Cross-Border Differences in Public Knowledge, Awareness, Behaviours and Beliefs related to Antibiotics and Antimicrobial Resistance across the island of Ireland

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Sahm, Aoife Fleming, Chikondi C. Kandulu, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6732914/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 16 Mar, 2026 Read the published version in BMC Public Health → Version 1 posted 11 You are reading this latest preprint version Abstract Background Antimicrobial resistance (AMR) is predicted to be liable for 10 million annual deaths worldwide by 2050, driven significantly by public cognitions and behaviours. Given the frequent social and economic interactions between people from Northern Ireland (NI) and Ireland (IRL), the cross-border spread of antibiotic-resistant bacteria is a concern. Little research compares public knowledge, awareness, beliefs and behaviours across the island of Ireland. This study aimed to address this gap in a post-COVID-19 era to inform targeted interventions. Methods A cross-sectional, nationally representative online survey with adults in NI and IRL assessed public knowledge, awareness, behaviours and beliefs related to antibiotics and AMR. Questions were taken from the World Health Organization (WHO) multi-country public awareness survey and four relating to ESKAPE pathogens were derived from literature. Statistical analyses of difference compared results between NI and IRL. Results Among 811 respondents, 415 (51.2%) were from NI and 396 (48.8%) were from IRL. Total knowledge of appropriate antibiotic use and antibiotic resistance was slightly higher in NI. Nearly two fifths (37.9%) in both countries incorrectly identified ‘cold and flu’ as treatable with antibiotics. Awareness of AMR-related terms was consistent across countries and lowest for ‘ESKAPE pathogens’(11%), and ‘AMR’ (21.5%). The media was the source of awareness stated by most respondents (41.2%) while specific campaigns was stated by the least (3.9%). Antibiotic use behaviours were consistent across countries, with over half (57%) having taken them within the last year. Those in NI were more agreeable with appropriate antibiotic use in addressing AMR, e.g., doctors only prescribing antibiotics when they are needed ( U = 73520, p = 0.001, r = 0.12). More respondents in IRL reported that there is not much they can do to stop antibiotic resistance ( U = 74747.50, p = 0.02, r = 0.08). Conclusions This study is among the first to explore cross-border differences in public knowledge, awareness, beliefs and behaviours related to antibiotic use and AMR across the island of Ireland. Despite differences emerging, there is room for improvement in both countries which requires an all-island approach to curb the spread of AMR across the island of Ireland. antimicrobial resistance public knowledge awareness behaviours beliefs antimicrobial stewardship Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Background The World Health Organization (WHO) recognise antimicrobial resistance (AMR) as a major threat to public health and healthcare systems( 1 ). Antibiotics which fail to kill bacteria lead to difficulties with infection prevention and control( 2 ), increased burden on healthcare systems( 3 ), and higher rates of morbidity and mortality( 4 ). Examples of bacteria which are highly resistant to antibiotics are a group known collectively as ESKAPE ( E = Enterococcus faecium , S = Staphylococcus aureus , K = Klebsiella pneumoniae , A = Acinetobacter baumannii , P = Pseudomonas aeruginosa , and E = Enterobacter species) pathogens, which are mostly responsible for nosocomial (hospital acquired) infections ( 5 ). Human cognitions like poor knowledge, lack of awareness, and misconceptions within beliefs have been described internationally as impeding the tackling of AMR( 6 – 9 ). The same has been said for human behaviours like high rates of inappropriate antimicrobial prescription and use( 10 , 11 ) and poor hygiene practices( 5 ). The effectiveness of infection prevention measures depends on behavioural insights( 12 ). Therefore, understanding these factors and their implications is fundamental in curbing the predicted AMR attributable death toll of 10 million annually worldwide by 2050( 13 ). Northern Ireland (NI) and Ireland (IRL) (collectively termed here as the island of Ireland) have high levels of antibiotic consumption. NI had the highest rate of total antibiotic consumption compared to England, Scotland or Wales (the United Kingdom (UK)) in 2021–2022; nearly double that of England (30.42 compared to 15.9 defined daily doses (DDD) per 1000 habitants per day)( 14 , 15 ). Antibiotic consumption in IRL in 2023 was 22.4 DDD, which was high compared to other European Union (EU)/European Economic Area (EEA) countries (range of 9.57 to 28.52 DDD) ( 16 ). Both NI and IRL have acknowledged the burden of AMR on public health and the health service and called for action to prevent it( 17 – 19 ). NI and IRL share an international border with no visa requirements for cross-border travel, permitting free movement and frequent social and commercial interactions. This is concerning as antimicrobial-resistant bacteria spread more frequently across countries and territories with increases in cross-trade and travel( 20 ). Despite these frequent interactions, NI and IRL have different healthcare and education systems, as well as cultural and national identities. Differences in cognitions and behaviours may therefore exist, which could inform the extent to which interventions should be tailored for each country. Nevertheless, cross-border approaches to tackling AMR are warranted and supported due to the inclusion of co-operation between NI and IRL on health in The Good Friday Agreement (the international peace treaty which outlined a political framework for power-sharing in NI in 1998) ( 21 ). Available research on public cognition and behaviours related to antibiotics and AMR across the island of Ireland is country specific. Northern Irish public research is limited and data is ten years old( 22 ). Recent IRL public research uses data just before and after the Coronavirus Disease 2019 (COVID-19) pandemic( 8 , 23 , 24 ). However, public knowledge, awareness, beliefs and behaviours around antimicrobials, infection and disease have changed since the COVID-19 pandemic( 25 , 26 ). An up-to-date cross-border comparison of these factors is warranted to address this literature gap. This would be among a small body of research, but to the best of the authors’ knowledge would add a novel contribution to existing work in this context. This study aimed to explore cross-border differences in public knowledge, awareness, beliefs and behaviours related to antibiotic use and AMR across the island of Ireland. These latest behavioural insights can be used to tailor public health strategies which aim to improve antimicrobial stewardship (AMS) and population-based protection against AMR. Methods Study design, setting and participants A mixed-methods cross-sectional survey was distributed online facilitated by Qualtrics research panel service in September 2024. Cochran’s sample size formula( 27 ) was used (95% confidence level and a margin of error of ± 5%). With this, the aim was to recruit 772 participants (386 in each country), therefore the quota was set at 800 to account for potential unusable responses. To reduce selection bias, we recruited a nationally representative sample based on the most recent NI and IRL national Census data on sex( 28 , 29 ). The survey took 10–15 minutes to complete. Adults living in NI or IRL were eligible to take part. Qualtrics advertised the study to those eligible within their participant panels. The target quota was reached within sixteen days, at which point the survey was closed. The exact reward rate for participation was allocated by Qualtrics (forms included SkyMiles, cash/gift cards, or retail outlet points). Measures The survey (see Supplementary material 1) comprised six sections of 18 closed questions and 2 open-ended questions. Sections 1–4 were taken from the WHO antibiotic resistance multi-country public awareness survey( 9 ). Section 5 questions were informed by a) existing literature( 30 ) and b) the WHO survey( 9 ) by modifying the topic of its questions to focus on ESKAPE pathogens while maintaining the original question structures. These were not formally piloted before data collection. Demographic data was collected using 14 questions; eight from the WHO( 9 ) and five from EuroQol’s EQ-5D-3L (EuroQol-5 Dimensions-3 Levels) standardised measure of health status( 31 ). The EQ-5D-3L produces a health rating across five categories (mobility, self-care, usual activities, pain/discomfort, anxiety/depression), each measured on a 3-level scale (1 = no problems, 2 = some problems, 3 = extreme problems). Overall scores were calculated using Dolan (1997)’s UK coefficients( 32 ). The EuroQol Visual Analogue Scale (EQ VAS), part of the EQ-5D-3L, was also used which rates overall health on a visual scale (0 = worst health you can imagine, 100 = best health you can imagine). The following measures were used but not analysed in this study due to lack of relevance to the research question; measures of vaccine hesitancy( 33 ), two open-ended questions about the survey topics, and sector of work to assess the difference in outcomes based on prior knowledge. Knowledge and awareness were measured using true/false or yes/no questions, or questions which required identifying one correct answer from multiple options. Behaviours were measured by the identification of occurrence of actions. Source-related questions were assessed from selection from a provided list. Beliefs were measured using a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree). Statistical analysis Data was exported from Qualtrics into IBM® SPSS® (Version 30) for analysis. Some demographic questions were optional, which was reflected in the response rates for each question. Eight of the main survey questions were asked conditionally if respondents answered ‘Yes’ to the related previous question which is reflected in the response rates. Therefore, missing values in these variables were considered as not applicable rather than missing. All remaining main survey questions were configured as forced response within Qualtrics, therefore there was no missing data to handle. Correct knowledge answers were based on what was deemed correct in the original measures, and from the literature on ESKAPE pathogen knowledge questions. Correct answers were re-coded as a score of 1 and incorrect responses were grouped and coded as 0. Four sum variables were created from these to give each participant an overall score of topic knowledge, with higher scores denoting higher knowledge. Prevalence of sources of awareness and behaviours, and beliefs were analysed using descriptive statistics. Cross-border differences were calculated using Pearson chi-square tests of independence (categorical data), Mann-Whitney U tests (ordinal data), and independent t-tests (total scores data). Statistical significance was defined as p < 0.05. Results Sample demographics A total of 811 responses were collected; 415(51.2%) from NI and 396(48.8%) from IRL (see Table 1). Of these, 407(50.2%) were female, 398(49.1%) were male, and five (0.6%) participants were self-described. Participant ages ranged from 18 to 89 years, with a mean age of 43.01 years and median age of 41 years (IQR=32-53). The most frequent educational level achieved was a Bachelor’s degree (n=252, 31.3%), and most identified as white (n=697,86.3%). Total EQ-5D-3L average health index scores( Mean, Standard Deviation ) were relatively poor (0.3,0.14), ranged from -0.06 to 0.87, and were similar in both countries ( t (809)=1.65, p =0.10, d =0.12). Those from IRL had a slightly higher average EQ-VAS perceived health score on the day of survey completion (74.60,18.76) than those from NI (70.79,22.44), ( t (809)=-2.61, p =0.009, d =-0.18). Knowledge of appropriate antibiotic use Most respondents across both countries(n=709,87.4%) knew to stop taking antibiotics only when all have been taken as directed, but respondents in NI showed higher knowledge on