11
Social Science & Medicine 64 (2007) 1842–1852 Telling stories: News media, health literacy and public policy in Canada Michael Hayes a, , Ian E. Ross b , Mike Gasher c , Donald Gutstein b , James R. Dunn d,e , Robert A. Hackett b a Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada V5A 1S6 b School of Communication, Simon Fraser University, Burnaby, BC, Canada V5A 1S6 c Department of Journalism, Concordia University, 7141 Sherbrooke Street West, Montreal, PQ, Canada H4B 1R6 d Inner City Health Research Unit, St. Michael’s Hospital, Toronto, ON, Canada M5B 1W8 e Department of Geography, University of Toronto, 30 Bond St., Toronto, ON, Canada M5B 1W8 Available online 2 March 2007 Abstract Mass media are very influential in shaping discourses about health but few studies have examined the extent to which newspaper coverage of such stories reflect issues embedded in health policy documents. We estimate the relative distribution of health stories using content analysis. Nine meta-topics are used to sort stories across a range of major influences shaping the health status of populations adapted from the document Toward a Healthy Future (Second Report on the Health of Canadians (1999)) (TAHF). A total of 4732 stories were analyzed from 13 Canadian daily newspapers (10 English, 3 French language) using a constructed week per quarter method. Stories were sampled from each chosen newspaper for the years 1993, 1995, 1997 and 2001. 72% (n ¼ 3405) of stories in this analysis were from English-language papers, 28% (n ¼ 1327) were from French-language papers. Topics related to health care (dealing either with issues of service provision and delivery or management and regulation) dominated newspaper stories, accounting for 65% of all stories. Physical environment topics accounted for about 13% of all stories, the socio-economic environment about 6% of stories, personal health practices about 5% of stories, and scientific advances in health research about 4% of stories. Other influences upon health identified in TAHF were rarely mentioned. The overall prominence of topics in newspapers is not consistent with the relative importance assigned to health influences in TAHF. Canadian newspapers rarely report on socio-economic influences frequently cited in the research literature (and reflected in TAHF) as being most influential in shaping population health outcomes. r 2007 Elsevier Ltd. All rights reserved. Keywords: Canada; Population health; Public policy; News media; Socio-economic environment; Determinants of health; Discourse; Content analysis By excluding or marginalizing other perspec- tives—notably, a more explicitly political analy- sis of the origins of illness—the media play a significant part in narrowing public debate about health, illness and medicine. Anne Karpf (1988, Doctoring the Media, p. 2). ARTICLE IN PRESS www.elsevier.com/locate/socscimed 0277-9536/$ - see front matter r 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2007.01.015 Corresponding author. Tel.: +1 250 920 4165; fax: +1 250 920 4265. E-mail addresses: [email protected] (M. Hayes), [email protected] (I.E. Ross), [email protected] (M. Gasher), [email protected] (D. Gutstein), [email protected] (J.R. Dunn), [email protected] (R.A. Hackett).

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ARTICLE IN PRESS

0277-9536/$ - se

doi:10.1016/j.so

�Correspondfax: +1250 920

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Social Science & Medicine 64 (2007) 1842–1852

www.elsevier.com/locate/socscimed

Telling stories: News media, health literacy andpublic policy in Canada

Michael Hayesa,�, Ian E. Rossb, Mike Gasherc, Donald Gutsteinb,James R. Dunnd,e, Robert A. Hackettb

aFaculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada V5A 1S6bSchool of Communication, Simon Fraser University, Burnaby, BC, Canada V5A 1S6

cDepartment of Journalism, Concordia University, 7141 Sherbrooke Street West, Montreal, PQ, Canada H4B 1R6dInner City Health Research Unit, St. Michael’s Hospital, Toronto, ON, Canada M5B 1W8

eDepartment of Geography, University of Toronto, 30 Bond St., Toronto, ON, Canada M5B 1W8

Available online 2 March 2007

Abstract

Mass media are very influential in shaping discourses about health but few studies have examined the extent to which

newspaper coverage of such stories reflect issues embedded in health policy documents. We estimate the relative

distribution of health stories using content analysis. Nine meta-topics are used to sort stories across a range of major

influences shaping the health status of populations adapted from the document Toward a Healthy Future (Second Report

on the Health of Canadians (1999)) (TAHF). A total of 4732 stories were analyzed from 13 Canadian daily newspapers (10

English, 3 French language) using a constructed week per quarter method. Stories were sampled from each chosen

newspaper for the years 1993, 1995, 1997 and 2001. 72% (n ¼ 3405) of stories in this analysis were from English-language

papers, 28% (n ¼ 1327) were from French-language papers.

Topics related to health care (dealing either with issues of service provision and delivery or management and regulation)

dominated newspaper stories, accounting for 65% of all stories. Physical environment topics accounted for about 13% of

all stories, the socio-economic environment about 6% of stories, personal health practices about 5% of stories, and

scientific advances in health research about 4% of stories. Other influences upon health identified in TAHF were rarely

mentioned. The overall prominence of topics in newspapers is not consistent with the relative importance assigned to

health influences in TAHF. Canadian newspapers rarely report on socio-economic influences frequently cited in the

research literature (and reflected in TAHF) as being most influential in shaping population health outcomes.

r 2007 Elsevier Ltd. All rights reserved.

