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Recent Trends in Research on Health Portrayals in the Media

From TV, Newspapers, and Magazines to Websites, YouTube, and Manga

James D. Robinson, Teresa L. Thompson, Jeanine Warisse Turner, Robert R. Agne, and Yan Tian

The concern voiced by social critics about portrayals of health issues in the mass media stems from the belief that the mass media are so pervasive that they are nearly inescapable. However, it is not the pervasiveness of the media alone that prompts concern about the way health issues are portrayed in the media. A growing body of research suggests that exposure to those portrayals can impact the audience in a variety of different ways. Discussions of these impacts include social learning and modeling, issue framing, cognitive priming, agenda setting, spiral of silence, and cultivation. While this chapter focuses on media content, audience members can be, and indeed are, influenced by these portrayals under some conditions. Given this, it is important to review recent research examining media portrayals of health issues in order to determine the kinds of information the audience is receiving about health and wellness.

Early literature on media portrayals often focused on media representations of sex and violence because scholars and social critics alike were concerned that the media could promote antisocial behavior. Anecdotal evidence of this potential for audience influence was often provided as a way of demonstrating the need for such research. For example, scholars and social critics cited the statistic that television character Marcus Welby M.D. received thousands of pieces of mail requesting medical advice (Gross & Jefferies-Fox, 1978), while a major publication like Time (“Television,” 1984) discussed copycat crimes generated from media portrayals. Examples of these events abound, and include Joseph Brandt setting his wife on fire after watching Farah Fawcett in the made-for-TV movie The Burning Bed (1984). Exactly what it means to request medical advice from a TV character is not clearly delineated by those scholars, but the actor Robert Young was not a physician, and if it were not for his success on Father Knows Best (1954–1960) and Marcus Welby, M.D. (1969–1976), it is unlikely audience members would have been as interested in his diagnostic skills. It is interesting to note that even today the Internet is literally littered with social critics pointing to audience responses to the good doctor Welby.

Media scholars employing content analysis have always been interested in the accuracy of those media portrayals (c.f. Berelson, 1952; DeFleur, 1964). Scholars often compared the race, gender, and age of TV characters with those distributions within the US population as a way of identifying an expected value for the demography of television. Evidence of the paucity of female characters and/or characters of color was provided by comparison with their respective percentages within the population. Similarly, scholars interested in health portrayals have also relied on comparisons between media portrayals and best health practices as a means of demonstrating the accuracy or the inaccuracy of media portrayals (Gerbner, Morgan, & Signorielli, 1982). For example, Kauffman (1980) employed the food pyramid as a criterion for interpreting TV portrayals of eating. Turow and Coe (1985) compared TV portrayals of misdiagnoses with national averages provided by the medical industry. Diefenbach (1997) examined the realism and accuracy of mental health portrayals. He found that characters with mental illness were between 10 and 20 times more violent than US citizens diagnosed with mental health problems.

This trend continues and can be seen in a recent investigation examining prime-time medical dramas. Moeller, Sadler, Moeller, and Rahey (2010) investigated how seizures are portrayed on Grey's Anatomy, House, Private Practice, and the last five seasons of ER. Not surprisingly, they found the portrayals a convenient narrative technique for adding drama and pushing the storyline along, but less than accurate in the portrayals of seizures and, perhaps more importantly, the treatment of those seizures. Specifically, 46% of the seizures in the episodes studied were found to be inconsistent with the recommendations of the National Epilepsy Foundation's guidelines for seizure first aid, while only 29% were consistent with those guidelines. Contrary to some portrayals, holding the patient down and/or putting something in the patient's mouth are inappropriate and medically contraindicated.

Health portrayal researchers must also consider the fact that patients want more information about their illness, treatment options, and side effects of treatments than they receive from their physicians. Further, they want written patient information or healthcare literature to supplement the information provided during office consultations (Donovan, 1991). So it is natural that when looking for health information, patients often turn to the mass media. Mills and Davidson (2002) and others have found that television, newspapers, and magazines are important sources of health information for many patients. Similarly, the Internet has also become an important source for health information (Dutta-Bergman, 2005; Fox, 2005).

Scholarly Outlets for Content-Analytic Investigations

In a recent investigation, Manganello and Blake (2010) identified studies published between 1985 and 2005 that examined portrayals of health and health-related issues in the mass media. The search yielded 441 articles published in 182 different academic journals over the two decades. Each article was coded for the type of media examined, health issue, theoretical rationale, and journal title. Forty-nine percent of the articles appeared in just five journals: Sex Roles (n = 23), Journal of Broadcasting and Electronic Media (n = 21), American Journal of Public Health (n = 17), Journal of Health Communication (n = 14), and Journal of Communication (n = 14). The most frequently content-analyzed media channels were magazines (35%), newspapers (31%), and television (29%). Fewer than 10% of the articles analyzed more than one media channel within a single investigation. While most of the content-analytic investigations focused on the articles in magazines and newspapers, 45% of the magazine studies focused on advertisements and 16% analyzed articles and advertisements and/or magazine covers. In the case of television, only 27% of the studies examined advertisements and 14% examined television news. The remaining 59% studied entertainment programming on television.

