7
Media

Mass media plays a central role in people’s lives. Its importance is evident in the amount of time people spend watching television, surfing the World Wide Web, listening to music, and reading newspapers and magazines. The delivery of information through mass media is instant and available around the clock. The proliferation of communication technologies— miniature TVs, handheld radios, and personal computer companions such as Blackberry and Palm Pilot—contribute to the omnipresence of the media in daily life. More and more, a growing proportion of “life experience” is mediated through communication technologies instead of being directly experienced or witnessed. The public health community and policy makers often do not appreciate the importance and power of the media in shaping the health of the public. More importantly, media outlets or organizations do not see themselves as a part of, or contributing to the public health system. As this chapter discusses, however, the media plays a number of roles in educating the public about health issues and has a responsibility to report accurate health and science information to the public.

In this chapter, the committee examines the potential role of the media as an actor in the public health system, that is, how it can use its presence and power to lead to the mobilization of societal action that creates the conditions for health. The chapter specifically discusses how the news media can place health issues on the national public agenda and can catalyze action at the national and local levels. The chapter also addresses how advertising media, entertainment media, and the Internet provide health-related information that can reinforce or alter norms and attitudes that



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The Future of the Public’s Health in the 21st Century 7 Media Mass media plays a central role in people’s lives. Its importance is evident in the amount of time people spend watching television, surfing the World Wide Web, listening to music, and reading newspapers and magazines. The delivery of information through mass media is instant and available around the clock. The proliferation of communication technologies— miniature TVs, handheld radios, and personal computer companions such as Blackberry and Palm Pilot—contribute to the omnipresence of the media in daily life. More and more, a growing proportion of “life experience” is mediated through communication technologies instead of being directly experienced or witnessed. The public health community and policy makers often do not appreciate the importance and power of the media in shaping the health of the public. More importantly, media outlets or organizations do not see themselves as a part of, or contributing to the public health system. As this chapter discusses, however, the media plays a number of roles in educating the public about health issues and has a responsibility to report accurate health and science information to the public. In this chapter, the committee examines the potential role of the media as an actor in the public health system, that is, how it can use its presence and power to lead to the mobilization of societal action that creates the conditions for health. The chapter specifically discusses how the news media can place health issues on the national public agenda and can catalyze action at the national and local levels. The chapter also addresses how advertising media, entertainment media, and the Internet provide health-related information that can reinforce or alter norms and attitudes that

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The Future of the Public’s Health in the 21st Century influence individual behavioral and societal changes. The chapter concludes with a brief discussion of the theories that help us understand the impact of the media on behavioral change and on evaluation and research issues, including the difficulties in predicting the outcomes of media campaigns. The committee recommends a number of steps that can be taken to further enhance the role of the media in improving the population’s health. NEWS MEDIA AND THE NATIONAL PUBLIC AGENDA The ubiquitous nature of the news media, in particular, makes it a powerful tool for directing attention to specific issues. Generally, Americans look to the news media for coverage of events and to help us understand the world around us. Although the news media does not specifically tell us what to think, it plays an important role in identifying what issues we should think about (McCombs and Shaw, 1972). The more coverage a topic receives in the news, the more likely it is to be a concern of the public. Conversely, issues not mentioned by the media are likely to be ignored or to receive little attention. The unfolding news coverage of HIV/AIDS provides a good example of how an important health issue may be invisible to the public eye until the media bring it to light. The first publicly documented cases of AIDS were reported in the June 5, 1981, issue of Morbidity and Mortality Weekly Report (MMWR) (CDC, 1981a). The publication provided five case histories of previously healthy, young (ages 29 to 36) homosexual men from the Los Angeles area who developed Pneumocystis carinii pneumonia (PCP), an affliction usually seen in severely immunodepressed patients, and a myriad of other opportunistic infections. A July issue of MMWR (CDC, 1981a) reported Kaposi’s sarcoma in 26 homosexual men and additional cases of PCP in Los Angeles and San Francisco. Physicians were alerted about Kaposi’s sarcoma, PCP, and other opportunistic infections associated with immunosuppression in homosexual men. A subsequent issue of MMWR (CDC, 1982c) reported 70 additional cases of Kaposi’s sarcoma and PCP, and by December 1981, the Centers for Disease Control and Prevention (CDC) had reported more than 150 deaths. During this time, news media coverage of the illnesses that appeared to be affecting homosexual men was limited. According to an analysis conducted by the Kaiser Family Foundation (1996), it was only in August 1982 that the New York Times brought readers up to date on an emerging and puzzling health crisis in the homosexual community. The article, “A Disease’s Spread Provokes Anxiety,” used the term acquired immune deficiency syndrome, or AIDS, for the first time. Later that year, the Washington Post reported on the death of an infant who had received a transfusion of blood from a donor with AIDS (CDC, 1982b). By 1983, a Newsweek

