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.”
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, 2012; Shaughnessy, 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, 2002; Wakefield, 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 (Mitchell, 2013; 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.
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 Anatomy, ER, 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, 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 change the military's practices. Kirsten Gillibrand (D-NY), Senator and Chairwoman of the Personnel Subcommittee on the Armed Services Committee, cited The Invisible War as shaping her decision to draft a bill to overhaul military sexual-assault policies by removing the chain of command from prosecuting 127sexual assaults. Although the bill was defeated in March of 2014, her yearlong campaign drew many supporters and put the issue firmly on the political agenda.
Media as a Health Promotion Tool
Media can promote health in three ways: public education, social marketing, and media advocacy. The first two are often used to help people change their health behaviors by acquiring important information they lacked (public education) or through visual or verbal messaging that can shift a person's attitudes and values (social marketing). Both can also be used in political campaigns and to shape public policy, but media advocacy specifically targets public policy.
Media advocacy is the strategic use of media to apply pressure to advance a social or public policy initiative (Dorfman & Krasnow 2014; Wallack & Dorfman, 1996). It is a tool for policy change by mobilizing constituencies and stakeholders to support or oppose specific policy changes. It is a means of political action. It differs from social marketing and public education approaches to public health, as noted in Table 14-1. Media advocacy defines the primary problem as a power gap, as opposed to an information gap, so mobilization of stakeholders is needed to influence the development of public policies.
Media Advocacy Versus Social Marketing and Public Education Approaches to Public Health
Social Marketing and Public Education
Individual as advocate
Individual as audience
Advances healthy public policies
Develops health messages
Changes the environment
Changes the individual
Target is person with power to make change
Target is person with problem or is at risk
Addresses the power gap
Addresses the information gap
Adapted from Wallack, L., & Dorfman, L. (1996). Media advocacy: A strategy for advancing policy and promoting health. Health Education Quarterly, 23(3), 297. Copyright 1996 by Sage Publications. Reprinted by permission of Sage Publications.
The success of Mothers Against Drunk Driving (MADD) illustrates the power of media advocacy. MADD was formed in 1980 at a time when a drunk driver could kill a child and it would not be treated as a crime. MADD developed a policy agenda aimed at preventing drunk driving. It developed a Rating the States program to bring public attention to what state governments were and were not doing to fight alcohol-impaired driving. Then, just after Thanksgiving (the beginning of a period of high numbers of alcohol-related traffic accidents), MADD representatives held local press conferences with their state's officials and members of other advocacy groups to announce the state's rating. Local and national broadcast and print press brought the story to an estimated 62.5 million people. Subsequently, lawmakers in at least eight states took action to address drunken driving (Russell et al., 1995).
Today, MADD's website ( www.madd.org ) provides information in a number of areas: policies that people can endorse, a walk to raise funds to support the organization's work, a link to its Twitter page, and news about drunk driving initiatives. Getting on the news media's agenda is one of the functions of media advocacy (Dorfman & Krasnow, 2014). With numerous competing potential stories, media advocacy employs strategies to frame an issue in a way that will attract media coverage. For example, MADD often created media events by putting a wrecked car in front of a local high school a few days prior to a prom. Journalists flocked to these events and the visual impact of the wrecked car got people's attention. The news accounts and parental outrage that resulted from these media events eventually led to wide social support for the concept of the designated driver and harsher penalties for driving under the influence.
How a message is presented is as important as getting the attention of the news media. Debates surrounding the passage and implementation of the Affordable Care Act demonstrate this point. It certainly got on the media's agenda, but many 128important messages were lost in the news coverage that emphasized the controversies such as death panels and horror stories of individuals finding their insurance policies cancelled.
Getting an issue on the agenda of the public and policymakers and shaping the message requires framing. Framing “defines the boundaries of public discussion about an issue” (Wallack & Dorfman, 1996, p. 299). Even more simply put, a frame is a “thought organizer” (Gamson, 2004, p. 245). Reframing involves breaking out of the dominant perspective (or frame) on an issue to define a new way of thinking about it that can lead to very different ideas about potentially effective policy responses. Reframing requires working hard to understand the dominant frame, the values that underpin it as well as its limitations, and then exploring new frames.
