Popular Media and Exposure to Health and Risk Messages
Summary and Keywords
Popular media are a source of information, a powerful socializing agent, and generate sociopolitical and sociocultural meanings that impinge on health promotion and/or disease prevention efforts and individual lived experiences. Thus, motivated by the goal of improving individual and social health, multidisciplinary scholars attend to the implications of entertainment and news media with regard to a range of topics such as individual health threats related to prevention, health conditions and illnesses, patient–provider interactions and expectations, public health issues related to crisis management and health recommendations, and public policy. Scholarship in this line of research may approach the study of popular media guided by the social scientific tradition of media effects theory to explain and predict response or by critical theory to consider ideological implications and employ different methodologies to describe and evaluate the images of health and health-related matters to which people are being exposed or that focus on media representations or audience (both individual and societal) response.
Popular Media Defined
Popular media may be understood as mass-mediated messages in the domains of entertainment, news/journalism, and advertising. At first glance, this appears to be a fairly straightforward definition, yet in the context of health communication scholarship, which includes a large body of research referencing these domains in various ways, this definition requires some explanation. First, “popular” (mass) media are best understood in contrast to other mass media texts. Keep in mind that from the start of the health communication discipline in the early 1970s, mass-mediated messages have been an integral part of health promotion and education efforts that employed various forms of print and broadcast mass media to circulate pro-health messages. In one line of research and practice called entertainment-education, health professionals actively seek to educate individuals by integrating health messages in mainstream popular entertainment media (discussed below). More aptly referred to as health education and/or health promotion (mass) media, health professionals produce these mass-mediated messages to foster individual cognitive, affective, and behavioral changes hoping that they will lead to better individual and public health outcomes. Alternatively, popular (mass) media are manifestations of popular culture. Though a number of ways to define popular culture have emerged alongside the changing landscape of social theory, it is helpful to think in terms of “that with which it is being contrasted” (Storey, 2013, p. 13). In the context of health communication, the definition of mass-mediated popular culture texts—that is, popular media—presumes nothing other than the absence of mass-mediated communication identifiably designed for a definable health promotion/education goal.
Second, given that the proliferation of media technologies make entertainment, news, and advertising available through a variety of media—indeed, the same media formats used for health communication interventions—it is necessary to note that the (mass) medium itself (television, film, radio, newspaper, magazine, Internet, etc.) is not the distinguishing characteristic of popular media. As alluded to above, the message producer differentiates popular media from other mass-mediated communication and new technologies allow for differing degrees of authorship. Though some health-related popular media research attends to the static webpages of news organizations, the Internet has irrevocably altered the media environment (Lupton, 2016). On the one hand, the Internet is simply another medium for distributing messages to mass audiences and Internet content may mirror that of traditional media. For instance, movies and TV shows can now be watched via the Internet, most major news organizations have a website, and advertising “pop-ups” are almost inevitable whenever one accesses the Internet. Yet the Internet also allows for various forms of audience interactivity (i.e., authorship) not possible with traditional media such as comment sections, blogs, and social networks (e.g., Facebook, Spotify, Twitter). Acknowledging the distinctive characteristics of social media in contrast to “traditional” mass media helps to define “popular media.” Briefly, social media are Internet-based applications which are multidirectional and incorporate interactive tools alterable by lay public users, whereas traditional media are one-directional messages created by an individual (often corporate or institutional) producer which cannot be altered by audience members.
Research on news and entertainment media, though taking slightly different tracks, tends to run parallel and toward similar types of conclusions, therefore this article focuses on scholarship related to these domains of popular media. However, this article does not discuss the research on advertising that is intentionally persuasive, often with the undeniable goal of selling the very products and behavioral choices that health professionals seek to mitigate through their research. Though some research attempts to “expose” the unhealthy aspects of commercial sales efforts with regard to tobacco, alcohol, and nutrition—research that could prove useful in media advocacy and media literacy efforts discussed below—advertising research seems to have shifted to analyzing the persuasive appeals of direct-to-consumer (DTC) and over-the-counter (OTC) print and broadcast sales efforts.
Entertainment and news media scholars share a concern with the seemingly unintentional biases of the producers, addressing a wide range of topics such as individual health threats related to prevention (e.g., risk, wellness) and health conditions and illnesses (e.g., cancer, mental health), patient–provider interactions and expectations, public health issues related to crisis management (e.g., infectious disease) and health recommendations (e.g., immunization, mammograms, food safety, organ donation), or public policy regulations that affect public health (e.g., alcohol and tobacco control). To explore these issues, scholars may attend to media representations or to viewer effects/response, which, in turn, may invoke different relevant theory and/or methodologies such as quantitative social scientific or qualitative interpretive/critical methods. Understanding how popular media can influence individuals and society may equip health professionals committed to improving health outcomes to collaborate with media producers and educate consumers. By panning out to review this research, this article highlights some of the common avenues of scholarly exploration.