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The Future of the Public’s Health in the 21st Century TABLE 7–1 Media Coverage of AIDS Year News Story October 1985 Death of Rock Hudson, a well-known public figure August 1987 Florida family burned out of home; a dramatic case of public anxiety concerning AIDS leading to violence. Arsonists were seeking to keep the family’s AIDS-afflicted hemophiliac sons out of the local school system April 1990 Ryan White’s death at age 18. White contracted HIV at age 13 through blood products used to treat his hemophilia. He was the country’s best-known victim of AIDS as a result of nonsexual transmission June 1991 Public request by Kimberly Bergalis to test health professionals for AIDS. Kimberly contracted HIV from her dentist. Her dramatic case raised the controversial issue of AIDS testing for health care professionals November 1991 Magic Johnson reveals his HIV-positive status. Johnson was the first major public figure not in a higher-risk group to announce his HIV-positive status and to attribute it to heterosexual activity and was the first major professional athlete (he was the National Basketball Association’s most valuable player three times) to leave his sport because of HIV infection February 1993 Arthur Ashe dies of AIDS. Ashe, a renowned tennis star, political activist, and social commentator, contracted HIV through a blood transfusion during a surgical procedure   SOURCE: Kaiser Family Foundation (1996). poll found that 9 in 10 Americans over 18 years of age had heard about AIDS but were generally uninformed or misinformed. Subsequent coverage of AIDS included several newsmaker and public interest stories that further increased the public’s concern about AIDS. News media coverage during the mid- to late 1980s may have contributed to improved public awareness and knowledge of AIDS. By 1989, Gallup surveys indicated that nearly all adults were aware that HIV, the virus that causes AIDS, can be transmitted by shared needles (98 percent), homosexual intercourse (96 percent), and heterosexual intercourse (95 percent) (Kaiser Family Foundation, 1996). Table 7–1 gives examples of the media coverage of AIDS from 1985 to 1993. The media also play an important role in gaining the attention of specific opinion leaders, including politicians, governmental regulators, community leaders, and corporate executives, among others. Between 1982

