Toxic. Firearms. Sexual. Motor. Illicit Use. Activity. Agents. Agents. Behavior. Vehicle of Drugs ... tort the portrayal of the leading causes of death and their risk ...
Relative Risk in the News Media: A Quantification of Misrepresentation Karen Frost, MPH, Erica Frank, MD, MPH, and Edward Maibach, PhD
Introduction Although the news media's representation of health risk information is often lamented, the extent to which the media distort the causes of mortality has never been adequately quantified. The American public depends on news media for reliable health information.1-3 Previous studies, however, indicate that the public has a skewed perception of relative mortality rates." Biases such as the overestimation of infrequent causes of mortality and the underestimation of frequent causes may be, in part, attributable to the media's misrepresentation of mortality.5 The print news media exert an agenda-setting function7 in that issues reported in the media are more likely to be seen as important and meritorious of public discourse.8-1 Amount of copy space is an important indicator of perceived newsworthiness.7 A limited number of previous studies have investigated disproportionate reporting of mortality; however, they either failed to quantify the disproportion,3 used extremely limited samples,'2 or are outdated.12 The current study employed content analysis to compare representations of mortality in national print media with actual mortality and risk factors for mortality in 1990.
Methods The World Almanac and Book of Facts 1992 was used to determine the 1990 circulation figures for periodicals in the following categories: weekly news magazines; general interest women's magazines; general interest monthly magazines; and daily newspapers.'3 The publication with the widest circulation in its category was selected to represent that category. The following publications were selected: Time (weekly news magazine, circulation 4 094 935); Family Circle (general interest women's magazine, circulation 5 431 779); Reader's Digest (general interest monthly magazine, circulation 16 264 547); and USA Today (daily newspaper, circulation 1 347 450). A random sample of 12 issues of each periodical from 1990 (except for Reader's Digest, all
issues of which were used) was selected for analysis. Each of the periodicals was coded f4.mortality-related text (measured in sare centimeters) based on definitions of the nine leading risk factors for death'4 and the 11 leading causes of death'5 in 1990. Only text involving mortality of Americans was eligible for coding. Advertisements (including classifieds), photographs, obituaries, fiction, and text about war were excluded. All other text, including relevant photograph captions, tables of contents, and magazine covers, was considered eligible. Causes of mortality were coded in all instances where they were mentioned. The sentence in which the mortality cause appeared was considered the least measurable unit; for example, when an article contained only one sentence referring to a cause of mortality, that sentence alone was measured for analysis. To be coded as a discussion of a risk factor, text must have clearly stated that the mortality was due explicitly to a risk factor or must have implied or stated the potential for mortality at some time in the future due to the effects of the risk factor. When necessary, selections were coded under more than one heading. For example, text regarding an instance of lung cancer stated to have been caused by smoking cigarettes was classified as an issue involving both malignant neoplasms and tobacco. When a cause of or risk factor for mortality appeared in a title, both the title and the accompanying text were measured in full; this was likewise the case when a title included the word "death" or some variation thereof, as in "Twenty Confirmed Dead in Accident" or "Lethal Injections Claim Lives of Two." Titles were otherwise not coded, and full Karen Frost and Edward Maibach are with the Emory University School of Public Health, and Erica Frank is with the Department of Family and
Preventive Medicine, Emory University School of Medicine, Atlanta, GA. Edward Maibach is also with Porter Novelli, Washington, DC. Requests for reprints should be sent to Erica Frank, MD, MPH, Department of Family and Preventive Medicine, Emory University School of Medicine, 69 Butler St, Atlanta, GA 30303-3219. This paper was accepted July 29, 1996.
May 1997, Vol. 87, No. 5
Publc Health Briefs
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CAUSES OF MORTALITY
Note. COPD = chronic obstructive pulmonary disease; RR = relative risk. Source. Actual mortality percentages are from the National Center for Health Statistics.15
FIGURE 1-Percentages of actual mortality (shaded bars) vs copy devoted to mortality (unshaded bars) in print news media, by cause of death, 1990.
articles were otherwise dissected for relevant passages. A single investigator iteratively coded all of the content; as protocol modifications were made, all previously coded material was recoded. A second individual independently coded a randomly selected subsample of periodical content to determine interrater reliability; approximately 10% of the material was double-coded in this manner. With 58 matches out of a possible 69, interrater reliability was determined to be 84.1%. These matches were then compared with regard to square-centimeter measurements and were ranked according to percentage of disagreement. The median percentage of agreement was 92.8%. For every cause of and risk factor for death, a risk ratio was calculated to compare the proportion of actual deaths attributable to the cause with the proportion of copy accorded to the cause.
May 1997, Vol. 87, No. 5
Results There were substantial disparities between actual causes of death and the amount of coverage given those causes in the print media. For most causes of and risk factors for death, there was a substantial disproportion between the amount of text devoted to the cause and the actual number of deaths attributable to the cause (Figures 1 and 2). Most underrepresented by the news media were tobacco use (which received 23% of expected copy), cerebrovascular disease (31%), and heart disease (33%). Illicit use of drugs (1740%), motor vehicles (1280%), toxic agents (1070%), and homicide (733%) were most overrepresented.
Conclusions The amount of print media devoted to certain causes of mortality is impres-
sively disproportionate to the actual number of deaths attributable to those causes. While a few risk factors (alcohol, firearms, diet, and sexual behavior) and one cause of mortality (suicide) were reported at a frequency proportionate to their occurrence, the 11th-ranked cause of death, homicide, received virtually the same amount of news media coverage as heart disease, the top-ranked cause. Similarly, the lowest-ranking risk factor for mortality, use of illicit drugs, and the No. 2 risk factor, diet and activity patterns, received nearly equal news media coverage. This study is the first to quantify the extremely disproportionate representations of mortality causes and risk factors in the national print media. News media over- and underemphasize certain causes of death for a variety of reasons, including competition for viewers and commercial interests.9 This pattern has been particularly well documented in the case of the leading risk American Journal of Public Health 843
Public Health Briefs
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RISK FACTORS Source. Actual risk factor-related mortality percentages are from McGinnis and Foege14 (reprinted with permission, Association).
