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July 2020

A framework, methods and tools to bolster outpatient health literacy regarding antimicrobial stewardship 1


Patient education and awareness are often included in national action plans to foster antimicrobial stewardship (AMS) in the community. However, effective communication strategies are lacking and enhancing the public’s health literacy of AMS is an under-recognised approach to help address antimicrobial resistance. The authors of this paper describe four core elements of enhancing AMS health literacy in the outpatient setting using a Centers for Disease Control and Prevention (CDC) framework.

Key points

Leadership commitment to AMS health literacy

  • Commitment at the highest level to integrate AMS health literacy into system operations is crucial for lasting change.
    • A gap analysis checklist is provided for clinics to assess and monitor their commitment to AMS health literacy.

Interventions/actions to enhance AMS health literacy

  • Surveys show that most patients do not have the necessary understanding of antibiotics for proper AMS; therefore, all patients should be approached with the assumption that they may not understand the information provided and there is a need to confirm and ensure their understanding (as per the Health Literate Care Model).
  • “Teach-back” is a general health literacy technique to ensure information is understood in which the clinician assesses patient recall and comprehension of any explanation given and then clarifies and amends the explanation as necessary.
  • For the development of patient communication materials, the CDC Clear Communication Index can be used to ensure written information is understandable for patients, including those with low health literacy.
  • With “watchful waiting”, when an antibiotic prescription is given with instructions to not immediately administer the antibiotic, effective communication on appropriate antibiotic use and risks versus benefits may help deter unnecessary use.
  • When it is appropriate to consider patient preference, shared decision-making between the clinician and patient after discussing the options, benefits and risks may help to decrease antibiotic prescribing.


  • Data should be gathered to monitor the impact of efforts to improve health literacy and AMS, e.g. with periodic point prevalence studies.


  • A list of resources that are readily available to enhance AMS health literacy is provided, including tools to improve communication and materials to be used directly with patients.


Improved communication between providers and patients is crucial to enhance AMS. The four core elements of enhancing AMS health literacy in the outpatient setting can be easily implemented in clinical practice and numerous resources are available to assist providers in integrating AMS health literacy practices in routine care.


  1. Hermsen ED, MacGeorge EL, Andresen ML, et al. Decreasing the peril of antimicrobial resistance through enhanced health literacy in outpatient settings: An underrecognized approach to advance antimicrobial stewardship. Adv Ther. 2020;37(2):918-932.

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