Using the Power of Media to Influence Health Policy and Politics

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UsingthePowerofMediatoInfluenceHealthPolicyandPolitics.docx

Using the Power of Media to Influence Health Policy and Politics

Beth Gharrity Gardner, Barbara Glickstein, Diana J. Mason

“Power relations … as well as the processes challenging institutionalized power relations are increasingly shaped and decided in the communication field.”

Manual Castells

In the 2008 Presidential campaign, social media did for the Obama campaign what the then new media of television did for John F. Kennedy in 1960. From the onset of his campaign, then U.S. Senator Barack Obama (D-IL) enlisted the support of Chris Hughes, a founder of Facebook, and David Axelrod, a former partner in the public relations firm ASK Public Strategies. Hughes and Axelrod built a team that marshaled every tool in the social media and marketing toolbox to create and sustain the Obama campaign. The campaign was ahead of competitors in using social media to connect with a growing audience of followers on Facebook, Twitter, and blogs. In the general election, then Senator Obama had 118,107 followers on Twitter, outpacing his opponent John McCain's 2865 followers by a factor of 40 to 1 (Lardinois, 2008). He used social media to build a grassroots movement that resulted in his historic victory (Talbot, 2008).

By the 2012 Presidential elections, the majority of social media users expected candidates to have a social media presence and stated that social media provided information that influenced their voting decisions (Steele, 2012). These trends among voters, and young voters in particular, were not lost on the Romney and Obama campaigns. By the eve of the 2012 conventions, both campaigns were regularly updating blogs on their websites and posting to Twitter, Facebook, and YouTube. As in 2008, Obama drastically outpaced all of his competitors in the volume of messages sent, the number of followers or fans, and in social media response (e.g., shares, views, and comments) (Pew Research Center's Journalism Project Staff, 2012Shaughnessy, 2012). Voters also played a larger role in communicating campaign messages. In 2012, the top five trending political topics on Facebook were “Barak Obama,” “Mitt Romney,” “voted,” “four more years,” and “Paul Ryan” (Groshek & Al-Rawi, 2013). Social media is now fully integrated into political campaigning and engagement (see Chapter 48).

The use of social media has not been limited to political campaigning. Launched immediately after Obama's 2008 win, Change.gov provided a website for people to share their ideas for improving legislation before it was signed into law. This sent the message that Obama had no intention of being limited by a traditional media operation as President. Rather, he was going to continue to engage people in supporting his agenda for the nation through multiple channels. When health care reform was teetering from a growing army of dissenters blocking its passage, he continued using social media to mobilize supporters to pressure Congress to act before the April 2010 recess. President Obama also took to the road and held town meetings in key communities because he knew that these meetings would garner reports on primetime television and radio and take a front-page position in newspapers. He could count on the primetime news including a sound bite and visual image of him speaking before a crowd of enthusiastic Ohioans. The personal appearances were a way to get his message to those who were not yet social media enthusiasts and to reinforce it with those who were already his followers on Twitter and 121Facebook. In 2014, when the open enrollment window for signing up for health insurance drew to a close, Obama appeared on the show “Between Two Ferns,” an online parody of celebrity interviews hosted by comedian Zach Galifianakis, to urge young adults to go to Healthcare.gov to sign up for health insurance. This unlikely appearance garnered coverage across traditional and social media platforms.

New digital information and communication technologies have dramatically changed how and what we think about communicating with others, whether connecting with family or building a grassroots political movement to push policymakers to pass new laws. Even traditional media outlets are now augmenting their work with all sorts of social media to extend their reach, impact, and, in some cases, survival. Legislators are routinely launching blogs, using Facebook, and tweeting to make their voices heard and to connect with their constituents. This chapter looks at the integration of traditional and social media as powerful tools for nurses to harness in shaping health policy and politics. Throughout, we draw insights from contemporary and past cases to highlight the role of media in influencing health policy and politics.

Seismic Shift in Media: One-to-Many and Many-to-Many

In the 21st century there has been a seismic shift in the way media is created and distributed. For many years, the dominant paradigm in media was a model in which one broadcaster sent a message out to a mass audience. This broadcast model is referred to as the one-to-many model. This model has been challenged by the Internet and user-generated content in which many people create media and distribute it to their individualized networks. This new model is sometimes referred to as the many-to-many model because it provides opportunities for feedback and interaction, features that have led to the ubiquitous use of the term “social media.”