Keywords: Canada; Population health; Public policy; News media; Socio-economic environment; Determinants of health; Discourse;

Content analysis

e front matter r 2007 Elsevier Ltd. All rights reserved.

cscimed.2007.01.015

ing author. Tel.: +1 250 920 4165;

4265.

esses: [email protected] (M. Hayes),

om (I.E. Ross),

oncordia.ca (M. Gasher),

(D. Gutstein),

onto.ca (J.R. Dunn),

(R.A. Hackett).

By excluding or marginalizing other perspec-tives—notably, a more explicitly political analy-sis of the origins of illness—the media play asignificant part in narrowing public debate abouthealth, illness and medicine.

Anne Karpf (1988, Doctoring the Media, p. 2).

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Introduction

Mass media are very influential in shapingdiscourses about health (Dorfman, 2001; Maibach& Parrot, 1995; Seale, 2003; Wallack, 2000;Wallack, Dorfman, Jernigan, & Themba, 1993).Researchers have examined several questions con-cerning how health-related issues are portrayedin the media (see Entwistle & Sheldon, 1999;Parrott, 1996 for reviews) including: body images(Signorelli, 1993; Strasburger, 1995); particulardiseases (Brown, Zavestoski, McCormick, Mandel-baum, & Luebke, 2001; Clarke, 1999; Fisher, Gandy& Janus, 1981); the uptake of health care (Grilli,Freemantle, Minozzi, Domenighetti, & Finer, 1998;Leask & Chapman, 2002; Mintzes et al., 2003) andcoverage of pharmaceuticals (Cassels et al., 2003).

Few studies have examined reporting across therange of health influences identified as contributingto social gradients in health outcomes. Davidson,Hunt, and Kitzinger (2003) examined media repre-sentations of Britain’s New Labor governmentpublic health policies to address inequalities inhealth. They found that differences in the ways thatthe issue of health inequalities were presentedrelated to the ideological position of the newspaper.They also found that political context and thetiming of news stories greatly influenced the natureand extent of coverage given to the release of officialpolicy documents. Commers, Visser, and De Leeuw(2000) analyzed the content of 600 newspaperstories randomly selected from the five largestDutch daily newspapers with national circulationto determine the extent to which stories reflectedor were consistent with the central tenets of theOttawa Charter for Health Promotion (Governmentof Canada, 1986) and the Jakarta Declaration

(WHO, 1997). These include a focus on socio-structural determinants of health, equity, healthbehaviors, reduced medicalization, community par-ticipation and empowerment, and professionalmediation and advocacy for health. They foundthat little coverage was given to issues of equity,reduced medicalization, or behavioral and commu-nity-based interventions and conclude that theDutch press does not strongly reflect the centraltenets of health promotion.

The frequency with which identified healthinfluences are covered in newspapers is broadlyreflective of general public discourses about healthinfluences, and newspapers help inform this dis-course although they are not mere reflectors of it

(Kitzinger, 1999). Several factors influence both thetopic coverage and framing of news stories, includ-ing reporter interest, routines and use of sources, theideological position of the publisher or owner, andthe actions of groups interested in particular issues(Dorfman, 2001; Seale, 2003; Shoemaker & Reese,1996).

Study purpose

Given the central importance accorded to broadinfluences upon health—especially ‘social determi-nants’—in federal and provincial health policydocuments in Canada over the last 30 years, wesought to determine the distribution of health newsstories in Canadian newspapers. Despite the factthat Canadian work has contributed significantly toconceptualizing broad determinants of health(through the Lalonde (1974) Report, the OttawaCharter for Health Promotion (1986), and the workof the Canadian Institute for Advanced Researchgroup in Population Health (Evans, Barer, &Marmor, 1994) for example), analysts have notedthat Canadian social policy practice fails to reflectthe rhetoric of population health (Glouberman,2001; Lavis, 2002). Furthermore, research hasshown that the Canadian public has a limitedunderstanding of the broad determinants of health(Canadian Population Health Initiative, 2005;Reutter, Dennis, & Wilson, 2001).

The taxonomic framework we use to categorizethe relative frequency of health topic coverage isbased on the document Toward a Healthy Future

(TAHF) (Ministry of Public Works and Govern-ment Services Canada, 1999). TAHF was producedby the Federal/Provincial/Territorial AdvisoryCommittee on Population Health and its releaseendorsed by health ministers in all jurisdictions inCanada as a means of stimulating policy develop-ment to address health inequalities and improveoverall health outcomes. TAHF is organized aroundsix chapters corresponding to the major identifiedinfluences shaping the health status of populations:(i) the socio-economic environment; (ii) healthychild development; (iii) the physical environment;(iv) personal health practices; (v) health services;and (vi) biology and genetic endowment.

The purpose of this descriptive study is toestablish a baseline to monitor change in reportingover time, and to provide a point of departure forother studies aimed at understanding the gulfbetween research and policy analysis on the one

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hand, and practice and public knowledge about thebroad health determinants on the other. Elsewhere,we provide an analysis of in-depth interviews withhealth beat reporters in Canada, which suggests thatreporter sources (especially their reliance on parti-cular scientific journals) and their own understand-ing of health influences (which tend to emphasizepersonal behaviors) helps, in part, to explain thedistribution of stories reported here (Gasher et al.,in press). Continuing work focuses on specific waysthat stories relating to ‘social determinants’ areframed in Canadian reporting.