Popular Media in Health Communication
During the nascent years of the health communication discipline, popular media were not immediately posed as markedly germane to health education and promotion. In the 1984 foundational textbook Health Communication: Theory and Practice, Gary L. Kreps and Barbara C. Thornton briefly alluded to popular mass media, commenting that newspapers had “not been found to be as influential in setting agendas for the public in health related campaigns” as in political campaigns (p. 79). With regard to entertainment media they noted that in film and on television doctors and the health care system were depicted as either overly positive or negative and, in doing so, set unrealistic expectations for audience members. The remainder of the chapter “Mediated Communication in Health Care” was devoted to the use of print, audiovisual, and interactive media (i.e., telephones, closed-circuit television, and computers) by health professionals as tools for disseminating health information. That perspective changed quickly.
By 1990, the growth of popular media research related to health, illness, and medicine could be seen in most health communication survey textbooks and edited volumes, books that investigated health-related representations in different genres and topics, and the surge of empirical research in a range of interdisciplinary journals (see Kline, 2006). A 2013 meta-analysis of flagship journal articles published between 2000 and 2009 in Health Communication and the Journal of Health Communication found that the top non-physical health topic addressed was the role of media in health (Nazione, Pace, Russell, & Silk, 2013). The recent Sage Encyclopedia of Health Communication includes a number of specific sections related to popular media as well as discussions regarding the implications of popular media representations in other topics not explicitly about popular media (Thompson, 2014).
Perhaps most telling, the implications of popular media for public health are now recognized by public health agencies: Healthy People 2010 alluded to the relevance of “images of health in the mass media and the culture at large” (USDHHS, 2000), and The Future of the Public’s Health in the 21st Century, produced by the Institute of Medicine (2003), included extended discussions of journalism, entertainment, and advertising. Since 1997, the Centers for Disease Control and Prevention (CDC) and later the National Cancer Institute (NCI), as well as a number of other funding agencies, have worked in collaboration with Hollywood, Health & Society at the USC Annenberg Norman Lear Center, which seeks to provide “entertainment industry professionals with accurate and timely information for health storylines” (Hollywood, Health & Society, 2016a).
Not all cultures have the same access to and experience with mass media (Dutta, 2008), but to say that mass media are pervasive and ubiquitous in 21st-century society seems to be self-evident. From a health communication viewpoint, popular media serves as a source of information, functions as a powerful socializing agent, and generates sociopolitical and sociocultural meanings. Thus, the need for research on popular media in health communication has been guided by two assumptions: that health promotion and/or disease prevention efforts might be helped or hindered by the pervasive ideas and images of health and illness in popular media and that personal and social understandings resulting from exposure to these ideas and images impinge on individual lived experiences of health and illness. Ultimately, this research is motivated by the goal of improving individual and social health.
Popular media research related to health and risk communication is inherently multidisciplinary and has benefited from work in the areas of sociology (Lupton, 2000; Seale, 2004), psychology (Anstiss & Lyons, 2014; Lyons, 2000), the medical professions (Czarny, Faden, Nolan, Bodensiek, & Sugarman, 2008; Weaver, 2013), and areas of specialization within the discipline of communication such as rhetorical (Baglia & Foster, 2015; Kline, 2010) and media studies (Bryant & Oliver, 2009). Popular media research can be found in a range of academic journals outside those specifically about media studies, with some of the most receptive outlets including Health Communication, the Journal of Health Communication, Social Science & Medicine, the Sociology of Health & Illness, Health: An Interdisciplinary Journal for the Social Study of Health, Illness and Medicine, Women & Health, the Journal of Health Psychology, and Psychology & Health. Scholars in these disciplines may or may not self-identify as health communication professionals, but their research contributes to the discussion of “what we as a society do collectively to assure the conditions in which people can be healthy” (Institute of Medicine, 2003, p. xi). This does not necessarily mean there is academic consensus regarding steps to be taken to improve health outcomes or social well-being, and health-related popular media research employs contrasting—often paradigmatically antithetical—approaches to the study of popular media and health communication (Zoller & Kline, 2008).
To be clear, consistent with media studies in general (Bryant & Miron, 2004), many health communication popular media studies are not grounded in a particular theory (Hannawa, García-Jiménez, Candrian, Rossmann, & Schulz, 2015; Manganello & Blake, 2010), though theories may be referenced, mentioned as a framework, or used as moderating variables such as sensation-seeking in audience effects studies (Stoolmiller, Gerrard, Sargent, Worth, & Gibbons, 2010) or as coding categories in content-analytic studies such as the health belief model (McWhirter & Hoffman-Goetz, 2016) or the extended parallel process model (Goodall & Reed, 2013). Still, the corpus of research typically situates research questions and study design within two trajectories—media effects approaches and critical approaches.
Media Effects Approaches
In the social scientific tradition, the chief interest of media effects research is in explaining and (putatively) predicting media influence. Relying on the same general rationale as the impetus for the study, authors note that (a theory suggests) media representations may affect attitudes, beliefs, and behaviors of individuals, social understandings, and/or policymaker decisions. Thus, scholars maintain, media content should be analyzed to describe the messages circulated or to which audiences are exposed. Scholars may draw conclusions about potential effects from the analysis of content, or they may extend the analysis to analyze corresponding attitudes, beliefs, and/or behaviors to confirm correlation between representations and response.
