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Why The Media Matter
The news media have gained unprecedented influence at international, national, and local levels. The combined forces of globalization and technological advances mean that events on one side of the world almost instantaneously make the news in far-distant lands. When research is published in a journal in England, for example, it can create headlines and influence public debate in Africa. A health crisis in North America can quickly induce public and political responses throughout Australasia. The news media have a powerful effect on societies generally, in transmitting information, setting agendas, and influencing behavior of the public and private sectors, and of communities and individuals. These effects are particularly relevant for the health sector because of the media’s interest in reporting health issues; the public’s great interest in health issues fuels the media’s coverage of health, and this in turn drives public interest. Media coverage has been shown to have a range of effects relevant to public health, including influencing individuals’ health behaviors and understanding (Caburnay et al., 2003), health service utilization (Lawton et al., 2003; Schwartz and Woloshin, 2004; Chapman et al., 2005), government priorities, policies, and legislation (Harwood et al., 2005; Bryan-Jones and Chapman, 2006), and the actions of other sectors in society. The news, as noted by Dorfman et al. (2005), is a place of public conversation where policy issues are framed and debated. The agendas and behaviors of health professionals and researchers are also influenced by media coverage; studies covered by the media, for example, have higher citation rates than those that are not (Phillips et al., 1991; Chapman and Lupton, 1994).
Media coverage can have both positive and negative implications for public health. Widespread reporting of the dangers of smoking has been implicated in declining rates of smoking (Pierce and Gilpin, 2001). Coverage has also been credited with policy and legislative changes beneficial to public health in a wide range of areas, including tobacco and alcohol control (Woodruff, 1996; Asbridge, 2004). Content analyses of U.S. news media coverage (Long et al., 2006), of tobacco editorials (Smith et al., 2005), and of newspaper coverage in the United States and Australia (Durrant et al., 2003; Clegg Smith et al., 2005) show a general trend toward positive stories and support for policy advances. Indeed, the U.S. Advocacy Institute stated unequivocally, ‘‘News coverage has been the lifeblood of the tobacco control movement’’ (Advocacy Institute, 1999).
Lack of media coverage can also be a health issue, with the U.S. media’s early disinterest in AIDS being blamed for a lack of government action there. Otten (1992) cites a health policy analyst’s view that Washington did not pay attention to AIDS because the press did not. Others have noted the media’s lack of interest in sexually transmissible diseases more broadly (Davidson and Wallack, 2004). Media coverage can also promote information or responses that are not to the benefit of public health. Widespread reporting about vaccine safety concerns in the United Kingdom and elsewhere has been blamed for declines in vaccination rates (Leask, 2002). At the other end of the spectrum, media reporting has been shown to generally underplay the risks of medicines while overstating the benefits (Moynihan et al., 2000). Media coverage can distort political priorities, resource allocation, and public health and clinical practices (Sheldon, 2007). Its skewing of public perceptions of risk can have health consequences; for example, heightened parental concerns about children’s safety are often cited as a factor in childhood inactivity and obesity (Sweet, 2007). The media can also frame issues in a way that is not helpful for public health. Its preference for stories about medical advances, new drugs, high-technology equipment, and medical experts rather than public health agendas or broad policy issues has been noted (Haas et al., 2001; Caburnay et al., 2003). This has the potential to perpetuate victimblaming, rather than putting the focus on the broader social and environmental contributors to poor health. A recent analysis of health-related newspaper stories in Canada showed that socioeconomic influences were rarely cited as being influential in shaping population health outcomes (Hayes et al., 2007), contrary to the emphasis on this connection in the research literature. On the other hand, reporters and commentators were quite ruthless in highlighting the glaring social and cultural inequalities exposed in the aftermath of Hurricane Katrina (Alexander and Hanson, 2007).