this compared to IRL (n=375,90.4%, n=334,84.3% respectively; p =0.01, ϕ =0.09). Just over half of respondents (n=457,56.4%) in both countries reported that it is inappropriate to use antibiotics based on having been prescribed antibiotics previously for similar symptoms, but respondents in NI showed higher knowledge compared to IRL (n=251,60.5%, n=206,52% respectively; p =0.02, ϕ =0.09). Knowledge of the inappropriateness of sharing antibiotics was high (n=692,85.3%) and similar across both countries ( p =0.24, ϕ =0.04) (Table 2). Knowledge of conditions which can be treated with antibiotics was similar in both countries, ranging from 65% prevalence of correct identification for gonorrhoea (n=527; p =0.10, ϕ =0.06), 79.4% for skin or wound infection (n=644; p =0.14, ϕ =0.05), to 85.5% for bladder infection/Urinary Tract Infection (UTI) (n=693; p =0.20, ϕ =0.05). Knowledge of malaria, which cannot be treated with antibiotics, was similarly poor in both countries, correctly identified by only 41.7% (n=338; p =0.78 ,ϕ =0.01). Knowledge was similarly moderate across both countries for fever and measles, correctly identified by 53% (n=430; p =0.07, ϕ =0.06) and 65.5% (n=531; p =0.69, ϕ =0.01) respectively. Knowledge of the remaining conditions which are not treatable with antibiotics was moderate to high across both countries, ranging from 47.5% (sore throat) to 84.8% (headaches) correct identification. More respondents from NI compared to IRL answered six conditions correctly: sore throat (n=211,50.8%; n=174,43.9% respectively; p =0.05, ϕ =0.07), diarrhoea (n=354,85.3%; n=305,77% respectively; p =0.003, ϕ =0.11), cold and flu (n=312,75.2%; n=246,62.1% respectively; p <0.001, ϕ =0.14), body aches (n=361,87%; n=301,76% respectively; p <0.001, ϕ =0.14), headaches (n=369,88.9%; n=319,80.6% respectively; p <0.001, ϕ =0.12), and Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) (n=306,73.7%; n=263,66.4% respectively; p =0.02, ϕ =0.08). Total appropriate antibiotic use knowledge scores( M,SD ) ranged from 3 to 15 across both countries. The average score was higher in NI than IRL (10.97,2.67; 10.08,2.71 respectively; p <0.001, d =.33) (see Figure 1). Knowledge of antibiotic resistance Antibiotic resistance knowledge was mostly high across both countries (see Figure 2). Collectively, most respondents (n=711,87.7%) reported that it was true that ‘If bacteria are resistant to antibiotics, it can be very difficult or impossible to treat the infections they cause’ and that ‘Antibiotic resistance is an issue in other countries but not here’ is false (n=677,83.5%). More respondents from NI correctly identified these statements (n=373,89.9%; n=358,86.3% respectively) compared to IRL (n=338,85.4%; n=319,80.6% respectively; p =0.05, ϕ= 0.07; p =0.03, ϕ= 0.08). Correct identification of the remaining statements was moderate to high and similar in both countries: “Many infections are becoming increasingly resistant to treatment by antibiotics” as true (n=705,76.9%; p =0.38, ϕ =.03); “Antibiotic resistance is an issue that could affect me or my family” as true (n=626,77.2%; p =0.11, ϕ =0.06); “Antibiotic resistance is only a problem for people who take antibiotics regularly” as false (n=470,58%; p =0.18, ϕ =0.05); “Bacteria which are resistant to antibiotics can be spread from person to person” as true (n=539,66.5%; p =0.38, ϕ =0.03) and; “Antibiotic-resistant infections could make medical procedures like surgery, organ transplants, and cancer treatment much more dangerous” as true (n=696,85.8%; p =0.17, ϕ =0.05). Both countries showed similarly low levels of knowledge, as most respondents incorrectly selected ‘Antibiotic resistance occurs when your body becomes resistant to antibiotics and they no longer work as well” as true (n=721,88.9%; p =0.37, ϕ =0.03). Total antibiotic resistance knowledge scores( M,SD ) ranged from 1 to 8 (5.57,1.37), with those from NI having a higher average score compared to IRL (5.69,1.29; 5.43,1.4 respectively; ( t (809)=2.75; p =0.006, d =0.19)). Knowledge of the use of antibiotics in agriculture Collectively, just over half of respondents in both countries (n=456,56.2%; p =0.59, ϕ= 0 . 04) correctly knew that antibiotics are widely used in agriculture in Ireland. Over a third of respondents (n=289,35.6%) across both countries said they did not know. Knowledge of ESKAPE pathogens Figure 3 shows that knowledge about ESKAPE pathogens was moderate and similar across countries. 61.4%(n=498) accurately identified ESKAPE pathogens: ‘ are a major threat to public health globally’ (p =0.08, ϕ =0.06); ‘are typically harmless and rarely cause infections in humans’ as false (n=541,66.7%; p =0.29, ϕ =0.04); ‘are only found in hospitals and healthcare settings’ as false (n=564,69.5%; p =0.06, ϕ =0.07), and; ‘can resist practically all types of treatment used to fight them’ as true (n=490,60.4%; p =0.41, ϕ =0.03). Total ESKAPE pathogen knowledge scores ( M,SD ) ranged from 0 to 4 (2.58,1.07) and were moderate and similar across countries (2.58,1.07; t (809)=1.71; p =0.09, d =0.12). Awareness Awareness(see Figure 4) was high in both countries for the terms ‘antibiotic resistance’ , ‘drug resistance’ and ‘superbugs’ , with 80.1%(n=650), 76.6%(n=621) and 76%(n=616) respectively having heard of them. However, more from NI (n=350,84.3%; n=334,80.5%, n=335,80.7% respectively) compared to IRL (n=300, 75.8%; n=287,72.5%; n=281,71% respectively) had heard of them ( p <0.001, ϕ =0.11; p <0.001, ϕ =0.09; p <0.001, ϕ =0.11 respectively). Moderate levels of awareness were shown in both countries for ‘antibiotic-resistant bacteria’ (n=546,67.3%; p =0.15, ϕ =0.05). Poor levels were shown across countries of ‘antimicrobial resistance’ (n=334,41.2%; p =0.90, ϕ =0.01), ‘AMR’ (n=174,21.5%; p =0.86, ϕ =0.01), and ‘ESKAPE pathogens’ (n=87,10.7%; p =0.20, ϕ =0.03). Only 6.9%(n=56) had heard of none of the terms. The media (newspaper, television, radio, social media) was the most common source of awareness in both countries, with an average reach of 41.2%. This was followed by a doctor or nurse(34.6%). The least common source was a specific campaign (3.9%) (see Figure 5). Behaviours Over one third of respondents in both countries had most recently taken antibiotics more than a year ago (n=284,35%), and over one quarter in the last 6 months (n=220,27.1%). Most respondents in both countries had received the antibiotics/prescription from a doctor/nurse/pharmacist (n=740,93.1%, p =0.53, ϕ =0.02), received advice on how to take them (n= 702,88.3%, p =0.55, ϕ =0.02), and got them from a medical store or pharmacy (n=735,92.5%) (see Table 3). Beliefs about ways to address antibiotic resistance Most agreement (M,SD) was shown overall for ‘ People should use antibiotics only when they are prescribed by a doctor or nurse’ (4.65,.71), but those from NI showed higher agreement compared to IRL (4.72,.65; 4.58,1.17 respectively; p =0.002, r =0.11). The same was shown for ‘Doctors should only prescribe antibiotics when needed’ (4.65,.60), higher again in those from NI compared to IRL (4.72,.57; 4.59,.62 respectively; p =0.001, r =0.12). Additionally, ‘people should not keep antibiotics and use them later for other illnesses’ was highly agreed with overall (4.15,1.13), but more so by those in NI compared to IRL(4.24,1.09; 4.05,1.17 respectively; p =0.01, r =0.09). People in both countries showed high agreement with: ‘people washing their hands regularly’ (4.62,.68; p =0.22, r =0.04); ‘parents should make sure all of their children’s vaccinations are up to date’ (4.52,.84; p =0.55, r =0.02); ‘pharmaceutical companies should develop new antibiotics’ (4.03,.88; p =0.41, r =0.03); ‘governments should reward the development of new antibiotics’ (3.92,.99; p =0.46, r =0.03) and; ‘farmers should give fewer antibiotics to food-producing animals’ (3.95,1; p =0.82, r =0.01) (see Figure 6). Beliefs about the scale of antibiotic resistance The strongest belief ( M,SD ) in both countries was with ‘Everyone needs to take responsibility for using antibiotics responsibly’ (4.62,0.63), with those from NI compared to IRL showing higher agreement (4.71,0.55; 4.53,0.70 respectively; p <0.001, r =0.15). Neutrality was collectively shown around believing ‘There is not much people like me can do to stop antibiotic resistance’ (3.09,1.09), but those from IRL compared to NI showed higher agreement (3.17,1.04; 3.01,1.13 respectively; p =0.02, r =0.08). Those from IRL also showed higher agreement with ‘I am not at risk of getting an antibiotic-resistant infection, as long as I take my antibiotics correctly’ compared to those from NI (3.36,1.14; 3.14,1.22 respectively; p =0.01, r =0.09). Moderate agreement in both countries was shown for: ‘I am worried about the impact that antibiotic resistance will have on my health, and that of my family’ (3.77,1.03; p =0.32, r =0.04), ‘Antibiotic resistance is one of the biggest problems the world faces’ (3.41,1.08, p =0.90, r =0.01), and ‘Medical experts will solve the problem of antibiotic resistance before it becomes too serious’ (3.35,.95; p =0.23, r =0.04) (see Figure 7). Beliefs about ESKAPE pathogens Respondents in both countries were in moderate agreement ( M,SD ) that: ‘I feel confident about the current methods and treatments available to combat ESKAPE pathogens’ (3.26,0.85; p =0.69, r =0.01); ‘I am concerned about ESKAPE pathogens causing a major global health threat’ (3.39,.85; p =0.40, r =0.03); ‘I would feel less worried if they were able to get a vaccination to protect against ESKAPE pathogens’ (3.44,0.92; p =0.93, r =0.003), and ‘I am afraid that ESKAPE pathogens could cause outbreaks or epidemics ( 3.37,.88; p =0.95, r =0.002). Respondents from IRL compared to NI showed higher agreement with ‘I am worried about the impact ESKAPE pathogens could have on my health and that of my family’ (3.46,0.87; 3.32,0.88 respectively; p =0.03, r =0.007) (Figure 8). Discussion This is one of the first cross-border studies on antibiotic and AMR-related knowledge, awareness, beliefs and behaviours across the island of Ireland, and the first in a decade to include an NI sample. The findings show similarity between NI and IRL across these factors, supporting cross-border and collaborative approaches in addressing AMR. Total knowledge of appropriate antibiotic use was good in both countries (10.97 average correct answers in NI and 10.08 in IRL out of a possible 15). Complementing this, both countries showed high agreement with believing everyone should take responsibility for the responsible use of antibiotics. Small significant differences showed those from NI had higher knowledge of when to stop taking antibiotics and the inappropriateness of using antibiotics based on being prescribed them previously for similar symptoms. NI knowledge on when to stop taking antibiotics has remained consistently high since 2014/15 ( 22 ), suggesting COVID-19 has not decreased this knowledge which is positive for ongoing AMR control efforts in a post-pandemic era. In contrast, IRL findings show around a 10% decline in this knowledge, 84.3% compared to 2022 findings of 94% ( 8 ), and regression to similar results found in 2018 and 2019 ( 23 , 34 ). However, the reliability of comparisons to these earlier studies is open to scrutiny due to differing methodologies, sample sizes and potential issues with national representativeness. Moreover, around two-fifths in both countries incorrectly answered that antibiotics can be used based on being prescribed them previously for similar symptoms. This is not surprising due to pattern recognition from past health experiences being a strong predictor of subsequent health behaviours ( 35 ). NI and IRL’s current public health messaging encourages people to (i) not share antibiotics and (ii) finish the course as directed, but does not mention the request or use of antibiotics based on being prescribed them previously for similar symptoms ( 36 , 37 ). Public health messaging and healthcare professional advice should strive to cover all these elements to reinforce this appropriate use. Disregarding differences, overall good knowledge levels indicate probable adherence to ongoing educational initiatives and advisory efforts which are positive in the tackling of AMR ( 6 – 9 ). Correct identification of