Claudette G. Artwick, Ph.D.
August 2015
From live coverage
of open-heart surgery (Heussner, 2012) to the latest on Alzheimer’s disease
(Kolata, 2012), health information on Twitter is on the rise (Heussner, 2012;
Dugan, 2012). Doctors, politicians, and journalists are generating “tweets by
the millions” (Kenen, 2013), offering information with the potential to improve
health literacy and ultimately the nation’s overall health (Pearl, 2013). These social media conversations are taking
place in the midst of an effort to move the nation “from a focus on sickness
and disease to one based on prevention and wellness” (Benjamin, 2011, 3). But, at the same time, health coverage in the
mainstream media has come under fire for weaknesses that range from ignoring the
potential harms of a treatment to outright disease-mongering (Health News
Review, 2013).
As more reporters adopt Twitter into their
daily routines, will we see patterns from mainstream health coverage carrying
over to the social media platform? And
in this specialized field where many journalists are also medical doctors, how is news and information about health and
sickness framed? For journalists
overall, professional norms and practices are being “normalized” on Twitter (Lasorsa,
Lewis, & Holton, 2012) while also evolving into new forms (Hermida, Lewis,
& Zamith, 2012). What is the case
for health journalists? And is their
focus on disease and treatment, or on wellness and prevention? This study explores these questions by
examining Twitter content of 25 top-followed U.S. health journalists.
Health information and the Internet
More than seven in
ten U.S. Internet users look online for health information (Fox & Duggan,
2013), accessing resources ranging from government-supported websites like
MedLine Plus (2012) to doctor/journalist blogs such as CNN’s Sanjay Gupta (2012). Whether seeking information on Alzheimer’s in
one of 17 languages (alz.org, 2012) or participating in a Zoster discussion on
WebMD (2012), symptoms on a specific disease or treatment dominate Internet
users’ searches (Fox, 2011). People are
looking for help with their questions about health and sickness, with more than
a third of Internet users seeking information to self-diagnose (Fox &
Duggan, 2013). On social media, nearly
one-fourth of users have followed friends’ health postings on the network (Fox,
2011b). And the public and medical
professionals are managing care using online resources. Hello Health (2012) offers prescription renewal via email, online
scheduling, and video chat features. Another
such service, the virtual doctor’s office Sherpaa, examines patients via email
and texting (Stein, 2013).
Interest in online
health information extends to journalists who report on health, who generally
look upon these resources favorably. Nearly two-thirds of respondents to an
Association of Health Care Journalists’ member survey said the new platforms
for news such as blogs, multimedia, and enhanced features like transcripts and
longer interviews had a “mostly positive influence on health journalism…” (Schwitzer,
2009: 6).
Twitter and health
In 2012,
health-related tweets increased more than 50 percent (Heussner, 2012; Dugan,
2012). Along with the expanding Twitter
activity is a growing body of scholarship in this area. Researchers have built models to track
disease through Twitter (Paul & Dredze, 2011) and studied dissemination of
information on the social network related to antibiotics (Scanfeld, Scanfeld,
& Larson, 2010) and concussions (Sullivan, Schneiders, Cheang, Kitto, Lee,
Redhead, Ward, Ahmed, & McCrory, 2012). Teams have explored tweets about influenza
to detect epidemics (Aramaki, Maskawa, & Morita, 2011) and to assess disease
activity in real time (Signorini, Segre, & Polgreen, 2011). Studies have also explored the public’s tweets
on menstruation (Thornton, 2011), mammograms and pap smears (Lyles, López,
Pasick & Sarkar, 2013), and smoking cessation (Prochaska et al., 2012). And an examination of health care media showed
that more than a third of the tweets studied focused on the business of health (Matthews,
2013).
Doctors on Twitter: The international directory, Twitter Doctors (2013), lists more than
1,000 doctors and links to their Twitter profiles. The most popular include Dr.
