Public perceptions on antibiotic use and resistance: a social media–based multicountry survey during WAAW 2022

Highlights

• •Higher education and science background were linked to better antibiotic knowledge.
• •Only 38% knew that antibiotics treat bacteria.
• •Many expected antibiotics for colds and would question doctors if not prescribed.
• •Awareness of harms reduced antibiotic-seeking behavior.
• •Culturally tailored education and digital outreach are urgently needed.

Abstract

Objectives

This study aimed to assess the global public’s knowledge, attitudes, and practices concerning antibiotic use and antimicrobial resistance (AMR) during World Antimicrobial Awareness Week 2022 because public engagement is crucial in promoting responsible antibiotic use.

Methods

A validated trilingual questionnaire (Cronbach α 0.78) created in Google Forms was disseminated via the social media platforms of the Diagnostic and Antimicrobial Stewardship to Protect Antibiotics study group, yielding 766 responses from 30 countries. The survey explored the respondents’ sociodemographic data, antibiotic knowledge, AMR awareness, and behavioral intentions in common clinical scenarios. Statistical analysis evaluated knowledge, attitudes, and practices scores by education level, academic background, and geographic region.

Results

Respondents were predominantly from Asia and Africa. Higher education levels overall and a science background in particular were strongly associated with higher knowledge and more positive attitudes (P < 0.001). However, only 38% knew that antibiotics treat bacterial infections. Over half expected antibiotics for cold or flu symptoms; 31% would question why doctors were not prescribing them, and 18.5% would seek a second opinion. Awareness of the impact of antibiotics on the gut microbiome and fetal health was linked to reduced antibiotic-seeking behavior.

Conclusion

The findings primarily reflect engagement from the Middle East and the Indian subcontinent. The critical gaps in the public’s understanding of appropriate antibiotic use support the need for school- and university-based AMR curricula, greater community engagement, and strategic use of digital platforms to foster responsible antibiotic practices.

Introduction

Antimicrobial resistance (AMR) is a global health crisis that threatens the effectiveness of modern medicine by undermining the treatment of infectious diseases [1]. The World Health Organization (WHO) advocates antimicrobial stewardship, which promotes the appropriate use of antimicrobials, maximizing the therapeutic benefit while minimizing drug-related toxicity and the development of resistance [2]. However, it is increasingly recognized that stewardship interventions targeting health care professionals alone are insufficient. AMR is fundamentally a social and behavioral problem, shaped by public knowledge, cultural beliefs, expectations from health care providers, economic pressures, and access to medicines [3,4]. Addressing AMR, therefore, requires not only clinical interventions but also sustained public engagement and behavior change.

Over the past two decades, numerous studies have examined public knowledge, attitudes, and practices (KAPs) related to antibiotic use and resistance across different countries. Systematic reviews have consistently demonstrated widespread misconceptions, including the belief that antibiotics are effective against viral infections, a poor understanding of resistance mechanisms, and strong expectations for antibiotic prescriptions for self-limiting illnesses [5,6]. The WHO’s multicountry public awareness survey (2015), which included respondents from 12 countries across all WHO regions, highlighted major gaps in public understanding about antibiotic use worldwide [7]. Similar findings have been reported from Europe, Asia, Africa, and North America, indicating that inappropriate antibiotic expectations and self-medication behaviors are widespread across high- and low- and middle-income settings [[8], [9], [10], [11]].

Most published KAP surveys have been conducted within single countries or limited regions, often using traditional recruitment approaches, such as household surveys, clinic-based sampling, or telephone interviews [11,12]. Relatively few studies have explored the potential of global health campaigns—such as World Antimicrobial Awareness Week (WAAW)—as an opportunity to simultaneously measure public perceptions while leveraging heightened public attention on AMR. WAAW is a global campaign led by the WHO and its partner organizations to improve awareness and understanding of AMR and encourage best practices among the public, health care professionals, and policymakers. Harnessing this period of increased visibility would provide a unique opportunity to capture public perceptions while contributing to awareness-raising efforts.