antibiotic-treatable conditions ranged from 41.7–85.5% across both countries, highlighting mixed knowledge levels. More from NI compared to IRL correctly identified HIV/AIDS, headaches, body aches, cold and flu, diarrhoea, and sore throat as not being treatable with antibiotics. However, viral and bacterial infections can present with similar symptoms, such as sore throat and fever ( 38 ). Therefore, some results may reflect the aligning of symptoms with which antibiotics were previously used rather than poor knowledge. Common misconceptions were still evident, such as cold and flu being incorrectly identified by 31.2% of our sample as being antibiotic treatable. Previous IRL findings regarding this are conflicting; a study in 2019 found that much more (78%) said they would take an antibiotic for a cold or flu, but 47% said antibiotics are not effective against viral infections ( 23 ). Since then, only 20% in IRL in 2022 were found to wrongly think antibiotics are effective against colds ( 8 ), but 41% in 2023 thought antibiotics can kill viruses ( 24 ). Our NI knowledge gap prevalence regarding this is much higher than the 8% found in NI in 2014/15 ( 22 ), suggesting knowledge may have decreased in NI. Regardless, the level of knowledge gaps in both countries are a concern as high rates of flu coupled with common misconceptions around its treatment could lead to inappropriate management and virus survival. Seasonal flu vaccines are offered to those who are most at risk if infected with the flu across the island of Ireland (e.g. older people, those who are pregnant). Discussions around treatment options if infected with the flu should take place during these programmes, GP (General Practitioner) appointments, or at the community pharmacy, in an aim to educate about, and reduce inappropriate use of, antibiotics for cold and flu. Total knowledge of antibiotic resistance was good across the island of Ireland, with an average of 5.57 correct answers out of 8. Significant differences showed those from NI had a statistically significant slightly higher average score, with better knowledge of the implications of AMR in treating infections and AMR as a national and global problem. However, in both countries around only one tenth correctly identified the basic definition of AMR, similar to global findings ( 7 , 9 ). Conceptual change theory ( 39 ) explains that misconceptions of basic definitions can impede overall learning and understanding of a topic. Efforts should be made to improve the understanding of this basic definition as a basis to improve overall knowledge of antibiotic resistance in both countries. Moderate knowledge and uncertainty in beliefs about ESKAPE pathogens was found in both countries. Around a third to two-fifths of respondents answered the ESKAPE pathogen knowledge questions incorrectly, evidencing knowledge gaps. No reference to ESKAPE pathogens could be found in NI and IRL public health messaging. As a result, while these questions aimed to gather insight into public knowledge, responses may be based on acquiescence bias. The validity of knowledge and belief measurement is therefore questionable. ESKAPE pathogens are mostly found in clinical environments, however are still implicated in life-threatening hospital infections WHO( 40 , 41 ). Public health messaging across the island of Ireland should begin to reference ESKAPE pathogens to inform positive behaviours which mitigate their threat. Both countries showed equally moderately strong beliefs that farmers should give fewer antibiotics to food-producing animals. However, over a third across both countries were unsure if antibiotics are widely used in agriculture, highlighting gaps in knowledge. Comparable data could not be found for NI, however this level of uncertainty in IRL around antibiotic use in agriculture aligns with those found in 2019 ( 23 ) and lack of knowledge of the ban on antibiotic use within the EU to stimulate growth in farm animals found in 2022 ( 8 ). The AMR-related problems associated with the use of antibiotics in agriculture have been widely documented ( 5 , 13 , 42 ). Research on education efforts has emphasised the need to use multiple communication efforts that target and leverage the values and belief systems of different consumer groups ( 43 ). The NI and IRL One Health approaches which discuss such efforts are now out of date ( 17 , 18 ). The updated approaches should include educational efforts for the public around the use of antibiotics in agriculture which is emphasised as necessary by the WHO ( 5 ). Despite small significant differences being found, awareness was high for terms like ‘antibiotic resistance’, ‘superbugs’, and ‘drug resistance’ which are commonly used in public awareness and media campaigns to date across the island of Ireland. Similar to global research, awareness was low in both countries for more technical and abbreviated terms like ‘antimicrobial resistance’, ‘AMR’, ( 9 ) and ‘ESKAPE pathogens’ which are used less in campaigns. Abbreviations are universally used in healthcare dialogue, so low awareness could hinder overall understanding during conversations with healthcare professionals or if included in healthcare messaging. Research has shown that expansion of medical abbreviations can improve patient understanding of health information ( 44 ). AMR-related health messaging and healthcare professionals across Ireland should therefore avoid using abbreviations like ‘AMR’ and ‘ESKAPE’, instead using full terms with clear definitions to enhance awareness, engagement and understanding of AMR ( 45 , 46 ). A doctor/nurse and the media were the two most cited sources of awareness in both countries; while discourse with healthcare professionals is encouraging, the reach of the media could be problematic due to its potential to provide unreliable and misleading information ( 47 – 50 ). Low health literacy is related to the inability to evaluate information effectively ( 51 ), therefore credible and reliable organisations should ensure AMR-related content is accurate. Despite specific campaigns being a reliable and trustworthy source, these were the least cited source in both countries. Further research is required to evaluate their reach to increase this engagement. Behaviours around antibiotic use were consistent across both countries. Similar to previous IRL-specific and global findings, ( 8 , 9 , 23 ), appropriate antibiotic use behaviours were prevalent across both countries with regards obtainment and receiving advice. This is encouraging as these behaviours reduce the likelihood of inappropriate antibiotic use across Ireland which is a main driver of AMR ( 10 , 11 ). However, over half (57%) of people self-reported antibiotic use within the last year. These findings complement the high rates of antibiotic prescribing reported in both countries ( 14 , 16 , 52 , 53 ). While timing of use does not mean such use is inappropriate use, these levels are still a concern due to the increase in likelihood of bacteria becoming resistant and escalating the prevalence of AMR ( 10 , 11 ). To mitigate this risk, antimicrobial stewardship programs should continue to monitor antibiotic use and promote appropriate prescribing and adherence practices across Ireland. Some small differences were found between countries in beliefs about ways to address antibiotic resistance and the scale of it as a problem. Strong agreement was shown with ways to address it, but support for the statements regarding the scale of the problem were more tentative. Moderate agreement in both countries that medical experts will solve the problem of antibiotic resistance before it becomes too serious suggests the public somewhat believe in a ‘hands-off’ approach. However, highest agreement was shown with everyone needing to take responsibility for the responsible use of antibiotics, suggesting the public are aware of the importance of their actions, which aligns with the One Health policies’ recommendations ( 17 , 18 ). Both countries strongly believed in hand washing, which is positive as this is known to prevent the spread of bacteria ( 5 ). Both countries also strongly believed in parents making sure their children’s vaccinations are up to date, suggesting that if vaccines were to become available in relation to AMR, the public across Ireland may believe in the importance of taking it. This is hopeful due to the widely documented role of vaccines in reducing the burden of AMR ( 54 , 55 ). Uncertainty was evident in both countries around the development of new antibiotics. The importance of new antibiotics in addressing AMR has been highlighted due increasing rates of AMR-related illness and death ( 56 ). Confirmation bias highlights that people favour information that confirms their beliefs ( 57 ), therefore any moderate agreement could reflect some of the gaps in knowledge. Efforts should focus on reinforcing the already strong beliefs through public health messaging and addressing uncertainty with positive stories, for example positive breakthrough antibiotic development studies and their benefits in addressing AMR ( 58 ), in an aim to address specific uncertainties. The insights gained in this cross-border study highlight the importance of understanding the dynamics of behaviours in areas where antibiotic-resistant bacteria can spread more frequently due to social and economic engagement ( 20 ). It is one of the first studies to attempt to assess knowledge and beliefs related to ESKAPE pathogens as no standardised measure could be found. The validity and reliability of related results may warrant scrutiny due to acquiescence bias, highlighting the need for a validated measure in future research. However, the findings still provide an insight into potential knowledge gaps and uncertainty around ESKAPE pathogens’ rising threat to public health. While the WHO survey was the main measure used ( 9 ), the findings are nearly a decade old. Due to the changes in public cognitions and behaviours around antimicrobials and infectious diseases since the pandemic ( 25 , 26 ), comparisons were difficult to draw. A follow-up international survey would be beneficial to assess and compare current global trends. Finally, it is difficult to fully ascertain reasons behind the differences between NI and IRL in this study as reasons for such are multifaceted. Future qualitative research should aim to gather public views and experiences to further inform interventions across the island of Ireland. Conclusion To the best of the authors’ knowledge, this research is a novel contribution towards the understanding of knowledge, awareness, behaviours and beliefs around antibiotics and antimicrobial resistance across the island of Ireland. Despite small differences being highlighted between countries, mostly regarding knowledge and beliefs, the small-to-moderate effect sizes and large sample size warrants an all-island approach to addressing misconceptions. Overall, antibiotic consumption is high, and gaps remain in public knowledge and awareness which can inform behaviours and beliefs. There is also particular uncertainty around the use of antibiotics in agriculture and ESKAPE pathogens. If efforts are not made to address misconceptions, the death toll resulting from AMR could quickly rise to that of a pandemic ( 56 ). These findings can inform the tailoring of public health strategies to improve population-based protection against subsequent infectious diseases arising from AMR across the island of Ireland. Abbreviations AIDS Acquired Immunodeficiency Syndrome AIVRT All-Island Vaccine Research and Training Alliance AMR Antimicrobial resistance AMS Antimicrobial stewardship COVID-19 Coronavirus Disease 2019 EEA European Economic Area EQ-5D-3L EuroQol-5 Dimensions-3 Levels EQ-VAS EuroQol-Visual Analogue Scale ESKAPE Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species EU European Union GP General Practitioner HEA Higher Education Authority HIV Human Immunodeficiency Virus IBM® International Business Machines® IRL Ireland M,SD Mean, Standard Deviation NI Northern Ireland SPSS® Statistical Package for the Social Sciences® UK United Kingdom UTI Urinary Tract Infection WHO World Health Organization Declarations Clinical trial