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Covering Controversy: What Are the Implications for Women's Health?

2015; Elsevier BV; Volume: 25; Issue: 4 Linguagem: Inglês

10.1016/j.whi.2015.04.011

1878-4321

Rebekah H. Nagler, Erika Franklin Fowler, Sarah E. Gollust,

Climate Change Communication and Perception

We see it while skimming newspaper headlines, watching the nightly news, and, increasingly, scanning our social media feeds: high volumes of conflicting and controversial information about issues relevant to women's health. Already in 2015, several such controversial issues have occupied media attention, including conflict over childhood vaccination decisions after a measles outbreak in California (Loehrke and Szabo, 2015Loehrke J. Szabo L. The measles outbreak and vaccine controversy, visualized. USA Today, 2015www.usatoday.com/story/news/2015/02/05/measles-vaccine-immunization-health/22916079/Google Scholar), resurgence in controversy surrounding the human papillomavirus (HPV) vaccine after a Toronto newspaper published a sensationalist story highlighting dramatic and unproven vaccine side effects (English, 2015English K. Public editor criticizes the Star's Gardasil story: Scientific evidence has concluded the HPV vaccine is safe and effective so why did Star publish a story that raised alarms about its safety?. Toronto Star, 2015www.thestar.com/opinion/public_editor/2015/02/13/public-editor-criticizes-the-stars-gardasil-story.htmlGoogle Scholar), and the release of draft U.S. Preventive Service Task Force (USPSTF) breast cancer screening recommendations (USPSTF, 2015U.S. Preventive Services Task Force (USPSTF)Draft recommendation statement: Breast cancer: Screening.2015www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementDraft/breast-cancer-screening1Google Scholar). Although it is well known that the media can have a positive influence on health-related attitudes and behaviors (Ramirez et al., 2013Ramirez A.S. Freres D. Martinez L.S. Lewis N. Bourgoin A. Kelly B.J. Hornik R.C. et al.Information seeking from media and family/friends increases the likelihood of engaging in healthy lifestyle behaviors.Journal of Health Communication. 2013; 18: 527-542Crossref PubMed Scopus (74) Google Scholar, Redmond et al., 2010Redmond N. Baer H.J. Clark C.R. Lipsitz S. Hicks L.S. Sources of health information related to preventive health behaviors in a national study.American Journal of Preventive Medicine. 2010; 38: 620-627.e2Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar), mass media messages that broadcast conflicting and controversial health information raise the potential for adverse effects. Although there is some evidence that exposure to media conflict and controversy is associated with public confusion, decreased trust in health recommendations, and less adoption of prevention and screening behaviors (Han et al., 2009Han P.K. Moser R.P. Klein W.M. Beckjord E.B. Dunlavy A.C. Hesse B.W. Predictors of perceived ambiguity about cancer prevention recommendations: Sociodemographic factors and mass media exposures.Health Communication. 2009; 24: 764-772Crossref PubMed Scopus (31) Google Scholar, Nagler, 2014Nagler R.H. Adverse outcomes associated with media exposure to contradictory nutrition messages.Journal of Health Communication. 2014; 19: 24-40Crossref PubMed Scopus (160) Google Scholar), this research arena remains underexplored. In this commentary, we call for rigorous scientific attention to the effects of widely publicized women's health controversies. Using the HPV vaccine and mammography screening as examples, we begin by summarizing (based on our and others' research) key aspects of news media coverage of these important health issues. In both cases, health professionals, scientific experts, advocates, and politicians have competed to shape the debate, resulting in media depiction of a high degree of controversy. Yet, as described herein, little empirical research is available to understand the effects of this competitive, often politicized, media discourse on outcomes including trust in medicine, support for policies, intentions to seek medical care, and engagement in health behaviors. Given that health issues continue to be presented with conflict and through political lenses, this phenomenon will be even more important for women's health experts to consider in the future. We therefore conclude by outlining future research directions and implications for clinical and public health communication. Since gaining approval from the U.S. Food and Drug Administration for girls in 2006 (and boys in 2009), the HPV vaccine has been rife with controversy. Supporters have underscored the vaccine's efficacy at preventing cervical cancer, and many have called for mandated vaccination for middle school entry. In contrast, detractors have argued that vaccine side effects are uncertain, questioned whether vaccine endorsement would promote sexual promiscuity, expressed concern about the vaccine price, and stipulated that a mandate is government intrusion (Colgrove et al., 2010Colgrove J. Abiola S. Mello M.M. HPV vaccination mandates–lawmaking amid political and scientific controversy.New England Journal of Medicine. 