While most studies are not overtly theoretical, four theories emerge as guiding principles for this research. Almost three decades ago, the first Health Communication article to explore messages in newspapers was premised on agenda-setting theory (Payne, Ratzan, & Baukus, 1989), and the first in the journal to consider messages in entertainment media (i.e., prime time TV) was based on cultivation theory (Larson, 1991). Though media reception theory has evolved in response to the changing media environment (e.g., new technologies, globalization; see Fortner & Fackler, 2014), these two theories continue to undergird much of the media effects research generally considered to be within the purview of health communication (Manganello & Fishbein, 2009). Given their initial macro-level approach to understanding the implications of popular media for society, these theories did not explicitly provide methodological guidelines for more micro-level analyses of representations and perceptual effects, thus also common in this research are framing theory and social cognitive theory, which may be used separately or to complement agenda-setting and cultivation theoretical rationales and methodological frameworks.
Agenda-Setting Theory and Framing Theory
Agenda-setting theory proposes that the news media influences the salience or importance of particular sociopolitical issues for audiences (McCombs & Guo, 2014). By repeatedly covering certain topics, news media focuses audience attention on some issues and deflects attention away from others, effectively determining the matters that need more immediate action or setting the agenda for public debate. In turn, points of contention are deliberated and seemingly resolved in the public mediated forum, presumably leading to social understandings and the implementation of public policies. To determine if media has contributed to agenda-setting, research describes media messages using content-analytic methods and then compares these to some measure of audience attitudes/beliefs (e.g., public opinion polls, surveys) to determine whether audience perceptions are consistent with prevalent media messages. For example, when researchers sought to determine whether daily newspapers in Melbourne, Australia, served an agenda-setting function with regard to adult tanning attitudes and perceived susceptibility to skin cancer, they used a previously published content analysis that provided data regarding article prominence, theme and topic slant as “a proxy for news media trends” on the topic (Dixon, Warne, Scully, Dobbinson, & Wakefield, 2014). They then compared these elements to survey results of self-reported attitudes and beliefs about tanning and skin cancer and found there was a correlation. Thus, agenda-setting research necessarily involves some form of content analysis to describe news messages to which audiences are exposed.
However, because agenda-setting theory does not expressly detail a method for describing or evaluating media messages per se, often aligned with agenda-setting theory (and referred to as 2nd level agenda-setting), framing theory (Cacciatore, Scheufele, & Iyengar, 2016) provides a methodological lens for analyzing media messages. Introduced independent from agenda-setting theory, the central premise of framing theory is that as a people narrate experiences or circumstances, they consciously and unconsciously choose from among a number of possible explanations, emphasizing some aspects and downplaying or omitting others. These frames define problems, diagnose causes, make moral judgments, and suggest remedies (Entman, 1993) and alternative schemas for interpreting how “essentially identical decision-making scenarios” will affect the way people evaluate and respond to a given issue (Scheufele & Tewskbury, 2007). For instance, in deliberations regarding tobacco policies, smoking may be framed as an individual rights issue (Mejia et al., 2014) or as a public health issue (Champion & Chapman, 2005). Notably, when the public-health frame prevailed in Australian news media, policies to mandate smoke free bars were successful (Champion & Chapman, 2005). Framing choices in news media has also been shown to affect information seeking (Weeks, Friedenberg, Southwell, & Slater, 2012) as well as individual perceptions of health threats with regard to personal risk (Bigman, 2014), fatalism (Niederdeppe et al., 2014), and attribution of individual responsibility versus social responsibility (Major, 2009; Stefanik-Sidener, 2013).
Combining agenda-setting theory and framing theory to assess news media—the extent of attention to a particular issue (prevalence) as well as the textual attributes of the issue explanation (composition)—allows scholars to identify the health issues gaining currency, the alternative viewpoints of stakeholders and variation in their proposed solutions, as well as the ramifications for individuals and society if behavioral choices or public policy follow from these representations.
Cultivation Theory and Social Cognitive Theory
Whereas agenda-setting and framing are typically used in the study of news media, cultivation theory and social cognitive theory are the mainstay of entertainment media research. Cultivation theory asserts that mass-mediated entertainment representations shape individual perceptions of social reality by presenting the world in a consistent yet ultimately misleading manner (Morgan, Shanahan, & Signorielli, 2015). The proposed “cultivation effect” was conceptualized as a gradual, long-term, and cumulative outcome of viewing coherent themes across television programming undifferentiated by entertainment genre or specific shows. Particularly interested in television as the “dominant storyteller” of that era, cultivation scholars contended that the more time people spent watching TV, the more people would begin to believe that the virtual reality of television was an accurate representation of the “real” world. The deeply held skepticism of television that inspired cultivation theory continues to permeate entertainment media research related to health.
With its systems approach to evaluating the implications of mass mediated messages for sociocultural understandings, cultivation theory was, at least initially, a macro-level explanation that acknowledged the reciprocal relationship between media institutions, messages, and audiences. Introduced as an alternative to media research design concerned with delineating the correlation between individual attitudes and behavior and the individual’s exposure to specific media, cultivation analysis did not attempt to explain the cognitive link between viewer perceptions (e.g., selection of messages, information-processing, effects of specific messages) and cultivation effects (Potter, 2014). Rather, the assumption was that cognitive outcomes could be inferred by analyzing media content and then comparing the attitudes and beliefs of heavy viewers and light viewers to determine how closely they aligned with the mediated representation. In short, if a person is a heavy viewer of TV and holds (inaccurate) beliefs consistent with TV representations, the inference is that these beliefs are the result of extensive TV viewing. For example, in a study that compared survey responses of a representative sample of U.S. adults to a content analysis of top medical show episodes at that time, the amount of time spent watching TV was associated with viewer overestimation of “dramatic diagnoses” and “exaggerated mortality rates” (Hetsroni, 2014).
