Representation and Reception of Complementary and Alternative Medicine on Television. An Audiovisual Framing Analysis of Medical Uncertainty

Michael Grimm (Hans-Bredow-Institut for Media Research at the University of Hamburg, Germany)

Summary of the Project

Relevance

The dominant and paternal role of medical experts in doctor-patient relationships has been increasingly replaced by the ideal of a shared decision making process, in which patients become more involved, and that is supposed to lead to better treatment decisions, a higher therapy compliance and more effective outcomes (Rimer, Briss, Zeller, Chan & Woolf, 2004). To participate in this process, patients need to gain an adequate understanding of medical information regarding their illness and treatment options. Since these are usually fields, in which patients hold little to no prior expertise, the way they gather information and deal with it becomes crucial for their ability to make informed decisions.

Making informed decisions is particularly important for cancer patients, for whom treatment decisions become a matter of life and death. One field of treatments that holds particular challenges for them is complementary and alternative medicine (CAM). CAM refers to treatments that are used with or instead of standard medical care, such as acupuncture, yoga or homeopathy (National Cancer Institute, 2014). While about 35 to 50 per cent of cancer patients use CAM at some point during their disease (Horneber et al., 2010; Molassiotis et al., 2005), due to a lack of evidence-based information and the resulting medical uncertainty, there is a controversial debate on its status in cancer treatment among medical experts and it is often difficult for doctors to guide patients during shared decision making (Dooley et al., 2004). Accordingly, many patients rather take notice of CAM in media and use it as primary information source (Molassiotis et al., 2005).

In this, audiovisual information on television with its potential to communicate issues in a multimodal way can be particularly unobtrusive in shaping patients’ attitudes (Milde, 2009), especially in areas with little empirical evidence (establishing effect; Scheufele & Scheufele, 2010).

Research Questions

We therefore ask:

1) How are CAM treatments audiovisually represented in television coverage?

2) How are different audiovisual representations of CAM treatments perceived by patients?

Theoretical Framework

The theoretical framework of this project builds on the well-established framing approach (Entman, 1993) and adapts it to audiovisual phenomena. The theoretical concept of audiovisual framing accordingly describes the accentuation of certain aspects of reality (here: a particular CAM treatment) over others by means of verbal and visual communication, thereby suggesting certain patterns of interpretation (i.e. audiovisual frames), which may then influence information interpretation and evaluation as well as potential behavioral consequences (comp. Entman, 1993; Coleman, 2010).

The framing approach is particularly suited to anticipate the research questions, since – as a “bridging model for communication research” (Reese, 2001) – it allows to link phenomena from different contexts of the communication process (de Vreese, 2005; Entman, 1993). In this, the idea of a frame applies to medial as well as cognitive concepts (Reese, 2001). Media frames may be understood as latent patterns of meaning in media content, whereas cognitive frames refer to mental structures of communicators and recipients (Scheufele, 1999). Frames may be described by identifying subordinate concepts often referred to as frame elements. They include “reasoning devices” (Entman, 1993), such as how a particular issue is defined (problem definition), who is to be held responsible for causing the issue (causal interpretation), how the issue is evaluated (evaluation) and how it should be treated (treatment recommendation), and “framing devices” (van Gorp, 2007, 2010; Tankard, 2001) relating to the use of metaphors, keywords and images.

Since television broadcasts contain both, verbal as well as visual information with particular communicative potentials and limitations (Geise & Baden, 2014), different relations between the two modalities may occur (Dan & Ihlen, 2011; Scheufele, 2001) in the constitution of the overarching audiovisual frame: verbal information may frame visual information (“word stories”), visual information may frame verbal information (“picture stories”), verbal and visual information may add to each other (“mutual reinforcement”), or verbal and visual information may constitute separate patterns of interpretation (“different frames”).

Methods

The project applies two interconnected methodological approaches to analyze the research questions: a media analysis to answer the first question and a reception analysis to answer the second question.

