Introduction
Health literacy, defined as the ability to obtain, process, and understand health information, is a major determinant of health outcomes.2 High health literacy empowers individuals to follow medical advice correctly, recognize the importance of adhering to prescribed treatments and seek information, all of which contributes to better health outcomes. Health information and systems have become increasingly complex and difficult to understand. Like many other developed countries, Australia’s population faces challenges of low literacy levels.3 Almost 60% of Australian adults have low health literacy with a notable overrepresentation from culturally and linguistically diverse (CALD) backgrounds.3 Similarly, in the United Kingdom 40% of the population struggle with health content that has been developed for consumers, and 60% have difficulty with content involving numbers and statistics. 4 In the United States, the National Assessment of Adult Literacy Survey found that 36% of the adult population had basic or below-basic health literacy.Reference Kutner, Greenberg and Jin5
There is a strong causal link between low health literacy and adverse events.3 In Australia, 250,000 hospital admissions and 400,000 emergency presentations each year are related to medication problems – half of which are preventable.Reference Phillips, Nigro and Macolino6 Reference Lim, Ellett and Semple7 Antibiotics are high-risk medications which can cause significant patient harm when misused. Yet, many consumers tend to overestimate the benefits whilst underestimating their associated risks. In Australia, infections are a leading cause for hospital readmission, causing significant burden to the healthcare system.Reference Lydeamore, Mitchell and Bucknall8 Poor patient understanding of prescribed antibiotic treatment contributes to non-adherence, treatment failure, and readmission. Improving health literacy can support engagement with using antibiotics appropriately and helping to prevent antimicrobial resistance (AMR).Reference Tang, Millar and Moore9
The AMS Clinical Care Standard (CCS) was developed by the Australian Commission on Safety and Quality in Health Care to reduce healthcare variation and outline the expected care for consumers who are prescribed an antibiotic. The AMS CCS recommends that consumers prescribed antibiotics should receive information on their use, when to stop, potential side effects, and a review plan. This is essential to support shared decision-making and enhance adherence to treatment.10
Despite these expectations of care set by the AMS CCS, there are evident gaps and variation in the delivery of antibiotic information to consumers. Healthcare workers may find it a challenge to provide comprehensive information to CALD populations due to language barriers.
The study aims to investigate the health literacy, perspectives, and experiences of CALD patients prescribed antibiotic therapy at a tertiary hospital in Western Sydney, Australia. This research seeks to improve understanding of the drivers and barriers of antibiotic health literacy in CALD patients and identify future strategies or interventions to deliver safe, quality care, particularly around quality use of antibiotics.
Methods
The 21-question survey was adapted from a study in Melbourne, Australia, on patient understanding of antimicrobial treatmentReference Yeoh, George and Rajkhowa11 and informed by the investigator’s experiences. The survey included both multiple-choice and close-ended questions (Appendix 1) on demographics, patient’s understanding of antibiotic information received, and what patient’s wanted to know about their treatment. Prior antibiotic knowledge was not assessed in the questionnaire. It was piloted among a subset of elderly and non-English-speaking patients for validation. After piloting, the survey was translated by the Health Literacy Hub12 into the following languages: Mandarin, Arabic, Filipino, and Hindi. These languages were chosen as they were the most common languages spoken in Western Sydney.Reference Justice13 14 As older adults are more likely to be hospitalized than younger populations, piloting with this group helped ensure that the questions were clear and understandable for the majority of hospitalized patients.1The study was approved by the Western Sydney Local Health District Human Research Ethics Committee (2021/ETH11803).
The survey was conducted over May to November 2023 at a Western Sydney tertiary hospital. The study recruited adult CALD patients (≥18 yr) admitted under the surgical, geriatric, or respiratory specialties who had been on systemic antibiotics for acute infections for at least 72 hours. These specialties were chosen due to the high volume of antibiotic use in these specialties. CALD patients were defined as individuals born overseas and were limited to the ethnic groups: Arabic, Chinese, Indian, and Filipino. Exclusion criteria included patients aged under 18 years, admitted under other specialties and had an intensive care unit (ICU) admission during the same hospital encounter. Patients unable to read or write, had a cognitive impairment or a disability were also excluded. Additionally, patients who were receiving antibiotics for prophylaxis rather than treatment of an acute infection were excluded. Patients meeting the study criteria were identified from a list generated via the Cerner Reporting Portal. The Cerner Reporting Portal is a component of the Cerner electronic health record (EHR) system, which is used in Western Sydney Local Health District.
Patients were screened for eligibility based on their birthplace and inclusion in the specified ethnic groups. Following this process, their medication chart was screened to ensure duration of systemic antibiotics was ≥ 72 hours. Investigators then approached eligible patients to invite them to take part in the study. Surveys were either completed by the patient, carer, or family member, or with the assistance of a translator. Participation in the study was voluntary, and patients provided written consent before completing the survey. A sample size of at least 150 patients was considered sufficient for a descriptive survey-based study and is comparably larger than a similar study conducted in Melbourne, Australia.Reference Yeoh, George and Rajkhowa11
Data were analyzed using Microsoft Excel. Demographic variables and responses were analyzed using descriptive statistics and results presented as percentages and frequencies.