1993 American Medical
FIGURE 2-Percentages of actual risk factor-related mortality (shaded bars) vs copy devoted to risk factor-related mortality (unshaded bars) in print news media, by risk factor, 1990.
factor for death, tobacco use, where the relative lack of news coverage has been attributed to the influence that tobacco companies, with their enormous advertising budgets, have over media organizations.'6 News reporting is also driven by rarity, novelty, commercial viability, and drama more than by concems about relative risk.'7 Yet the unusual, novel, lucrative, or dramatic report must be placed in a broader context to help the reader better interpret the story's implications. Studies of cognition indicate that people judge the frequency or probability of an occurrence by the ease with which they can retrieve relevant instances from memory or imagination.'8 This bias of cognition is referred to as the availability heuristic. The media's overemphasis on certain causes of death helps distort public risk perception by making these causes more available and thus more easily retrieved.5"6"8 The print news media's distorted representations of mortality likely 844 American Journal of Public Health
skew the public's perceptions of risk through a second cognitive mechanism as well. Studies of risk perception indicate that threats that are perceived to be externally imposed loom larger than self-imposed threats.6 Thus, not only do the news media emphasize relatively rarer causes of and risk factors for death, but those causes emphasized are those that are instinctively overestimated.'9 These data quantify the extent to which modem journalistic practices distort the portrayal of the leading causes of death and their risk factors. Merely quantifying these pervasive and widely discussed reporting biases is unlikely to affect the output of the journalistic process. Rather, we believe that the primary value of such quantification is to persuade health professionals to aggressively and proactively work with the news media to produce a more balanced agenda and to counteract the effects of journalistic practices that distort accurate presentations of relative risk. Health professionals must
focus the attention of the news media and the public on the health issues of greatest concern so that the most prevalent health risks receive appropriate attention. D
References 1. Gellert GA, Higgins KV, Lowery RM, Maxwell RM. A national survey of public health officers' interactions with the media. JAMA. 1994;271:1285-1289. 2. Nelkin D. Managing biomedical news.Social Res. 1985;52:625-646. 3. Singer E, Endreny P. Reporting hazards: their benefits and costs. J Communication. 1987;37: 10-26. 4. Fischhoff B. Managing risk perception. Issues Sci Technol. 1985;2:83-96. 5. Lichtenstein S, Slovic P, Fischhoff B, Layman M, Combs B. Judged frequency of lethal events. J Exp Psychol Hum Learning. 1978;4:551-581. 6. Slovic P. Perception of risk. Science.
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May 1997, Vol. 87, No. 5
Public Health Briefs 9. Meyer P. News media responsiveness to public health. In: Atkin C, Wallack L, eds. Mass Communication and Public Health. Newbury Park, Calif: Sage Publications; 1990:52-59. 10. Wallack L, Dorfman L. Television news, hegemony, and health. Am J Public Health. 1992;82: 125-126. 11. Weiner SL. Tampons and toxic shock syndrome: consumer protection or public confusion? In: Sapolsky HM, ed. Consuming Fears. New York, NY: Basic Books Inc; 1986:141-158.
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Many studies1-6 have identified the personal, social, and economic characteristics that influence parents to have their child immunized appropriately, and there has been a determined effort to educate the public and improve access to vaccines among high-risk populations. Public assistance programs have the potential of providing immunization opportunities for at-risk children.6 In a study of measles outbreaks in five US cities, 40% to 91% of unvaccinated preschool children with measles were enrolled in one or more public assistance programs.7 These unvaccinated children had regular contact with the Women, Infants, and Children (WIC); Aid to Families with Dependent Children (AFDC); Medicaid; or food stamp program. And despite expanded Medicaid coverage, US children on Medicaid have fewer well baby visits and consequently less adequate immunizations than others.4 Thus, recent initiatives have focused on improving access through Medicaid providers, the WIC program, and AFDC clinics,7'8 and federal policies have been changed to encourage vaccination opportunities. To measure progress in improving historically low immunization levels, the state of Texas undertook a populationbased 1994 survey of vaccination coverage in children less than 2 years of age. In this study, we documented vaccination coverage levels for different demographic segments of the population. We also
examined how immunization status varied with enrollment in the WIC, AFDC, food stamp, and Medicaid programs and with private health insurance coverage. Each provides opportunities to promote immunization, and studies that measure the immunization status of participants are critical to the intervention effort.
Methods Survey Design The survey, consisting of populationbased household samples from 30 Texas counties, was designed to assess immunization levels statewide. Ten counties were preselected because their coverage levels were of interest as a result of their population size or race/ethnic composition. To represent the remainder of the state, we randomly selected 20 counties with selection probabilities proportional to the number of births. For all but 4 counties, we used a three-stage sampling process (census block groups, blocks, and housing units) to randomly select households. In 4 sparsely populated counties, we changed the design to reduce costs and increase efficiency by randomly selecting children from county birth records. The authors are with the Texas Department of Health, Austin. Requests for reprints should be sent to Lucina Suarez, MS, Associateship for Disease Control and Prevention, Texas Department of Health, 1100 W 49th St, Austin, TX 78756. This paper was accepted June 28, 1996.
American Journal of Public Health 845