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The Future of the Public’s Health in the 21st Century and 1987, several members of the U.S. Congress placed AIDS on the political agenda by holding hearings on the growing numbers of people afflicted by it and research into its causes and prevention. Celebrity activists and spokespersons covered by the media also increased the visibility of AIDS on the political agenda. However, it was not until 1987 that President Ronald Reagan gave his first public speech about AIDS. During that year the Congress also passed legislation that took into account the larger societal implications of the epidemic and that went beyond funding for AIDS prevention, research, and treatment efforts. The AIDS Federal Policy Act of 1987 prevented discrimination against individuals with disabilities—including those with HIV/AIDS. In 1988, as public recognition of the burgeoning AIDS epidemic increased, the growing need for information was addressed by a booklet sent to all 107 million U.S. households by then-Surgeon General C. Everett Koop. Understanding AIDS: A Message from the Surgeon General was one of the largest educational public health mailings in U.S. history (Koop, 2002). Political attention to AIDS continued to grow from the late 1980s through 1990. Advocacy groups and celebrities used news media coverage to bring attention to the case of Ryan White, an Indiana teenager who acquired AIDS through blood products used to treat his hemophilia, and to AIDS issues in general (AIDS Project Los Angeles, 2001). In August 1990, the Ryan White Comprehensive AIDS Resources (CARE) Act was enacted, a few months after Ryan’s death. This landmark legislation authorized funds in emergency relief to cities devastated by the AIDS epidemic (P.L. 101–381). As noted earlier, a high level of media coverage about a topic elicits public attention and concern. In the case of HIV/AIDS, the news media engaged public attention and stimulated policy response. Shuchman (2002) provides several examples of journalism as a catalyst of health care system change. A New York Times probe of fraudulent practices at the Columbia/HCA Healthcare Corp. chain of hospitals in March of 1997 led to a federal criminal investigation of the company (Gottlieb et al., 1997). A Los Angeles Times series on the U.S. Food and Drug Administration’s system of drug approval in 2000 strengthened the claims of those advocating tighter controls at the agency (Willman, 2000). Extensive coverage by the Washington Post and others of the death of a young patient in a university-based gene therapy experiment resulted in stronger federal protections for patients enrolled in clinical trials (Nelson, 2000). A Boston Globe series on the hazards of placebo-control trials in psychiatry was one of several journalistic investigations that resulted in changes in the way psychiatric patients are enrolled in research protocols (Whitaker and Kong, 1998) (quoted in Shuchman, 2002).

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The Future of the Public’s Health in the 21st Century News attention to specific issues, however, may also distort public perceptions and change behavior in adverse ways. Gilliam and colleagues (1995) found that the public’s concern regarding crime increased, despite little actual change in the frequency of criminal activity and national survey statistics indicating a declining population-adjusted rate of crime over the previous two decades. The authors note that although Americans do not experience crime directly, they receive large doses of crime coverage from the media. The authors suggest that such coverage drives Americans to name crime as the most important problem facing the country and shapes public attitudes toward criminals, the death penalty, mandatory jail sentences, and “three strikes” laws. In response to public concerns, policy makers endorse strategies to strengthen law enforcement and the criminal justice system. Dorfman and Thorson (1998) also note that one by-product of media reporting on crime and violence is that readers receive a distorted picture of the world and that people react to reading and hearing news about crime and violence by fearing their world. Dorfman and colleagues (2001) have developed techniques to enable journalists to report on highly unusual crimes without misrepresenting the patterns of violence in their communities and creating misguided fears. Such techniques for reporting on violence integrate a public health perspective and offer readers information to understand the determinants of violence and to develop strategies for reducing violence in the community (Stevens, 1998). NEWS MEDIA AS A CATALYST TO PROMOTE HEALTH AT THE COMMUNITY LEVEL The AIDS example illustrates the role of the news media in placing the AIDS epidemic in the public light and on the national political and legislative agendas. The news media can also function as a catalyst for action at the local or community level. The story of “motel families” living across the street from Disneyland in Orange County, California, demonstrates the power of the news media to highlight social issues and stimulate action by local government and community members. Over a period of 6 months in 1998, Laura Saari, a writer for the Orange County Register, brought to light the sharp social and economic contrast that exists in one of California’s more affluent counties, where one in five children lives in poverty. The article on motel children uses the voices of children to poignantly communicate the impact of poverty on their lives (see Box 7–1). The story had a significant influence on the community; more that 1,100 people contacted the paper to offer $200,000 in donations, 50 tons of food, 8,000 toys, and thousands of volunteer hours. The media coverage also activated a response by the local government. The Orange County