An analysis of the most frequently studied health issues suggests that the majority of the articles focused on substance abuse (22%), violence (20%), sex and sexual behavior (16%), and body image/obesity (15%). Fifty-five percent of the articles cited at least one theory or model as the rationale (or partial rationale) for the study, and 70% reported intercoder agreement or reliability estimates for the content categories.

With that study providing a solid baseline for further investigation, the authors of the present chapter examined content-analytic investigations published over the past five years. The analysis of these investigations yielded three notable trends within health portrayals research: (1) the investigation of a wider variety of illnesses and health issues; (2) the application of a wider variety of theoretical rationales for the investigations; and (3) increasing diversity as evidenced by greater emphasis on international portrayals and a wider variety of media channels.

Recent Trends in Content-Analytic Investigations

The Examination of Illness and Health Issues

Even the most cursory examination of the health portrayals literature leaves the reader with a strong impression that scholars are looking at a wide variety of illnesses and health issues. Without empirical testing it is impossible to state that researchers are examining a much wider range of illnesses and health issues than they have in the past, but it certainly appears to be the case.

For example, Quick (2010) conducted a large-scale content-analytic investigation of the portrayals of steroid use on television news programs. While previous work (Denham, 2004a, 2004b) examined portrayals of steroid use by specific individuals (e.g., Carl Lewis and Ken Caminiti), Quick analyzed all portrayals between 1990 and 2008 on three networks (ABC, CBS, and NBC) to see how the issue of steroid use was framed in the media. Using the health belief model (Janz & Becker, 1984) to generate content categories, Quick found that 64.5% of the news stories studied identified one or more of the barriers facing those individuals when they decided whether or not they should take steroids. The barriers included illegality (73%), drug testing/getting caught (15%), health costs (12%), suspensions (12%), fines for steroid use (<1%), and the expense of buying steroids (<1%). Similarly, stories not mentioning health consequences were far more common than stories identifying the health consequences of steroid use across all three time periods sampled (1990–1996, 1997–2002, and 2003–2008).

A second example of the increase in types of health issues investigated by some scholars can be seen in the interest in direct-to-consumer advertising of prescription drugs (DTCA). DTCA – the marketing of prescription drugs to audiences through newspaper, magazine, and/or television advertising – is a relatively new advertising technique, and one that has just recently begun being examined by health communication researchers. Among the industrialized nations it is legal only in the United States and New Zealand. Examination of manuscripts sent to the journal Health Communication since 2008 indicates that 12 manuscripts focusing on DTCA have been submitted for publication. To date only Sokol, Wackowski, and Lewis (2010) have examined these DTC advertisements to see the kinds of information that is provided to consumers.

Sokol and colleagues (2010) analyzed the five women's magazines with the highest circulation rates (Cosmopolitan, Glamour, Redbook, Ladies Home Journal, and Good Housekeeping) published between July 2005 and June 2006. The DTC advertisements found were produced by 35 different marketing companies and focused on 56 different medications as well as 36 different medical conditions, the most common of which were chronic conditions (42.7%), mental health problems (15.4%), lifestyle conditions (14.5%), cardiovascular conditions (12.8%), acute conditions (7.7%), and cancer (6.8%). Most often the name of the drug (40%) and the condition to be treated by the drug (62%) were identified in the headline of the advertisement. Initially examining the unique magazine advertisements, the researchers observed that 84.2% of the ads were product claim ads for prescription drugs. Product claim ads identify a particular drug by name and associate that drug with the particular health problem it is intended to resolve or manage. Far less common (10.1%) were: (1) help-seeking advertisements – designed to educate and raise consumer awareness but including no references to any particular drug names; and (2) reminder advertisements (5.8%) – those advertisements that identify medication names but do not link them to a particular malady.

A fourth example of the increase in health issue diversity can be found in an investigation by Johnson, Henderson, Pederson, and Stonecipher (2011). The researchers' concerns over how newspapers portray asthma is predicated on the prevalence of the disease within the population (just under 12% of US citizens have asthma at some point in their lives), the costs associated with asthma (about $20 billion annually), and the fact that there is no known cure for asthma (American Lung Association, 2010). A total of 203 articles focusing on asthma were identified, nearly half of which focused on issues other than asthma (e.g., air quality and allergies). Eighty-five percent of the stories contained one or more asthma management strategy (e.g., avoidance of drugs), and 43% contained at least one fear-based message (e.g., asthma is scary, asthma is stifling, or asthma can kill).