2010; 363: 758-791Crossref Scopus (81) Google Scholar). Such conflicting views routinely play out in the media: more than 2,000 articles about HPV vaccine policy appeared in U.S. newspapers from 2006 to 2008, with 30% of these articles explicitly mentioning controversy in the headline or main text (Fowler and Gollust, 2015Fowler E.F. Gollust S.E. The content and effect of politicized health controversies.Annals of the American Academy of Political and Social Science. 2015; 658: 155-171Crossref Scopus (60) Google Scholar); another study demonstrated that 66% of HPV vaccine news coverage from 2005 to 2009 contained conflict (Casciotti et al., 2014Casciotti D.M. Smith K.C. Klassen A.C. Topics associated with conflict in print news coverage of the HPV vaccine during 2005 to 2009.Human Vaccines & Immunotherapeutics. 2014; 10: 3466-3474Crossref PubMed Scopus (12) Google Scholar). Controversy continues to resurface—even though vaccine mandates have fallen from state legislative agendas and the target population now includes girls and boys 1Content analyses suggest that HPV media coverage has focused primarily on females—perhaps partly explained by pre-2009 study timeframes—but recently researchers have begun examining coverage of males, arguing they should be integral to vaccination discourse (Casciotti et al., 2014Casciotti D.M. Smith K.C. Tsui A. Klassen A.C. Discussions of adolescent sexuality in news media coverage of the HPV vaccine.Journal of Adolescence. 2014; 37: 133-143Crossref PubMed Scopus (23) Google Scholar).—such as when then-presidential candidate Michele Bachmann made headlines criticizing the vaccine's side effects in 2011 (Gostin, 2011Gostin L.O. Mandatory HPV vaccination and political debate.Journal of the American Medical Association. 2011; 306: 1699-1700Crossref PubMed Scopus (36) Google Scholar), or when a now-retracted Toronto Star article reported patient anecdotes about dramatic yet inaccurate vaccine safety concerns (English, 2015English K. Public editor criticizes the Star's Gardasil story: Scientific evidence has concluded the HPV vaccine is safe and effective so why did Star publish a story that raised alarms about its safety?. Toronto Star, 2015www.thestar.com/opinion/public_editor/2015/02/13/public-editor-criticizes-the-stars-gardasil-story.htmlGoogle Scholar). Yet whether media dissemination of HPV vaccine controversy actually has effects on public attitudes and behaviors is an empirical question. Thus far, the evidence base is thin, but there is reason to believe that intense media exposure may have affected the public (Kahan, 2013Kahan D.M. A risky science communication environment for vaccines.Science. 2013; 342: 53-54Crossref PubMed Scopus (94) Google Scholar). Vaccine awareness is high, at nearly 70% of the population, yet uptake remains low: in 2013, only 37.6% of eligible girls aged 13 to 17 received all three recommended doses (Elam-Evans et al., 2014Elam-Evans L.D. Yankey D. Jeyarajah J. Singleton J.A. Curtis R.C. MacNeil J. Hariri S. National, regional, state, and selected local area vaccination coverage among adolescents aged 13-17 years–United States, 2013.MMWR Morbidity and Mortality Weekly Report. 2014; 63: 625-633PubMed Google Scholar). Scholars have speculated that low uptake could be a result of politicized discourse about HPV. For instance, we found that political ideology was a predictor of vaccine awareness (Gollust et al., 2013Gollust S.E. Attanasio L. Dempsey A. Benson A.M. Fowler E.F. Political and news media factors shaping public awareness of the HPV vaccine.Women's Health Issues. 2013; 23: e143-e151Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar). Additionally, studies suggest that media framing of the HPV vaccine's goals and benefits may have influenced public perceptions; participants supported a vaccine framed as "cancer prevention" more than one framed as (Leader et al., 2009Leader A.E. Weiner J.L. Kelly B.J. Hornik R.C. Cappella J.N. Effects of information framing on human papillomavirus vaccination.Journal of Women's Health. 