Inappropriate antibiotic use is a social practice, not just a knowledge gap: Uncovering the 'township effect' and systemic drivers of antibiotic use in South Africa
1
Department of Public Health Pharmacy and Management, Sefako Makgatho Health Sciences University, Pretoria, South Africa
2
Department of Pharmacology, University of Pretoria, Pretoria, South Africa
3
Applied Microbial and Health Biotechnology Institute, Cape Peninsula University of Technology, Cape Town, South Africa
4
Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, United Kingdom
5
Antibiotic Policy Group, University of London, London, United Kingdom
6
School of Health Sciences, University of Manchester, Manchester, United Kingdom
7
South African Vaccination and Immunisation Centre, Sefako Makgatho Health Sciences University, Pretoria, South Africa
Popul. Med. 2026;8(Supplement Supplement 1):A231
ABSTRACT
INTRODUCTION:
Antimicrobial resistance (AMR) threatens global public health, yet stewardship in the Global South often relies on a "knowledge deficit" model, assuming education changes behaviour. This ignores complex socio-structural drivers in resource-constrained settings. This study aimed to investigate how social norms and health literacy shape antibiotic use behaviours among patients in primary healthcare (PHC) settings.
METHODS:
A large-scale cross-sectional survey was conducted amongst 1283 patients across 25 public-sector PHC facilities in South Africa. Data was collected on tablets via face-to-face interviews. The locally developed and psychometrically validated Community Antimicrobial Use Scale (CAMUS) was used to measure five behavioural domains of antimicrobial use. Functional health literacy was assessed in a nested sub-sample (n=463) using the Health Literacy Test for Limited Literacy Populations. Multivariable generalized linear models were fitted to identify independent predictors of non-prescribed antibiotic use, adjusting for sociodemographic factors.
RESULTS:
Participants were predominantly female (67.4%) with 39.5% unemployed. Overall, 22.8% of participants reported obtaining antibiotics without a prescription. Geography was a significant driver: non-prescribed use was notably higher in high-density peri-urban settlements (36.3%) compared to rural areas (16.0%; p<0.001). While general antibiotic knowledge scores were high, knowledge alone did not protect against social pressure. In the multivariable model, inadequate health literacy emerged as the strongest independent predictor of inequality, associated with a 13-fold increase in the odds of non-prescribed antibiotic access (aOR=13.86; 95% CI: 2.60–73.93; p=0.002).
CONCLUSIONS:
Findings confirmed a distinct "township effect", suggesting that inappropriate antibiotic use in South Africa is not merely a knowledge gap, but a social practice rooted in rapid urbanisation and health inequity. Traditional "awareness" campaigns failing to address these determinants will remain ineffective. To secure a sustainable future for antimicrobials, public health strategy must pivot from passive education to community-embedded interventions, leveraging community health workers to bridge literacy gaps and reshape household norms.
Antimicrobial resistance (AMR) threatens global public health, yet stewardship in the Global South often relies on a "knowledge deficit" model, assuming education changes behaviour. This ignores complex socio-structural drivers in resource-constrained settings. This study aimed to investigate how social norms and health literacy shape antibiotic use behaviours among patients in primary healthcare (PHC) settings.
METHODS:
A large-scale cross-sectional survey was conducted amongst 1283 patients across 25 public-sector PHC facilities in South Africa. Data was collected on tablets via face-to-face interviews. The locally developed and psychometrically validated Community Antimicrobial Use Scale (CAMUS) was used to measure five behavioural domains of antimicrobial use. Functional health literacy was assessed in a nested sub-sample (n=463) using the Health Literacy Test for Limited Literacy Populations. Multivariable generalized linear models were fitted to identify independent predictors of non-prescribed antibiotic use, adjusting for sociodemographic factors.
RESULTS:
Participants were predominantly female (67.4%) with 39.5% unemployed. Overall, 22.8% of participants reported obtaining antibiotics without a prescription. Geography was a significant driver: non-prescribed use was notably higher in high-density peri-urban settlements (36.3%) compared to rural areas (16.0%; p<0.001). While general antibiotic knowledge scores were high, knowledge alone did not protect against social pressure. In the multivariable model, inadequate health literacy emerged as the strongest independent predictor of inequality, associated with a 13-fold increase in the odds of non-prescribed antibiotic access (aOR=13.86; 95% CI: 2.60–73.93; p=0.002).
CONCLUSIONS:
Findings confirmed a distinct "township effect", suggesting that inappropriate antibiotic use in South Africa is not merely a knowledge gap, but a social practice rooted in rapid urbanisation and health inequity. Traditional "awareness" campaigns failing to address these determinants will remain ineffective. To secure a sustainable future for antimicrobials, public health strategy must pivot from passive education to community-embedded interventions, leveraging community health workers to bridge literacy gaps and reshape household norms.
| eISSN: | 2654-1459 |
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