Finally, recent investigations focusing on health portrayals have not ignored mental health issues. Rather than simply examining portrayals of mental health, and recognizing that physical activity, a healthy diet, social activity, and engagement are believed to benefit our cognitive health, Friedman, Laditka, Laditka, and Mathews (2010) examined 178 articles published between 2006 and 2007 in the 20 most widely circulated magazines with a variety of different intended audiences. They found that the most common focus of cognitive health articles was diet, and there was little discussion of other factors affecting cognitive health such as hypertension or diabetes. Publications oriented toward the African American audience were least likely to contain stories and columns focusing on cognitive health. Equally troubling was the lack of emphasis placed on social activity as an antidote for cognitive decline – only 15.2% of the articles made mention of this fact. When mentioned, social activity was most often relegated to a list of things that might help, and little emphasis was placed on this important cognitive health consideration. Similarly, physical activity was seldom mentioned by itself as an activity that can reduce the risk of cognitive decline. The importance of physical activity on a variety of other health problems, including hypertension, obesity, vascular health, and diabetes, was also largely ignored.

To strengthen our contention that there has been an increase in illnesses and health issues examined by portrayals researchers, a list of the articles focusing on health portrayals that were submitted for publication in the longest-standing journal in the area, Health Communication; between 2006 and 2011, was generated. The partial list of health illnesses and health topics included hormone therapy, sex education, transgendered community websites, sexual behavior and HIV, alcohol abuse, cough syrup contamination, food advertising, congenital cytomegalovirus, cigarette advertising, human papilloma virus (HPV) and the HPV vaccine, nutrient content claims, skin cancer, heart disease, organ donation, DTCA, smoking fetish videos, diet, tanning, health website privacy policy statements, clean air, depression and cognitive health, portrayals of healthcare professionals (including physicians, nurses, nutritionists, psychiatrists, counselors, physical therapists, pharmacists, masseuses, and paramedics), avian flu, medical tourism, breast cancer, substance abuse, alcohol abuse, and breastfeeding. Perhaps the most unusual issues investigated within one of these content studies were Lapinski's (2006) examination of pro-eating disorder websites and Kim, Paek, and Lynn's (2010) examination of smoking fetish videos.

The Employment of Theory

The majority of the studies examined in the writing of this chapter were theoretically based. This comes as no surprise, as Manganello and Blake (2010) found that 55% of the content analyses published between 1985 and 2005 in the journal Health Communication cited at least one theory or model. Our examination of all articles published in Health Communication between 2006 and 2011 suggests that this trend continues and is strengthening.

Initially a list of all content-analytic investigations that focused on health portrayals was generated. This list contained all articles that were published, rejected, or to be revised and was then reduced to the 22 articles that had been accepted for publication. Each article was then coded for inclusion of a theoretical rationale. Seventy-seven percent of the published articles cited at least one theory or model (n = 17) and 31.8% of the published articles cited two or more theories (n = 7). Of the five additional investigations focusing on health portrayals, one was a descriptive study of media portrayals, two were rhetorical analyses, and two were textual analyses.

From this analysis it is clear that researchers employ a variety of different theories in their efforts to describe media portrayals of illness and health. Our review of the 22 content-analytic investigations published in Health Communication suggests the most commonly employed theory was Bandura's (1986) social cognitive theory (28.6%, n = 6). Researchers employing social cognitive theory or social learning theory typically focus on the kinds of behaviors and/or the kinds of information that audience members learn about health from the media.

The second most common theoretical base (19.0%, n = 4) for content-analytic investigations was framing theory (Kahneman & Tversky, 2000; McCombs & Ghanem, 2001; Tversky & Kahneman, 1981). Studies based on framing typically focus on how health issues are presented or framed as a way of extending the simpler issue salience approach typically employed by research based on agenda setting. Framing studies look at how the argument or issue is presented rather than just the number of times an issue is presented in the media.

Agenda setting (McCombs & Shaw, 1972) was the third most common theoretical rationale for the health portrayals research examined (14%, n = 3). Agenda-setting research focuses on how frequently a health issue is portrayed and/or the prominence of the issue. Generally, the agenda-setting rationale does not examine issue framing unless both are mentioned explicitly.

Tied for the fourth most common theoretical rationale (9.5%, n = 2) are the health belief model (Rosenstock, 1974), cultivation theory (Gerbner, 1970), and the extended parallel processing model (Witte, 1992). Other theories used only once within the 22 studies included: social identity theory (Tajfel, 1974), theory of planned behavior (Ajzen, 1985), social exchange theory (Thibaut & Kelley, 1959), narrative theory (Fisher, 1987), and the sexual imagery model (Byrne, 1977).

For example, Greenberg, Rosaen, Worrell, Salmon, and Volkman (2009) examined media portrayals of eating and drinking on children's television shows. Within this investigation they employed both Bandura's (1986) social cognitive theory and Gerbner's (1970) cultivation theory in their efforts to gain insight into the problem of obesity in the United States. The role the media play in this problem has been investigated by a number of scholars, who generally find that the eating and drinking habits of TV characters are far from healthy. In this investigation, Greenberg and colleagues (2009) examined 50 children's shows, 50 shows targeted at 9- to 14-year-olds, 40 afternoon soap operas, and 50 prime-time programs and found reason for social critics to be concerned. Specifically, they observed that eating and drinking are common activities and foods considered unhealthy – foods containing oils, solid fats, and foods with added sugars (OFFS) – are particularly prevalent. These potentially problematic foods are typically eaten as snacks or treats and are quite commonly ingested on programs oriented toward younger viewers. They also found that the consumption of alcohol is customary on shows viewed by children aged 9 to 14 and that drinking often occurs as a social activity within the context of a celebration. Greenberg and colleagues also found few negative consequences for eating unhealthy foods or drinking alcohol, and observed social rewards associated with drinking alcohol on these programs. Teens in particular are often shown characters that are drinking alcohol, and such drinking is often associated with partying and general merriment.

