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a Department of Health Policy and Management, Harvard School of Public Health, and the John F. Kennedy School of Government, Harvard University
Correspondence: Felicia Mebane, PhD, Department of Health Policy and Management, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115. E-mail: fmebane{at}hsph.harvard.edu.
Laurence G. Branch, PhD
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Key Words: Politics • Health policy • Aging • Public opinion • Knowledge
An issue of ongoing debate among gerontologists and policymakers concerns government funding for institutional and community-based long-term care services. Many experts and advocates have argued for increased government support for home and community-based alternatives to institutional care. Although government funding for home-based care has increased in recent years, institutional care continues to receive the large majority of funding. In 1998, 73% of the $48.5 billion that the federal government spent on long-term care went to nursing homes. Nearly 90% of the $20.1 billion that state and local governments spent on long-term care in the same year went to nursing homes (Health Care Financing Administration, 1999).
One argument for increasing government support for community-based care is the fact that a large majority of Americans aged 45 and older (86%) have expressed a desire to avoid an institutional setting when they need help taking care of themselves (AARP 2000
). Additionally, a large majority of adults aged 70 years and older who believe they may need long-term care in the coming year (76%) do not have the personal resources to pay for care. A similar proportion of the general public is concerned about how they will finance long-term care for themselves and their spouses (Harvard School of Public Health and Louis Harris and Associates 1995; National Council on Aging and John Hancock Mutual Life Insurance Company 1999). Given this combination of factors, why is there no public outcry for more government funding of home and community-based care?
One explanation involves Americans' lack of knowledge about long-term care alternatives. A majority of Americans believe that most long-term care is provided in nursing homes. In fact, about 80% of long-term care is provided by friends and family members at home. Additionally, two thirds of all Americans cannot pass a quiz with simple questions about the costs and financing of long-term care (National Council on Aging and John Hancock Mutual Life Insurance Company 1999). The most recent survey to extensively measure the public's knowledge of available long-term care services showed that even older Americans are unfamiliar with a variety of long-term care services. A sizable minority of adults aged 50 years and older (28%) had not heard of or read about home health care. About 41% of these adults had not heard of adult day care or congregate living, and 47% had not heard of assisted living arrangements. Conversely, most adults aged 50 years and older (82%) had heard of or read about skilled nursing facilities (Harvard School of Public Health and Louis Harris and Associates 1995). Finally, in a recent series of focus groups, older Americans tended to focus on nursing home experiences, and most of them remained unfamiliar with community-based long-term care services (G. Wright, AARP, personal communication, May 16, 2000).
Although future surveys are likely to show that the public's familiarity with long-term care services has increased with the recent growth in long-term care services, millions of Americans are likely to be unfamiliar with most long-term care services. Americans are not likely to demand services that they do not know about, and they are not likely to support policies involving services that are not familiar.
Growing demand for long-term care services and continued budgetary pressures to curb health care spending ensure that the debate about what forms of long-term care should be supported by government, and to what extent, will not abate in the near future. As policies concerning long-term care evolve, it is critical for policymakers, health care providers, and researchers to understand what information is influencing the public's knowledge, priorities, and attitudes about long-term care policy.
This study is the first to examine what information about long-term care is conveyed to the public by a major source of health information: news media. In 1998, two thirds of Americans (68%) regularly read a daily newspaper. Fifty-seven percent of Americans regularly watched network news programs, and 38% watched national nightly news on CBS, NBC, or ABC. Forty percent of Americans regularly watch one of the cable news networks, and 23% regularly watch the Cable News Network (CNN). Finally, about one half of Americans (52%) regularly listen to news on the radio, and 15% regularly listen to National Public Radio (NPR; Pew Research Center for the People and the Press 1998).
According to the Pew Research Center's reported tabulations for selected programs, in 1998 older Americans were more likely than younger Americans to regularly watch nightly network news and CNN and were just as likely to listen regularly to NPR. Nearly one half of Americans aged 50–64 years (49%) regularly watch nightly news on CBS, ABC, or NBC. Fifty-five percent of people aged 65 years and older regularly watch nightly news on these networks. By comparison, 23% of people aged 18–29 years and 33% of people aged 30–49 years regularly watch nightly news on these networks. Similarly, 28% of people aged 50–64 years and 30% of adults aged 65 years and older regularly watch CNN. Sixteen and 21% of people aged 18–29 and 30–49 years, respectively, regularly watch CNN. Finally, about 15% of all of the age groups regularly listen to NPR.