Social media has increasingly been recognized as a powerful tool for public health communication and engagement, offering the potential to reach diverse populations rapidly and across geographic boundaries [7]. However, its application as a recruitment strategy for multicountry AMR KAP research remains underexplored. In this context, the Diagnostic and Antimicrobial stewardship (DASH) to Protect Antibiotics group (https://dashuti.com/) conducted a multicountry cross-sectional KAP survey during WAAW 2022, using a trilingual questionnaire disseminated through multiple social media platforms. The analysis of this information will enable targeted educational interventions and inform future efforts to engage citizens as valuable stakeholders in reducing AMR.

Methods

A comprehensive questionnaire was prepared to assess KAPs about antibiotic use and AMR among the general population during WAAW 2022, in consultation with the principal investigators (PIs) of participating DASH centers. Ethical approval was obtained from the Medical Research Ethics Committee, College of Medicine & Health Sciences, Sultan Qaboos University (ref. No. SQU-EC/377/2021), as well as from the collaborating centers. Participants were recruited worldwide using a convenience sampling approach through social media platforms during WAAW 2022 (November 18-24). The survey link (Google Forms, Google LLC, Mountain View, CA, USA) was disseminated by members of the multicentric DASH group through their professional social media accounts (LinkedIn, Facebook, Instagram, and X [formerly known as Twitter]) and WhatsApp networks, including community groups (family and nonmedical groups), institutional, academic, and health care–related groups. Participation was voluntary and anonymous.

Eligibility criteria included (i) the ability to read one of the survey languages (English, Arabic, or Hindi) and (ii) consent to participate.

The questionnaire encompassed multifaceted issues related to AMR and the appropriate use of antibiotics. The questions were mostly developed by the PI, whereas some were adapted from preexisting instruments [1,[13], [14], [15], [16], [17]]. The questionnaire was crafted in a deliberately layered format to understand the respondents’ depth of understanding. For example, although one of the initial questions ascertained their familiarity with the term “antibiotic,” another inquired about situations when antibiotics should be used, followed by a qualifying question that specifically inquired about their target (bacterial, viral, fungal, or parasitic infections). The knowledge items assessed awareness and understanding of antibiotics, AMR, and the consequences of misuse (e.g. spectrum of activity, resistance, gut microbiome, and pregnancy-related effects). Attitude items reflected the respondents’ beliefs and evaluative positions regarding antibiotic use (e.g. expectations for antibiotics, acceptance of symptomatic treatment, views on over-the-counter access, and perceived superiority of newer or more expensive antibiotics). To ensure content relevance and clarity, the draft questionnaire underwent expert review by the co-PIs of the DASH group who assessed the items for relevance, comprehensiveness, and appropriateness.

The questionnaire was subsequently piloted among 30 healthy citizens donating blood at the Sultan Qaboos University blood bank to assess clarity, comprehension, and usability. The raw data sheets were encrypted with VeraCrypt (IDRIX, Paris, France), using the Advanced Encryption Standard with a 256-bit key length (Advanced Encryption Standard-256). The Cronbach’s α was 0.78, which confirmed high internal consistency of the questionnaire.

The questionnaire consisted of four parts: sociodemographic characteristics, academic background, knowledge of antibiotics and their use, and awareness of AMR. To assess the attitudes and practices toward antibiotic use, participants were presented with a vignette describing a scenario in which they or their child developed mild symptoms of a cold and the flu, including low-grade fever, sore throat, and runny nose. They were asked how they would respond to eight potential actions using a five-point Likert scale. The classification of questionnaire items into KAP domains was based on conceptual relevance rather than strict psychometric separation.

Responses were reviewed for obvious duplication and analyzed in relation to greater or lesser alignment with evidence-based principles of appropriate antibiotic use. For items influenced by contextual factors (e.g. health care access or regulatory environments), the scoring was interpreted as indicative rather than absolute. The KAP scores were used primarily for comparative analyses across demographic and regional groups rather than as definitive measures of “correct” or “incorrect” behavior. Links to two instructional videos were shared at the end of the questionnaire to spread awareness about AMR among all respondents.

Statistical analysis

The score for KAP was calculated by assigning 1 for correct answers and 0 for incorrect answers to each question. Then, the scores for each domain were summed across related questions. To improve interpretability, scores were transformed to a scale from 0 to 100. The scores for KAP were described using the mean ± SD. The Kolmogorov–Smirnov normality test was performed on the scores for the three domains across different groups. The Mann–Whitney U and Kruskal–Wallis tests were used to compare the scores in the groups based on education level, educational major, and region. Three-way multivariate analysis of variance was implemented to evaluate the effect of the level of education, field of education, and region on the KAPs. A P-value less than 0.05 was considered statistically significant for all tests. All statistical analyses were conducted using SPSS version 29 (IBM Corp., Armonk, NY).

