Jessie Daniels, Barbara Glickstein and Diana J. Mason “Whoever controls the media—the images—controls the culture.” —Allen Ginsberg In February 2007, then United States Senator Barack Obama (D-IL) had a conversation with Marc Andreessen, a founder of Netscape (one of the original browsers, pre-dating Google) and member of the board of directors of Facebook. The conversation was about using social media to build a political campaign that could upset frontrunner Hillary Rodham Clinton in the Democratic primary election for the U.S. presidency. In 2004, presidential candidate Howard Dean had used a viral Web strategy to build a campaign war chest through small donations from large numbers of people. Obama had a vision for building upon Dean’s success, and he hired Chris Hughes, another founder of Facebook, to manage his presidential campaign’s social media effort. David Axelrod, Obama’s top adviser, was formerly a partner in ASK Public Strategies, a public relations firm. Together, Hughes and Axelrod built a team that marshaled every tool in the social media and marketing tool box to create and sustain the Obama campaign and brand. They launched an expert viral marketing campaign including: Obama ringtones, product placement (Obama ads in sports video games), and a 30-minute infomercial that was played on YouTube. The campaign’s effort spawned additional digital videos as well, including the “I Got a Crush…On Obama,” video and the celebrity-filled video called “Yes We Can,” featuring Black-Eyed Peas front man Wil.I.Am, both of which went viral, spreading to millions of viewers in just days of being posted online. The Obama campaign led competitors in using social media to connect with a growing audience of followers on Facebook, Twitter, MySpace, and blogs. In the general election, he had 118,107 followers on Twitter, outpacing his opponent John McCain’s 2865 followers by a factor of 40 to 1 (Lardinois, 2008). Obama used social media to build a grassroots movement that resulted in his historic election (Talbot, 2008). But he knew that the use of social media is not simply a campaign technique—it’s a way of interacting, building an activist community, and engaging people in ways that matter to them. As president, he quickly launched www.change.gov for people to share their ideas for reforming the country, sending the message that he had no intention of regressing to a traditional media operation as president. Rather, he was going to continue to engage people in supporting his agenda for the nation. When health care reform was teetering from a growing army of discontents blocking its passage, he continued using social media to mobilize supporters to pressure Congress to act before the April 2010 recess. President Obama also took to the road and held town meetings in key communities because he knew that these town meetings would garner reports on primetime television, radio coverage, and front page position in newspapers. He could count on the primetime news including a sound bite and visual image of him speaking before a crowd of enthusiastic Ohioans, cheering for passing some form of health care reform legislation. The personal appearances were a way to get his message to those who were not yet social media mavens and to reinforce it with those who were already his followers on Twitter and Facebook. The Web has dramatically changed how we think about communicating with others, whether to connect with family or build a grassroots political movement to push policymakers to pass new laws. Even traditional media outlets are now augmenting their work with all sorts of social media to extend their reach and impact. Legislators are launching blogs, using Facebook, and “Tweeting” to make their voices heard and connect with their constituents. In fact, engaging citizens in government is reshaping the way government works. This chapter looks at the integration of traditional and social media as powerful tools for nurses to harness in shaping health policy and politics. There has been a seismic shift in the way media is created and distributed. For many years, the dominant paradigm in media was a model in which one broadcaster sent a message out to a mass audience. This broadcast model is referred to as “one-to-many.” Today, this model is being challenged by the advent of the Internet and user-generated-content in which many people create media and distribute it to their networks. This new model is sometimes referred to as “many-to-many.” Traditional media in radio, television, film, and newspapers was based on the idea that one broadcaster would try to reach as many audience members as possible. But for those interested in influencing health policy and politics through the media, there were many advantages and some significant disadvantages to the one-to-many model of broadcast media (Abramson, 2003). Radio, film, and television have all been used to communicate messages about health to consumers and policymakers alike. What all these media share is the ability to broadcast a message to a mass audience, sometimes in the millions or tens of millions. When there were very few media outlets, it was possible to broadcast a consistent message to a wide audience. The use of mass media has been a major tool in health promotion campaigns because it reaches a large audience. Media is a powerful tool that is capable of promoting healthy social change (Whitney & Viswanath, 2004). There are also disadvantages to mass media