Introduction: Health in the nexus of information, lifeworld, and literacy

Health information and information regarding health-related topics have, in recent years, increased in multimodality, multimediality, and quantity. Online and offline lifeworlds are becoming living spaces for cultures of health knowledge. The notion of health, however, does not incorporate a clear definition, but shall be considered as individually and socially produced, constructed, and organized (Hurrelmann and Franzkowiak 2022). The internet plays an increasingly important role when it comes to searching for and finding health information (Baumann et al. 2020). In relation to a flourishing online health information landscape, which exemplified itself in a so-called infodemic (Nielsen et al. 2020) during the coronavirus pandemic, the notion of health information is discussed in terms of evidence-based health information (EBHI) standards and quality aspects. The scope and character of what should be considered reliable health information was thoroughly discussed in Germany (Arbeitsgruppe GPGI 2016; Koch 2021; Lühnen et al. 2017). According to the good practice guidelines for health information (GPGI), the notion of health information refers to knowledge about health and illness, their effects, early detection, diagnosis, treatment, palliation, rehabilitation, and aftercare of diseases, and relates to medical decisions, care and coping with illness, and everyday life with an illness (Arbeitsgruppe GPGI 2016; Lühnen et al. 2017). The quality criteria defined in these good practice guidelines apply to health information formats that are published by authorities (health professionals or institutions with a professional responsibility) and incorporate decision-relevant content.

Moreover, the notion of health communication also refers to holistic processes in terms of mediation and exchange of knowledge, experience, opinions, and feelings regarding health and illness. This exchange occurs among all people involved in health-related processes, such as professional service providers, patients, and advice seekers interested in issues of health and illness or public health policy (Baumann and Hurrelmann 2014; Hurrelmann and Leppin 2001).

Health information as an element of communication might be contextualized in relation to the concept of medium, which can focus on different dimensions of media in the world: media as machines (computer, TV, radio), media institutions (public service broadcasting, private publishing houses), and mass media formats (newspaper, podcast, website, broadcasting, social media). In all of those dimensions, media can carry meaning, which is captured in the postulate the medium is the message by philosopher of media theory Marshall McLuhan (1976). Furthermore, philosopher Sybille Krämer argues that a medium is not solely the message — moreover, the message keeps traces of the medium (Krämer 2003). Hence, it seems fruitful to take a closer look at media and messages of health information in non-medical contexts to learn more about the bigger picture of health information in everyday life and lifeworlds.

In everyday life, processes of using information and media for communication relate to societal dimensions. In his theory of communicative action, German philosopher and sociologist Jürgen Habermas (2014a, b) developed a two-stage concept of society as system and lifeworld. Habermas elaborated on the structural components of lifeworld (i.e., culture and society), and identified communicative action as constitutive for understanding and agreement in a lifeworld. While Habermas elaborates his theory extensively, for the purpose of this paper we take note of his distinction between media of interaction — symbolically generalized media of communication — (e.g., money or power) and generalized forms of communication. The basic prerequisite of communicative action is a common understanding (consensus via communicative agreement) among interlocutors on claims of validityFootnote 1. Mass mediaFootnote 2, as part of the generalized forms of communication, produce the public by bringing about an abstract concurrence of virtually present networks of spatial and temporal communicative contents. In other words, the public constitutes itself based on flows of communication, which are motivated by the lifeworld, and the public’s quality as an institution of the lifeworld is based on discourse. Nevertheless, Habermas sees mass media to be pressurized by political and economic interests and relates his observations to the thesis of colonization of lifeworlds by imperatives of system rationalities. He critically points to a decoupling of system and lifeworld by processes in which economic and administrative rationalities (imperatives of system rationalities) intrude into the space of generalized forms of communication and question the abovementioned consensus on validity claims as a prerequisite for communicative action  (Habermas 2014a, b).

Thus, a colonization of system rationalities overwrites consensus-dependent communicative practices in everyday life via monetary and power relations. Consequently, when non-linguistic, monetary, and administrative media of interaction replace communicative media, a fragmentation of general consciousness or opinion might be at the end of this process (Müller-Doohm 2008).

Representations of health in health information and implicit health knowledge

Media in the form of written texts, graphs, images (e.g., anatomical sketches or magnetic resonance imaging [MRI] scans), simulations, or videos represent health issues on a visual basis, conveying health-related topics, cultures, statuses, and values. According to German media and cultural scientist Andreas Hepp (1999), media play a central role in the communicative construction of sociocultural reality in current society. The cultural studies discuss this phenomenon in terms of representation. The British cultural scientist Stuart Hall (1997) defines representation as a process to produce meaning via the use of language. Nevertheless, representation should not be understood in terms of reflection of reality, but as parts of the process that builds sociocultural constructions of reality. Therefore, discursive formations, in which a certain set of rules or practices dominate, regulate the possibilities of meaningful statements and ultimately the possibilities of representation of something (Hepp 1999).