Results

The outreach of the social media platforms was remarkable because 766 nonduplicate responses were received from 30 countries: six from the Indian subcontinent (India, Pakistan, Bangladesh, Nepal, Maldives, and Myanmar), eight from the Middle East and North Africa (MENA) comprising of Afghanistan, Oman, Iran, Iraq, UAE, Qatar, Egypt, and Bahrain, seven from Africa (Kenya, Sudan, Tanzania, South Africa, Zimbabwe, Cameroon, and Botswana), five from Eurasia (Armenia, Russia, United Kingdom, Norway, and Moldova), and four from North America and the Caribbean (United States, The Bahamas, and Trinidad and Tobago) and the Pacific (Philippines).

Respondents were predominantly from the Indian subcontinent (393), followed by the Middle East (304). Maximum engagement was from Indians (43.9%), Omanis (38.5%), and Pakistanis (7.4%). Most responses were in English (85%), followed by Arabic (14.7%); the remaining were in Hindi. The geographic distribution of respondents reflects, in part, the location of the investigators and the networks through which the survey was disseminated. A large proportion of the DASH collaborators are based in South Asia, the Middle East, and North Africa, and the survey link was primarily shared within these regions.

As Table 1 shows, the population surveyed was heterogeneous, with educational levels ranging from high school diploma to Doctors' of Philosophy (Ph.D.); 36% held Bachelor’s and 33% Master’s degrees. Among them, 149 had majored in humanities and 369 in the sciences. Knowledge scores increased progressively with educational attainment (P < 0.001), with approximately a 17-24 point difference between school-level and doctoral respondents on a 0-100 scale. As the educational level increased, a significant increase in the knowledge domain was observed (P < 0.001); the doctorates demonstrated the highest mean knowledge score (70.37 ± 19.85). Respondents with science backgrounds (medicine, nursing, pharmacy, dentistry, allied health sciences, biological sciences, chemistry, physics, engineering, and other natural or applied sciences) demonstrated substantially higher knowledge scores than those from humanities (arts, social sciences, business, law, education, and related nonscience disciplines) (63.89 vs 50.34; P < 0.001), alongside significant differences in attitude (P = 0.003) and practice (P = 0.05), as seen in Figure 1B-D. However, overall, the differences in attitude and practice scores were insignificant. The KAP score differed significantly across various regions, as shown in Figure 1A. The African respondents demonstrated the highest mean knowledge score (86.84 ± 12.31), attitude (61.40 ± 25.49), and practice scores (54.73 ± 16.11) among the various regions. The Eurasians’ mean knowledge score was 74.31 ± 17.80, whereas MENA had the lowest mean score (54.53 ± 22.47). It was interesting to note that on evaluating the effect of the levels of education, fields of education, and the regions on all three KAP domains by multivariate analysis of variance, it was revealed that the differences were statistically significant (Supplementary Table S1). Although significant regional differences were observed, these findings should be interpreted cautiously because some regional subgroups, particularly Africa, Eurasia, and the United States and the Caribbean, had relatively small sample sizes and may not be representative of the broader populations.

Table 1.

Comparison of knowledge, attitude, and practice among different educational backgrounds and regions.

Demographic profile		N	Knowledge	Attitude	Practice
Total		750	59.18 ± 22.47	42.20 ± 22.61	41.95 ± 21.87
Educational Level	School	22	52.84 ± 25.28	31.82 ± 22.37	31.82 ± 25.19
	Diploma	55	46.59 ± 18.97	43.03 ± 20.21	43.63 ± 21.80
	Bachelor	273	56.09 ± 21.79	41.33 ± 21.77	41.76 ± 21.76
	Master	245	64.34 ± 22.51	43.47 ± 23.72	43.02 ± 21.09
	Higher Diploma	94	55.72 ± 20.81	40.78 ± 22.08	44.26 ± 24.34
	PhD	58	70.37 ± 19.85	46.55 ± 23.31	36.89 ± 19.39
	P-valuea		<0.001	0.14	0.07
Educational major	Sciences	369	63.89 ± 22.39	44.31 ± 22.84	43.63 ± 21.23
	Humanity	149	50.34 ± 19.72	37.47 ± 21.74	39.19 ± 21.67
	P-valueb		<0.001	0.003	0.05
Region	Indian subcontinent	389	60.52 ± 21.45	42.93 ± 23.85	39.13 ± 21.21
	MENA	313	54.53 ± 22.47	39.62 ± 19.69	44.47 ± 22.26
	Africa	19	86.84 ± 12.31	61.40 ± 25.49	54.73 ± 16.11
	Eurasia	9	74.31 ± 17.80	50.0 ± 27.64	44.45 ± 24.04
	United States and the Caribbean	12	64.06 ± 23.56	48.61 ± 27.94	45.0 ± 22.76
	P-valuea		<0.001	0.002	0.001

