Public Health Media Advocacy
by
Lori Dorfman, Michael Bakal, Priscilla Gonzalez
  • LAST REVIEWED: 28 June 2017
  • LAST MODIFIED: 23 August 2017
  • DOI: 10.1093/obo/9780199756797-0111

Introduction

The history of public health is clear: social conditions and the physical environment are important determinants of health. To improve social conditions and physical environments in lasting and meaningful ways, public health practitioners must be involved in policy development and policy advocacy, since policy defines the structures and sets the rules for society. News portrayals of health issues are significant for how they influence policymakers and the public regarding who has responsibility for preventing and treating health problems. Issues are not considered by the public and policymakers unless they are visible, and they are not visible unless the news or other media have brought them to light. Media advocacy is an approach to health communications that helps people understand the importance and reach of news coverage, the need to participate actively in shaping such coverage, and the methods to do so effectively. While media advocates do reach beyond news media to advertising and entertainment as well as social media, news remains a priority because of its influence on policy. Media advocacy differs significantly from traditional mass communications approaches because it focuses on changing conditions and environments rather than changing personal health behavior. Media advocacy emphasizes institutional accountability, which typically receives less attention from the news than individually oriented solutions. The practice was developed by tobacco and alcohol control advocates who applied political campaign tactics in the context of scientific approaches to prevention. Public health practitioners continue to use media advocacy in tobacco and alcohol control and have expanded its application to policy advocacy on childhood lead poisoning, violence and injury control, early care and education, nutrition, physical activity, health inequities, and affordable housing, among other issues.

General Overviews

Media advocacy is the strategic use of the mass media to support community organizing to advance a social or public policy initiative. Essential steps include strategy development, setting the agenda, shaping the debate, and advancing policy. Media advocacy may be confused with other health communications strategies such as social marketing or public information campaigns because, at the tactical level, they all strive to garner news attention, sometimes called “earned media.” Media advocacy differs from other health communications in its target audience. Most health communications treat audiences as consumers, targeting the population with the health problem with information so they can reduce their risk for illness or injury. Rather than targeting the people with a particular health problem with information, media advocates target policymakers and those who can be mobilized to influence them. Media advocacy treats audiences as citizens in a democratic process designed to change policies that shape environments. Institute of Medicine 2003, and Wallack and Dorfman 1996 describe the basics of media advocacy with examples from violence, affordable housing, and nutrition, among other topics. Cutting and Themba-Nixon 2003 examines the special case of media advocacy applied to racial justice, which is relevant for public health practitioners working to rectify health inequities. Dorfman and Wallack 1993 explores the application of media advocacy to paid advertising in contrast to public service announcements (PSAs), a common health communications tactic.

  • Cutting, Hunter, and Makani Themba-Nixon. 2003. Talking the walk: A communications guide for racial justice. Oakland, CA: AK Press.

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    Written for activists who want to challenge racist stereotypes in the news, this guide provides a comprehensive overview on how to use media advocacy to reframe the debate and work with journalists more effectively to promote racial justice.

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    • Dorfman, Lori, and Lawrence Wallack. 1993. Advertising health: The case for counter-ads. Public Health Reports 108.6: 716–726.

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      Defines counter-ads as a strategy to frame public health problems in sociopolitical contexts and promote policy, as opposed to public service announcements (PSAs), which tend to focus on uncontroversial notions of behavior change. Uses the first comprehensive tobacco media campaign from California to illustrate the continuum from PSAs to counter-ads.

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      • Institute of Medicine. 2003. Media. In The future of the public’s health in the 21st century. Edited by the Committee on Assuring the Health of the Public in the 21st Century, 307–357. Washington, DC: National Academies Press.

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        Describes the media’s critical role in generating national attention and action on public health issues. Discusses health communication strategies, distinguishes between social marketing and media advocacy. Concludes with a summary of behavior change and media impact theories, and a discussion of evaluation and research.

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        • Wallack, Lawrence, and Lori Dorfman. 1996. Media advocacy: A strategy for advancing policy and promoting health. Health Education Quarterly 23.3: 293–317.

