INTRODUCTION

Media advocacy, the strategic use of mass media to support community organizing and advance healthy public policy (39), evolved in the late 1980s as tobacco and alcohol control advocates observed the policy success of public interest and consumer groups working on similar issues (38). Public interest advocates employed an array of strategies and tactics that were more common in political campaigns than in public health efforts (12). Public health efforts, however, had a strong basis in epidemiology. This article describes the result of that evolution: an approach that blends science, politics, and advocacy to advance public health goals. We begin by explaining how media advocacy can bolster public health practitioners' efforts to advance social justice and work to solve some of our country's most complex social and political issues. We discuss the foundations of media advocacy, how the theory translates to practical application, and the challenges of evaluating media advocacy campaigns.

Public Health as Social Justice

For more than a generation, public health practitioners have been guided by the work of Daniel Beauchamp, who argues that the ethic of public health is social justice, “a way of asserting the value and priority of all human life” (3, p. 8). Beauchamp called for newly constructed collective definitions of public health problems that clearly communicate “that the origins of [death and disability] lie beyond merely individual factors,” which have since been described as the socio-ecological model (3, p. 9). A formidable barrier to achieving social justice is the competing ethic of market justice. Beauchamp explains that market justice is rooted in the basic notion that the unfettered marketplace is the best way to serve people's desires. Market justice ideals have long dominated political and cultural life in the United States. Much of the debate on public health policy issues concerns whether or how to restrain the marketplace with regulation, which, according to market justice ideals, should be tolerated only in limited circumstances. Tensions between social justice and market justice values are at the heart of nearly every major public health policy debate.

Public Health Moves Wicked Problems Upstream

According to the Institute of Medicine, the basic mission of public health is to ensure the conditions in which people can be healthy (8). When public health practitioners acknowledge that personal behavior is only part of what determines health status, they must contend with the physical, social, and political environments surrounding individuals. Public health's defining metaphor—the upstream/downstream story—illustrates this perspective: If health workers are so busy rescuing drowning people downstream (i.e., people who are already sick or dying), then they do not have time to go upstream to see what is causing so many people to fall into the river (i.e., get sick) in the first place. Although medical treatment is essential—and often in short supply—the mission of public health in particular is to go upstream and identify the determinants of health status for populations, to intervene, and to develop policies that will foster conditions that stop the problems before they start. Upstream approaches recognize that social, political, and economic factors require basic social change to alter the conditions under which people easily fall into the river.

Upstream problems are complex, “wicked problems” with layers of cause and effect that are difficult to disentangle from society's other social problems, such as poverty, unemployment, education, or housing (34). In their seminal paper, Rittel & Webber (34) argue that social scientists searching for rational answers to society's ills must wrestle with how political interests influence the definition of the problem itself: “[T]he formulation of a wicked problem is the problem!” (p. 161, emphasis in original). Wicked problems are not amenable to technical fixes; they require political solutions that very often involve government. However, trust in government has declined precipitously (30) in the United States in the early twenty-first century as politics have become more polarized and the role of government—and so the role of public health—has been challenged. It is in this political context that public health advocates used media advocacy to make the case for the policy solutions they seek.

Public Health Focuses on Policy

Policy is an important tool for reaching public health's ambitious goal and improving the social determinants of health. Policies define the structures and set the rules by which we live. If public health practitioners and community organizers are going to improve social conditions and physical environments in lasting and meaningful ways, they must be involved in policy development and policy advocacy.

Media advocacy is a tool for those working upstream on primary prevention policy that transforms environments. Changing the terms of debate so that upstream policy approaches are considered fairly means public health advocates must be able to explain that other forces, in addition to genetics and personal choice, affect health (11). Media advocacy applies social justice values to the practice of addressing the social determinants of health.

MEDIA ADVOCACY: A TOOL FOR IMPROVING ENVIRONMENTS AND PROTECTING POPULATIONS

As a tool for advancing and supporting community organizing and policy advocacy, media advocacy draws on theories from political science, cognitive linguistics, sociology, and other fields concerned with how public opinion is formed and political behavior is influenced. In particular, agenda-setting and media-framing theories underlie and inform media advocacy practice.

Media Advocacy Differs from Other Health Communications

Most health communications treat audiences as consumers, targeting them with information so they can reduce their risk for illness or injury. Other communication strategies operate from exchange theories that assume the health problem derives from a lack of information (12). In these approaches, the people with the problem are the audience for top-down messages exhorting healthier behavior.

