Written by Claire Kilpatrick
For over 10 years I have been fascinated with the words, indeed the language, we use in infection prevention and control (IPC). I channelled that interest into a multi country project where we tested some of the commonly used words in hand hygiene improvement, and have both published and presented on this (winning an innovation award, no less), and also talked about it in a podcast.
So, it made sense that I was invited to take part in an IPC Partners journal club, where I reviewed the paper: Risk communication about AMR: content analysis or metaphor use in global public discourse by Krockow et al, published in 2024. As well as a personal interest, I was driven to review the paper also because of my respect for the work of these authors.
To start, the authors noted the following as the reasons for exploring this topic; antimicrobial resistance (AMR) causes ~4.95 million associated deaths globally annually, public understanding of AMR remains poor, persistent misconceptions include – “Antibiotics work for viruses, I can stop them when I start to feel better”, People become resistant rather than bacteria”, etc.and communications, so far, have failed to influence perceptions.
What is interesting in this paper is the angle taken – the focus is not on the words per se but on metaphors. The author’s state that “a metaphor is a figure of speech that involves using words which literally apply to one thing (the ‘source’) to figuratively describe another (the ‘target’)” and that “this invites a comparison, highlighting correspondences between the two domains”, for example, “just as hostile enemy soldiers can invade a country and wreak havoc, so too can bacteria enter and damage the human body.”
The authors outlined in the paper that four metaphor themes accounted for 75% of all metaphors, following a search of websites and media, qualitative content analysis and thematic coding. These were categorised as:
- War against resistance
- Heroes and villains
- Post-antibiotic apocalypse
- Silent creeping threat.
It was described that “while the metaphors found were emotionally powerful and attention‑grabbing, they often misrepresented AMR as a finite fight between good and evil, rather than an ongoing, ecological challenge driven by microbial evolution and human behaviour”.
Some of the specific metaphors found were; “silent tsunami”, “medical dark ages”, “post-antibiotic apocalypse”.
A critique of these found that “fear-based metaphors may increase awareness, but also induce paralysis or fatalism”. The potential for paralysis or fatalism resonates with reflections undertaken by Julie Storr in her book chapter entitled – Do campaigns make you anxious: A focus on unintended consequences. There she prompts us to think about how messages are developed and delivered. Srivastava in 2019 wrote about language being a powerful tool in promoting healthy behaviours, and while choosing to focus on communication with patients, highlighted that “principles of effective communication such as tone and non-judgmental language among healthcare professionals” can ensure information is perceived as factual and as such, I believe, more impactful. They focused on the point that words have the capacity to empower or devastate people. We have also focused on the power of words and use of language in a previous blog and have reflected on the history of war metaphors in particular.
However, it seems that despite what we know on this topic, there is no clear solution to how we might consider adapting our language, if this is needed, which it likely is. Not just in relation to metaphors that might be used, but in every-day language. The journal club discussions concluded the same – we need a solution. But while we think about how to develop one, I suggest some immediate reflections and actions below.
Reflections and actions
I reflected on some of the journal club stimulation.
Firstly, a question asked on the journal club was – should IPC include the term management in its title? Here were some of the questions I posed to stimulate a decision on this matter:
- Who do we want to reach and influence?
- What are we trying to achieve?
- What does this word infer/what mood are we trying to create?
There may be no right or wrong answer for the terms we use, but instead a series of questions and criteria might be necessary to help us understand our reasoning, and not just based on our commonly used medical or improvement terminology.
Secondly, here is a summary of some of the key things I highlighted in relation to this topic:
- Use of particular language in day to day IPC, including, for example, use of the word compliance – what impact it this having when we use it in relation to hand hygiene and other IPC measures?
- IPC can’t fix everything, alone – the importance of collaboration and co-creation cannot be over emphasised – how many IPC teams liaise with communication, social or behavioural science, or human factors experts routinely?
- Learn from what has gone before – there is a wealth of learning to be had from both the research and operational implementation of hand hygiene improvement efforts across the globe that is relevant to this, and indeed many current IPC challenges. Hand hygiene is IPC and just because there is a pervading attitude in some areas that we have “done” hand hygiene and should move on, we can’t have a cancel culture when we think of hand hygiene! A mature, leadership, learning approach would be to draw on what worked and what didn’t in these decades of hand hygiene promotions, campaigning and improvement efforts.
In essence, to me, this isn’t just about metaphors. Thinking about how we communicate has the opportunity to address the area of health literacy, as also mentioned in the reviewed paper, as well as the misinformation challenge we are living through. Because as highlighted by Helen Clark at the 79th World Health Assembly in Geneva recently, misinformation is not just an issue of communication, it’s an issue of trust. As such the language we use can influence the trust we are aiming to build with those we work with. And trust is critical for successful implementation – a feature often outlined by the center for implementation. Health literacy isn’t just about access to information, it is essentially human, and using language that makes our IPC and AMR messages human is important, ergo considering the right metaphors and language that we use. I recently heard people say that using the word science is a turn off!
There is a lot to unpack here, and with a heavy IPC workload we might not think this has anything to do with the day to day IPC work. However, as I highlighted in the journal club – a feature in the WHO global action plan and monitoring framework is that all countries are expected to create a:
“National advocacy strategy and implementation plan, including the identification of local experts/champions, developed and implemented (by 2026).”
And for those interesting in research, consider this recommendation from the recently issued global research priorities paper:
“Determine the influence of message framing and use of language within {hand hygiene} campaigns across different cultures, contexts and cadres of the health workforce (including leaders).”
Everyone can play a role in all of this – showing and living IPC leadership for a service which has to compete with other priorities and needs to be fit for purpose in our times.
The paper reviewed concluded that many AMR metaphors amplify fear more than understanding and that future AMR and as such IPC communications may need to shift
“from war…to stewardship, ecology, relationships, and collective responsibility.”
Here I pose some final questions in this regard:
- Are war metaphors, for example, useful or harmful in IPC?
- Can fear-based messaging still be justified, even in times of emergency – are they overused?
- What metaphors actually engage healthcare workers to change their behaviour?
- Are there IPC metaphors we should retire?
- What would a person-centred metaphor for AMR look like?
- Does healthcare overestimate the power of awareness campaigns?
- What would your {revised} communication plan look like?
- How would you inform it? Who would be involved?
- How would/do you know you are using the right language?
- How would you sustain consistent use of the right language?
And some actions that can be taken now:
- Plan for how you talk about IPC
- Be purposeful with regards to the ideas that you generate for communicating on IPC – it might seem like a good idea but…Take some stimulation from a paper we previously published which outlined education entertainment (on YouTube) used to inform, influence, and shift societal and individual behaviours
- Test the language you are using or plan to use – what are people’s immediate perceptions, reactions?
- Review an available checklist of actions related to preparing and implementing communication and advocacy strategies, including deciding who to collaborate with to ensure the right expertise
- Outline how you will evaluate your communication activities.
I wonder, what the most common phrase you hear used in IPC is? Maybe this is a good place to start with regards to understanding if the language you are using is having the affect you would like to see.
I will end with a use of a metaphor from Prof Val Curtis, from around two decades ago, which very much relates to prevent of infection and falls into the category of a conventional metaphor reflecting human experience. This, and such metaphors, might be quickly forgotten, however, it still effectively frames the point. It went something like this:
“A bar of soap is like a vaccine that protects those suffering from conditions that make diarrhoeal disease in children far too common and life threatening.”
Thank you to Jon Otter and Phil Norville for the opportunity to discuss this topic on the journal club.