Keywords

1 Introduction

Health communication has been defined as “any type of human communication whose content is concerned with health” (Rogers 1996, p. 15). This broad understanding includes a variety of health-relevant communication such as media coverage, advertising, online support groups, health application in smartphones, fictional content in entertainment formats and other ones. These formats could also be scrutinized by the means of content analysis. However, in this chapter we only focus on the news coverage of health topics by media or news organizations, i.e., health (care) or medical journalism (Walsh-Childers et al. 2018). While medical journalism rather focuses on healthcare and the medical treatment of diseases, health journalism also includes public health (promotion) topics such as physical activity, fitness, well-being, and nutrition in relation to the holistic health definition by the World Health Organization (1946). It mainly aims at informing and explaining health issues and health policies in an evidence-based and understandable way (Wormer 2011). This field of research has considerable overlaps with research fields such as science communication, risk communication, and organizational communication about health topics.

The content of health-related news coverage most often includes information about the risks and the treatment options of diverse diseases (Ruhrmann and Guenther 2014). Above all, prevention or screening measures (e.g., vaccinations for communicable disease or mammography for cancer prevention) and innovations in medical therapy are also a relevant part of health news (Ruhrmann and Guenther 2014). Advances in medical research and resulting chances and risks are often presented as controversies (Ruhrmann et al. 2011). Journalists increasingly include ethical issues or financial costs of healthcare in their coverage, but questions of health policies or (financial) complexities of the health system are still neglected (Wormer 2014).

A recent systematic analysis of studies in medical journalism (Catalan-Matamoros and Peñafiel-Saiz 2019a) showed that vaccination as a health topic clearly dominated health news research, with 13 studies focusing on HPV vaccine coverage (Gollust et al. 2016), while other topics like pharmaceutical funding, health politics or medication errors were much less frequently analyzed (Catalan-Matamoros and Peñafiel-Saiz 2019a). An earlier overview of health-related studies revealed that most studies analyzed media content about cancer, HIV/AIDS, smoking, alcohol consumption, and nutrition (Nazione et al. 2013).

2 Common Research Designs and Combinations of Methods

News coverage of health topics is presented in various forms (text, pictures or audiovisual) in a broad spectrum of very different media channels (e.g., print, television, websites or social media). Due to increasing convergence of media formats and transformation processes in news production (Walsh-Childers et al. 2018) different formats, sources and media channels are mixed. Thus, different kinds of content analysis methods have to be integrated in order to examine, for example, posts on social media, which often contain text as well as images andvideos. Here, a combination of quantitative and qualitative, manual and automated, textual and visual methods for content analysis is utilized to examine health journalism (Dobbelaer et al. 2018). To integrate the audiences’ perspective in the content analysis, eye-tracking data can be combined with the content analysis of texts. This approach is used to select only those textual or visual contents that are looked at by the readers (e.g., Kessler et al. 2020).

The analysis of visual, auditive or interactive materials like images, video or audio seems especially relevant, because they have been (in contrast to text) far less often analyzed by researchers (Catalan-Matamoros and Peñafiel-Saiz 2019a). This does neither reflect journalistic processes nor the mass media preferences of the public. Rather, this imbalance is due to the typical sampling procedures of media researchers, because text-based media content, such as print and online news articles, is more easily available and codable (Teixeira et al. 2012). Still, journalists increasingly transmit their information via podcasts, videocasts, or datavisualizations (Malecki et al. 2019) Thus, health communication scholars should consider these formats when examining health coverage.

With regards to the analysis of images and videos, some exceptions can be found: For example, Kessler and Schwender (2012) analyzed portrayals of older people in news magazines. Catalan-Matamoros and Peñafiel-Saiz (2019b) found that visuals appeared in 56% of the coverage about vaccines in the flagship Spanish newspapers. Yoo and Kim (2012) studied the portrayal of obesity in YouTube Videos. Cohen et al. (2019) examined the presentation of body positivity in Instagram posts (captions and images).