Media advocacy is less about delivering a message and more about raising voices in a democratic process using policy to change systems and conditions. Rather than targeting the people with the health problem, media advocates target policy makers and those who can be mobilized to influence them (40), harnessing the power of the media to apply pressure on decision makers for policy change. Media advocacy's narrow audience is the policy decision maker—sometimes a single person or a few committee members. The policy action will ultimately affect whole populations, but the target for the actual policy change is narrow. Media advocacy helps people understand the importance and reach of news coverage, the need to participate actively in shaping such coverage, and the methods for doing so effectively.

Theoretical Underpinnings of Media Advocacy

Media advocacy's blend of science, politics, and advocacy means that it draws on several theoretical foundations and disciplines, including political science, communications, and cognitive linguistics. Agenda setting and framing have been the core concepts informing media advocacy strategy.

Successful policy advocates pay attention to the news because the news media largely determine what issues we collectively think about, how we think about them, and what kinds of alternatives are considered viable; the news media set the agenda and terms of debate for policy makers and the public (9, 16, 25, 26). The public and policy makers do not consider issues seriously unless they are visible, and they are not visible unless the media have brought them to light. Public health advocates cannot afford to have their issues go unnoticed or to be caught unprepared when the events of the day catapult their issues into public discussion. Media advocacy helps advocates be prepared to create news and react to news on their issues.

Framing, a key component of media advocacy, is the process by which people extract meaning from content of all kinds, including words, pictures, or interactions. Cognitive linguists have described how all audiences come to new information they see or hear with preformed ideas about the way the world works, why problems occur, and who is responsible for solving those problems (21). This process of reconciling new information with one's existing understanding is called framing. In an unconscious and automatic process, people weigh new information against well-formed ideas that have been reinforced in their thinking over time. We call these established ways of thinking the default frame.

Understanding the default frame is a fundamental precursor to developing a media advocacy strategy. In the United States, the default frame is typically one of rugged individualism that emphasizes personal responsibility for solving problems. In the case of housing, for example, a default frame would suggest that families are responsible for working hard enough to afford a home and for keeping their own homes safe and healthy. But this frame is an incomplete understanding of housing because it leaves out other actors, including the role of government in providing mortgage benefits or city services such as water and garbage collection, among others, to protect residents and create environments that are healthy for all to enjoy. Public health advocates often have to reframe issues from an individual to an environmental perspective, showing that where people live, work, and play directly affects health.

Although people can hold multiple, even contradictory, frames in their heads concurrently, the ones that get triggered and repeated more often have a better chance of influencing people's interpretations. Although people may inherently understand that it is not tenants' fault if they live in houses with lead paint, for example, the default frame will lead many people to blame tenants, asking questions such as, “Why don't they do a better job keeping the house clean?” (a question that misunderstands the nature of residential lead poisoning) or “Why don't they just move?” (a question that assumes resources and mobility that are not available to some families). In this case, housing advocates would need to understand and explain the complex issues behind substandard housing to reframe the issue to one of shared responsibility that can reinforce and support policy change for reducing health impacts from lead paint exposure. Because of the power of default frames, it is not always obvious that the solution will likely involve a role for government in addition to appropriate personal responsibility.

Media advocacy focuses on media framing, defined by Entman (15) as selecting and making salient certain aspects of perceived reality “in such a way as to promote a particular problem definition, causal interpretation, moral evaluation, and/or treatment recommendation for the item described” (p. 52). Media advocates refine the concept as framing for access, the objective of which is to capture journalists' attention by focusing on what is considered newsworthy, and framing for content, the objective of which is to reframe a public health issue to highlight environmental factors, core values, and the desired policy solution. This typically means that media advocates must emphasize shared individual and societal responsibility for solving problems. This frame tends to be deemphasized in news coverage, which often highlights individuals and events. Iyengar (18) has found that such episodic news results in audience interpretations that tend to blame the victim, whereas more thematic news helps audiences understand the impact of environments on personal outcomes. In media advocacy, the goal is often to reframe from episodic to thematic frames, which we liken to the difference between stories framed as portraits focused narrowly on individuals or events and those framed as landscapes that can reveal the context surrounding individuals and events (13).

Applying Media Advocacy

Media advocacy may be confused with other health communication strategies such as social marketing or public information campaigns because, at the tactical level, they all strive to garner attention—attention from the public, from policy makers, and from the news. Media advocates may use mass communication to reach a narrow audience of one or two people—members of a legislative committee or a school board, for example—who have the power to make the policy decision that shapes conditions in a given environment. Media advocacy's strategies and tactics keep a sharp focus on supporting community organizing and policy advocacy.