Media Analysis

In a standardized media analysis, all broadcasts from a six months’ timeframe (November 2012 to April 2013) mentioning at least one CAM treatment were identified by conducting a keyword search via a speech recognition software on all German-speaking television programs (e.g. “cancer” AND “treatment”).

In a first step, verbal frames are identified for each mentioned CAM treatment by coding certain frame elements. Therefore, we theoretically relate to Entman’s frame elements and inductively adapt and elaborate them in a qualitative analysis of a subsample of the material: 1) treatment definition (e.g. attributions like “alternative”, “supportive” or “new”), 2) treatment evaluation (e.g. benefits like “curing cancer” or harms like “causing side effects”) and 3) treatment recommendation (e.g. statements on complementary or exclusive use).

In a second step, visual frames are identified by analyzing the motifs of single shots sharing at least one single image with a respective verbal frame. By aggregating visual motifs with a high internal consistency and, at the same time, a high external difference (comp. Grittmann, 2007), we identify moving image types, which may be associated with certain socio-culturally shared patterns of interpretation (e.g. “talking doctors in white suits” implying medical knowledge and evidence).

In a final step, multimodal relations between verbal and visual frames are analyzed to identify overarching audiovisual frames for particular CAM treatments.

Reception Analysis

Drawing from the media analysis, two prototypical broadcasts will be identified and used as audiovisual stimuli in a reception study, applying a qualitative, quasi-experimental design. Two groups of participants will watch the two prototypical broadcasts. The first group will watch the first broadcast with sound and the second broadcast muted, so the focus will be exclusively on the visual information. The second group will watch the first broadcast muted and the second broadcast with sound.

During the reception process, participants will be asked to verbalize what they see (and hear) in the broadcast by applying a thinking aloud procedure. After the reception, participants will be queried on their perception of particular verbal and visual frame elements in a semi-structured interview, to allow for an interconnection between the results of media and reception analysis.

References

Coleman, R. (2010). Framing the Pictures in Our Heads: Exploring the Framing and Agenda-Setting Effects of Visual Images. In P. D’Angelo & J. Kuypers (Eds.), Doing News Framing Analysis. Empirical and Theoretical Perspectives (pp. 233-261). New York, NY: Routledge.

Dan, V., & Ihlen, Ø. (2011). Towards the Empirical Assessment of Complex Frames: A Method for Combining Analysis of Verbal and Visual Elements. Paper präsentiert im Rahmen der ICA-Jahreskonferenz in Boston, MA.

de Vreese, C. H. (2005). News framing: Theory and Typology. Information Design Journal + Document Design, 13(1), 51-62.

Dooley, M. J., Lee, D. Y. L., & Marriott, J. L. (2004). Practitioners’ sources of clinical information on complementary and alternative medicine in oncology. Supportive Care in Cancer, 12(2), 114-119.

Geise, S., & Baden, C. (2014). Putting the Image Back Into the Frame: Modeling the Linkage Between Visual Communication and Frame-Processing Theory. Communication Theory, 25, 46-69.

Entman, R. M. (1993). Framing: Toward Clarification of a Fractured Paradigm. Journal of Communication, 43(4), 51-58.

Horneber, M., Büschel, G., Dennert, G., & Wilhelm, C. (2010). Unkonventionelle Verfahren in der Onkologie. [Unconventional treatments in oncology.] In W. Hiddemann & C. R. Betram (Hrsg.), Die Onkologie [Oncology] (pp. 586-611). Berlin/Heidelberg: Springer.

Milde, J. (2009). Vermitteln und Verstehen. Zur Verständlichkeit von Wissenschaftsfilmen im Fernsehen. [Mediating and understanding. On the comprehensibility of science films on television.] Wiesbaden: VS Verlag für Sozialwissenschaften.

Molassiotis, A., Fernandez-Ortega, P., Pud, D., Ozden, G., Scott, J. A., Panteli, V., Margulies, A., Browall, M., Magri, M., Selvekerova, S., Madsen, E., Milovics, L., Bruyns, I., Gudmundsdottir, G., Hummerston, S., Ahmad, A. M.-A., Platin, N., Kearney, N., & Patiraki, E. (2005). Use of complementary and alternative medicine in cancer patients: a European survey. Annals of Oncology, 16(4), 655-663.