In conclusion, it seems necessary to broaden the media repertoire that is considered for content analysis. While most content analyses still rely on traditional newspapers (Catalan-Matamoros and Peñafiel-Saiz 2019a), a lot of health issues such as nutrition are presented in magazines (e.g., lifestyle, wellness issues), books (e.g., self-help books), brochures as well as user-generated content like blogs, user comments, and influencer profiles (Jones and Taylor 2013). Recent studies increasingly rely on the (semi-)automated content analysis to analyze health coverage in online or social media like Twitter and YouTube (Gibson et al. 2019). Using computational methods, the analysis of health news coverage by professional journalists can also be extended to the analysis of user comments (Lee and McElroy 2019).

Systematic analyses of the research field have revealed that (quantitative) content analyses are frequently used to examine health journalism (Hannawa et al. 2015; Kline 2006; Meadows 2017). To answer research questions about the attitudes or practices of journalists or news production processes, content analyses are often combined with surveys and in-depth interviews among communicators or observations in newsrooms. Another more recent strand of research also analyzes the hyperlinks within health news that are provided by journalists as „digital navigation cues […] in the increasingly complex and vast online health information“ (Stroobant 2019, p. 2138).

In addition, content analyses are often the basis for research about media usage, information seeking or media effects (Scherer and Link 2019). Consequently, content analyses are often conducted in combination with surveys or experiments. For example, in framing research a content analysis can reveal the presence of social determinants of diabetes in news coverage (Gollust and Lantz 2009), while experimental testing of such messages can inform about their effects on recipients’ opinion and attitudes towards this health issue (Gollust et al. 2009). Another study analyzed news portrayals of cancer causes and prevention in television and newspaper. In a second study, the authors tested the effects of this coverage on cancer-related attitudes (Niederdeppe et al. 2014). Here, also long-term content analyses are needed to detect relations with temporal developments or certain events and a resulting change of attitudes or behavior of the audience. For example, a content analysis of 30 years of news coverage on breast cancer has shown not only an increase of coverage and therefore rising public awareness for this topic over time, but also how the media coverage intertwines, e.g., with celebrity cases that in turn appeared to draw attention to the importance of early detection methods, such as mammography (Sooyoung Cho 2006).

3 Main Constructs Employed in Content Analyses of Health Coverage

Many studies in the research field health communication lack theoretical foundation and only present descriptive and comparative results. Manganello and Blake (2010) found in their meta-analysis of health communication studies that 55% of the content analyses in the sample were based on certain theories or approaches. Mostly these approaches originate from media usage or media effects research, such as the social-cognitive theory (Bandura 2001), the cultivation approach (Gerbner et al. 1986), agenda-setting (Rössler 2019), or framing (see below). This indicates that researchers are rather interested in the effects of media content than the production or creators of media content (Scherer and Link 2019).

Quality: Many content analyses of health information examine the quality, i.e., the fulfillment of certain criteria such as evidence and understandability of the content. Both of these criteria are increasingly relevant as people use online health information more frequently and in addition to the information from their physician for medical decision making (Wang et al. 2019). Thus, analyzing the accuracy of content becomes even more relevant. However, the internet provides a variety of health information from diverse sources, which are very heterogeneous in their medical expertise and their interests. As Schwitzer (2017) points out, there are many quality problems due to hurried, incomplete, poorly researched news, which are not necessarily published with a deceitful intent and thus are so-called fake news. For example, anti-vaccination websites of play a large role in disseminating misinformation (Kata 2010). Here, misinformation was indicated by the use of outdated sources, misrepresentations, false conclusion, self-referencing, or no references, to support the given claims.

To measure quality, the content of health news coverage is either compared to evidence-based medical recommendations and theoretical assumptions, or the quality of media content is continuously judged by journalists or medical experts with respect to different criteria. Comparisons of news content with healthcare guidelines or medical results and the derived recommendations regularly reveal a great divergence. For instance, user-generated health information (such as YouTube videos) about vaccination often present a much more negative attitude towards vaccination (than, for instance, the recommendations of the World Health Organization) and are also lacking evidence based information (Briones et al. 2012). Journalistic content is frequently criticized for not reflecting the medical recommendations as well. While state policy and institutions like the Center for Disease Control and Prevention clearly recommended the HPV vaccine for boys, media coverage was more concerned about the controversies around the vaccine in the context of the presidential campaign in 2011. Only 25% of news articles mentioned that boys were also vaccine-eligible (Krakow and Rogers 2016).