Since the pictorial turn, imagery has been emphasized as an entity of communicating meaning (Mitchell 1994). Next to written text, images became meaningful as scientific data; and image science, visual anthropology, or visual ethnography have established themselves as meaningful methodologies (Kolb 2021). Therefore, methods to analyze and understand images and their meaning became of great interest. When attempting to scientifically to analyze images, one can draw on discourses and methodologies in semiotics, the arts, and photography. Analyzing the content of an image, the production of the image, or the meaning an audience attributes to it, allows insights into the image design, social meaning, cultural meaning, or communicative meaning (Kolb 2021). Therefore, descriptive methods and hermeneutics became entry points for analysis.

In the semiotics of Roland Barthes (1986), photographic theory is outlined which distinguishes between the studium and the punctum of an image. Whereas the punctum is considered a breaking or piercing element of the photography, a random piece that pierces the attention of the spectator, the studium can be described as the overall polite interest in a photograph. The studium allows the encounter with the photographer, it allows one to comprehend the intentions of the operators. However, the punctum pierces the studium like an arrow, and it can foster emotions or draw on morals or immoralities; the punctum itself is indifferent and unconscious (Barthes 1986).

Hence, when engaging with the discourse of health information, visual representations, images, and pictures can become valuable media to understand appraisals of health information in everyday life. Drawing on William J.T. Mitchell (1994), the German sociologist Ralf Bohnsack (2010) argues that one can understand through imagery; hence, a verbal or written explanation is not necessary to understand a picture. Furthermore, he argues, that one can understand imagery as important for practical action and, therefore, relevant for understanding social action (Bohnsack 2010).

An understanding or orientation of action and everyday practices through imagery as a medium is embedded in tacit knowledgeFootnote 3 and lies below levels of conceptual or verbal explications (Bohnsack 2010; Mannheim 1980). Tacit knowledge is anchored in social context. Therefore, all action is based on a relevant social context and complex construction of meaning. Theses contexts are shared by individuals. Based on his notion of conjunctive recognition, German sociologist Karl Mannheim (1980) later coined the notion of conjunctive or collective knowledge, which emerges in shared experience-based space. Therefore, conjunctive spaces of experience are understood as the basis of all individual knowledge — Mannheim uses the analogy of a font, which makes out the word view (Mannheim 1980). Tacit knowledge in the context of photographs refers to a transition from iconography to iconology (Bohnsack 2010; Panofsky 1955). Engaging with representations of representation allows insights into inherent meanings of health; moreover, it allows for learning more about how the providers of the picture content present health, and how the recipients appraise those presentations of health against the background of shared conjunctive spaces.

Health literacy

With increasing information about health being available to patients and citizens, competencies in the context of health information become an important factor. Patients and citizens need skills for accessing, understanding, appraising, and applying health information in everyday life in ways that support their judgement and decision-making regarding different factors in the context of maintaining or improving quality of life during the life course: healthcare, health promotion, and disease prevention (Sørensen et al. 2012). In the context of the internet, digital health literacy is key. Relating to Ole Norgaard et al. (2015), individuals need skills to process information, need basic knowledge about  their own health, about the navigation through healthcare systems, and need motivation to engage with digital services. Those skills are further specified by Kolpatzik et al. (2020). The authors elaborate on eight specific dimensions of competencies, pertaining to: (1) computers, (2) data, (3) privacy, (4) reading and writing, (5) media, (6) searching and finding, (7) information, and (8) health information (Kolpatzik et al. 2020). Norgaard et al. (2015) point out that e-health  systems must provide access to functional digital services, and a fit between these services and the needs of individual users (Norgaard et al. 2015). Furthermore, Kolpatzik et al. (2020) elaborate on the responsibility of health information  systems and advocate a low-threshold access to electronic aids, target group-specific offers, and the involvement of the target group in the technical development of these. Furthermore, on the content level, the system is responsible for the access to evidence-based information, the consideration of lay comprehensibility, and the development of measures to increase adherence.

However, subjective perceptions and evaluations of health and illness exist in parallel to these definitions. Health can be both defined and understood in either worldwide or in local and socially situated terms (Napier et al. 2014). Thus, multidimensional understandings of health co-exist on a societal level. Health knowledge is being used and practiced in complex everyday life (worlds) by people for either self-care or for taking care of others. Hence, in the light of health information, and self-determined and knowledge-based care for health, specific (digital) health literacy skills are required, which are critical to empowerment (Nutbeam 1998, 2000). Hence, Ilona Kickbusch and Daniela Maag (2008) defined health literacy as a capacity that allows individuals to make sound decisions regarding their health in everyday life in any context. These contexts can be the home of an individual, the community, the workplace, the health care system, the market place, or the political arena. Peoples’ abilities to control their health, seek out information, and take responsibilities are crucial parts of a critical empowerment strategy (Kickbusch and Maag 2008).

Hence, critical health literacy not only aims at achieving individual health benefits, but includes the empowerment of communities and the reduction of social health inequalities (Abel and Benkert 2022). Abel and Benkert (2022) stress the abilities to reflect upon factors that determine health, to process them, and to apply the results of the reflection to individual or collective actions for health regardless of the context as important factors. For dealing with health information in complex lifeworlds, Silja Samerski therefore proposes a lifeworld-oriented conception of health literacy, which allows people to empower themselves and to be able to apply health knowledge to care for their own health or that of others (Samerski 2019).

