Communicating population health: Print news media coverage of type 2 diabetes☆
Introduction
Diabetes rates are rising globally. In the United States, 24 million people have diabetes, an increase of 132% since 1980. More than 90% of total diabetes prevalence is type 2 diabetes (in contrast to type 1, or juvenile, diabetes), which affects the poor, African Americans, Latinos, and Native Americans disproportionately. Whereas under 10% of American whites have diabetes, nearly 15% of African Americans have diabetes, and rates among the poorest are three times that of the wealthiest (CDC, 2007, Kanjilal et al., 2006). Because of the growing magnitude of the problem, effective and timely strategies will be required to address the population burden of type 2 diabetes, in the United States and internationally. Numerous policies might prove effective, ranging from behavioral interventions, pharmaceuticals, weight loss surgery, or policies to create healthier environments (Colagiuri, Colagiuri, Yach, & Pramming, 2006). Type 2 diabetes is strongly influenced by health behaviors, which are shaped by environmental influences and social structural factors (Brown et al., 2004). As a result, as McKinlay and Marceau (2000) argued, “profoundly different [policy] actions are required depending upon which level of intervention one focuses” (p. 758). Which types of policies the public and policymakers will support may hinge on their understanding of diabetes.
People get much of their information about health and health policy from the news media (Brodie, Hamel, Altman, Blendon, & Benson, 2003) and research demonstrates the media's influence across cultures and settings (Seale, 2003). The media can shape the public's opinions about what issues are important and emphasize particular ways of thinking about a problem (Gamson et al., 1992, Iyengar and Kinder, 1987). Since policymakers are often responsive to the public's opinions on policy issues (Hutchings, 2003), the public's perceptions of diabetes may contribute to the policy process.
However, the contested nature of type 2 diabetes—its causal and diagnostic flexibility and moral ambiguity—complicates its presentations and perceptions. Type 2 diabetes is not a single entity with consistent meaning across time and contexts; it can be constructed as an illness in and of itself, or as one of many risk factors contributing to a burgeoning meta-diagnosis of metabolic syndrome and its constellation of cardiovascular complications (Aronowitz, 2008, Rock, 2003). Moreover, whereas the public may consider diabetes to be medicalized and thus legitimated as an illness over which the medical profession has authority (given a long history of medical screening and treatment), its epidemiologic and bodily associations with obesity and socioeconomic disadvantage (and accompanying negative moral valence) suggest the potential for mixed public perceptions (Brown, 1995). In this paper, we analyze print news media presentations of type 2 diabetes, focusing on the coverage of individual and social causes, individual and socially-oriented solutions, and health disparities.
Media coverage of health problems is not a simple reflection of the health issues that are most prominent in society. Rather, coverage patterns are the product of a competitive process among multiple actors vying for finite amounts of attention and space in which to define a problem, assign blame, and suggest who is responsible for addressing it (Blumer, 1971, Gusfield, 1981, Hilgartner and Bosk, 1988). Media coverage can influence the public through at least two processes: agenda-setting and framing.
Agenda-setting is the news media's selection of which issues to cover. Whether or not a problem appears in the news influences which problems the public considers important (Iyengar & Kinder, 1987). In the United States, print news media attention tends to be proportional to disease mortality (Adelman & Verbrugge, 2000). However, diseases that claim disproportionately more black lives (including diabetes) get less media attention, suggesting the problem of racial disparities may not yet be high on the public's agenda (Armstrong, Carpenter, & Hojnacki, 2006).
The second major process of news media influence is framing, the media's selection of particular aspects of social problems to emphasize (Entman, 1993). Two media frames relevant to type 2 diabetes policy are social group frames and causal frames. Regarding the former, research demonstrates that frames that highlight a particular social group will activate predisposing attitudes about that group in the public's policy considerations (Kinder & Sanders, 1996). Thus, framing diabetes as a problem more common among the poor and minorities could mobilize those members of the public concerned about social justice to support policies to address disparities (Benford and Snow, 2000, Gamson, 1992). On the other hand, media framing of the social groups disproportionately affected by diabetes could have negative consequences, if the frames activate unsympathetic racial stereotypes about the target group into the public's considerations about policies to help that group (Gilens, 1999).
A second relevant category of media frames is content about diabetes' causes, since perceptions of a problem's causes can affect the public's attributions of responsibility (Gusfield, 1981, Iyengar, 1991, Stone, 1989). Theory suggests that when people associate individual behaviors or genetics as causes of some illness, the public would attribute responsibility to address the illness to individuals (to whom they would assign more blame, in the case of behavioral causes), whereas when they identify structural or environmental causal factors, they would more likely support governmental responsibility to intervene (Conrad, 1997, Tesh, 1994). Empirical evidence supports these assumptions. Weiner, Perry, and Magnusson (1988) demonstrated that the public assigns more stigma to those conditions they perceive are caused by factors under the individual's control. Taylor-Clark, Mebane, Steelfisher, and Blendon (2007), citing U.S. national survey data, observed that those who believed that patients' behaviors caused health care disparities were less likely to support federal responsibility for ameliorating these disparities than those who attributed the causes to patient circumstances. Similarly, Reutter, Harrison, and Neufeld (2002) found that Canadians who believed in behavioral or medical explanations for health inequalities were less supportive of social policies to address poverty than those who endorsed structural explanations.