Framing applies to all messaging and policy work, whether changing staffing policies in a hospital or promoting legislation that will remove soft drinks from schools. Framing for access to the media entails shaping the issue in a way that will attract media attention. It helps to attach the issue to a local concern, anniversaries, or celebrities or to make news by holding events that will attract the press, such as releasing new research at a press conference (Jernigan & Wright, 1996). Linking to issues already on the political agenda or the media's agenda (as newsworthy) can also be advantageous to gaining access. Most importantly, it requires some element of controversy (albeit not over the accuracy of an advocate's facts), conflict, injustice, or irony. The targeted medium or media will shape how the story is presented. For example, television requires compelling visual images. If a broad audience is to be reached, a powerful, brief message on television can provide a quick frame for an issue and influence how people will view it, but the interactive nature of social media provides the opportunity for others to continue to reframe a message, helping people to break out of a dominant frame.
Framing for content once you are in front of the media is more difficult than framing for access. A compelling individual story may gain visibility in some media, but there is no guarantee that the reporter or social media activists will focus on the public policy changes that are desired. Wallack and Dorfman (1996, p. 300) suggest that this reframing can be accomplished by the following:
• Emphasizing the social dimensions of the problem and translating an individual's personal story into a public issue
• Shifting the responsibility for the problem from the individual to the executive or public official whose decisions can address the problem
• Presenting solutions as policy alternatives
• Making a practical appeal to support the solution
• Using compelling images and symbols that resonate with the values of the audience
• Using the authentic voices of people who have experience with the problem
• Anticipating the opposition and knowing all sides of the issue
Focus on Reporting
Few journalists have the time and the editorial support or the breadth and depth of knowledge about science to provide thorough reporting on health issues that have policy implications. This often results in less-than-adequate reporting on important issues, such as how communities should respond to the West Nile virus. Roche (2002) examined print media coverage of the approaches to reducing the mosquito population to reduce the incidence of, and mortality from, West Nile encephalitis. None of the newspapers or magazines examined gave any information about risk of mortality from pesticide exposure or a cost analysis of this approach. Roche concluded that the public is “operating ‘in the dark’ in evaluating the question of whether pesticides should be deployed.”
Nurses can assist journalists and cyberactivists by both reframing health policy issues and providing the depth of detail that others may lack. For example, a journalist covering a story on the nursing shortage has focused on the faculty shortage and the need to produce more nurses. You could help the journalist to see that framing the story as purely 129one of a supply issue, getting more people into the pipeline, misses the important issues of retention of existing nurses. While talking with this journalist does not ensure that your frame will be incorporated into the journalist's story, you can publicize the frame you believe is important through your blog, Facebook page, or Twitter account.
One strategy is to facilitate information exchange in the public arena by becoming news makers, aggregators, or curators of health news. Posting links to news articles and research on critical policy issues on social media sites, such as Facebook, makes the news easy to find. As searching for health information has become the third most popular online activity for all Internet users 18 and over (Zickuhr, 2010), nurses are positioned to explain complex health policy issues by breaking them down. This can be done not just for information sharing but also for civil engagement so that people will act, whether by having a conversation with a co-worker about the issue or contacting government representatives. Facebook friends, including other nurse colleagues, can share on Facebook, which reposts these articles to their personal networks to widen the community. Social networking can generate a buzz and create conversations about an issue or policy. It is digital activism and it has enormous potential to build networks, propagate power, and frame issues.
Effective Use of Media
The following recommendations provide readers with a starting point for effectively using traditional and social media.
Positioning Yourself as an Expert
Health policy was once the domain of a limited field of experts setting the agenda for everyone else. The rise of user-generated content signals a radical departure from this approach. It signifies a profound transformation in what it means to be an expert and who is an expert. New media provides nurses with platforms to reach the public as media makers and aggregators of reliable health research information.
There are many types of credentials, although they are typically thought of as degrees from educational institutions, work titles, and affiliations. Some institutions require that their employees notify them of any interaction with the media, but this may be unnecessary if you don't name the institution in your interview or other communication. For example, you could be a nurse in women's health at a community hospital.
Become an Expert in Your Field.
Becoming the go-to person who is the expert on a topic or particular field is another way to establish yourself as an expert. You can establish this by launching your own professional website, blog, and Twitter and Facebook pages, as well as by meeting with local journalists who cover health.