Research interest and aim

This research was conducted as part of the research project Orientation aids in dealing with health information on the internet (OriGes). Based on the empirical research in the context of this project, two websites were created as orientation aids for German-speaking internet users: www.gesund-im-netz.net andwww.klick2health.net.Footnote 4 The aim was to gain insight into people’s customs and preferences in dealing with health information on the internet, and to strengthen skills and literacy so that citizens can select and identify reliable and high-quality online health information by themselves (Jünger et al. 2022). The project posed questions regarding the role and relevance of online health information in everyday life; ultimately, it aimed at giving insights as to how the orientation aids can be used as such, and how to develop them further into applicable and needs-oriented tools for everyday life.

Against the background of the acknowledgement of subjective experience-based knowledge, the study reported in this paper aims at reconstructing frames of orientation regarding everyday encounters with representations of health and health information. The everyday knowledge that guides people’s actions and practices is of particular interest. Effects and cognitions of health information have already been studied thoroughly in the fields of health literacy, health communication, and public health (Fromm et al. 2011; Samerski and Müller 2019; Schaeffer et al. 2021). However, appraisals of health information outside a medical or specifically health-related context and the related discursive negotiations  have to date been less frequently considered.

Therefore, the analysis in this study focuses on appraisals of random encounters (in contrast to self-initiated encounters) in everyday life with what individuals perceive as health information, and respective consequences for action. Ultimately, collective formations of appraisals regarding health information are reconstructed. The data will contribute to the development of health information applicable to everyday life and enrich initiatives to support health literacy. Furthermore, the data are expected to inform the advancement of the abovementioned orientation aid websites.

Methods

In this study, the sociology of knowledge as a theoretical framework is chosen as the overarching research programm. Photo-elicitation diary method was used for data collection, and documentary method as analytical approach (Bohnsack et al. 2013; Keller 2011; Mannheim 1952).

Photo-elicitation diary study

As appraisals to health information in everyday life were of interest in this study, empirical data was collected in everyday life. In order to understand everyday life with and around health information, a longitudinal design using the diary method was deemed appropriate in order to answer the research question. Diary studies are particularly suitable for investigating the experience-based spaces and orientation patterns of people (Lamnek and Krell 2016; Yurtaeva 2017). The only recruiting criteria for participants in this study were age 35–65, German language skills, as well as technical prerequisites (internet access and availability of hardware and software). The sampling process (convenience sample) allowed us to span a great variety of different socio-demographic backgrounds (sample description in Table 1). Therefore, a rather simple and participative method for data collection was of interest. Hence, this study combined the diary methodology with the photo-elicitation method. Participants of this study were invited to collect visual impressions of their everyday life with health information via photographs. This approach allowed for a high degree of flexibility and self-determination for the participants. Following the diary phase, researchers conducted follow-up interviews, drawing on the photo-elicitation method. This approach  goes back to John Collier’s (1957) visual anthropology, in which photos are used to enrich qualitative interviews. Photos are integrated into the interview, while the participant is asked to comment on the visual images (Carter and Mankoff 2005; Collier 1957; Harper 2002). The method is used today in studies of anthropology, sociology, and ethnography. It offers the possibility to overcome linguistic, spatial, or temporal barriers and is thus able to capture the life of a person within his or her individual context.

Data collection process: diary and elicitation phases

Participants were recruited via announcements in local supermarkets and online via eBay Kleinanzeigen. After recruiting a total of 11 adults for the study, collecting written formal consent and sociodemographic data, and 15-min pre-study calls with each participant, an online kick-off workshop with all participants opened the data collection phase. The workshop comprised an introduction to the orientation aid websites and a phase of interaction and reflection among the participants. Participants specifically engaged with the following topics: researching health information online and search engines, self-determination in the search process, and information for doctors’ visits. Additionally, topics like  health information quality, trust in health information, and information behavior and experiences were reflected. Hence, participants entered the diary phase with a priori exposition to the notion of health information.

After the online workshop, a 3-week diary phase began in November 2021. Participants were invited and encouraged to take photos of anything they considered health information in situ, and to send those photographs via email or messenger app (signal), including some written field notes (situation, media, location). In total, participants sent 297 pictures in 21 days.

At the beginning of December 2021, the research team conducted a data screening workshop and identified initial themes and concepts in the data. In light of the large number of photographs submitted by some participants, it was necessary to select pictures for the elicitation interviews: participants were invited to choose and nominate three of their pictures themselves (according to the participant’s subjective relevance). In addition, the research team chose one picture (from the generated photo pool) for each participant. The elicitation interviews (Dimbath 2013; Ndione and Remy 2018) were conducted in December 2021 and January 2022. Due to the coronavirus pandemic restrictions, the interviews with the participants had to take place online again.

Sample

The sample comprises 11 participants (6 women, 5 men, 0 diverse) between the ages of 35 – 65 years (see Table 1). First languages were German, Arabic/ bilingual Arabic-Kurdish, Russian, and bilingual German-Polish. All interviews were conducted in German language. People worked in different fields and came from a wide range of socio-economic backgrounds. Three participants reported having chronic illnesses. Nearly all participants used the internet once or more every day. The search for health information spanned from once a month up to more than once per day — most participants searched for health information several times per week. Participants sent between five and 76 pictures each during the diary phase. The Ethics Committee of the Medical Faculty of the University of Cologne advised and positively reviewed the present research project. Participants received an expense allowance of €105.