As the province of Quebec has both its ownnationalism and arguably has been the mostsuccessful jurisdiction in implementing public po-licies consistent with the population health frame-work, we also wanted to determine if there weredifferences between English- and French-languagenewspapers in their reporting of health stories.Regional differences, differences between broad-sheet and tabloid papers, and differences betweenwire stories and beat reporter stories were otherdimensions of interest in this analysis. (Our plan tolook at differences by newspaper ownership had tobe abandoned because most of the newspaperschanged hands over the study period, and owner-ship is highly concentrated). We also estimated theproportion of stories contained in newspapers onthe sampled days that were about the socio-economic environment (poverty, housing, employ-ment and social support) but failed to make anexplicit reference to health outcomes associated withthese factors.

We specifically chose newspapers for threereasons. First, in Canada newspapers are theagenda-setting media. While it is possible for othernews media to ‘break’ stories of national orinternational significance, newspapers most fre-quently do so. Second, newspapers are easier tomanage from a research perspective. The writtenrecord available centrally and electronically throughtext databases makes it possible to study diversemarkets across the country, something that wouldnot be feasible for television or radio, and there aretoo few newsmagazines in Canada to allow for arobust analysis. Third, the concentration of mediain Canada, which increased substantially over thecourse of the study, has implications for the rangeof stories covered by the press. There is a significantintegration of media in Canada at present, sonewspaper stories have considerable presence intelevision and radio programming.

Method

Newspaper selection

Newspapers were purposively chosen from acrossCanada based on a number of criteria. Selectednewspapers had to: be a major daily, be availableelectronically, reflect a mix of ownership, andinclude papers published in both official languages(English and French). Our sample included the twonational English language papers (Globe and Mail,National Post) and papers from seven regionalmarkets: Vancouver (Vancouver Sun), Calgary(Calgary Herald, Calgary Sun), Toronto (Toronto

Star, Toronto Sun), Ottawa (Ottawa Citizen),Montreal (Montreal Gazette, Le Devoir, La Presse),Quebec City (Le Soliel ) and Halifax (Halifax

Chronicle Herald ). In Calgary and Toronto, wechose both a broadsheet (Calgary Herald, Toronto

Star) and tabloid (Calgary Sun, Toronto Sun) tocompare within market differences in format. Fourdatabases were used to draw the sample: Lexis-Nexis,Canadian NewsDisc, the Globe and Mail news disk,and Biblio Branchee. The Halifax Chronicle Herald

was available only on microfiche but includedbecause it is the largest paper in the Maritime region.Thus, our sample of news stories was drawn from 13newspapers. Odd years between 1993 and 2001 werechosen to allow comparison over time. Samples werenot available for all 13 newspapers for each of thefive study years. The National Post did not beginpublishing until 1998, so is included in the 1999 and2001 samples only. The Calgary Sun was notavailable electronically for the years 1993, 1995 or1997 and the Toronto Sun for 1993 and part of 1995,so are excluded for these years.

Story sample

Prior to selecting the story sample, we conducteda pilot study of 500 newspaper stories drawn fromthree major Canadian daily newspapers (Globe and

Mail, National Post and The Vancouver Sun) for theyear 2000. The pilot allowed us to develop thecoding protocol, test the mechanics of our studydesign, estimate the likely distribution of storiesacross the taxonomic framework we had chosen,and determine if categories needed to be added tothe taxonomy to cover stories about health notcaptured in TAHF.

To compensate for the variation by both day ofthe week and month of the year in the number of

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health stories published, a constructed week perquarter method was used to sample news stories(Riffe, Aust, & Lacy, 1993). One day of the weekwas randomly chosen for each calendar quarter ofthe five study years (yielding 20 constructed weeks)and all news items meeting the inclusion criteria forthis study were selected from each of the newspapersfor every day of each constructed week.

The following inclusion criteria were appliedthrough three stages. The first stage involved theelectronic process of selecting all stories with thekeyword ‘health’ unless: the health issue was notdiscussed in the title, subtitle, or first four para-graphs of the story; the term ‘health’ was used in ametaphorical sense only (of the economy, anorganization, etc.); the item was a financial sum-mary, a stock quote, obituary or an advertisement;or the item was a chart, description of photograph,a letter to the editor, or a brief story (under 100words). For the Halifax Chronicle Herald thesample was constructed manually by scanning allrelevant sections of the newspaper for each day ofeach constructed week. One of us (IR) assembledthe initial sample of English language stories andscanned all selected items to filter out stories thatobviously did not meet our criteria. One of thecoders in Montreal similarly scanned the Frenchlanguage stories. This process yielded 7060 stories,each of which was reproduced as a paper copy andassigned a unique identification number.

The second stage involved the same selectioncriteria but applied by coders using content analysis.This process excluded 492 stories, leaving a sampleof 6578. Coders recorded simple publication details ofthis entire group (discussed below). The third stageinvolved full coding of an item according to studyprotocol if: it appeared in the international, national,or regional sections of the newspaper, or was a‘health and lifestyle’ item from the leisure, recrea-tion, entertainment or related sections (excludingsports, classifieds, business and advertisements) and

not an editorial or opinion piece. This latter group(n ¼ �900), defined as not having a source otherthan the author and/or on the editorial and opinionpage(s), is the focus of a separate study. The totalnumber of stories used in the present analysis is4732, of which 72% (n ¼ 3405) were from English-language papers and 28% (n ¼ 1327) from French-language papers. Of the total, 4139 stories (87.5%)are from the news sections and 503 (10.6%) are from‘health and lifestyle’ sections, while 90 (1.9%) werenot specified or could not be determined.