The continuous monitoring of quality in health journalism is institutionalized in different countries under terms like HealthNewsReview in Canada and the United States or media doctor in Australia and Germany (Schwitzer 2008; Wormer 2011). Catalogues with criteria like understandability, the portrayal of costs, benefits, risks as well as transparency about conflict of interests and independent sources are used to judge the quality of health news (Serong et al. 2019). Although the vast amount of health news makes it impossible to test all of them (and false information in user-generated content on social media might even be the more severe issue), these reviews indicate that only a minority of articles fulfill the quality criteria of the monitoring. One often failed criterion was the discussion of the available evidence for the presented results (Anhäuser and Wormer 2012).

A further reason for the decline in quality of health information are time constraints, a lack of staff resources as well as a lack of necessary skills in newsroom staffing (Walsh-Childers et al. 2018). Many producers in the health-related social media production, e.g., for topics like nutrition, fitness or similar are not medically trained, and even journalists reporting on health news often lack the competence for interpreting scientific results (Walsh-Childers et al. 2018). Another factor that can have a negative impact on the quality of health information is the influence of public relations activities by powerful actors, e.g., pharmaceutical companies or medical journals. They provide the media with ready-made news, including professional storytelling, which are often copied without further editing (Dobbelaer et al. 2018). Thus, the quality of newspaper articles is highly influenced by the quality of press releases issued by medical journals (Schwartz et al. 2012). Only content analyses that compare input and output can detect these influences clearly (for an example see Reifegerste et al. 2014). But beyond quality concerns it might also be relevant to include different actors of the health-related discourse. By analyzing the sourcing practices behind the content, Dobbelaer et al. (2018) found that patients and civil society actors are more often cited in weeklies and women’s magazines than in general interest and health magazines. This emphasizes the need to include more diverse media formats in content analyses.

Frequency of topics and intensity of media coverage: The frequency or intensity of media coverage of a certain health issue often differs from the prevalence or mortality rates and therefore the societal impact of this health issue, because journalists select their stories based on news values and audience perceptions and not only on public sphere orientations or health reporting (Holland 2018). Thus, media coverage about specific health topics rather reacts to acute risks or crisis, controversially discussed diseases or treatment options, or the case of celebrities. For example, the AIDS/HIV infection of the actor Rock Hudson and his dead in 1985 or the breast cancer of Angelina Jolie intensified reporting about these topics without a change of the mortality or prevalence rates (Cajkovac 2015; LoRusso 2017).

The accentuation to the point of overrepresentation of some topics also entails that others are underrepresented in the media coverage in relation to their prevalence or importance for the public. Additionally, diseases and health problems that rarely exist in certain countries are often missing in media coverage (Kline 2006). Historically, cancer disease was underrepresented in the media due to stigmatization in the first decades (Grimm and Baumann 2019). In recent media coverage, mental health issues are less often reported than physical health problems (Scherr 2019). To detect such blind spots, results of content analyses have to be compared to health reports.

Inaccuracies and exaggerations: In addition to underrepresentation, inaccuracies and exaggerations can contribute to the stigmatization of certain health issues as well. This especially affects mental health, as media descriptions of mental illness and the mentally ill are often characterized by inaccuracies, exaggerations, or misinformation. Thus, in media coverage mental illnesses are often associated with crimes and violence (Ma 2017). For example, a content analysis of Italian newspaper articles focusing on violent acts like homicide found that about 40% of these deeds were addressed to people with mental illnesses (Carpiniello et al. 2007). Findings from McGinty et al. (2014) suggest that the media often portray the issue of serious mental illness in the context of mass shootings and therefore strongly emphasize the association between mental health issues and violence. In consequence, patients are presented not only as peculiar and different, but also as dangerous. Thus, the media maintain misconceptions and stigma (Klin and Lemish 2008; Srivastava et al. 2018). Again, content analyses are crucial for identifying such misconceptions in the media coverage and therefore a first step towards reducing stigma. While most content analyses still report negative portrayals of mental illness, other results suggest the number of such stories is decreasing (Ma 2017).