Table 1 Sample photo-elicitation diary study socio-demographic information
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Material: overview of included images

The interviews were transcribed verbatim, using content-based semantic transcription with linguistic equalization/smoothing (Dresing and Pehl 2015). The large data sample of 297 pictures was systematically filed. Interviews and pictures were analyzed using MAXQDA 2020.4.2 software (VERBI Software. Consult. Sozialforschung. GmbH 2020). Short descriptive summaries of each picture were generated, drawing on iconographic methods. Three different levels of construction of the photographs were identified. There were (1) pictures of self-initiated research, (2) staged pictures, where participants intended to express a topic, meaning, or opinion, and lastly, (3) pictures of random encounters with health and health information.

Focusing on the tacit knowledge of participants when encountering health information in everyday life, the analysis was focused on 25 photographs which were chosen for the elicitation interviews and which were based on random encounters with a piece of health information. Furthermore, respective interview segments relating to the included pictures and chosen by thematic relevance and metaphorical density (Bohnsack et al. 2013) as well as field notes sent along by the participants were included in the analysis.

The included photographs were categorized regarding (1) format, (2) medium/technology, (3) sender/originator, and (4) topic/theme. Photographs were either screenshots (online) or photos taken in the analog world from magazines, social media, e-mail account websites, public transport, billboards, leaflets, apps, and packaging. Content formats included articles, news feeds, social media posts, headlines, and commercials. Participants encountered topics referring to sleep, the coronavirus pandemic, complementary medicine, do it yourself culture, women’s health, physical fitness, food and diet, caretaking, oncology, and disease management.

The included topics were addressed by health insurance, newspapers and magazines, telegram groups, public broadcasting, science and research, associations, the private sector, and government.

Documentary analysis process

The documentary method was used for the reconstruction of the documentary meaning of each picture (Bohnsack 2006; Bohnsack et al. 2010; Panofsky 2006). As a practice of interpretation, the documentary method distinguishes between two levels of meaning, immanent and documentary meaning. Immanent meaning refers to the literal meaning, whereas documentary meaning focuses on the socio-cultural context of origin (at least what is manifested of it). The shaping of action enables the interpreter to access the documentary meaning.

The transcripts were analyzed - using the documentary method as well. Interpretations of the relevant passages in the transcripts were formulated as memos using MAXQDA software (VERBI Software. Consult. Sozialforschung. GmbH 2020). In a second step, reflecting interpretations were developed. The collection of reflecting interpretations allowed a first attempt to understand underlying appraisal patterns. Further, their analysis allowed the reconstruction of so-called orientation patterns as salient reflections of the way participants dealt with a certain topic. The regularity of the experience and the documentary content of meaning that lies in this regularity — hence, the frame of orientation of this experience — is reconstructed if continuity can be identified across narrative sequences. Other empirical cases were compared and contrasted (comparative analysis), which ensured methodological control of the identified orientation frames (Bohnsack et al. 2013).

To analyze the data corpus, the following process was applied (Fig. 1):

Fig. 1
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Process of documentary analysis

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Two researchers independently created iconographic descriptions of the studium (Barthes 1986) of each picture chosen for each interview case. Subsequently, formulating and reflecting interpretations were performed, and the reflecting interpretations were contrasted within and between cases to reconstruct implicit orientation frames for each photograph.

Documentary research serves both comparative sequential analysis and the generation of multidimensional typologies. The identification of different sequences of text sections in different cases and the reconstruction of the respective frames of orientation can flow into a systematic typology. In the application of the comparative analysis (comparing cases, themes, socio-genetic aspects), the tertium comparison was worked out, and thus meaning-genetic typologies were formed from the reconstructed orientation frames. Ultimately, a typification of appraisal patterns was built, and the reconstruction of the respective frames of orientation went into a systematic typification. (Bohnsack et al. 2018).

Results

Based on our analysis, we identified resonance (Rosa 2019) as a salient pattern underlying all further engagement with a certain health topic. The reconstruction was based on participants’ resonance with a specific health information in a certain situation, which was then photographed. First, during the diary phase, participants chose the situations they photographed themselves, according to their attention and connection with the encountered health information in the world. Later, for the interviews, participants again chose three pictures out of their individual collection according to what Barthes (1986) calls the punctum (that which captures the interest) of the image.

Typification of images/content frames

The analysis of the 25 photographs elaborated on in the interviews led to the reconstruction of different types of orientation frames employed by the providers of the picture content. Formulating and reflecting interpretations as well as comparative analysis between cases allowed the reconstruction of the following six orientation frame types (see Fig. 2).

Fig. 2
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Reflective interpretations and key narratives of image content

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Firstly, a do it yourself (DIY) frame was identified, encouraging viewers to take action and create self-made solutions. An exemplary photograph for this frame is an Instagram screenshot of an advertisement posting by hellofresh.de, a German meal delivery company (Appendix, Data-ID: 54_211127_TBS04f). The posting’s title roughly translates to “Four herbal do it yourself home remedies against a cold”.