These findings by Greenberg and colleagues (2009) are interesting for a variety of reasons – not the least of which is that they illustrate that researchers need to recognize that media portrayals can impact audience members in different ways. From the perspective of social cognitive theory, the audience is more actively involved with the learning and/or imitating process. In the case of teens exposed to drinking, the paucity of negative consequences and the association with merriment suggest viewers can learn that drinking results in fun and few negative consequences. In the case of young children eating junk food, cultivation theory suggests children need not learn or even notice the relationship between the unhealthy behavior and its consequences. Merely being exposed to themes on television can yield the belief that overeating or eating in a less than healthy manner is not only acceptable, it is to a large degree the “American way of life.”

Other researchers also employed multiple theoretical models in their analysis of health portrayals. Quick (2010) employed media framing theory and the health belief model in his investigation of steroid use. Baek and Mayer (2010) employed Bandura's (1986) social cognitive theory and Byrne's (1977) sexual imagery model in their investigation of sexual imagery in cigarette advertising. Gold, Cohen, and Shumate (2008) used social cognitive theory (Bandura, 1986) and Fisher's (1987) narrative theory in their examination of proscriptive models and evidence in smoking advertisements. Rains and Bosch (2009) used social exchange theory (Thibaut & Kelley, 1959) and exchange theory (Bagozzi, 1979) in their investigation of health website privacy statements. And, as was pointed out above, Greenberg and colleagues (2009) employed social cognitive theory (Bandura, 1986) and cultivation theory (Gerbner, 1970).

The remaining two articles employed three theories within their investigation. Noar, Clark, Cole, and Lustria (2006) used social cognitive theory (Bandura, 1986), media framing (Kahneman & Tversky, 2000; McCombs & Ghanem, 2001), and the extended parallel processing model (Witte, 1992). Wang and Gantz (2010) employed agenda setting (McCombs & Shaw, 1972), social learning (Bandura, 1986), and cultivation theory (Gerbner, 1970).

The use of multiple theoretical models is advantageous to the researcher because it allows more sophisticated content-analytic schemes to be employed. Researchers can use the theory, the previous research findings, and the known boundary conditions of the theory to fine-tune their categories. In addition, the use of multiple theoretical models allows researchers to pit different theories against one another. These competitive situations can produce significant insight into the validity of the various theories.

In addition to using multiple theories in their investigation, Baek and Mayer (2010) also employ a public policy argument in their examination of sexual imagery in cigarette advertising. While concerns about portrayals of sexual imagery and the dangers of smoking have long been of interest to communication scholars, this investigation focuses on the legal arrangement known as the Master Settlement Agreement (MSA) to determine whether depictions of sexual imagery changed after the agreement. The MSA was signed in 1998 by the four major US tobacco manufacturers and the Attorneys General of 46 US states, prohibiting advertising and promotional practices targeting youth. The MSA was in principle an effort to restrict or limit the amount of cigarette advertising exposure to which the youth of the United States were subjected.

Baek and Mayer (2010) suggest that cigarette advertisers began to modify their techniques to incorporate more sexual imagery into the advertisements in an effort to encourage the purchasing of tobacco products without overtly targeting young people. The authors' concern was, then, to determine if sexual imagery in cigarette advertising had changed since the agreement was signed. The results of the investigation suggest that there was a significant increase in scantily clad female models after the agreement. Further, the incidence of advertisements containing sexually explicit material and ads depicting voyeurism increased after the agreement was reached. The authors contend that this change in the visuals of the advertising is an attempt to influence young people without violating the letter of the agreement.

Media Channels and Internationalization

Health communication scholars have begun examining an ever widening variety of different media channels in their efforts to document portrayals of illness and health issues. In the analysis of articles published in Health Communication between 1985 and 2005, Manganello and Blake (2010) found that 35% of the studies focused on magazines, 31% focused on newspapers, and 29% focused on television. As a point of comparison, seven articles (31.8%) published in Health Communication between 2006 and 2011 examined TV portrayals of health, six articles (27.3%) examined content found on the Internet, five articles (22.7%) examined health portrayals from newspapers, and four articles (18.2%) focused on health portrayals in magazines. Channel variety, however, is more than simply the addition of the Internet to traditional media channels such as TV, newspapers, radio, and magazines.