We now have convergence media, or the interweaving of traditional and social media. Rather than these platforms remaining separate, traditional and networked media are working side by side. For instance, even though the New York Times in print or even as an app is mostly a one-to-many broadcasting media model, the newspaper's blogs, videos, and comment sections reflect the digital side of the newspaper as a networked media platform. News organizations exclusive to the online environment have been created and some veteran print publications have moved entirely or mostly online, but the degree of convergence is unclear (Hindman, 2009).

Mass Media: the One-to-Many Model

Traditional media in radio, television, film, and newspapers was based on the idea that one broadcaster would try to reach as many audience members as possible. However, for those interested in influencing health policy and politics through the media there were many advantages and some significant disadvantages to the one-to-many model of broadcast media (Abramson, 2003).

Radio, film, and television have all been used to communicate messages about health to consumers and policymakers alike. What all these media share is the ability to broadcast a message to a mass audience, sometimes in the millions or tens of millions. When there were few media outlets it was possible to repeatedly broadcast a consistent message to a wide audience. The use of mass media has been a major tool in health promotion campaigns because it reaches a large audience and is capable of promoting healthy social change (Institute of Medicine, 2002Wakefield, Loken & Hornik, 2010).

There are also disadvantages to mass media communications. Large corporations own media outlets and control what goes out through their channels and the expense of buying time or space in major media outlets can be prohibitive, especially for nonprofit organizations. Mass media campaigns, by definition, are intended to reach a wide audience but are not as effective at reaching target populations. For example, a mass media campaign about HIV prevention may reach a wide audience but fail to reach the specific population that is most vulnerable to infection. However, political operatives have developed increasingly sophisticated approaches to segmenting and targeting specific electoral districts with mass media when they want 122to pressure a policymaker who may hold a deciding vote on an important bill. Such organizations buy commercial time on the dominant television station in that policymaker's district. However, what no form of mass media does very well is allow users to create and distribute their own content with the messages they find most important.

Many-to-Many: User-Generated Content and the “Prosumer”

The rise of the Internet, and specifically websites that rely on users to generate content, are part of a new landscape of media creation and distribution. The early Internet featured websites that were one-way flows of information. The paradigm-shifting quality of the Internet began to emerge with the rise of Web 2.0, a term popularized by Tim O'Reilly (2005) at a conference in 2004. Web 2.0 refers to a range of Internet practices based on information-sharing, social networks, and collaborations, rather than the one-way communication style of the early era of the Internet. The key idea with the concept of Web 2.0 is that people are using the Internet to connect with other people, through their old face-to-face networks and through newly formed online social networks and communities of interest.

Prosumption is a term that some people use to describe this shift. Prosumption is the idea that producing and consuming are combined in this new many-to-many paradigm. Rather than an elite few who produce media for a mass audience to consume, now we are all both producers and consumers, or prosumers of media. The many-to-many paradigm refers not to a new form of technology but to a new way that people make use of that technology (Ritzer & Jurgenson, 2010). Social media tools may work best by enabling the development of communities of interest and social networks that successfully narrowcast, as opposed to broadcast, to like-minded individuals. Only time will tell how the many-to-many model will permeate the political communication landscape. Regardless, the collaborative, information-sharing Internet practices have broad implications for health media, policy, and politics, but they do not mean the end of mass media.

The Power of Media

A now classic example of the power of media in shaping health policy arose during the first months of William Jefferson Clinton's presidency when he tried but failed to enact health care reform legislation despite campaigning on a policy platform that sought to guarantee comprehensive health care coverage for every American. In 1993, he proposed the Health Security Act to Congress and the public with the hope that this would become a landmark legislation. Clinton's proposal initially had substantial public support, because many believed the country had a moral imperative to extend health care coverage to all who live in the United States. However, according to an analysis by the Annenberg Public Policy Center of the University of Pennsylvania (1995), one of the primary factors that unraveled the legislation's progress was the Harry and Louise campaign (a series of television advertisements about two fictional characters, Harry and Louise), which was sponsored by the Health Insurance Association of America (HIAA), an ardent opponent to the President's plan.