Coding protocol

The coding protocol contained 94 items asso-ciated with seven categories of information. Simple

publication details included the title of the story, itsidentifying number, coder identification, date ofcoding, newspaper, section, page number, day of themonth, day of the week, month and year. Story

prominence concerned the placement of the story(front page of newspaper, front page of section,other location), word count and whether or not thestory was accompanied by artwork (photograph,cartoon, graph or other image). Story characteristics

included genre (hard (i.e., time reference within thestory of events happening within the previous dayor two) or soft (no time referent) news), geographiclocation, story dateline (i.e., the location of theauthor of the story), and story byline (staff reporter,wire service, guest writer). The story topic included a15 word story summary created by each of thecoders to help them focus on what they identified asthe central topic of each story within the taxonomicframework developed for this research (described indetail below). The remaining three protocol cate-gories were included to aid the framing analysesplanned as subsequent phases of this project.

The taxonomic framework was based on the sixchapter headings of TAHF, with some slight mod-ification. Our pilot study indicated that the vastmajority of stories concerned health services, so wedifferentiated this category into stories dealing withhealth care management and regulation issues, andthose concerned with service provision and delivery.We also added two categories; one to cover storiesabout basic scientific advances such as the isolation ofa gene, protein or enzyme associated with any disease,condition or trait influencing health status but not yetpart of the sphere of health services; the other tocapture any story not sufficiently contained within theprevious eight categories. In all, our taxonomyincluded nine meta-topics. Four of these meta-topicsincluded sub-topics that were derived from the TAHF

document or from the pilot study to provide a moredetailed description of the meta-topics as they sub-sume a wide range of issues, situations and/or healthinfluences. The complete list of meta-topics, sub-topics and their definitions may be found at /http://www.sfu.ca/�mhayes/publications/table1.pdfS.

Coding of stories according to the meta-topicsand sub-topics proceeded in four steps. Afterreading a sampled story, coders were instructed towrite a summary of no more than 15 words

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describing the main focus of each story as the firststep. In the pilot study we found this process greatlyincreased inter-coder agreement in assigning storiesto meta-topics and sub-topics. As it was possible forstories to deal with more than one of our meta-topics (for example, a story dealing with issues ofhealth service provision as well as regulation bygovernment), the second step required coders todetermine if there was any mention of each of thenine meta-topics in the article (topic mentioned yes/no). The third step required coders to determinewhich one of the nine meta-topics best described thecentral focus of the story. If the meta-topiccontained a sub-topic, coders were instructed toidentify the sub-topic that best described the storyfocus as the fourth step in the coding of topics.

Coder selection and training

Two groups of coders were used to analyze thecontent of sampled stories. The Vancouver groupconsisted of eight coders who analyzed all of theEnglish language stories. The Montreal groupincluded four bi-lingual coders who coded all ofthe French language stories. Coders were chosenfrom among senior-level undergraduate students incommunication (Vancouver) and journalism (Mon-treal). Two-day workshops were held with eachcoder group. To assess the degree of inter-coderagreement between meta-topic categories, a smallsub-sample of both English and French stories(n ¼ 50) was circulated to each of the coders in therespective groups. Coders were blind to whichstories were included in this sub-sample, but aware

Mentioned Health Topics from 1993

0

10

20

30

40

50

60

70

1993 1995 1997 1999

Sampled years

Per

cent

age

of S

tori

es

Fig. 1. Frequency (%) of any

that we would measure inter-coder agreement. Allstories and their coded information were returned toVancouver for processing and data entry.

Results

Inter-coder agreement

Inter-coder agreement was assessed separately forthe English and French language stories in thesample for the central topic and for any mention ofthe topic. Kappa scores for each group were highlystatistically significant (p ¼o0.001), indicating ahigh level of inter-rater reliability at the level ofmeta-topics.

Any mention

The frequency with which meta-topics are men-tioned in sampled stories is shown in Fig. 1.Throughout the entire study period, issues asso-ciated with health care were the most frequently andconsistently mentioned news items. More than 60%of stories in each sampled year mentioned manage-ment and regulation issues (mean ¼ 61.3%; 2905stories). Service provision and delivery topicsincreased from 40% to over 50% (mean ¼ 45.6%;2159 stories). About 25% of stories mentioned someaspect of the physical environment (1119 stories).Stories mentioning the socio-economic environment(859 stories) or personal health practices (761stories) had similar patterns of mention. Bothdipped to a low of 10% in 1995 but were mentionedin between 15% and 20% of stories in other years.

to 2001

2001

mention of topic by year.

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Child development issues were mentioned in about10% of stories (n ¼ 429), while biology and genetics(n ¼ 208), scientific advances (n ¼ 294), and othertopics (n ¼ 286) were mentioned relatively infre-quently.

