Agenda Setting in Health and Risk Messaging
Summary and Keywords
Since McCombs and Shaw first introduced the theory in 1972, agenda setting has emerged as one of the most influential perspectives in the study of the effects of mass media. Broadly defined, “agenda setting” refers to the ability of mass media sources to identify the most salient topics, thereby “setting the agendas” for audiences. In telling us what to think about, then, mass media sources are perceived to play an influential role in determining priorities related to policies, values, and knowledge on a given topic or issue.
Scholars have studied this phenomenon according to both object (issue) salience and attribute salience and along aggregate and individual audience responses. The audience characteristics of need for orientation, uncertainty, relevance, and involvement are advanced as moderating and predicting agenda-setting effects. When agenda-setting theory is applied to the study of messaging related to health and risk communication, scholars have reviewed and identified common themes and topics that generally include media’s role in educating and informing the public about specific health conditions as well as public health priorities and administrative policies.
Agenda setting is often examined in terms of measuring mass media effects on audiences. Looking at interpersonal communication, such as that coming from medical providers, opinion leaders, or peer networks, in studies will allow research to examine the combined effects of interpersonal and mass communication. Testing possible interactions among differing sources of information along with assessment of issue and attribute salience among audiences according to an agenda-setting framework serves to document audience trends and lived experiences with regard to mass media, health, and risk communication.
The study of mass media according to their effects on audiences is the dominant paradigm in mass communication research. There are both practical and ethical reasons for this emphasis. The study of effects can be done using a broad range of research methods, and concerns about possible harmful effects of mass media exposure are likely among the general public (Harris & Sanborn, 2014). Its assumptions, in looking at various possible direct, conditional, and cumulative effects of mass media exposure among audience members, combined with a general emphasis on quantitative research methods across the body of research clearly situate agenda-setting theory within this perspective.
In 1972, McCombs and Shaw published research on voting behaviors among undecided voters in Chapel Hill, North Carolina, ranking key issues considered representative of the public agenda. When compared with the key issues reported by the major news sources, the issues corresponded highly, leading McCombs and Shaw to establish what, after decades of supporting research, has become a foundational assumption regarding the relationship between social and political agendas: the agenda-setting function of mass media.
Broadly defined, “agenda setting” refers to the ability of mass media sources to identify the most salient topics, thereby “setting the agendas” for audiences. In telling us what to think about, then, mass media sources are perceived to play an influential role in determining priorities related to policies, values, and knowledge on a given topic or issue. An “agenda” is defined as a set of attributes associated with an issue. Agenda setting may be examined by looking broadly at defined agendas (first level) and attributes associated with an agenda (second level).
The “Acapulco Typology” was advanced by McCombs to describe the key positions, as reflected in measurement strategies, scholars have used to advance our understanding of how mass media set public agendas. The typology arranges examinations of the agenda-setting function of the mass media into four categories along two dichotomous dimensions: along one, an assessment of the entire set of items that make an agenda versus an examination of attributes within an agenda, and along the other, aggregate measures of salience versus individual-level measures.
In the “Competition” perspective, the entire agenda and aggregate levels of salience are combined, while in the “Automaton” perspective, the entire agenda and individual levels of salience are examined. The “Natural History” perspective examines a single attribute and aggregate levels of salience, while the “Cognitive Portrait” perspective measures a single attribute and individual levels of salience. Looking across these four dimensions, the body of research on agenda setting to date enables confidence in the agenda-setting phenomenon as a legitimate media effect.
On the broad level, “mass communication effects can result from the sheer volume of exposure, as we see in first-level agenda setting” (McCombs & Reynolds, 2002, p. 15). Research documenting powerful media effects, such as those documented by Rogers in 2002, appears to illustrate first-level agenda-setting effects. In comparison, and in particular with regard to the ability to examine the effects of attributes of interest within the agendas of health and risk, attention has been paid to the study of the second-level, or attribute agenda setting.
Kim, Sheufele, and Shanahan (2002) wrote about the attribute agenda function of the press and the public’s evaluation of a local issue, studying effects in terms of perceived salience as a result of media influence. These scholars found that not only were their findings consistent with agenda-setting assumptions, but an additional priming effect had occurred. In other words, mass media were able to not only set agendas but also influence how audiences thought about certain issues. Studies such as these have led the scholarly community to generally assume that mass media can have powerful influence over audiences, on certain topics and in certain conditions, and in concert with other forms of communication about an issue.