In times of public health crisis, such as natural disasters or infectious diseases outbreaks, the media can be both helpful and obstructive. The French media were criticized (Boyer et al., 2005) for not giving the public practical preventive information during the 2003 heat wave, and for emphasizing business and ecological issues above public health policy. Television news journalists have been criticized for their emphasis on crime, property damage, and mortality figures during coverage of disasters while giving low priority to disaster preparedness and public health issues that occur in the aftermath (Anzur, 2000).
Relevant Trends And Developments In The Media
The media industry is in a state of transition internationally (Simons, 2006). In many countries, the future of ‘old’ media forms such as newspapers and television is unclear, due to cost pressures and competition for audiences and advertisers from ‘new’ media forms using the Internet and digital technologies.
The implications of these developments for public health are mixed. On the one hand, many traditional media outlets have fewer resources for in-depth, informed reporting generally (Collins et al., 2006). The corporatization of news values and the rise of celebrity-based tabloid style reporting also mitigate against in-depth examination of issues of significant public interest. The media generally recognizes health as an area likely to appeal to its audiences, with Haas and colleagues (2001) contending that health and medicine stories are the most frequent items of all news coverage. However, media outlets seeking to attract wealthy audiences (capable of attracting wealthy advertisers) are less likely to focus on health issues relevant to marginalized or disadvantaged groups in society (Armstrong et al., 2006).
The rise of new media forms has broadened the range of opportunities for reporting and also made information and news far more accessible to more diverse audiences. As Nightingale and Ross point out, the ‘‘proliferation of technologies for reproduction and distribution of media forms [has] allowed people to enjoy them in situations of their own choosing rather than at the whim of the broadcaster’’ (2003: 1). The advent of new media technologies and forms is also changing the nature of the relationship between media and its audiences, encouraging a more interactive dialogue and potentially allowing a greater range of voices to be heard (Nightingale and Ross, 2003). Blogging on the Internet has allowed citizens to report on their stories and opinions. Citizen journalism has increased the public’s access to and often their sense of involvement in news events and issues. This was evident, for example, after the 2007 massacre at a Virginia tertiary institution in the United States. Policinski (2007) observed:
Blogs provided a new-age supplement to the candlelight vigils and posted expressions of sorrow, and a means for citizens and journalists alike to talk to each other as never before about campus security, gun control and mental health.
He notes however, that ‘‘it’s much too soon to assess the full impact of this new combination of mainstream media and dramatic and personal ways of experiencing – not just receiving – the news.’’
The advent of new media forms and technologies has also been significant for those countries with controlled or repressed media, where it has made it more difficult for governments to suppress information and debate. However, journalist organizations argue that media freedom is under increasing threat around the world from hostile governments, conflict, and war (International Federation of Journalists, 2007). Even in democratic countries, the ability of the media to report on issues of public interest is being curtailed (Media, Entertainment and Arts Alliance, 2007). This poses a real threat to democracy, as Vivian asserts that ‘‘an informed and involved citizenry is possible in modern democracy only when the mass media work well’’ (Vivian, 2007: 3).
The Media And Public Health
As the nature and scope of public health has evolved and developed, so too has the field’s appreciation of the media’s role in its work. As public health has moved away from a focus on the behavior of individuals and toward working on the broader socioeconomic and environmental determinants of health, its approach to the media has likewise become more sophisticated. The public health sector increasingly views the media not so much as a vehicle for transmitting health information to individuals but as an opportunity for influencing the political, social, and environmental determinants of health (Gomm et al., 2006). Media advocacy typically involves coalitions working to achieve strategic use of the news media to advance a public policy initiative, often in the face of opposition from those with a vested interest in the status quo. It is increasingly seen as a core tool of the so-called ‘new public health,’ and its use has been reported by public health practitioners working across fields such as tobacco, alcohol, nutrition, cardiovascular disease, gun control, and transport (Wallack, 1994; Brownson et al., 1995; Glanz et al., 1995; Holder and Treno, 1997; Chapman and Wakefield, 2001; Mindell, 2001; Stillman et al., 2001; Hingson and Howland, 2002; Champion and Chapman, 2005; Gomm et al., 2006). The international reach of the media is increasingly relevant given the global nature of many contemporary public health concerns – whether the threat of new and emerging infectious diseases, the rise of chronic health problems such as obesity and diabetes, or the promotion of unhealthy products such as tobacco.