Actors portrayed a white, middle-class couple voicing grave concerns about the bill. They said, “Under the President's bill, we'll lose our right to choose our own physician,” and “What happens if the plan runs out of money?” Although the ads were not the only reason for the demise of the Clinton plan, the Harry and Louise television spots encouraged fear and negativity within the span of 60 seconds. Suddenly, it seemed as though many of the Americans who had been concerned about the growing numbers of uninsured would become more concerned about how the bill would affect their own health care options and withdraw their support from the Act. What few people realize is that even though a large segment of the population remained convinced that the health care system needed major change, the commercials convinced decision makers that public sentiment was against the reforms. This is one of the things that make the media so powerful: media discourse impacts policymaking because policymakers “assume its pervasive influence” (Gamson, 2004, p. 243). The target audience for the Harry and Louise ads was not the 123public directly; rather, it was policymakers and those who could influence how the public perceived the issue, such as journalists. The ads originally aired in the country's major media centers: Washington, DC; Los Angeles; New York City; and Atlanta. They were seen and reported on by journalists. In fact, the ads and the issue under debate got more airtime by becoming part of the journalists' news stories (West, Heith, & Goodwin, 1996). Many people saw the ads or heard about them through viewing them on the evening news, not as a paid advertisement.

The Harry and Louise commercials are an example of the power of the media in policy and politics. It was a deliberate media strategy to reframe a public policy issue and mobilize a public constituency around it. The media saturate large numbers of people with images that directly or indirectly influence their opinions, shape their attitudes and beliefs, and transform their behavior (McLuhan, 1964). As such, understanding what is and is not shifting in the templates of message production, dissemination, and consumption is crucial for understanding media impacts.

Media campaigns such as these often rely on invoking viewer reactions through the use of misleading or extreme characterizations of legislation or opponents. Recent research suggests that such uncivil discourse is on the rise, especially in nontraditional media, such as talk radio and political blogs (Sobieraj & Berry, 2011; Jamieson, 2012). Given the traditional news values of controversy and conflict, such talk in new media channels may be especially likely to gain coverage from other media outlets. Another longstanding pathway to mass influence is through large media advertising expenditures. The amount of spending on political advertisements is often the largest segment of lobbying expenditure for sponsoring organizations. In 2014, an estimated $2.6 billion was spent on political advertising (Kantar U.S. Insights, 2014). Media advertising campaigns often conceal sponsorship with ambiguous or misleading names and may use cloaked websites to enhance the effectiveness of their deception. Cloaked websites are published by individuals or groups who conceal authorship to deliberately disguise a hidden political agenda (Daniels, 2009). The lack of transparency of political advertising has a Machiavellian quality to it. Although advertisements for a political candidate are required to include a statement from the candidate that he or she authorized the ad, no such requirement exists for transparency of sponsorship of ads advocating policy positions.

Who Controls the Media?

The traditional media industry has been owned by six major corporations that, prior to the growth of social media, controlled 90% of the news Americans read, saw, or heard (Lutz, 2012). In 2003, the Federal Communications Commission voted to ease the restrictions on cross-ownership between different news entities, permitting one corporation to own the primary television, radio, and newspaper outlets in a community. This enabled a single corporation to control messages and put forth a particular perspective. CNN founder Ted Turner objected to this consolidation of corporate media power, arguing that allowing this cross-ownership “will extend the market dominance of the media corporations that control most of what Americans read, see, or hear” and “give them more power to cut important ideas out of the public debate” (Harris, 2005, p. 83).

The gap created by the declining revenue streams and reduced newsrooms for traditional or legacy media are starting to be filled by actors building new news operations and resuscitating long-standing ones. For instance, the Kaiser Family Foundation launched its own nonprofit news organization, Kaiser Health News, in 2009. Their content is now regularly carried in traditional news outlets. Newer digital news outlets are also gaining revenue and recruiting talent from traditional media news staffs. Revenue is recently coming from entrepreneurs who are investing in the media industry; for example, Amazon.com founder Jeff Bezos purchased the Washington Post in 2013. Although traditional news media continue to face revenue challenges, the largest numbers of journalists producing original reporting still come from the newspaper industry (Mitchell2013; 2014). In this more digital and diversified media field, the pathways to 124getting on the public's agenda may be more complex but many of the traditional media still adhere to familiar lines of influence.

Social media can actually drive traditional media to cover issues that major newsrooms may not deem worthy of their limited space and time, thus advancing political advocacy. One success story is that of the YouTube video campaign, Kony 2012, launched by Invisible Children, seeking to spur international awareness of the actions of Ugandan warlord Joseph Kony and his Lord's Resistance Army. Within a few days the video drew millions of viewers and spread to other social media such as Twitter, where it became the top story. Within weeks, the Senate introduced a bipartisan resolution condemning Kony. According to Senator Lindsey Graham (R-SC), “This is about someone who, without the Internet and YouTube, their dastardly deeds would not resonate with politicians. When you get 100 million Americans looking at something, you will get our attention” (Wong, 2012).