MENA, Middle East and North Africa.

^aKruskal–Wallis test.

^bMann–Whitney test.

Figure 1.

Marginal mean scores of knowledge (A), attitudes (B), and practices (C) across regions and fields of education (D).

Awareness, knowledge, and beliefs about antibiotics and AMR

A large majority, 747 (97.5%), reported that they were familiar with the word antibiotic. However, when the discriminating questions regarding the use of antibiotics were asked, 289 (38%) reported that they were used for treating infections, among whom only 242 (31.6%) correctly identified that antibiotics act against bacteria alone, whereas 33% (251) and 29% (224) believed that they also targeted fungi and viruses, respectively.

A majority, 612 (79.9%), were familiar with the term AMR (P < 0.001); 37% had learned about it in college and 23% from social media. A higher educational level was significantly associated with greater awareness of AMR (P < 0.001).

Appropriate use of antibiotics

In response to the open-ended question, “When should antibiotics be used?”, a lack of clarity was observed, with 35.12% of the respondents mentioning the larger umbrella term “infection,” whereas 25.98% gave ambiguous entries and 10.97% of participants provided no response. Symptoms such as fever, headache, body pain, illness, injury, allergy, or surgery were mentioned by 17.36%. As seen in Table 2, 10.57% mentioned specific clinical diagnoses/conditions, such as tonsillitis, pneumonia, diarrhea, and urinary tract infections, among others.

Table 2.

Responses to the question “When should antibiotics be used?”

Response	No. (%)
Infection	269 (35.12%)
Ambiguous responses	199 (25.98%)
General or nonlocalized, nonspecific, symptom-based responses: fever, headache, body pain, illness, inflammation, injury, allergy, or surgery	133 (17.36%)
Specific clinical diagnoses/condition based responses: tonsillitis, pneumonia, diarrhea, urinary tract infection (UTI), osteomyelitis, meningitis, otitis media, sepsis, or dental infection	81 (10.57%)
No response/blank	84 (10.97%)

Health care–seeking behavior and expectations regarding antibiotic utilization

The majority, 502 (65.5%), placed trust in the allopathic system, whereas the remainder preferred traditional systems of medicine. When asked whether they would expect antibiotics from their doctor when they or their child had a cold or the flu (low-grade fever, sore throat, and runny nose), 53.3% responded in the affirmative (36.6% expected antibiotics and 16.7% would demand them). Antibiotic-seeking behavior was observed in 41.1% who indicated they would question the doctor if antibiotics were not prescribed (16.9% definitely and 26.2% probably), although only 18.5% stated they would seek a second opinion and 52.9% said they would not (Table 3). In the next query, when asked if they would question the doctor’s decision to prescribe antibiotics, 72.8% replied in the affirmative. Willingness to take symptomatic treatment, monitor symptoms, and consider alternative treatments, if necessary, was demonstrated by 82.1%. Those with lower education were more likely to expect a prescription for antibiotics than those with higher levels of education (P = 0.003) and more likely to demand it (P = 0.009).

Table 3.

The health care–seeking behavior and expectations around antibiotic use.