Concerns have been raised, however, that media advocacy is undervalued and underdeveloped as a public health discipline. Chapman (1999) has argued that the impact of media coverage on smoking rates and public perceptions of the tobacco industry, for example, is relatively understudied. He has also described advocacy as a ‘‘Cinderella branch of public health practice’’ (2004a: 361), and noted that few Master of Public Health programs formally address advocacy, there are comparatively few textbooks, and no journals devoted to its exploration.
Engaging With The Media: Potential Benefits
As with any intervention, decisions about whether to engage with the media, or how to do so, involve weighing up potential benefits, risks, and barriers.
As outlined in previous sections, media coverage can have a powerful impact in framing debate and influencing politicians, policy makers, professionals, the general public, and other groups, including the private sector. It can help to undermine barriers to better public health; for example, routine negative publicity about the tobacco industry is credited with undermining its public credibility and political influence (Christofides et al., 1999). The work of the Dart Center for Journalism and Trauma, based in the United States and with branches in Europe and Australasia, is helping to improve media coverage of violence and trauma.
There is also an opportunity cost to not engaging with the media, especially as many interests detrimental to public health are skilled at using the media to advance their causes (Freudenberg, 2005).
Wallack and Dorfman (1996) argue that media advocacy is too important not to do. They also describe how media advocacy provides a framework for moving the focus of health debates from individual behavior to behavior of policy makers. As they note, it addresses the power gap, rather than simply the information gap.
Media advocacy has also been recognized as a tool for promoting understanding and implementation of evidence-based approaches to practice and policy. Building coalitions to engage with media advocacy can have a side effect of helping to develop networks, skills, and capacity. Media advocacy can also be seen as a way of restoring power to communities and giving them the skills to cultivate and amplify their voice in public debates (Wallack, 1994).
Apart from the potential public benefits, engaging with the media can be helpful for academics and other advocates in raising their professional and personal profiles and increasing their spheres of influence. It has been suggested that the criteria for judging academic performance should be expanded to include academics’ work in knowledge translation or in ensuring their work influences policy or practice, and media advocacy is one way of achieving this.
It has been argued, however, that the evidence base for media advocacy as a reliable strategy for promoting health policy or behavior change is limited (Niederdeppe et al., 2007). This is at least partly because of the difficulty of evaluating interventions in complex, uncontrolled environments where many variables are at play (Stead et al., 2002). As well, measuring the effectiveness of media advocacy interventions is not as straightforward as with other public health programs because of the episodic and cyclic nature of media coverage on any given topic (Stillman et al., 2001).
Engaging With The Media: Potential Risks
Potential risks of engaging with the media arise at a number of levels: risks to public health objectives and thus to the public, and risks to those engaging with the media.
Engaging with the media is not always helpful, especially if it results in a debate dominated by stakeholders unsympathetic to public health objectives. One study of a community-wide intervention to reduce underage drinking in Louisiana suggested that increasing media coverage had potential to do harm as well as good (Harwood et al., 2005). Increased media coverage was associated with successful agenda setting but also with unsuccessful attempts to pass legislation. The successful passage of legislation tended to coincide with low coverage. The authors concluded that press inattention has potential benefits for policy makers in not allowing the opposition to mobilize and in allowing relevant interests to negotiate and compromise out of the public view. However, they also noted that the media spotlight might be helpful if behind-the scenes negotiations fail, or for blocking undesirable legislation. Other authors have concluded that while media advocacy may be successful in garnering attention, this does not always translate into helpful policy changes (Niederdeppe et al., 2007). Others have noted that news coverage featuring an important public health issue can do more harm than good if it reinforces approaches and attitudes that blame the victim and exclude the roles of governments and other institutions in solving the problem (Dorfman et al., 2005). As well, not everything done in the name of public health advocacy is always in the public interest. There is the possibility of misuse or of people mistaking their personal motives as being in the public interest.