A similar study shows that a sizable percentage of all Americans (40%) rely on television as their primary source of health and medical news. For older Americans, dependence on television for health and medical news varies. Forty-three percent of Americans aged 50–59 years rely on television as their primary source of health-related news, compared with about one third of Americans aged 60 years and older. Similarly, 16% of all Americans most often get health-related news from daily newspapers. Among older Americans, 19% of 50–59-year-olds and 12% of adults aged 60 years and older fall into this category. Finally, 4% of the general public and older Americans rely on radio news as their primary source for this type of information (National Health Council 1997). For the millions of Americans who watch, read, or listen to news, do media influence how they view long-term care services and policy, and if so, how?
Measuring media's impact on the public's knowledge of and attitudes toward issues is a difficult task. Media messages are among myriad influences on a person's cognitive processes as he or she collects information about an issue and makes decisions about the importance of an issue, how societal issues should be addressed, and so forth. Despite these difficulties, researchers have presented convincing evidence suggesting that media messages are received and processed by audiences and can influence audiences' priorities, perceptions of political life and political actors, and attributions of responsibility for social problems.
One impact media may have on the public's conception of long-term care problems and concerns relates to media's selection of newsworthy issues. For individuals who have limited free time and interest in the full range of societal issues, media coverage focuses attention on the long-term care issues that are reported.
A considerable amount of research suggests that how media report newsworthy issues also sends cues that influence audiences' views of national affairs. For example, people are more likely to notice and remember stories placed in the front of media coverage or stories that receive lengthy coverage (Behr and Iyengar 1985; Graber 1988; Smith 1992). Additionally, numerous studies and experiments have shown that among issues reported by media, issues that receive a large volume of coverage tend to be more salient with the public (e.g., Cohen 1963; Eaton 1989; Iyengar and Kinder 1987; Iyengar, Peters, and Kinder 1982; McCombs and Shaw 1972; Rogers, Dearing, and Chang 1991). This evidence suggests that the presentation of media coverage influences what issues the public considers to be the top issues facing the nation.
Not only does media coverage affect which issues reach the public agenda and their importance once there, how media frame issues (i.e., discusses causes, effects, etc.) affects what attributes of national issues become part of public discourse and expectations. For example, one experiment demonstrated that when media stories direct attention to poverty as a national outcome or on national programs addressing the issue, the audience's explanations for poverty focus on societal factors such as national economic conditions that lead to fewer available jobs; when media focus on examples of individual poor people, explanations for poverty focus on individual characteristics such as a lack of education and job skills (Iyengar 1987). Other studies provide supporting evidence for using various national issues as examples, including the economy and racial inequality (Benton and Frazier 1976; Iyengar 1991). Knowing how media are framing long-term care issues will provide valuable insights for policymakers because the public's attributions of responsibility for the causes or treatment of national issues shape their preferences for public policy (Iyengar 1987, Iyengar 1989).
To understand better the public's knowledge and views of long-term care services in a recent year, I addressed several key questions in this study. First, when long-term care was the focus of a news story in 1998, what topics were reported and what aspects of these topics were discussed? Second, which long-term care topics were emphasized with prominent placement in media coverage in 1998? Finally, what problems or new information was used to frame the long-term care topics reported in 1998?
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I searched several Lexis-Nexis Academic Universe databases in May 2000 to provide the unfiltered data for different news media. For print media, the Major Newspapers database was examined. This database includes U.S. papers from every region of the country that were in the top 50 in circulation in the Editor & Publisher International Yearbook in each year. Newspapers published outside the United States must be written in English and listed as a newspaper in Benn's Media directory or one of the top 5% in circulation for the country. When the searches were conducted, the database included 43 major newspapers, with 29 of them based in the United States. (See Appendix, Note 2, for a list of sources.)
The broadcast media stories were obtained from the Transcripts database. These sources include three of the major networks (NBC, ABC, and CBS), one cable news network (CNN), and one major source of radio news (NPR).
