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

## TL;DR

This study creates effective metaphors to improve public understanding of antibiotic resistance through international collaboration and expert feedback.

## Contribution

The study introduces 38 globally endorsed metaphors for AMR communication developed via participatory methods.

## Key findings

- Co-design workshops generated 89 initial metaphors for AMR communication.
- 38 metaphors were endorsed by AMR communication experts from 27 countries.
- The metaphors use relatable domains like nature and firefighting instead of alarmist imagery.

## 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.

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