Engaging with the media can also incur significant costs to the individuals and organizations involved. It is demanding, time-consuming work, often involving conflict and lack of control over outcomes. In one reported case, a confrontational media campaign exposed schisms in an organization that left it a far less effective advocate for policy change (DeJong, 1996). Public health advocates who develop a high media profile can face professional jealousy and criticism, which may or may not be legitimate. Their involvement in controversial debates can antagonize powerful enemies, including ‘‘retributive governments and litigious industries’’ (Chapman, 2001). Chapman has also reported receiving death threats because of his work lobbying for gun control.
Engaging With The Media: Potential Barriers
The barriers to effective media engagement are many, and reflect both the nature of the media industry as well as the public health sector.
As Dorfman (2003) has noted, newsworthiness rather than public health goals influences selection and reporting of health stories. The media operate in an intensely competitive environment and fight hard to attract and retain the interest of audiences overwhelmed by information and time pressures. It does this by telling dramatic stories and using human interest or personal anecdotes. This focus on individual stories and behaviors is a major barrier to those trying to reframe issues in a public health perspective. Obesity has, for example, been framed in much public debate as an issue of personal responsibility, which poses challenges to those seeking to influence the social and economic forces implicated (Dorfman and Wallack, 2007), and similar concerns have been raised about reporting of alcohol-related issues (Slater et al., 2006).
The media’s appetite for drama also means that sensational events, such as shark attacks, tend to garner more and bigger headlines than more ‘everyday’ and less dramatic events, such as deaths from smoking. One person killed by eating contaminated food can be more newsworthy than 4 million dying the world over, each and every year, from consuming tobacco products bought off the same store shelves (Shatenstein and Chapman, 2002). Journalists’ attitudes to health issues and how they should be covered are influenced by broader cultural and societal norms. In the United States, for example it has been argued that the dominant social value of individualism can be a barrier for those seeking to put health problems into a broader context (Wallack and Lawrence, 2005). Mental health advocacy groups, concerned by media coverage that both reflects and contributes to stigma about mental illness, have developed projects to promote more positive and accurate portrayals of mental illness. One such example is the Stigma Watch project run by Sane Australia. Further, most journalists covering health issues do not have specialist knowledge or expertise in the area. This can be a significant barrier to accurate and informed reporting, as was shown in a study of Nigerian journalists’ attitudes to AIDS, in which 29% believed HIV could be transmitted by a mosquito bite (Isibor and Ajuwon, 2004). The International Federation of Journalists is training journalists throughout Asia and Africa to improve their reporting of AIDS. Particular barriers may arise in developing countries, including limited exposure to media, low literacy levels, messages not being relevant to the audience’s needs, and the low credibility of messages conveyed by media controlled by government (Merson et al., 2006).
The media, deluged by information and events competing for limited news space and airtime, also has a short attention span. Few events receive prominent coverage for more than a few days at a time. Achieving sustained coverage for public health issues requires dedicated, long-term effort (Woodruff, 1996). It is a marathon, not a sprint, as tobacco control advocates have learned. Smith and Wakefield (2005) noted a decline in the media coverage of key problems such as addiction and the adverse health effects of smoking, suggesting that this was because the issues were no longer considered contentious. The Advocacy Institute (1999) has suggested that high-profile coverage of tobacco left many Americans believing the problem has been dealt with, and that years exposing tobacco industry wrongdoing has left the public numbed to additional revelations.