communications. Large corporations own media outlets and control what goes out through their channels. The expense of buying time or space in major media outlets can be prohibitive, especially for non-profit organizations. Mass media campaigns, by definition, are intended to reach a wide audience but are not as effective at reaching specific, target populations. For example, a mass media campaign about HIV prevention may reach a wide audience but may fail to reach the specific population that is most vulnerable to infection. However, political operatives have developed increasingly sophisticated approaches to segmenting and targeting specific electoral districts with mass media when they want to pressure a policymaker who may hold a deciding vote on an important bill. They buy commercial time on the dominant television station in that policymaker’s district. But what no form of mass media does very well (or, at all) is to allow users to create and distribute their own content with messages they find most important. The rise of the Internet, and specifically websites that rely on users to generate content, are part of a new landscape of media creation and distribution. The early Internet featured “brochure” websites that were one-way flows of information. The paradigm-shifting quality of the Internet began to emerge with the rise of Web 2.0 (pronounced: “web two point oh”), a term coined by Tim O’Reilly (2005) at a conference in 2004. Web 2.0 refers to a range of web-based Internet practices based on information sharing, social networks, and collaboration rather than the one-way communication style of the early era of the Internet. The key idea with the concept of Web 2.0 is that people are using the Internet to connect with other people, through their old face-to-face networks and through newly formed online networks. “Prosumption” is another way that some people talk about this shift. Prosumption is the idea that “producing” and “consuming” are combined in this new many-to-many paradigm. Rather than an elite few who “produce” media for a mass audience to “consume,” now we are all both “producers” and “consumers,” or prosumers of media. The many-to-many paradigm does not refer to a new form of technology but rather a new way that everyday people make use of that technology (Ritzer & Jurgenson, 2010). The collaborative, information-sharing Internet practices have broad implications for health media, policy, and politics, but they do not mean the end of mass media. A classic example of the power of media in shaping health policy arose during the first months of William Jefferson Clinton’s presidency, when he tried but failed to enact health care reform legislation despite campaigning on a policy platform that sought to guarantee comprehensive health care coverage for every American. In September 1993, he proposed the Health Security Act to Congress and the public with the hope and anticipation that this would become landmark legislation. Clinton’s proposal initially had substantial public support, because many believed the country had a moral imperative to extend health care coverage to all who live here. However, according to an analysis by the Annenberg Public Policy Center of the University of Pennsylvania (1995), one of the top factors that unraveled the legislation’s progress was the “Harry and Louise” campaign (a series of television advertisements about two curious characters, Harry and Louise), which was sponsored by the Health Insurance Association of America (HIAA), an ardent opponent to the president’s plan. Actors portrayed this couple voicing grave concerns about the bill. They said, “Under the President’s bill, we’ll lose our right to choose our own physician,” and “What happens if the plan runs out of money?” Although the advertisements were not the only reason for the demise of the Health Security Act, the Harry and Louise television spots effectively planted fear and negativity in the hearts and minds of many citizens within the span of 60 seconds. Suddenly, many of the Americans who had been concerned about the growing numbers of uninsured became more concerned about how the bill would affect their own health care options and withdrew their support from the Act. What many do not realize about the Harry and Louise ads is that the target audience was not the public, directly. Rather, it was policymakers and those who could influence how the public perceived the issue: journalists. The ads originally aired in the country’s major media centers: Washington, DC; Los Angeles; New York City; and Atlanta. They were seen and reported on by journalists. In fact, the ads got more airtime by becoming part of the journalists’ news stories. Many people who saw the ads did so through viewing them as part of the evening news, not as a paid advertisement. The Harry and Louise commercials are an example of a deliberate media strategy to reframe a public policy issue and mobilize a public constituency around it. It is one illustration of the power of the media in policy and politics. The media saturate this nation and much of the world with images that change people’s opinions, shape their attitudes and beliefs, and transform their behavior (McAlister, 1991). In today’s media landscape, the Harry and Louise television ads would also be posted on YouTube for millions more to view. Bloggers would include links to the video, as would people who write about it on their Facebook or Twitter pages. Yet, the