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RUNNING HEAD: ANTIBIOTIC RESISTANCE

Antibiotic Resistance and Public Health Literacy

Brian Cummings

Portland State University

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Introduction

Health literacy, defined as “understanding, accessing, and appropriately using health related tools

and services”, is a foundational aspect of public health education (Thatcher, 2012). It concerns

questions like “what should I do about my illness?”, “how do I talk to my doctor?”, and “what do

I do with this medicine?” Health literacy depends on multiple subjective filters--society, culture,

religion, political affiliation, and so on—that shape our perceptions, beliefs, and behaviors.

These in turn influence what Norman calls “conceptual models”, the various mental schema we

use to negotiate and navigate the world.

Despite the critical importance of—and recent trends towards (Thatcher, 2012)—more nuanced

approaches to health literacy, significant knowledge gaps remain on the subject of antibiotic

resistance, a growing threat with dire consequences if ignored. These knowledge gaps are

especially prevalent among specific user groups that are underserved or even ignored by public

health educators. The problem—which I will refer to as “health illiteracy”—can be divided into

three component parts: document-centered design, technocratic delivery, and a poor

understanding of users and their needs.

Public health materials take many different forms—textual, visual, auditory, or some

combination thereof. Fact sheets and posters are among the most widely used and well-known of

these. At their best, fact sheets are a synergistic combination of visual and textual elements that

are cheap and easy to produce, able to fit just about any potential user. However, poor design or

rhetorical blunders can frustrate or sabotage what should be a simple and intuitive document.

Posters use striking imagery and stylized text to command attention. They are also larger than

fact sheets, sometimes considerably so, and are less reliant on text to convey information.

Visuals must be chosen carefully, lest the user ignore or misinterpret the poster’s message.
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Technocratic delivery is a one-way approach that situates users as passive receptacles of expert

knowledge rather than dynamic partners engaged in ongoing dialogue. With public health

materials, it usually manifests as overcomplication (assumed competence is too high) or

overabundance (too much information all at once) that leave the user scratching their head in

confusion. This stems from a longstanding belief that more facts equals greater understanding.

This falls into what’s known as the “windowpane theory of communication”, the idea that “if the

words are…polished well, the audience will understand” (Thatcher, 2012).

The reality is quite different. Most people don't care about data—they want stories that are

personal and relevant to them (Ruhrmann, 2015). With fact sheets and posters, those stories must

be told in a relatively short time. Otherwise, users will ignore the message and look elsewhere. A

natural—if not inevitable—consequence of technocratic delivery is an ignorance—or

dismissal—of user needs. False universality—a “one size fits all” approach—is a common

strategy among scientific and technical experts, a way to shoehorn users of diverse backgrounds,

beliefs, and ways of knowing into simple and sortable categories for the sake of efficiency.

Thatcher’s comparison of latinx fotonovelas—a format that “dramatizes health information in

culturally appropriate ways”—against the “analytical, objective, and individual” assumptions of

Anglo designs is a prime illustration of this divergence. The former uses familiar experiences

(i.e. family situations, games, drama) that evoke cultural and perceptual norms of specific users

(recently immigrated latinx). It is what Norman would call a human-centered design. The latter

may be suitable for American or European audiences but is frequently pushed on others for

whom data-focused delivery is neither suitable nor appropriate.

If health illiteracy is to be effectively addressed, users must be treated as full and complete

partners in public health education. Norman’s seminal work, The Design of Everyday Things, is
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the basis of my design analysis. His philosophy of human-centered design puts the emphasis

where it should be—on the “needs, capabilities, and behaviors” of users (Norman, 2013).

Human-centered design is concerned with discoverability and understanding, execution and

evaluation, and the means and mechanisms by which those elements are incorporated into end

products. After all, humans are not mindless executors of logic functions and algorithms—they

are creatures of habit and heuristic who navigate their environment in fluid, imperfect ways.