Health and Risk as Agendas and Attributes
Culbertson and Stempel (1984) conducted one of the earliest studies examining agenda setting and medical news, comparing public agendas collected via telephone survey data with local newspaper coverage of health issues. Thirteen health-related topics were coded in a content analysis of 11 newspapers. While the research found high consistency across publications in terms of the most frequent health topics covered, agenda-setting effects were “weak or nonexistent” across the eight main categories or attributes within the identified healthcare agenda. Based on their analyses, Culbertson and Stempel (1984) conclude, “the relatively great emphasis on news about diseases and specific health problems appeared to have little if any impact on people’s agendas” (p. 60).
In 1992, Wallack and Dorfman published an American Journal of Public Health article summarizing research on health agendas present in television news. This study involved a content analysis of broadcast news to examine framing and agenda setting of health issues and found, in general, that health stories were presented in terms of individual behavior or responsibility. Conversely, social and economic factors external to the individual were “largely ignored.” The media further emphasized the science of biomedical or technological solutions to health problems. Wallack and Dorfman (1992, p. 126) wrote that their findings contributed to “public health problems being understood in isolation from the larger social and political context … Journalistic practices likely contribute to the hegemony of individual-level explanations of health issues and so may systematically inhibit a broader public health understanding of health problems.”
Recent research has advanced these earlier studies and furthered the examination of the agenda-setting function of mass media through the application of the theory to a variety of health and risk topics and through the use of a range of methodologies. Some studies applying agenda-setting theory to health and risk communication have relied on content analyses to identify health and risk agendas present in news outlets. Lee and Len-Rios (2014) identified topic salience in reporting through an analysis of second-level agenda setting about obesity in black and general audience newspapers, while Barnes, Hanson, Novilla, Meacham, and McIntyre (2008) analyzed local and national U.S. newspapers to examine media coverage of issues related to Hurricane Katrina.
Other studies have incorporated audience measures in attempting to more clearly define linkages between communication about health and risk, public perceptions, and policy. For example, Dixon, Warne, Scully, Dobbinson, and Wakefield (2014) compared media content with telephone survey data to assess agenda-setting effects of sun-related news coverage on public attitudes and beliefs about skin cancer in Australia. The study was successful in documenting second-level agenda setting effects among audience segments, documenting specific types of appeals, or attributes, and their effects on older and younger audiences. Conway (2013) content-analyzed national U.S. newspapers, news broadcasts, and major metropolitan newspapers and compared data to the Rasmussen national public opinion poll to examine second-level agenda-setting effects related to media coverage of “Obamacare.” The results of this study suggest negative coverage of the national health policy legislation had an impact on audience evaluations, and in comparing survey results with news media content, attitude strength was correlated with media coverage along both attributes and agendas.
In research examining newspaper coverage of tobacco issues focused on youth, Smith and Wakefield (2006) found that media coverage tended to conceptualize the health issue as being one of a need for greater individual-level education rather than structural or policy changes. Trumbo (2012) applied agenda-setting theory in an examination of newspaper coverage of attributes related to influenza and influenza-related medical visits, and Jarlenski and Barry (2013) investigated the ability of mass media to set public agendas related to trans-fat risks. Each of these studies documented agenda-setting effects among audiences related to important health and risk issues.
Some scholars have conducted content studies to examine possible agenda-setting effects across media platforms, or intermedia agenda-setting effects, with coverage of health issues in African media being an area of particular interest. While such studies cannot be viewed as providing direct correlations between audience reactions and media content, they are useful in providing systematic assessments of health-related content in identifying dominant content and themes appearing in significant news outlets, as a direct measure of issues and topics media professionals have chosen to highlight in their reporting. These types of studies are also valuable when direct assessments of audiences are not available or feasible, or when researchers are attempting to assess the efforts of opinion leaders or nedia advocacy efforts in comparing types of coverage across varying media outlets. To illustrate, Pratt, Ha, and Pratt (2002), in research on reporting of issues related to major diseases in sub-Saharan Africa, found that media coverage and framing of major diseases such as malaria, tuberculosis, and AIDS were reported differently by newspapers, magazines, and medical journals. The study additionally found that AIDS was framed as a stigmatized disease in newspapers and magazines, but not in medical journals. Based on their findings, Pratt et al. (2002) concluded, “this study has shown that African media practitioners have not articulated the issues with the community model, which would involve the public at large, in mind” (p. 901).