Entertainment media scholars may accept the premise that TV “cultivates” attitudes and beliefs and therefore use it as a rationale for their research, but rather than using the original method of comparing the attitudes and beliefs of light to heavy viewer perception, scholars often turn to other theory to explain the cognitive mechanisms by which cultivation works. In particular, social cognitive theory (SCT; originally social learning theory) (Bandura, 2009) is typical in studies wherein the cultivation premise is invoked. SCT suggests that people can learn by observing others for clues about appropriate and/or desirable health practices, rather than by their own trial-and-error actions. Because SCT accepts that role models can be fictional characters whereby narrative portrayals provide virtual role models of (un)healthy behaviors (Morgan, Movius, & Cody, 2009), it neatly aligns with the assumptions of cultivation theory. This reliance on SCT has led to increased interest in the implications of narrative persuasion with its corollary concepts of, among others, identification, transportation, and parasocial interaction (Moyer-Gusé & Nabi, 2010; Murphy, Frank, Moran, & Patnoe-Woodley, 2011). By attending to cognitive processes rather than total TV viewing time as a predictor of cultivation indicators, the inclusion of SCT has led to a more micro-analytic approach in cultivation research (Potter, 2014).
Whereas media effects approaches attempt to explain and predict the ways in which media influences individual and social perceptions, the goal of the critical scholar is to disrupt existing beliefs about particular practices or institutions with the hope that such challenges will lead to positive social transformation. Though more common in disciplines such as sociology and medical humanities than in health communication journals, critical approaches add to the discussion of popular media in health communication by actively attending to the meanings and ideologies related to health, illness, and medicine fostered by the mass media (Zoller & Kline, 2008). In the early 1990s, medical sociologist Deborah Lupton (1994b) observed that the role of culture had been ignored or reduced to a “lifestyle practices” variable in the predominant individually focused behavioral change model. Informed by a range of theoretical orientations including cultural studies, postcolonial theory, postmodern theories, feminist studies, and queer theory, critical scholarship relies on the concept of social constructionism or, as relates to health, the manner in which cultural meanings, illness experiences, and medical knowledge (Conrad & Barker, 2010) are constituted through social interaction and symbolic activity (Lupton, 2000). Thus, critical scholars highlight the ideological implications of media representations by examining “which stories get told and [more importantly] which are suppressed” in ways that privilege certain (dominant) interests while deflecting attention from other (marginalized) interests (Hodgetts & Chamberlain, 2006, p. 321).
Taken together, media effects research along with critical cultural studies provide a more holistic account of popular media influences than each individual approach alone. For instance, whereas micro-analytic approaches associated with media effects research may deflect attention from the contextual factors that can “shape the audience’s interpretation of portrayals” (Kunkel, 2009, p. 21), the macro-analytic approach of critical/cultural research provides “thick description” (Zoller & Kline, 2008). Thus, in contrast to one quantitative content-analytic study that drew on the health belief model and protection motivation theory to evaluate the accuracy of information about breast cancer in consumer magazines (where “accuracy” was defined by medical professionals) (Walsh-Childers, Edwards, & Grobmyer, 2011), Lupton’s (1994a) critical analysis of breast cancer representations in Australian press emphasized the ideological implications of privileging the “technological imperative” thereby “value[ing] procedures over people, displacing the patient as the central concern” (p. 84).
Given the diversity of approaches to the study of popular media as relates to health and illness, it should be no surprise that empirical research demonstrates a range of findings. Yet, there are some common threads.
Images and Impact
Empirical research of popular media as it relates to health, illness, and medicine generally addresses one topic (e.g., cancer, smoking/alcohol use) in one media domain (e.g., news, entertainment) in a particular medium (e.g., print or TV) that is intended for a specific audience (e.g., a mainstream/heterogeneous audience or, less often, a sociodemographically differentiated audience such as African American, Hispanic/Latino, LGBTQ, etc.).
In one line of empirical research, scholars seek to describe and evaluate the images of health and health-related matters to which people are being exposed. In other words, scholars are interested in how the “text” or “discourse” invites audience members to make sense of the issue depicted. Broadly speaking, textual analysis is either content-analytic (intended to identify replicable or generalizable thematic categories) (Jordan, Kunkel, & Manganello, 2009) or interpretive/critical (intended to provide unique interpretations) (Zoller & Kline, 2008). In theory, these two approaches are generally treated as dichotomous with content analysis conceptualized as descriptive and quantitative and interpretive/critical analysis as explanatory and qualitative (Kline, 2003). In practice, however, the lines are often blurred, and it is probably more useful to consider them as opposite boundaries in a spectrum of textual/discourse analytic methodologies.