Oz, who tops the list with 3.1 million followers, and Dr. Drew of HLN TV, with
3 million. Much of their Twitter content
pertains to the treatment of disease. An
examination of more than 2 million physician tweets showed that nearly half
related to treatment, with childhood diseases and diabetes topping the
discussion (Matthews, 2013). And research on 260 doctors showed nearly half of
the 5,000 tweets studied were health or medical related, and 12 percent were
self-promotional (Chretien, Azar, & Kind, 2011).
Tweets are also coming
out of operating rooms and medical-related government agencies. A Houston hospital live-tweeted open-heart
surgery (Heussner, 2012), with a cardiologist on hand to answer questions, and
photos preceded by warnings that the content might be graphic (TwitterMedia, 2012).
And The Centers for Disease Control and Prevention and director, Dr. Tom
Frieden (2013), host Twitter chats on topics ranging from eradicating polio to
emergency preparedness The chats were started in 2011 to “amplify CDC’s health
and safety messages” (Jones & Carey, 2012).
Social media use
has become so prevalent among physicians that the American Medical Association
(2010) posts its social media policy online, which highlights safeguarding
patient privacy and maintaining “appropriate boundaries.” Other resources include a book by Dr. Kevin
Pho that offers guidelines for physicians on managing their online reputations
(Chen, 2013).
Health reporters on Twitter: During the 2013 Association of Health
Care Journalists’ conference attendees posted hundreds of tweets per hour to
the hashtag #AHCJ13 (2013), including those coming out of a session on social
media reporting. Holcomb, Gross, & Mitchell (2011) found health reporters
to be more “interactive” than others; engaging followers in 6 percent of tweets,
and retweeting 22 percent of their tweets.
But as journalists adopt Twitter as a platform for communicating about
health, mainstream media health news has faced criticism from experts as well
as the general public. And in an
environment where journalists have been found to normalize Twitter (Lasorsa, et
al., 2012), concerns about deficiencies in mainstream health news reporting may
be carrying over to Twitter.
Health coverage in mainstream media
Consumers
perceive that the media sensationalize health news (Van Slooten, Friedman &
Tanner, 2013). And independent medical
experts and scholars are calling attention to other shortcomings
(healthnewsreview.org, 2013). An examination of 500 U.S. health news stories
showed deficiencies in 62-77 percent of the reports, including a failure to adequately
cover “costs, harms,
benefits, the quality of the evidence, and the existence of other options…” (Schwitzer,
2008: 701). And an analysis of 78 television news websites
showed that nearly 15 percent of stories included no attribution from health
sources (Tanner & Friedman, 2011). Earlier work showed half of the stories citing
an expert or scientific study included a source with a financial tie to the
drug being covered (Moynihan, et al., 2000).
Story ideas frequently
come from other news organizations, as shown by a nationwide survey of nearly
800 journalists (Len-Rios, et al., 2009).
Journalists working for national media were more reliant on scientific
journals for initial story ideas than were local journalists (Viswanath, et
al., 2008), and also showed differences in sources by media type.
Framing and health news
The way news is reported, or
framed, has been explored in relation to audience perceptions and
behaviors. Drawing from Goffman (1974:
24) “…we tend to perceive events in terms of primary frameworks, and the type
of framework we employ provides a way of describing the event to which it is
applied.” Journalists employ frames in storytelling, and included among the
body of research on framing and perceptions of news are studies focusing on
health news. Coleman, Thorson, &
Wilkins (2011) found stories with a thematic frame that included context and
prevention strategies related to readers’ support for improving their own
health behaviors. The framing of
obesity in news has also been documented.
An analysis of 500 obesity stories showed mentions of personal causes
significantly outnumbered attributions of societal responsibility (Kim &
Willis, 2007). Image framing of obesity
on national news websites showed “the majority (72%) of overweight and obese
individuals depicted in online news photographs were stigmatized.” The images highlighted bare stomachs and
lower bodies, were shot from the side or rear, and were often headless. (Heuer,
McClure, & Puhl, 2011:8). Obese and
overweight people in online news stories were also shown eating unhealthy
foods, wearing clothes that did not fit, and being sedentary (Puhl, Peterson, DePierre,
& Luedicke, 2013). Another study found obesity moving toward environmental
causes and away from biology and personal behavior (Lawrence, 2004: 69).
