Antimicrobial resistance (AMR) is a major threat to public health, but finding an effective way to communicate that threat to the public—and explain how overuse of antibiotics makes the problem worse—is notoriously difficult.

To date, many public messaging campaigns aiming to encourage responsible antibiotic use by the public—like not seeking antibiotics when you have a viral infection—have had a limited impact. Part of the problem is that many people are unaware of what AMR is. And even among those who are aware of AMR, it’s a complex topic.

For starters, many people are confused by the term “antimicrobial resistance,” said Stephen Flusberg, PhD, an assistant professor of cognitive science at Vassar College in Poughkeepsie, New York. Some think it’s a person’s body that becomes resistant to antibiotics, rather than the bacteria. And many people struggle with understanding evolution by natural selection, which is the process that explains why bacteria become resistant to antibiotics.

Another challenge is that many people see AMR as an abstract and distant threat rather than an issue that affects them personally. Trying to convince people that unnecessary use of an antibiotic today could result in an antibiotic-resistant infection that affects them 10 or 15 years from now can be a hard sell. Especially when they have a respiratory infection that they just can’t shake and believe an antibiotic will help them get better.

“There are a lot of issues with how complex the problem is, how abstract and far removed it is from people’s everyday experiences,” Flusberg told CIDRAP News.

It’s a challenge that Alistair Thorpe, PhD, a researcher and professor at the University of Utah’s Spencer Fox Eccles School of Medicine, has spent a lot of time thinking about.

“It’s a really tricky thing,” Thorpe said. “That temporal and physical distance is something that we’ve always found to be a challenge when we’re trying to communicate about the threat posed by antimicrobial resistance.”

Using analogies to make AMR more understandable

One strategy for framing the threat of AMR that’s garnered interest is the use of analogies. “Analogies can make complex or unfamiliar health threats more understandable by relating them to familiar experiences or concepts,” Thorpe and co-authors wrote in a paper published last week in Clinical Infectious Diseases.

The analogy chosen by Thorpe and his colleagues to convey the threat posed by AMR and unnecessary antibiotic use was the COVID-19 pandemic—a health crisis that everyone experienced and could relate to. Thorpe said that after speaking with clinicians who were trying to use this framing to help dissuade patients from unnecessary antibiotic use, he and his colleagues decided it was an approach worth testing systematically.

“We really want to develop strategies that are meaningful, intuitive, and helpful for patients, so when I saw that people were doing this, I thought we really should test it,” Thorpe said.

The paper describes an online survey that presented respondents with one of three messages. The first message described the impact of the AMR crisis as “much more severe than anything we’ve seen before” and “much more difficult to control.” The second message began by reminding survey respondents of the devastation caused by the COVID pandemic, then suggesting the impact of AMR will be more severe and difficult to control. The third message was a series of posters with graphics comparing AMR and COVID-19. 

That temporal and physical distance is something that we’ve always found to be a challenge when we’re trying to communicate about the threat posed by antimicrobial resistance.

All three messages ended by reminding people that most cold and flu symptoms can be treated at home with Tylenol (acetaminophen) or ibuprofen, plenty of fluids, and rest. Respondents were then presented with a scenario describing a viral respiratory infection and asked whether they would visit a primary care physician and/or seek antibiotics.

Thorpe explained that they asked about intentions to seek care, because that can start a process that leads to a patient getting an antibiotic.

“When we look at the literature on like what drives a lot of non–guideline-concordant prescribing from the patient side, it all starts from that visit,” he said. 

COVID analogy doesn’t hit

The messages comparing AMR to COVID-19 failed to move the needle, however. Overall, 67% of the 972 respondents (mean age, 42 years; 58% female) who completed the study said they would probably-or-definitely visit a primary care physician, and 64% said they probably-or-definitely want to take antibiotics—with no statistically significant difference between the three groups. 

Thorpe said that while he wasn’t surprised about the results, he was definitely disappointed. “It would be nice to have a strategy that we could tell people, ‘This is a great way to communicate to your patients and the public about AMR,’” he said.

Thorpe and his co-authors think the strategy may have failed because too much time has passed since the emergency phase of the COVID-19 pandemic, or because some respondents felt that the pandemic was a unique “one-off” event. Another explanation is that some respondents may have felt the impact of the pandemic was exaggerated—a theory supported by Flusberg.

“A lot of people think, ‘You know what? COVID wasn’t a big deal—I can’t believe they made me stay at home. I lost business. I lost money,’” said Flusberg, who wasn’t involved in the study. So some respondents may have had strong negative feelings about the pandemic and the response, rather than being concerned about the virus and its impact, he explained.

For Eva Krockow, PhD, an associate professor of psychology at the University of Leicester who wasn’t involved in the study, the lack of effect may reflect a problem with the “aptness of the overall comparison.”

“The comparison to COVID-19 might have helped to communicate the overall severity of the threat,” Krockow said in an email. “However, it didn’t communicate any other aspects that would have helped understanding of AMR or indeed appropriate AMR-related behaviours.”

For example, Krockow noted, while the messages stressed the importance of staying home and using antibiotics only when necessary, they didn’t explain the reason for that recommendation.

“The audience might not understand that antibiotic overuse can exacerbate resistance,” she said. “The comparison with COVID-19 doesn’t offer any helpful learning in this regard.”

Public health messages need to be tested

While he’s disappointed, Thorpe said there’s a benefit to learning that the COVID-19 analogy was not effective at dissuading unnecessary antibiotic use. 

“We want to know the strategies that are not useful,” he said. “We would not want to direct public health campaign messages toward this strategy when we haven’t seen any benefit in doing so.”

Krockow and Flusberg, who have studied and written about the use of metaphors for communicating AMR risk, said the study highlights the importance of using empirical methods to figure out the best way to communicate about AMR. 

“Historically when it comes to health communication, what you had was people who just used their intuition and said, ‘I think this will work. I’m going to do this. Let me spend lots of money and put up all these posters all over the city,’” Flusberg said. “And I just don’t think in this day and age that’s the right approach.”