Packaging-based visual-storytelling nudge to improve antibiotic adherence in uncomplicated urinary tract infection - a pilot randomized trial in Pakistan

Sep 29, 2026

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Antibiotic resistance is driven by non-adherence, and low-cost, scalable behavior nudges are needed. A parallel two-arm pilot randomized controlled trial tested feasibility of a visual storytelling sticker affixed to oral antibiotic packaging for patients with uncomplicated urinary tract infections in Pakistan. Conducted across six tertiary-care hospitals (May–July 2025), the study assessed recruitment, retention, and intervention delivery fidelity as primary outcomes, while pill-count adherence served as an exploratory endpoint.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages10

Reading Time25 min

AccessFree to download

Abstract

Background

Methods

Results

Conclusions

Introduction

Antibiotic resistance and non-adherence

Need for low-resource, scalable interventions

Strengths and limitations

Feasibility and workflow-related data collection

Cognitive-load considerations

Generalizability constraints

Hussain et al. BMC Infectious Diseases (2026) 26:9 BMC Infectious Diseases [https://doi.org/10.1186/s12879-025-12246-x](https://doi.org/10.1186/s12879-025-12246-x) RESEARCH Open Access Packaging-based visual-storytelling nudge to improve antibiotic adherence in uncomplicated urinary tract infection: a pilot randomized trial in Pakistan Iltaf Hussain 1,2,3,4†, Sen Xu 1,2,3,4†, Yi Dong 1,2,3,4, Muhammad Fawad Rasool5, Jamshid Ullah6, Amjad Khan7,8, Muhtar Kadirhaz 1,2,3,4, Miaomiao Xu 1,2,3,4, Chengzhou Tang 1,2,3,4, Wei Zhao 1,2,3,4, Faiz Ullah Khan9,10, Jie Chang 1,2,3,4* and Yu Fang 1,2,3,4* Abstract Background Antibiotic resistance (ABR) is a growing public health issue, where non-adherence to antibiotics accelerates the development of resistance. Packaging-based nudge interventions may offer a low-cost and scalable solution. This pilot randomized controlled trial (RCT) assessed the feasibility of a visual storytelling sticker affixed to antibiotic packaging to improve antibiotic adherence in patients with uncomplicated urinary tract infections (UTIs) . Methods A parallel two-arm pilot RCT was conducted across six tertiary-care hospitals between May and July 2025. Physician-confirmed uncomplicated UTI patients, prescribed with oral antibiotics, were randomized in a 1:1 manner to receive either antibiotics with a visual storytelling sticker (intervention) or standard care (control) . Primary outcomes were feasibility metrics, including recruitment, retention, and intervention delivery fidelity. Antibiotic adherence, measured by pill count at the completion of treatment, was assessed as an exploratory outcome. Results Of the 120 patients approached, 114 were screened, and 84 were deemed eligible. Seventy patients consented, of whom 66 were randomized (33 per arm) . The recruitment and retention rates were 61.4% and 84. 8%, respectively, whereas the intervention delivery fidelity was 87 . 5% . Exploratory analysis showed a 14. 3% improvement in adherence in the intervention group (63 . 3%, 95%CI 61.1–65. 5) compared with the control group (49%, 95%CI 46.5–51. 5), though the study was not powered to test effectiveness. Conclusions This pilot trial showed that a packaging-based visual storytelling sticker can be successfully integrated into antibiotic dispensing workflows. Preliminary adherence differences offer estimates to inform sample size and design of a larger, definitive RCT. †Iltaf Hussain and Sen Xu contributed equally to this work. *Correspondence: Jie Chang [jiechang@xjtu.edu.cn](jiechang@xjtu.edu.cn)[ ](jiechang@xjtu.edu.cn)Yu Fang [yufang@xjtu.edu.cn](yufang@xjtu.edu.cn) Full list of author information is available at the end of the article © The Author(s) 2025. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit [http://creativecommons.org/l](http://creativecommons.org/l)icenses/by/4.0/. Trial registration Chinese Clinical Trial Registry (ChiCTR), ChiCTR2500111346 . Registered on 30 October 2025. Retrospectively registered. Strengths and limitations • A pilot randomized trial was conducted to evaluate the feasibility of a packaging-based, behaviorally informed intervention aimed at improving antibiotic adherence among urinary tract infection pat

FAQs

What intervention was evaluated in the pilot trial?

The trial evaluated a visual storytelling sticker affixed to antibiotic packaging to nudge patients toward better adherence while receiving oral antibiotics.

How were participants assigned to study arms?

Physician-confirmed patients with uncomplicated UTI who were prescribed oral antibiotics were randomized 1:1 into either the sticker intervention group or standard care.

What did the study measure as primary and exploratory outcomes?

Primary outcomes were feasibility metrics, including recruitment, retention, and intervention delivery fidelity. Exploratory analysis measured antibiotic adherence using pill count at treatment completion.

Sep 29, 2026

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