Some of the barriers to effective media engagement lie within the public health sector. Many public health practitioners are employed by governments, which often restrict their ability to engage in public debate (Regidor et al., 1997). Those working in academia do not necessarily see engaging with media or even disseminating their research findings as part of their core business (Dorfman, 2003). Indeed, researchers have reported difficulty in persuading colleagues to assist in efforts to publicize research relevant to tobacco control objectives (Chapman and Dominello, 2001). It has been suggested that academics may be reluctant to interpret research in terms of social change because this may require extrapolation beyond the ‘demonstrated facts’ and may be seen to compromise their scientific credibility (Rychetnik and Wise, 2004). Often, academics and other public health advocates do not have the time or institutional and administrative support to undertake such work. Even when public health professionals are willing and available to undertake media advocacy, they may lack the training and skills to be effective. The shortage of public health advocacy literature is a further obstacle for those wishing to develop skills and knowledge in the area (Chapman, 2004b).
Strategies And Tools For Engaging With The Media
The ‘two worlds’ paradigm has been widely used to explain how the differing priorities, expertise, and language of policy makers and researchers can impede the translation of evidence into policy and practice (Lin, 2004). The concept is also useful for those in the public health sector seeking to engage more effectively with the media. Public health professionals who understand and respect the differences between their world and that of the media are more likely to be able to engage effectively (Arkin, 1990; Woodruff, 1996). Trying to change the realities of the media world is more likely to be frustrating than successful, while working within those constraints may at least be more productive – if perhaps equally frustrating. These constraints include the time-pressured, competitive nature of the industry and its reliance on conflict and controversy, anecdote and sensationalism. However, taking a strategic approach to the media can help turn these potential negatives into positives for public health advocacy.
While attempting to provide a broad overview of media strategies relevant to public health goals, we are mindful that our perspective is very much skewed to the context of Western, democratic countries. Not all of the suggested strategies will be appropriate or even possible in every culture or context. Nonetheless, the globalization of the media suggests that at least some of the following elements of a media strategy may be broadly generalizable or applicable.
Planning And Preparation
The importance of identifying the public health problem and the objectives of media advocacy has been widely noted (Wallack and Dorfman, 1996; Gomm et al., 2006). Formal or informal surveys of key media players can help put the public health community in touch with the priorities and viewpoints of the various media (Arkin, 1990; Finer et al., 1997). Blows et al. (2005) have noted the wisdom of anticipating and strategically examining the strengths and weaknesses of likely opposing arguments and recognizing that facts do not necessarily speak for themselves, as other values, concerns, and agendas may have significant influence on policy outcomes.
It is valuable to keep asking the question, during both planning and execution of any campaign, of whether media advocacy is likely to be the most effective way of achieving the desired outcome. Chapman (2004) suggests that advocates should, wherever possible, try to first work with government or other decision makers to effect change. Politicians and other key decision makers are naturally keen to avoid being pressured and to be seen to lead initiatives, he says, and criticism can close doors. In such circumstances, he recommends dividing advocacy voices into the moderates who will continue to work the ‘inside route’ with government and the vanguards who will take a critical public role in the media, setting the public agenda.
Supportive coalitions and networks of supportive interests are often useful for adding depth and breadth to the campaign, and for reducing the likelihood of it being portrayed as the work of a self-interested, single-interest group or ‘the usual suspects’ (Chapman, 2004b; Gomm et al., 2006).
Organizations and spokespeople can benefit from formal media training to help them effectively frame and present messages and compete with adversaries (Dorfman et al., 2005). Rehearsing messages and practicing for interviews is recommended (Chapman, 2004b). It has been suggested that governments have a role to play in supporting community leaders and others to train in media advocacy techniques (Brownson et al., 1995). Public health officers in the United States have identified their own need for training in media skills (Gellert et al., 1994). Underrepresented stakeholders may also need assistance (Dorfman, 2003).
Identifying Appropriate Spokespeople
Spokespeople need to be accessible, effective, credible, reliable, and mindful of media deadline pressures (Wallack and Dorfman, 1996; Gomm et al., 2006).
Establishing and nurturing relationships with key media people or organizations, from journalists to editors and chief executive officers, can be productive, help develop a sense of mutual respect and understanding, and break down barriers (Arkin, 1990; Leask, 2002). Professional organizations representing journalists can also provide useful contacts.