2009; 18: 225-233Crossref PubMed Scopus (65) Google Scholar). We also found that a "controversy frame"—which presented medical and political conflict surrounding proposed HPV vaccine policy—reduced public support for school vaccine mandates (Gollust et al., 2010Gollust S.E. Dempsey A.F. Lantz P.M. Ubel P.A. Fowler E.F. Controversy undermines support for state mandates on the human papillomavirus vaccine.Health Affairs (Millwood). 2010; 29: 2041-2046Crossref PubMed Scopus (45) Google Scholar). Similarly, media coverage of mammography screening has been both controversial and politically charged. In fact, the past 20 years have been marked by substantial expert disagreement about the use of mammography screening. In both 1993 and 1997, experts disputed the age at which women should begin having mammograms and the frequency with which they should receive them (Fletcher et al., 1993Fletcher S.W. Black W. Harris R. Rimer B.K. Shapiro S. Report of the International Workshop on Screening for Breast Cancer.Journal of the National Cancer Institute. 1993; 85: 1644-1656Crossref PubMed Scopus (680) Google Scholar, NIH Consensus Development Panel, 1997NIH Consensus Development PanelNational Institutes of Health Consensus Development Conference statement: Breast cancer screening for women ages 40-49, January 21-23, 1997.Journal of the National Cancer Institute. 1997; 89: 1015-1026Crossref PubMed Scopus (138) Google Scholar). In 2001, controversy erupted again, when a meta-analysis concluded that there was insufficient evidence to recommend mammography for women of any age (Olsen and Gotzsche, 2001Olsen O. Gotzsche P.C. Cochrane review on screening for breast cancer with mammography.Lancet. 2001; 358: 1340-1342Abstract Full Text Full Text PDF PubMed Scopus (616) Google Scholar). Controversy was reignited in 2009 when the USPSTF downgraded mammography screening for women ages 40 to 49 to a C rating (recommendation against routine screening; USPSTF, 2009U.S. Preventive Services Task Force (USPSTF)Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement.Annals of Internal Medicine. 2009; 151 (w-236): 716-726Crossref PubMed Scopus (0) Google Scholar). This move was followed by a flurry of media coverage, counter-recommendations from the American Cancer Society (ACS) and the American College of Radiology (ACR), and outrage from some breast cancer survivors and advocates (Rabin, 2009Rabin R.C. New guidelines on breast cancer draw opposition. New York Times, 2009www.nytimes.com/2009/11/17/health/17scre.html?_r=0Google Scholar). In the wake of the controversy, the USPSTF amended the guidelines, emphasizing the value of informed decision making for women under 50. Most recently, the USPSTF released updated breast cancer screening draft recommendations in April 2015. These recommendations are consistent with those released in 2009, reiterate the need for informed decision making for women ages 40 to 49 (USPSTF, 2015U.S. Preventive Services Task Force (USPSTF)Draft recommendation statement: Breast cancer: Screening.2015www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementDraft/breast-cancer-screening1Google Scholar), and to date have garnered both media attention (Hobson, 2015Hobson K. Federal panel revisits contested recommendations on mammograms. NPR, 2015www.npr.org/blogs/health/2015/04/20/401006116/federal-panel-revisits-contested-recommendation-on-mammogramsGoogle Scholar) and resistance from professional organizations (ACR, 2015American College of Radiology (ACR)ACR and SBI: draft USPSTF breast cancer screening recommendations would cost thousands of lives and could eliminate mammography insurance coverage for millions of women. PR Newswire, 2015www.prnewswire.comGoogle Scholar). Media content analyses of the 2009 controversy suggest that news coverage often dramatized the conflict and was, at times, misleading. In a sample of 200 local and national television broadcasts and local newspaper stories (see Fowler and Gollust, 2015Fowler E.F. Gollust S.E. The content and effect of politicized health controversies.Annals of the American Academy of Political and Social Science. 