Results
A total of 177 survey responses were collected. The median age of patients was 70 years old (21–99), and 95/177 (53.7%) were male. Languages other than English were spoken at home by 171/177 patients (96.6%), with a further 6/177 (3.4%) reporting partially speaking another language (Table 1). When accessing health services, 45/177 (25.5%) expressed a need for an interpreter. Majority of CALD patients surveyed did not speak English as their primary language. Patient’s country of birth, primary language spoken, and education level are presented in Table 1.
Table 1. Baseline characteristics of patients surveyed
It was reported by 160/177 (90.4%) patients that a doctor, nurse, pharmacist, or allied health professional (hospital staff member) informed them they were taking an antibiotic, and 158/177 (89.3%) knew why they were taking the antibiotic. However, only 27/177 (15.3%) were given written information about the antibiotic, and just 23/177 (13.0%) patients were given information in a language that they understood. There were 67/177 (37.9%) patients who were informed of their treatment duration and 35/177 (19.8%) informed on the side effects. A total of 92/177 (52.0%) patients reported that a hospital staff member explained that their treatment would be reviewed. Additionally, 62/177 (35.0%) knew they had to continue the antibiotic at home, yet only 43/177 (24.3%) had been told how to take it, while 19/177 (10.7%) had not.
A total of 125/177 (70.6%) patients reported that they were informed about their antibiotic treatment by a doctor, 72/177 (40.7%) by a nurse, 3/177 (1.7%) by a pharmacist, and 22/177 (12.4%) by other health care workers. Patients reported wanting the following information:
confirmation that they were taking an antibiotic (78/177; 44.1%), potential side effects (106/177; 59.9%), interactions with other medications (75/177; 42.4%), duration of treatment (96/177; 54.2%), and other antibiotic-related information (16/177; 9.0%). Of the delivery of the information, 47/177 (26.6%) patients reported that they preferred written information, 44/177 (24.9%) preferred verbal, and 86/177 (48.6%) preferred both written and verbal information. When asked whom they would like the information to be delivered by, 79/177 (44.6%) patients preferred a doctor, 16/177 (9.0%) preferred a nurse, 8/177 (4.5%) preferred a pharmacist, and 91/177 (51.4%) preferred any health care professional.
Discussion
There are significant gaps in the provision of antibiotic information to CALD patients. The findings from this study reflect similar research conducted in Melbourne.Reference Yeoh, George and Rajkhowa11 In both studies, while the majority of patients were informed they were receiving antibiotics, only one-fifth were informed of the potential side effects, and just over one-third were informed on the duration of treatment. Only a small proportion of patients received written information in both studies. Communication gaps may occur due to language barrier, limited time available for counseling, and limited understanding of healthcare workers on how to convey culturally appropriate information.
A systematic review on antibiotic use in aged care explored the views of residents, carers, and family members. The review highlights the need for more targeted research to understand consumer attitudes and beliefs about antibiotic use.Reference Gyawali, Gamboa and Rolfe15 The systematic review reported that all but one of the included studies had sample sizes smaller than 50 participants, making our study one of the largest of its kind.Reference Gyawali, Gamboa and Rolfe15
Limitations of this study include challenges with potential recall bias, as the data collected relied on the patient’s memory. Additionally, selection bias and varying levels of literacy amongst those chosen may have affected the reliability of data collected. The study was conducted at a single site which may limit the generalizability of the findings. Furthermore, there were several limitations to the questionnaire, including use of close-ended questions, the absence of general medication literacy questions, count of admissions to hospital, and questions related to transition to outpatient parenteral antimicrobial therapy. These limitations restricted the ability to gain further insights and guide improvement strategies.
The study did not collected information on what language patients that received written information received it in. However, it is likely that the resources were provided in English, as that is the language in which the hospital resources are written.
The findings demonstrate variability in the level of information communicated and understood by CALD patients. It is important to improve communication strategies including standardizing written materials in multiple languages and providing training on culturally appropriate care. Future research should explore the effectiveness of these strategies in improving patient understanding and outcomes.
Engaging patients in shared decision-making is crucial in improving AMS.16 Educating patients about the appropriate use of antibiotics especially the distinction between bacterial and viral infections, is essential in combating misconceptions about antimicrobials.Reference Cals, Boumans and Lardinois17 Effective communication with CALD patients supports informed treatment choices which in turn improves their overall health outcomes. Strengthening health literacy in CALD populations should be a priority for AMS programs.
Table 2. Patient responses to antibiotic information provided at the hospital
Supplementary material
The supplementary material for this article can be found at https://doi.org/10.1017/ash.2025.10108
Acknowledgements
This project was made possible through a grant provided by the Western Sydney Local Health District Research and Education Network. We gratefully acknowledge their support, which enabled the successful completion of this work.
Competing interests
All authors report no conflicts of interest relevant to this article.
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