To hit the mark of human-centered design, five fundamental concepts must be considered.

Affordances, the relationship between person and artifact, are what allow people to use or act

upon things in the first place. With public health documents, that means conveying information

in ways that are relevant, significant, and understandable to the user. A well-written but

incomprehensible document may technically afford reading, but it does not afford the user that

option. Affordances rely on well-placed signifiers, signs and signals that help users figure out

what to interact with and how. Fact sheets, posters, and other public health materials make use of

signifiers by arranging text such that readers will naturally follow it with their eyes.

Constraints are restrictions that simplify choices and reduce cognitive load. Public health

materials deal primarily with logical and semantic constraints, often at the expense of cultural

constraints outside those of the author(s). An effective public health document must have a

readily apparent “path” to follow, one that is meaningful and appropriate to the user. Mappings,

the relations between two sets of things, are part and parcel of public health materials. Fact

sheets and posters attempt to link visuals and text to form unified meanings that are more than

the sum of their parts. Failing to do so is a failure of design—and of communication.

Feedback—the apparent results of an action—is harder to measure in static documents that are
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not necessarily designed for immediate cause and effect. However, it might be said that user

comprehension—health literacy—is a valid example of feedback in this context.

No analysis of design would be complete—or useful—without the addition of a rhetorical lens.

This is especially true for technical communication, which seeks to bridge the gap between

information and user such that their needs are met, and their desired outcomes achieved. A

rhetorical approach begins with a situation—the inciting need or exigence, the intended

audience/user group, and the constraints imposed by the rhetor.

Effective rhetorical communication relies on the five canons of rhetoric as explained by Covino

and Joliffe. Invention is the spark, struck by the flint and tinder of user analysis, that seeks to

determine what to present (Covino and Joliffe, 1995). A public health fact sheet, for example,

must contain salient information on a particular subject. That information must be properly

ordered, or arranged, so as to meet the needs of its audience. Only some facets of the whole—

capturing the audience/user group’s attention, providing context, a central message, and

(sometimes) an appeal to emotion—are applicable to public health materials, but it is still

valuable and necessary to consider. Style is necessarily constrained in the realm of public health

education, but the information presented must be delivered well if it is to be remembered long

enough to be used.

To successfully convey their message—that is, to get users to take specific and focused action to

protect themselves and their loved ones—public health materials must utilize some combination

of pathos, logos, and ethos. Pathos is often ignored or dismissed by public health educators, but

no one will act if the proper emotions (which vary according to the situation at hand) are not

evoked. Logos dominates public health and other scientific/technical materials, as they attempt to

portray their recommendations as logical and reasonable in light of the facts. Neither, however,
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can function without a solid foundation of ethos. Public health communicators must be perceived

as trustworthy and credible for people to listen to them. If not, their messages will go unheeded.

Background

Antibiotic resistance is one of the greatest public health threats facing the world today. Without

the means to combat pathogenic bacteria, we might return to a world where even the smallest

cuts and scrapes could prove fatal. Addressing this problem requires a multi-pronged solution, a

significant part of which is public education and outreach. Most people can define antibiotic

resistance, think of it as a serious problem, and even speculate on possible causes, but their

knowledge of specifics is limited (“Data Note: Public Awareness Around Antibiotic Resistance,”

2019). The fact that antibiotics kill bacteria is well-known, but fewer people know that

antibiotics don’t kill viruses (“Data Note: Public Awareness Around Antibiotic Resistance,”

2019). Indeed, it can be difficult for an untrained layperson to differentiate between bacteria and

viruses, let alone understand how that affects their provider's decisions on what to prescribe for a

given ailment. Some people even connect antibiotic resistance to the recent rise in viral

infections like measles. Small wonder that some 45% of Americans don't take antibiotics as

prescribed (“Data Note: Public Awareness Around Antibiotic Resistance,” 2019).

