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.
Data availability
The quantitative data set from all three rounds of the e-Delphi study and the full list of all metaphor ideas across the different project stages can be accessed via the Open Science Framework: https:/osf.io/r4tqx.
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Acknowledgements
The authors gratefully acknowledge the support of Seed Creativity Ltd in facilitating the UK co-design workshops, the contributions of 51 co-design participants from the UK and South Africa, and 37 international AMR expert communicators, the following of which gave permission to be named: Oluwatosin Akinwotu, Laura Alonso Irujo on behalf of EU-JAMRAI 2 Communication Team, Chris Angwin, Diane Ashiru-Oredope, Lejla Beglerovic, Adrian Brink, Liz Callegari, Edward Demicoli, José Pablo Díaz Madriz, Kenneth C. Egwu, Eva Garmendia, Brigitte Gschmeidler, Gertrude Mmboga Kayeyia, Francesco M. Labricciosa, Maryn McKenna, Jameela Mohammed Al-Salman, Fabrizio Motta, Carine Naim, Jacqueline Nassuna, Marissa Novel on behalf of CARB-X, Bukola Opeyemi Oluwarinde, Céline Pulcini, John H. Rex, Nour Shamas, Diane Shader Smith, Shobha Shukla, Ernest Tambo, Erick Venant.
Funding
This work was supported by an ESRC New Investigator Award to the lead author (Grant reference: ES/X001652/1). MM declares funding by Wellcome Trust CAMO-Net grant (226690/Z/22/Z).
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**Eva Krockow: ** Conceptualisation, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Writing—original draft, Writing—review & editing. **Meghann Jones: ** Data curation, Investigation, Project administration, Writing—review & editing. **Samkele Mkumbuzi: ** Conceptualisation, Investigation, Writing—review & editing. **Marc Mendelson: ** Conceptualisation, Writing—review & editing. **Carolyn Tarrant: ** Conceptualisation, Methodology, Writing—review & editing. **Robert Froud: ** Data curation, Formal analysis, Methodology, Writing—review & editing. **Anastasia Koch: ** Investigation, Writing—review & editing. **Stephen Flusberg: ** Writing—review & editing. **Emma Pitchforth: ** Conceptualisation, Methodology, Writing—review & editing.
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RF is a Delphi methodologist and a director of Clinvivo Ltd, which provided services to deliver the e-Delphi study. The authors declare no other competing interests.
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Krockow, E.M., Jones, M., Mkumbuzi, S. et al. Developing public health risk messages about antibiotic resistance using metaphors: an international co-design and e-Delphi consensus study. Sci Rep (2026). https://doi.org/10.1038/s41598-026-40577-5
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DOI: https://doi.org/10.1038/s41598-026-40577-5