Conversely, scholars may elect to explore the impact of mediated message or how audience members or society as a whole make sense of, react to, or respond to messages. A growing body of evidence, especially that stemming from cognitive/behavioral research, suggests that health messages conveyed in print and broadcast news, television programs, and film can produce significant change in viewer knowledge, attitudes, beliefs, and behavior. This research relies on audience reception measures identified through surveys, focus groups, interviews, experiments as well as public data, omnibus surveys, public opinion polls and national surveys, and actual legislation. Media Effects: Advances in Theory and Research (Bryant & Oliver, 2009) provides extensive reviews of research on media effects relevant to public health priorities including effects of media violence on aggressive behavior, the effects sex in the media has on attitudes (e.g., acceptance of premarital or extramarital sex) and behaviors (e.g., adolescent sexual activity), and the effects of media representations of body ideals on eating disorders and body image. The chapter “Effects of Media on Personal and Public Health” (Walsh-Childers & Brown, 2009, pp. 469–489) reviews research on news and entertainment media effects on individual knowledge and behavior related to obesity/overweight, substance use/abuse, sexuality, and news media as well as some public policy implications. From a critical perspective the “effects” or consequences of popular media representations manifest in the presence and ubiquity of certain (hegemonic) ideologies.
Regardless of theoretical or methodological approach, studies concerned with the images and impact of popular media generally attend to how media function as a source of information, role modeling, and ideological meaning. Almost invariably these studies demonstrate that popular media representations have troubling consequences for individuals, public policy, and sociopolitical context (Kline, 2003, 2006, 2011; Signorielli, 1993; Walsh-Childers & Brown, 2009). Though some studies identify health-positive implications, the overwhelming consensus appears to be that popular media are rife with informational deficits, counterproductive role models, and individualizing ideologies that frustrate efforts to enact pro-social and pro-health change. The following sections summarize some of the common findings related to the three functions mentioned above.
The impetus for much of the popular media research related to health and risk communication is the question of whether audiences who are exposed to health, illness, and medical messages are provided with the necessary knowledge about health threats and issues from which health-promoting decisions can be made. Some entertainment media research attends to the informational value of fictional programming, commenting on beneficial or, more often, suspect content. However, given the long-held belief that the purpose of news media is to equip citizens with relevant “facts” so they may make informed decisions, most research that examines informational value focuses on journalistic representations. Quite simply, at least with regard to health-related concerns, research would suggest that journalistic media appears to be failing this charge. Though informational value may vary by ethnic audience (Stryker, Emmons, & Viswanath, 2007) or culture (Shepherd & Seale, 2010; Tang & Peng, 2015), the preponderance of research found news media to be a poor source of information regarding a range of health threats and issues.
Kline’s (2003, 2006, 2011) reviews detailed various types of misinformation in news reports including over- and underreporting (i.e., the scope of illnesses attended to in the media do not reflect prevalent health threats), incomplete coverage of certain health topics especially with regard to prevention and treatment, and conflicting information due to thematic or framing variations in messages which may be exacerbated by conflicting information resulting from controversy. Others have noted the proclivity of news media to sensationalize health issues. These kinds of informational deficits continue to be found in news reporting in a number of countries including China (Bie & Tang, 2015), Australia (Imison & Schweinsberg, 2013), South Africa (Daku, Gibbs, & Heymann, 2012), and the United Kingdom (Washer & Joffe, 2006) and with regard to health topics that affect individuals such as alcohol and tobacco use, cancer, food and nutrition, and mental health as well as public health issues such as organ donation, immunization, genetics, tobacco control policies, medical tourism, food safety, and infectious disease.
The effects of these informational deficits on audience understandings are consequential and may lead to a decrease in knowledge about health risks and perceived self-efficacy to protect against health threats, add to information overload and confusion, and lower health-positive behavioral intentions.
Criticism of the informational value of popular media implies to some extent that individuals use information supplied by the media in active decision-making related to health; in contrast, the concept of role modeling suggests that people watch and emulate what other people do. Because narrative formats facilitate a viewer sense of involvement with the characters portrayed and their situations, researchers are drawn to consider TV and film as the primary source of popular media role models. One exception to this tendency is the research on entertainment celebrities in the news media which has suggested these celebrities can serve as positive role models (Beck, Aubuchon, McKenna, Ruhl, & Simmons, 2014; Frith, Raisborough, & Klein, 2013). More consistently, however, fictional characters (and pseudo-fictional characters in “reality” shows) unfettered by health consequences idealize and glorify practices related to a number of unhealthy behaviors (Kline, 2003, 2006, 2011) including sedentary lifestyles and consumption of junk food, substance use, risky sex, and violent behavior.
In particular, the research about media portrayals of tobacco, alcohol, illicit drug use, and risky sexual behavior taken together offers a useful example of how this research plays out with regard to a health threat. First, research that analyzes representations, primarily in television shows and movies, consistently details the manner in which entertainment media exclude messages about risk and responsibility even though these are behaviors that put individuals at risk but are amenable to lifestyle changes that could improve health outcomes. Even when studies find the overarching message to be “positive” from a health perspective, a qualifier is often given as to the “negative” potential of the portrayal. For instance, in depictions of alcohol use in prime time television series, the central alcohol message is more often associated with negative elements such as a crime, addiction, or lowered job performance, but the authors observe that imagery that associates drinking with “having fun” or “partying hard” may be more alluring (Russell & Russell, 2009). Likewise, a study of 33 different prime time scripted TV series popular among general, African American, and Hispanic audiences found the shows contained “moderate to strong educational content” yet concluded that representations also contained “a large amount of violence, alcohol, tobacco, and drugs” (Murphy, Hether, & Rideout, 2008, p. 14). The popular HBO television show Girls was found to be, for the most part, “scientifically accurate” in its portrayal of human papilloma virus (HPV) transmission, and it promoted “open and frank discussions of sexual health,” but the problem was that it lacked information on possible interventions and the characters were too worried about identifying the source of the infection (Rogers, 2016).