Central topic

The distribution of stories across central topics isshown in Fig. 2. Issues of health care dominatednews items. Over the study period, management andregulation topics fell from 50% of all storiessampled to about 43% (mean ¼ 45.2%; n ¼ 2189),but a corresponding increase in service and deliveryissues, from about 15% to about 22% of stories(mean ¼ 18.8%; n ¼ 886) produced remarkablylittle variation over time—about 65% of all storiessampled concern health care. There is also remark-able inter-year consistency in the frequency withwhich other topics are covered. On average, 12.6%of stories focused on the physical environment(n ¼ 596), 5.9% on the socio-economic environment(n ¼ 282), 5% on personal health practices (n ¼ 235),4.2% on health advances in basic science (n ¼ 198),1.5% on child development (n ¼ 73) and 1.1% onbiology and genetic endowment (n ¼ 51). 4.8% ofstories (n ¼ 222) fell into the ‘other’ category.

Differences between papers

We found statistically significant differences(p40.05) between English- and French-languagenewspapers. In relative terms, the English-language

Central Health Topics from 1993 to

0

10

20

30

40

50

60

1993 1995 1997 1999

Sampled years

Per

cent

age

of S

tori

es

Fig. 2. Frequency (%) of c

papers had a much greater proportion of health careservice provision and delivery topics (20.1% vs.15.3% of stories within language) and physicalenvironment topics (13.7% vs. 9.8%). The French-language papers had much greater proportions ofhealth care management and regulation topics(51.3% vs. 44.3%) and health advances in basicscience topics (6.8% vs. 3.2%).

We found no significant differences between thetwo national English-language papers (Globe and

Mail, National Post) and the regional English-language papers, nor did we find large differencesbetween the two tabloid papers (Calgary Sun,

Toronto Sun) and their broadsheet counterparts(Calgary Herald, Toronto Star) although in bothcases the tabloids carried proportionately fewerstories about health advances in basic sciencestories.

To determine if there were regional differences inreporting, we created three regions: Quebec (thethree French-language papers and the Montreal

Gazette), Ontario (Ottawa Citizen, Toronto Star andToronto Sun), and the West (Vancouver Sun,

Calgary Herald, Calgary Sun). (There were toofew stories from the Halifax Chronicle-Herald

(n ¼ 77) to include that paper in this analysis.)We found that the West region sample con-tained proportionally more stories about healthcare service provision and delivery, the Ontariosample contained more stories about the socio-economic environment, and the Quebec samplecontained more stories about health advances inbasic science.

2001

2001

entral topic by year.

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Sub-topic distribution

The distribution of sub-topics within the socio-economic environment, health care and physicalenvironment meta-categories is shown in Table 1.Issues of management (627), funding (n ¼ 588), andgovernment regulation (n ¼ 501) dominate the newsabout administrative aspects of health care issues.Most of these stories involve reporting on state-ments made by Ministers of health or othergovernment officials about levels of funding forhealth care services, or the range of services that are,should be or should not be funded. Inter-govern-mental relationships (especially those between thefederal government and individual provinces) areanother major theme within this category.

Health care treatment (including issues of access toservices such as wait lists or geographic proximity)

Table 1

Frequency of sub-topics within meta-categories

n

Health care: Management and regulation (n ¼ 2189)

Private health funding 133

Public health funding 455

Public health sector management 627

Government health care regulation 501

Judicial health regulation 296

Health ethical review 99

Other management and regulation 78

Health care: Service provision and delivery (n ¼ 886)

Prevention 76

Diagnosis 75

Treatment/management 229

Alternative/complimentary 57

Education/training 104

Error or malpractice 95

Advances 217

Other service or provision 33

Physical environment (n ¼ 596)

Natural environment hazards 50

Manmade environment hazards 215

Built environment 78

Animal hazards 60

Infectious disease 151

Other physical 42

Socio-economic environment (n ¼ 282)

Income 9

Education/literacy/numeracy 2

Employment 36

Self 49

Social support 65

Social violence 96

Other social 25

and advances in the provision of health care servicesdominate the stories related to issues of serviceprovision and delivery. With respect to the physicalenvironment, stories about human created hazardsand infectious diseases appear most frequently.

Of the 282 stories dealing with the general topicof the socio-economic environment, most concernissues of violence (n ¼ 96), social support (n ¼ 65)and aspects of individual self-perception (n ¼ 49)(both of which are largely related to issues of mentalhealth), and employment-related issues (n ¼ 36).Only 9 deal with issues of income in relation tohealth, and just 2 with issues of education andhealth. Together, these comprise 0.2% of allsampled stories.

Presence of stories about ‘social determinants’ not

explicitly linked to health

Our analysis demonstrates that discussion of theso-called ‘social determinants of health’ is virtuallynonexistent in newspaper coverage of health stories.In light of this finding, we attempted to estimate thenumber stories carried in the sampled newspaperson the sampled days that concerned issues related tosocial influences upon health but did not make anexplicit connection to health. We concentrated onlyon English-language newspapers for the years 1997,1999 and 2001. We chose three topics: work,education and poverty. We adopted analogouscriteria for selecting stories on these topics as wehad for selecting ‘health’ stories with one exception:we did not ascertain the central focus of the story.Rather, we were interested in looking at all storiescaptured by these keywords to determine the extentof overlap between these ‘socio-economic environ-ment’ topics and the sample of ‘health’ stories. Inthe small number of cases where selected storiesincluded more than one keyword (education andincome, work and income, etc.) the same storieswere included separately in the discussion thatfollows.

