Environmental Scan of Parent-Facing Health Information About Antibiotics in US Children’s Hospital Websites

Abstract

Nearly half of free-standing children’s hospital websites contain parent-facing resources about antibiotics. Most resources have information on safe antibiotic use, antibiotic resistance, and questions to ask clinicians. Accessibility can be improved by increasing readability, available languages, and multimedia. Future research should evaluate information accuracy, actionability, and comprehension with target audiences.

Antibiotic resistance is an urgent and growing global public health threat [1]. In 2019, to combat the emergence of antibiotic resistance, the Centers for Medicare and Medicaid Services (CMS) included antibiotic stewardship programs in acute care hospitals as a condition of eligibility for payments [2]. Although antibiotic stewardship programs largely target the prescribing patterns of clinicians, recent national guidelines and toolkits recommend the involvement of patients and families in antibiotic stewardship efforts [3]. Despite these recommendations, little is known about how this information is being delivered to parents, guardians, and/or caregivers of children (hereinafter referred to as “parents”) by children’s hospitals. Children’s hospital websites provide an opportunity for parents to search information about antibiotics. We performed an environmental scan to summarize the content and format of parent-facing resources (ie, informational web pages) regarding antibiotic use and resistance via publicly available websites of free-standing children’s hospitals.

METHODS

An environmental scan (structured search) was conducted across the websites of free-standing children’s hospitals in the United States from February to June 2020. The list of free-standing children’s hospitals was extracted from the Children’s Hospitals Graduate Medical Education program list of free-standing hospitals between the years 2000 and 2017 and the Children’s Hospital Association website, using the filter “not part of a system” [4]. Only free-standing children’s hospitals were included to circumvent the inclusion of websites that have content integrated with a larger health system (ie, resources targeted towards all ages). We only included resources that had wording directed to parents (eg, “your child”).

We followed a standardized protocol (Supplementary Material A) for each hospital website to identify and analyze parent-facing resources that primarily focus on antibiotics. Initial data extraction fields used in the protocol were developed by reviewing existing guideline recommendations from the Agency for Health Research and Quality (AHRQ) and Centers for Disease Control and Prevention (CDC) available regarding antibiotic use and resistance [3, 5]. All data collection fields are summarized in Supplementary Material B.

The data collection tool comprised general information (eg, website characteristics), content, and format. Content comprised the following categories: viral vs bacterial infections: information about antibiotics being used to treat bacterial and not viral infections, use of antibiotics: indications for and consequences related to antibiotic use, optimization of antibiotics: tailoring antibiotic treatments for specific conditions, adherence to antibiotics: best practices when following antibiotic prescriptions, and calls to action: prompts for communication between parents and clinicians about antibiotic use. Format included the medium of delivery, available languages, and simple measure of gobbledygook (SMOG) readability score [6].

Two reviewers independently extracted information from a random sample of 10% of hospitals at the beginning of the search. Inter-rater reliability was assessed using Cohen’s kappa and discrepancies were discussed to consensus with a third reviewer. All results were aggregated using descriptive statistics, and all analyses were completed at the hospital level.

RESULTS

Descriptive Characteristics

Out of 67 screened hospitals, about half (n = 33, 49%) of hospitals had a publicly available parent-facing resource regarding antibiotic use and, therefore, were included. Among included hospitals (N = 33), the number of staffed beds ranged from 106 to 724 (average: 326), and 32 (97%) were acute care hospitals. Excluded hospitals (N = 34) had between 30 to 415 beds (average: 163), 16 (47%) were Magnet-designated hospitals, and 24 (71%) were acute care hospitals.

Among included hospital websites, 28 (85%) had a patient/family-facing health information library, and 32 (97%) had a patient portal available from the homepage. Included hospitals were located across 22 US states (Figure 1). A total of 81 resources were identified and screened, leaving 53 unique resources after removing repeated resources from patient health information vendors such as KidsHealth and StayWell (Cohen’s kappa = 0.94). Hospitals with resources had between 1 and 6 resources available. Descriptive results were aggregated at the hospital level.