current media landscape would also spawn critical analyses of the ads by bloggers and unmasking the HIAA and their motives, potentially limiting the impact of the ads. Media campaigns such as these often rely on cloaked websites to enhance the effectiveness of their deception. Cloaked websites are published by individuals or groups who conceal authorship in order to deliberately disguise a hidden political agenda (Daniels, 2009). Consider an ad from the more recent, successful effort to pass the Affordable Care Act of 2010. During this political battle, an unknown political group with no clear affiliation to a political party created a video opposing the reform. In the ad, a variety of attractive-looking people declare, “I guess I’m racist” because they oppose health care reform. The central message of the video, although not immediately obvious, was a signal that a growing number of people opposed Obama’s policy on health care reform but that opposition was not rooted in any individual racism. The video had fairly high-quality production values, meaning it looked professionally produced and good enough to appear on broadcast television; yet, it was released exclusively on YouTube. The provocative video quickly went viral (meaning it was very popular and links to it spread via e-mail and blogs from person to person, much like a biological virus). Within 24 hours, it was one of the most viewed videos on YouTube—no small accomplishment among the millions of videos on the site. Once again, the political operatives behind this video did not have to buy airtime on television to get their message out. After the video became the top video on YouTube, several mainstream broadcast news media outlets re-aired it on television. Some of these were critical of the video, such as the Rachel Maddow Show on MSNBC, but the fact is that what started as a YouTube video was featured on several broadcast television shows within 24 hours. Health care reform legislation did eventually pass despite these types of campaigns. Yet, this instance of converging media1 illustrates just how sophisticated the use of multiple forms of media has become. The traditional media industry has been owned by six major corporations that, prior to the growth of social media, controlled 90% of the news Americans read, saw, or heard (Harris, 2005). In 2003, the Federal Communications Commission (made up of political appointees reflecting the then-dominant Republican party’s values) voted to ease the restrictions on cross-ownership between different news entities, permitting one corporation to own the primary television, radio, and newspaper outlets in a community, thus enabling one corporation to control messages and put forth a particular perspective. CNN founder Ted Turner objected to this consolidation of corporate media power, arguing that allowing this cross-ownership “will extend the market dominance of the media corporations that control most of what Americans read, see, or hear” and “give them more power to cut important ideas out of the public debate” (Harris, 2005, p. 83). Today, social media can actually drive traditional media to cover issues that major newsrooms may not deem worthy of their limited space and time. On June 12, 2009, Iran held its presidential elections between incumbent Mahmoud Ahmadinejad and rival Hossein Mousavi. The result was a landslide victory for Ahmadinejad; yet there was strong suspicion of voting fraud. This led to violent riots across Iran and protests worldwide. As protests erupted in the streets of numerous cities in Iran and in some cases turned violent, major broadcast media in the U.S. had almost no news on these events at all. Americans and others around the world and in Iran used the Twitter hashtag (e.g., a # symbol used to group messages on a specific topic) “#CNNfail” to track and share updates on what was happening in Iran that were pouring in from around the world. Twitter was the best source of information for second-by-second updates and breaking news on what was happening in Iran. People on-the-ground and across the globe chatted about the news out of Iran fed by social media more than mainstream news divisions. YouTube was a central distribution medium for the Iran riots with videos shot by people on the ground using their cell phones and small handheld cameras. The blogosphere was far quicker with news and multimedia from Iran then traditional news, illustrated by the spectacle of highly paid cable news anchors reading Twitter and blog updates on the air as part of their “reporting” a story. The social media photo site Flickr was quickly filled with gut-wrenching imagery from the ground showing photos of beatings, protests, and military action. This groundswell of news from and about Iran spread globally and nearly instantly through social media turned into a news item itself and was reported on by all traditional media outlets. Eventually, the focus shifted and CNN and other news outlets started covering stories about Iran. This example illustrates the power of social media to offset the corporate takeover of traditional media. This bodes well for nurses who have not always been able to garner media attention for their issues. Two studies during the 1990s documented nursing’s invisibility in the media (Buresh et al., 1991; Sigma Theta Tau International, 1998). Commissioned by The Honor Society of Nursing, Sigma Theta Tau International, the Woodhull Study on Nursing and the Media