Our survey asked the public attending a science communication event to identify the main reason underlying antimicrobial resistance in the world. Understanding the beliefs and explanatory frameworks used by citizens to make sense about the connections between antimicrobials, microorganisms and hosts, as well as the phenomenon of antimicrobial resistance, can facilitate the design and implementation of public awareness campaigns and strengthen future behaviour change interventions.

Nearly 2/3 of responses ascribed the emergence of resistance to the misuse or overuse of antibiotics in human and animal health. In view of the widely reported prevalence of suboptimal antimicrobial prescribing in human healthcare and its impact on AMR [12], and the evidence suggesting that resistance is intimately associated with antimicrobial use [13], such responses from the public could be considered adequate. Of the two factors, a much larger proportion of individuals considered human health as chiefly responsible for antimicrobial resistance, when compared with animal health. This perspective is remarkable in light of the relative consumption of antimicrobials in veterinary medicine and food production, several orders of magnitude higher than human health [14].

A final group of determinants including travel, suboptimal dosing, environmental contamination and suboptimal rapid diagnostics was considered by respondents to have a lower influence on the development of AMR. The crucial role of rapid diagnostics in AMR seemed clearly undervalued by the attendees to our event. Modern transport routes have proven to be very efficient adjunct mechanisms of pathogen transmission [15]. However, worldwide transfer of antimicrobial resistant organisms does not seem to match the mobility of humans across the globe [16]. Suboptimal dosing across human and animal health remains a persistent challenge, either from insufficient evidence about the optimal management for particular groups such as obese individuals [17], or from substandard medications [18]. Finally, the presence of antimicrobials and antimicrobial-resistant organisms in human food and animal feed as well as the environment and its impact on human and animal health have received growing attention [19]. Our participants attributed to the mass drug administration of antibiotics for public health reasons a moderate role in the growth of resistance. However, the evidence to support such perception is more uncertain [20–22].

The adequate responses we obtained need to be appraised within the UK context, where several awareness campaigns and interventions including public education have been conducted [23]. The effectiveness of such campaigns appears to be conflicting [24–26]. The UK Chief Medical Officer (CMO) has also generated considerable attention to the topic of antimicrobial resistance, developing public engagement materials and effectively guiding the social debate about antimicrobials and resistance in social media [27].

The limited public understanding of the scientific discourse related to antimicrobials may offer an explanation for the uncertain public campaign impact reported [28]. Such narrow understanding may reflect, overall, a lack of scientific skills and health literacy in particular of the population [29, 30]. Unless such deficits are taken into account and remedied, it is likely that recent recommendations directing healthcare workers to educate citizens about antibiotics at the point of clinical care [31] will have limited success.

Limitations

We conducted our investigation at a public engagement science event aimed at the public organised by a central London university. The ballot boxes were displayed within an area devoted to antimicrobial resistance, so the visitors may have been a self-selected sample of individuals interested in this field, possibly with increased education and information about AMR and its determinants or encouraged to look up information related to antimicrobials in advance. The ballot boxes were not masked so some respondents may have been persuaded to opt for the option which already had the highest number of votes. Equally, we cannot be sure that some responses were not provided by human or animal healthcare workers, scientists or researchers, therefore skewing the proportion of answers for the selected options.

Our activity only allowed people to select the main contributing factor to antimicrobial resistance in their opinion, where in reality antimicrobial resistance is an intricate and ‘wicked’ problem [32]. We did not include an option acknowledging resistance as a natural and evolutionary response of microorganisms to the pressure exercised by antimicrobials, therefore being a phenomenon that could be slowed but not completely stopped.

Due to the design of our activity, we did not have an opportunity to explore social and demographic attributes of those taking part in the survey, which would have been valuable to enrich hypothesis about current explanatory and decision making frameworks used by members of the public. Our findings must therefore be corroborated by surveys with larger samples. We were not able to explore participants’ views about the drivers of such overuse or misuse of antibiotics using qualitative approaches. However, these aspects have been partially described already [33].