2015; 658: 155-171Crossref Scopus (60) Google Scholar for detailed methods), we found that 33% of stories were presented in a politicized or controversial manner. Moreover, Table 1 documents the percentage of print and TV news stories that disseminated accurate and inaccurate messages about the 2009 USPSTF recommendations. More than one-third of coverage overall—and nearly one-half of TV stories—reported inaccurately that women in their 40s should not get screened at all, and significantly fewer TV than print stories emphasized the important point that women should make decisions with their providers. In sum, 70.5% of stories mentioned an argument in support of the recommendations, whereas 84.5% mentioned an argument in opposition (see Table 1 for specific arguments). Various sources contributed to these depictions of the mammography controversy, most commonly physicians and the ACS, cited in 58.5% and 53.5% of coverage, respectively. Other common voices included women generally (28.0%), women at risk for cancer (17.0%), cancer survivors (22.5%), and USPSTF members (27.5%). However, news coverage did not solely feature the health professionals or affected individuals we would expect to contribute their expertise; politicians or elected officials were cited in 19.5% of stories (Fowler and Gollust, 2015Fowler E.F. Gollust S.E. The content and effect of politicized health controversies.Annals of the American Academy of Political and Social Science. 2015; 658: 155-171Crossref Scopus (60) Google Scholar).Table 1Percentage of Media Stories Presenting Accurate/Inaccurate Information about and Arguments Supporting/Opposing the 2009 USPSTF Recommendations, by News Type%, Total Stories (n = 200)%, Print Stories (n = 87)%, TV Stories (n = 113)Presentation of Information about USPSTF Recommendations (T = true, F = false) Women ages 40–49 should not get routine screening (T)68.564.673.6 Women ages 50–74 should get screened every 2 years (T)57.055.258.4 Women ages 40–49 should not get screened (F)37.525.346.9∗∗ Breast self-examinations are not effective (F)20.516.123.9 Individual decisions are emphasized (T)20.533.310.6∗∗∗ Clinicians should not teach women breast self-examinations (T)18.526.412.4∗ Task force used rigorous methods (i.e., modeling) (T)17.033.34.4∗∗∗ Task force did not consider costs (T)11.520.74.4∗∗∗Presentation of Arguments Supporting USPSTF Recommendations Mentions any supporting argument70.585.159.3∗∗∗ Risk of false-positive results48.059.838.9∗∗ Harms of screening outweigh benefits36.049.425.7∗∗ Unnecessary biopsies43.055.233.6∗∗ Risk of anxiety/psychological harm33.050.619.5∗∗∗ Overtreatment24.543.79.7∗∗∗ Screening is less effective/accurate in women <5016.523.011.5∗ Risk of radiation14.016.112.4Presentation of Arguments Opposing USPSTF Recommendations Mentions any opposing argument84.589.780.5 Saving lives worth any costs35.041.430.1 Early detection is best strategy for cancer prevention/control31.529.932.7 Recommendations will confuse women26.021.829.2 Concern over costs is not valid justification20.024.116.8 Insurers may not cover mammograms17.521.814.2 Rationing care16.527.68.0∗∗∗ Recommendations will cause some women to die15.010.318.6 Burden of disease in women <5013.513.813.3 Task force used inappropriate/poor methods7.59.26.2 Inappropriate government interference7.512.63.5∗Indicates significant difference between print and TV news from χ2 square test, ∗p < .05, ∗∗p < .01, ∗∗∗p < .001. Open table in a new tab Indicates significant difference between print and TV news from χ2 square test, ∗p < .05, ∗∗p < .01, ∗∗∗p < .001. The intensity of media coverage of this women's health issue—and the fact that the news continues to erupt sporadically with coverage of the mammography controversy—suggests that the media would have an impact on public perceptions. Yet, as with the HPV vaccine, there is scarce empirical evidence documenting the effects of exposure. Limited research suggests that women perceive conflict and controversy surrounding mammography guidelines (Meissner et al., 2003Meissner H.I. Rimer B.K. Davis W.W. Eisner E.J. Siegler I.C. Another round in the mammography controversy.Journal of Women's Health. 2003; 12: 261-276Crossref PubMed Scopus (29) Google Scholar, Squiers et al., 2011Squiers L.B. Holden D.J. Dolina S.E. Kim A.E. Bann C.M. Renaud J.M. The public's response to the US Preventive Services Task Force's 2009 recommendations on mammography screening.American Journal of Preventive Medicine. 2011; 40: 497-504Abstract Full Text Full Text PDF PubMed Scopus (102) Google Scholar). One study found that exposure to mammography controversy may have influenced Internet seeking about screening (Weeks et al., 2012Weeks B.E. Friedenberg L.M. Southwell B.G. Slater J.S. Behavioral consequences of conflict-oriented health news coverage: The 2009 mammography guideline controversy and online information seeking.Health Communication. 