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The Future of the Public’s Health in the 21st Century BOX 7–1 Growing Up in “Toxic Communities” Sunday, August 2, 1998 Copyright ©The Orange County Register By Laura Saari Five children sit on the lip of the Dumpster and spear cans to get the money for a McDonald’s. A broken fan, onion peels, a gravy-stained box from a Salisbury steak TV dinner, a can of Hype Morning Rush Energy. “A toy bucket,” shouts Jeffrey Littlefield, 6. He wiggles a stick to get to the bucket before the other kids. He pulls up a fast-food chicken pail and smiles. Two black teeth. “I’m fishin’,” he says. “It’s a contest, whoever gets the most cans.” “Can I help?” asks Anthony Chavez, 3, trying to climb up. “I see French fries!” says a girl. She jumps in. The children live at a motel across from Disneyland. There was a time when tourists checked into motels such as this one, drawn to the U-Dial telephones and color TVs and a balcony view of the Happiest Place on Earth. Today, the vacancy signs are still up, but their neon tubes have lost their gas. Newer high-rise hotels lure the vacationers. And so the old rooms-by-the-day have become $140 rooms-by-the-week that soon become rooms-by-the-year, even though everyone always says they’re moving out tomorrow. For families who can’t find a way into the county’s rental market, the motels are the last stop before the homeless shelter or the street. And it’s not just here. A healthy economy and rising home prices have driven families across the nation into motels. Often, the buildings are in decay. The ceilings fall, the locks don’t latch, and the roaches don’t wait until dark. Some families live six or more people to a room. For the hundreds of children living in Orange County motels, violence often is a thin wall away, if that. Drug deals, prostitution, stabbings, assaults, theft, an occasional murder, a fugitive in hiding. The children are transient. Because of new occupancy limits in some cities, families must move on after 28 days. Social workers who are trying to protect the children often have difficulties just finding them, says Michael Riley, director of Orange County Children and Family Services. At some schools near motels, a third of the kids who sign up in the fall aren’t there at the end of the year. Head lice are chronic. Nurses have found roaches lodged deep inside children’s ears. “These children are consumed, 24 hours a day, with poverty—and it’s not just financial,” says Linda Dunlap, a nurse whose volunteer group, Project Dignity, works with families in motels. “It’s spiritual and emotional. They didn’t just decide one day they were going to surrender their spirits. They did it to survive.” The little ones seem too wise for their years, and too angry. Yet they share their last piece of bread with a neighbor. They protect each other fiercely. They try to create order where there is none.

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The Future of the Public’s Health in the 21st Century In grade school, many children are still hanging onto their dreams of what their lives could be. By the time they are teenagers, anger often has hardened into resentment, hopelessness, defiance. “I think the general population doesn’t understand what kind of lifestyle is being led in these places,” says Sgt. Joe Vargas of the Anaheim Police Department. “These are toxic communities. The kids are really starving for stability, and they don’t get it. We’re breeding criminals. We’re breeding kids who are growing up without the life skills necessary to function to their full potential.” That is the way grown-ups see life in motels. But things look different when you’re a kid. SOURCE: Saari (1998). Excerpted with permission of the Orange County Register. Board of Supervisors ordered an audit of services for motel children and directed $1 million in funds to create a housing program to help families move out of motels (Leaman, 1998). A nonprofit agency launched a $5 million capital campaign for a shelter to help motel families with drug abuse problems. The city of Anaheim, where the motels are located, also moved services into the motels so that families would have easier access to parenting classes, job training, and food programs. Many public health issues are not considered newsworthy. In contrast to the coverage of a frightening infectious disease epidemic such as AIDS or, more recently, the anthrax attacks, the story on motel children illustrates the everyday work of public health that involves struggles with endemic conditions and risk factors that are not considered news. The journalist was able to capture interest in an endemic situation by presenting the story in a novel way, and subsequent advocacy helped to keep the story and the public interest alive. NEWS MEDIA COVERAGE AND HEALTH INFORMATION Although news media coverage can help place a specific health issue on the national agenda, tensions exist among news reporters, scientists, and public health professionals as they seek to convey health news and information to the public, especially during a crisis. It is important to understand these tensions if the news media is to be involved in the public health system. The results of a survey of scientists and journalists are particularly helpful in understanding the attitudes of each toward the other and their