National Cancer Institute (2014). What is complementary and alternative medicine (CAM)? Online: http://www.cancer.gov/cancertopics/cam (10 June 2014).

Reese, S. D. (2001). Prologue – Framing Public Life: A Bridging Model for Media Research. In S. D. Reese, O. H. Gandy, & A. E. Grant (Eds.), Framing Public Life. Perspectives on Media and Our Understanding of the Social World (pp. 7-31). Mahwah, NJ: Erlbaum.

Rimer, B. K., Briss, P. A., Zeller, P. K., Chan, E. C. Y., & Woolf, S. H. (2004). Informed decision making: What is its role in cancer screening? Cancer, 101(S5), 1214-1228.

Scheufele, B. (2001). Visuelles Medien-Framing und Framing-Effekte. Zur Analyse visueller Kommunikation aus der Framing-Perspektive. [Visual media framing and framing effects. On the analysis of visual communication from the framing perspective.] In T. Knieper & M. G. Müller (Hrsg.), Kommunikation visuell – Das Bild als Forschungsgegenstand – Grundlagen und Perspektiven [Communication visually – The image as research object – Foundations and perspectives (pp. 144-158). Cologne: Halem.

Scheufele, D. A. (1999). Framing as a Theory of Media Effects. Journal of Communication, 49(1), 103-122.

Scheufele, B. T. & Scheufele, D. A. (2010). Of Spreading Activation, Applicability, and Schemas. Conceptual Distinctions and Their Operational Implications for Measuring Frames and Framing Effects. In P. D’Angelo & J. A. Kuypers (Eds.), Doing News Framing Analysis. Empirical and Theoretical Perspectives (pp. 110-134). New York, NY: Routledge.

Tankard, J. W. (2001). The Empirical Approach to the Study of Media Framing. In S. D. Reese, O. H. Gandy, A. E. Grant (Eds.), Framing Public Life. Perspectives on Media and Our Understanding of the Social World (pp. 95-106). Mahwah, NJ: Erlbaum.

van Gorp, B. (2007). The constructionist approach to framing: Bringing culture back in. Journal of Communication, 57(1), 60-78.

van Gorp, B. (2010). Strategies to take subjectivity out of framing analysis. In P. D’Angelo & J. Kuypers (Eds.), Doing news framing analysis: Empirical and theoretical perspectives (pp. 84-109). New York: Routledge.

Methodological Reflections

Methodological Potentials

The project provides a structured approach to the analysis of moving images and verbal-visual relations, making the procedure of analysis as transparent and retraceable as possible. The study will allow for a more comprehensive understanding of media frames and their reception in a dynamic process. It will facilitate a comparison of media frames and perceived audiovisual frames by applying frame elements as similar categories for the analyses.

Methodological Challenges

A major challenge for the media analysis is to define a suitable unit of analysis for verbal and visual as well as audiovisual frames. With regard to the visual frames, moving image types are derived for a quite specific thematic context and it will be interesting to see in how far they may be compared and generalized with regard to visual image types from other contexts of health communication. The matching of verbal and visual frame elements to deduce overarching audiovisual frames may be situated at different possible levels (e.g. on level of the semantic unit or on the level of the broadcast as a whole), implying different possible statements.

Regarding the reception analysis, the differentiation of verbal and visual information in reception will prove to be particularly challenging. Closely linked is the question in how far visual frame elements may be verbalized by recipients after all.

Methodological Limitations

On a theoretical level, the adaptation of Entman’s frame elements to the thematic context proved to be difficult and not all frame elements (e.g. causal interpretation) could be adequately adapted to the issue under investigation, resulting in questions if they can only be transferred to a limited range of issues. Deriving moving image types proves to be a transparent, but subjective process, particularly since there are hardly any studies that identify visual motifs and could be used as a reference point, yet.

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