An example of channel variety can be found in the work of Wang and Gantz (2010). While the researchers examined television content, they focused on local news programs in four media markets rather than the more common examination of national programming. Wang and Gantz (2010) argue that local programming needs closer scrutiny than it has traditionally received because 56% of US adults consider local news programs to be an important source of health information and because little previous research has focused on local news programming. In this investigation, the authors examined 1,382.5 hours of newscasts on seven channels (the affiliates of ABC, CBS, Fox, NBC, UPN, WB, and Univision) in four different markets (a major market, a large market, a medium market, and a small Midwestern market) aired between December 2004 and June 2005. Just over 8% of the 40,112 news stories focused on health issues, which means that about 1.26 health stories aired every 30 minutes. About 46% of the stories were less than 30 seconds in length and 74.5% of all stories lasted less than 60 seconds. Another example of the increasing interest in a wider variety of media channels can be seen in the TV channels selected by Wang and Gantz (2010). The addition of niche cable channels and international channels to the more typical big three (or big four with the addition of Fox) again illustrates how media portrayal research is changing.

While differences in markets were observed – the Indianapolis market had fewer health stories than Terre Haute, South Bend, and Chicago – the headline findings come from the frequency of illness types. Mental health stories rarely appear on the local news and gerontological health stories were even less common. The illnesses depicted or presented in descending order were as follows: cancer (12.2%), heart disease (5.5%), flu (3.4%), obesity (2%), diabetes (1.2%), joint and tissue disorders (1.2%), and lung diseases (1%). The distribution of general health issues was as follows: physical illness (46%), healthy living (24.8%), health insurance, health law or health policy (12%), parents and children (6.8%), environmental health issues (3.8%), mental health issues (3%), and aging (0.7%). Very few stories contained contrasting viewpoints on issues but most stories were neutral in tone and unlikely to produce unwarranted fear or a disinclination in viewers to engage in further health information seeking.

A second example of an increasing variety of media channels can be found in the studies examining YouTube videos. Tian (2010) used media framing theory in her examination of organ donation videos on YouTube. Kim and colleagues (2010), on the other hand, examined smoking fetish videos on YouTube. Smoking fetish videos are those produced by individuals that promote or encourage smoking, and in which the smoking is associated with sexual behavior. These pro-smoking messages are often geared toward adolescents, who make up the largest portion of Internet users. Kim and colleagues (2010) noted that pro-smoking messages on the Internet are rarely regulated, despite criticism and regulatory efforts against smoking. They further note that most smoking prevention programs, which are addressed toward adolescents, emphasize education about the long-term health consequences of smoking, but ignore the short-term benefits experienced by youth. These short-term benefits include looking cool and sexy – which is, of course, exactly what the smoking fetish videos do so well.

Employing social cognitive theory, the authors examine the prevalence of smoking fetish videos on YouTube, document the accessibility of those videos, and describe portrayals of smoking and the models who smoke in those videos. Using the search term smoking on YouTube identified 139,000 hits. When narrowing the search to smoking fetish videos (those containing smoking and sex), a total of 2,200 videos (or 1.6% of all smoking videos) was identified. While videos that are flagged must be approved by the YouTube staff to ensure the viewer is 18 years of age or older, only 15% of these videos were not accessible to children. It appears that over 95% of the videos contained explicit portrayals of inhaling and exhaling tobacco as well as models holding tobacco products. In just under 50% of the cases the models were shown lighting a cigarette (91%), cigars (3.2%), pipe (1.6%), or a hookah (.5%). Using the Motion Picture Association of America's (2005) scheme for rating content, only 40% of the videos would have been rated PG and 27.2% of the smoking fetish videos would have received a rating of R. And, again, these videos, unlike motion pictures, go unregulated on the Internet. Other recent content studies have examined other resources on the Internet for health portrayals, including Lapinski's (2006) examination of pro-eating disorder websites and Noar and colleagues' (2006) examination of safe-sex websites.

Scholars studying health portrayals did not ignore the fact that 60% of all teenagers pleasure-read on any given day (Rideout, Foehr, & Roberts, 2010) and many of those teens spend as much time reading as they spend playing videogames (Roberts, Foeher, & Rideout, 2005). In their quest to find out what those bookworms learned about health, Coyne, Callister, and Phillips (2011) examined alcohol and other substance use and abuse in adolescent novels. The authors used the New York Times Best Sellers List to identify 40 best-selling adolescent novels sold between June and July of 2008. Coding the 14,005 pages yielded a total of 357 incidents of substance use (including alcohol, tobacco, illegal drugs, and legal drugs). As expected, alcohol use (n = 240) was more common than all other substances combined (tobacco (n = 79), illegal drugs (n = 35), and legal drugs (n = 3)). Surprisingly, the most common reasons for substance use were habit or addiction (n = 98) and socializing (n = 86). Somewhat less frequent reasons for use were relaxing (n = 55), coping with stress and other difficulties (n = 50), and celebrating (9.0%, n = 32). The substances used in the stories were acquired by the user in 75% of the cases, and there were no consequences for substance use in 83% of the cases. Coyne and colleagues (2011) employed the general learning model (Buckley & Anderson, 2006) in this investigation to describe the mechanisms through which media portrayals may affect adolescent attitudes and behaviors. Unlike other models of media influence, proponents of the general learning model suggest the media can activate extant cognitions and cognitive scripts as well as create and strengthen those scripts over time. This investigation also points to an additional theory that has been used recently to guide health portrayals research.