To leverage this democratic process, advocates must be strategic. The layers of strategy framework helps advocates (a) define the problem, the solution, and the party who has the power to make the changes in systems or structures that will improve health outcomes; (b) identify how to reach them with media; (c) determine what to say to them; and (d) ascertain how to attract journalists' attention (4).

The overall strategy articulates the need for change at a structural level in light of the limitations of personal behavior change. The focus on structural change is rooted in the basic public health principle that creating change at the population level will have a greater impact than promoting change one person at a time. In developing an overall strategy, advocates must define the problem they seek to solve, name a specific solution they believe will help address the problem, and identify which individual or body has the power to create the change they seek. Only once advocates have thought through their overall strategy can they begin to consider the media, message, and access strategies that will help them achieve their goal.

The media strategy defines how—or whether—mass media, social media, or personal communication or some combination is best to further the overall strategy. Because in media advocacy the media (in all its modern shapes and sizes) is merely a tool for bringing attention to the need for policy change, and not an end unto itself, advocates must determine if and how the media will advance their policy change goals. Thus if advocates can influence the target in other ways, such as through in-person meetings or direct pressure from constituents, there may not be a need to engage the news media. And, if the media can be an effective vehicle for putting the issue on decision makers' agendas, developing a solid media strategy means thinking through which modes of communication and which news outlets will be most effective. Do the targets get their information from the local newspaper? Do they pay attention to online and social media sources? Do they listen to the radio? In today's information environment, it is likely a combination of all of these. For example, if advocates can negotiate with city government to remove lead contamination from its low-income housing stock, there may be no need for media advocacy. But if the city balks, then news coverage highlighting the health harms and policy solution could spur otherwise reluctant decision makers to act.

The message strategy includes the message, the messenger, and the audience: what will be said, who will say it, and to whom (as identified in the overall strategy). Messages generally answer three questions: What is the problem? What is the solution? And why does it matter? How the message is framed, including expressing shared values and moving from portraits to landscapes, can influence how the targets understand the problem and whether they recognize the solution as legitimate. The message will help advocates determine which details reporters will need when telling stories from a public health perspective. For example, a story about a child with lead poisoning may be dramatic and compelling but will do little to inspire action or systems change if there is no specific solution or policy goal illuminated in the story. In fact, the story may do more harm than good if it reinforces the idea that parents can solve this issue on their own.

The access strategy is about gaining access to journalists, bloggers, and others who have access to the desired audience (i.e., people in positions of power to create change). This strategy includes determining when and how to seek media attention and prepare spokespersons to deliver the message. An effective access strategy takes into consideration when media attention can have an impact on the policy process, perhaps leading up to a vote or budget deliberation, for example, and on what about the issue is newsworthy. Ultimately policy change takes time; inevitably, advocates will need to revise and redirect even the most thorough media advocacy plan. The most historic and far-reaching public health interventions—such as ensuring clean indoor air and clean water sources—have been and remain long-term policy battles. By working through the layers of strategy, and revisiting their goals and objectives, media advocates can track their progress and reroute themselves when needed.

Story elements are the pieces that reporters put together to tell a story—a picture, an interesting fact, a compelling statement from a source. Advocates cannot control how the reporter frames the issue, but they can control whom they put forward to make the case, what those spokespeople say, and how they illustrate the problem and solution. For example, a story about a family struggling to treat their child's asthma condition might be a vehicle for discussing the importance of access to asthma medication. But framing research shows that a story that focuses too narrowly on individuals will not help audiences understand the environmental factors at work (18). Media advocates think about what they can provide to reporters to help them tell an interesting story that supports the overall policy goal using various story elements: authentic voices, media bites, social math, and visuals.

Authentic voices are spokespeople who can provide a unique perspective on the problem and the need for a solution based on their personal or professional life experience. They might have suffered from the problem directly (typically referred to as victims or real people by reporters), such as those exposed to secondhand smoke living in multiunit housing or working in a restaurant where smoking is allowed. Or they might have other direct experience with the issue, e.g., as tobacco researchers, corner store merchants, health care providers, or community members. Media advocates think carefully about the range of authentic voices they can prepare to make their case because, as the saying goes, “the messenger is the message.” News professionals and the targeted decision makers will respond to who is speaking, not just to what they say. For example, researchers presenting information on the effect of tobacco marketing on children's health may be received differently than would young people who have quit smoking who make the same argument. Once advocates have cultivated and trained the right spokespeople, they can make their case in a variety of settings from community meetings and policy hearings to press events. People directly affected by the problem can become effective spokespeople by linking their experience to the need for a population-wide policy solution. For example, Newtown, Connecticut, emergency room physician Dr. William Begg told a Senate panel on gun violence, “People say that the overall number of assault weapon deaths is small. Please don't tell that to the people of Tucson or Aurora or Columbine or Virginia Tech, and don't tell that to the people in Newtown. This is a tipping point, and this is a public health issue” (41). Not every spokesperson has to say exactly the same thing, but they have to mean the same thing. Campaigns will rely on different authentic voices depending on the setting, audience, or immediate goal.