          DOI: 10.1177/109019819602300303Save Citation »Export Citation »E-mail Citation »

          Authors describe a case study of violence prevention in California and one on public housing in Chicago to illustrate how the essential elements of media advocacy—developing strategy, setting the agenda, and shaping debate—can be used to address public health problems.

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          Textbooks

          The first media advocacy textbooks, Wallack, et al. 1993 and Chapman and Lupton 1994, provide a theoretical background in agenda setting, framing, and discourse analysis; the essential elements of media advocacy practice; and case studies of media advocacy campaigns on topics ranging from tobacco, alcohol, injury, and HIV/AIDS, among others. Wallack, et al. 1993, and Wallack, et al. 1999 focus on media advocacy practiced in the United States; Chapman and Lupton 1994 examines media advocacy as practiced in Australia.

          • Chapman, Simon, and Deborah Lupton. 1994. The fight for public health: Principles and practice of media advocacy. London: BMJ.

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            The first half of this book focuses on theory and principles, including the importance of advocacy, how to analyze news coverage, and case studies. The second half describes the “A–Z” strategies for applying media advocacy using case studies and vignettes from various campaigns.

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            • Wallack, Lawrence, Lori Dorfman, David Jernigan, and Makani Themba. 1993. Media advocacy and public health: Power for prevention. Newbury Park, CA: SAGE.

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              Places media advocacy in the context of public health advocacy by articulating the fundamental tension in public health between strategies focused on individual behavior change and those addressing the environments in which health decisions are made. Describes agenda setting, framing, and media advocacy strategies, which are illustrated with short case studies.

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              • Wallack, Lawrence, Katie Woodruff, Lori Dorfman, and Iris Diaz. 1999. News for a change: An advocates’ guide to working with the media. Thousand Oaks, CA: SAGE.

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                Written for practitioners, this guide describes how to do media advocacy focusing on essential skills, including how to integrate media advocacy into an overall strategy, capture journalists’ attention, write letters to the editor and op-eds, and evaluate media advocacy campaigns. Incorporates worksheets and case studies.

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                Comparative Works

                Although social marketing can include attention to policy as well as behavior change, this body of work argues that, in practice, social marketing usually focuses on individuals rather than the conditions in which individuals make their health decisions. A key distinction is that social marketing generally focuses on supporting an exchange process that offers individuals health benefits by adopting new behavior, while media advocacy generally focuses on the policy process for changing the social and environmental conditions that shape health outcomes. This means that the “target audience” for social marketers is the population whose behavior needs to change; for media advocates, it is the policymakers with decision-making power and those who can apply direct pressure to policymakers. The authors describe the differences between various health communications strategies and explain why media advocacy is usually the best choice when the objective is to improve social and physical conditions by changing policy. Atkin and Wallack 1990 explores why traditional forms of mass communications, such as public information campaigns, have seen limited success, and makes the case for media advocacy. Rice and Atkin 2001 provides an in-depth overview of public education campaigns, while Wallack and Dorfman 2001 focuses on how media advocacy helps incorporate policy solutions to change environments rather than behavior. Winett and Wallack 1996 explains the differences between public information campaigns, social marketing, and media advocacy.

                • Atkin, Charles K., and Lawrence Wallack, eds. 1990. Mass communication and public health: Complexities and conflicts. Newbury Park, CA: SAGE.

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                  An anthology that discusses the influence of the mass media on public health issues. Explores shared responsibility and policy-making priorities. Chapter 11 deals directly with media advocacy, contrasting it with social marketing.

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                  • Rice, Ronald E., and Charles K. Atkin, eds. 2001. Public communication campaigns. 3d ed. Thousand Oaks, CA: SAGE.

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                    An anthology of public communication campaigns, their foundations, design, evaluation, and challenges, along with selected case studies. Chapter 31 focuses on the role of media advocacy, contrasting it to traditional health communication campaigns, and discussing the essential elements of media advocacy.