Secondly, a manipulation frame was observed, triggering or playing in lurid ways with peoples’ conception of being manipulated by the government or the system. An exemplary photograph shows a screenshot of the start page of e-mail provider gmx.de during the coronavirus pandemic (Appendix Data-ID: 5_211112_TBS06a). The title can be translated as “Head of WHO calls refresher vaccinations for healthy people a scandal”.

Thirdly, an optimization frame was identified, referring to numerous aspects of lifestyle, body, and mental health issues, suggesting that people can optimize and do even better. Exemplary for this frame is a screenshot of a commercial on Instagram. The commercial picture promotes an over-the-counter menopause product Serelys by the German company AVIVA PHARM GmbH titled “Naturally through menopause” (Appendix Data-ID: 4_211113_TBS04d).

Fourthly, there was a naturalness frame, which promotes herbal and natural products for health and well-being as opposed to industrial products. An exemplary photograph depicts a screenshot of a chatgroup, telegram messenger. The picture (Appendix Data-ID: 2_211111_TBS02a) shows two glasses of water with several slices of lemon accompanied by a short text arguing to drink lemon water every morning to reduce toxins in the body and regulate the kidney and bowel systems.

Furthermore, a fifth frame was identified. The security/protection frame plays with possible anxieties, but also the individual responsibility to take action and protect one’s health. An exemplary picture is a screenshot of an Instagram commercial by Nervoregin, which indicates that persistent sleep disorders weaken the immune system (Appendix Data-ID: 9_211113_TBS04i). Hence, protecting the immune system using the product Nervoregin is suggested to prevent such  weakening.

Lastly, there was a conformity frame, relating to people following rules and complying with standardized evidence-based narrations of health. An exemplary picture is the photograph of a magazine article with the subtitle “With globuli against Corona, this is how homeopathy becomes a deadly danger” (Appendix Data-ID: 27_211121_TBS08b).

Typification of appraisal patterns

The following analysis focuses on the reconstruction of appraisal patterns and respective consequences for action. The reconstruction does not refer to individual opinions, attitudes, or psychological mechanisms for appraisals. Rather, the reconstructive process carves out concepts, paradigms, and societal logics, which the appraisals touch upon. It was possible to reconstruct four meaning-genetic evaluation types, namely control, confidence, optimization, and responsibility. Furthermore, different approaches of action on how to engage with these encounters were identified: defence/acceptance, empowerment, protection, and reflection (see Fig. 3).

Fig. 3
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Typification of appraisals to health information

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Control

Being controlled

By comparing and contrasting reconstructed appraisal patterns between cases, superordinate categories of patterns were carved out.

Reflecting formulations carry concepts like coercion, information overload, and manipulation in the context of encountering health-related topics in everyday life. In particular, in relation to advertisement, it seemed inevitable to encounter health-related content which was expressed in relation to a feeling of overload. Others encountered health information in relation to a strong perception of manipulation. When elaborating on the diary entry, regarding the Serelys menopause product (Appendix Data-ID: 4_211113_TBS04d), a female participant expressed her discomfort when randomly being confronted with a health topic on Instagram she regards as personally sensitive:

"But I found it very interesting that, in their opinion (,) they know how old I am on Instagram, right? Uh, that they think they have to show me this advertisement now. I haven't looked into the product. […]" (TBS04, 44–49)

"I don't want to say that I have a huge problem with age, but I'm not really thrilled that I'm already over 40. I still live my life the way I have for the last 20 years, so it's just a number. But I don’t appreciate being confronted with it. It's like that for me (.) yes, by the way, remember, soon it will be your turn too. Of course, it's all in my head, I know that, right? Others laugh about it and don't care, but I found that somehow, (.) yes. This is not about a cold […]." (TBS04, 66–101)

When talking about this picture in the interview, the respondent reflected on the previous media behaviour on an abstract level and found social media algorithms to be manipulative. The participant claimed to not having actively engaged with this topic herself, and assumed direct algorithmic targeting due to her age. From the participant’s perspective, she was targeted due to algorithmic categorization, which imposed this topic onto her and therefore influenced how this female participant felt about her body and age in that situation. Hence, the Instagram algorithm controls the narrative of a healthy, vital female body, whilst the participant as an Instagram user cannot control the algorithm-based displayed content.

Thus, a dissonance between the experienced state of one’s own body and numerical age versus the experienced categorization of the Instagram algorithm is expressed. The algorithmic categorization and its implications led to strong rejection towards this categorization. For the purposes of the paper, this action shall be called defence. In this particular case, the direction of defence targets algorithmic control over the individual conceptualization of one’s own health and body.

Since the separate and initial documentary analysis process of the picture itself carved out a content frame called optimization, the participant’s rejection or defence against the algorithmic categorization can further be read as a defence against a perceived optimization pressure regarding natural physical occurrences and changes.

Being in control

As opposed to being manipulated and controlled by health information, the reconstructive process carved out yet a different dimension. Whilst some participants appraised random encounters with health information in terms of being controlled, others did so in relation to gaining or being in control.