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The Future of the Public’s Health in the 21st Century views on transmitting and translating scientific information through the media to the public. Hartz and Chappell (1997) found that scientists complained that reporters do not understand many of the basics of their methods, including the proper interpretation of statistics, probabilities, and risk. Journalists viewed scientists as being too immersed in esoteric jargon and unable to explain their work simply and cogently, whereas scientists said the news media oversimplify complex issues. Reporters also noted that scientists do not understand that “news” is a perishable commodity that must be made relevant to the reader and viewer (see Table 7–2). These findings allude to many of the tensions between the scientific community (including the public health community) and the journalism community that arise because of differences in defining what is newsworthy, differences in styles of communication (Nelkin, 1996, 1998; Hartz and Chappell, 1997), and differences in perceptions about the role of the media (Nelkin, 1996, 1998). In identifying newsworthy topics, journalists often seek out stories that are potential attention grabbers. The tenets of newsworthiness include controversy, broad interest, injustice, irony, local “peg,” personal angle, breakthrough, anniversary peg, seasonal peg, celebrity peg, and visuals that can make the story interesting (Wallack et al., 1999). Scientists and public health professionals believe that journalists, in writing attention-grabbing stories, often violate the traditional norms that guide scientific communication. Nelkin (1996, 1998) notes that media con TABLE 7–2 Scientists’ and Journalists’ Agreement with Various Negative Statements About the News Media Statement Scientists’ Agreement (%) Journalists’ Agreement (%) Few members of the news media understand the nature of science 91 77 News media reporters are ignorant of the process of science 69 46 News media reporters cannot interpret results 66 48 News media reporters overblow risks 61 45 News media reporters rarely get details right 56 62 Member of the media seek the sensational 76 69 Members of the news media focus on the trendy 79 67 News media reporters focus on personalities, not on findings 49 70 News media reporters want instant answers 75 52   SOURCE: Hartz and Chappell (1997).

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The Future of the Public’s Health in the 21st Century straints of time, brevity, and simplicity, for example, impede the careful documentation, nuanced positions, and caveats that scientists believe are necessary to discuss and present their work. Journalists, on the other hand, often see the use of caveats or qualifications as information that can be dismissed to improve the readability of a story. Furthermore, journalistic efforts to enhance audience interest may violate other traditional scientific norms. For example, to create a human interest angle, journalists may look for personal stories and individual cases, although this may distort research findings that have meaning only in a broader statistical context. Scientific journals may also contribute to the distortion of research findings. Scientific journals often prepare press releases for the news media to assist them in getting the story right. These attempts to translate research into news can be misleading. Woloshin and Schwartz (2002) reviewed the content of journal press releases and interviewed press officers at nine prominent medical journals. The study found that press releases do not routinely highlight study limitations or the role of industry funding. Formats for presenting data were also found to exaggerate the perceived importance of findings. Fueling these tensions is the fact that scientists, health care professionals, and policy experts rarely receive training in public communication, and reporters are not well trained in science, medicine, and statistics. Both groups are generally untrained in risk communication. A recent study (Voss, 2002) highlights reporters’ self-perceptions about their own ability to report health news. The study surveyed reporters and newspapers in five Midwestern states. In response to questions about reporting ability, 49.7 percent of respondents reported it was sometimes easy and sometimes difficult to understand key health issues, and 31 percent found it often or nearly always (2.7 percent) difficult to do. Also, 51.3 percent of respondents reported that it was sometimes easy or sometimes difficult to interpret statistical data, whereas 27.4 percent found it often or nearly always (6.2 percent) difficult. More than three-quarters of respondents (83 percent) reported that they had no training to cover health topics. Similarly, a national survey of journalists and news executives found that only 12 percent of reporters covering health care are viewed as “extremely prepared” and 43 percent are viewed as “prepared” to cover health care issues (Foundation for American Communications, 2002). To help ease these tensions and to improve the quality of the information delivered to the public, scientists and public health officials as well as journalists and editors should seek opportunities for training. The need for media training is acknowledged in the statement of Al Cross, President of the Society of Professional Journalists, who notes that “training is a good way to meet your public responsibilities” (quoted in Kees, 2002) and in the

