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

## TL;DR

A pilot study in Pakistan tested if visual stickers on antibiotic packaging could help patients with UTIs take their full course of antibiotics, showing promising feasibility and some improvement in adherence.

## Contribution

This study introduces a low-cost, behaviorally informed packaging-based nudge to improve antibiotic adherence in low-resource settings.

## Key findings

- The recruitment and retention rates were 61.4% and 84.8%, indicating the intervention is feasible to implement.
- The intervention delivery fidelity was 87.5%, showing high consistency in applying the visual stickers.
- Exploratory analysis showed a 14.3% improvement in adherence in the intervention group compared to the control group.

## Abstract

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).

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.

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.

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.

Chinese Clinical Trial Registry (ChiCTR), ChiCTR2500111346. Registered on 30 October 2025. Retrospectively registered.

The online version contains supplementary material available at 10.1186/s12879-025-12246-x.

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 patients in a low-resource setting.

Data on patient flow at each stage were collected to estimate recruitment, retention, and compliance rates.

The intervention was designed to minimize cognitive load, enabling patients with varying literacy levels to participate without additional counseling.

As a pilot study, the sample size was not powered to test clinical effectiveness, limiting conclusions to feasibility outcomes.

Conducted across six tertiary care hospitals, enhancing generalizability within the province, although results may not extend to rural or private-sector settings.

The online version contains supplementary material available at 10.1186/s12879-025-12246-x.