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                    • Wallack, Lawrence, and Lori Dorfman. 2001. Putting policy into health communication: The role of media advocacy. In Public communication campaigns. 3d ed. Edited by Ronald E. Rice and Charles K. Atkin, 389–401. Thousand Oaks, CA: SAGE.

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                      This chapter provides a brief overview of media advocacy and describes how its orientation differs from other health communications practices. The authors argue that media advocacy is necessary when the public health goal is focused on changing environments rather than personal health behavior.

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                      • Winett, Liana B., and Lawrence Wallack. 1996. Advancing public health goals through the mass media. Journal of Health Communication 1:173–196.

                        DOI: 10.1080/108107396128130Save Citation »Export Citation »E-mail Citation »

                        Authors describe and differentiate among three media strategies used to advance public health: social marketing, public relations, and media advocacy. They define social marketing and public relations as focused on information and changing behavior, and media advocacy as addressing gaps in power and resources at a systems level.

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                        Theoretical Foundations

                        The foundation of media advocacy is policy advocacy that is sometimes considered controversial within public health. Media advocacy draws on theories from political science, cognitive linguistics, sociology, and other fields concerned with how public opinion is formed and political behavior influenced. Theoretical work around agenda setting and media framing underlies and informs media advocacy practice. The theoretical foundation for media advocacy was laid in the late 1980s as public health groups sought to apply the successful strategies used by public interest and consumer groups to public health issues, principally tobacco and alcohol control. Building on this foundation, more recent work has explored the key theoretical issues of policy advocacy, agenda setting, and framing in the context of violence prevention, nutrition, health equity, and other public health issues.

                        Policy Advocacy

                        Policy development is considered a core function of public health, but policy advocacy remains controversial. Some practitioners fear that advocacy undermines the scientific authority that upholds public health. Others argue that without advocacy, public health goals cannot be achieved, as articulated in Chapman 2001. Tobacco control has been a particularly rich testing ground for this debate and a source of strength for policy advocates as tobacco control policies have resulted in demonstrated population health benefits. For example, Blaine, et al. 1997 shows how using media advocacy can help advance tobacco control policy. Freudenberg, et al. 2009 argues that it can also be used to change corporate policies. Finally, Themba 1999 describes how local coalitions have successfully advocated for policy change using media strategies. These articles articulate the realm of policy advocacy in public health, illustrating how advocacy is an essential public health practice.

                        • Blaine, Therese M., Jean L. Forster, Deborah Hennrikus, Stephen O’Neil, Mark Wolfson, and Huy Pham. 1997. Creating tobacco control policy at the local level: Implementation of a direct action organizing approach. Health Education & Behavior 24:640–651.

                          DOI: 10.1177/109019819702400510Save Citation »Export Citation »E-mail Citation »

                          Describes the goals, training, activities, and political factors of a tobacco control intervention that used community organizing and mobilization. Authors discuss how advocacy activities, including media advocacy, contributed to passing of tobacco ordinances in all seven communities investigated.

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                          • Chapman, Simon. 2001. Advocacy in public health: Roles and challenges. International Journal of Epidemiology 30:1226–1232.

                            DOI: 10.1093/ije/30.6.1226Save Citation »Export Citation »E-mail Citation »

                            Chapman provides a critical examination of recurrent debates about the appropriateness of public health advocacy. He reviews when it is justified for the state to regulate the liberty of individuals; answers concerns over advocacy strategies; and argues that advocacy is an essential function of public health.

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                            • Freudenberg, Nicholas, Sarah Picard Bradley, and Monica Serrano. 2009. Public health campaigns to change industry practices that damage health: An analysis of 12 case studies. Health Education and Behavior 36.2: 230–249.

                              DOI: 10.1177/1090198107301330Save Citation »Export Citation »E-mail Citation »

                              A systematic investigation of advocacy to change corporate practices in the alcohol, automobile, food and beverage, firearms, pharmaceutical, and tobacco industries. Authors describe the multiple advocacy techniques and various stakeholders, finding that advocates can achieve policy change and increase mobilization, and that “local campaigns may be more effective than national ones” (p. 230).

