Abstract

Background: Inappropriate antibiotic use in the community is a primary driver of antimicrobial resistance (AMR), particularly in low-and middle-income countries (LMICs) where primary healthcare (PHC) is the main point of contact. While stewardship efforts in South Africa have focused largely on prescribers and hospitals, the behavioral drivers of community antimicrobial use, specifically the 'demand side', remain poorly understood. This study aimed to address this gap by applying the newly developed Community Antimicrobial Use Scale (CAMUS) to quantify the prevalence of misuse and identify potential independent sociodemographic and behavioral factors associated with inappropriate antibiotic use among PHC patients in South Africa. Methods: A cross-sectional survey was conducted among 1,283 adult patients attending 25 public-sector PHC facilities in two provinces. Data was collected using the validated Community Antimicrobial Use Scale (CAMUS) and the Health Literacy Test for Limited Literacy Populations (HELT-LL). We quantified patterns of knowledge, social norms, expectations, and non-prescribed use. Multivariable logistic This is a provisional file, not the final typeset article regression models examined determinants of misuse and antibiotic demand. Results: General awareness of antibiotics existed, but major misconceptions persisted regarding their role in viral infections. Notably, 76.5% of participants attending PHC facilities believed antibiotics can treat colds and influenza. Non-prescribed use was reported by nearly a quarter of participants, with community pharmacies identified as the primary source (81.7%). While factual knowledge gaps were present, multivariable models revealed that social norms favoring non-prescribed use and inadequate health literacy were the strongest predictors of misuse. Patients with inadequate health literacy were significantly more likely to try and obtain antibiotics without a prescription compared to those with adequate literacy (aOR=13.86; 95% CI: 2.60–73.93). Conclusion: In this large PHC sample, inappropriate antibiotic use appeared to be linked with permissive social norms and health literacy gaps rather than knowledge deficits alone. Interventions that focus solely on correcting factual misconceptions may be insufficient to address inappropriate antibiotic use. Future stewardship strategies must explicitly target social norms, family influences, and pharmacy behavior, alongside strengthening patient-prescriber-pharmacy communication.