Figure 1.

Map of the United States displaying approximate locations of free-standing children’s hospitals with and without parent-facing resources about antibiotics.

Content and Format of Resources From Included Hospital Websites

All hospital websites had at least one resource that distinguished between common pediatric viral and bacterial infections (Table 1). The conditions mentioned most frequently in this context were: common cold/runny nose (n = 32, 97%) and sore throat (n = 27, 82%). All hospital websites mentioned antibiotic resistance as a risk or consequence of antibiotic use. Other risks/consequences mentioned were: allergic response or adverse effects (n = 24, 73%) and side effects (n = 22, 67%). Information on the tailoring of antibiotics was provided by 5 (15%) hospital websites. Most resources included text with headings (n = 32, 97%), except for one podcast. Nearly half of the text resources included: supplementary images (n = 14, 44%) and/or video with audio (n = 13, 41%). SMOG readability scores ranged from 6.5 to 12.9, with an average score of 9.5, which corresponds to grade level. Only 8 resources (24%) provided an option to view in Spanish or English. No other language options were identified.

Table 1.

Frequency of Parent-Facing Resource Content About Antibiotics Identified on Free-Standing Children’s Hospital Websites

Topic	n	%
Content
Mentions viral vs bacterial	33	100.0
Conditions re: viral vs bacterial
Common cold/runny nose	32	97.0
Sore throat (not strep throat)	27	81.8
Strep throat	25	75.8
Ear infection	25	75.8
Bronchitis/chest cold/cough	23	69.7
Influenza	22	66.7
Sinus infection	21	63.6
Urinary tract infection	19	57.6
Pneumonia	12	36.4
Diarrhea/vomiting and/or fever	10	30.3
Respiratory infection (unspecified)	7	21.2
Whooping cough	4	12.1
Consequences/risks of antibiotic use
Antibiotic resistance	33	100.0
Adverse effects (hives, allergies)	24	72.7
Common side effects (eg, nausea)	22	66.7
Risks associated with antibiotic-resistant infection  (eg, Clostridioides difficile infection, death)	16	48.5
Disturb gut flora/kill “good bacteria”	5	15.2
Methicillin-resistant Staphylococcus aureus	3	9.1
Hospitalization	3	9.1
Optimizing antibiotic prescribing
Tailoring antibiotics	5	15.2
Risks of broad spectrum vs narrow spectrum	3	9.1
Format
Text with headings	32	97.0
Supplemental images	14	42.4
Video and audio	13	39.4
Printable handout	2	6.1
Audio only	1	3.0
Links out to external resources
Centers for Disease Control and Prevention	12	36.3
Joint Commission	1	3.0
American Academy of Pediatrics	1	3.0
Languages available other than English
Spanish	8	24.2

Regarding calls to action (Table 2), parents were mostly advised to: use for the full amount and time prescribed (n = 26, 79%) and don’t use someone else’s prescribed antibiotics (n = 22, 67%). All hospitals encouraged parents to communicate with clinicians regarding antibiotic use; most directed parents to ask about the necessity of the antibiotic (n = 23, 70%) and to refrain from pressuring their provider for antibiotics (n = 22, 67%).

Table 2.

Frequency of Parent-Facing Calls to Action About Antibiotics Identified in Resources on Free-Standing Children’s Hospital Websites

Calls to Action	n	%
Mentions adhering to prescription	33	100.0
Topics re: adhering to prescription
Use for full amount and time prescribed	26	78.8
Don’t use someone else’s prescribed antibiotics	22	66.7
Don’t save leftover antibiotics	20	60.6
Don’t stop early, even if child feels better	13	39.4
No skipping doses	3	9.1
Communication with clinicians
Ask about the necessity of antibiotics	23	69.7
Do not pressure clinician for antibiotics	22	66.7
Ask about over-the-counter medications or natural remedies	20	60.6
“Watchful waiting” recommendationa	15	45.5
Ask about purpose of antibiotics	6	18.2
Ask about side effect management of antibiotics	5	15.2
Call clinician at signs of side effects	2	6.1

Watchful waiting or the “wait and watch” method is defined as advice to wait a few days to see if symptoms subside and, if not, to return to the clinician.