Work

The keywords ‘work(ing) condition’, ‘work(ing)environment’ and ‘work(ing) organization’ produced75 stories, of which 15 overlapped with stories in our‘health’ sample. Of these, 12 concerned stories aboutlabor disputes with nurses or doctors (coded as healthcare topics) and three concerned work place healthand safety issues (coded as physical environment

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topics). There were two other stories about publicsector labor negotiations that included the wordhealth in the first four paragraphs (health sectorworkers) not deemed by coders to be health-relatedstories. No stories in the sample explicitly discussedthe impact of work organization (such as decisionlatitude at work or workplace hierarchies) uponhealth. Health sector labor stories focused on issuesof relations between workers and government, wages,and working conditions—hours, support (or lackthereof) from affiliated workers such as registerednursing assistants and job stress. The impact of jobstress on health outcomes among health sectorworkers was not discussed in stories in this sample.Many of the 60 stories about working conditions withno overlap to the ‘health’ sample concerned labordisputes: strikes (current or threatened), contractnegotiations, and settlements.

Education

Of the 115 stories containing the keyword‘education’, 36 overlapped with ‘health’ stories. 19of these involved issues of health care (11 on topicsof service delivery and treatment, such as thetraining of health care personnel, public educationand awareness, or new advances from health careresearch; the remaining eight concerned issues ofmanagement and regulation). Five stories concernedissues of environmental contamination in or aroundschools (physical environment), four involved socio-economic environment topics (matching to sub-topics of social support (2), violence (1) and other(1)), three focused on healthy child development,two each were assigned to health advances andother topics, and one was assigned to personalhealth practices.

Of the 79 education stories that did not matchstories in the health sample, seven could have beenincluded in the health sample as they also containedthe keyword ‘health’ in the first four paragraphs.Three of these concerned separate reports ofenvironmental contamination in or around schoolsin three different newspapers and could have beenassigned to the category ‘physical environment’, twoconcerned separate reports of surveys of sexualactivity and knowledge about sex among teenagersthat could have been assigned to the category‘personal health practices’, one concerned anapology for practices of apartheid issued to blackformer medical students in South Africa that couldhave been assigned to the topic ‘health care: delivery

and treatment’ (sub-topic education), and onefocused on the future prospects of homeless youthin Quebec and should have been assigned to thecategory ‘socio-economic environment’.

Stories about education that did not involve animplicit link to health issues concerned a variety oftopics: the retiring of committed and well-likedteachers, fund-raising activities of schools forvarious causes, volunteering of teachers or students,focus features on particular schools, and variousother topics. The most frequently discussed issueswithin this group of stories concerned governmentfunding for education (n ¼ 15), labor disputes(n ¼ 14) and matters of education policy (n ¼ 5).

Also within this group were 10 stories thatcontained implicit links to health topics but noexplicit mention of the word ‘health’. There werethree stories about the importance of early humanlearning on future school and career success that didnot mention differential health outcomes in associa-tion with early child development, two stories aboutdemographic changes and the future of educationpolicy without concomitant mention of healthstatus, two stories about the impact of tuitionincreases upon access to higher education amonglower income groups, and single stories about drugand alcohol use among university students, sexeducation in schools, and bullying and schoolviolence.

Poverty

Of the 47 stories found using keywords ‘poverty’,‘poor’, and ‘low income’, 13 overlapped with the‘health’ sample. Of these, five were classified ashealth care topics, three were classified as socio-economic environment topics, two concernedhealthy child development topics, two on thephysical environment and one was not given acentral topic designation (but should have beenclassified as a health care topic). Of the 13, six had afocus on international issues (AIDS in Africa (3),hurricane Mitch, the impact of global warming onthe world’s poor, and living conditions of refugeesin Burundi), while the other seven concerneddomestic issues of homelessness (3), child poverty(2) and differential rates of survival from heartattack by social class (quoting a US study).

Of the remaining 34 stories, 15 had a global focuson people living in extreme poverty (mostly inAfrica) and three others concerned the impact ofglobal trade on the world’s poor. There were two

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stories about people living in poverty in the US. Theremaining 14 stories concerned people living inCanada. Of these, five focused on governmentexpenditures on welfare (or related topics ofthreatened cuts to services), three related to the rolethat service organizations play in providing servicesto the poor, and six discussed increasing disparitiesbetween affluent and poor Canadians or associatedtopics of the cost impacts of education or housingupon poorer Canadians.

Many of the 34 stories that did not overlap withthe ‘health’ sample did mention issues of healthamong poorer populations (especially stories with aglobal focus or those concerning changes in welfareprovision) but mentions of health were outside thefirst four paragraphs of the story, and thus notcaptured by the sampling process used. Themajority of these discussed the provision of healthservices and did not discuss health outcomes moregenerally. In some cases, stories ignored any healthlink even though the issue could have been a centralfeature of the story. For example, a story appearingin the Toronto Star (March 16, 2001 p. 35) entitled‘‘Rich, poor are even wider apart’’ discusses in greatdetail the growing divide in wealth among Cana-dians without mentioning health status differencesbetween income groups. Similarly, the story ‘‘Poorget shortchanged, Canadians tell poll’’ (Globe and

Mail, December 18, 1999) focuses on cuts to welfareprovision and discusses the service needs of poorerCanadians, but does not mention differences inglobal health outcomes among the poor comparedto other income groups.