Previous content analyses demonstrate the media's tendency to privilege the “downstream” individualized biological or behavioral causes of chronic illnesses over the “upstream” environmental or social structural determinants (Brown et al., 2001, Conrad, 1997, Lantz and Booth, 1998).1 Several recent studies of media framing of obesity identified a news media emphasis on behavioral causes (and individually-oriented solutions) over structural or environmental factors (Kim and Willis, 2007, Lawrence, 2004, Saguy and Almeling, 2008). The only previous content analysis specific to diabetes (using data from 25 articles from four U.S. and Canadian news sources) found that lifestyle and medical features, not societal causes and solutions, comprised the dominant diabetes frames (Rock, 2005).
This media emphasis on individual behavioral causes of disease is at odds with some health researchers' conclusions. While behaviors such as poor diet, physical inactivity, and smoking correlate strongly with mortality (McGinnis & Foege, 1993), these behaviors are influenced by socioeconomic resources and environmental factors, and they do not explain all of the variance in observed disparities in mortality (Lantz et al., 1998). In reaction to the dominance of individualized frames of health in public discourse, advocates seek to reframe public health problems to encompass social, political, and economic factors (Dorfman and Wallack, 2007, Wallack et al., 1993). Little extant research suggests to what extent these advocates have been successful in getting their message into the media.
The goal of this research was to evaluate quantitatively the construction of type 2 diabetes in the print news media, focusing on the extent to which print news media in 2005 and 2006 took a “population health” approach. We use this term to denote a style of media presentation of health issues that emphasizes social, economic, and population-level causes and solutions and also depicts health disparities as a social problem (Kindig and Stoddart, 2003, Niederdeppe et al., 2008).
Our content analysis had four aims. The first aim was to describe how articles depicted the causes of diabetes, particularly the balance of individually-oriented causes and social-oriented causes. The second aim was to describe how articles depicted policies or strategies for prevention, treatment, or management of diabetes, particularly the extent to which articles mentioned policies that target the socioeconomic determinants of diabetes. The third aim was to catalog media presentations of diabetes disparities. Finally, integrating the aforementioned domains, the last aim was to identify the article-level characteristics associated with newspapers' assuming a population health-oriented perspective.
This research has several strengths that differentiate it from previous content analyses of health topics. Often, researchers conduct content analyses of just a handful of major news outlets, assuming these data are representative of all coverage of the issue, ignoring potential differences across outlets. This assumption is problematic, given the diversity of newspapers' resources, audience demographics, and ideological orientations—all factors that shape content (Gans, 1979). In contrast, the present research relies upon a large sample of articles from 19 newspapers, facilitating multivariate approaches not possible in smaller samples. Finally, this work is the first to assess systematically the extent to which the U.S. news media communicate a population health perspective, a conceptual frame of growing importance in U.S. and international health policy (Mechanic, 2003, WHO, 2008) with implications across countries and settings for public support of policies that may improve population health.
Section snippets
Data
Articles were collected from 19 newspapers with full coverage in the LexisNexis database. Three of the newspapers (The New York Times, USA Today, and the Washington Post) are national papers. The other 16 papers comprise the top-circulation papers (at least 250,000 daily) contained in LexisNexis's “Major U.S. Newspapers” category in each of four Census regions: Northeast (Boston Globe, New York Daily News, New York Post); Midwest (St. Louis Post-Dispatch, Chicago Sun Times, Minneapolis Star
Results
Out of the 859 articles included in the sample, 158 (18.4%) were about exclusively type 1 diabetes, 374 (43.6%) were about exclusively type 2 diabetes, 131 (15.3%) were about both types, 177 (20.7%) discussed diabetes in general, two (0.23%) dealt exclusively with gestational diabetes, and 16 (1.9%) discussed gestational diabetes and type 2 diabetes. Since the goal of the study was to analyze media content about type 2 diabetes, we excluded any articles about only type 1 or gestational
Discussion
This study quantitatively evaluated news coverage of type 2 diabetes across 19 newspapers, presenting the most comprehensive evaluation of diabetes in the mass media to date. As researchers have observed in news coverage of obesity (Campo and Mastin, 2007, Kim and Willis, 2007, Lawrence, 2004, Saguy and Almeling, 2008) and other chronic conditions (Lantz & Booth, 1998), behavioral causes of diabetes dominated the media discussion. Messages about ways to address diabetes focused on behavioral
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We thank the excellent research assistance of Nonie Hamilton and Emily Glover. We also acknowledge Renée Anspach, Scott Greer, Nicholas Valentino, and Peter Ubel for their feedback on the manuscript. Funding for this research was provided from a small grant from the University of Michigan Robert Wood Johnson Foundation Health & Society Scholars program, and we thank the Robert Wood Johnson Health & Society Scholars Program for its financial support.