Question: If you or your child develop a cold and catch the flu with mild symptoms, including low-grade fever, sore throat, and runny nose, would you:	I definitely will N (%)	I probably will	I probably will not	I definitely will not
Go to a traditional healer?	67 (8.76)	196 (25.62)	193 (25.23)	309 (40.39)
Go to a doctor?	325 (42.43)	236 (30.81)	134 (17.49)	71 (9.27)
Expect the doctor to prescribe antibiotics for you?	157 (20.50)	278 (36.29)	216 (28.20)	115 (15.01)
Demand the doctor to prescribe antibiotics for you?	50 (6.53)	113 (14.75)	197 (25.72)	406 (53.00)
Ask the doctor why he/she refuses to prescribe antibiotics for you?	130 (16.97)	201 (26.24)	172 (22.45)	263 (34.33)
Ask the doctor why he/she prescribed antibiotics for you in case he/she did so?	282 (36.81)	276 (36.03)	124 (16.19)	84 (10.97)
Seek care elsewhere if the doctor did not prescribe antibiotics for you?	37 (4.83)	105 (13.71)	200 (26.11)	424 (55.35)
Take symptomatic treatment rather than antibiotics for cough and colds and monitor your symptoms in the next few days and see whether you need alternative treatment.	323 (42.17)	306 (39.95)	64 (8.36)	73 (9.53)

Awareness about gut microbiome, side effects of antibiotics, and AMR

A majority, 508 (66.3%), strongly agreed with the statement that “bacteria can develop resistance to antibiotics” (Table 4), and those with higher education were more aware of this possibility (P = 0.046), whereas 557 (73%) believed that taking suboptimal doses might promote resistance.

Table 4.

Respondents’ knowledge about antibiotics.

Statements and questions	Agree (%)	Disagree (%)	I don’t know (%)	Unsure (%)
Bacteria may become resistant to antibiotics when I take them.	512 (69%)	53 (7%)	72 (9%)	129 (15%)
If I don’t take the prescribed amount of antibiotics, they might not be effective for me in the future.	557 (73%)	83 (11%)	32 (4%)	94 (12%)
If the doctor told you that your symptoms do not require antibiotics, will you seek care elsewhere to get an antibiotic?	58 (8%)	653 (85%)	1 (1.%)	54 (7%)
If the antibiotics are more expensive or newer, they work better.	108 (14%)	429 (56%)	65 9%)	164 (21%)
Drug stores and pharmacies should offer antibiotics without a doctor’s prescription.	60 (8%)	645 (84%)	20 (3%)	40 (5%)
Antibiotics destroy the healthy intestinal flora. Consequently, harmful bacteria may overgrow.	402 (52%)	81 (11%)	99 (13%)	184 (24%)
A single dose of antibiotics makes the bacteria in your body more resistant to treatment.	287 (38%)	172 (23%)	79 (10%)	228 (29%)
Antibiotic use can weaken your body’s defense mechanisms. As a result, you are more likely to contract another infection.	425 (56%)	130 (17%)	68 (9%)	143 (19%)
People can spread resistant microorganisms to one another.	355 (46%)	114 (15%)	112 (15%)	185 (24%)
Future deaths from antibiotic resistance will exceed those from diabetes and cancer combined.	267 (36%)	55 (7%)	173 (23%)	262 (34%)
Antibiotics may harm the development of babies inside pregnant mothers.	480 (63%)	39 (5%)	102 (13%)	145 (19%)
Animals can transmit resistance to humans.	306 (40%)	97 (13%)	152 (20%)	211 (27%)

More than half of the respondents, 392 (51%), were aware that antibiotics kill healthy intestinal flora, compromising the host defense mechanism, 408 (53%), and allowing drug-resistant bacteria to proliferate. A large majority, 645 (83.7%), disagreed that drug stores and pharmacies should provide antibiotics without a doctor’s prescription, and 429 (56%) did not believe that more expensive or newer antibiotics were more effective.

A majority (63% [n = 309]) were aware that taking antibiotics during pregnancy could harm the fetus. Participants with higher education levels understood that deaths from antibiotic resistance would surpass those from chronic illnesses combined (P = 0.02) and that multidrug-resistant microorganisms could be transmitted between humans and animals (P = 0.011). The majority disagreed that a single dose of antibiotics would increase bacterial resistance (P = 0.02) or that using antibiotics would alter the body’s natural defense mechanisms, thus increasing the risk of contracting drug-resistant infections (P = 0.047).