In another comparison of different media outlets’ coverage of health information, Thompson and Yeboah (2013) reviewed content about malaria, hepatitis, and HIV/AIDS in Ghanaian newspapers and radio, considering that high illiteracy levels in that country significantly impact media use. In comparing newspaper and radio content related to health risk agendas, the authors noted that media convergence did not lead radio programming to set public health agendas. In another study, D’Angelo, Pollock, Kiernicki, and Shaw (2013) content-analyzed media coverage of news related to HIV/AIDS in Africa, concluding that media coverage generally framed social costs as responsibilities of non-governmental agencies, while government responsibility was emphasized slightly more in “contained democratic” versus “repressive autocratic” media systems. Media coverage of medical developments were consistent across media systems, while prevention campaigns were more often reported as successful in contained democratic versus repressive autocratic systems.
Scholars have also investigated various intersections between mass and interpersonal communication within the agenda-setting framework.1 Yanovitzky and Blitz (2000) studied the combined influence of mass media and interpersonal communication on women’s breast cancer screening, and in an example of agenda-setting theory applied to health issues, Jones, Denham, and Springston (2006) studied the effects of interpersonal communication in conjunction with mass communication among a group of college students and their mothers. This research looked at communication coming from interpersonal sources in a combined application of agenda setting and two-step flow theories and surveyed college students and their mothers on their experiences with breast cancer, breast cancer screening behaviors (female participants), and knowledge about breast cancer and genetics. Participants were also surveyed regarding their media use related to breast cancer topics.
Attribute agenda setting was further supported in a follow-up study by Jones and Pelton (2009), who content-analyzed the most commonly cited media sources and topics and found correlations with topics and sources most commonly identified by participants in the Jones et al. (2006) study.
Taking a slightly different, and highly valuable, approach to efforts to include possible effects of interpersonal communication on audience perceptions and attitudes, several scholars have extended our understanding of the agenda-setting function of mass media related to health and risk by including research on interpersonal opinion leaders, policymakers, or other stakeholders who are in a position to not only interpret but also influence media content. In one study examining the role of mass media in policy setting and implementation related to Ghana’s capitation policy for primary care maternal services, Koduah, Van Dijk, and Agyepong (2016) conducted content analysis of media messages along with in-depth interviews and observations among agency leaders, politicians, health practitioners, and community activists to examine the impact of “opposing stakeholders” on media coverage of health policy and subsequent changes. The study is an important example of how powerful stakeholders (in this case, medical providers) can use media to pressure policymakers through “contestation and resistance” efforts (Koduah et al., 2016, p. 6). In a study on the emergence of maternal health as a political priority in one state in India, scholars combined qualitative interviews with representatives from four stakeholder groups, comparing these results to news media content and situating in context of multiple policy efforts (Jat, Deo, Goicolea, Hurtig, & San Sebastian, 2013). This study found support for the influence of increasing media coverage on maternal health issues as one factor affecting policy change.
Other scholars have focused exclusively on interviewing media workers or journalists in attempts to identify motivations and perceptions among these key stakeholders. In one study, Strand (2010) examined factors associated with high media coverage of the HIV epidemic in southern Africa through qualitative interviews with media workers and found high levels of personal commitment to prevention behaviors, determined to be the result of interrelated factors such as personal experience. When situated within the broader context of agenda setting and health and risk, this scholarship could be integrated and examined along with other research considering involvement-related audience characteristics, as “personal experience” and “personal commitment” can be viewed and interpreted in the contexts of both involvement and need for orientation. In other research, Wallington, Blake, Taylor-Clark, and Viswanath (2010) interviewed health journalists working in the northeastern United States to assess possible barriers journalists face when covering health disparities. These scholars identified considerations journalists make when covering health news, with media professionals noting public impact and personal behavior change as common attributes of interest. Journalists cited difficulties in interpreting and evaluating medical information related to health disparities, highlighting opportunities for public health professionals to address related to influencing public dialogue about health disparities.