As with the negative outcomes associated with informational deficits in news, the health-adverse portrayals in entertainment media can have deleterious effects on the attitudes, beliefs, and behaviors of (especially adolescent and teen) viewers. Exposure to entertainment media has been shown to influence adolescent sexual activity and future intentions to be sexually active (Pardun, L’Engle, & Brown, 2005). Girls who watched 16 and Pregnant reported a lower perception of their own risk for pregnancy and a greater perception that the benefits of teen pregnancy outweigh the risks, which was surprising, given that the show was deliberately designed in consultation with the National Campaign to Prevent Teen and Unplanned Pregnancy (Aubrey, Behm-Morawitz, & Kim, 2014). Exposure to sexual assault depictions in shows like Law & Order, NCIS, and CSI led to varying degrees of rape myth acceptance (i.e., the woman was asking for it or it is not the man’s fault) and intention to adhere to denial of sexual consent or to refuse unwanted sexual activity (Hust, Marett, Lei, Ren, & Ran, 2015).
Entertainment media exposure has also been linked to adolescent use of tobacco, alcohol, and illicit drugs (Nunez-Smith et al., 2010) and adolescent smoking initiation in Germany, Iceland, the Netherlands, Poland, and the United Kingdom (Morgenstern et al., 2013). In China, smoking imagery in the movies was linked to young boys’ belief that smoking enhanced their masculine identity and young girls seeing smoking as an issue of empowerment (Davey & Zhao, 2012). On a more positive note, one study found that teen exposure to crime and emergency room programs seemed to increase alcohol risk perceptions and therefore may be a pro-social influence (Slater & Jain, 2011).
The power of popular media extends well beyond providing information and role models and into the realm of politics and ideology, and scholars often criticize the manner in which the ideological inflections in portrayals threaten physical, mental, and social health. Though ideological critiques are typically associated with critical perspectives, scholars from the full range of theoretical and methodological approaches to popular media research consistently lament the steady framing of health threats as a lifestyle choice or personal responsibility (i.e., individualize) rather than addressing political, economic, social, and structural influences on the experiences and outcomes related to health and illness. Individualizing discourse has been observed in the framing of a range of health topics such as tobacco and alcohol use and regulation, obesity, indoor air pollution, Alzheimer’s disease, diabetes, tuberculosis in South Africa, and health care costs.
A more critical stance on the individualization of health and illness maintains it is a result of pervasive ideological commitments associated with the biomedical paradigm of Western medicine. Despite the introduction of the biopsychosocial model of health and illness reflected in the World Health Organization (WHO) definition of health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity,” the enduring influence of the biomedical model continues to infuse all aspects of Western(ized) medicine. Over time, sociopolitical negotiations for legitimacy and authority to define and then treat (especially with complex technologies and pharmaceuticals) health and illness—negotiations often constituted, maintained, and perpetuated in popular media—have contributed to what critical scholars refer to as the “medicalization” (Busfield, 2017) of health and illness. The various corollaries of medicalization played out in popular media include professionalization (Turow, 2010), technologizing (Hallin, Brandt, & Briggs, 2013), pathologizing “normal” life circumstances (Foss, 2014), and, more recently, pharmaceuticalizing (Williams, Martin, & Gabe, 2011).
In keeping with this privileging of medical authority, and despite the suggestion that the “social contract between doctors and the public is being renegotiated” (Hodgetts & Chamberlain, 2006, p. 320), in popular media physicians and their practices are often lauded (Strauman & Goodier, 2011) and (relatively few) medical mistakes attributed to external or transitory causes (Foss, 2011). One drawback to this view of medicine is that people may anticipate the same level of care and interaction with their health care providers. Another danger is that in the process of medicalization, individuals are held responsible for ill health and blamed for their failure to maintain good health even if these are health problems over which they have little control.
The individualization of health and illness has several troubling effects. At the individual level, the emphasis on personal responsibility attribution has been linked to stigmatization of such health issues as obesity, mental illness, and autism both in the United States and internationally (Aragonès, López-Muntaner, Ceruelo, & Basora, 2014; Lee & An, 2016; Tang & Peng, 2015).
Not only does stigma affect the lived experience of the individuals subjected to vilification, but from a practical standpoint the emphasis on individual responsibility, perhaps ironically, inhibits people from seeking information and treatment. Personal-level attribution may also deflect attention from social-level policy solutions and subvert efforts to implement pro-health public policies. Indeed, the Pulitzer Prize–winning author of The Social Transformation of American Medicine, Paul Starr (2009), asserted that the professionalization of medical authority halted the expansion of the public health model by making it “difficult for other occupations to duplicate what they achieved” (p. S26).
Whereas individual-level framing may subvert health promotion efforts, it may also be the case that the use of societal-level framing can actually bolster these efforts by reducing stigma, contributing to personal, interpersonal, and social responsibility behaviors, and reinforcing positive attitudes toward pro-health policy efforts.