2012; 27: 158-166Crossref PubMed Scopus (56) Google Scholar), and some scholars have examined provider communication about mammography (Nekhlyudov and Braddock, 2009Nekhlyudov L. Braddock C.H. An approach to enhance communication about screening mammography in primary care.Journal of Women's Health. 2009; 18: 1403-1412Crossref PubMed Scopus (27) Google Scholar). Although two population-based studies found no effects of the recommendations on women's screening in their 40s (Block et al., 2013Block L.D. Jarlenski M.P. Wu A.W. Bennett W.L. Mammography use among women ages 40-49 after the 2009 U.S. Preventive Services Task Force recommendation.Journal of General Internal Medicine. 2013; 28: 1447-1453Crossref PubMed Scopus (37) Google Scholar, Pace et al., 2013Pace L.E. He Y.L. Keating N.L. Trends in mammography screening rates after publication of the 2009 US Preventive Services Task Force recommendations.Cancer. 2013; 119: 2518-2523Crossref PubMed Scopus (116) Google Scholar), a 2014 study described utilization trends among the privately insured that were consistent with public confusion (Wang et al., 2014Wang A.T. Fan J.Q. Van Houten H.K. Tilburt J.C. Stout N.K. Montori V.M. Shah N.D. Impact of the 2009 US Preventive Services Task Force guidelines on screening mammography rates on women in their 40s.PLoS One. 2014; 9: 6Google Scholar). Such evidence cannot directly identify the role of media in influencing these patterns. To date, no studies have attempted to causally link real-world media exposure to mammography controversy with attitudinal or behavioral outcomes. Given the limited extant research in this area, examining the influence of media controversy—especially controversy that is political in nature—is critically important. In fact, scholarship outside of public health and medicine illuminates why generating a stronger evidence base on media effects of health controversies is so important. Below, we briefly review this scholarship and outline questions germane to women's health researchers and practitioners. A mixed-methods approach is well-suited to answering these questions: for example, content analysis to understand media coverage, survey and experimental designs to assess effects of exposure to media controversy, and key informant interviews to explore stakeholders' communication about controversy. New research in political communication examines how competing media messages influence the public. This research shows, for instance, that people can form significantly different opinions based on whether they are exposed to competing messages simultaneously versus over time (Chong and Druckman, 2010Chong D. Druckman J.N. Dynamic public opinion: Communication effects over time.American Political Science Review. 2010; 104: 663-680Crossref Scopus (203) Google Scholar). As we described above and in Table 1, the cancer-specific media environment is characterized by contradictory messages delivered to audiences over time. Examining the influence of these competing messages requires addressing key questions: Which message characteristics, such as values-laden content or statistics, does the public perceive as stronger or more persuasive? What happens when women are exposed to one message that contains values and another (possibly later) message with data? Which message trumps the other, and for whom? How should practitioners communicate about HPV and mammography, in campaigns or the clinic, given the competitive media discourse reaching women? Social scientists also examine processes known as "motivated reasoning," which can explain why some health educational approaches do not work as intended (Taber and Lodge, 2006Taber C.S. Lodge M. Motivated skepticism in the evaluation of political beliefs.American Journal of Political Science. 2006; 50: 755-769Crossref Scopus (2055) Google Scholar). In brief, people incorporate arguments or educational messages consistent with their prior values and beliefs (confirmation bias) and reject those that are divergent. The public's faith—or lack thereof—in vaccines and routine screenings may be one powerful predisposing factor. Indeed, emerging evidence suggests that, at least in the case of childhood immunizations, this may be true (Nyhan et al., 2014Nyhan B. Reifler J. Richey S. Freed G.L. Effective messages in vaccine promotion: A randomized trial.Pediatrics. 