The diary photograph of a leaflet named “Learning how to give care at home: individual trainings and courses for care-giving relatives” (Appendix Data-ID: 5_211115_TBS10a) resonated with an adult woman in a caregiving situation, who lives in a socio-economically marginalized neighborhood, speaks Kurdish as a first language, and learned German as an adult.

“Uh, how we learn to give care at home. Uh, that at the moment so many of us or of our family who need care like that. And I would like to/ want to (.) I don’t like a stranger to take over care-giving, like for example, in an old people's home. Also, especially with us, in our tradition […] And that's why I find, when you find information like that about care, uh (,) for example, my father now, he lives alone, uh was in the situation that he needs a uh care (.) Or so/ so slowly that we deal with, uh what kind of caretaking will he need later/ what could you do in what situation, what should I do now. […]" (TBS10, 216-264)

The reconstructive process carved out an orientation frame for the encounter with this information based on reflective interpretations regarding self-determination and participation. The above-mentioned respondent indicated during the interview that she saw the leaflet on a visit to a friend, who works in a senior citizens office and took it with her to read it in her own time at home. This way she was able to take the time she needed to familiarize herself with the content and information in the German language. Due to the short brochure character of the information, she could share the content knowledge with her community and family. On a second level, this information led to an action the authors called self-empowerment, as the information posed an opportunity to fulfil her wish to take care of her elderly father, who lives in Germany as well and has little German language skills.

Hence, the information is appraised in relation to being in control of health and health-related practices due to self-determination and participation. The appraisal of being in control was nourished by being able to understand the information and being able to generate knowledge through language access.

Therefore, the appraisal pattern regarding being in control or being without control was unified in the orientation frame of control, which includes polarizing dimensions.

Optimization

The concept of optimization was reconstructed as an ambiguous orientation frame regarding health information in everyday life. On the one hand, this frame communicates a narrative of improvement regarding the self, the body, and personal health status. On the other, the reconstructive process also carved out a multidimensional appraisal pattern regarding encounters with random health information in relation to optimization.

However, the reconstructive process of appraisals also carved out a multidimensional appraisal pattern regarding encounters with random health information on the receivers’ side in relation to optimization. The orientation frame was reconstructed via reflecting interpretations regarding the impulse for optimization and self-improvement in relation to physical fitness and body shape, or the compensation for physical weaknesses. Furthermore, technological devices and tools were appraised as optimizing for the arrangement of sports training. Additionally, the adaption to socially desired health standards was appraised in relation to optimization.

Responsibility

Furthermore, the reflecting interpretations led to the reconstruction of yet another appraisal pattern, namely responsibility. Reflecting interpretations regarding the prevention of illness and provision of health information and participation were the underlying basis for the reconstruction of this appraisal pattern. The appraisal pattern of preventing illness was associated with an individual responsibility, while the provision of health information and participation in health practices were associated with the system’s responsibility.

Exemplary for this appraisal pattern is a photograph that a male participant took in the gym (Appendix Data-ID: 4_2111_TBS09c). It shows a gym promotion poster which is titled “Health isn’t everything, but without health, everything is nothing”. Underneath the slogan, the poster depicts the new reduced price for signing a membership at the gym. In the background, young people are depicted in a group workout, kicking the right leg into the air in a fighting position. The male participant was in fact already a member in this gym and encountered this poster on his way out after a workout. The participant appraised the poster in relation to an individual responsibility for fitness, health, and prevention of serious illness. The respondent focused on benefits of physical activity for the body and mind, implying that activity and health in life need training. The idea of training and strengthening fitness, and therefore health, but also compensation of lifestyle, can be read in terms of the poster content pattern of optimization. The action that follows the appraisal of responsibility is an urgency to protect and secure health, whilst understanding this activity as his individual and personal responsibility.

Confidence

Confidence as an appraisal pattern was reconstructed based on reflecting interpretations in relation to trust and mistrust in health content. Whereas some reflections regarded trust in the health care system and trust in resonance with a theme, others regarded mistrust in media coverage and public debate (especially in the context of the coronavirus pandemic) as well as  mistrust in health technology. Hence, the reconstruction of this appraisal pattern showed high ambivalence and multi-dimensionality.

On a forest walk, the female participant encountered health information concerning African swine fever (Appendix Data-ID: 9_211112_TSB08b). The information board gave written information in several languages and was posted by the German Federal Ministry of Food and Agriculture. In the interview, the participant claimed strong trust in the ministry as a source for health information. The participant trusted the governmental warning and information as well as recommendations for action. This appraisal further strengthened the construction of an action pattern, called acceptance. The picture of the information board was associated with the protection and security frame. Hence, it indicates that information in the protection and security frame seems to be accepted in relation confidence in the content (see Fig. 3).

On the other hand, a female participant encountered an advertisement for a pelvic floor fitness device in a shopping magazine, deposited  in her home letter box. When flipping through the pages, she saw the advertisement titled “Pelvic Floor Fitness 2.0” (Appendix Data-ID: 3_211119_TBS03a) advertising a training toy that might help with incontinence and improve sexual pleasure. The photograph shows the informative text and below three smartphone screens with different features of the accompanying app.