Another health
news frame highlights prescription drug treatments. Some suggest that coverage may be related to consumer
demand for the drugs presented:
“We do, though,
indirectly help market them by the kinds of stories we write, which can
stimulate demand. Stories touting the benefits of the latest gee-whiz drug,
coupled with ads by the drug maker, are powerful stuff” (Lieberman, 2008).
Moynihan, Heath, & Henry (2002: 886) argue that, “The
social construction of illness is being replaced by the corporate construction
of disease.” Campaigns that raise
awareness of diseases and conditions that are “widespread” and “treatable,” can
expand markets for pharmaceutical products. And companies market stories to the media
designed to create fear about a disease or a condition that can be addressed
with the latest treatment (Moynihan, et al., 2002).
Physician-journalists: Doctors who are also journalists face a
“delicate balance” in the conflicting requirements of the two professions
(Linden, 2011). As doctors, abiding by
the Hippocratic oath requires keeping patient information private, while
journalism strives to enlighten the public by disseminating information
(Linden, 2011). The potential for
exploiting patients by using them in stories has been raised as an ethical
dilemma for physician-journalists (Linden, 2011). Doctors’ relationships with the
pharmaceutical industry have also been highlighted as a conflict of interest (Ornstein, Weber, & Nguyen, 2010), as has
the potential influence of drug companies on journalists (Lipworth, et al.,
2012).
Twitter and journalism
In seven years, Twitter has grown from a side project (Williams, 2009)
to an information network that is “affecting the way news is gathered,
disseminated, and consumed” (Hermida, 2012, 2). More than 200 million
people, including 10,000-plus journalists, use Twitter (Sreenivasan, 2012; What
is Twitter? 2013). And mainstream news
media are attracting large numbers of Twitter followers, often exceeding their
circulation many times over (nytimes on Twitter, 2012).
Data show that the
majority of journalists are using this information network on the job (Oriella,
2011; Cision, 2010), linking to their stories, live-tweeting events, engaging
with their communities, and more, (Twitter for Newsrooms, 2012). While
research shows that journalists “normalize” Twitter to fit existing
professional norms and practices (Lasorsa, et al., 2012), it also indicates new
forms emerging, such as active participation (An, Cha, Gummadi, and Crowcroft,
2011; Sheffer and Schultz, 2010) and source diversification through @mentions
(Hermida, et al., 2012, Artwick, 2013).
Research questions
The study’s framework takes into account both the
“normalization” of mainstream news conventions on Twitter and the potential for
developing new practices. It also
recognizes the national strategy to improve health and quality of life
by “moving the nation from a focus on sickness and disease to one based on
prevention and wellness” (Benjamin, 2011: 3). And, is set within a mainstream news environment where health reporting has
generated a range of concerns—from deficiencies in coverage to potential
conflicts of interest—and where story frame can relate to consumers’
perceptions.
Within
this framework, the study asks the following about health journalists and
Twitter:
RQ1: How do health journalists on Twitter frame
health news? Is their focus on disease
and treatment or wellness and prevention?
RQ2: What do
health journalists’ tweets say about their reporting practices on Twitter?
RQ3: Are
characteristics including gender and whether a journalist is also a medical
doctor related to reporting on Twitter?
Method
Using
constructed-week sampling, the study analyzed 635 tweets from 25 U.S. health
journalists on Twitter. It selected for
analysis the Twitter accounts of the 25 most-followed U.S. health journalists
listed on the website MuckRack. MuckRack’s compilation of journalists on Twitter
has served as a source for sampling journalists who use the social network (Lasorsa,
et al., 2012). While other journalists
and non-journalists also tweet about health, this research focused solely on
journalists who specialize in reporting on health. It chose the most-followed health journalists
to help assure an active level of tweeting as well as identifying those
reporters in this specialization with the highest readership and potential for
impact.