found that nurses were included in health stories in major print media (newspapers and news magazines published in September 1997) less than 4% of the time, even when they would have been germane to the story. An even more disturbing finding was the fact that nurses were represented in health care industry publications (such as Modern Healthcare) less than 1% of the time. Buresh and Gordon (2006) suggest that findings such as these could be a systematic journalistic bias against nursing. But they also note that nurses have not been proactive in accessing traditional media. Social media provides an opportunity for nurses to not wait for traditional media to value their perspectives. Instead, nurses can use social media to create and distribute messages and to engage others to care about an issue and discuss it from various vantage points. But will nurses seize this opportunity? On March 15, 2010, Medical, Marketing & Media, a monthly business publication for health care marketers, published the results of an online survey on nurses’ and physicians’ use of social media (Arnold, 2010). The survey found that only 11% of nurses said they used Twitter and 77% had visited Facebook. The authors noted that this was about one year behind the general population. If nurses want visibility, they must become cyberactivists,2 fusing the old and new media methods to allow for the widest range of engagement of the public. Nursing organizations are particularly well-positioned to mount focused social media campaigns because they already have a list of people who can begin the viral spreading of messages. But the social network lines are getting crowded; and establishing a reputation for reliable, important information that others want to regularly take note of requires a thoughtful strategy. Distributed campaigns are increasingly a part of a political strategy, whether for winning an election, getting an issue on policymakers’ or the public’s agenda, or garnering support for a new policy initiative. Obama’s social media campaign strategy is called a distributed campaign—a bottom-up rather than a top-down approach to political campaigns that depends upon viral spreading from the grassroots rather than message broadcasting and control by the campaign staff (Ozimek, 2005). These campaigns are designed to involve more than core supporters. They seek to engage swing voters, provide opportunities for core supporters to craft messages that may appeal to these swing voters more effectively than messages created by central campaign staff, and thereby strengthen the commitment of core supporters to the campaign. E-mail, blogs, and various other social media venues are used by campaign staff to begin a dialogue that is subsequently taken over and developed by a broad community of supporters. Whether people are reached by e-mails, Facebook or Twitter updates, or other means, distributed campaigns provide people with tools for activism, such as petitions to sign, e-mail scripts to send, or letters to sign and send to legislators. Organizations such as Democracy In Action (http://salsalabs.com/democracyinaction) are available to help build the capacity of groups that want to develop action tools that reach diverse audiences in distributive campaigns. Living in a media-saturated world can sometimes feel like being in a cacophony of conflicting voices. The challenge is how to use these powerful tools most effectively as the media model changes. One of the most important roles that media plays is getting issues on the agendas of the public and policymakers. What the mainstream media do or do not cover is equally powerful in determining what issues are considered by policymakers. The news media are instrumental in getting issues onto the agenda of policymakers, but non-news entertainment television programs can mobilize public constituencies around an issue. Television continues to be the dominant form of media in most people’s lives, despite the rise of new forms of media online. The television is on more than 8 hours a day in the average American household (Nielsen Reports, 2007). Teenagers still spend more time watching TV than they do online (Generation M2, 2010). The Internet may be where people go to find out about a health issue, but they often first become aware of the issue through television. Turow (1996) points out that non-news television entertainment is particularly loaded with rhetoric that often stereotypes power relationships and may be more successful than the news in shaping people’s images of the world. Highly viewed TV presentations of health care hold political significance that should be assessed alongside news. Medical and nursing dramas on broadcast and cable television, such as Grey’s Anatomy, ER, and Nurse Jackie, are often important sources of information about health and health policy for a wide audience. Researchers Turow and Gans (2002) systematically evaluated one television season of four hour-long medical dramas and found that health care policy issues appeared regularly in the programs. Evidence from a national telephone survey indicates that the percentage of regular viewers of the show ER who were aware that HPV is a sexually transmitted disease was higher (28%) one week after viewing an episode of the show about HPV than before seeing the show (9%). Even 6 weeks after viewing the episode, 16% had retained this knowledge. This capacity to quickly get a message out to millions of people through an