Patient knowledge, attitudes and behaviors related to antimicrobial use in South African primary health care: Development and testing of the CAMUS and the implications

Nishana Ramdas ^1* Thobani Biyela ¹ Mapula Thema ¹ Mncengeli Sibanda ¹ Tiyani Milta Sono ^1,2 Stephen Campbell ^1,3 Natalie Schellack ⁴ Brian Godman ^1,5,6* Johanna Catharina Meyer ¹

• ¹ Department of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Pretoria, South Africa
• ² Owner, Saselamani Pharmacy, Saselamani, South Africa
• ³ School of Health Sciences, The University of Manchester, Manchester, England, United Kingdom
• ⁴ Department of Pharmacology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
• ⁵ Pharmacoepidemiology, Strathclyde Institute of Pharmacy and Biomedical Sciences, Faculty of Science, University of Strathclyde, Glasgow, United Kingdom
• ⁶ Centre for Neonatal and Paediatric Infection, Institute for Infection and Immunity, St George’s Hospital, London, United Kingdom

Background: Antimicrobial resistance (AMR) poses a global health threat, particularly in low-and middle-income countries (LMICs) including South Africa where limited resources and knowledge gaps exacerbate inappropriate antimicrobial use. To address this, the community antimicrobial use scale (CAMUS) was developed to assess patients' knowledge, attitudes and behaviors regarding antimicrobial use in South African primary healthcare (PHC) settings, with the aim of informing antimicrobial stewardship (AMS) strategies. Methods: Development of the CAMUS was informed by a scoping review and theoretical constructs from the Health Belief Model, Social Cognitive Theory, and Theory of Planned Behavior. A pilot study was subsequently conducted in two South African districts, Tshwane (an urban ) and Greater Letaba (a rural district), with 30 adult participants to provide insights into patients' understanding of the items. Data collection involved administering CAMUS alongside a health literacy test followed by cognitive interviews to refine clarity and ensure understanding. A feasibility assessment was also conducted to evaluate the practical implementation of CAMUS in PHC settings. Results: Participants demonstrated varied knowledge of antimicrobial use. While 60% correctly identified antibiotics as effective for bacterial infections, 93.33% incorrectly believed antibiotics could treat viral illnesses such as colds. Marginal health literacy was prevalent (86.67%). The CAMUS demonstrated feasibility, with an average completion time of 10 minutes. Questions were iteratively revised to improve future clarity and relevance based on the results of the cognitive interviews. Key findings highlighted misconceptions about antibiotics and the influence of social norms and systemic barriers on antimicrobial use behaviors. Conclusion: The CAMUS effectively captures the knowledge, attitudes and behaviors of antimicrobial use in South African PHC settings. Pilot testing demonstrated its feasibility to use it as a tool to assess patient knowledge, attitudes and behaviors related to antimicrobial use in a larger population, to subsequently guide AMS initiatives by addressing knowledge gaps and related barriers to improve future antimicrobial use. Future research will include development of a shorter version of the CAMUS, followed by validation in larger, more diverse populations and in local languages to enhance its usability in combatingwhen investigating antimicrobial use and AMR across LMICs