According to a survey conducted a week after the video's release, the way people learned about this story varied strikingly by age cohort. Around half of young adults (aged 18 to 29) who had heard about the video first did so through social media, compared with an even mix of social and traditional news sources for those aged 30 to 49. Traditional media, especially television, informed most adults aged 50 and over (Rainie et al., 2012b).

The ownership of the Internet (e.g., online infrastructures, operating systems, and search engines) is following consolidation patterns similar to traditional media, with a few large companies such as Apple, Google, Yahoo!, Facebook, and Microsoft dominating the field (Freepress.net, 2014). Nonetheless, the more decentralized structure of the Web may better enable citizens to not only break news, but shape it. This bodes well for nurses who have not always been able to garner media attention for their issues. A study commissioned by Sigma Theta Tau and published in 1998 documented nursing's invisibility in the media. The Woodhull Study on Nursing and the Media found that nurses were included in health stories in major print media (newspapers and news magazines published in September 1997) less than 4% of the time, even when they would have been germane to the story. And even more disturbing, nurses were represented in health care industry publications (such as Modern Healthcare) less than 1% of the time.

These findings may indicate a systematic journalistic bias against nursing. They also arise because nurses have not been proactive in accessing traditional media. Social media provides an opportunity for nurses to not wait for traditional media to value their perspectives. Nurses can use social media to create and distribute messages, to engage others to care about an issue, and to discuss issues from various vantage points. Given that the annual Gallup Poll continues to find that Americans rate the honesty and ethical standards of nurses higher than any other profession (e.g., in 2013, 82% for nurses, 69% for physicians, 21% for newspaper reporters, 8% for members of Congress), nurses have a unique opportunity to send persuasive messages (Gallup, 2014).

If nurses want visibility, they must become cyberactivists. Cyberactivists are people who want to create change in a variety of issues and have taken up the use of new media technologies and strategies that characterize Web 2.0 (McCaughey & Ayers, 2003), fusing the old and new media methods to allow for the widest range of engagement with the public. It has never been easier to become a cyberactivist because new digital technologies have lowered the motivational thresholds for activism, making it much easier to create, join, and coordinate groups (Shirky, 2008; Polletta et al., 2013). Nursing organizations are particularly well positioned to mount focused social media campaigns because they already have a list of people who can begin the spreading of messages. However, social networks are becoming crowded, so getting noticed requires a thoughtful strategy.

Distributed Campaigns

Obama's social media campaign strategy was a distributed campaign, a bottom-up rather than a top-down approach to political campaigns that depends on a message spreading from the grassroots rather than broadcasting and control by the campaign staff (Ozimek, 2005). These campaigns are designed 125to involve more than core supporters. Distributed campaigns seek to engage swing voters and to provide opportunities for core supporters to craft messages that may appeal to these swing voters more effectively than messages created by campaign staff, thereby strengthening the commitment of core supporters to the campaign. E-mail, blogs, and other social media are used by campaign staff to initiate a dialogue that is subsequently developed by a broad community of supporters. Additionally, supporter-generated content such as more personalized Facebook groups and YouTube videos can be incorporated into the campaign.

Evidence supports the potential for distributed campaigns. In terms of shaping political communication, a 2012 Pew Internet and American Life Project survey found that 66% of social media users (estimated to be 39% of all American adults) are politically active on these sites, by posting links to political stories, encouraging others to vote, or encouraging others to take political action (Rainie et al., 2012a; Smith, 2013). In terms of consuming political information, a 2013 Pew survey indicates that approximately half of Facebook and Twitter users obtained news on those sites (Holcomb, Gottfried, & Mitchell, 2013).

Distributed campaigns provide people with tools for activism such as petitions to sign, e-mail scripts to send, or letters to sign and send to legislators. Organizations, such as Democracy in Action ( salsalabs.com/democracyinaction ), are available to help build the capacity of groups that want to develop action tools for reaching diverse audiences in distributive campaigns. Living in a media-saturated world can sometimes feel like being in a cacophony of conflicting voices. The challenge is how to use these powerful tools most effectively.

Linking in to Existing Communities

Most people regularly find information online from sources that are familiar or already aligned with their views (Hindman, 2009). Similarly, popular search engines such as Yahoo! and Google structure or filter links in a way that facilitates this return to the familiar and the mainstream. One way to work both with and around these patterns may be to link into existing communities of interest and social networks rooted in friends and family. In the Kony 2012 case discussed earlier, Senator Chris Coons (D-DE) told reporters that his 12-year-old twins and his 11-year-old daughter alerted him to the issue (Wong, 2012), which they and their peers most likely learned about through social media (Rainie et al., 2012b). Just as they have offline, the networked worlds of friendship, family, hobbies, and leisure groups may routinely overlap with political engagement and communication.