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                              • Themba, Makani M. 1999. Making policy, making change: How communities are taking law into their own hands. Berkeley, CA: Chardon.

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                                Written primarily for public health coalitions, this book provides several case studies on local policy work and examines common lessons learned. Chapter 5, “Talking Policy: Media and the Message,” is especially relevant to understanding the role of the media and designing effective policy advocacy initiatives.

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                                Agenda Setting

                                Agenda setting is the process by which an “issue is illuminated, its importance is acknowledged by the general public, and subsequently, action is taken on the issue” (Wallack, et al. 1993, p. 61; see Textbooks). Media advocates aim to set the agenda on their issue with the intention of making it a priority for their policy targets, usually key decision makers, and those who can influence those decision makers. The objective is to put the issue on the public, media, and policy agendas and sustain that attention until they have achieved their objective. The key literature on agenda setting comes from scholars in political science who examine interactions among the media agenda, public agenda, and policy agenda, very often finding that the media agenda dictates the public and policy agendas. Cheyne, et al. 2014 examines, in the context of the debate on banning menthol cigarettes, the competitive agenda-setting efforts of the tobacco industry and public health groups. These citations include the classic study on agenda setting, Dearing and Rogers 1996, along with Dearing and Rogers 1992 on the application of the practice’s concepts to a public health issue (HIV/AIDS). Leskovec, et al. 2009 and Pew Research Center 2010 discuss the changing roles of the mainstream media and social media in setting the news agendas. Salmon, et al. 2003 examines the agenda-setting process in relation to different “public will” campaigns. Smith, et al. 2008 argues that the volume of news can set the agenda in a way that benefits public health goals regardless of the specific news content.

                                • Cheyne, Andrew, Lori Dorfman, Richard A. Daynard, Pamela Mejia, and Mark Gottlieb. 2014. The debate on regulating menthol cigarettes: Closing a dangerous loophole vs freedom of choice. American Journal of Public Health 104.7: e54–e61.

                                  DOI: 10.2105/AJPH.2014.302025Save Citation »Export Citation »E-mail Citation »

                                  This article describes how public health advocates and industry representatives battled to control the agenda around the banning of menthol cigarettes. A key lesson for advocates is that while continuous media coverage of a public health issue may not be a feasible goal, media advocacy efforts should be intensified at strategic moments, such in the days preceding a key vote.

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                                  • Dearing, James W., and Everett M. Rogers. 1992. AIDS and the media agenda. In AIDS: A communication perspective. Edited by Timothy Edgar, Mary Anne Fitzpatrick, and Vicki S. Freimuth, 173–194. Hillsdale, NJ: Erlbaum.

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                                    This chapter uses news coverage on AIDS to illustrate the process of media agenda setting. It contrasts the organized and rapid response to AIDS in San Francisco with the slower national response in the United States, and discusses the role of the New York Times, network television, and the federal government.

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                                    • Dearing, James W., and Everett M. Rogers. 1996. Agenda-setting. Thousand Oaks, CA: SAGE.

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                                      Provides a detailed overview of agenda setting, including the interactions among the media agenda, public agenda, and policy agenda.

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                                      • Leskovec, Jure, Lars Backstrom, and Jon Kleinberg. 2009. Meme-tracking and the dynamics of the news cycle. In Proceedings of the Fifteenth ACM SIGKDD International Conference on Knowledge Discovery and Data Mining, 28 June–1 July, Paris. 497–506. New York: Association for Computing Machinery.

                                        DOI: 10.1145/1557019.1557077Save Citation »Export Citation »E-mail Citation »

                                        The authors propose a technical framework for “meme-tracking” and show how this approach can be used to assess agenda setting in the news media. They conclude that at the time of the study, the mainstream media were setting the agenda for the blogosphere and other online outlets.

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                                        • Pew Research Center. 2010. New media, old media: How blogs and social media agendas relate and differ from the traditional press. Washington, DC: Pew Research Center.

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                                          Examines top news stories that people discuss and link to on blogs, Twitter, and YouTube. Authors find that the mainstream press still tends to set the agenda for social media, although topics differ across platforms based on type of news, source of information, and audience.