Reporters face serious time and space constraints in their stories, and social media has condensed text even further, sometimes down to 140 characters. No matter how complicated the issue, only a few sentences from the most compelling spokespeople are likely to appear in any given news story. The challenge is for advocates to create concise statements—media bites—to increase the chance that their most important points are repeated.

Media bites communicate the core message but may be tailored to respond to a specific hard question or be shortened to emphasize one key point.

When developing strong messages, advocates must also avoid statements that could undermine their overall strategy. Taking a cue from cognitive linguist George Lakoff, who argues that saying “Don't think of an elephant!” (21) practically guarantees listeners will think of an elephant, media advocate Liana Winett warns that when advocates find themselves using “not,” “despite,” or similar terms in their media bites, they are probably invoking the opposition's argument, what she calls “elephant triggers” (L. Winett, personal communication). For example, advocates for restrictions on sugary beverages reinforce their opposition's frame when they defend their policy choice with statements such as, “We're not trying to be the pop police or anything…” (36). The advocates' intentions in these examples are to bolster support for their goal by addressing concerns about government overreach. But they put their goal in terms of their opponents' frame instead of establishing their own frame about health. The practice of answering the opposition's claims is appropriate in some contexts, but with media advocacy, especially in a media bite that is likely to be repeated without much background, advocates should avoid repeating the opposition's frame.

Every day we are bombarded with news stories involving very large numbers. Media advocates use “social math” to translate statistics and other data so they become interesting to the journalist, meaningful to the audience, and helpful in advancing public policy (39). Social math uses comparisons to other issues, populations, geographic areas, changes over time, or policy solutions. It can be created by restating large numbers in terms of time or place, personalizing or localizing numbers, or making comparisons that help bring a picture to mind. The best social math surprises people and provokes an emotional response. Social math examples can be a powerful tool because striking comparisons stay with people and can become part of the policy debate.

Whether they are broadcast, print, or web-based, media stories rely on images in our increasingly visual culture. When advocates pitch an event or story, reporters will often ask, “What will I see when I get there?” What they are really asking is, “What will I show my viewers or readers if I do this story?” If the policy goal is to reduce the pollution that causes high rates of asthma, advocates could hold a press conference outside so that reporters can photograph the sources of pollution, such as a refinery spewing toxic exhaust or a highway filled with diesel trucks. Good visuals can help reporters—and decision makers—see past an individual portrait to the landscape.

Since the rise of Facebook, Twitter, and other social media, many have speculated about the potential of these social media to move huge numbers of people toward a common goal. It remains to be seen whether the platforms facilitate advocacy and political pressure (37) or if they merely allow like-minded people to expedite their communication with each other.

What we do know, however, is that social media are making news—and so media advocacy—faster, more widespread, and perhaps, more effective. Consider one example.

In February 2012, the Susan G. Komen for the Cure Foundation announced a decision to discontinue breast cancer screening funding to Planned Parenthood Affiliates of America owing to Komen's policy not to contribute to organizations under congressional investigation. In 2011, a House of Representatives subcommittee initiated an investigation into Planned Parenthood's compliance with rules about the use of federal funds to support abortion-related services (31).

In response, the Planned Parenthood Federation of America launched a social media campaign to raise awareness—and money—to challenge Komen's decision (31). Komen reversed its decision three days later. In those three days, the number of “likes” on Planned Parenthood's Facebook page shot up by 10,000, and the organization raised $3 million (more than three times the amount that Komen had threatened to cut) (23, 28, 32).

The Komen decision and subsequent reversal illustrate the speed of online media advocacy. Very quickly, Planned Parenthood's supporters made their voices heard and put pressure on Komen. They did this primarily through Facebook, where thousands of users posted comments about their disagreement with the Komen decision. Social media allowed Planned Parenthood's supporters to respond in real time and bring national attention to an issue that may have otherwise flown under the media radar (33).

Planned Parenthood framed the decision as Komen “succumb[ing] to political pressure” and “jeopardiz[ing] any woman's access to lifesaving screenings and services” (31). Moreover, by waiting three days—a long time by social media timetables—Komen lost any opportunity to reframe the online conversation and instead was forced to respond to Planned Parenthood's frame. In addition, by focusing on its breast cancer screening services—an issue far less political than the contraception and abortion services with which the organization is usually associated—Planned Parenthood was able to broaden its support base, including members from many of the local Komen affiliates who were worried about losing access to screening and treatment (19).