The
period of analysis included August and September 2011. A sample week was constructed by randomly
selecting one Sunday from all available Sundays in that period, one Monday, and
so on. Constructed-week sampling has
been tested and used as a reliable method for sampling media content (Riffe,
Aust, and Lacy, 1993). All tweets from each journalist’s Twitter account were
collected for the following dates in 2011: August 6, 14, 17, and 29, and September
1, 2, and 13.
The
researchers collected the data by accessing the selected reporters’ Twitter
accounts and copying the sampled tweets into a Word document for numbering and
coding. Two research assistants coded
the tweets after pretesting the coding categories on a separate collection of
tweets.
Variables
Measuring framing: The following
variables are examined separately for frequency and together as
crosstabulations using Pearson’s Chi Square.
·
Topic - This
measures the major topic of the tweet.
Categories include: disease, drugs/drug business, healthcare/doctors/insurance,
diet/exercise, other health-related, non-health-related. (The original list contained 27 topics, and
was condensed to the six categories named above.)
·
Disease – Each
tweet is coded for mention of disease. Categories
include: heart, cancer, diabetes, stroke, arthritis/inflammatory, STDs,
insect-borne, cognitive (Alzheimer’s, dementia), mental illness, flu/colds,
obesity, allergies, contamination-related (e-coli, listeria), AIDS/HIV,
measles, kidney stones, asthma, dermatitis, Sjogren’s, other disease, not
disease. For more than one disease, the
first mention is coded.
·
Frame –
The tweet focuses on: prevention, treatment, other health-related, other
non-health.
Measuring reporting practices:
·
Link – The
variable measures the links in reporters’ tweets. Categories include: none, reporter’s own
content, content by other staff in the reporter’s news organization, other news
organization content, official content (politician, public employee, non-phamaceutical
business), citizen, government agency, independent health organization,
university scientist/researcher, health care provider, journal article, private
foundation, pharmaceutical company or spokesperson, journalism industry,
entertainment, other, can’t tell (broken link), and multiple links.
·
Retweet – The
categories for retweets are the same as listed above for links.
·
Live – This
measures whether a tweet is covering something as it is happening. Categories include: not a live event, planned
event, breaking news, other.
·
Engaging
with public – The reporter is: participating in a chat, asking a question
of all followers (not in chat), sending @mention (not in chat), retweeting a
follower’s message (not in chat), not interacting with public.
Measuring journalists’ characteristic: These variables are measured for
frequency and also crosstabulated with variables from the above categories.
·
Reporter
gender – The sender of each tweet is coded as male or female.
·
Reporter
MD – The reporter is or is not a medical doctor.
An intercoder
reliability test on 10 percent of cases yielded a 93 percent agreement and Cohen’s
Kappa reliability coefficient of .84. Cohen’s
Kappa and percent agreement for each variable indicate acceptable levels of
reliability (Lombard, 2010; Krippendorff, 2004): topic=.89, 91.8%; disease=.68,
91.8%; frame=.78, 86.9%; link=.94, 96.7%; retweet=.74, 90.2%; live=undefined,
100%, engage=.87, 93.4%. The researcher assigned
gender and reporter medical doctor values to each tweet based on reporter
Twitter profiles.
Results
Two-thirds of the 635
tweets analyzed focused on a health-related topic. Prescription drugs and the medical industry
dominated the discussion, accounting for 35.8 percent of the health-related
tweets. Next in prevalence (29.4
percent) were tweets on specific diseases.
And only 10 percent of health-related tweets featured diet or
exercise.
RQ1 asked how health journalists on
Twitter frame health news, and the results show a predominant treatment frame
for tweets about disease (46.4 percent).
Only 17.6 percent of disease-related tweets were framed as prevention. The rest were neither treatment nor
prevention, but focused on growing epidemics, celebrities, or other terms. The findings also revealed differences in
framing by disease, with a focus on prevention for heart disease and treatment
for mental illness.
RQ2 asked what health journalists’
tweets say about their reporting practices on Twitter. The journalists used links to share their own
news organization content as well as to connect users to other sources of
information. A substantial number of tweets, 42.4 percent, linked to external
content, including government reports, health websites, and other news
organization content.