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                                          • Salmon, Charles T., L. A. Post, and Robin E. Christensen. 2003. Mobilizing public will for social change. Washington, DC: Communications Consortium Media Center.

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                                            The authors describe public will campaigns, including theories, challenges, strategies, evaluation, and relevant case studies. Section IV (pp. 8–22) is especially relevant to media advocacy and agenda setting, discussing social problem construction, agenda building, framing, mass communication and social perceptions, social capital, and social marketing.

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                                            • Smith, K. Clegg, M. A. Wakefield, Y. Terry-McElrath, F. J. Chaloupka, B. Flay, L. Johnston, A. Saba, and C. Siebel. 2008. Relation between newspaper coverage of tobacco issues and smoking attitudes and behaviour among American teens. Tobacco Control 17:17–24.

                                              DOI: 10.1136/tc.2007.020495Save Citation »Export Citation »E-mail Citation »

                                              Using content analysis of newspaper coverage on tobacco, the authors investigate whether community-level factors influence smoking attitudes and behaviors among youth. Among their findings is that the more news articles published, the greater the odds of perceiving smoking as harmful. Recommends media advocacy as a strategy to generate and sustain news attention to keep tobacco on the public agenda so as to promote “policy change that is protective for youth” (p. 22).

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                                              Framing

                                              Framing, a key component of media advocacy, is the process by which people extract meaning from texts of all kinds, including words, pictures, or even interactions. Media advocacy focuses on media framing, defined by Entman 1993 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). The selected chapters in Ryan 1991 provide a foundation and applications in media framing, and Winett 1997 describes how to conduct a framing analysis. Media advocates further refine the concept as framing for access, where the objective is to capture journalists’ attention by focusing on what is considered newsworthy, and framing for content, where the objective is to reframe a public health issue to highlight environmental factors and the desired policy solution. Typically, this means that media advocates must emphasize shared responsibility for solving problems across individuals and society, articulated by Beauchamp 1976 as the difference between market justice and social justice. This frame tends to be deemphasized in news coverage that often highlights individuals and events. Iyengar 1991 finds that such episodic news results in audience interpretations that tend to blame the victim, while 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 Dorfman, et al. 2005 likens to the difference between stories framed as portraits focused narrowly on individuals or events versus those framed as landscapes that can reveal the context surrounding individuals and events. This set of citations includes the anchoring public health–framing text of Beauchamp 1976, the classic definitional texts of Entman 1993 and Gamson 1992, and more recent research from practitioners who have applied the concepts to issues, such as nutrition in Dorfman and Wallack 2007 and health disparities in Kim, et al. 2010, and violence in Thibodeau and Boroditsky 2011.

                                              • Beauchamp, Dan E. 1976. Public health as social justice. Inquiry 13.1: 3–14.

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                                                Beauchamp argues that the ethic of public health is social justice and that a shift from market justice to social justice values is needed in order to advance public health. Beauchamp’s contrast is a foundation for understanding public health framing as it is applied in media advocacy.

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                                                • Callaghan, Karen, and Frauke Schnell. 2001. Assessing the democratic debate: How the news media frame elite policy discourse. Political Communication 18.2: 183–213.

                                                  DOI: 10.1080/105846001750322970Save Citation »Export Citation »E-mail Citation »

                                                  Using the public conversation around gun control as a case study, Callaghan and Schell examine the extent to which frames presented in the news media mirror frames advanced by interest groups and/or politicians. Their analyses showed that, to a greater degree than expected, media appeared to advance frames that were independent of either group. This study suggests that media may exercise greater autonomy in framing public debates than is commonly understood.

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                                                  • Chong, Dennis, and James N. Druckman. 2007. Framing theory. Annual Review of Political Science 10.1: 103–126.

                                                    DOI: 10.1146/annurev.polisci.10.072805.103054Save Citation »Export Citation »E-mail Citation »

                                                    The authors provide a comprehensive review of framing as understood in the public opinion field. They describe how multiple factors—including audiences’ prior beliefs, the salience of an issue, values, repetition of frames, individual motivation, and perceived relevance—influence public opinion in the context of competitive framing environments.