Use Personal and Clinical Experience.
Part of why MADD's campaign has been compelling is their strategic use of stories from women whose children have been killed as a result of drunk driving. These bereaved mothers involved with MADD have transformed themselves into experts on the policy of driving while intoxicated and have used their experience to make this point with policymakers. Similarly, people who were infected with HIV/AIDS in the 1980s and believed that the federal government was acting too slowly to move treatment through clinical trials made themselves experts on the science of the disease and by using a variety of tactics including personal accounts of their illnesses, forced policymakers to speed up the time for drugs to reach the market. The Internet facilitates the rise of this kind of expertise.
Getting Your Message Across
Getting your message to the appropriate target audience requires careful analysis and planning. For example, you might want to target a message to local homeowners, many of whom watch a particular TV station's evening news. To get television coverage, you must have a visual story. California nurses staged a media event on a senior health issue by staging a “rock around the clock” marathon, with seniors in rocking chairs outside an insurance 130company. They received press coverage of the event, which elicited some supportive letters to the editor as well as some negative press from seniors who said that they were stereotyping older adults. See Box 14-1 for guidelines for getting your message across in traditional media, and Box 14-2 for ways to use social media tools to reach an audience.
Guidelines for Getting Your Message Across
The following guidelines will help you shape your message and get it delivered to the right media:
• What is the nature of the issue?
• What is the context of the issue? (e.g., timing, history, and current political environment)
• Who is, or could be, interested in this issue?
• What's the angle or the “so what”? Why should anyone care? What is news?
• Is there a sound bite that represents the issue in a catchy, memorable way?
• Can you craft rhetoric that will represent core values of the target audience?
• How can you frame nursing's interests as the public's interests (e.g., as consumers, mothers, fathers, women, taxpayers, and health professionals)?
The Target Audience
• Who is the target audience? Is it the public, policymakers, or journalists?
• If the public is the target audience, which segments of the public?
• What medium is appropriate for the target audience? Does this audience watch television? If so, are the members of this audience likely to watch a talk show or a news magazine show? Or do they read newspapers, listen to radio, or surf the Internet? Or are they likely to do all of these?
Access to the Media
• What relationships do you have with reporters and producers? Have you called or written letters or thank-you notes to particular journalists? Have you requested a meeting with the editorial board of the local community newspaper to discuss your issue and what the members of the board might think about reporting on it?
• How can you get the media's attention? Is there a hot issue you can connect your issue to? Is there a compelling human interest story? Do you have a press release that describes your issue in a succinct, compelling way? Do you have other printed materials that will attract journalists' attention within the first 3 seconds of viewing it? Are there photographs you can take in advance and then send out with your press release? Can you digitalize the images and make them available on a website for downloading onto a newspaper?
• Whom should you contact in the medium or media of choice?
• Are you prepared? Are you news conscious? Do you watch, listen, clip, and track who covers what and how they cover it? What is the format of the program, and who is the journalist? What is the style of the program or journalist?
• Who are your spokespersons? Do they have the requisite expertise on the issue? Do they have a visual or voice presence appropriate for the medium? What is their personal connection to the issue, and do they have stories to tell? Have they been trained or rehearsed for the interview?
• Prepare for the interview. Obtain information on your interviewer and the program by reviewing the interviewer's work or talking with public relations experts in your area. Select the one, two, or three major points that you want to get across in the interview. Identify potential controversies and how you would respond to them, and rehearse the interview with a colleague.
• During the interview, listen attentively to the interviewer. Recognize opportunities to control the interview and get your primary point across more than once. What is your sound bite? Even if the interviewer asks a question that does not address your agenda, return the focus of the interview to your agenda and to your sound bite with finesse and persistence.
• Try to be an interesting guest. Come ready with rich, illustrative stories. Avoid yes or no answers to questions.
• Know that you do not have to answer all questions and should avoid providing comments that would embarrass you if they were headlines. If you don't know the answer to a question, say so and offer to get back to the interviewer with the information.
• Avoid being disrespectful or arguing with the interviewer.
• Remember that being interviewed can be an anxiety-producing experience for many people. This is a normal reaction. Do some slow deep-breathing or relaxation exercises before the interview, but know that some nervousness can be energizing.
