Low-cost and low-barrier antibiotic stewardship strategies are urgently needed to deal with the widespread problem of antibiotic resistance. Social norm feedback could be a promising strategy. In this mixed-methods systematic review (PROSPERO: CRD42022361039), we aimed to identify the key behaviour change techniques used in social norm feedback for antibiotic stewardship and assess their effectiveness in reducing antibiotic prescribing. We searched PubMed, Embase, Web of Science, and Scopus for peer-reviewed studies published between Jan 1, 2000, and Jan 20, 2022. 3547 studies were screened, of which 23 studies reporting the effects of social norm feedback interventions on antibiotic prescribing met the inclusion criteria. 19 behaviour change techniques were tested in the included studies. The meta-analyses showed that social norm feedback is an effective strategy for reducing antibiotic prescribing, with an overall rate difference of 4% (p<0·0001). The behaviour change technique with the highest effective ratio (ER=13) was information about health consequences, followed by instruction on how to perform the behaviour (ER=9) and adding objects to the environment (ER=9). Social norm feedback is a promising strategy to reduce antibiotic prescribing, and can be incorporated into the clinical decision-making support system.
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