Agenda Setting, Media Advocacy, and Public Health
As Dorfman and Krasnow write, “agenda setting and framing have been the core concepts informing media strategy” (2014, p. 296), with agenda setting’s theoretical assumptions serving as the underpinnings of any media advocacy efforts related to public communication about health and risk. A number of studies have specifically examined agenda-setting effects from this media advocacy perspective, as when specifically related to the potential for news media to influence public health policy. These types of studies, in specifically looking at the effects of mass communication on public policy, represent an agenda-building or advocacy perspective, extending our understanding of the agenda-setting process related to health and risk communication. To illustrate, Sato (2003) examined the intersection of public interest groups and mass media’s effects on smoking policy in Japan, and in a study of first- and second-level agenda-setting effects related to broad issues of crime, unemployment, health, poverty, and education in Chile, Valenzuela (2011) examined agenda-building relationships between president and media in a “top-down pattern” of agenda adoption. In this study, Valenzuela (2011) found policy preferences were negotiated between the president and news media, without noticeable public input. In other research, expert stakeholders’ impact as drivers of media coverage and policy has been studied related to chlorine in Canadian drinking water (Driedger & Eyles, 2003) long-term care rebalancing in the United States (Miller et al., 2015), and public communication about autism leading to the passage of the U.S. Combating Autism Act of 2006 (McKeever, 2012).
In pursuing questions related to the impact of media coverage on policies related to health and risk, scholars have turned to increasingly sophisticated research designs and combined methods of inquiry. In one study, Kiousis, Park, Kim, and Go (2013) examined agenda-setting effects related to healthcare reform in the United States through a triangulated methodology including content analysis of news media coverage and “information subsidies” provided by federal government offices, Congress, and other healthcare-related stakeholder groups, combined with an assessment of “policymaking activity.” The analyses revealed several significant correlations among information subsidies, news media coverage, and policymaking activity and found robust linkages concerning issue attribute salience. Specifically, “in terms of issue salience, modest associations were found between information subsidies and news media coverage, while strong linkages were found between information subsidies and policymaking activity” (Kiousis et al., 2013, p. 664). Based on these findings, Kiousis et al. (2013) conclude that “stakeholder salience” is an important object to include, along with issue salience, in studies seeking to document agenda-setting and agenda-building effects.
Event history analysis was employed by Kiss (2013) in a study designed to examine agenda-setting effects and legislation to regulate bisphenol A (BPA), a chemical used in plastics and sealants in the United States. Policies related to BPA are intriguing from a scientific perspective, since “there is deep scientific conflict over whether BPA causes harmful effects to humans at levels at which we are currently exposed” (Kiss, 2013, p. 695). Kiss used event history analysis—“a well-established statistical method with roots in epidemiology, medicine, public health, and engineering processes, where the object of interest is the start of some process until the onset of some other event” (2013, p. 697)—employing information from state legislative databases to track the rate at which states adopted or considered legislation banning products made from BPA. To determine the effects of media coverage on legislative activity, daily newspaper coverage about BPA was content-analyzed and relationships between specific topics, or attributes, were compared to legislative outcomes. Controlling for environmental sentiment, partisanship, professionalism, and regional diffusion, “increased levels of high-impact newspaper coverage about potential negative health hazards was weakly related to the chance that a state would introduce legislation for the first time but strongly and significantly related to the chance that a state would introduce legislation banning products made with BPA a second time” (Kiss, 2013, p. 709).
Discussion of the Literature
Hundreds of studies conducted over nearly four decades have applied agenda setting’s theoretical constructs to examine mass media’s ability to set public agendas on a variety of social and political issues. With few exceptions, the extension of agenda-setting theory by scholars wishing to examine the effects of media coverage of health and risk has taken place primarily during the past decade (2006–2016). Scholars have examined broad health and risk agendas as well as their associated attributes. Some studies have consisted of content analyses of texts, while others have included examinations of communication from individuals, groups, and organizations to consider possible effects of in concert with mass media. Effects of media coverage on public health policy are documented, along with the influence of government and other agencies on media coverage about health.
Clearly, research has demonstrated the potential for agenda-setting theory to be applied to health and risk communication. In identifying the most salient topics among audiences related to various health and risk issues, these investigations could be particularly relevant in conditions when risks are immediate and pose significant threats, such as research conducted on the effects of media on the HIV/AIDS epidemic in African nations and states. Other important scholarship has looked at mass media’s ability to set agendas for public health policies on a range of issues, and documented source factors related to agenda setting, showing variations in news outlets and individual factors as moderating variables. Intermedia agenda setting studies, designed to specifically examine which media outlets and forms are most influential in setting each other’s, and in turn, public agendas about health and risk, will continue to be important and relevant as the mass communication landscape shifts to include social media and other “new” media sources as part of the communication mix.