DISCUSSION

Parent-facing antibiotic information was publicly available in roughly half of the eligible hospitals. The limited availability of information is understandable given that national initiatives have only recently introduced the role of patient and family engagement in antibiotic stewardship efforts in 2019 [3]. The results of this study emphasize the importance of having information in an accessible and actionable format for parents to engage in antibiotic stewardship efforts.

We found several opportunities for improvement in accessibility from our search. Resources had an average grade level of 9.5, which is higher than the recommended sixth-grade reading level for health information resources [7], and were limited in language availability. Meaningful infographics or visualizations may help to support comprehension of antibiotic stewardship due to their prior success in supplementing comprehension of complex health topics among individuals with limited English proficiency and low health literacy [8, 9].

Our findings show that existing resources have a breadth of information on indications for antibiotics and risks of antibiotic resistance but are lacking information on optimal antibiotic prescribing. Notably, all included hospitals provided information about common conditions for which antibiotic use is frequently inappropriate. This is an important teaching point because studies show that antibiotics are commonly wrongly prescribed for infections that are viral rather than bacterial, and symptoms often overlap among these conditions [3, 10]. Previous studies have found that some parents underestimate the threat of antibiotic resistance by assuming that resistance only affects frequent antibiotic users [11]. We found that hospital websites included descriptions of several consequences of antibiotics and antibiotic resistance, suggesting that hospitals are making active efforts to reframe antibiotics as a potential source of harm. Lastly, existing guidelines recommend teaching families broadly about optimal antibiotic prescribing [3]. We found that only a quarter of hospitals covered the topic of narrow vs broad spectrum antibiotics in our study. The lack of resources about antibiotic prescribing may reflect the prevailing view that selecting an antibiotic for treatment is the sole responsibility of the clinician and medical team.

Limitations

It is possible that we missed other relevant resources due to the restrictions placed on the search strategy and protocol. However, we intended to closely simulate a brief search conducted by a parent who may not be familiar with words related to antibiotic use (eg, “resistance”) or to related conditions. Our environmental scan was limited to evaluating the inclusion of parent-facing antibiotic stewardship information on hospital websites. Future research is needed to evaluate the accuracy of information contained for parents. Not all states in the United States are represented in this search, due to the uneven distribution of free-standing children’s hospitals across the nation. However, the hospitals included in the sample represent every region of the United States (Northeast, Midwest, South, and West). Finally, it is possible that many children’s hospitals have not yet adapted to the rising need for the availability of online health information. Our findings provide a snapshot of the information that was publicly available in the first half of 2020 and the methods used herein can be replicated in the future to determine trends in the availability of parent-facing antibiotic use information over time.

CONCLUSION

Across free-standing children’s hospital websites, parent-facing resources about antibiotics provide useful information regarding optimal antibiotic use, risks associated with antibiotic resistance, and prompts to communicate with clinicians; yet, these resources can be improved in terms of availability (eg, more hospitals providing resources) and accessibility (eg, languages and access for low health literacy). Ultimately, it is a collaborative effort between parents and healthcare professionals to ensure that antibiotics are prescribed and used appropriately, and future research should involve target audiences in the creation, comprehension testing, and implementation of educational resources.

Notes

Acknowledgments

We would like to acknowledge Dr Philip Zachariah for his clinical insight and expertise provided to inform this paper.

Financial support. This work was supported by the National Institute of Nursing Research at the National Institutes of Health (T32NR007969, PI: Bakken) at Columbia University School of Nursing.

Potential conflicts of interest . All authors: No reported conflicts.

All authors have submitted the ICMJE Form for Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.