Diving into specific user groups sheds further light on this problem. Two-thirds of men believe

that viral infections can be cured by antibiotics or do not know enough to say, and over half of

elderly respondents expressed similar views (“Data Note: Public Awareness Around Antibiotic

Resistance,” 2019). Beyond that, ignorance is inversely related to socioeconomic factors such as

education and income (“Data Note: Public Awareness Around Antibiotic Resistance,” 2019).
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My chosen artifacts consist of several public health fact sheets—one from the CDC, a set of

related materials from the Oregon Health Authority, and one from the WHO—on the subject of

antibiotic resistance. These artifacts were drawn from an initial repository of sixteen artifacts in

total. Close analysis will make visible the technical communication problems that contribute to

the overarching issue of health illiteracy.

Example 1: Antibiotic Resistance: 5 Things to Know—CDC

This example uses color

contrast (purple and black

text against a cream white

background) and large font

size to afford the act of

reading. A numbered list—

one through five—signifies

the proper path to follow.

Constraints are both logical

and semantic. Key points are

followed by explanatory text to offset the inherent complexity of the subject matter. Information

is conveyed using plain language and short sentences so that meanings are immediately and

obviously apparent. In addition to its function as affordance, contrasting colors map follow-up

text to its governing point. Feedback takes the form of recommended actions. Point 3, “healthy

habits can protect you from infection and stop germs from spreading”, suggests vaccinating,

handwashing, and other common practices to prevent infection. Point 4 urges users to ask their
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provider if antibiotics are necessary for their condition, while point 5 stresses the need to report

international travel or medical treatment received abroad during a checkup.

These elements could be improved in several ways. Explanatory text, while helpful, is dull gray

in color, which makes it harder for users (particularly those who are visually impaired) to read.

The numbered list employs a two-column format that complicates the expected left-to-right path.

A landscape design would allow for a single-column list that is more intuitive for users to follow.

The prevalence of antibiotic resistance creates an exigence that warrants public health materials

like this one. Audience, in this case, consists of a diverse array of lay publics, including the

underserved groups mentioned at the beginning of this section. Constraints are both genre-related

and organizational. The CDC is likely aware of existing genre conventions but may have

modified them (or created new ones) using their own policies and procedures.

This fact sheet uses contrasting colors and large, bold font to capture the attention of its

audience. Background information is provided just below the main title. The bottommost line

uses statistics written in bold text to inspire a sense of urgency in the user. The central idea—to

give five facts about antibiotic resistance—is plainly stated in the title. The sheet concludes with

a statement of self-efficacy—"Your actions can help combat antibiotic resistance”—and refers

the user to the relevant section of the CDC website (5 things to know). Style is concise and

focused. Each point is written in plain terms that speak to users with differing levels of

education. Memory is invoked by associating main points with supplementary text. The overall

delivery is simple and direct, a useful approach for delivering healthcare information. However,

some cultures may prefer a more narrative and/or visually driven format.
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This document is primarily driven by logos and ethos, with pathos serving as an introductory

device to get the user’s attention. The plain style of delivery combined with the CDC’s strong

organizational ethos is meant to convince and reassure the user. This strategy is favored by

American technical communicators but may not be appropriate or desirable for all possible users.

Example 2: AWARE materials—Oregon Health Authority

The Alliance Working for

Antibiotic Resistance Education

(AWARE) is a nationwide initiative

designed to mitigate the problem of

antibiotic resistance through

education and outreach. To further

this initiative, the Oregon Health

Authority has produced a wide

range of materials on topics of

public health. For this purpose, I

have considered five AWARE fact

sheets—cold, cough infection, sinus

infection, sore throat, and ear

infection—as one representative

sample.

AWARE fact sheets follow a standardized format that is designed to afford reading by the user.

This format is organized as follows: causes, duration, see a healthcare provider for (symptoms),

treatment, and how to feel better (home care). The progression of topics acts as a guide for the
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user to follow. Clearly marked headings act as logical and semantic constraints for user behavior.