"It's basically information that's worth double-checking for me. Well, not this one in particular, they already call it a “toy”. Um (...), if you call something a toy, for me that's a sign, um, that it's, um, more of a toy. Because that's the translation for it. I find that a bit inappropriate to be honest. If it's about health issues and if this thing costs €129 and it is supposed to support me, then it can't be a toy." (TBS03, 141-144)

The appraisal at hand was mistrust. The participant wondered about the use and placement of the word toy; the Anglicism was also used in the German text. The connection of health information in the magazine under a medically connotated title led to dissonance with the displayed playfulness of the device. Hence, the information itself seemed less credible and was met with mistrust. Whilst the content of the picture was categorized with the optimization frame, the appraisal pattern of mistrust towards the perceived optimization narration of the female body, especially the pelvic floor, for medical and sexual reasons was rejected.

Reconstructing conjunctive spaces of experience

In line with the overall goal of the documentary method, shared conjunctive knowledge was reconstructed through the appraisal patterns of random encounters with health information. The data showed that encounters with health representation in everyday life are not restricted to self-imposed search attempts or discussions with health professionals, but can just as well be random, unexpected, or even unwanted in everyday life situations.

Through the processes of comparing and contrasting cases, a typification of appraisal patterns was built: control, optimization, responsibility, and confidence. Contrasting and comparing the appraisal patterns with picture content frames indicated different ambiguities regarding the relationship between receivers and content.

Firstly, appraisals regarding the orientation frame of control (control frame appraisals) were retrieved in relation to picture content frames like protection and safety, optimization, manipulation, do it yourself (DIY), and conformity. Those relations indicate that health content frames like protecting and optimizing one’s health transport a narrative of a possible controllability of health. This controllability might protect one’s health just as well as it might be misused or manipulative.

Secondly, optimization frame appraisals were retrieved from photograph content frames like optimization and conformity. This appraisal pattern might be read in relation to the controllability frame, since the possibility to optimize health implies the general controllability and effectivity of an individual’s action on health. However, the reconstruction of this pattern based on content frames like conformity might indicate a perceived optimization pressure.

Thirdly, the responsibility frame appraisals were connected with picture content frames like optimization, protection, and security, as well as  DIY. This uncovers a perceived or experienced responsibility to optimize health, to protect, and secure one’s health. Additionally, it exposes the narrative of responsible action, or rather, responsibility to take action oneself and to do it yourself. Lastly, the confidence frame appraisals (trust and mistrust) were reconstructed in relation to picture content frames like optimization, protection and security, naturalness, conformity, and DIY. In this case, the immanent ambiguity of this appraisal pattern, which stretches from trust to mistrust, is directed at picture contents that confront the receivers with narratives like optimization but also naturalness.

Through this reconstructive process, a shared experience-based knowledge was uncovered, which shall be called the narrative of individual responsibility for vitality. The reconstructed content patterns demonstrate the scopes for action, but also in relation to optimization, protection and security, and conformity. Furthermore, the typology itself indicates a common experience relating to controllability of one’s own health and scope for action. Therefore, the reconstructed common conjunctive knowledge shall be described as a shared perceived ambiguity between a feeling of individual responsibility for one’s health and a feeling of limited control over the scope for action to actually take this responsibility. Nevertheless, the shared feeling regarding individual responsibility for health refers to the narrative of striving for an optimum when it comes to a healthy and vital life. It seems that within the shared experience-based knowledge, the narrative of responsibility regarding health is somehow related to a conviction that health as a physical entity has an optimum (see Fig. 4).

Fig. 4
figure 4

Reconstruction of conjunctive spaces

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Discussion

In the following, the results of this study shall be discussed and contextualized regarding media theory and public health discourses. Ultimately, the sociology of knowledge approach offers a fruitful framework for interpreting the problematizations in relation to knowledge configuration, discourse production, and power effects (Keller 2011), which were identified when reconstructing the appraisal patterns concerning health information.

The results indicate that from an everyday life perspective, the notion of health information is understood in a much wider sense than standards for evidence-based health information (EBHI) imply. When asked to document encounters with health information in everyday life, many participants photographed or visually captured a variety of formats, contents, and informative levels, like health advertisements, notifications and tips, or guidelines for action concerning a health topic. Hence, a discrepancy between the EBHI definition of the notion of health information, and subjective perceptions and understandings of the notion in everyday life, becomes apparent. These findings can be understood in light of McLuhan’s (1976) and Krämer’s (2003) contributions regarding messages carrying traces of media. Whereas within the professional or academic health communication discourse, the notion of health information is clearly defined in terms of operationalizable quality standards, from a media theory perspective, one can argue that health information as part of health communication can be understood at least in a twofold sense: as message or information (on a content level) and as medium, a shell, capable of mediating  messages.

Additionally, this study indicates the particular role of algorithms as media (media intermediaries) that mediate  information or messages. Non-transparent criteria and processes used by algorithms that determine social media or search engines, and respective advertisements adhere to messages on the content level, occasionally being evaluated with mistrust. Participants’ appraisals and reactions to contents in relation to the control frame indicated a certain scepticism and rejection. Hence, media do mediate specific content and the content carries traces of media, which need to be further investigated in future research, especially considering artificial intelligence (AI) search engine tools or chatbots. It might be important to research possible fragmentations of the public’s opinion on health based on different health messages in media. The practically produced public (Habermas 2014a) of health information and the public’s conception of health information impressively show the relevance of everyday life for the notion of health information.

