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

This study addresses the persistent gap between the global threat of antimicrobial resistance (AMR) and low public awareness by developing and systematically evaluating new metaphors to improve communication and encourage behaviour change. Through co-design workshops with members of the public and doctors in the UK and the public in South Africa (n=51 total), researchers generated 89 initial metaphors, expanded them with 101 additional suggestions, and then assessed their appropriateness via a three-round e-Delphi process involving 37 AMR communication experts from 27 countries. Using the UCLA/RAND method, 38 metaphors were endorsed for global use. Rather than relying on alarmist “war” or “doomsday” framing, the selected metaphors draw on relatable domains such as nature, tools and firefighting, offering culturally adaptable and constructive ways to explain AMR; the study provides a methodological blueprint for participatory, evidence-based health communication design.