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The Future of the Public’s Health in the 21st Century words of Melinda Voss, executive director of the Association of Health Care Journalists: It seems to me that it is more important than ever that we as journalists really know how to do our jobs right, because so many critical policy decisions are being made that affect everyone. The ability to properly report medical studies and survey research and the ability to interpret statistics are all a part of doing the job right. We owe it to our audiences. (quoted in Kees, 2002) In response to the need for better health and science reporting, governmental agencies and foundations have developed programs for journalists that seek to provide them with experiences that will deepen their subject matter knowledge and strengthen their reporting. With funding from the John S. and James L. Knight Foundation, the CDC Foundation sponsors the Knight Journalism Fellowship at CDC (CDC Foundation, 2002). The fellowship provides classroom instruction in epidemiology and biostatistics, public health intervention, public health structure, and health reporting. Fellows are also provided with opportunities to observe investigations of disease outbreaks and participate in research and field practice (http://www.cdcfoundation.org/fellowships/knight/fellowship.html). The Kaiser Family Foundation (2002b) sponsors three fellowship programs for journalists. The Kaiser Media Fellowships in Health provide print or broadcast journalists and editors interested in health issues with an annual stipend that allows them to pursue individual projects on a wide range of health and social policy issues. The Kaiser Media Internships in Urban Health provide minority journalists interested in urban public health reporting with practical experiences in reporting on the health beat. The Kaiser Media Mini-Fellowships provide travel and research grants to journalists to research and report on health policy and public health issues. Both the Kaiser Family Foundation and the CDC-Knight fellowships, as well as others,1 facilitate a healthy dialogue between health officials and reporters and contribute to the development of a well-trained cadre of health journalists. Journalist associations also have begun to take a lead in providing opportunities for journalists to improve the quality of information they provide to the public. The Association of Health Care Journalists (AHCJ), for example, is an independent, nonprofit organization dedicated to advancing public understanding of health care issues. Its mission is to improve the quality, accuracy, and visibility of health care reporting, writing, and editing. One of the ways the association works to enhance the understand 1   Although not dedicated specifically to health issues, the Pew Charitable Trusts sponsors the Fellowships in International Journalism (www.pewfellowships.org), which may cover health issues in other countries.

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The Future of the Public’s Health in the 21st Century ing between journalists and health care experts is by offering workshops and training resources on current and emerging issues in health care and reporting skills. With support from the Robert Wood Johnson Foundation, the association recently published Covering the Quality of Health Care—A Resource Guide for Journalists (AHCJ, 2002b). The importance of effective communication among public health officials, the media, and the public is particularly critical during crises. During such times, the news media play an important role in amplifying or attenuating the public’s perception of risk and serve as a key link in the risk communication process. The media played a key role in reporting the anthrax attacks following the terrorist attacks on September 11, 2001. The events emphasized the need to communicate scientific and medical information in a way that the public can understand and to provide clear information about the concepts of risk and how to apply them. In November 2001, Dr. Kenneth Shine, president of the Institute of Medicine, advised Congress that communication to the public and to health professionals about the anthrax terrorist attack were found to be insufficient and needed improvement to deal more effectively with future situations that may compromise public health or national security. He stated: Within the Department of Health and Human Services, there must be a single credible medical/public health expert spokesperson that reports regularly, most likely daily, to the American people in regard to an outbreak with national significance. This is analogous to the situation in local communities where there is a need for such an individual to communicate on behalf of the local health department. Several months before the anthrax outbreak, uninformed statements on local television in a community with two cases of meningococcal meningitis resulted in thousands of individuals taking antibiotics or seeking immunizations that were not indicated. Local stores of antibiotics were depleted and many people were subjected to risk from unnecessary treatment. This episode emphasizes the need for credible medical/public health information during natural events, as well as during those that are produced by terrorism. In the case of the anthrax episodes, the media responded by interviewing countless number of individuals. Among them was a self-professed pundit who announced he was an expert on the “anthrax virus.” Anthrax is a bacterium, not a virus. In many cases, well-intentioned infectious disease specialists who knew a good deal about the literature on anthrax could provide accurate retrospective information, but when pressed about the current events, they were not privy to the information about the cases that had occurred. They were then forced to either acknowledge their limitations, which the responsible experts did, or in the case of others less responsible, to speculate based on news reports, rumors, and a variety of other kinds of incomplete or false information.