• Write a letter of thanks to the producer or journalist afterward.
• Provide feedback to the producer or journalist on the response that you have received to the interview or the program or coverage.
Using Social Media
Mobile Text Messaging
Mobile and particularly text messaging is the ideal medium for communicating with everyone equally, regardless of their age, gender, or economic status. To get started, do the following:
• Create a subscriber base with zip codes so text alerts can be targeted to subscribers; you can then ask people in a specific Congressional district to contact their representative about an important issue.
• Send alerts about a news item, an action, or a “meet-up”—the calling of a gathering of people for a shared interest.
• Send a link to a website or local news item.
• Feature a text-alert campaign on your website homepage.
Blogs are great ways for you to share your opinions and ideas on health and social topics and to bring attention to important issues. The following are some tips for blogging:
• Be creative.
• Engage your audience and invite readers to get involved.
• Tell important stories.
• Share your process (how your organization works).
• Share successes and challenges.
• Write short, action-oriented posts.
• Link to interesting local news.
• Find your niche.
• Be a subject matter expert.
• Be conversational.
• Write like you'd talk to your neighbor.
One website that provides easy tools for starting a blog is www.wordpress.com .
Facebook ( www.facebook.com )
Facebook provides a vehicle for building and growing a community. Lots of people are on Facebook to stay connected with friends and family. You can also create a Facebook page for your professional life, since mixing the two can be problematic if you're a clinician.
• Create a page for your organization or specific causes or issues; updates may include a new action item and a new goal.
• Upload relevant videos, photos, and articles.
• Turn your cause into a campaign.
• Set an achievable goal, and find a creative way to engage people to invite their friends.
• Host short-term causes.
• Use the announcements feature to keep followers informed.
• Always send new info.
• Keep it short.
• If one idea doesn't work too well, don't be afraid to shut it down and try a new idea!
Twitter ( www.twitter.com )
Twitter asks one question, “What are you doing?” Answers must be under 140 characters in length and can be sent via mobile texting, instant message, or the Internet.
Photos and videos can provide important visual messages, enabling issues to get on the public's agenda by drawing attention to a cause. YouTube has created an online video community. Flickr is a way to manage and access photos.
Blogging and Microblogging
Increasingly, blogs are used as ways to communicate personal experiences and opinions. Theresa Brown is an oncology nurse living and working in Pittsburgh. Her first career was as a doctorally prepared English professor before deciding that she wanted to work more closely with people. She wrote a narrative about a dying patient that was published on the first page of the New York TimesScience section, which until then had been dominated by physicians' narratives. She was then invited to contribute to the Times' health blog, Well. As a result, issues of concern to practicing nurses received regular visibility through her posts. Her expertise as a nurse in cancer care is clearly valued by those who post responses to her blog entries.
Twitter, an example of microblogging, is a great way for nurses to listen as well as to talk to others on a very direct level. Twitter allows users to post short, 140-character messages (called tweets). For longer conversations, people use hashtags (# symbols) to track topics. People are very creative in the way they use Twitter and it holds a great deal of potential for nurses. For example, a Twitter TweetChat is a prearranged chat that happens on Twitter through the use of Twitter posts (tweets) that include a predefined hashtag to link those tweets together in a virtual conversation. There is even a URL that provides a schedule of health-related TweetChats ( www.symplur.com/healthcare-hashtags/tweet-chats/ ). When you can't attend a conference but know the hashtag that is being used by those in attendance, you can search for it on Twitter, read the live tweets, and join the discussion by tweeting from wherever you are. It represents both a media and a marketing tool. Each presenter's remarks and recommendations can reach a wider audience.
You can also use Twitter to convey a position on legislation that is up for a vote on the local, state, or national level to inform public debate on how this policy will impact the health and well-being of individuals and communities. Also, you can use Twitter and other social media to link to relevant data supporting a particular position and to see what others are saying about this policy: Is it positive? Negative? Misinformed? Journalists frequently use Twitter to find sources of information on stories they are covering or to simply uncover new stories. Following key health journalists can provide opportunities for recommending yourself or other nurses as experts on specific topics or to help them to reframe their stories.