hour-long drama is part of the reason that many health advocates work to get their particular issue included in a storyline of a major network drama. For many working in public health, storyline placement is considered the “gold standard” for achieving advocacy goals. Perhaps not surprisingly then, when National Institutes of Health (NIH) wanted to get out a message that “drug addiction is a brain disease,” they turned to HBO. In a landmark collaboration between HBO, the NIH, and the Robert Wood Johnson Foundation, the cable network launched The Addiction Series (2007), an award-winning collection of documentary films about substance use, each by a leading director. Of course, The Addiction Series also included a website with more information about treatment options and a lively discussion board (Bauder, 2007). Documentary films, in conjunction with online campaigns, are influencing health policy and politics, while achieving mainstream commercial success. For example, Morgan Spurlock’s Super Size Me (2004) explored the health impact of fast food on childhood obesity, fueling changes in local school and community policies requiring posting of calories in fast food stores, changing the foods and beverages available in schools, and ramping up exercise options in schools. Michael Moore’s documentary SiCKO (2005) examined health care policy in the U.S., helping to raise the public’s awareness of how bad the U.S. health care system had become at a time when health care reform was on the nation’s agenda. Many of those who were uncertain about whether or not health care reform was needed became converts after watching SiCKO. For some media activists concerned with health policy, Internet technologies have transformed documentary films into just one element in a multimodal social action campaign. Perhaps the archetypal example of how media is converging across multiple platforms and creating change in awareness about health and galvanizing movement for policy change around an important health issue is the development of Food, Inc. (2008). In 2001, journalist and filmmaker Robert Kenner read Fast Food Nation, a book by Eric Schlosser about the rise of agribusiness, and Kenner was appalled. He wanted to do something about the industrialization of the food supply, so he started work on the documentary that would eventually become Food, Inc. Kenner collaborated with Schlosser on the film (Schlosser is listed as co-producer). The online presence for Food, Inc. (http://www.foodincthemovie.com) is a vast repository of further information about the issues surrounding the industrialization of food. It includes opportunities to participate in activism, such as signing the online petition to reauthorize the Child Nutrition Act, which would support healthy food choices in schools. The film also inspired another book (Food, Inc.), an e-version that can be downloaded at the website, or a hard copy can be ordered from online booksellers. The social action campaign around Food, Inc. started with a heavily researched book and became a documentary film, a website, another book, and links for people to take action. This exemplifies how people are converging media to shape health and health policy. Media can promote health in three ways: public education, social marketing, and media advocacy. The first two are often used to help people change their health behaviors by acquiring important information that they lacked (public education) or through visual or verbal messaging that can shift the individual’s thinking, attitudes, and values (social marketing). Both of these can also be used to shape public policy and in political campaigns, but media advocacy specifically targets public policy. Media advocacy is the strategic use of media to apply pressure to advance a social or public policy initiative (Dorfman, Wallack, & Woodruff, 2005; Jernigan & Wright, 1996; Wallack & Dorfman, 1996). It is a tool for policy change—a way of mobilizing constituencies and stakeholders to support or oppose specific policy changes. It is a means of political action (DeJong, 1996). It differs from social marketing and public education approaches to public health, as noted in Table 10-1. Media advocacy defines the primary problem as a power gap, as opposed to an information gap, so mobilization of stakeholders is needed to influence the development of public policies. TABLE 10-1 Media Advocacy Versus Social Marketing and Public Education Approaches to Public Health Adapted from Wallack, L., & Dorfman, L. (1996). Media advocacy: A strategy for advancing policy and promoting health. Health Education Quarterly, 23 (3), 297. Copyright 1996 by Sage Publications. Reprinted by permission of Sage Publications.
Using the Power of Media to Influence Health Policy and Politics
Seismic Shift in Media: One-to-Many and Many-to-Many
Mass Media: The One-to-Many Model
Many-to-Many: User-Generated Content and the Rise of the “Prosumer”
The Power of Media
Who Controls the Media?
Distributed Campaigns
Getting on the Public’s Agenda
Media as a Health Promotion Tool
Media Advocacy
Media Advocacy
Social Marketing and Public Education
Individual as advocate
Individual as audience
Advances healthy public policies
Develops health messages
Changes the environment
Changes the individual
Target is person with power to make change
Target is person with problem or at risk
Addresses the power gap
Addresses the information gap
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