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                                                    • Dorfman, Lori, and Lawrence Wallack. 2007. Moving nutrition upstream: The case for reframing obesity. Journal of Nutrition Education and Behavior 39:S45–S50.

                                                      DOI: 10.1016/j.jneb.2006.08.018Save Citation »Export Citation »E-mail Citation »

                                                      The authors provide an example of framing applied to nutrition, arguing that it be reframed to include social, economic, and political contexts. They show how the term “obesity” construes nutrition narrowly in terms of personal responsibility that, they argue, could inhibit policy advocacy to change nutrition environments.

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                                                      • Dorfman, Lori, Lawrence Wallack, and Katie Woodruff. 2005. More than a message: Framing public health advocacy to change corporate practices. Health Education and Behavior 32.4: 320–336.

                                                        DOI: 10.1177/1090198105275046Save Citation »Export Citation »E-mail Citation »

                                                        The authors use Beauchamp’s comparison of market justice and social justice as the basis for understanding how the tensions between individual and collective responsibility are framed in public health policy debates. They expand on Beauchamp’s construct with concepts from cognitive linguistics that emphasize the importance of values frames.

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                                                        • Entman, Robert. 1993. Framing: Toward clarification of a fractured paradigm. Journal of Communication 43.4: 51–58.

                                                          DOI: 10.1111/j.1460-2466.1993.tb01304.xSave Citation »Export Citation »E-mail Citation »

                                                          A classic article that offers a well-accepted definition of news frames and framing using mass communication as an example. According to Entman, “framing involves selection and salience and frames define problems” (p. 52). He argues for a consistent definition of framing in the communication literature.

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                                                          • Gandy, Oscar H., and Zhan Li. 2005. Framing comparative risk: A preliminary analysis. Howard Journal of Communication 16:71–86.

                                                            DOI: 10.1080/10646170590948956Save Citation »Export Citation »E-mail Citation »

                                                            In an illuminating analysis with implications for Communicating about Health Equity, the authors find that news stories on black-white health disparities are far more likely to be described in terms of disadvantage faced by blacks than unearned advantage enjoyed by whites. Moreover, the authors find that few articles identify racism as a causal explanation for disparate health outcomes. Results suggest that well-meaning journalists may unwittingly contribute to the construction of a narrative that blames the victims of racial injustice.

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                                                            • Gamson, William A. 1992. Talking politics. Cambridge, UK: Cambridge Univ. Press.

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                                                              In this classic text, Gamson compares public and media discourse, demonstrating the complexity of opinion formation using experiences from small group discussions among working people on four politically controversial topics: affirmative action, nuclear power, the Arab–Israeli conflict, and problems in American industry.

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                                                              • Iyengar, Shanto. 1991. Is anyone responsible? Chicago: Univ. of Chicago Press.

                                                                DOI: 10.7208/chicago/9780226388533.001.0001Save Citation »Export Citation »E-mail Citation »

                                                                In this influential series of experiments, Iyengar investigates the effects of typical television news frames on the public’s perceptions of political responsibility and accountability. He finds that episodic news dominates network news and inspires interpretations of personal responsibility, while thematic frames leave viewers with perceptions of broader accountability.

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                                                                • Kim, Annice E., Shiriki Kumanyika, Daniel Shive, Uzy Igweatu, and Son-Ho Kim. 2010. Coverage and framing of racial and ethnic health disparities in US newspapers, 1996–2005. American Journal of Public Health 100:S224–S231.

                                                                  DOI: 10.2105/AJPH.2009.171678Save Citation »Export Citation »E-mail Citation »

                                                                  Examines how causes and solutions around racial and ethnic disparities are framed in the media. Finds that behavioral explanations dominated the causes and solutions given and very few stories integrated social justice rationales. Authors argue that behavioral explanations may hinder “public support for policy solutions to eliminate racial/ethnic disparities” (S229).