It is, however, possible to deviate from the “path” as needed. A worried mother, for example,

might be more interested in the “see a healthcare provider for:” section before—or to the

exclusion of—all else. Relationships between pieces of information are mapped with headings

and body text. Feedback is immediate and relevant. Users are presented with actionable content

that can be quickly—sometimes immediately—verified.

AWARE fact sheets arose from a clear and present exigence—public confusion regarding

appropriate use of antibiotics. These materials are intended for a broad audience that is made up

of many different user groups, each with their own needs and concerns. The Oregon Health

Authority—the rhetor—has imposed an obvious set of constraints upon these materials. All

follow the same format and structure—only the specific information is different.

Oregon AWARE materials use a bright orange bar with large white title text to capture users’

attention. Background information consists of a short “causes of” section in the top left corner,

just below the title bar. This explains the condition itself in basic terms. There is not a central

idea per se, but there is a central purpose—to convey information about a specific medical

condition to patients and their loved ones. Titles such as “Ear Infection Patient Information

Sheet” reflect this. There is little to no direct emotional appeal, but the choice of language—

particularly the “how to feel better” section—evokes a sense of calm reassurance. The “see a

healthcare provider for” section is a conditional call to action. If a patient or their loved one

exhibits any of the listed symptoms, they are encouraged to seek treatment. AWARE materials

employ a concise, clinical style that may not be appropriate or desirable for all users. It is,

however, possible that whatever alternative materials are available are more suitable for users

with different accessibility or culture related needs.

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Headings that can be reused and repurposed, along with bullet point lists for instructional

content, enable users to make associations between connected elements (i.e. headings and body

text). Delivery adheres to what Thatcher terms the “Anglo Dominant” form—that is, an

“analytical, objective, and individual approach” that suits “broad U.S. cultural values” (2012).

Such a delivery, while useful to many, is not a catch-all. Some users— “recent immigrants who

generally bring oral traditions and Mexican rhetorical expectations to rhetorical situations”, for

example—might prefer a mode of delivery that more closely adheres to their cultural norms

(Thatcher, 2012).

Pathos is almost nonexistent within these materials—only the aforementioned calming language

can be said to address this element of persuasion. The Oregon Health Authority is well-known

within its area of operation. Any materials disseminated therein will carry that organizational

ethos. That is, unless users (e.g. recent transplants, first generation immigrants, etc.) are

unfamiliar with the Oregon Health Authority and its role within the state. Even then, a name like

“Oregon Health Authority” conveys the sort of gravitas that is often associated with official

communications. As with the CDC materials, logos reigns supreme. Information is presented as

logical cause-and-effect, meant to instill a sense of individual efficacy in the user. For users from

collectivist cultures, this can be ineffective or even harmful. If alternative materials are simply

translated as is without changing the format, that sends a problematic message to users who don’t

fit into the dominant cultural framework.

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Example 3: Handle Antibiotics with Care—WHO

This example, taken from the

World Health Organization

(WHO), affords user

comprehension by using pictorial

elements and brightly colored text

in tandem. A cyclical chart is used

to convey information—a useful

signifier, but imperfectly executed.

There are no arrows to guide the

user’s eyes in one direction or the

other. Instead, lines terminate in

ambiguous dots that put the burden

of choice entirely on the user. The WHO has a global user base. This subjects them to much

tighter constraints than, say, the Oregon Health Authority must contend with. They must, for

example, account for many different—and often conflicting—sociocultural norms without

diluting or distorting their intended message.

Mapping is accomplished through an ingenious use of color coding—purple bacteria

accompanied by purple text, for instance. The most crucial point— “always follow the advice of

a qualified healthcare professional when taking antibiotics”—is placed squarely in the middle.

Doing so means that, no matter where the user’s eyes go, this recommendation will always be

visible. Feedback is not present here. Rather, this document is designed to explain the problem of

antibiotic resistance in simple, accessible terms.

