Background
Chronic, non-communicable diseases (hereafter ‘chronic diseases’) such as cancer, diabetes mellitus and cardiovascular disease, are a major contributor to the global burden of disease and are responsible for over 40 million deaths per year [
1]. Despite increasing recognition of the urgent need to tackle chronic diseases [
2] and growing evidence on both the effectiveness and cost-effectiveness of prevention [
3], significant progress has not yet been made.
Chronic diseases are a complex problem, with multifactorial causes that extend beyond individual behaviours and include the social, environmental and socio-economic aspects of the environments in which people live, work and play [
4]. Chronic disease prevention therefore requires coordinated, inter-sectoral efforts at the individual, community and population levels [
4,
5]. For example, addressing childhood obesity is likely to require a range of interventions, including restricting junk food advertising to children, teaching cookery skills to new parents, providing nutritional information on food labels, changing school canteen menus, improving pricing and availability of fresh food, and reformulating processed foods [
6]. Garnering public and political support and momentum for such actions requires a shift away from thinking at the individual level to an appreciation of the social, environmental and cultural drivers for behaviour, and an understanding of the interrelated nature of chronic disease causes, risk factors and solutions.
The public is continually exposed to mass media, including news, entertainment and advertising media, through channels such as television, radio, movies, newspapers, magazines and the internet. Such exposure is likely to play a key role in shaping attitudes and behaviours of relevance to chronic disease prevention [
7]. News media lies at the nexus of the public and policy agenda and news coverage of issues and events both shapes and reflects public and political opinion [
8]. While print newspapers are considered to be something of a ‘dying industry’, online news media exposure continues to increase, with much of the population having direct access 24 hours a day, 7 days a week, from almost any location [
9]. Thus, the news media continues to be a vital social institution and digital technologies have reshaped this industry in recent years. In particular, the emergence of an array of new actors, such as BuzzFeed, The Huffington Post and The Conversation, along with the growth of social media platforms and blogs, has resulted in significant changes in who and what constitutes the news media institution. Further, the ease of sharing content across social networks, as well as the so-called ‘echo-chamber’ effect, have changed the flow of information, including what gets amplified and how. Understanding how these shifts in the media landscape affect the public and political agenda setting process will therefore be of increasing importance going forward.
The study of news media communication occurs within a multidisciplinary paradigm with roots in sociology and political science, and draws heavily on framing theory, which concerns the “holistic study of media effects on individuals and audiences” (p. 423 )[
10], focusing on four elements of the communication process: the sender, the receiver, the (informative) message and culture [
10]. Framing theory posits that messages are packaged in particular ways to emphasize certain pieces of information and de-emphasise others [
11,
12], and particular framings will “promote a particular problem definition, causal interpretation, moral evaluation, and/or treatment recommendation” (p.53 )[
11]. Research within this paradigm has revealed that the nature of information conveyed through the media, including what gets reported, the amount of coverage received and the way in which it is represented can have a powerful effect on knowledge, attitudes, and behaviours [
12‐
18]. In addition to shaping societal attitudes towards issues, media coverage is a societal product in itself, such that issue framing is constrained by social structures, values and norms [
19,
20]. Thus understanding how issues are framed can provide insights into wider trends in society.
Other forms of media, including entertainment, commercial advertising, and social marketing are also likely to play a role in influencing public attitudes, opinions and behaviours of relevance to chronic disease. For example, commercial advertising through television commercials, online advertising campaigns, and point of sale advertising are used often to influence consumer behaviours that may increase the risk of chronic diseases, such as encouraging consumption of unhealthy foods or alcohol (e.g., [
21‐
23]), and may also encourage the purchase of products or services that promote health, such as commercial weight loss programs or meal plans. Social marketing campaigns may employ mass media channels to encourage healthy behaviours, such as smoking cessation, responsible alcohol consumption, and cancer screening (see, for example [
24] for a review of mass media campaigns to change health behaviour). Entertainment media, such as films, television shows and music videos may influence attitudes and behaviours of relevance to chronic disease for example by using plotlines that raise awareness of issues related to chronic disease, or model behaviours such as smoking and alcohol consumption [
25].
In recent years there has been a proliferation of media research on issues of relevance to chronic disease (including disease risks, causes and solutions). While such a growth in research is promising both in terms of interest in this field and the potential for new and useful knowledge to emerge, the volume and breadth of evidence can be overwhelming for those who need to access the key messages from this research, such as policy makers and practitioners. In particular, both original research articles and reviews have tended to ‘zoom in’ on specific issues, such as how obesity is portrayed within news media (e.g. [
26‐
29]) or the framing of arguments around smoking restrictions (e.g. [
30‐
35]), and to date, no comprehensive synthesis or mapping of the area as a whole exists.