Such overlap is evident in data from the 2013 University of Southern California Annenberg School for Communication and Journalism's national digital future survey (Center for the Digital Future, 2013). In 2013, 16.7% of Internet users identified themselves as a member of an online community, defined as “a group that shares thoughts or ideas, or works on common projects, through electronic communication only.” More than half of these groups were devoted to members' hobbies (62%). Other groups were social (39%) or professional (33%) with only 12% described as political. However, 85% of online community members said they used the Internet to participate in communities related to social causes (this was up 10% from 2007 and 40% from 2006); and nearly three quarters said they had participated in new social causes since they joined an online community.

Friends, family, and communities of interest may convince those who might not otherwise join a cause to join because they help to either create concern about the cause or motivate the individual to shift from concern to participation (Polletta et al., 2013). As these exchanges are increasingly enabled through social media networks, traditional media avenues for getting on the public's agenda are being restructured.

Getting on the Public's Agenda

One of the most important roles that the media plays is getting issues on the agendas of the public and policymakers. What the mainstream media do or do not cover is equally powerful in determining which issues policymakers take into consideration. But the mainstream media's role in defining what 126is mainstream appears to be diminishing due to three interrelated factors: the abundance of new social media platforms, the lowered costs of producing media campaigns that can directly reach the public, and the downsizing among traditional news media outlets that may be undermining the quality of their reporting. The news-consuming public has responded to these interrelated trends. A survey conducted by the PEW Research Center early in 2013 found that nearly a third of people abandoned a particular news source because it was no longer providing the quality information they had come to expect (Enda & Mitchell, 2013). The Digital Future Report (Center for the Digital Future, 2013) also found that 30% of Internet users stopped a subscription to a newspaper or magazine because they could get the same information online. Additionally, more people are seeking out news stories they hear about via social media, even when they weren't looking (Mitchell, 2014). Most American adults (73%) get news from family and friends through word of mouth, but now around 15% are getting it from family and friends through social networking, and the percentage relying on social media is even higher for 18- to 29-year olds (nearly 25%) (Mitchell, 2013).

News as Entertainment: Infotainment

The news media remain instrumental in getting issues onto the agenda of policymakers and generating the political campaign interest that encourages citizens to the voting booths (Groshek & Dimitrova, 2011), but non-news entertainment television programs can also mobilize public constituencies around an issue. Although the Internet has become a more important source for entertainment among Internet users, television remains the primary source for entertainment (Center for the Digital Future, 2013). This may be caused by the fact that television continues to be the dominant form of media in most people's lives, despite the rise of other forms of media online. In 2013, the television was on around 35 hours per week in the average American household (Nielsen Reports, 2013). Teenagers still spend more time watching TV than they do online (Rideout, Foehr, & Roberts, 2010). The Internet may be where people go to find out about a health issue, but they often first become aware of the issue through television and films.

Turow (1996) points out that non-news television entertainment that often stereotypes power relationships may be more successful than the news in shaping people's views of issues. Highly viewed TV presentations of health care hold political significance that should be assessed alongside news. Medical and nursing dramas on broadcast and cable television, such as Grey's AnatomyER, and Nurse Jackie, are often important sources of information about health and health policy for a wide audience. Researchers Turow and Gans (2002) systematically evaluated one television season of four hour-long medical dramas and found that health care policy issues appeared regularly in the programs. Evidence from a national telephone survey indicates that the percentage of regular viewers of the show ER who were aware that HPV is a sexually transmitted disease was higher (28%) one week after viewing an episode of the show about HPV than before seeing the show (9%). Even 6 weeks after viewing the episode, 16% had retained this knowledge. This capacity to quickly get a message out to millions of people through an hour-long drama is part of the reason that many health advocates work to get their particular issue included in a storyline of a major network drama.

Documentary Films

Documentary films, in conjunction with online campaigns, are influencing health policy and politics while achieving mainstream commercial success. For example, two documentaries, The Invisible War(2012) and Service: When Women Come Marching Home (2011) were groundbreaking in creating public conversations about military sexual assault. Both were viewed by members of Congress and used as organizing tools nationally to get the public behind an agenda to …