2014; 133: e835-e842Crossref PubMed Scopus (773) Google Scholar). This research suggests that messages that include particular source cues, such as a speaker's political orientation, enhance the likelihood of processing messages in "filtered" ways. Given the already high levels of political polarization among the public, when health issues are politicized by including political components or sources, the psychological processes of motivated reasoning are even more likely—possibly leading to the rejection of health-promoting messages. Key questions that emerge include: How does the inclusion of political content or sources in messages about women's health controversies shape the message response? To what extent do women's past vaccination or screening behaviors influence their responses to new messages, particularly contradictory ones? How can health communication be more effective in combating strong predisposing beliefs, especially given increasing evidence of overutilization of services that some patients hold as sacred, such as annual mammograms or well-woman visits (Rosenbaum, 2014Rosenbaum L. Invisible risks, emotional choices — Mammography and medical decision making.New England Journal of Medicine. 2014; 371: 1549-1552Crossref PubMed Scopus (35) Google Scholar)? Understanding the answers to these questions, and, more broadly, building the evidence base for the effects of health controversy on the public, is essential—not only for the field of health communication, but for all professionals interested in improving women's health. Yet although we need generalizable research on these questions, we also need evidence on underserved women in particular. The effects of media conflict and controversy may be more pronounced among women from vulnerable populations who have lower health literacy, fewer opportunities for clinical interactions, and higher baseline levels of medical mistrust. Research on communication inequalities (Viswanath, 2006Viswanath K. Public communications and its role in reducing and eliminating health disparities.in: Thomson G.E. Mitchell F. Williams M.B. Examining the health disparities research plan of the National Institutes of Health: Unfinished business. National Academies Press, Washington, DC2006: 215-253Google Scholar)—defined as differences in social groups' ability to access, attend to, process, retain, and act on information—suggests not only that lower levels of health literacy could influence processing of conflicting messages, but that underserved women may have fewer opportunities and/or feel less able to discuss any confusion with clinicians. The potential for differential message effects among underserved women is concerning, given persistent disparities in both HPV vaccination and cancer screening. By understanding the increasingly complex, competitive information landscape and its effects, we can successfully intervene to improve communication and ameliorate misunderstandings about the HPV vaccine, mammography, and other important women's health issues. Such interventions might include the design of persuasive messages for use in communication campaigns or decision aids for use in clinical practices, which would help women to negotiate media conflict and controversy. Alternatively, we could intervene at the institutional level by developing a toolkit that would help journalists to report women's health research while providing contextual information, and without relying on the tried-and-true "conflict hook." Ultimately, enhancing communication about controversial issues should be considered alongside other interventions to improve women's health and prevent widening disparities. We thank Laura Attanasio and Anne Dwyer for research assistance. Rebekah H. Nagler, PhD, is Assistant Professor in the School of Journalism & Mass Communication at the University of Minnesota. Her research examines media effects on health outcomes, with a particular focus on women's health and cancer prevention. Erika Franklin Fowler, PhD, is Assistant Professor of Government at Wesleyan University and Co-Director of the Wesleyan Media Project. Her research focuses on political communication, examining the content and effect of media messages in both electoral and health policy spheres. Sarah E. Gollust, PhD, is Assistant Professor in the Division of Health Policy and Management at the University of Minnesota. Her research examines media coverage of and public opinion toward controversial health policy issues, including childhood obesity, the HPV vaccine, and mammography screening.