The data also show
that the journalists retweeted information originating outside their own
newsrooms. Other news organization
content accounted for 23.6 percent of retweets, researchers’ content, 22.1
percent, and citizens’ tweets, 18.1 percent.
About 11 percent of
tweets were generated during live events—specifically chats the journalists
organized and participated in.
The majority of
the journalists’ tweets were interactions, and of those, 70 percent were
@mentions, including 13.6 percent RT@ tweets.
RQ3 asked if gender or being a medical
doctor related to the way health journalists reported using Twitter. The sampled tweets came from 10 male and 15
female journalists. The men tweeted more than the women, sending an average of
36 tweets each for the constructed week, while each woman averaged 19. Prescription
drugs and the pharmaceutical industry dominated the men’s conversations (48
percent of their health-related tweets), while the women focused on other
health-related topics (34 percent), from the prevalence of diabetes to Venus
Williams living with Sjogren’s syndrome.
About half of the men’s tweets and one-fourth of the women’s focused on
disease. Overall, nearly two-thirds of
tweets about disease used a treatment frame (64.4 percent). This skewed male, as they framed 60 percent
of disease tweets as treatment. The women associated disease with treatment in only
11.4 percent of theirs.
One-fifth of the
journalists were also medical doctors.
The MDs tweeted more than the other journalists, averaging 35 and 23 tweets
respectively. They also focused on
disease in 69.3 percent of their health-related tweets, versus only 12.4 percent
for the other journalists. Those who were not doctors focused on drugs and the
pharmaceutical business in 48.7 percent of their health-related tweets, while
the physician-journalists did so in only 5.5 percent of theirs. Topic was significantly related to whether a
journalist was a medical doctor (X2=167.735, N=635, P<.001).
The medical
doctors also focused on treatment in their tweets more than the non-MDs. A
Chi-Square test revealed a significant relationship between frame and whether a
journalist was a medical doctor (X2=76.804, N=635, P<.001).
Discussion
The health
journalists’ tweets examined in this study suggest that some of the weaknesses
in mainstream health coverage are being carried over to Twitter. But at the same time, the journalists appear
to be adopting the platform to interact with the public, for live coverage, and
to share information beyond their own newsrooms. So, while the data point to a “normalization” of professional
practices on Twitter (Lasorsa, Lewis, & Holton, 2012) for health
journalists, they also suggest that new forms (Hermida, Lewis, & Zamith,
2012) also appear to be evolving.
What does this
mean for the framing of health news? The findings indicate a focus on disease
and treatment over wellness and prevention.
However, the journalists framed their tweets differently depending on
the diseases they were writing about, their gender, and whether they were also
physicians.
The majority of
heart disease tweets were framed as prevention, largely highlighting Dr. Sanjay
Gupta’s documentary “The Last Heart Attack,” which explored the impact of diet
and lifestyle on hearth health. And more
than half of the tweets on sexually transmitted diseases were framed as
prevention, largely due to discussions on the HPV vaccine. A treatment frame, on the other hand,
appeared in 8 of 10 tweets on mental illness.
The bulk of those tweets came out of a live Twitter chat about
depression with ABC News Chief Medical Editor Dr. Richard Besser. And while most touched on therapy, issues
related to stigma, family, and resources for getting help were also discussed. So, even though prevention was not an
emphasis, the chat featured a strong educational component. Most of the tweets about cancer were neither
prevention nor treatment, as they focused primarily on a study that revealed
cancer in firefighters who responded to the 9/11 attacks.
Men framed the
majority of their tweets about disease as treatment, while women did so
minimally. For the prevention frame,
none of the men’s tweets focused on diet and exercise, while nearly one-fourth
of the women’s did. But for both men and
women, this topic was largely framed as neither prevention nor treatment.