Digital Media and Social Networking Sites (SNS)
The development of Web 2.0 has meant increased participation and media attention on virtual communities, most frequently in social networking sites (SNS) such as Facebook, Twitter, LinkedIn, Pinterest, Google+, and MySpace. The impact that SNS will have on health policy is still emerging but there are some intriguing early examples of the advantage they may hold for advocacy. For instance, Facebook is emerging as an important venue for debate about health policy, and not just among people typically thought of as policymakers. The health care reform battle sparked a huge number of for- and against-themed pages, such as Ohio Against Health Care Reform (81 fans), Wyoming for Health Care Reform (247 fans), and the perennial Facebook meme, “I bet we can find 1,000,000 people who support/oppose” health care reform. Although measuring the effectiveness of such Facebook campaigns remains elusive, we will likely see more of this type of activity as health care reform is implemented.
Not everyone understands the potential of social media for shaping advocacy. Lovejoy and Saxon (2012) examined the content of tweets from the 100 largest nonprofit organizations in the United States, 24% of which were health-oriented. The authors identified three primary communication functions: information, community, and action. They found that the bulk of communications sent information (58%), 26% reinforced community via more interactive messages, and only 16% promoted some form of action such as donating, volunteering, or 132engaging in advocacy. Guo and Saxton (2014) applied the same typology to investigate the tweets of 188 civil rights and advocacy organizations and had strikingly similar findings: 67% information, 20% community, and 12% action. Research on nonprofit organizations' use of social media has also shown that the interactive features of Facebook are often underused (Waters et al., 2009). These studies suggest that nonprofit organizations are not yet as successful at reinforcing and building an online community and then mobilizing it.
The first obligation that all nurses have is to be knowledgeable consumers of media. Nurses must seek out unbiased information before taking positions on policy issues and be able to critically evaluate media messages, assess who controls the media, and identify whose vested interests are being protected or promoted. Nurses should add www.mediachannel.org and www.freepress.net to their Internet favorites and evaluate their sources.
Getting to know the nature and quality of a particular journalist's or cyberactivist's work can help you to decide how much to trust it. Ask the following questions:
• Do they frequently misrepresent issues?
• Are their stories sensationalized or exaggerated?
• Do they present all sides of an issue with accuracy, fairness, and depth?
What is the Medium?
The first step is to ask yourself from where you get your information and news.
• What is the reputation of the television or radio station, program, newspaper, or website? Is it known for balanced coverage of health-related issues? Is it partisan?
• Does it cover international and national, as well as state and local, issues?
• Is it a credible source of information about health issues and policies?
These questions provide a basis to judge whether or not the information and news you are getting is credible and representative of a broad sector of public opinion. You will need a sample of various media presentations of the issue to evaluate their messages and effectiveness.
Who is Sending the Message?
Part of understanding what the real message is about comes from knowing who is behind the message and why. You could interpret the real message behind the Harry and Louise commercials against President Clinton's health care reform legislation once you knew they were sponsored by the HIAA. If the legislation had passed, the majority of insurance companies would have been locked out of the health care market.
For news media, ask the following questions: Who owns this medium? Who sponsors the website? What are the owner's biases? In addition, more and more newspapers and online venues are using the Associated Press (AP), or other major national papers, as their source for stories. The AP does not investigate; they attend events, accept news releases, and file reports. If newspapers are using abridged stories from other papers, the news slant or bias of the other paper reflects the bias or slant of the paper you are analyzing. As newspaper and television newsroom budgets get slashed, few news outlets are able to afford investigative journalism. To preserve this important aspect of journalism, nonprofit investigative news organizations have arisen to fill the void, such as the online Kaiser Health News, founded and supported by the Kaiser Family Foundation, and ProPublica, supported by a major multiyear commitment of funding by the Sandler Foundation. While Kaiser Health News is specific to health, ProPublica is not but does cover health issues. For example, it published a series of reports on the excessive delays in the California State Board of Registered Nursing's actions on complaints against nurses who were found guilty of drug abuse, sexual assaults on patients, and homicides ( www.propublica.org/series/nurses ). The reporting by Pulitzer Prize-winning journalist Charles Ornstein and Tracy Weber resulted in the governor removing several board members who were up for reappointment and the executive secretary resigning.
What is the Message, and What Rhetoric is Used?