As noted above, the broadening examination of health portrayals also includes a focus on international contexts. An interesting example of scholars examining international content is Liu, Liu, Xiao, Cai, and Xu's (2010) study of depictions of skin cancer in Chinese newspapers. Liu and colleagues content-analyzed 134 articles about skin cancer published in Chinese newspapers between 2000 and 2007. The articles represent 1.8% of the articles found in the database focusing on cancer; the number of articles about skin cancer increased from 10 articles in the year 2000 to a high of 35 articles in 2006. The most commonly discussed type of skin cancer was melanoma – discussed in just over 38% of the articles; treatment of skin cancer was discussed in 41.8% of the articles analyzed.

In an effort to strengthen our contention that scholars are looking at a wider variety of channels, an analysis of articles that were not published was also performed. Robinson and Agne (2010) examined 99 articles that were rejected for publication in the journal Health Communication. From this inventory of articles that were not published, a list of health portrayals topics was compiled. In some cases the authors of these manuscripts were asked to make revisions and declined, and in other cases the articles were rejected by reviewers. Clearly, the articles examining health portrayals focused on a wide variety of health issues and channels. Some of the more interesting channels investigated by the researchers include: English-language newspapers from India, results from Google searches, Japanese newspapers, medical tourism websites, and Japanese manga or graphic novels. This list is not intended to be exhaustive. We applaud the authors for their creativity, and are pleased to report that in several cases the articles have been subsequently published in Health Communication or elsewhere.

The Big Picture

Communication scholars and researchers have long been interested in the way health issues are portrayed within the media, and it appears that such interest has not waned. The argument that health communication scholars have begun studying an expanding list of illnesses and health issues has been made but certainly not decided here. Examination of other research publication venues and even conference presentations will need scrutiny, and the results of those analyses will need to be compared with historical data on health portrayals.

New technologies such as the Internet have also generated new channels and research opportunities (e.g., Facebook, blogs, YouTube, and websites). Those channels were not available prior to the widespread adoption of the Internet. Perhaps even more importantly, these new channels allow media content to be produced by sources other than the media conglomerates that once held the reins to the mass media. These technological innovations also make the study of traditional media channels such as newspapers or magazines much easier and in many cases much easier for sampling. Further, the availability of these materials online has in some cases made identifying search terms far easier than manually examining print materials page by page. In fact, historians may one day describe this time as a renaissance period for scholars interested in studying health portrayals.

It is clear from the analysis of health portrayals that the widespread adoption of Internet-based technologies contributes to the examination of new health concerns. For example, before the advent of the Internet, scholars interested in analyzing proeating disorder content would have had a much more difficult time finding the content to analyze. Concern about such portrayals would have been far less because the content would not have been readily available as such websites make that information today. Similarly, the thought of trying to publish a content analysis of smoking fetish home movies gives a researcher pause. Again, access to the content would have been difficult and the small opportunity for audience exposure to such materials would all but ensure such study would never have been considered. YouTube videos demand scrutiny by mass media scholars because home movies are now viewed by so many people. For example, in 2010 the first five games aired on ESPN's Monday Night Football averaged approximately 11 million households, with 15 million viewers watching these games (Zurawik, 2010). Those are great numbers – the kind of ratings of which a cable network dreams. For comparison's sake, however, the original viral video commonly referred to as the Star Wars Kid was viewed some 20 million times between 2003 and 2006 (Wei, 2010). The video was so popular that many variations of that film clip were developed, and the many variations of that video had been viewed some 900 million times during the same time frame (Wei, 2010). Current estimates suggest that the video and its many variations have been viewed over a billion times (Wei, 2010).

In some cases, such as portrayals of cloning or food irradiation, the particular health issues result from technological development. In other cases technological developments simply make niche content (e.g., smoking fetish videos) widely available, more widely consumed, more amenable, and more viable as a health topic for researchers. In fact, the widespread proliferation of TV channels has seemingly contributed to a leveling of the playing field in the pursuit of gaining an audience. To give this contention some detail and context, consider that when the Nielsen ratings began in 1950, the average home had one TV set while in the year 2010, well over 80% of all homes had more than one TV and, in fact, over 30% of all homes reported having four or more TV sets (Godinez, 2010). Similarly, in the 1950s the average household received three TV channels (Godinez, 2010), while in the 1970s the average household received about 10 TV channels, and in 2010 Nielsen data suggest the average household received a whopping 118.6 channels (Marketing Charts, 2010). The proliferation of TV channels and TV sets within the home allows viewers within a single household to watch different programs. During the 1970s the three TV networks, for example, accounted for about 95% of the total audience and today less than half of the TV programming consumed can be found on a network (Harris, 2008).

