Developing public health risk messages about antibiotic resistance using metaphors: an international co-design and e-Delphi consensus study

Abstract

Antimicrobial resistance (AMR) is a global health threat, yet public awareness of its causes and risks remains low, limiting behaviour change. Metaphors—linking abstract ideas to familiar concepts—are promising but underused tools in AMR communication. We conducted the first systematic mixed-methods study to develop novel metaphors addressing key misunderstandings and behaviours. Co-design workshops with the public and doctors in the UK (n = 29) and public in South Africa (n = 22) generated 89 initial metaphors. These were extended through 101 additional suggestions, and evaluated via a 3-round e-Delphi study with 37 AMR communication experts from 27 countries, using the UCLA/RAND appropriateness method. 38 metaphors were endorsed for global use. Invoking domains like nature, tools, and fire fighting, they offer relatable, culturally resonant alternatives to alarmist war and doomsday imagery. This study pioneers participatory methods in behavioural science and provides a blueprint for co-creating health messages, such as tailoring AMR metaphors to specific needs.

Supplementary Information: The online version contains supplementary material available at 10.1038/s41598-026-40577-5.

Keywords: Analogy; Antibiotic resistance; Antimicrobial resistance; Drug-resistant infections; Metaphor; Public health; Risk communication.

Fig. 1

Examples of previous public health campaign materials about AMR incorporating visual metaphors. (a) Metaphorical comparison of antibiotic misuse with casual consumption of sweets as part of the ‘Handle antibiotics with care campaign’, image courtesy of WHO, used with permission, campaign available at: https://www.who.int/news-room/events/detail/2017/11/13/default-calendar/world-antibiotic-awareness-week-2017. (b) Metaphorical comparison of antibiotic use and virus software for treating viral infections as part of the 2017 European Antibiotic Awareness Day campaign, image adapted from ECDC, under CC BY 4.0, campaign available at: https://antibiotic.ecdc.europa.eu/en/poster-effective-protection-against-colds-or-flu-neither-are-antibiotics-antivirus. (c) Metaphorical comparison of an incomplete antibiotics course to a half-groomed dog as part of the ‘Don’t Leave It Halfway’ campaign from the first edition of the European Joint Action on Antimicrobial Resistance and Healthcare-Associated Infections (EU-JAMRAI) funded by the former Consumers, Health, Agriculture and Food Executive Agency (CHAFEA) of the European Commission under the Grant Agreement 761,296, used with permission, campaign available at: https://eu-jamrai.eu/jamrai1/dontleaveithalfway/.

Fig. 2

Key demographics of e-Delphi panellists. (a) Distribution of participants’ country of work by continent. (b) Distribution of participants’ employment sectors. c Participants’ work locations in the context of a global map.

Fig. 3

Overview of e-Delphi procedure and items rated in each round. Study process across three rounds of rating, including the number of metaphor items rated in each round, the origin of these items (original metaphor items suggested during co-design workshops or newly suggested metaphors from e-Delphi participants), the number of items removed in each round, and the number of items that were significantly reworded following participant feedback. All items from Round 1 were reworded following participant calls for shorter, more direct metaphors.