Addressing the “Problem” of Popular Media
While much has been revealed about the content and effects of popular media on individuals and policymakers, thereby adding to increased recognition of popular media influence, health communication as a discipline is fundamentally committed to pro-social and pro-health transformation. Thus, health professionals have turned their attention to the strategic use of popular media to promote and advance public health commitments by enlisting support from news media producers through media advocacy and entertainment media producers through entertainment-education initiatives. Understanding that these dedicated efforts to transform media representations are not likely to correct all of the problems with popular media representations, health professionals encourage the education of consumers through media literacy interventions.
At its core, media advocacy is the “the strategic use of mass media to support community organizing and advance healthy public policy” (Dorfman & Krasnow, 2014, p. 294). Whereas the definition implies the use of any form of mass media to advance a health-promoting initiative, more commonly it applies to the strategic use of journalistic media. Proponents of media advocacy note that journalists follow the lead of public health efforts which tend to focus on the individual experiencing the health problem (e.g., smokers) and therefore seek to prompt individuals to modify personal behavior (e.g., quit smoking). Media advocacy challenges this approach to improving health outcomes, suggesting that more attention should be paid to the physical, social, economic, and political environments surrounding individuals with a concomitant goal of influencing social and public policies. Thus, media advocacy efforts seek to leverage journalistic media as a means of reframing health issues as a social or collective responsibility rather than an individual behavior choice.
In redirecting the locus of responsibility for the health problem, media attention may influence public opinion, which, in turn, applies pressure on those who are in a position to implement public policies that will lead to structural changes. As Hodgetts (2006) explains, “media coverage is often taken to reflect public opinion regarding policy issues, and as a result policies are more likely to be developed and implemented if policy makers consider there to be sufficient public support ‘expressed through’ media coverage”(p. 318). Health communication and public health scholarship can contribute to media advocacy efforts and has led to more positive discussions of dementia in Belgian newspapers (Van Gorp & Vercruysse, 2012), the reduction of anti-immunization messages in New Zealand news media (Goodyear-Smith, Petousis-Harris, Vanlaar, Turner, & Ram, 2007), the improvement of journalistic reporting of suicide in Australia (Pirkis, Blood, Skehan, & Dare, 2010), and increased stakeholder awareness of clinic policy issues in California (Gardner, Geierstanger, Brindis, & McConnel, 2010). The Berkeley Media Studies Group established by Lawrence Wallack and Lori Dorfman (BMSG, 2016) has engaged in numerous successful media advocacy initiatives (Gibson, 2010).
The problem is that journalists, though ostensibly interested in comprehensive, accurate, and balanced coverage of news topics and issues, are constrained by their own institutional barriers and producer agendas. Even principled journalists must contend with the underlying need for advertising revenues to subsidize news industry profits (i.e., profit motive), and advertisers may be disinclined to juxtapose “unhealthy” products against news detailing health threats related to their products (Gibson, 2010). Perhaps more profound, it may be difficult for journalists to reconcile traditional news values with public health objectives (Arroyave, 2012). That is, news values dictate that stories be timely, proximal, prominent, consequential, and unusual, include a human interest angle, and involve some conflict or drama, and journalists choose to cover news that more closely aligns with these criteria.
Certainly, breaking public health news meets many of these traditional news values, but such stories may have a short life span. For instance, when the first HPV vaccine (Gardasil©) was introduced and approved by the FDA, media attention began to escalate (Eberth, Kline, Moskowitz, Montealegre, & Scheurer, 2014). Extending the newsworthiness of the topic, the public controversy over making this vaccine mandatory for school-age girls kept the storyline alive until it reached its zenith 9 months after the approval. At that point, news reports about the HPV vaccine began to decline (though, notably, the public “discussion” continued to increase via the Internet). Of course, the news media would later respond as new developments with the HPV vaccine emerged, though, again, with varying degrees of informational value for audiences.
Unfortunately, news values do not accommodate the lengthy explanations and tentative findings associated with scientific research and related policy development. As noted above, health communication scholarship often berates news media for inconsistencies, yet innovations in science and developments in public policy related to scientific discovery necessitate corrections and modifications as new findings surface. Still, journalist Susan Dentzer (2009),who as of January 2017 is an elected member of the National Academy of Medicine, contends that journalists consistently “ignore complexities” of health issues (p. 1), disregard past research, thereby failing to provide “reasonable context for readers or viewers,” inevitably “frame a story as new or different” (p. 2), and report on issues “whether reporters understand them or not” (p. 3). Perhaps better training of journalists could address these shortcomings.
However, controversial issues add another layer of complexity when reporting health issues, and the idea that “balanced reporting” might correct deficiencies in news reporting presents another dilemma for journalists as well as health advocates. Using British and American news coverage of the autism vaccine controversy as a case study, Christopher E. Clarke (2008) questioned if “balance” should be defined by quantity or quality, how journalists should reconcile dissention when various stakeholders express opinions “at odds with the scientific consensus,” and whether balanced reporting might itself “represent a form of bias.” Even if these questions could be answered, it is still the case that neither journalists nor health advocates can “control the context and content of opponents’ contributions” (Hilton, Wood, Patterson, & Katikireddi, 2014, p. 162).