The implications of channel proliferation to studying health portrayals are many and not lost on scholars and researchers. Channels attracting an audience that once was deemed as secondary to network TV or the highest rated magazines or newspapers must now be more closely considered as sources of health information. Leydon and colleagues (2000), Mills and Davidson (2002), and others have found that television, newspapers, and magazines are primary sources of health information for many people. Patients are also employing the Internet in their quest for health information. For example, approximately 75% of all US citizens use the Internet (USC, 2004), and 79% of these users report having searched for health information online (Fox, 2005). In fact, over 50% of all US Internet users report having looked for information about specific diseases or medical problems, certain medical treatments or procedures, and diet, nutrition, vitamins, or nutritional supplements at one time or another (Fox, 2005). The fact that people use the mass media for health information further strengthens the argument for studying a wide array of health issues. In fact, the further a health issue is from the mainstream, it is arguable, the more reliant or dependent the consumer is on a particular source of information (Ball-Rokeach & DeFleur, 1976) Robinson & Tian, 2009). This realization suggests that scholars should focus on a wide variety of media channels in their efforts to describe health portrayals.

Further, Dutta-Bergman (2004) suggests that media usage/consumption is not a zero-sum game. Instead, he argues that consumers of the media will employ the various channels in a complementary fashion. He suggests people interested in sports will watch sports programming on television, listen to sports programming on the radio, read about sports in newspapers and magazines, and surf the Internet for information about sports. Similarly, people interested in health information will actively seek out information from any channel that they believe will provide that information. Support for the contention, labeled media complementarity theory, is growing, and the research suggests that audience members seeking out information from the media (particularly health information) are guided by need and interest (Tian & Robinson, 2008a, 2008b).

Scholars employing media complementarity theory as part of the basis for their study, then, have the beginning of a rationale for studying health portrayals across media channels. If people use the media purposefully, it is reasonable to examine what they will find about a particular health issue across channels. Obviously, this also suggests that scholars need to consider and perhaps reconsider the commonly used practice of sampling by channel.

In years gone by, scholars may have been hesitant to undertake a large-scale project of local news, such as that described above by Wang and Gantz (2010), for fear of reviewer criticisms about the sample. Studying content from a variety of different media channels is also advantageous to health communication scholars by allowing additional insight into the relative importance of channel characteristics on those media portrayals. For example, scholars focusing on television news programs are likely to find that whether or not a health issue is covered may be determined by the availability of video to air along with the story. This notion of channel bias has been discussed in great detail within the mass communication community, and such bias can impact what issues are aired and how they are depicted to some degree (Cantor, 1980).

Similarly, scholars focusing on time-bound channels such as newspapers are likely to find an event bias (Boorstin, 1961). Stories about health issues are more likely if there is a precipitating event that can be described within the story. Hunger is hardly news, but a hunger strike or famine may be news. By studying media content from different channels, scholars can begin parsing the differences in channel characteristics and other determinants of how media content is portrayed. In short, scholars examining health portrayals across a variety of different channels can begin to parse the effects of channel properties, editorial policies, and market economics. Stories that are told in the same way regardless of channel are interesting, but finding that stories are told differently depending on the channel would be even more interesting. Stories that are told in the same way in channels with and without editorial control certainly deserve a different kind of attention than stories that are told differently depending on the channel on which they are found. New media channels such as blogs are undoubtedly constrained in many ways – just as the content aired on more traditional media channels is constrained by time and space, advertising interests and costs, and social and political pressures. However, by studying the content differences in these disparate channels, insights into the similarities and differences that exist may be identified. Examining how health issues are depicted in different countries may assist us in better understanding the impact of factors such as culture, economics, government regulations, and social pressures on media portrayals. Likewise, examining how health issues are depicted in different countries may also assist us in better understanding the impact of media portrayals. Health issues that are treated differently in different countries would be expected to produce difference effects within audience members. The first step, however, is the mapping of these health portrayals.

Not unrelated to the proliferation of media channels being examined by health portrayals researchers is the increasing diversity in the types of health issues being examined. The examination of such a multitude of health issues provides scholars an interesting opportunity to better understand health attitudes and knowledge, the media, and culture. Using these disparate health issues as a window into the culture may shed some light on how and why the media portray particular issues. For example, a scholar looking at how eating disorders are framed might be able to make interesting comparisons with the way HIV/AIDS is portrayed. Similarly, a scholar looking at eating disorders might examine how obesity is framed relative to anorexia nervosa or bulimia. Such an analysis takes content analysis of health portrayals from a purely descriptive endeavor – based primarily on the opportunity for audience learning – into the realm of interpretation and culture studies. Commonalities in the way diverse health issues are portrayed can provide insights into whether the portrayals are a function of the channels, misunderstanding of the health issue, literary license, or other societal forces. Meta-analytic techniques dividing health portrayals into acute and chronic illnesses may shed light onto the why and how health issues are depicted.