Framing Messages With The Media’s Audiences In Mind
Think about who to reach, and how to make the messages, including any visual imagery, relevant to their needs, interests, and values. Dorfman and colleagues (2005) note that how a message is framed can either establish or bolster support for the change or reinforce the opposition. Understanding local culture, values, and context is critical (Chapman and Lupton, 1994; Clegg Smith et al., 2006). It can help to use data in a catchy, appealing format that the general public can easily grasp. Or use local data to make national problems relevant to a local audience (Chapman and Dominello, 2001; Dorfman, 2003).
The use of anecdotes can be anathema to public health professionals more comfortable with the currency of scientific evidence. However, stories and narrative techniques are effective communication devices and can be used to transmit evidence and knowledge. Metaphors and analogies are other powerful communication tools. Chapman (2001) argues that the sound bite that ‘‘a nonsmoking section of a restaurant is about as useless as a non-urinating section of a swimming pool’’ probably conveys more to the average person than any scientist’s earnest pronouncement.
Using Plain Language
Specialists in any field are so immersed in jargon that they often do not appreciate how much of their language is jargon-based, or that the rest of the world may not understand it. Jargon of any sort is a turn-off for the media and their audiences. It is critical to translate the professional lexicon into plain English.
Building A Well-Stocked Media Tool Kit
These are tools that can help make the message more relevant and useful to the media’s needs. They include the staging of newsworthy events and the harnessing of the media-pulling power of celebrities (Chapman and Leask, 2001; Chapman, 2004b; Chapman et al., 2005).
Engaging survivors and patients in advocacy can also add a powerful human face to the public health issue and make it more difficult for adversaries to dismiss public health ‘do-gooders’ (McLoughlin and Fennell, 2000). Media releases are an extremely cost-effective way of generating reportage that can expose potentially millions of people to public health information (Chapman et al., 2007). Pegging the message to local events, anniversaries, and other ‘news hooks’ can also help boost media interest (Wallack and Dorfman, 1996). Other tools include writing letters to the editor and telephoning talk-radio programs (Bryan-Jones and Chapman, 2006).
It is far easier, cheaper, and more effective to piggyback an issue or message onto an issue that is already dominating news headlines than to attempt to generate news interest in a ‘cold’ issue. The most carefully planned and executed media strategy culminating in a staged event, such as a news conference or the release of a report, will always be trumped by a major news event such as a disaster. This highlights the value of being responsive to unfolding events (Chapman and Wakefield, 2001).
Systematic monitoring and analysis of health coverage can help provide insights into how issues are being framed by the public, opponents, and decisions makers, and also to identify opportunities for advocacy. Monitoring and evaluation of media coverage can be a tool for promoting better reporting. This is the aim of linked projects in the United States, Canada, and Australia that evaluate media reporting of new treatments, with the aim of encouraging more balanced media reporting. Meanwhile, the Centre for Reviews and Dissemination at the University of York is behind the Web-based service Hitting the Headlines, which produces a rapid analysis of the evidence behind selected health stories reported in British newspapers. In a similar vein, a collaboration between journalists and academics has produced a tip sheet with the aim of improving reporting on medical treatments.
Utilizing New Technologies
The Internet and the digital age have opened up many new possibilities for media advocacy, including establishment of websites, e-mailing lists, and newsletters.
Persistence And Resilience
Media advocacy is demanding, labor-intensive, and difficult work that inevitably involves setbacks and frustrations. Take a long-term perspective.
Media coverage has a significant impact on public health by shaping the attitudes and actions of not only the general public but also policy makers, health professionals, and interest groups. Public health advocates who engage strategically with the media can do much to advance public health goals, but this requires planning, skills, and commitment. A greater investment in implementation and evaluation of media advocacy strategies would help develop a more useful evidence base for the field. The rapid development of new and emerging media technologies and forms is likely to bring new opportunities and challenges.
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