For each year between 1995 and 1999, the three news stories that were closely followed by the largest percentages of the public are also presented. These data were gathered from the Pew Research Center for the People & the Press (2000) report titled Public Attentiveness to Major News Stories: 1986–1999.
To compare long-term care coverage in 1998 with coverage of other stories in 1998, I analyzed story headlines reported daily to media outlets as TV Track (compiled by U.S. Newswire) to determine the topics broadcast by CBS, NBC, and ABC on Monday through Friday. I used the Lexis-Nexis Academic Universe Transcripts database to compare the number of long-term care stories in NPR, CNN, and the major newspapers with a measure of the total number of health-related stories. I added the term health care to the long-term care terms to collect stories about a broader range of health issues. Again, the terms were included in the title or first paragraph(s) of each story and the resulting data include non-U.S. sources, talk shows, and so forth. Finally, the Kaiser/Harvard Health News Index provided an indication of the top health stories the public followed in 1998.
The primary results from this analysis are based on data from the Lexis-Nexis Academic Major Newspapers and Transcripts databases as described previously. The data were collected and coded from March to June 1999. Media sources included 29 U.S. newspapers, ABC, CBS, NBC, CNN, and NPR.
For each source, all of the stories produced throughout 1998 and containing words related to long-term care in the headline or first paragraph(s) (11,224 stories) were briefly examined. Letters to the editor, obituaries, news about other countries or in non-U.S. papers, talk show discussions, later publication of the same story, and advice columns were not included in these final data. To narrow the data to stories that were most likely to have an impact on the public, I also excluded articles if long-term care was not discussed in at least one third of the story. The resulting 1,380 news stories (1,331 newspaper stories, 29 stories from the three networks, 9 stories from CNN, and 11 stories from NPR) represent news coverage throughout 1998 that focused on long-term care. For the major newspapers, 22 of the 29 newspapers provided stories for the final analysis. (See Appendix, Note 3, for a list of the 22 major newspapers that provided stories for this analysis.)
One aim of this exploratory analysis was to compare media coverage of a variety of long-term care services. The emphasis on 1 year of media coverage rather than on samples of coverage from several years allowed for a complete examination of topics that are reported infrequently.
Coding Methodology
Weber 1990 describes content analysis as a research method used by numerous types of social scientists to make valid inferences from communications, including speeches, historic documents, open-ended interviews, dialog between physicians and patients, news stories, entertainment programs, and so forth. Although the rules of this inferential process vary depending on theoretical and substantive interests, the central idea is to classify the many words of the communication into much fewer content categories.
This content analysis focused on four simple elements of each long-term care story. The first element was the primary topic. At least one third of the story had to refer to the topic for it to be considered primary. The second element was the secondary topic. This variable captured what aspect of the primary topic was the focus of the story. The coder began with a list of likely topics for these two elements that expanded as new topics emerged from the data.
The third element highlighted which long-term care newspaper articles likely had the most impact on public attitudes. Along with other objective characteristics of the story, such as date published and media organization, the page number for each story was recorded. All stories with the page numbers 1, 1A, A1, and A01 were coded as having been published on the front page of the first section of the newspaper. This method of accounting likely missed long-term care stories published on the front page of separate health or medical sections.
To determine how media framed or explained long-term care issues, which was the fourth element, each story was coded for up to three mentions of broader problems or underlying issues related to the primary topic. Again, the coder began with a list of likely explanations that was expanded to include all underlying issues reported throughout 1998. (This variable was not coded for the 34 abstracts describing The Wall Street Journal stories because they did not provide enough information.)
Although the coder was given instructions on how to define each variable and was trained and evaluated to ensure consistency, the results are subject to human error. To test intercoder reliability of the coding, the full texts of 10% of the newspaper articles were also coded by a second coder. Intercoder agreement rates were 89% or greater for all analyzed variables. All of the broadcast stories were coded by two coders, and any discrepancies were resolved by the author.