Of course heightened audience awareness of health issues can produce patients who are actively involved in their healthcare, and it can also lead the hypochondriacs among us to new heights of concern. Health portrayals researchers need to be ever mindful that content analysis needs to be more than an exercise based on the simple counting of things. What “more” coverage of something indicates is a debatable issue, but at the very least content analysis needs to be based in a strong theoretical rationale.

Manganello and Blake (2010) found that researchers examining health portrayals are likely to employ a theoretical rationale for their study. The theory can and should be used as the basis for conducting the content analysis as well as the basis of the content-analytic category scheme employed within the investigation when possible. For example, a researcher analyzing how cancer patients are portrayed on television may use Cutrona and Russell's (1990) work as a basis for coding the types of social support they receive within a medical drama. The researcher then starts the research with a commonly accepted set of descriptions of the types of social support. The availability of extant operational and conceptual definitions of key variables can assist the researcher by ensuring particular types of social support do not go unexamined. Previous social support research can be translated into useful and theoretically significant content categories. This allows the researcher to extend the theory as well as map the portrayals of health within the media. Obviously, the use of more than one theory may allow the researcher to generate even more sophisticated content-analytic schemes and ultimately make such research more valuable. Finally, the use of Cutrona and Russell's (1990) work may encourage the researcher to examine how patients provide social support to others – an opportunity that patients welcome. This kind of direction is why scholars should use theory and research in the development of their category systems. The need to provide social support to others is precisely the kind of category that might go unexplored without consideration of such theoretical work as that of Cutrona and Russell (1990).

Scholars frequently use more than one theoretical position as the basis for their study and/or the basis for their content analysis scheme. The use of multiple theoretical perspectives potentially allows the development of a more nuanced content category scheme. For example, a researcher might use Cutrona and Russell's (1990) typology to identify the different types of social support provided and Bandura's (1986) social cognitive theory to provide a theoretical basis for coding the consequences of social support. In this way the researcher can describe how social support is portrayed in the media and also identify character responses to social support.

In addition, the use of multiple theories allows scholars to examine the relative benefits of different theoretical perspectives – particularly in content studies that also gather audience effects data. For example, a researcher might examine how the media portray health issues from the agenda-setting perspective. Such research would focus on frequency of portrayals. Some researchers go beyond simple frequency counts and code the portrayals for prominence. Other researchers examine the same issue from the agenda-setting perspective and also incorporate media framing theory in the design of the study. For example, a news article can frame alcoholism as a health issue or it can portray alcoholism as a social problem or even an individual psychological problem. For example, is drinking framed as something people do to celebrate or something they do when things go bad? The frames (e.g., alcoholism is a social problem or a health issue) lead the audience to view alcoholism as a particular kind of problem – based on the way it is portrayed in the media.

Still another researcher interested in media portrayals of alcoholism might use agenda setting and priming theory as the basis of their study. They would do this to determine the affective responses likely to occur within the audience members as they are exposed to the health issue. Is the issue of drunkenness portrayed as a “joke or a good time” or is it portrayed as a tragic problem? Researchers might use priming here instead of framing because they want to know the kinds of affect the person will associate with excessive drinking.

Still another researcher might couple social cognitive theory with agenda setting to see what the audience learns from the characters that they could subsequently imitate. And yet another researcher might use agenda setting and cultivation theory as a way of looking at the issue of alcoholism on a larger, cultural level. This researcher might be interested in determining if the media portray alcoholism as an individual problem or a problem that will be solved by the government, the medical profession, or some other institution. Has the problem of alcoholism been medicalized by the media or has the government been portrayed as paternalistic and the caretaker of the citizenry?

At first blush these studies seem very similar, but in actuality all that they share is a focus on portrayals of alcoholism. In all of these cases, researchers are basing their work on the fact that the audience is learning or being conditioned by media portrayals. What they learn and how they learn it, however, can differ dramatically from theory to theory. However, the use of multiple theories in a study focusing on health portrayals need not employ theories that are to some degree variations on a theme.

For example, a content analysis examining portrayals of healthcare professionals might use social cognitive theory to determine what viewers/readers learn from the media about doctors and nurses. A second theory, however, such as Knapp's (1984) relational development model, might be useful for examining how the patient–physician relationship develops. Or the scholar might use the pragmatic perspective of Watzlawick, Beavin, and Jackson (1967) as a way of getting at the mechanisms that TV characters use to develop relationships with audience members. Both of these theories are quite far afield from a learning model and could shed interesting light on health portrayals.

Finally, it is important to keep in mind that media portrayals are a function of a multitude of factors, including culture, storytelling convention, history, economics, time and event biases, current events, and technological development, to name but a few. While these considerations are outside the scope of this chapter, they are offered as a reminder for scholars to focus on the specific details of the portrayals, the impact of such portrayals on health decisions made by audience members, as well as broader societal concerns. The study of health portrayals is an important area of research that needs to be grounded theoretically and less an exercise in pure description. It is hoped that the trends identified within this chapter provide some insights and some direction for future research. We believe studying media content in a variety of different ways is important because it helps establish the fact that content is indeed reflective of something beyond simple chance in the way it is portrayed.

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