Uncertainty and evidence depiction: Research suggests that new evidence for health topics is often presented in a biologically deterministic and simplified manner (Brechman et al. 2009). For example, through comparing the depiction of genetic research results relating to cancer outcomes in press releases and mainstream print media to the original presentation in scholarly journals, Brechman et al. (2011) show that as scientific knowledge is filtered and translated for a broader public, there are changes and inconsistencies resulting in media coverage that does not fairly represent the original research. Additionally, the scientific evidence is rarely discussed in science articles, and research findings are mostly presented as scientifically certain (Guenther et al. 2019). Moreover, research indicates that medical issues on science TV programs are depicted with different levels of evidence, presenting different argumentations (Kessler 2016).

Framing of health issues: Another analytical construct often employed in content analyses of health coverage is framing. In one of the most operationalized framing definitions (Matthes 2014), Entman (1993) describes framing mainly as process of selection and salience. From the four framing elements Entman refers to in his definition, the mediated attribution of responsibility for causes and remedies (treatments, solutions) is eminently relevant for public health, as these so-called responsibility frames (Iyengar 1990; Semetko and Valkenburg 2000) play a key role in the formation of public opinion by affecting attributions of responsibility (Gollust et al. 2013) and intentions for individual health behavior, interpersonal behavior or societal participation (Sun et al. 2016). For several health topics, e.g., obesity (Kim and Willis 2007), eating disorders (O’Hara and Smith 2007), cognitive enhancement (Schäfer et al. 2016), diabetes (Stefanik-Sidener 2013), molecular medicine (Ruhrmann et al. 2015) or depression (Zhang et al. 2016), research has shown that the media attribute more causal and problem-solving responsibilities to the individual than to the society. This may not only affect the willingness to help others, but also lead to dismissive attitudes towards institutional or organizational interventions (Lundell et al. 2013) as well as self-stigmatization in patients (Vogel et al. 2006).

Besides examining media frames through content analyses, researchers have extensively studied the effects of framing on the audience (Borah 2011). This is especially true for gain and loss framing of health topics, which has been analysed by a variety of effect studies (e.g., Latimer et al. 2008; Mays and Evans 2017; Park et al. 2010). Future research should additionally focus on the portrayal of gain and loss in health coverage.

4 Research Desiderata

The future development of studies analyzing health-related media coverage should provide a more comprehensive perspective, including more cultures, health systems, and countries; as well as a broader media perspective by examining more magazines, television, andradio content (Catalan-Matamoros and Peñafiel-Saiz 2019a). Furthermore, research should assess the content of other professional information providers, such as information services of hospitals, more frequently (Kessler and Schmidt-Weitmann 2019). Finally, content analyses should account for visual communication like images and videos on Instagram, YouTube and Pinterest (Guidry et al. 2016) or visuals in print health materials (e.g., about cancer) (King 2015).

Another bias in research relates to the underrepresentation of publications (and thus also of media coverage) from developing countries. While most research stems from the US or other high-income countries, there is a lack of studies from low-income countries or countries with diverse cultures or different media systems (Catalan-Matamoros and Peñafiel-Saiz 2019a). However, it can be assumed the media coverage of health topics also reflects the different cultural backgrounds and health systems. For example, a content analysis by Zhang and Jin (2015) examined the differences regarding the framing between Chinese and US newspapers, exploring how cultural values and organizational constraints influenced the frame-building process. The results suggest that diverging cultural values (collectivistic in China vs. individualistic in the US) may shape the ways in which news media emphasize either societal or individual responsibilities when covering depression. However, such comparisons of media coverage in culturally different countries are still rare exceptions.

In addition, future research should consider health information seeking behaviors more frequently: The searching behavior could serve as a starting point for content analyses (e.g., the Google search results of users, Madden et al. 2012) instead of relying on traditional (top-down fixed) sampling techniques. Thus, it could be useful to combine content analyses with eye-tracking or log data of websites or apps (Kessler and Guenther 2017). Another way of extending the perspective to user-generated content could be to integrate the analysis of content in online support groups or health platforms (Link 2019). Finally, in order to a more comprehensive view on factors that influence health news production as well as effects on the audience’s attitudes and behavior, more longitudinal studies in combination with other methods are necessary.

Relevant Variables in DOCA – Database of Variables for Content Analysis

Quality: https://doi.org/10.34778/2a

Inaccuracies and exaggerations: https://doi.org/10.34778/2b

Framing responsibility: https://doi.org/10.34778/2d

Stigmatization: https://doi.org/10.34778/2c