Overall antibiotic-seeking behavior was lower in participants who believed that (i) antibiotics destroy healthy intestinal flora, leading to the overgrowth of harmful multidrug-resistant bacteria (P = 0.019), (ii) deaths caused by antibiotic resistance will surpass those caused by chronic diseases (P = 0.005), (iii) antibiotic use can negatively impact fetal development, (iv) weaken the body’s defense system (P = 0.045), and (v) poor adherence to prescribed antibiotics would render them ineffective in the future (P = 0.02).

Discussion

This survey provides important insights into global awareness, beliefs, and behaviors around antibiotics and AMR. The questionnaire was carefully constructed to differentiate superficial from deeper conceptual knowledge and better understand attitudes and practices.

Responses were collected from 766 participants across 30 countries during WAAW 2022. Global engagement with antibiotics and AMR is reflected in the time invested by the respondents in filling out the questionnaire and highlights the outreach of social media platforms.

Higher education was linked to lower demand for antibiotics and a greater willingness to accept symptomatic treatment. This supports previous findings that education is key in shaping attitudes toward responsible antibiotic use [18]. Respondents with a background in science performed better in knowledge (P < 0.001) and attitude (P = 0.003) than those from humanities, underscoring the importance of disseminating this knowledge across all disciplines, not just to students with a science background. However, overall, differences in attitude and practice scores were insignificant, suggesting that higher education improves awareness but does not uniformly translate into improved antibiotic stewardship behaviors. In fact, we reiterate the recommendation that application-based education about AMR and responsible use of antibiotics should begin in school, thus expanding the targeted population [5,19]. It was interesting to note that the effects of the level of education (P = 0.001), field of education (P < 0.001), and region (P < 0.001) were statistically significant for all three KAP domains.

A majority, 747 (97.5%), self-reported that they were familiar with the term antibiotics. However, when a discriminating question was asked regarding the use of antibiotics, only 289 (38%) were aware that they were used for treating infections. In fact, among them, only 242 (31.6%) correctly identified that antibiotics act against bacteria alone and not against viruses, fungi, and parasites. We believe this reflects the distinction between superficial awareness generated by campaigns and a deeper conceptual understanding of appropriate antibiotic use.

The relatively high self-reported familiarity with the term “AMR,” despite a poorer understanding of appropriate antibiotic indications, may reflect campaign-period exposure during WAAW, where repeated social media messaging may enhance recognition of terminology without necessarily improving deeper conceptual understanding. This pattern is consistent with global evidence showing that public familiarity with antibiotics does not equate to accurate understanding [5,19]. This lack of understanding is a major contributor to the misuse of antibiotics and the emergence of antibiotic-resistant bacteria [1]. What is notable in the present study is that these gaps were observed despite recruitment during WAAW within a highly educated, digitally engaged population, suggesting that awareness campaigns alone may be insufficient to ensure deeper conceptual understanding. This underscores the need for more targeted, behaviorally informed communication strategies rather than purely informational campaigns to drive sustained behavior change [18].

Responses to the open-ended question, “When should antibiotics be used?” revealed a significant gap in understanding. Only 10.57% of participants mentioned appropriate medical indications, such as pneumonia, urinary tract infection, or meningitis. They, however, also mentioned conditions where antibiotics are not always warranted (tonsillitis, diarrhea, and otitis media). So, although the responses in this group reflect a closer alignment with potential antibiotic-indicated conditions, the distinction is not always clear.

A large number (35.12%) provided vague answers, such as “infection,” whereas others (17.36%) cited nonspecific symptoms or broad clinical situations, which, by themselves, do not justify antibiotic treatment without a defined bacterial diagnosis or clinical indication, reflecting limited specificity and lower alignment with evidence-based antibiotic use. This mirrors findings from global KAP surveys, where unclear health concepts often hinder understanding of antibiotic use [6].

More than half of the respondents reported that they would expect or demand antibiotics for colds or flu symptoms, reflecting persistent expectations for antibiotics in self-limiting viral illnesses. The coexistence of antibiotic expectations and a high tendency to question antibiotic prescriptions suggests respondent ambivalence and limited confidence in antibiotic decision-making, underscoring the need for communication tools that explain when antibiotics are indicated. Duan et al. [20] reported similar expectations across diverse settings and align with reports from low- and middle-income countries and even high-income nations, where patient demand drives unnecessary antibiotic use [10]. The findings of this study suggest that targeted education of the public is needed.