Within this paper we aim to provide an initial mapping of media research on topics of relevance to chronic disease. In particular, we explore the scope and nature of research on how issues related to chronic disease prevention have been portrayed across various forms of media in order to provide an overview of the key focus areas and highlight gaps and opportunities for future investigation. In doing so we seek to address the following research questions:
-
What are the key trends in research on media coverage of chronic diseases?
-
How has research on media coverage of chronic diseases changed over time?
-
What are the key gaps and opportunities for further research on media coverage of chronic diseases?
Discussion
We aimed to explore the scope and nature of research on media coverage of issues related to chronic disease. Research in this area has proliferated over the last three decades, with a particularly steep increase in the number of studies published since 2000. Across the sample, behavioural risk factors for chronic disease, tobacco smoking and nutrition especially, have received the most research attention. The volume of research on media portrayals of nutrition appears to be driven by research on advertising media, where there has been considerable focus on how unhealthy foods are marketed, particularly to children. In contrast, the volume of articles related to smoking seems to be driven by a combination of studies of cigarette marketing and news media representations of smoking. The large proportion of research articles examining media portrayals of smoking is unsurprising when considered in light of the huge shifts in public and political opinion in relation to tobacco control legislation, policy, and program support in recent decades. For example, since the 1970s in Australia, tobacco control advocacy, which is often enacted through news and other media coverage, has resulted in significant gains including advertising bans, increased taxation and banning of smoking in indoor spaces [
287]. Much of the pioneering work in media advocacy and framing of public health issues therefore originated in tobacco control, and has paved the way for research into media portrayals of other public health issues [
255,
288].
The findings revealed a tendency for studies to focus on single health topics, with those studies that did consider multiple health topics tending to either examine closely related topics, such as nutrition and obesity, or focus on the amount of coverage across different topics [
91,
183]. Comparative analyses, such as those considering similarities and differences in media coverage of policies to encourage different health behaviours, such as smoking cessation and weight control [
289] or considering the differential effects of framing effects on audience attitudes depending on health topic [
168] were few and far between. In addition, there was only a handful of multi-country studies, for example, exploring how obesity was framed within news media in France and the US [
290], and the impact of policies around online marketing of food to children across three countries [
291]. Comparative approaches across countries and settings allow for exploration of the various contextual and cultural factors that influence media portrayal of issues related to chronic disease prevention, and allow broader insights and generalisations to be drawn. While such approaches may be challenging to undertake (not least when there are language differences to take into account), cross-country policy approaches to chronic disease prevention, such as those within the European Union or driven by the World Health Organisation require cross-country understanding of the media landscape.
The majority of studies in this review have focused on analyses of the
content of media, with a large proportion of studies in each media category considering the
content and characteristics of media coverage of a variety of issues (news = 92%, entertainment = 85%, social media = 98%, marketing = 88%). In contrast, a much smaller proportion of studies in each media category were concerned with the impact of
exposure to media (news = 15%, entertainment = 20%, social media = 31%, marketing = 16%). This difference may reflect the relative ease of describing and analysing media content compared with assessing the impact of exposure to content on factors such as audience attitudes and behaviours. However, while studies of media content are valuable in demonstrating what issues are likely to gain traction within the media and provide important insights into the way that issues are being communicated to the public, it is also critical to understand the impact that such communications have on audiences’ attitudes and behaviours. The effects of message framing on audiences cannot be taken for granted as audiences are not passive receptacles for information. Instead individuals actively engage with messages to a greater or lesser extent, and may accept, reject or negotiate how they interpret information, particularly in light of their existing knowledge, attitudes, beliefs, biases and previous experiences [
292]. Understanding the factors that influence message interpretation is crucial in thinking about audience segmentation and targeting, and the range of potential impacts that a single message could have on different groups and across contexts of contrasting social and physical geographies. A good example of this is a study of differences in Republican vs. Democrat voter attitudes towards policy following presentation of the same message [
170]. However, studying the effects of exposure to media is challenging, particularly as the social nature of interpreting media messages is difficult to capture through experimental methods, and reactions studied under artificial settings may not provide insights that are generalisable to community-based settings [
293,
294]. However, social media platforms may provide us with a natural laboratory in which these kinds of effects could be studied (see below for a discussion of this).
There were also very few studies that consider the factors that influence media reporting of issues related to chronic disease. News reporting can be shaped by personal and professional biases [
295], and understanding these biases is vital if we are to move beyond simple description of news stories towards strategies to change the way that issues related to chronic disease are portrayed.