Furthermore, applying Habermas’ (2014a, 2021) elaborations on mass media pressure to health information, one might argue for an ambiguous or even ambivalent system rationale and pressure. While health politics stress the importance of evidence-based health information (Arbeitsgruppe GPGI 2016; Koch 2021; Lühnen et al. 2017), the economic system promotes health information in relation to its innate capitalistic motives. Considering this dichotomy regarding political and economic pressure on health information as part of health communication, the ability to identify and distinguish between different levels of quality aspects of health information is highly relevant.

Hence, critical health literacy (Abel and Benkert 2022; Nutbeam 2000) becomes all the more important. It might not only be valuable for individuals to have competencies in finding, understanding, appraising, and using health information; it might be particularly important to have skills that allow for the reflection of health narratives and ethical dimensions within health information. Regarding the reconstructed societal health paradigm of optimal vitalization, one can reflect on consequences of such a strong health impetus which goes along with perceived high individual responsibility and at the same time unequal socio-economic resources. The results touch upon the question of responsibilization referring to the sociology of the body (Hahn 2010) of the individual. It shall be highlighted how easily the concept of individual responsibility for health is adapted, as the data shows especially in the field of physical fitness and the immune system. It might be fruitful to further investigate this in relation to advertisement promises for medical products. The results align with a discussion in public health ethics regarding the expansion of principlism and a stronger focus on autonomy, devolving a higher degree of responsibility to the individual to manage and control one’s health (Lewis 2006; Morley et al. 2020).

Furthermore, the reconstructed appraisal patterns underline questions of independence and self-determination regarding the construction of health knowledge on an individual level, which is at mercy of societal, algorithmic, and capitalistic systems, confronting users with health narratives and messages according to the systems' immanent market rules.

Hence, this regards the relationship between health information and knowledge. Medical and public health researcher Ellen Kuhlmann (2006) criticized that information becomes technology to legitimize power in the health system and reflects on the relationship between the legitimizing power of information and the social acceptance of knowledge systems. Digitalization allows citizens to access medical knowledge and participate in certain medical and health discourses, hereby bringing pluralistic, subjective, and practice knowledge systems into the field. Therefore, the question arises as to how these changes might transform the understanding and claim to the only one truth — and how plural knowledge systems can be reasonably integrated in a way that protects citizens from harm via disinformation, misinformation, or mal-information in health communication, but still values subjectivity and context dependency of knowledge (Kuhlmann 2006).

Hence, it seems relevant to question the scope for actual empowerment through health literacy in a health care system that focuses on individual responsibility, while media and economic systems promote the very same idea for monetary reasons. Perhaps approaches like critical health literacy can encourage and support these kinds of individual reflections regarding the perception and narration of body and health.

Conclusion

Applying these findings to health literacy initiatives like the project-based orientation aid websites (https://www.gesund-im-netz.net and https://www.klick2health.net), offering further educational and reflexive content material regarding different narratives and ethical perspectives on health and health information on the internet needs to be considered. Acknowledging the complex and deep pervasiveness of health information in everyday life, users need skills to identify different dimensions of health information in everyday life and respective narrations, as well as ethical implications in the context of health. Hence, spaces for empowerment, in which citizens exchange individual and common experiences, can be helpful instruments to foster critical health literacy on an individual and organizational level. In participative projects like the present photo-elicitation diary study, citizens discuss and learn together, and become sensitive for the complexity of health information in everyday life. Online tools which aim at strengthening health literacy might consider offering educative content regarding health narrations, with a particular focus on implicit normativity and ethical assumptions inherent to health information. These approaches would be first steps towards building critical health literacy, so that citizens can learn to identify and reflect about traces of media in health messages, as well as discursive struggles and controversies around health knowledge.

Strengths and limitations

In our study, we followed a participatory research design and conducted a photo-elicitation diary study which allowed the researchers to get insights into lifeworlds in the context of health information. The participatory and visual approach of the data collection method allowed participants to contribute diary data to this study, with less focus on language competencies. Additionally, the data collection method ensured visual insights into everyday life and individual in-depth interview stimuli. The documentary method allowed for a reconstructive analytical approach of verbal and visual data and implicit knowledge and appraisal patterns when encountering health information in everyday life.

Limitations include the pre-exposure of participants to a lifeworld-oriented definition of health information prior to the diary phase, which might have primed participants’ perception of health information. The task to photograph encounters with health information may have caused participants to focus on stimuli that, under different circumstances, they would not have noticed or considered as health information. Additionally, effects of social desirability need to be considered, as some participants intended to send ‘helpful’ data. On the other hand, there were some cases where participants deliberately did not send photographs of encounters with health information in relation to the coronavirus since they felt this would be too repetitive in our study, considering the mass of information on this topic. Nevertheless, participants without exception gave positive feedback on the task to focus on health information during their everyday life. The increased awareness for this topic as a result of participating in the study was highlighted as a particularly positive effect of this study.