Whereas media advocacy involves journalistic collaboration, entertainment-education is a theory-driven effort to either employ the narrative elements of entertainment media in creating interventions or to incorporate pro-health, pro-social messages in popular media representations. As the leading scholars in the area of entertainment-education Arvind Singhal and Everett M. Rogers (2004) explained, entertainment-education “is the process of purposely designing and implementing a media message to both entertain and educate, in order to increase audience members’ knowledge about an educational issue, create favorable attitudes, shift social norms, and change overt behavior” (p. 5). There are numerous examples of entertainment-education initiatives outside the United States and most have been long-running series produced by health professionals that are dedicated to the health education endeavor (Singhal & Rogers, 1999).
In the United States, however, efforts by government or non-profit agencies to produce entertainment programming focused solely on health education messages may be difficult because the U.S. media industry is largely controlled by privately owned for-profit entities seeking the largest audience market share and committed to generating revenue from advertisers who may be resistant to controversial health messages (Brown & Walsh-Childers, 2002). Thus, rather than trying to create entire shows devoted to health education, health advocates working within an entertainment-education framework seek to encourage producers of entertainment media to revise unhealthy storylines and/or embed pro-health messages. Thus, by providing “entertainment industry professionals with accurate and timely information for health storylines,” Hollywood, Health & Society (HH&S), a non-profit organization housed at the University of Southern California’s Annenberg Norman Lear Center, has “worked with 91 TV series on 35 networks” and “confirmed 877 air dates for storylines” from their consultations (Hollywood, Health & Society, 2016a). Their successes are detailed in numerous scholarly publications (Hollywood, Health & Society, 2016b).
Yet, as with media advocacy specialists, those who seek to engage in entertainment-education initiatives with U.S. media producers must contend with institutional constraints. Perhaps most importantly, they must identify storylines that will appeal to producers. For instance, notwithstanding HS&S efforts to provide a writer for the TV show Numb3rs with factual evidence regarding organ transplant procedures by arranging for a consultation with a transplant surgeon who tried to dispel the black market organ donation myth and emphasize the critical shortage of organs, the storyline still involved black market organ donations (Movius, Cody, Huang, Berkowitz, & Morgan, 2007). HH&S considered this a successful intervention, however, because the storyline also included accurate information about the need for organ donation and the importance of signing the organ donation card. Viewers who were exposed to this type of dramatic encouragement to sign organ donation cards were more likely to become donors (Morgan et al., 2009).
Another approach to ameliorating the potentially negative effects of popular media representations is to help individuals develop media literacy skills. The United Nations Education, Scientific and Cultural Organization (UNESCO) defines media literacy as “Understanding and using mass media in either an assertive or nonassertive way, including an informed and critical understanding of media, the techniques they employ and their effects” (Grizzle et al., 2013, p. 191). This includes “the ability to read, analyze, evaluate and produce communication in a variety of media forms (e.g., television, print, radio, computers etc.) [and] the ability to decode, analyze, evaluate and produce communication in a variety of forms” (Grizzle et al., 2013, p. 191). Studies have shown that media literacy interventions can have positive effects on media-related and behavior-related outcomes such as knowledge, critical abilities, understanding of media influence, and sense of realism, with even greater success if the media literacy lesson was reinforced through multiple sessions (Jeong, Cho, & Hwang, 2012).
Opportunities for Future Research
The study of popular media as it relates to health and illness presents numerous opportunities for scholars to expand the breadth and depth of scholarship.
First, the study of health and risk communication and popular media would benefit from a more inclusive and thorough examination of a wider range of sociocultural groups and health/illness concerns. In addition to teasing out the implications of popular media representations for racial and ethnic groups, which is much needed in this area of scholarship, research could attend to groups of individuals who identify with and whose health experiences are influenced by other aspects of their personhood such as being LGBTQ, a member of the military, or a single parent. Likewise, the topics and issues that garner attention could be expanded to include a broader range than those overtly amenable to lifestyle change or those that happen to be “current” issues (e.g., HIV in the late ’80s early ’90s and HPV in the past decade). In particular, popular media scholarship might focus on popular media representation and influence with regard to systemic social, political, and economic determinants of ability to engage in recommended health behaviors. For instance, much is said in research about portrayals of unhealthy food consumption, but little is said with regard to how popular media participates in audience understandings of access to healthy food.
Second, scholarship in this area could provide deeper insights into the implications and influence of popular media by taking advantage of the rich theoretical and methodological contributions from the range of interdisciplinary scholars. Research that attends to the content of specific news and entertainment media is a valuable means of discerning how specific representations invite audiences to understand and respond to particular health concerns. Similarly, media effects research concerned with demonstrating correlations between audience use of specific media and attitudes, beliefs, and behaviors can help clarify the cognitive mechanisms at work as people make sense of these representations. However, popular media influences are both fragmented and copious; individuals are deluged with a surfeit of popular media experiences. To understand and address the influence of popular media on individual health understandings, beliefs, and behaviors, as well as the sociopolitical ramifications of mediated health communication, research must adapt to this new popular media terrain (Ramasubramanian & Martin, 2009, p. 100). To do so, scholars must draw on a wider range of theoretical perspectives including contemporary media theory (Fortner & Fackler, 2014) and consider collaborative efforts to integrate the strengths of contrasting theoretical approaches (e.g., interpretive/critical with social scientific).
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