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.