# A systematic review of antimicrobial stewardship education for undergraduate students in medicine, nursing, pharmacy, dentistry, veterinary science and midwifery using COM-B framework

## TL;DR

This study reviews how antimicrobial stewardship education is taught to undergraduate students across various healthcare fields and finds that it focuses mostly on knowledge rather than skills or motivation.

## Contribution

The paper introduces a systematic evaluation of AMS education using the COM-B framework, highlighting gaps in behavioral coverage.

## Key findings

- Most AMS education focuses on psychological capability, particularly knowledge and reasoning.
- Fewer studies address physical capability or automatic motivation, often through simulation or practice.
- Curricula should integrate rehearsal, teamwork, and identity development for effective stewardship training.

## Abstract

Antimicrobial resistance (AMR) is a global health challenge driven by inappropriate prescribing. Antimicrobial stewardship (AMS) education during undergraduate training is important to prepare future healthcare professionals for responsible prescribing, yet provision remains inconsistent across disciplines. To systematically review AMS educational interventions for undergraduate medical, pharmacy, nursing, dental, veterinary and midwifery students, and evaluate the behavioural coverage using the COM-B framework.

A protocol was registered on PROSPERO (CRD420250655653). Six databases were searched on 4 February 2025. Eligible studies evaluated AMS educational interventions for undergraduate students. Data were independently extracted in duplicate, methodological quality appraised using Medical Education Research Study Quality Instrument (MERSQI) and findings were synthesized narratively using COM-B.

Of 7771 records screened, 42 studies were included, involving 8567 students across six continents. Most were single-group pre-/post-designs, with two randomized controlled trials. All studies addressed psychological capability, mainly by increasing knowledge and reasoning, while reflective motivation was supported in 25/42. Physical opportunity (20/42) and social opportunity (18/42) were less frequent, typically via structured cases or teamwork. Physical capability (9/42) and automatic motivation (2/42) were least represented, usually through simulation, supervised practice or affective engagement. MERSQI scores indicated moderate methodological quality overall.

Undergraduate AMS education is widespread but uneven in its coverage, with emphasis on knowledge and limited attention to skills, opportunities and motivation. Applying COM-B highlights the need for curricula to combine knowledge with rehearsal, authentic resources, teamwork, identity development and positive engagement to prepare graduates for stewardship practice.