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). In 4 of the past 5 years, the top story garnered considerably more followers than the next two stories. For example, in 1996, 69% of the public closely followed stories about the TWA crash in July compared with about 56% of the public who closely followed stories about the pipe bomb set at the Olympics held in Atlanta, GA, in July and the presidential election results discussed in December. In 1998, the top story had fewer close followers than top stories in other years, and the second and third most followed stories had similar numbers of followers. In 1998, all of the most closely followed stories related to gun violence. About half of the public closely followed stories about shootings in schools in Jonesboro, AK, and Springfield, OR, in March and June, respectively, and the shooting of a Capitol Hill police officer in July.
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Despite considerable news coverage in newspapers and on CNN and NPR, long-term care was not one of the top health-related issues that the public followed in 1998 (Kaiser/Harvard Program on the Public and Health Policy 1998). Stories about tobacco (antismoking legislation in May and a possible legal settlement in November), the bombing of an abortion clinic in Birmingham, AL, in January, and the hope for a cure for cancer in May were the top three general health stories that the public closely followed. The top three health policy stories the public closely followed were President Clinton's proposed changes to Medicare in January, consumer protection legislation for people in HMOs/managed care in July, and reports about HMOs and other health plans pulling out of Medicare in September and October.
The primary focus of this analysis was the 1,380 stories that focused on long-term care topics that were published and broadcast by the major newspapers and broadcast media throughout 1998. Both CNN and NPR averaged about 1 long-term care news story per month. Twenty-two of the major U.S. newspapers averaged about 60 stories focusing on long-term care stories per year. A regular reader of one of these major newspapers could have read about 5 long-term care stories each month. Including the seven major U.S. newspapers that did not have a story that focused on long-term care as defined in this study, the average number of long-term care stories published each month became 4.
The volume of long-term care media coverage tends to ebb and flow throughout the year in response to the occurrence of newsworthy events and editorial choices concerning which news should be reported and how much. For example, readers of 22 major U.S. newspapers saw the most number of articles about long-term care (134) in October of 1998. The Boston Globe (Massachusetts) and the St. Petersburg Times (Florida) had the largest number of articles in October with 19 and 18, respectively. For both of these papers, more than 80% of the long-term care stories concerned local health care providers and elderly citizens rather than national policy. In comparison, the number of network news stories about long-term care peaked in July at 16. Ten of these stories were prompted by an investigation into the quality of care in California nursing homes and a White House report highlighting nursing home abuse that led to hearings in Congress and proposals from President Clinton for addressing the problems. CBS dominated the network coverage of long-term care in July with 10 stories, 6 of which were about abusive care in nursing homes.
Nursing Homes Were the Most Covered Long-Term Care Topic in 1998
Nursing homes were the primary topic for the largest percentage of long-term care stories in 1998 for each of the media sources (Table 2 ). The network news had the highest percentage of long-term care stories about nursing homes with 76% of their 29 stories, followed by 64% of NPR's 11 stories and 56% of CNN's 9 stories. Thirty-eight percent of the 1,331 newspaper articles about long-term care were about nursing homes.
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For two of the media sources, one element of the primary topic was highlighted in about half of the coverage (Table 3 ). Fifty-two percent of the long-term care coverage in major newspapers reported business-related elements, such as mergers or hiring practices. Fifty-six percent of the CNN coverage highlighted quality-of-care issues concerning the primary topic. Quality of care and other issues coded as miscellaneous were the elements of interest for 38% and 31% of the network news coverage, respectively. The NPR coverage did not tend to focus on any one aspect of the primary topics.
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Long-Term Care Topics on the Front Page in 1998
In 1998, 12% of all newspaper coverage of long-term care topics was featured on the front page (Table 4 ). For each of the three long-term care topics most often covered, nursing homes, assisted living facilities, and home health care, the percentage of each topic's coverage that was reported on the front page ranged from 11% to 13%. None of the long-term care topics covered in 1998 garnered more than 20% of coverage on the front page. The Lexis-Nexis Academic Universe database did not include the necessary information to extend this analysis to the other news mediums.
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Unfiltered counts of any mention of long-term care indicate that 1998 may be the beginning of an upward trend in media coverage of long-term care. With the exception of CNN, the volume of long-term care coverage in 1998 is likely indicative of the volume in recent years.
A look at the top stories closely followed by the public in the past 5 years shows that although the specific stories differ each year, the trend is the same. No health-related story was the most followed story in any year since 1995.