What is the ostensible message that is being delivered, and what is the real message? What rhetoric is used to get the real message across? In 2009, pollster Frank Luntz of the Luntz Research Companies leaked a 28-page memo of sound bites and rhetoric designed to stop the Washington takeover of health care to Politico. The memo, entitled “The Language of Health Care,” is reminiscent of the analysis Luntz provided to Republicans for the 2004 presidential campaign and that was used by the Republicans to win legislative battles and political campaigns in 2006. His 2009 analysis provides insight into the language used to frame health care reform by federal policymakers. For example, he proposed that the phrase that “would ‘scare people more’ about the future of American healthcare” was: “That the government will decide what treatment I can or can't have” (Luntz, 2009, p. 24). PolitiFact.com chose “a government takeover of health care” as the 2010 Lie of the Year because it played a key 134role in public opinion about the ACA (Adair & Holan, 2010). Rhetoric relies on “words that work” and those that do not work based on polling results. One of the words not to say was: private health care/free market health care. Instead, the document advocated the phrase: patient-centered health care.
Every issue has spin doctors who develop believable messages based on focus groups and polling. As messages are repeated in the media, they become believable. It is essential to be attentive to the language used in media messages whether delivered directly by policymakers, pundits, or advocates, and to evaluate the credibility, bias, and intentions of these sources. What and whom should we believe?
Images also convey important messages. As Luntz's (2005) New American Lexicon notes, “Language is your base. Symbols knock it out of the park. The American people cannot always be expected to directly grasp the connection between your policies and your principles. Symbols bridge this gap, so use them” (Section 2, p. 2). The document promotes the obvious symbols of the American flag and Statue of Liberty. But consider the symbols used by health insurance companies to advertise to employed individuals and families. These ads use pictures of healthy active adults and bright-eyed children rather than images of obese individuals or people disabled by arthritis to attract new members to their insurance products. These are examples of targeted media messages in which images are symbols to augment carefully crafted rhetoric to sway a target audience to believe or act in a particular way.
Is the Message Effective?
Does the message attract your attention? Does it appeal to your logic and to your emotions? Does it undermine the opposition's position?
Is the Message Accurate?
Who is the reporter or cyberactivist and what reputation do they have? Are they credible, with a reputation for accuracy and balanced coverage of an issue? What viewpoints are missing? Whose voice is represented in the message or article?
Responding to the Media
One of the most important ways to influence public opinion is to respond to what is read, seen, or heard in the media. Letters to the editor or call-ins to talk radio programs can be powerful ways to reframe an issue or put it on the public's agenda.
Op-eds (thought to be derived from opposite the editorial page or opinion editorial) allow a more in-depth response to current issues and provide a way to get an issue on the public's agenda. Although they may be solicited by a newspaper or magazine, local community papers often are eager to receive op-eds that describe an important issue, include a story that illustrates the local impact of the problem, and suggest possible solutions.
Tips for successful op-eds include:
• Keep it short and within the word limit specified by the publication.
• Hook it to a national event if the publication or website has a national focus, or to a local event for local publications.
• Have a timely topic, concisely and clearly written in a conversational style, and with an unexpected or provocative slant.
• Include details or clinical examples to bring the commentary alive.
• Use data to support your argument
• Define the problem, possible solutions and include a call to action.
Similarly, letters to the editor should be written immediately after the original story is published and follow the publication's guidelines for letters. They should be concise and make a specific point relevant to the article.
Calling in to talk radio provides another opportunity for sharing your perspectives. Identify yourself as a registered nurse and stay on the line while the host or program guest responds to your point or question. You may need to correct a misunderstanding or offer additional clarifying information.
Finally, it is always a good idea to contact a journalist to thank him or her for a good story. If you have a blog, be sure to link to the story in a post. If you see a tweet you like, you can retweet it to others who follow you. If you are on Facebook and like 135someone's posting, you can click on the Like icon and continue the spread of the posting.
Nurses have not always been taught how to use the media as a health promotion tool. Harnessing the traditional and new social media will provide opportunities to shape healthy public policies and engage in political activism.
1. What are your major news sources? What are the potential biases of these sources?
2. How is framing and rhetoric shaping media discussions of a current health or social policy issue? What are the competing frames or rhetoric? How else might the issue be framed?
3. If you were to talk with a journalist about an issue of concern to you, how would you frame the issue? What language or images would you use for the frame?
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