number Not applicable. Ethics approval and consent to participate Ethical approval was granted by the Faculty of Engineering and Physical Sciences at Queen’s University Belfast (03 June 2024, reference EPS 24_68). This study was carried out in accordance with the Declaration of Helsinki. All participants provided informed consent after reading the study information sheet before survey completion. Consent for publication Consent to publish is provided by Queen’s University Belfast. Queen’s University Belfast and University College Cork have joint intellectual property rights. Availability of data and materials The datasets generated and/or analysed during the current study are available in the QUB PURE repository. This manuscript complies with The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement for cross-sectional studies (https://doi.org/10.1016/j.jclinepi.2007.11.008). The study was registered to use the EQ-5D-3L (registration ID 66281). Competing interests The authors declare that they have no competing interests. Funding This study was funded by the Higher Education Authority (HEA), Strand 2. Authors’ contributions CS and GS designed the study and prepared the research proposal. CS analysed and interpreted all data and wrote the first draft of the manuscript. GS critically reviewed the first and second draft and CS made any amendments. EB, LJS, AF, CCK, and ACM critically reviewed the third draft, and CS made any amendments. All authors read and approved the final version of this manuscript. Acknowledgements This research is carried out under the All-island Vaccine Research & Training Alliance (AIVRT) hub. The authors would like to thank the hub for their continued support and guidance. References World Health Organization.Antimicrobial resistance [Internet]. World Health Organization. Accessed 18 December 2024. Available from https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance. 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5","display":"","copyAsset":false,"role":"figure","size":104960,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of NI and IRL survey respondents’ sources of awareness for AMR-related terms(n=159-570)\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-6732914/v1/032a751b9a8e04054aa45c3f.png"},{"id":84464846,"identity":"ba26f35f-b175-476a-b506-faa4baa20dc1","added_by":"auto","created_at":"2025-06-12 09:33:07","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":180003,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of NI and IRL survey respondents’ level of agreement with ways to address antibiotic resistance(n = 811)\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-6732914/v1/02fa1f8d0929bd30bf1598c8.png"},{"id":84466177,"identity":"e88581c5-d212-4ada-b36a-0c6f2f4e2135","added_by":"auto","created_at":"2025-06-12 09:41:07","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":179168,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of NI and IRL survey respondents’ average level of agreement with the scale of antibiotic resistance as a problem(n = 811)\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-6732914/v1/3dbde65522cf8c4c198a708f.png"},{"id":84466179,"identity":"be57cfe9-4c1e-4de6-bd53-51f5318f5fe5","added_by":"auto","created_at":"2025-06-12 09:41:07","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":145670,"visible":true,"origin":"","legend":"\u003cp\u003eComparison NI and IRL survey respondents’ average level of agreement with statements about ESKAPE pathogens (n=811)\u003c/p\u003e","description":"","filename":"8.png","url":"https://assets-eu.researchsquare.com/files/rs-6732914/v1/1df42da92c5e4699b00602d4.png"},{"id":105224668,"identity":"2b670cea-5dfb-4252-9896-caee1475b96f","added_by":"auto","created_at":"2026-03-23 16:15:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1817421,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6732914/v1/5b071fda-1ece-47a3-8363-5ab93fd0c95f.pdf"},{"id":84466171,"identity":"9caf120f-4193-4aea-accf-45c3fd9341ef","added_by":"auto","created_at":"2025-06-12 09:41:07","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":33614,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarymaterial1.docx","url":"https://assets-eu.researchsquare.com/files/rs-6732914/v1/305a64ed27bb17d9f0d4bfc9.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Cross-Border Differences in Public Knowledge, Awareness, Behaviours and Beliefs related to Antibiotics and Antimicrobial Resistance across the island of Ireland","fulltext":[{"header":"Background","content":"\u003cp\u003eThe World Health Organization (WHO) recognise antimicrobial resistance (AMR) as a major threat to public health and healthcare systems(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Antibiotics which fail to kill bacteria lead to difficulties with infection prevention and control(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e), increased burden on healthcare systems(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), and higher rates of morbidity and mortality(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Examples of bacteria which are highly resistant to antibiotics are a group known collectively as ESKAPE (\u003cb\u003eE\u003c/b\u003e\u0026thinsp;=\u0026thinsp;\u003cem\u003eEnterococcus faecium\u003c/em\u003e, \u003cb\u003eS\u003c/b\u003e\u0026thinsp;=\u0026thinsp;\u003cem\u003eStaphylococcus aureus\u003c/em\u003e, \u003cb\u003eK\u003c/b\u003e\u0026thinsp;=\u0026thinsp;\u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e, \u003cb\u003eA\u003c/b\u003e\u0026thinsp;=\u0026thinsp;\u003cem\u003eAcinetobacter baumannii\u003c/em\u003e, \u003cb\u003eP\u003c/b\u003e\u0026thinsp;=\u0026thinsp;\u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e, and \u003cb\u003eE\u003c/b\u003e\u0026thinsp;=\u0026thinsp;\u003cem\u003eEnterobacter\u003c/em\u003e species) pathogens, which are mostly responsible for nosocomial (hospital acquired) infections (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Human cognitions like poor knowledge, lack of awareness, and misconceptions within beliefs have been described internationally as impeding the tackling of AMR(\u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). The same has been said for human behaviours like high rates of inappropriate antimicrobial prescription and use(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) and poor hygiene practices(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). The effectiveness of infection prevention measures depends on behavioural insights(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Therefore, understanding these factors and their implications is fundamental in curbing the predicted AMR attributable death toll of 10\u0026nbsp;million annually worldwide by 2050(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Northern Ireland (NI) and Ireland (IRL) (collectively termed here as the island of Ireland) have high levels of antibiotic consumption. NI had the highest rate of total antibiotic consumption compared to England, Scotland or Wales (the United Kingdom (UK)) in 2021\u0026ndash;2022; nearly double that of England (30.42 compared to 15.9 defined daily doses (DDD) per 1000 habitants per day)(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Antibiotic consumption in IRL in 2023 was 22.4 DDD, which was high compared to other European Union (EU)/European Economic Area (EEA) countries (range of 9.57 to 28.52 DDD) (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Both NI and IRL have acknowledged the burden of AMR on public health and the health service and called for action to prevent it(\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). NI and IRL share an international border with no visa requirements for cross-border travel, permitting free movement and frequent social and commercial interactions. This is concerning as antimicrobial-resistant bacteria spread more frequently across countries and territories with increases in cross-trade and travel(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Despite these frequent interactions, NI and IRL have different healthcare and education systems, as well as cultural and national identities. Differences in cognitions and behaviours may therefore exist, which could inform the extent to which interventions should be tailored for each country. Nevertheless, cross-border approaches to tackling AMR are warranted and supported due to the inclusion of co-operation between NI and IRL on health in The Good Friday Agreement (the international peace treaty which outlined a political framework for power-sharing in NI in 1998) (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Available research on public cognition and behaviours related to antibiotics and AMR across the island of Ireland is country specific. Northern Irish public research is limited and data is ten years old(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Recent IRL public research uses data just before and after the Coronavirus Disease 2019 (COVID-19) pandemic(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). However, public knowledge, awareness, beliefs and behaviours around antimicrobials, infection and disease have changed since the COVID-19 pandemic(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). An up-to-date cross-border comparison of these factors is warranted to address this literature gap. This would be among a small body of research, but to the best of the authors\u0026rsquo; knowledge would add a novel contribution to existing work in this context. This study aimed to explore cross-border differences in public knowledge, awareness, beliefs and behaviours related to antibiotic use and AMR across the island of Ireland. These latest behavioural insights can be used to tailor public health strategies which aim to improve antimicrobial stewardship (AMS) and population-based protection against AMR.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design, setting and participants\u003c/h2\u003e \u003cp\u003eA mixed-methods cross-sectional survey was distributed online facilitated by Qualtrics research panel service in September 2024. Cochran\u0026rsquo;s sample size formula(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) was used (95% confidence level and a margin of error of \u0026plusmn;\u0026thinsp;5%). With this, the aim was to recruit 772 participants (386 in each country), therefore the quota was set at 800 to account for potential unusable responses. To reduce selection bias, we recruited a nationally representative sample based on the most recent NI and IRL national Census data on sex(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). The survey took 10\u0026ndash;15 minutes to complete. Adults living in NI or IRL were eligible to take part. Qualtrics advertised the study to those eligible within their participant panels. The target quota was reached within sixteen days, at which point the survey was closed. The exact reward rate for participation was allocated by Qualtrics (forms included SkyMiles, cash/gift cards, or retail outlet points).