In documenting causality in the agenda setting process, research should continue to follow in the tradition of McCombs and Shaw’s original intent in providing not only content analyses of text but also comparisons of media coverage with direct measures of public agendas and opinions. Social media could provide valuable insights here, as many platforms include built-in mechanisms to content analyze with time stamp measures of audience response. These new platforms enable us to document who influences whom (or at least which messages occur in conjunction with measures of audience perceptions). Studies that only examine media content without providing a correlation with measures of existing public agendas, or attributes within agendas, cannot directly measure salience, an important aspect of agenda-setting theory. However, while studies that rely exclusively on examining media content are not directly testing the agenda-setting phenomenon, such research has been insightful in identifying which news agendas are the most frequently covered in various geopolitical areas and provides important baseline measures for comparisons.
The most promising research methods in this area of scholarship are those that involve triangulation, as multiple direct measures of both media content and audience perceptions are needed to directly assess the agenda-setting ability of the press. To illustrate, some recent studies have conducted extensive qualitative research combined with quantitative analysis to draw logical and significant conclusions related not only to the effects of media coverage on audiences but also who influences whom. Studies that involve interviews and other direct examinations of key stakeholders and media advocates are able to even more accurately assess the path of influence in the agenda-setting model. Scholars should also continue to incorporate health informatics to provide valuable measures of the relationship of these data to public perceptions and media representations of health and risk.
In revisiting McCombs’ Acapulco Typology as a method of categorizing the research done on agenda setting related to health and risk messaging, studies may be observed as documenting research across the spectrum, including examinations of media coverage of both broad agendas and attributes, and looking at effects at individual and societal levels. For example, research following the competition perspective, looking at categorical agenda-setting effects among aggregate audiences, allows researchers to provide evidence of mass media’s ability to influence effects on social change and policy. Such an approach is reflective of public health’s broadly defined, population-based priorities and mission. Comparatively, studies representing the natural history, cognitive portrait, and automaton perspectives can shed light on varying levels of influence of mass media related to health and risk perceptions and communication.
An area of study that has unique potential to advance the study of health and risk communication from an agenda-setting perspective is in conducting and extending research on individual-level audience characteristics and factors as an approach to identify how such factors serve to influence or moderate the ability of mass media to set public agendas, both broadly and at the attribute or second level. For example, one audience characteristic that has received some interest among scholars, and should continue to be explored, is need for orientation.
Need for orientation is conceptualized as cognitive mapping defined in terms of relevance and uncertainty: when relevance and uncertainty are both high, need for orientation is high (McCombs & Reynolds, 2002). With regard to agenda setting and health and risk communication, there is potential to study how health or other risks correspond with need for orientation, and in turn possible correspondence with those risks are communicated through mass media. Uncertainty management (see Brashers, 2001) is widely considered to be a key factor in information seeking and other communication behaviors related to health and has been specifically explored in relationship to media effects on public perceptions about breast cancer risk (Jones et al., 2007). Addressing relevance and uncertainty as constructs of interest in developing audience-centered messages about health and risk should further our understanding of the agenda-setting process across a range of agendas and issues.
The construct of involvement, which may be viewed as a related construct to relevance, includes the extent to which an individual is interested and personally involved in a topic and was examined as an audience characteristic by Yang and Stone (2003) and, later, by Jones et al. (2007). These studies found effects related to involvement and agenda setting at the attribute level. To extend this line of research, the construct should continue to be examined as an indicator or predictor of agenda setting and priming effects. When applied to health and risk communication and perceptions from an agenda-setting framework, such scholarship would be particularly useful at the attribute level, looking at specific health settings, audiences, and conditions.
Finally, more research should be done to represent the perspectives and characteristics of media gatekeepers and other influencers, acknowledging the critical role media workers, policymakers, and others play in setting and constructing public health and risk agendas. Direct examination of each level or “entry point” in the agenda-setting process must continue to provide a full picture of the ability for mass media to set public agendas on health and risk topics.
If the future of public health continues to shift toward an increased focus on community or stakeholder empowerment, scholarship employing an agenda-setting framework will remain particularly relevant. In documenting the ability of mass media to work in concert with other forms of communication to influence audiences according to agendas, issues, and attributes, the theory is particularly well suited to examine research, process, and products of health agenda setting, agenda building, and media advocacy efforts, as these correspond well with identifiable and measurable health policies, conditions, and issues. The research in this area provides important insights into the mechanisms and processes through which mass media work to set public agendas about a number of social issues, including health and risk.
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