The findings also
showed differences in tweets for journalists who were also medical doctors. In
addition to tweeting more frequently, the MDs focused on disease in nearly 70
percent of their health-related tweets, versus only 12 percent for the other
journalists, who instead covered drugs and the pharmaceutical business. The medical doctors also focused on treatment
in their tweets more than the non-MDs. A general discussion of treatment during
a Twitter chat on depression accounted for the bulk of these tweets. But the
doctors never discussed diet or exercise in a prevention or treatment context,
while the other journalists did so more than one-fourth of the time.
Prescription drugs
and the drug business were also framed differently by journalists and
physician-journalists. The doctors used
a prevention frame for a majority of those tweets, versus about 12 percent for
the other journalists. This suggests the
doctors equated drugs with prevention while the non-MDs focused more on the
business of drugs.
The journalists in
this study also used Twitter to share content from their own newsrooms, other
news organizations, and other sources. More
than four out of ten tweets linked to external content, which is remarkably
similar to other findings on journalists and linking (Lasorsa et al., 2012; Artwick,
2013). And nearly a third of those links
connected to other news organization content, which aligns with mainstream news
findings in which health journalists relied on other news media for story ideas
(Len-Rios et al., 2009). In essence, the
links were directing the Twitter followers to read stories covered by other
news media. But they also sent followers
to scientific reports and government agency information in nearly one-fifth of
links.
In a more
traditional function, Twitter served as a platform to disseminate the health
journalists’ own news organization content. Four in ten links connected the
reader to the journalists’ stories or those generated by colleagues in their
own newsroom. While this may appear
somewhat high, the figure is considerably lower than the 93 percent found on
major news organization’s Twitter feeds (Holcomb, Gross, and Mitchell, 2011),
and 58 percent among metro reporters (Artwick, 2013). This suggests that health journalists are
directing their readers to not only their own content, but to a broader base of
information in their network of health news sources.
The same appears
to be true for retweets in the health journalists’ Twitter streams. What stands
out here is that Twitter appears to facilitate the dissemination of information
health journalists receive from other journalists, researchers, and the public
through the retweet function. Instead
of, or in addition to, using those sources to develop their own stories, the
health journalists can share them with followers immediately, without the need
to further write or report.
The platform also
lends itself to live event coverage, and to interaction with through chats with
experts and the public. The majority of
the journalists’ tweets were interactions, including @mentions and retweets. So, not only did they communicate
semi-privately via @mentions, they also shared those conversations more widely
by retweeting them to all followers.
Documenting
content is the first step toward understanding how health journalists and their
use of Twitter may impact health literacy and ultimately the nation’s overall
health. The major limitation of content
analysis is that it does not measure effects. Moving forward, future studies would explore
exposure to and meaning-making from health journalists’ tweets.
Conclusions
The data analyzed in
this research showed that the 25 most popular U.S. health journalists on
Twitter focused largely on disease and treatment over wellness and prevention
in their health-related tweets. But at
the same time, they interacted through live chats and retweeted conversations
with followers, offering the potential to convey prevention strategies and improve
health literacy. Given the public’s
thirst for health information online (Fox & Duggan, 2013), these
interactions provide yet another avenue for acquiring that knowledge. As a whole, the findings suggest that journalists
are carrying some mainstream media practices over to Twitter, while also
adopting social-media-specific engagement and communication in health news
journalism.
The
findings also revealed interesting distinctions between physician-journalists and
non-MDs and differences related to gender.
Disease dominated the doctors’ Twitter streams while the non-MDs focused
more on drugs and the pharmaceutical business.
When doctors tweeted about drugs, it was largely through a prevention
frame. They never mentioned exercise or
diet in terms of prevention, but instead associated disease prevention with
drugs. Women journalists, on the other
hand, did discuss prevention in about a fourth of their diet and exercise tweets.
Overall, amidst a
national effort to direct the nation away from a focus on disease toward prevention
and wellness (Benjamin, 2011), the health journalists’ Twitter streams in this
study suggest little movement in that direction. However, while the tweets as a whole
presented a focus on disease, treatment, and the pharmaceutical industry, a
closer look at specific diseases did reveal some emphasis on prevention and
education. These tweets are noteworthy considering
the potential to improve health behaviors through context and prevention frames
(Coleman, et al., 2011).
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