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cp\u003eThe survey (see Supplementary material 1) comprised six sections of 18 closed questions and 2 open-ended questions. Sections 1\u0026ndash;4 were taken from the WHO antibiotic resistance multi-country public awareness survey(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Section 5 questions were informed by a) existing literature(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e) and b) the WHO survey(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) by modifying the topic of its questions to focus on ESKAPE pathogens while maintaining the original question structures. These were not formally piloted before data collection. Demographic data was collected using 14 questions; eight from the WHO(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) and five from EuroQol\u0026rsquo;s EQ-5D-3L (EuroQol-5 Dimensions-3 Levels) standardised measure of health status(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). The EQ-5D-3L produces a health rating across five categories (mobility, self-care, usual activities, pain/discomfort, anxiety/depression), each measured on a 3-level scale (1\u0026thinsp;=\u0026thinsp;no problems, 2\u0026thinsp;=\u0026thinsp;some problems, 3\u0026thinsp;=\u0026thinsp;extreme problems). Overall scores were calculated using Dolan (1997)\u0026rsquo;s UK coefficients(\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). The EuroQol Visual Analogue Scale (EQ VAS), part of the EQ-5D-3L, was also used which rates overall health on a visual scale (0\u0026thinsp;=\u0026thinsp;worst health you can imagine, 100\u0026thinsp;=\u0026thinsp;best health you can imagine). The following measures were used but not analysed in this study due to lack of relevance to the research question; measures of vaccine hesitancy(\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e), two open-ended questions about the survey topics, and sector of work to assess the difference in outcomes based on prior knowledge. Knowledge and awareness were measured using true/false or yes/no questions, or questions which required identifying one correct answer from multiple options. Behaviours were measured by the identification of occurrence of actions. Source-related questions were assessed from selection from a provided list. Beliefs were measured using a 5-point Likert scale (1\u0026thinsp;=\u0026thinsp;strongly disagree, 5\u0026thinsp;=\u0026thinsp;strongly agree).\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eData was exported from Qualtrics into IBM\u0026reg; SPSS\u0026reg; (Version 30) for analysis. Some demographic questions were optional, which was reflected in the response rates for each question. Eight of the main survey questions were asked conditionally if respondents answered \u0026lsquo;Yes\u0026rsquo; to the related previous question which is reflected in the response rates. Therefore, missing values in these variables were considered as not applicable rather than missing. All remaining main survey questions were configured as forced response within Qualtrics, therefore there was no missing data to handle. Correct knowledge answers were based on what was deemed correct in the original measures, and from the literature on ESKAPE pathogen knowledge questions. Correct answers were re-coded as a score of 1 and incorrect responses were grouped and coded as 0. Four sum variables were created from these to give each participant an overall score of topic knowledge, with higher scores denoting higher knowledge. Prevalence of sources of awareness and behaviours, and beliefs were analysed using descriptive statistics. Cross-border differences were calculated using Pearson chi-square tests of independence (categorical data), Mann-Whitney U tests (ordinal data), and independent t-tests (total scores data). Statistical significance was defined as p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eSample demographics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 811 responses were collected; 415(51.2%) from NI and 396(48.8%) from IRL (see Table 1). Of these, 407(50.2%) were female, 398(49.1%) were male, and five (0.6%) participants were self-described. Participant ages ranged from 18 to 89 years, with a mean age of 43.01 years and median age of 41 years (IQR=32-53). The most frequent educational level achieved was a Bachelor\u0026rsquo;s degree (n=252, 31.3%), and most identified as white (n=697,86.3%). Total EQ-5D-3L average health index scores(\u003cem\u003eMean, Standard Deviation\u003c/em\u003e) were relatively poor (0.3,0.14), ranged from -0.06 to 0.87, and were similar in both countries (\u003cem\u003et\u003c/em\u003e(809)=1.65,\u003cem\u003ep\u003c/em\u003e=0.10,\u003cem\u003ed\u003c/em\u003e=0.12). Those from IRL had a slightly higher average EQ-VAS perceived health score on the day of survey completion (74.60,18.76) than those from NI (70.79,22.44), (\u003cem\u003et\u003c/em\u003e(809)=-2.61,\u003cem\u003ep\u003c/em\u003e=0.009,\u003cem\u003ed\u003c/em\u003e=-0.18).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKnowledge of appropriate antibiotic use\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost respondents across both countries(n=709,87.4%) knew to stop taking antibiotics only when all have been taken as directed, but respondents in NI showed higher knowledge on this compared to IRL (n=375,90.4%, n=334,84.3% respectively; \u003cem\u003ep\u003c/em\u003e=0.01,\u003cem\u003eϕ\u003c/em\u003e=0.09). Just over half of respondents (n=457,56.4%) in both countries reported that it is inappropriate to use antibiotics based on having been prescribed antibiotics previously for similar symptoms, but respondents in NI showed higher knowledge compared to IRL (n=251,60.5%, n=206,52% respectively; \u003cem\u003ep\u003c/em\u003e=0.02,\u003cem\u003eϕ\u003c/em\u003e=0.09). Knowledge of the inappropriateness of sharing antibiotics was high (n=692,85.3%) and similar across both countries (\u003cem\u003ep\u003c/em\u003e=0.24,\u003cem\u003eϕ\u003c/em\u003e=0.04) (Table 2).\u003c/p\u003e\n\u003cp\u003eKnowledge of conditions which can be treated with antibiotics was similar in both countries, ranging from 65% prevalence of correct identification for gonorrhoea (n=527;\u003cem\u003ep\u003c/em\u003e=0.10,\u003cem\u003eϕ\u003c/em\u003e=0.06), 79.4% for skin or wound infection (n=644;\u003cem\u003ep\u003c/em\u003e=0.14,\u003cem\u003eϕ\u003c/em\u003e=0.05), to 85.5% for bladder infection/Urinary Tract Infection (UTI) (n=693;\u003cem\u003ep\u003c/em\u003e=0.20,\u003cem\u003eϕ\u003c/em\u003e=0.05). Knowledge of malaria, which cannot be treated with antibiotics, was similarly poor in both countries, correctly identified by only 41.7% (n=338;\u003cem\u003ep\u003c/em\u003e=0.78\u003cem\u003e,ϕ\u003c/em\u003e=0.01). Knowledge was similarly moderate across both countries for fever and measles, correctly identified by 53% (n=430;\u003cem\u003ep\u003c/em\u003e=0.07,\u003cem\u003eϕ\u003c/em\u003e=0.06) and 65.5% (n=531;\u003cem\u003ep\u003c/em\u003e=0.69,\u003cem\u003eϕ\u003c/em\u003e=0.01) respectively. Knowledge of the remaining conditions which are not treatable with antibiotics was moderate to high across both countries, ranging from 47.5% (sore throat) to 84.8% (headaches) correct identification. More respondents from NI compared to IRL answered six conditions correctly: sore throat (n=211,50.8%; n=174,43.9% respectively; \u003cem\u003ep\u003c/em\u003e=0.05,\u003cem\u003eϕ\u003c/em\u003e=0.07), diarrhoea (n=354,85.3%; n=305,77% respectively; \u003cem\u003ep\u003c/em\u003e=0.003,\u003cem\u003eϕ\u003c/em\u003e=0.11), cold and flu (n=312,75.2%; n=246,62.1% respectively; \u0026nbsp;\u003cem\u003ep\u003c/em\u003e\u0026lt;0.001,\u003cem\u003eϕ\u003c/em\u003e=0.14), body aches (n=361,87%; n=301,76% respectively; \u003cem\u003ep\u003c/em\u003e\u0026lt;0.001,\u003cem\u003eϕ\u003c/em\u003e=0.14), headaches (n=369,88.9%; n=319,80.6% respectively; \u003cem\u003ep\u003c/em\u003e\u0026lt;0.001,\u003cem\u003eϕ\u003c/em\u003e=0.12), and Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) (n=306,73.7%; n=263,66.4% respectively; \u003cem\u003ep\u003c/em\u003e=0.02,\u003cem\u003eϕ\u003c/em\u003e=0.08). Total appropriate antibiotic use knowledge scores(\u003cem\u003eM,SD\u003c/em\u003e) ranged from 3 to 15 across both countries. The average score was higher in NI than IRL (10.97,2.67; 10.08,2.71 respectively; \u003cem\u003ep\u003c/em\u003e\u0026lt;0.001, \u003cem\u003ed\u003c/em\u003e=.33) (see Figure 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKnowledge of antibiotic resistance\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAntibiotic resistance knowledge was mostly high across both countries (see Figure 2). Collectively, most respondents (n=711,87.7%) reported that it was true that \u003cem\u003e\u0026lsquo;If bacteria are resistant to antibiotics, it can be very difficult or impossible to treat the infections they cause\u0026rsquo;\u0026nbsp;\u003c/em\u003eand that \u003cem\u003e\u0026lsquo;Antibiotic resistance is an issue in other countries but not here\u0026rsquo;\u0026nbsp;\u003c/em\u003eis false (n=677,83.5%). More respondents from NI correctly identified these statements (n=373,89.9%; n=358,86.3% respectively) compared to IRL (n=338,85.4%; n=319,80.6% respectively; \u003cem\u003ep\u003c/em\u003e=0.05,\u003cem\u003eϕ=\u003c/em\u003e0.07; \u003cem\u003ep\u003c/em\u003e=0.03,\u003cem\u003eϕ=\u003c/em\u003e0.08). Correct identification of the remaining statements was moderate to high and similar in both countries: \u003cem\u003e\u0026ldquo;Many infections are becoming increasingly resistant to treatment by antibiotics\u0026rdquo;\u0026nbsp;\u003c/em\u003eas true\u003cem\u003e\u0026nbsp;\u003c/em\u003e(n=705,76.9%; \u003cem\u003ep\u003c/em\u003e=0.38,\u003cem\u003eϕ\u003c/em\u003e=.03); \u003cem\u003e\u0026ldquo;Antibiotic resistance is an issue that could affect me or my family\u0026rdquo;\u003c/em\u003e as true\u003cem\u003e\u0026nbsp;\u003c/em\u003e(n=626,77.2%; \u003cem\u003ep\u003c/em\u003e=0.11,\u003cem\u003eϕ\u003c/em\u003e=0.06); \u003cem\u003e\u0026ldquo;Antibiotic resistance is only a problem for people who take antibiotics regularly\u0026rdquo;\u003c/em\u003e as false (n=470,58%; \u003cem\u003ep\u003c/em\u003e=0.18,\u003cem\u003eϕ\u003c/em\u003e=0.05); \u003cem\u003e\u0026ldquo;Bacteria which are resistant to antibiotics can be spread from person to person\u0026rdquo;\u0026nbsp;\u003c/em\u003eas true (n=539,66.5%; \u003cem\u003ep\u003c/em\u003e=0.38,\u003cem\u003eϕ\u003c/em\u003e=0.03) and; \u003cem\u003e\u0026ldquo;Antibiotic-resistant infections could make medical procedures like surgery, organ transplants, and cancer treatment much more dangerous\u0026rdquo;\u0026nbsp;\u003c/em\u003eas true (n=696,85.8%; \u003cem\u003ep\u003c/em\u003e=0.17,\u003cem\u003eϕ\u003c/em\u003e=0.05). Both countries showed similarly low levels of knowledge, as most respondents incorrectly selected \u003cem\u003e\u0026lsquo;Antibiotic resistance occurs when your body becomes resistant to antibiotics and they no longer work as well\u0026rdquo;\u003c/em\u003e as true (n=721,88.9%; \u003cem\u003ep\u003c/em\u003e=0.37,\u003cem\u003eϕ\u003c/em\u003e=0.03). Total antibiotic resistance knowledge scores(\u003cem\u003eM,SD\u003c/em\u003e) ranged from 1 to 8 (5.57,1.37), with those from NI having a higher average score compared to IRL (5.69,1.29; 5.43,1.4 respectively; (\u003cem\u003et\u003c/em\u003e(809)=2.75; \u003cem\u003ep\u003c/em\u003e=0.006, \u003cem\u003ed\u003c/em\u003e=0.19)).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKnowledge of the use of antibiotics in agriculture\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCollectively, just over half of respondents in both countries (n=456,56.2%; \u003cem\u003ep\u003c/em\u003e=0.59,\u003cem\u003eϕ=\u003c/em\u003e0\u003cem\u003e.\u003c/em\u003e04) correctly knew that antibiotics are widely used in agriculture in Ireland. Over a third of respondents (n=289,35.6%) across both countries said they did not know.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKnowledge of ESKAPE pathogens\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFigure 3 shows that knowledge about ESKAPE pathogens was moderate and similar across countries. 61.4%(n=498) accurately identified ESKAPE pathogens: \u0026lsquo;\u003cem\u003eare a major threat to public health globally\u0026rsquo; (p\u003c/em\u003e=0.08,\u003cem\u003eϕ\u003c/em\u003e=0.06); \u003cem\u003e\u0026lsquo;are typically harmless and rarely cause infections in humans\u0026rsquo;\u0026nbsp;\u003c/em\u003eas false (n=541,66.7%; \u003cem\u003ep\u003c/em\u003e=0.29,\u003cem\u003eϕ\u003c/em\u003e=0.04); \u003cem\u003e\u0026lsquo;are only found in hospitals and healthcare settings\u0026rsquo;\u0026nbsp;\u003c/em\u003eas false (n=564,69.5%; \u003cem\u003ep\u003c/em\u003e=0.06,\u003cem\u003eϕ\u003c/em\u003e=0.07), and; \u003cem\u003e\u0026lsquo;can resist practically all types of treatment used to fight them\u0026rsquo;\u0026nbsp;\u003c/em\u003eas true (n=490,60.4%; \u003cem\u003ep\u003c/em\u003e=0.41,\u003cem\u003eϕ\u003c/em\u003e=0.03). Total ESKAPE pathogen knowledge scores (\u003cem\u003eM,SD\u003c/em\u003e) ranged from 0 to 4 (2.58,1.07) and were moderate and similar across countries (2.58,1.07; \u003cem\u003et\u003c/em\u003e(809)=1.71;\u003cem\u003ep\u003c/em\u003e=0.09,\u003cem\u003ed\u003c/em\u003e=0.12).