Assuming that the public's attention to a story is influenced by its volume of media coverage, the relatively low levels of attention for the top three issues in 1998 suggest that there may have been more space for coverage of health issues in 1998. The number of stories closely followed by at least one third of the public suggests that the public closely followed more topics in 1998 than in any year since 1995. In 1998, 16 topics were closely followed by at least a third of the public compared with the next closest year, 1996, in which 12 topics were closely followed by at least one third of the public. However, among the 16 topics closely followed by a third of the public in 1998, including three stories about weather-related events and three stories about aspects of President Clinton's impeachment scandal, none were health related.
Looking more specifically at the context of long-term care coverage in 1998 reveals a similar picture. Of the top health-related stories in 1998, none concerned long-term care. By these measures, health-related issues tended not to be the topics that people followed closely, and when they did follow health issues, long-term care did not capture their attention.
The public's lack of attention to long-term care topics in the news throughout 1998 may be the result of how long-term care topics were presented to the public. Long-term care events and issues were reported in a small percentage of both health-related coverage and all coverage throughout 1998. Additionally, long-term care topics tended not to be emphasized on the front page of newspaper coverage. By volume and placement, stories about long-term care did not have much opportunity to capture the public's attention throughout 1998.
When media did publish or broadcast stories about long-term care, nursing homes were the topic most often featured. Nursing homes attract media attention, in part, because their problems often involve conflict between real people that can be easily described and pictured (Jamieson and Campbell 1992). Additionally, a significant amount of government money funds nursing home care compared with other long-term care arrangements that have recently emerged as viable alternatives. The government's focus on the funding and quality of nursing home care and the public's familiarity with local nursing homes ensure that nursing homes will be an issue of ongoing concern for many media organizations.
This cycle—which leads from public experience with nursing homes, to media coverage of nursing homes, to public demand for programs and policies concerning nursing homes, to government funding and regulation of nursing homes, to more media coverage of nursing homes, and so on—also helps to ensure that the public's expectations about long-term care policy include solutions to problems with nursing home care. Any strategy for expanding long-term care policy discourse should attempt to generate similar cycles for other types of long-term care services. Suggestions for how gerontologists may play a role in this type of strategy are offered in the following paragraphs.
Few of the stories about long-term care discussed the broader context surrounding the topic. This pattern suggests that no single underlying issue, such as rapid market growth or cuts in government funding, is being used to frame the reported long-term care topics. The choice of which context to link to long-term care issues affects how people judge the importance of these issues, whether or not they are willing to support policy action, and which actions they will support. For example, people may be more willing to invest government resources to address a long-term care issue if the problem is linked to conditions beyond anyone's control, such as an aging population, rather than the business practices of health care providers. Watching for the emergence of particular explanations for long-term care issues in media coverage should be an important task for researchers during future policy debates. These results provide a baseline for future trends.
The results of this study should be viewed in light of serious consideration of what media coverage of long-term care should entail. Is an average of five newspaper stories a month the "right" amount of coverage for long-term care issues? What is the "right" mix of topics or emphasis on the front page? How should we determine the standard? Should the volume of coverage be compared with other health-related issues? With changes in demand for long-term care services? Solely based on the occurrence of "newsworthy" events? Should coverage reflect the balance of government funding?
As markets for long-term care develop and demand increases, now is the time for proponents of community and home-based long-term care alternatives to develop strategies to systematically influence whether or not journalists cover a range of long-term care options and how. Guided by a vigorous debate concerning what the public should know about long-term care and how long-term care should be covered by media, policymakers, researchers, and health care providers should establish professional relationships with journalists who cover long-term care issues. Long-term care experts should "report" research findings and possible stories about long-term care to their journalist colleagues. Researchers and health care professionals should also provide the dreaded "sound-bite" or brief explanation that can provide context to newsworthy events, such as legislative proposals or political debate about Medicare financing. Finally, experts should become involved with organizations, like the Association of Health Care Journalists, that strive toward better coverage of health issues. As a reliable source of information about long-term care issues, experts who direct attention to newsworthy long-term care topics or provide context for long-term care issues in a manner that can easily fit into a news story can influence media coverage of these issues and, ultimately, the public's view of national affairs.
This analysis is the first step toward a more comprehensive view of information provided by media and its effect on the public's knowledge and attitudes toward long-term care issues and services. Future research could expand these findings via the following suggestions.