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The Future of the Public’s Health in the 21st Century The difficulty in health promotion program evaluation lies in the fact that every evaluation presents its own demands in terms of the trade-off between rigor and cost. Although randomized control trials are the “gold standard” for evaluating the impact of an intervention, they are rarely feasible for community- or population-based programs. Trade-offs between rigor and feasibility are inevitable and are best addressed by informed researchers who can control relevant threats to validity. Thus, there is a need not only to evaluate health promotion interventions but also to develop an evidence base for what works, among whom, and to what degree. Research Research on the effectiveness of media promotions for changing health-related behavior has been conducted for some time. The most commonly researched topics have been tobacco use, alcohol abuse, screening for cancer and other diseases, seat belt use, and the promotion of contraceptives and methods to prevent STDs. These studies have shown that the media can be used to increase knowledge about appropriate behaviors, create more positive attitudes toward the health behaviors, and lead to behavioral change among audience members. This triad of outcomes, knowledge (K), attitudes (A), and practices (P), has provided a convenient shorthand for guiding research on the effectiveness of media-driven health promotions. The degree of evidence for KAP models of behavioral change, however, is limited (Valente et al., 1998). Further research is needed to determine whether the KAP model is a useful one for understanding the impacts of media communication and what other models can or should be developed to understand media-generated behavioral change. Regardless of the steps that precede behavioral change, media communication has been found to influence behavioral change. In a series of meta-analyses, Snyder (2001) has discovered that media communication about health have been shown to create about an 8-percentage-point change in behavior. Media communication creates more change when it promotes the adoption of new behavior (condom promotion) than when it attempts to get people to quit addictive behaviors (tobacco use). Research by Flynn and colleagues (1992, 1994) also suggests that media campaigns combined with other strategies such as school smoking prevention programs are effective in changing behavior. Thus, although the mechanisms for their effectiveness are not entirely understood, the media play a vital role in assuring the health of the public in the twenty-first century. The top priority for the research agenda on the effect of media communication on health behavior is to conduct basic research on how the media influence individual health decisions as well as the public’s health (Logan et al., 1999). This research would attempt to understand how media commu-

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The Future of the Public’s Health in the 21st Century nications affect health-related behavior by understanding the steps to behavioral change and comparing different theories of behavioral change within a media intervention framework. A second priority is to determine which media vehicles should be used for which purposes to determine the most effective way to communicate health information to the public. Most research has been conducted with the understanding that the mass media is useful for raising awareness and driving the public agenda, but behavioral decisions are also influenced by interpersonal communication. The interaction between interpersonal communication and media messages, however, is not well understood (Valente and Saba, 1998, 2001). For example, do the media prompt interpersonal discussions that then set in motion a series of behavioral change steps? A third priority is to develop the evidence base for how health communication can better influence public policy. Research is needed particularly on the overall strategies of media advocacy and social marketing for effecting policy changes, in particular changes that may shape the social determinants of health. Research that can tease out the effects of media communication from community organizing and policy advocacy is also needed. Furthermore, a deeper understanding of which strategies are most appropriate and suited to which goals would be useful to public health practitioners. The committee recommends that public health and communication researchers develop an evidence base on media influences on health knowledge and behavior, as well as on the promotion of healthy public policy. CONCLUDING OBSERVATIONS In this age of information, there is good reason to acknowledge the potential of the mass media in assuring population health. Print and broadcast news media outlets, entertainment television, and the Internet constitute immensely influential channels through which people gather their information, accurate or not, about health. Given the speed and diversity of media outlets, they cannot be considered mere commentators in dialogues on popular culture about health, health risk, and health behaviors. They can foster and participate in informal interfaces (e.g., professional connections and contact points) and formal interfaces (e.g., fellowships and other cross-training for media and public health professionals) with academia. Also, the media and governmental public health agencies can enhance their understanding of each other’s methods and perspectives (e.g., through communication between health officials and journalists or reporters). It is time that media outlets acknowledge their role in the public health system, the strength of their influence, and their potential for assuring the public’s health.

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