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAwareness\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAwareness(see Figure 4) was high in both countries for the terms \u003cem\u003e\u0026lsquo;antibiotic resistance\u0026rsquo;\u003c/em\u003e, \u003cem\u003e\u0026lsquo;drug resistance\u0026rsquo;\u003c/em\u003e and \u003cem\u003e\u0026lsquo;superbugs\u0026rsquo;\u003c/em\u003e, with 80.1%(n=650), 76.6%(n=621) and 76%(n=616) respectively having heard of them. However, more from NI (n=350,84.3%; n=334,80.5%, n=335,80.7% respectively) \u003cdel cite=\"mailto:Gillian%20Shorter\" datetime=\"2025-03-24T15:46\"\u003e\u0026nbsp;\u003c/del\u003ecompared to IRL (n=300, 75.8%; n=287,72.5%; n=281,71% respectively) had heard of them (\u003cem\u003ep\u003c/em\u003e\u0026lt;0.001,\u003cem\u003eϕ\u003c/em\u003e=0.11; \u003cem\u003ep\u003c/em\u003e\u0026lt;0.001,\u003cem\u003eϕ\u003c/em\u003e=0.09; \u003cem\u003ep\u003c/em\u003e\u0026lt;0.001,\u003cem\u003eϕ\u003c/em\u003e=0.11 respectively). Moderate levels of awareness were shown in both countries for \u003cem\u003e\u0026lsquo;antibiotic-resistant bacteria\u0026rsquo;\u003c/em\u003e (n=546,67.3%; \u003cem\u003ep\u003c/em\u003e=0.15,\u003cem\u003eϕ\u003c/em\u003e=0.05). Poor levels were shown across countries of \u003cem\u003e\u0026lsquo;antimicrobial resistance\u0026rsquo;\u003c/em\u003e (n=334,41.2%; \u003cem\u003ep\u003c/em\u003e=0.90,\u003cem\u003eϕ\u003c/em\u003e=0.01), \u003cem\u003e\u0026lsquo;AMR\u0026rsquo;\u0026nbsp;\u003c/em\u003e(n=174,21.5%; \u003cem\u003ep\u003c/em\u003e=0.86,\u003cem\u003eϕ\u003c/em\u003e=0.01), and \u003cem\u003e\u0026lsquo;ESKAPE pathogens\u0026rsquo;\u003c/em\u003e (n=87,10.7%; \u003cem\u003ep\u003c/em\u003e=0.20,\u003cem\u003eϕ\u003c/em\u003e=0.03). Only 6.9%(n=56) had heard of none of the terms. The media (newspaper, television, radio, social media) was the most common source of awareness in both countries, with an average reach of 41.2%. This was followed by a doctor or nurse(34.6%). The least common source was a specific campaign (3.9%) (see Figure 5).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBehaviours\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOver one third of respondents in both countries had most recently taken antibiotics more than a year ago (n=284,35%), and over one quarter in the last 6 months (n=220,27.1%). Most respondents in both countries had received the antibiotics/prescription from a doctor/nurse/pharmacist (n=740,93.1%, \u003cem\u003ep\u003c/em\u003e=0.53,\u003cem\u003e\u0026nbsp;ϕ\u003c/em\u003e=0.02), received advice on how to take them (n= 702,88.3%,\u003cem\u003ep\u003c/em\u003e=0.55,\u003cem\u003e\u0026nbsp;ϕ\u003c/em\u003e=0.02), and got them from a medical store or pharmacy (n=735,92.5%) (see Table 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBeliefs about ways to address antibiotic resistance\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost agreement \u003cem\u003e(M,SD)\u0026nbsp;\u003c/em\u003ewas shown overall for \u0026lsquo;\u003cem\u003ePeople should use antibiotics only when they are prescribed by a doctor or nurse\u0026rsquo;\u0026nbsp;\u003c/em\u003e(4.65,.71), but those from NI showed higher agreement compared to IRL (4.72,.65; 4.58,1.17 respectively; \u003cem\u003ep\u003c/em\u003e=0.002,\u003cem\u003er\u003c/em\u003e=0.11). The same was shown for \u003cem\u003e\u0026lsquo;Doctors should only prescribe antibiotics when needed\u0026rsquo;\u0026nbsp;\u003c/em\u003e(4.65,.60), higher again in those from NI compared to IRL (4.72,.57; 4.59,.62 respectively; \u003cem\u003ep\u003c/em\u003e=0.001,\u003cem\u003er\u003c/em\u003e=0.12). Additionally, \u003cem\u003e\u0026lsquo;people should not keep antibiotics and use them later for other illnesses\u0026rsquo;\u003c/em\u003e was highly agreed with overall (4.15,1.13), but more so by those in NI compared to IRL(4.24,1.09; 4.05,1.17 respectively; \u003cem\u003ep\u003c/em\u003e=0.01,\u003cem\u003er\u003c/em\u003e=0.09). People in both countries showed high agreement with: \u003cem\u003e\u0026lsquo;people washing their hands regularly\u0026rsquo;\u003c/em\u003e (4.62,.68; \u003cem\u003ep\u003c/em\u003e=0.22,\u003cem\u003er\u003c/em\u003e=0.04); \u003cem\u003e\u0026lsquo;parents should make sure all of their children\u0026rsquo;s vaccinations are up to date\u0026rsquo;\u003c/em\u003e (4.52,.84; \u003cem\u003ep\u003c/em\u003e=0.55,\u003cem\u003er\u003c/em\u003e=0.02); \u003cem\u003e\u0026lsquo;pharmaceutical companies should develop new antibiotics\u0026rsquo;\u0026nbsp;\u003c/em\u003e(4.03,.88; \u003cem\u003ep\u003c/em\u003e=0.41,\u003cem\u003er\u003c/em\u003e=0.03); \u003cem\u003e\u0026lsquo;governments should reward the development of new antibiotics\u0026rsquo;\u003c/em\u003e (3.92,.99; \u003cem\u003ep\u003c/em\u003e=0.46,\u003cem\u003er\u003c/em\u003e=0.03) and; \u003cem\u003e\u0026lsquo;farmers should give fewer\u0026nbsp;\u003c/em\u003e\u003cem\u003eantibiotics to food-producing animals\u0026rsquo;\u0026nbsp;\u003c/em\u003e(3.95,1; \u003cem\u003ep\u003c/em\u003e=0.82,\u003cem\u003er\u003c/em\u003e=0.01) (see Figure 6).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBeliefs about the scale of antibiotic resistance \u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe strongest belief (\u003cem\u003eM,SD\u003c/em\u003e) in both countries was with \u003cem\u003e\u0026lsquo;Everyone needs to take responsibility for using antibiotics responsibly\u0026rsquo;\u003c/em\u003e(4.62,0.63), with those from NI compared to IRL showing higher agreement (4.71,0.55; 4.53,0.70 respectively; \u003cem\u003ep\u003c/em\u003e\u0026lt;0.001,\u003cem\u003er\u003c/em\u003e=0.15). Neutrality was collectively shown around believing \u003cem\u003e\u0026lsquo;There is not much people like me can do to stop antibiotic resistance\u0026rsquo;\u0026nbsp;\u003c/em\u003e(3.09,1.09), but those from IRL compared to NI showed higher agreement (3.17,1.04; 3.01,1.13 respectively; \u003cem\u003ep\u003c/em\u003e=0.02,\u003cem\u003er\u003c/em\u003e=0.08). Those from IRL also showed higher agreement with \u003cem\u003e\u0026lsquo;I am not at risk of getting an antibiotic-resistant infection, as long as I take my antibiotics correctly\u0026rsquo;\u0026nbsp;\u003c/em\u003ecompared to those from NI\u003cem\u003e\u0026nbsp;\u003c/em\u003e(3.36,1.14; 3.14,1.22 respectively; \u003cem\u003ep\u003c/em\u003e=0.01,\u003cem\u003er\u003c/em\u003e=0.09). Moderate agreement in both countries was shown for: \u003cem\u003e\u0026lsquo;I am worried about the impact that antibiotic resistance will have on my health, and that of my family\u0026rsquo;\u003c/em\u003e (3.77,1.03; \u003cem\u003ep\u003c/em\u003e=0.32,\u003cem\u003er\u003c/em\u003e=0.04), \u003cem\u003e\u0026lsquo;Antibiotic resistance is one of the biggest problems the world faces\u0026rsquo;\u0026nbsp;\u003c/em\u003e(3.41,1.08, \u003cem\u003ep\u003c/em\u003e=0.90,\u003cem\u003er\u003c/em\u003e=0.01), and \u003cem\u003e\u0026lsquo;Medical experts will solve the problem of antibiotic resistance\u0026nbsp;\u003c/em\u003e\u003cem\u003ebefore it becomes too serious\u0026rsquo;\u0026nbsp;\u003c/em\u003e(3.35,.95; \u003cem\u003ep\u003c/em\u003e=0.23,\u003cem\u003er\u003c/em\u003e=0.04) (see Figure 7).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBeliefs about ESKAPE pathogens\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRespondents in both countries were in moderate agreement (\u003cem\u003eM,SD\u003c/em\u003e) that: \u003cem\u003e\u0026lsquo;I feel confident about the current methods and treatments available to combat ESKAPE pathogens\u0026rsquo;\u003c/em\u003e (3.26,0.85; \u003cem\u003ep\u003c/em\u003e=0.69,\u003cem\u003er\u003c/em\u003e=0.01); \u003cem\u003e\u0026lsquo;I am concerned about ESKAPE pathogens causing a major global health threat\u0026rsquo;\u003c/em\u003e (3.39,.85; \u003cem\u003ep\u003c/em\u003e=0.40,\u003cem\u003er\u003c/em\u003e=0.03); \u003cem\u003e\u0026lsquo;I would feel less worried if they were able to get a vaccination to protect against ESKAPE pathogens\u0026rsquo;\u003c/em\u003e (3.44,0.92; \u003cem\u003ep\u003c/em\u003e=0.93,\u003cem\u003er\u003c/em\u003e=0.003), and \u003cem\u003e\u0026lsquo;I am afraid that ESKAPE pathogens could cause outbreaks or epidemics (\u003c/em\u003e3.37,.88; \u003cem\u003ep\u003c/em\u003e=0.95,\u003cem\u003er\u003c/em\u003e=0.002). Respondents from IRL compared to NI showed higher agreement with \u003cem\u003e\u0026lsquo;I am worried about the impact ESKAPE pathogens could have on my health and that of my family\u0026rsquo;\u003c/em\u003e (3.46,0.87; 3.32,0.88 respectively; \u003cem\u003ep\u003c/em\u003e=0.03, \u003cem\u003er\u003c/em\u003e=0.007) (Figure 8).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis is one of the first cross-border studies on antibiotic and AMR-related knowledge, awareness, beliefs and behaviours across the island of Ireland, and the first in a decade to include an NI sample. The findings show similarity between NI and IRL across these factors, supporting cross-border and collaborative approaches in addressing AMR. Total knowledge of appropriate antibiotic use was good in both countries (10.97 average correct answers in NI and 10.08 in IRL out of a possible 15). Complementing this, both countries showed high agreement with believing everyone should take responsibility for the responsible use of antibiotics. Small significant differences showed those from NI had higher knowledge of when to stop taking antibiotics and the inappropriateness of using antibiotics based on being prescribed them previously for similar symptoms. NI knowledge on when to stop taking antibiotics has remained consistently high since 2014/15 (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), suggesting COVID-19 has not decreased this knowledge which is positive for ongoing AMR control efforts in a post-pandemic era. In contrast, IRL findings show around a 10% decline in this knowledge, 84.3% compared to 2022 findings of 94% (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), and regression to similar results found in 2018 and 2019 (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). However, the reliability of comparisons to these earlier studies is open to scrutiny due to differing methodologies, sample sizes and potential issues with national representativeness. Moreover, around two-fifths in both countries incorrectly answered that antibiotics can be used based on being prescribed them previously for similar symptoms. This is not surprising due to pattern recognition from past health experiences being a strong predictor of subsequent health behaviours (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). NI and IRL\u0026rsquo;s current public health messaging encourages people to (i) not share antibiotics and (ii) finish the course as directed, but does not mention the request or use of antibiotics based on being prescribed them previously for similar symptoms (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). Public health messaging and healthcare professional advice should strive to cover all these elements to reinforce this appropriate use. Disregarding differences, overall good knowledge levels indicate probable adherence to ongoing educational initiatives and advisory efforts which are positive in the tackling of AMR (\u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Correct identification of antibiotic-treatable conditions ranged from 41.7\u0026ndash;85.5% across both countries, highlighting mixed knowledge levels. More from NI compared to IRL correctly identified HIV/AIDS, headaches, body aches, cold and flu, diarrhoea, and sore throat as not being treatable with antibiotics. However, viral and bacterial infections can present with similar symptoms, such as sore throat and fever (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Therefore, some results may reflect the aligning of symptoms with which antibiotics were previously used rather than poor knowledge. Common misconceptions were still evident, such as cold and flu being incorrectly identified by 31.2% of our sample as being antibiotic treatable. Previous IRL findings regarding this are conflicting; a study in 2019 found that much more (78%) said they would take an antibiotic for a cold or flu, but 47% said antibiotics are not effective against viral infections (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Since