Social gradient

Finally, we looked for any reference to the phrase‘social gradient’ in any of the English-languagenewspapers on any day without filters for any yearwithin the range of our sample (1993–2001). Wefound only two mentions of the term among themillions of items searched. Both of these were lettersto the editor, one (Calgary Herald, 1997) arguingthat reductions in wages of workers in Albertacontributes to social gradients in health outcomes,the other (Toronto Star, 2000), from the School ofKinesiology and Health Sciences at York Univer-sity, a response to a letter claiming that itmisrepresented a previous story about researchfindings on health outcomes associated with physi-cal inactivity. A more general search of newspaperdatabases found one other reference to ‘social

gradient’ and health; a story in the Edmonton

Journal about the work of Richard Wilkinson andhis observations regarding the distribution of healthstatus in populations in the developed world, andpromoting his lecture at the University of Alberta(Edmonton Journal, 2002).

Conclusion

Our study reveals a significant difference in focusbetween health influences identified in policy state-ments and newspaper coverage of health stories.Despite the appearance of the Lalonde Report morethan thirty years ago, and its concern to bothexpand the public’s understanding of health influ-ences and to demonstrate that health involves morethan simply health care, Canadian newspapercoverage of stories about health are still over-whelmingly about health care. Indeed, there seemsto be an inverted relationship between the relativeimpact of identified health influences from policydocuments and the coverage afforded to them innewspaper stories. The absence of any discussionabout social gradients in health indicates thatnewspapers do not find the central observationdriving the population health perspective in publicpolicy newsworthy. Even the stories that we haveclassified as being concerned with the socialenvironment largely fail to discuss broad issues ofthe welfare state in relation to health—housing andhousing policy, child development and related issuesof education and child care, the social relations ofwork environments (as opposed to exposures tophysical hazards), community design and urbaninfrastructure, etc. Implicit in the obsession withissues of health care is the notion that this aspect ofthe welfare state is singularly important to main-taining and improving human health. Debates as towhether investments in the health care sector comeat the expense of investments elsewhere within thewelfare state (in education, housing, income supple-mentation, etc.) rarely appear in Canadian news-papers. Newspapers appear to do little to advancelevels of critical health literacy on broad determi-nants of health in Canada.

This phase of our research represents a basicattempt to establish the relative prominence ofspecific topics in Canadian newspapers. To be sure,the subjective nature of the coding process will haveinfluenced the relative estimates of topic prominencereported here. Given that stories may have coveredmore than one of the topics or sub-topics of our

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taxonomic framework, the true estimate of topicprominence undoubtedly carries with it somemargin of error. For example, stories aboutmanagement and regulation of health care issues(provision of home care) may also have referred toissues of housing though home care was givengreater prominence in coverage. Examination of‘socio-economic environment’ sub-topics revealedthat the entire sample may have excluded a smallpercentage of stories that could have been deemedto be ‘health’ stories. But the focus of such storieswas not exclusively on the socio-economic environ-ment, even though the keywords used to identify thestories were associated with this topic. Thus, storiesrelated to personal health practices, early childdevelopment, aspects of health care provision/delivery or management/regulation and the socio-economic environment were all represented amongthose stories that might conceivably have beenincluded in the original ‘health’ sample but judgedby coders not to have had a main focus on health. Inthe final analysis, the estimated relative prominenceof the topics analyzed here does reflect the actualreporting practices of news stories about ‘health’ inCanada. Clearly, researchers, policy makers andpublic health advocates interested in reducinghealth inequalities have much work to do to changethe current state of reporting practice.

Acknowledgments

This study was funded by the Social Science andHumanities Research Council of Canada (Grant no.839-2000-1050). We gratefully acknowledge thissupport. We wish to thank the coders who workedon this project: Brandy Weber, Heather Dow, JennySoininen, John Shannon, Shauna Jones, ArjunTremblay, Genevieve Martel, Valerie Carreau,Adriana Modica, Bunni Gannan, Lindsay Stewart,and Imran Munir. Thanks, too, to Rahim Moined-din for assistance with the analysis, and thereviewers for helpful comments.

References

Brown, P., Zavestoski, S. M., McCormick, S., Mandelbaum, J.,

& Luebke, T. (2001). Print media coverage of environmental

causation of breast cancer. Sociology of Health and Illness, 23,

747–775.

Canadian Population Health Initiative. (2005). Select highlights

on public views of the social determinants of health. Ottawa:

Canadian Institute for Health Information.

Calgary Herald. (1997). Re ‘‘Tumbling wages Alberta’s reality’’.

Herald, April 23, p. J4.

Cassels, A., Hughes, M. A., Cole, C., Mintzes, B., Lexchin, J., &

McCormack, P. J. (2003). Drugs in the news: An analysis of

Canadian newspaper coverage on new prescription drugs.

Canadian Medical Association Journal, 168, 1133–1137.

Clarke, J. N. (1999). Breast cancer in mass circulating magazines

in the USA and Canada, 1974–1995. Women and Health, 28,

113–130.

Commers, M. J., Visser, G., & De Leeuw, E. (2000). Representa-

tions of preconditions for and determinants of health in the

Dutch press. Health Promotion International, 15, 321–332.