In terms of the types of media that have been studied, news and marketing media have been the most frequent focus of research across the time period, with comparatively fewer studies of social media, such as Twitter, Facebook and YouTube. This is likely to be a historical bias which reflects the relatively recent growth of social media and advances in techniques for the analysis of social media data. In recent years the media landscape has changed, and continues to change rapidly, as people increasingly use social media platforms to access news and entertainment media, as well as to interact with others [
9]. An understanding of how issues related to chronic disease are being portrayed and discussed within these social media spaces will be crucial going forwards. In particular, social media platforms represent a more interactive form of media engagement that traditional channels such as newspapers and radio, allowing audiences to share and discuss information in real time, while algorithms such as those used by Facebook use a range of information to target the content that users are exposed to. Social media platforms therefore provide fertile ground for research examining the diffusion and reverberation of information within and across networks, audience discussion and opinions about a range of issues, and provide opportunities for experiments to test how audience react to and interact with different kinds of messages related to chronic disease. There is already pioneering work happening within this space, and we would expect to see a rapid growth in research in these areas in the coming years.
Limitations
Within this scoping review we have provided a snapshot of the current landscape of research on media portrayals of issues related to chronic disease, highlighting the key focus areas across the field as a whole, and thus going further than previous reviews which have tended to focus on media portrayals of single health topics or media types (e.g. [
296,
297]). As a result, this review was necessarily broad and our search strategy reflects this, for example in the decision to use a select subset of key MESH headings to capture articles in each of the topic areas rather than an exhaustive list of key words. As pointed out by one of the reviewers of this article, this may have resulted in the omission of relevant papers that used different terms from those contained in our search strategy. For example, it was noted that the work by Emery and colleagues on Twitter content related to tobacco use [
298,
299] was not picked up within our search. However, a
post-hoc deployment of our search strategy in Medline with the inclusion of additional search terms related to the original search terms for ‘smoking’ (addition terms: Tobacco Smoking/ OR Tobacco/ OR Tobacco, Smokeless/ OR Electronic Nicotine Delivery Systems/ OR Tobacco Products/ OR Vaping/ OR e-cig*.mp OR cigarette.mp OR juul.mp) and ‘social media’ (additional terms: facebook.mp OR twitter.mp OR Instagram.mp OR youtube.mp) only returned an additional 26 and 9 articles respectively (prior to any screening to assess whether these additional studies met the inclusion criteria). Similarly, we recognise that the decision to use ‘content analysis’ as search term (see Table
1) may have resulted in the omission of studies using different approaches such as discourse or textual analysis. However, the use of ‘frame’ and ‘framing’ as alongside ‘content analysis’ (see Table
1) meant that articles that examined framing of chronic disease issues using approaches other than content analysis were still captured within our search. Indeed, a post-hoc re-run of our search strategy with the addition of ‘discourse analysis’ and ‘text analysis’ in Medline, only returned an additional 34 results prior to any screening. As such, while a minority of papers may indeed have been missed as a result of our search strategy, this review still serves as a useful and novel snapshot of the literature, as intended when we set out to undertake a scoping review, and the current search strategy is unlikely to have significantly biased the findings.
The breadth of this review, spanning media coverage of a range of non-communicable diseases and their risk factors, meant that there was an extremely high volume of search results returned and articles included, which had implications for our handling of the data. First, due to the volume of results returned from the databases searches, and the intention for this review to be a ‘rapid mapping’ of key themes in this area, we did not extend the search to include unpublished literature or hand-searching of journals and recognise that this may have led to some studies being missed. Second, while it would have been desirable to have a second reviewer check all references for inclusion and data extraction, the volume of literature precluded this. Instead, we engaged in frequent discussions within the research team to ensure consistency and discuss uncertainties as they arose, and additional reviewers checked randomly selected subsets of data and demonstrated a high level of agreement (see ‘Study selection’). Finally, while more applicable to systematic reviews than scoping reviews, the large number of studies included within our sample meant that critical appraisal of the evidence and assessment of study quality was beyond the scope of this review.
Finally, the volume of studies identified within this review also presented challenges to data synthesis. For example, while we have identified a number of studies examining media portrayals of different policy interventions such as smoking regulation and sugar taxes, a more in depth synthesis of these papers to draw out similarities and differences in how different policies are framed within the news media and how this influences public opinion will be a valuable next step. Another insight that would be important to follow up is how risks, causes and solutions of chronic diseases have been framed across the topic areas in order to identify similarities and differences and the impacts of different framings across topics.
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