then, only 20% in IRL in 2022 were found to wrongly think antibiotics are effective against colds (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), but 41% in 2023 thought antibiotics can kill viruses (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Our NI knowledge gap prevalence regarding this is much higher than the 8% found in NI in 2014/15 (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), suggesting knowledge may have decreased in NI. Regardless, the level of knowledge gaps in both countries are a concern as high rates of flu coupled with common misconceptions around its treatment could lead to inappropriate management and virus survival. Seasonal flu vaccines are offered to those who are most at risk if infected with the flu across the island of Ireland (e.g. older people, those who are pregnant). Discussions around treatment options if infected with the flu should take place during these programmes, GP (General Practitioner) appointments, or at the community pharmacy, in an aim to educate about, and reduce inappropriate use of, antibiotics for cold and flu. Total knowledge of antibiotic resistance was good across the island of Ireland, with an average of 5.57 correct answers out of 8. Significant differences showed those from NI had a statistically significant slightly higher average score, with better knowledge of the implications of AMR in treating infections and AMR as a national and global problem. However, in both countries around only one tenth correctly identified the basic definition of AMR, similar to global findings (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Conceptual change theory (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e) explains that misconceptions of basic definitions can impede overall learning and understanding of a topic. Efforts should be made to improve the understanding of this basic definition as a basis to improve overall knowledge of antibiotic resistance in both countries. Moderate knowledge and uncertainty in beliefs about ESKAPE pathogens was found in both countries. Around a third to two-fifths of respondents answered the ESKAPE pathogen knowledge questions incorrectly, evidencing knowledge gaps. No reference to ESKAPE pathogens could be found in NI and IRL public health messaging. As a result, while these questions aimed to gather insight into public knowledge, responses may be based on acquiescence bias. The validity of knowledge and belief measurement is therefore questionable. ESKAPE pathogens are mostly found in clinical environments, however are still implicated in life-threatening hospital infections WHO(\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). Public health messaging across the island of Ireland should begin to reference ESKAPE pathogens to inform positive behaviours which mitigate their threat. Both countries showed equally moderately strong beliefs that farmers should give fewer antibiotics to food-producing animals. However, over a third across both countries were unsure if antibiotics are widely used in agriculture, highlighting gaps in knowledge. Comparable data could not be found for NI, however this level of uncertainty in IRL around antibiotic use in agriculture aligns with those found in 2019 (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) and lack of knowledge of the ban on antibiotic use within the EU to stimulate growth in farm animals found in 2022 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). The AMR-related problems associated with the use of antibiotics in agriculture have been widely documented (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). Research on education efforts has emphasised the need to use multiple communication efforts that target and leverage the values and belief systems of different consumer groups (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). The NI and IRL One Health approaches which discuss such efforts are now out of date (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). The updated approaches should include educational efforts for the public around the use of antibiotics in agriculture which is emphasised as necessary by the WHO (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Despite small significant differences being found, awareness was high for terms like \u0026lsquo;antibiotic resistance\u0026rsquo;, \u0026lsquo;superbugs\u0026rsquo;, and \u0026lsquo;drug resistance\u0026rsquo; which are commonly used in public awareness and media campaigns to date across the island of Ireland. Similar to global research, awareness was low in both countries for more technical and abbreviated terms like \u0026lsquo;antimicrobial resistance\u0026rsquo;, \u0026lsquo;AMR\u0026rsquo;, (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) and \u0026lsquo;ESKAPE pathogens\u0026rsquo; which are used less in campaigns. Abbreviations are universally used in healthcare dialogue, so low awareness could hinder overall understanding during conversations with healthcare professionals or if included in healthcare messaging. Research has shown that expansion of medical abbreviations can improve patient understanding of health information (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). AMR-related health messaging and healthcare professionals across Ireland should therefore avoid using abbreviations like \u0026lsquo;AMR\u0026rsquo; and \u0026lsquo;ESKAPE\u0026rsquo;, instead using full terms with clear definitions to enhance awareness, engagement and understanding of AMR (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e). A doctor/nurse and the media were the two most cited sources of awareness in both countries; while discourse with healthcare professionals is encouraging, the reach of the media could be problematic due to its potential to provide unreliable and misleading information (\u003cspan additionalcitationids=\"CR48 CR49\" citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e). Low health literacy is related to the inability to evaluate information effectively (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e), therefore credible and reliable organisations should ensure AMR-related content is accurate. Despite specific campaigns being a reliable and trustworthy source, these were the least cited source in both countries. Further research is required to evaluate their reach to increase this engagement. Behaviours around antibiotic use were consistent across both countries. Similar to previous IRL-specific and global findings, (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e), appropriate antibiotic use behaviours were prevalent across both countries with regards obtainment and receiving advice. This is encouraging as these behaviours reduce the likelihood of inappropriate antibiotic use across Ireland which is a main driver of AMR (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). However, over half (57%) of people self-reported antibiotic use within the last year. These findings complement the high rates of antibiotic prescribing reported in both countries (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e). While timing of use does not mean such use is inappropriate use, these levels are still a concern due to the increase in likelihood of bacteria becoming resistant and escalating the prevalence of AMR (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). To mitigate this risk, antimicrobial stewardship programs should continue to monitor antibiotic use and promote appropriate prescribing and adherence practices across Ireland. Some small differences were found between countries in beliefs about ways to address antibiotic resistance and the scale of it as a problem. Strong agreement was shown with ways to address it, but support for the statements regarding the scale of the problem were more tentative. Moderate agreement in both countries that medical experts will solve the problem of antibiotic resistance before it becomes too serious suggests the public somewhat believe in a \u0026lsquo;hands-off\u0026rsquo; approach. However, highest agreement was shown with everyone needing to take responsibility for the responsible use of antibiotics, suggesting the public are aware of the importance of their actions, which aligns with the One Health policies\u0026rsquo; recommendations (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Both countries strongly believed in hand washing, which is positive as this is known to prevent the spread of bacteria (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Both countries also strongly believed in parents making sure their children\u0026rsquo;s vaccinations are up to date, suggesting that if vaccines were to become available in relation to AMR, the public across Ireland may believe in the importance of taking it. This is hopeful due to the widely documented role of vaccines in reducing the burden of AMR (\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e). Uncertainty was evident in both countries around the development of new antibiotics. The importance of new antibiotics in addressing AMR has been highlighted due increasing rates of AMR-related illness and death (\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e). Confirmation bias highlights that people favour information that confirms their beliefs (\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e), therefore any moderate agreement could reflect some of the gaps in knowledge. Efforts should focus on reinforcing the already strong beliefs through public health messaging and addressing uncertainty with positive stories, for example positive breakthrough antibiotic development studies and their benefits in addressing AMR (\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e), in an aim to address specific uncertainties. The insights gained in this cross-border study highlight the importance of understanding the dynamics of behaviours in areas where antibiotic-resistant bacteria can spread more frequently due to social and economic engagement (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). It is one of the first studies to attempt to assess knowledge and beliefs related to ESKAPE pathogens as no standardised measure could be found. The validity and reliability of related results may warrant scrutiny due to acquiescence bias, highlighting the need for a validated measure in future research. However, the findings still provide an insight into potential knowledge gaps and uncertainty around ESKAPE pathogens\u0026rsquo; rising threat to public health. While the WHO survey was the main measure used (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), the findings are nearly a decade old. Due to the changes in public cognitions and behaviours around antimicrobials and infectious diseases since the pandemic (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), comparisons were difficult to draw. A follow-up international survey would be beneficial to assess and compare current global trends. Finally, it is difficult to fully ascertain reasons behind the differences between NI and IRL in this study as reasons for such are multifaceted. Future qualitative research should aim to gather public views and experiences to further inform interventions across the island of Ireland.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eTo the best of the authors\u0026rsquo; knowledge, this research is a novel contribution towards the understanding of knowledge, awareness, behaviours and beliefs around antibiotics and antimicrobial resistance across the island of Ireland. Despite small differences being highlighted between countries, mostly regarding knowledge and beliefs, the small-to-moderate effect sizes and large sample size warrants an all-island approach to addressing misconceptions. Overall, antibiotic consumption is high, and gaps remain in public knowledge and awareness which can inform behaviours and beliefs. There is also particular uncertainty around the use of antibiotics in agriculture and ESKAPE pathogens. If efforts are not made to address misconceptions, the death toll resulting from AMR could quickly rise to that of a pandemic (\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e). These findings can inform the tailoring of public health strategies to improve population-based protection against subsequent infectious diseases arising from AMR across the island of Ireland.