Davidson, R., Hunt, K., & Kitzinger, J. (2003). ‘Radical

blueprint for social change’? Media representations of New

Labour’s policies on public health. Sociology of Health and

Illness, 25(6), 532–552.

Dorfman, L. (2001). Mass communication and public health.

Berkeley: University of California.

Edmonton Journal. (2002). Gap between rich, poor a concern,

researcher says; Health problems stem from social, income

inequalities. March 4, p. A7

Entwistle, V., & Sheldon, T. (1999). The picture of health?

Media coverage of the health service. In B. Franklin (Ed.),

Social policy, the media and misrepresentation. London:

Routeldge.

Evans, R. G., Barer, M. L., & Marmor, T. R. (Eds.). (1994). Why

are some people healthy and others not? The determinants of

health of populations. New York: Aldine de Gruyter.

Fisher, J., Gandy, O., & Janus, N. (1981). The role of popular

media in defining sickness and health. In E. McAnany, J.

Schnitman, & N. Janus (Eds.), Communication and social

structure: Critical studies in mass media research. New York:

Praeger.

Gasher, M., Hayes, M. V., Ross, I., Hackett, R. A., Gutstein, D.,

Dunn, J. R. (in press). Spreading the news: social determi-

nants of health reportage in Canadian daily newspapers.

Canadian Journal of Communication, in press.

Glouberman, S. (2001). Towards a new perspective on health

policy. Canadian policy research networks (H:03). Ottawa:

Renouf Publishing.

Government of Canada. (1986). Ottawa Charter for Health

Promotion. Reprinted in Health Promotion International, 1,

418.

Grilli, R., Freemantle, N., Minozzi, S. Domenighetti, G., &

Finer, D. (1998). Impact of mass media on health services

utilization (Cochrane Review). The Cochrane Library, Issue 4.

Reported in (2000). Evidence-Based Healthcare 4, 2.

Karpf, A. (1988). Doctoring the media—The reporting of health

and medicine. London: Routledge.

Kitzinger, J. (1999). A sociology of media power. Key issues in

audience reception research. In G. Philo (Ed.), Message

received. Harlow: Longman.

Lalonde, M. (1974). A new perspective on the health of Canadians.

Ottawa: Minister of Supply and Services Canada, Govern-

ment of Canada.

Lavis, J. N. (2002). Ideas at the margin or marginalized ideas?

Non-medical determinants of health in Canada. Health

Affairs, 21(2), 107–112.

Leask, J., & Chapman, S. (2002). ‘The hard cold facts’

immunization and vaccine preventable diseases in Australia’s

newsprint media. 1993–1998. Social Science & Medicine, 54,

445–457.

Page 11: Telling stories: News media, health literacy and public policy in Canada

ARTICLE IN PRESSM. Hayes et al. / Social Science & Medicine 64 (2007) 1842–18521852

Maibach, E., & Parrot, R. (Eds.). (1995). Designing health

messages: Approaches from communication theory and public

health practice. Thousand Oaks, CA: Sage Publications.

Ministry of Public Works and Government Services Canada.

(1999). Toward a healthy future: Second report on the health of

Canadians. Ottawa: Federal/Provincial/Territorial Advisory

Committee on Population Health.

Mintzes, B., Barer, M. L., Kravitz, R. L., Bassett, K., Lexchin, J.,

Kazanjian, A., et al. (2003). How does direct-to-consumer

advertising (DTCA) affect prescribing? A survey in primary

care environments with and without legal DTCA. Canadian

Medical Association Journal, 196, 405–412.

Parrott, R. (1996). Advocate or adversary? The self-reflexive roles

of media messages for health. Critical Studies in Mass

Communication, 13, 266–278.

Reutter, L. I., Dennis, D. J., & Wilson, D. R. (2001). Young

parents’ understanding and actions related to the determinants

of health. Canadian Journal of Public Health, 92, 335–339.

Riffe, D., Aust, C. F., & Lacy, S. R. (1993). The effectiveness

of random, consecutive day and constructed week sampling

in newspaper content analysis. Journalism Quarterly, 70,

133–139.

Seale, C. (2003). Health and media: An overview. Sociology of

Health and Illness, 25, 513–531.

Shoemaker, P., & Reese, S. (1996). Mediating the message:

Theories of influence on mass media content (2nd ed.). New

York: Longman.

Signorelli, N. (1993). Mass media images and impact on health:

A sourcebook. Westport, CN: Greenwood Press.

Strasburger, V. (1995). Adolescents and the media: Medical and

psychological impact. Thousand Oaks, CA: Sage Publications.

Toronto Star. (2000). Re ‘Fat’ tax punishes poor, Letter.

November 28; and Overweight Canadians taxing health

system. November 27, p. A31.

Wallack, L., Dorfman, L., Jernigan, D., & Themba, M. (1993).

Media advocacy and public health: Power for prevention.

Newbury Park, CA: Sage Publications.

Wallack, L. (2000). The role of mass media in creating social

capital: A new direction for public health. In B. D. Smedley,

& L. S. Syme (Eds.), Promoting health: Intervention strategies

from social and behavioural research. Washington, DC:

Institute of Medicine, National Academy Press.

WHO. (1997). Jakarta declaration for health promotion in the 21st

century. Geneva: World Health Organization.