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The global persistence of health illiteracy—from incomplete or incorrect understanding—is a

pressing exigence that demands a response (WHO, 2013). User groups, by necessity, are

extremely diverse. Some groups, however, are more vulnerable or underserved than most. These

groups are similar to those in the U.S.—low SES, low education, poor health status, and old age,

among others—and require special attention to reach (WHO, 2013). The WHO seems to be

aware of this and has imposed some rhetorical constraints (such as the lack of directional arrows)

on this document.

Bright, color-coded text and simple pictures are effective ways to grab users’ attention. The

largest image—two healthcare providers—is especially hard to miss. The document itself

corrects fundamental misconceptions about antibiotic resistance and provides context when

necessary, making it a valuable source of background information. The central idea, “You can

help reduce antibiotic resistance”, is directly above the central image (WHO, nd-a). It also serves

as a prominent call to action. Emotion is not directly invoked, but the syncretic use of visuals and

text conveys the seriousness of the problem without resorting to scare tactics.

The style of this document is straightforward and concise. Small black text acts as a set up for

larger, colorful text that conveys points of emphasis. This tactic allows the WHO to focus the

attention of their users. Memory is perhaps the most effectively addressed canon in this

document. Visuals are not only paired with text but are color-coordinated as well. This helps

users make the necessary connections and remember key points. The overall delivery is visually

driven and textually supported—a suitable means of dissemination for a multifaceted user base.

Appeals to pathos take two main forms: threat and uncertainty (“one of the biggest threats to

global health”, “antibiotic resistance can affect anyone”) and self-efficacy messages (“You can

help reduce antibiotic resistance) (WHO, nd-a). The WHO is an established organization with a
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global presence, infusing materials like this one with substantial organizational ethos. Asking

users to follow their provider’s instructions when taking antibiotics is a more direct and localized

appeal to ethos. The document relies heavily on logos, but not to an overwhelming degree.

Information exists in bite-sized chunks that are connected (by means of proximity and color-

coding) to pictures. This aids in comprehension and builds retention.

Discussion and implications

Public health educational materials are designed to deliver necessary information in a quick and

efficient manner. However, that can sometimes come at the user’s expense. The use of written

text is one such example. Most fact sheets rely on written text to some degree—it is, perhaps, an

unavoidable constraint of the form—but there is a tendency to treat it as merely a means of

transmittal. It may not always be recognized as such, but written text is a visual element as much

as it is an informative or persuasive one. Typography—color, size, font, etc.—must be

considered when designing public health documents.

Technocratic delivery has significant implications for the design of public health fact sheets.

Arrangement, for example, is not always given the attention it requires. This may stem from a

misconception that logical information is sufficient in and of itself. That is not the case. If the

order and flow of information is not immediately apparent, users will become confused and

frustrated, which may cause them to give up on the document and seek out other (possibly

dubious) sources. Gulfs of execution are generally well-addressed, but the same can’t be said for

gulfs of evaluation. Granted, this does not necessarily apply to documents in the same way that it

does to devices, but it is a valid concern all the same. If there is no way for users to evaluate the

information they receive—either by looking for confirmation from trusted sources or trying it out

themselves—they may come to perceive it as useless or irrelevant.

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Rhetorically, there is much cause for concern. Thatcher’s “Anglo dominant” form pervades all

facets of the rhetorical process. Even when linked to pertinent images, a logical, impersonal tone

is quite common. This might work for broad (dominant) U.S. culture, but it is neither useful nor

desirable for marginalized groups, particularly recent immigrants with limited (or no) English

proficiency. Information overload is another consequence of this approach. Users differ greatly,

but the need for relevant and useful information is a common thread that is not always addressed.

Too much information serves only to undermine the document’s purpose and alienate the user. In

other cases, attempts to reach multiple user groups backfire when some are (intentionally or

accidentally) prioritized over the rest. When, as in the case of Containing Unusual Resistance,

information meant for experts is paired with—and overcrowds—recommendations for lay users,

that sends a troubling message to the latter group. They might wonder if the CDC truly cares

about them and their families.