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAIDS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Acquired Immunodeficiency Syndrome\u003c/p\u003e\n\u003cp\u003eAIVRT\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;All-Island Vaccine Research and Training Alliance\u003c/p\u003e\n\u003cp\u003eAMR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Antimicrobial resistance\u003c/p\u003e\n\u003cp\u003eAMS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Antimicrobial stewardship\u003c/p\u003e\n\u003cp\u003eCOVID-19 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Coronavirus Disease 2019\u003c/p\u003e\n\u003cp\u003eEEA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;European Economic Area\u003c/p\u003e\n\u003cp\u003eEQ-5D-3L\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;EuroQol-5 Dimensions-3 Levels\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEQ-VAS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;EuroQol-Visual Analogue Scale\u003c/p\u003e\n\u003cp\u003eESKAPE\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter\u0026nbsp;species\u003c/p\u003e\n\u003cp\u003eEU\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;European Union\u003c/p\u003e\n\u003cp\u003eGP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;General Practitioner\u003c/p\u003e\n\u003cp\u003eHEA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Higher Education Authority\u003c/p\u003e\n\u003cp\u003eHIV \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Human Immunodeficiency Virus\u003c/p\u003e\n\u003cp\u003eIBM\u0026reg;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;International Business Machines\u0026reg;\u003c/p\u003e\n\u003cp\u003eIRL\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Ireland\u003c/p\u003e\n\u003cp\u003eM,SD\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Mean, Standard Deviation\u003c/p\u003e\n\u003cp\u003eNI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Northern Ireland\u003c/p\u003e\n\u003cp\u003eSPSS\u0026reg;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Statistical Package for the Social Sciences\u0026reg;\u003c/p\u003e\n\u003cp\u003eUK\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;United Kingdom\u003c/p\u003e\n\u003cp\u003eUTI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Urinary Tract Infection\u003c/p\u003e\n\u003cp\u003eWHO \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; World Health Organization\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was granted by the Faculty of Engineering and Physical Sciences at Queen’s University Belfast (03 June 2024, reference EPS 24_68). This study was carried out in accordance with the Declaration of Helsinki. All participants provided informed consent after reading the study information sheet before survey completion.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConsent to publish is provided by Queen’s University Belfast. Queen’s University Belfast and University College Cork have joint intellectual property rights.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are available in the QUB PURE repository. This manuscript complies with The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement for cross-sectional studies (https://doi.org/10.1016/j.jclinepi.2007.11.008). The study was registered to use the EQ-5D-3L (registration ID 66281).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was funded by the Higher Education Authority (HEA), Strand 2.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCS and GS designed the study and prepared the research proposal. CS analysed and interpreted all data and wrote the first draft of the manuscript. GS critically reviewed the first and second draft and CS made any amendments. EB, LJS, AF, CCK, and ACM critically reviewed the third draft, and CS made any amendments. All authors read and approved the final version of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research is carried out under the All-island Vaccine Research \u0026amp; Training Alliance (AIVRT) hub. The authors would like to thank the hub for their continued support and guidance.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Health Organization.Antimicrobial resistance [Internet]. World Health Organization. Accessed 18 December 2024. Available from https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance.\u003c/li\u003e\n\u003cli\u003eAhmed SK, Hussein S, Qurbani K, Ibrahim RH, Fareeq A, Mahmood KA, et al. Antimicrobial resistance: impacts, challenges, and future prospects. Journal of Medicine, Surgery, and Public Health. 2024;2024 Apr 1(2):100081.\u003c/li\u003e\n\u003cli\u003eFerri M, Ranucci E, Romagnoli P, Giaccone V. 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Environment \u0026amp; Health. 2024;2(9):618-22.\u003c/li\u003e\n\u003cli\u003eRegan \u0026Aacute;, Sweeney S, McKernan C, Benson T, Dean M. Consumer perception and understanding of the risks of antibiotic use and antimicrobial resistance in farming. Agriculture and Human Values. 2023;40(3):989-1001.\u003c/li\u003e\n\u003cli\u003eLiu LG, Russell D, Turchioe MR, Myers AC, Vawdrey DK, Creber RMM. Effect of expansion of abbreviations and acronyms on patient comprehension of their health records: a randomized clinical trial. JAMA Network Open. 2022;5(5):e2212320-e.\u003c/li\u003e\n\u003cli\u003ePraska C, Pitt MB, Marmet J, Gotlieb R, Charpentier V, Hause E, et al. Laypeople\u0026rsquo;s (mis) understanding of common medical acronyms. Hospital Pediatrics. 2023;13(10):e269-e73.\u003c/li\u003e\n\u003cli\u003eHamiel U, Hecht I, Nemet A, Pe\u0026rsquo;er L, Man V, Hilely A, et al. Frequency, comprehension and attitudes of physicians towards abbreviations in the medical record. 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Surveillance of Antimicrobial Use and Resistance in Northern Ireland Report 2019-2021. In: Belfast: Public Health Agency. Public Health Agency. 2021. https://www.publichealth.hscni.net/sites/default/files/2024-07/AMR%20annual%20report%202019_2021_0.pdf. Accessed 04 January 2025.\u003c/li\u003e\n\u003cli\u003eHenriques-Normark B, Normark S. Bacterial vaccines and antibiotic resistance. . Upsala journal of medical sciences. 2014; 119(2):205-8.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Summary WHO SAGE conclusions and recommendations on Vaccine Hesitancy. In: Strategic Advisory Group of Experts on Immunization (SAGE). World Health Organization. 2015. https://www.who.int/docs/default-source/immunization/demand/summary-of-sage-vaccinehesitancy-en.pdf?sfvrsn=abbfd5c8_2. Accessed 07 September 2024.\u003c/li\u003e\n\u003cli\u003eBr\u0026uuml;ssow H. The antibiotic resistance crisis and the development of new antibiotics. Microbial Biotechnology. 2024;17(7):e14510.\u003c/li\u003e\n\u003cli\u003eNickerson RS. Confirmation bias: A ubiquitous phenomenon in many guises. Review of general psychology. 1998;2(2):175-220.\u003c/li\u003e\n\u003cli\u003eBelseck N. New antibiotic class effective against multidrug-resistant bacteria. Medical Chronicle. 2024;2024(4):6-.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"antimicrobial resistance, public, knowledge, awareness, behaviours, beliefs, antimicrobial stewardship","lastPublishedDoi":"10.21203/rs.3.rs-6732914/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6732914/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eAntimicrobial resistance (AMR) is predicted to be liable for 10\u0026nbsp;million annual deaths worldwide by 2050, driven significantly by public cognitions and behaviours. Given the frequent social and economic interactions between people from Northern Ireland (NI) and Ireland (IRL), the cross-border spread of antibiotic-resistant bacteria is a concern. Little research compares public knowledge, awareness, beliefs and behaviours across the island of Ireland. This study aimed to address this gap in a post-COVID-19 era to inform targeted interventions.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA cross-sectional, nationally representative online survey with adults in NI and IRL assessed public knowledge, awareness, behaviours and beliefs related to antibiotics and AMR. Questions were taken from the World Health Organization (WHO) multi-country public awareness survey and four relating to ESKAPE pathogens were derived from literature. Statistical analyses of difference compared results between NI and IRL.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAmong 811 respondents, 415 (51.2%) were from NI and 396 (48.8%) were from IRL. Total knowledge of appropriate antibiotic use and antibiotic resistance was slightly higher in NI. Nearly two fifths (37.9%) in both countries incorrectly identified \u0026lsquo;cold and flu\u0026rsquo; as treatable with antibiotics. Awareness of AMR-related terms was consistent across countries and lowest for \u0026lsquo;ESKAPE pathogens\u0026rsquo;(11%), and \u0026lsquo;AMR\u0026rsquo; (21.5%). The media was the source of awareness stated by most respondents (41.2%) while specific campaigns was stated by the least (3.9%). Antibiotic use behaviours were consistent across countries, with over half (57%) having taken them within the last year. Those in NI were more agreeable with appropriate antibiotic use in addressing AMR, e.g., doctors only prescribing antibiotics when they are needed (\u003cem\u003eU\u003c/em\u003e\u0026thinsp;=\u0026thinsp;73520, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001, \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.12). More respondents in IRL reported that there is not much they can do to stop antibiotic resistance (\u003cem\u003eU\u003c/em\u003e\u0026thinsp;=\u0026thinsp;74747.50, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.02, \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.08).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThis study is among the first to explore cross-border differences in public knowledge, awareness, beliefs and behaviours related to antibiotic use and AMR across the island of Ireland. Despite differences emerging, there is room for improvement in both countries which requires an all-island approach to curb the spread of AMR across the island of Ireland.\u003c/p\u003e","manuscriptTitle":"Cross-Border Differences in Public Knowledge, Awareness, Behaviours and Beliefs related to Antibiotics and Antimicrobial Resistance across the island of Ireland","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-12 09:33:02","doi":"10.21203/rs.3.rs-6732914/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-24T07:44:37+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"169752858175901100039451751709831143344","date":"2025-08-27T19:41:18+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-25T15:21:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"264651487133707058641206081391627282922","date":"2025-08-24T18:03:28+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-09T11:19:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"51146620329497752966903046511865726837","date":"2025-06-12T07:47:44+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-10T18:45:58+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-27T05:38:42+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-26T13:45:47+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-26T13:45:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-05-23T12:25:12+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b06b19ff-2db1-458d-a313-d400ce17aaa9","owner":[],"postedDate":"June 12th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-23T16:12:14+00:00","versionOfRecord":{"articleIdentity":"rs-6732914","link":"https://doi.org/10.1186/s12889-026-27024-w","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2026-03-16 15:58:32","publishedOnDateReadable":"March 16th, 2026"},"versionCreatedAt":"2025-06-12 09:33:02","video":"","vorDoi":"10.1186/s12889-026-27024-w","vorDoiUrl":"https://doi.org/10.1186/s12889-026-27024-w","workflowStages":[]},"version":"v1","identity":"rs-6732914","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6732914","identity":"rs-6732914","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}