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Center for Health Literacy Promotion Blog

Misuse of Antibiotics:Does low health literacy explain it?

This is a commentary on  “Parental Health Literacy, Knowledge and Beliefs  Regarding Upper Respiratory Infection (URI) in an Urban Latino Immigrant Population” published June 16, 2012 in the Journal of Urban Health.
Antibiotics have no place in the management of colds since they are viral infections, and antibiotics work only against bacteria. Still, some immigrant parents improperly use antibiotics to treat their children’s colds. A recent study [1] concludes that parents’ injudicious use of antibiotics should be addressed by targeted education to increase their knowledge and compliance.  This study must be interpreted with caution.
Measurement Error
The researchers defined health literacy broadly as a personal asset that enables parents to use information to manage personal and family health and healthcare [2]. But they measured it as a deficit in reading skill, one of many functional, interactive and reflective skills needed to understand and apply health information [2]. They used two  measures (REALM and NVS) that are widely recognized as reading tests and not measures of health literacy [3]. Further, when the two tests produced widely different results, the authors concluded that the tests measure different cognitive deficits, reading and “reasoning ability”. 
The reading test results were used to demonstrate that parents who misuse antibiotics have low health literacy (reading ability) combined with limited English proficiency and a cultural tendency to misuse antibiotics originating in countries-of-origin where they are available OTC.  The authors recommend targeted education to increase parents’ knowledge of antibiotics so they will use them appropriately. 
This recommendation implies that parents’ misuse of antibiotics is due to lack of knowledge related to their limited reading and reasoning ability and limited English proficiency. It further implies that knowledge will translate to more appropriate and health promoting use of antibiotics.
Confirmation Bias
Confirmation bias refers to the human tendency to search for and interpret information in a way that confirms one's preconceptions. In this case, exclusive focus on perceived cognitive deficits in parents precluded consideration of possible systemic problems and solutions and led to a proposed solution that is likely to be infeasible and ineffective. 
The authors did not consider published research on use of antibiotics that might have led to a different conclusion.  One study found that 75% of adults who present with URI expect to get antibiotics [3]. This indicates that the erroneous belief that antibiotics are good for a cold is widespread and not limited to immigrants or poor readers.
Other studies have shown that US physicians prescribe antibiotics to 75% of those who present with URI [ 4];  and further that most of those prescriptions are for non-recommended, broad spectrum, more-expensive antibiotics [5]. 
Does physicians’ injudicious use of antibiotics indicate that they have difficulty understanding established guidelines? Probably not.  If we assume that physicians have knowledge of antibiotics, it follows that knowledge is insufficient to achieve judicious use, even among fully informed native English speakers with strong reading  and reasoning skills. 
If clinicians took the REALM and the NVS, would their scores indicate inability to understand basic health information needed to make appropriate health decisions? Probably not.
Misuse of antibiotics is a complex issue.  It cannot be explained by parents’ or patients’ limited reading or reasoning ability or by immigrants’ limited English proficiency.  Educational programs for parents will not change the pattern.
Health literacy research is fraught with conceptual confusion and measurement issues. Read critically!
1. Dunn-Navarra et al. “Parental Health Literacy, Knowledge and Beliefs Regarding URI upper respiratory infection) in an urban Latino Immigrant Population” Journal of Urban Health 16 June 2012

2.  Nutbeam, D. (2008). The evolving concept of health literacy. Social Science & Medicine 67, 2072-2078.

3.  Berkman, N.D., DeWalt, D.A., Pignone, M.P., Sheridan, S.L., Lohr, K.N., Lux L., et al. (2004). Literacy and health outcomes. Evidence Report/Technology Assessment No. 87 (Prepared by RTI International–University of North Carolina Evidence-based Practice Center under Contract No. 290-02-0016). AHRQ Publication No. 04-E007-2. Rockville, MD: Agency for Healthcare Research and Quality.

4.  Macfarlane J, Holmes W, Gard P, et al: Reducing antibiotic use for acute bronchitis in              primary care: blinded, randomised controlled trial of patient information leaflet. BMJ. 2002, 324: 91-94.

5.  Hirschman JV. Antibiotics for common respiratory tract infections in adults. Arch Intern Med. 2002, 162: 256-264

6.  Steinman MA, Landefeld CS, Gonzales R. Predictors of broad-spectrum antibiotic prescribing for acute respiratory tract infections in adult primary care. JAMA. 2003, 289: 719-725.
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