Behavioral analysis indicated that fewer than 19% would seek a second opinion if antibiotics were not prescribed, whereas 72.8% would question the doctor if antibiotics were given. Concerns about polypharmacy, unnecessary prescribing, and out-of-pocket costs may contribute to greater scrutiny of antibiotic prescriptions rather than good conceptual understanding and point to greater consumer engagement with perceived unnecessary medication. Overall, this growing interest in understanding the reasons behind prescribing decisions is a positive sign for shared decision-making. This compares favorably to other studies where 48% and 47.3% expected their doctor to prescribe antibiotics for their illness [11,12]. Greater awareness and buy-in by the public will nudge clinicians to practice judicious antimicrobial prescribing. Butler et al. [21] (1998), Carter et al. [22] (2016), and Sirota et al. [23] reported that antimicrobial prescriptions increased 10-fold when physicians perceived that patients expected antibiotics.

Most respondents understood that misuse leads to bacterial resistance, side effects, harms gut microbiota, and can threaten fetal development. Participants who recognized these risks were less likely to seek or demand antibiotics. This aligns with behavioral theory models suggesting that knowledge can influence intentions and actions [24]. In contrast, other studies report that only 25% demonstrated knowledge about the adverse effects of antibiotic resistance, and 58% were unaware of the potential health dangers associated with antibiotic resistance [12,25]. Infections caused by drug-resistant organisms can spread through direct or indirect contact with humans and animals, highlighting the need for a One Health approach to tackle AMR. Public rejection of nonprescription antibiotic access (83.7%) and skepticism about the superiority of newer or more expensive antibiotics (56%) indicate a critical awareness of pharmaceutical marketing myths and a move toward evidence-based thinking. A lack of awareness about the consequences of antibiotic overuse, the over-the-counter availability of antimicrobials, and self-medication can significantly exacerbate the threat of antibiotic resistance to a serious level [12,26].

Many countries represented in this survey, including India, Oman, and several African nations, have developed National Action Plans on antimicrobial resistance aligned with the WHO Global Action Plan on AMR, which includes improved public awareness, communication, and education as one of its strategic objectives [27,28]. Most incorporate awareness-raising and education activities, but reviews of national plans indicate that the implementation of these components remains inconsistent and variable across countries, especially in terms of translating policy frameworks into effective public education and community engagement [29,30]. Regional differences in KAP scores were observed; however, these findings should be interpreted with caution. Although respondents from Africa and Eurasia demonstrated higher mean scores in some domains, these subgroups were relatively small compared with the Indian subcontinent and MENA groups and may not be representative of the broader regional populations. The observed variation may reflect differences in sample composition, educational profile, professional background, and the social or institutional networks through which the survey was disseminated rather than true population-level differences.

In the post–coronavirus disease 2019 context, our findings demonstrate the opportunities and limitations of digital engagement for public education on AMR. Social media platforms have become central channels for health information dissemination and public engagement, enabling a broad reach at a relatively low cost [18,31,32]. However, the clear skew toward highly educated respondents in this study is a well-recognized limitation of social media–recruited surveys [33]. This highlights an important challenge for research and intervention design: although digital platforms can enhance reach, complementary offline and community-based strategies are needed to ensure the inclusion of populations with lower digital access [34].

Conclusion

This multicountry survey highlights significant variability in public awareness surrounding antibiotic use and AMR. Although most respondents were familiar with the term “antibiotics,” fewer than half were able to correctly state when antibiotics should be used, and misconceptions regarding their effectiveness against viral illnesses were common. However, it is also clear from this study that knowledge does not equate to behavioral change.

Future interventions should prioritize not only awareness but also the quality of understanding and behavior change. Interventions focused on correcting misconceptions, reinforcing social norms around prudent antibiotic use, and strengthening trust in clinicians’ prescribing decisions are likely to be more effective than information-based campaigns alone.

Limitations

The conceptual overlap between KAP domains and the context-dependent nature of certain items may limit the precision of domain-specific scoring, and results should, therefore, be interpreted primarily in a comparative rather than an absolute sense. As with other anonymous online surveys, inattentive or hurried responses cannot be completely excluded despite duplicate screening and internal consistency checks. The respondents were predominantly from Asian and African countries, with the majority of the responses coming from India and Oman, highlighting a limitation of social media outreach.

Declaration of competing interest

The authors have no competing interests to declare.