In some cases, that lack of attention leaves users with little to no actionable information (i.e.

recommendations, steps, etc.) to apply. The ones who suffer most from this sort of dismissal are

underserved and vulnerable user groups like low SES, the elderly, and immunocompromised

patients. A concurrent problem is a general lack of pathos appeals. Some exceptions do exist—

the “how to feel better” section of the AWARE pamphlets, “your actions can help” in Antibiotic

Resistance: 5 Things to Know, and so on—but these are few and far between. What’s more, they

appear to be more unintentional benefits than deliberate rhetorical choices. Logos, and to a lesser

extent ethos, are overwhelmingly favored.

The consequences of inaction are significant. Poor comprehension equates to a lack of

information access. If users cannot access and leverage the information necessary to protect

themselves, they will be at greater risk of negative health outcomes—persistent or recurring

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infections, longer hospital stays, higher medical bills, and possibly even death. Repairs—

between information and user, and between user and expert—are desperately needed.

Solutions

Solutions begin with the user in mind. Otherwise, the technocratic flaws that pervade existing

materials will continue to exist.

One way to approach this problem is by extending the analysis done here to include a broad

selection of public health materials from all over the world. Researchers would take note of

strengths and weaknesses in both design (information and visual) and rhetorical delivery, basing

their analysis on a comprehensive list of pre-defined criteria. This team would include graphic

designers, typographers, public health educators, and technical writers. User feedback must be

solicited and incorporated throughout. Once that step has been completed, the team would devise

and test a set of prototype materials with different user groups. This iterative process of

refinement and revision would result in finely tuned messages for specific user groups and would

inform and improve best practices in public health communication more broadly.

Another potential solution is to crowd source public health education on the subject of antibiotic

resistance. A comprehensive survey—what users currently know, what they don’t know, what

they want to know—would help public health educators and technical communicators gauge the

current state of health literacy among lay publics. This survey would require a holistic approach

that situates users not as isolated units, but as interdependent members of larger community

systems. The research team would use this data to create and disseminate prototype materials as

open source projects. That would allow communities to engage in an ongoing participatory
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dialogue—mediated by savvy technical communicators—with public health educators and

practitioners.

If time and resources are at a premium, a standardized model—or several—could be designed

and released in fairly short order. Iterative feedback would still be involved, but at a later point in

the process. Initial feedback would be replaced by intuition-driven user personas. This is far from

ideal, but it may prove necessary if circumstances warrant.

Recommendations

In the context of public health education, technical communicators must bridge the gap between

information and user with interventions that speak to the unique circumstances of specific

groups. A participatory design process with open source engagement would give users a

meaningful seat at the table. They would be full and complete partners, working with technical

communicators and subject matter experts to create materials that blend science and narrative

into a useful, synergistic whole. Having opportunities to contribute to the design and

development process would not only make users feel valid and included--it would give them the

knowledge and skills to be advocates for health literacy.

Executive Summary

Scope and objective: Analyzed several public health materials on the subject of antibiotic

resistance using a composite framework of design and rhetoric. The goal was to make visible the

problem of health illiteracy on this subject and identify avenues for improvement.

Findings and recommendations: The analysis identified several major areas of deficiency: (1) A

preference for “Anglo dominant” communication that does not appeal to all potential users, (2)

Excessive or irrelevant information, (3) Ignoring the design/typographic element of text, and (4)
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The relative lack of personal protective information. The report offers three potential solutions

and recommends that a participatory design process be adopted.

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Antibiotic Resistance: 5 Things To Know. (n.d.). Retrieved from

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Covino, William, and David Jolliffe. “What Is Rhetoric?” Rhetoric: Concepts, Definitions,

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https://www.oregon.gov/oha/PH/DISEASESCONDITIONS/COMMUNICABLEDISEAS

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