Beyond the unique aspects of an online media strategy, Planned Parenthood's efforts were successful in large part because its leaders applied the organization's overall strategy to guide the campaign. For decades, the Planned Parenthood headquarters (where much of its advocacy work is rooted) and the local clinics (where services are delivered) have focused on one singular goal: increasing women's access to health services. Despite that most news reports highlighted the long-standing pressure on Komen from conservative groups to cut ties with an organization that supports abortion rights, Planned Parenthood focused its efforts on how the cuts would limit women's access to health services (2). To this end, the organization repeatedly included references to “education,” “screening,” and “life-saving services” in its message about what was at stake as a result of the Komen decision (31).

Ensuring that the overall strategy informs the message and media access strategies is critical for media advocacy, online or otherwise. The Planned Parenthood campaign was successful because of the explicit link it made between Komen's decision and Planned Parenthood's overarching goal to provide access to health services for women.

In terms of its media strategy, Planned Parenthood made a very conscious decision to leverage the media (social media, in this case) to get its message across. Planned Parenthood tried to engage directly with Komen to protest the funding cuts, and when it received no response (31), took its message directly to Facebook, where it used public outcry to put pressure on Komen. This strategy was a risk because there was no guarantee that the public was going to support Planned Parenthood's campaign, but ultimately it was very savvy.

Planned Parenthood's message strategy focused on the specific breast cancer services that would be lost by the funding cuts. The organization strategically focused the conversation on breast cancer screening to remind the public that the organization provides an array of women's health services, not just abortion (which is significantly more controversial than breast cancer services). This message strategy likely helped Planned Parenthood gain such widespread support, including from people who may not support abortion rights.

Planned Parenthood likely used social media as part of its media access strategy because social media allows a message to be delivered in real time; thus, the organization could rally support quickly, potentially faster than Komen could craft a response. Facebook (and other social networking sites) are controlled by their user base, so Planned Parenthood did not have to depend on newsroom editors to decide if they wanted to pick up the story. Ultimately, the momentum of the Planned Parenthood campaign in itself became a news story in key national outlets such as the New York Times, which helped Planned Parenthood put pressure on Komen to change its decision.

Evaluating Media Advocacy

Media advocacy is difficult to evaluate. The key outcome measure for media advocacy is whether the desired policy is passed. However, disentangling media advocacy's contribution to the policy process from the effects of community organizing or policy advocacy—or other events or secular trends—is challenging, especially because policies can take years, sometimes decades, to pass. For these reasons, most evaluations of media advocacy are qualitative case studies that describe the process of conducting media advocacy. A few experiments have verified the theoretical foundations of media advocacy (24). Most evaluations of media advocacy have examined efforts to enact either tobacco or alcohol control policy, likely because media advocacy was developed first in those fields. As media advocates expand their practice, we should start to see media advocacy evaluated in other public health policy arenas (10).

Media advocates regularly assess their results by examining the news coverage they generate to ascertain whether they got what they intended, how the issue was covered, and whether the coverage appeared in outlets viewed by their target(s) (40). Beyond a single campaign, media advocates evaluate success by determining whether they have become a regular source for journalists. Once advocates become a source for reporters, they have a great opportunity to provide their data and information in the stories that get told about their issue. Becoming a reliable media source is a long-term win for media advocates. In addition, media advocates can assess whether their efforts helped them build community support for the overall goal. Although community outreach is not necessarily the first objective of media advocacy, a strong campaign can measure its success in part by how much community support it has. After all, the more people who are bolstering and delivering a strong public health message, the more decision makers will feel the pressure to create strong public health policy.

CONCLUSION

Public health's mission is about improving conditions so that everyone can maintain health and avoid disability and premature death. Changing conditions is an inherently political process that demands decision makers wrestle with competing interests for inevitably limited resources. Media advocacy is one of the few tools public health practitioners have for influencing public debate about those decisions so that health is prioritized. Media advocates use mass media in its most powerful form to foster a democratic process so that residents and others can participate in the decisions that affect the neighborhoods, schools, workplaces, and communities that shape their health. Media advocacy accelerates and amplifies community organizing and policy advocacy, helping public health practitioners, activists, and residents frame their issues so that the landscape of conditions comes into view and public health solutions are illuminated.

disclosure statement

The authors are not aware of any affiliations, memberships, funding, or financial holdings that might be perceived as affecting the objectivity of this review.