level to enhance the prudent use of antibiotics. The survey also included information on measures and interventions not described in the literature.
  1. Literature review on the determinants of antibiotic use without a prescription in the ambulatory care setting (Lescure et al., 2018). 
  2. Expert meetings and consensus statements 
  • An expert meeting with a group of 20 experts was organized to review and discuss the interventions that EU Member States could use to reduce the non-prudent use of antibiotics. 
  • An international conference was organized to present and discuss the results. The conference was held on 17 June 2016 and a Conference Statement was published.


  1. Country-dialogue meetings to engage with national stakeholders and prepare action plans. These meetings were held in six EU Member States (Cyprus, Greece, Hungary, Italy, Romania, and Spain). Each Member State had a local organizer and all the relevant stakeholders were represented at the meetings.


The Country-dialogue meetings typically lasted one day and were organized in a dynamic, pro-active manner. There were presentations by the ARNA team, break-out group discussions and presentations by the local stakeholders. 


In countries where there was a National Plan to address AMR (like Spain), non-prudent use of antibiotics was discussed within the context of the plan, whilst in countries with no plan (e.g. Hungary and Italy), participants were asked to start developing a national plan to address the non-prudent use of antibiotics. On most occasions, it was the first time the stakeholders had gathered to discuss the issue of non-prudent use of antibiotics and formulate a multi-disciplinary plan for their country. 



AMR and the non-prudent use of antibiotics are complex issues that can only be addressed via a multidisciplinary approach, including input from social scientists (e.g. to study the healthcare system, to assess behaviours and devise interventions and to assess the legal framework of antibiotic use). The ARNA project addressed the problem of non-prudent use of antibiotics from a social scientist perspective and generally approached the problem from three levels: a) the healthcare system level, b) the healthcare-professional level, and c) the patient level.


Policy recommendations were developed and then discussed in the country-dialogue meetings where all national stakeholders were present, including the Ministries of Health. The country-dialogue meetings were a moment where solutions for the problem were discussed by key stakeholders and a plan was developed for the next steps. Importantly, WHO Euro has adopted the ARNA approach and is now applying it in non-EU countries (e.g. Turkey, Ukraine, and Russia) where the non-prudent use of antibiotics is a much bigger problem than in the EU.


The ARNA project shows that social scientists can play an important role in addressing a medical public health problem. Importantly, we found that to develop a multidisciplinary approach that aims to have a long-term impact, one needs co-ordination at a national and/or regional level, and that this can be achieved via a multisector and multidisciplinary National AMR Plan. 


Ideally, one would like to integrate a “learning cycle” into the process, something similar to the Quality Improvement Collaboratives (QIC). This would require continued funding of the ARNA project and collaboration with the selected countries over multiple years. Progress with the different policies could then be monitored over time, lessons could be learnt and shared, and long-term structural changes related to AMR could probably be achieved.



  • John Paget

Epidemiologist and Senior Scientist at the Netherlands Institute for Health Services Research (Nivel)

  • Liset van Dijk 

Sociologist and Research coordinator at the Netherlands Insitute for Health Services Research (Nivel) and honorary professor Pharmacy Health Services Research at the University of Groningen


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