A more sophisticated analysis of the content of media coverage of long-term care would lead to a better understanding of the quality of the coverage and what the public can learn from the information. Although parsing news stories into objective categories may not capture the full meaning of the story when the story elements are combined, researchers can examine elements other than the topic of the story (e.g., words used to describe problems and policies, how often stories rely on objective measures of problems, and expert and political sources used to provide context for the story) to gain a better understanding of media messages (see Brodie, Brady, and Altman 1998; Colby and Cook 1991).
Analysis of the text of media stories does not capture all of the information that the viewer or listener gets when watching news on television or listening to news on the radio. A more comprehensive study of broadcast media would also analyze the images and sounds that add meaning to the words that are broadcast (see Jernigan and Dorfman 1996).
One goal of media communication analysis is to link media messages to public knowledge and attitudes about long-term care. Establishing this link would require a longitudinal study of media coverage, the results of which could be correlated with changes in public knowledge and opinion (see Fan and Norem 1992). A longitudinal study of long-term care coverage would also establish trends in coverage that can be monitored.
Two additional dimensions can be explored to expand the findings of this study. The first dimension would be an examination of why media cover long-term care as they do. Data for this type of analysis would include interviews with journalists to determine how long-term care stories are generated; a study of long-term care stories provided by wire services that provide stories to media outlets; and an examination of the occurrence of events, problems, research studies, or legislation that could be the impetus for a news story. The second dimension is the link between knowledge that Americans may gain from media and the effect of this knowledge on their behavior. Although evidence linking political knowledge and voting or other political behavior is mixed, there is some indication that people act on health-related information they receive. (For a review of the role of political information, see Bartels 1996.) More than half of Americans (58%) say that they have changed their behavior or taken an action as a result of having read, seen, or heard a medical or health news story in media (National Health Council 1997). This finding suggests that understanding media messages is important for understanding personal health choices as well as the general direction of public policy.
Finally, future studies of media presentation of long-term care should explore other news sources, especially local and internet sources, and non-news sources of information that are provided via media. Advertising, music videos, and entertainment shows also provide information and images concerning older Americans that can affect the public's view of long-term care.
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Received for publication March 15, 2000. Accepted for publication August 22, 2000.
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Major newspaper sources for story counts in 1995–1999 were The Arizona Republic, Asian Wall Street Journal Week (abstracts), Atlanta Journal and Constitution, Banking Law Newsletters, The Boston Globe, The Boston Herald, Chicago Sun-Times, Chicago Tribune, The Cleveland Plain Dealer, Daily Mirror and Sunday Mirror, Daily Record and Sunday Mail, The Daily Yomiuri, The Daily/Sunday Telegraph, The Dallas Morning News, Financial Times, The Gazette (Montreal), The Guardian, Herald (Glasgow), The Houston Chronicle, The Independent, Jerusalem Post, Los Angeles Times, The Louisville Courier-Journal, Minneapolis Star Tribune, Morning Call (Allentown), New York Times, Newsday, The Observer, Orlando Sentinel, Rocky Mountain News, Sacramento Bee, San Francisco Chronicle, Scotsman/Scotland on Sunday, The Seattle Times, Singapore Business Times, Singapore Straits Times, South China Morning Post, St. Louis Post-Dispatch, St. Petersburg Times, Times and The Sunday Times, The Toronto Star, USA Today, The Wall Street Journal (abstracts), and The Washington Post.
The news sources providing stories for analysis were the major U.S. newspapers The Arizona Republic, Atlanta Journal and Constitution, The Boston Globe, The Boston Herald, Chicago Sun-Times, The Cleveland Plain Dealer, The Hartford Courant, The Houston Chronicle, Los Angeles Times, The Louisville Courier-Journal, Minneapolis Star Tribune, New York Times, Rocky Mountain News, Sacramento Bee, San Francisco Chronicle, The Seattle Times, St. Louis Post-Dispatch, St. Petersburg Times, USA Today, USA Weekend, The Wall Street Journal (abstracts), and The Washington Post. We also used the broadcast news transcripts of ABC News, CBS News, NBC News, Cable News Network (general, not financial), and National Public Radio.
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