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                                                                  • Ryan, Charlotte. 1991. Prime time activism. Boston: South End Press.

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                                                                    Ryan provides sharp analytical applications of framing to media advocacy. Chapter 3, “Getting Framed: The Media Shape Reality,” defines and discusses framing, showing how it shapes news stories and public debate. Chapter 4, “Frame Contests,” delves into the strategic use of framing by advocates, showing how to connect frames with cultural themes that resonate with audiences.

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                                                                    • Thibodeau, Paul H., and Lera Boroditsky. 2011. Metaphors we think with: The role of metaphor in reasoning. PLoS One 6.2: e16782.

                                                                      DOI: 10.1371/journal.pone.0016782Save Citation »Export Citation »E-mail Citation »

                                                                      Examines how subtle differences in metaphors used in news stories about violence influence readers’ perceptions of the nature of violence and the solutions needed to address it. Stories in which violence is described using the metaphor of a lurking beast are found to elicit more punitive responses than stories in which violence is metaphorically likened to a spreading virus. This appears to confirm the findings of Iyengar 1991.

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                                                                      • Winett, Liana. 1997. Advocate’s guide to developing framing memos. In Do the media govern? Politicians, voters, and reporters in America. Edited by Shanto Iyengar and Richard Reeves, 420–432. Thousand Oaks, CA: SAGE.

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                                                                        This chapter illustrates how to conduct a framing analysis of news coverage with definitions, examples, and practical steps.

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                                                                        Communicating about Health Equity

                                                                        Health equity is defined by the WHO as “the absence of avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically.” Because such “remediable differences” are observed in virtually every contemporary public health issue, achieving health equity is widely understood as a key public health goal. However, communicating about health equity entails unique challenges. As scholar John Powell describes, the default frame of individualism can create a false perception that policies aimed at promoting the wellbeing of specific groups will necessarily detract from the welfare of others. Thus, reframing health equity from a zero-sum proposition to a universal goal is key. While specific directives for communicating about health equity do not exist, there are useful guides. Powell 2012 introduces the construct of “targeted universalism” to convey the idea that universal goods—such as health—are best achieved through social policies that are targeted to the contextually determined needs of specific groups. Jones 2000 uses an allegory about a gardener to illustrate how factors in the environment can mistakenly be attributed to individuals on the basis of their race. The birdcage metaphor in Frye 1983 makes use of a familiar object to make the abstract concept of structural oppression more tangible. Shenker-Osorio 2012 argues that effective communication about economic inequality requires that we shift from metaphors that portray the economy as natural to those that describe it as a human-made phenomenon. Thus, a common feature of the citations included herein is their use of readily accessible concepts and familiar metaphors to illustrate complex, potentially divisive ideas.

                                                                        • Frye, M. 1983. The politics of reality: Essays in feminist theory. Berkeley, CA: Crossing Press.

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                                                                          Frye’s essay on oppression introduces the metaphor of a birdcage to illustrate the systemic nature of sexism, racism, classism, and other forms of oppression. Like a birdcage, in which no single bar impedes a captive bird’s ability to escape, a system of oppression comprises multiple unjust institutions whose impacts are interlocking and cumulative. The birdcage metaphor has been used widely to illustrate the concept of systemic injustice.

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                                                                          • Jones, C. P. 2000. Levels of racism: A theoretic framework and a gardener’s tale. American Journal of Public Health 90.8: 1212–1215.

                                                                            DOI: 10.2105/AJPH.90.8.1212Save Citation »Export Citation »E-mail Citation »

                                                                            This seminal paper uses an allegory about a flower gardener to illustrate three levels of racism: institutionalized, personally mediated, and internalized. The gardener’s tale has been used extensively to describe how racism involves more than just individual prejudice.

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                                                                            • Powell, J. 2012. Racing to justice. Bloomington: Indiana Univ. Press.

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                                                                              This far-reaching text on race and racism argues that racism remains deeply entrenched in contemporary US society, even as “post-racial” discourses proliferate. Powell introduces the concept of targeted universalism as a guiding principle for social policy and as a communications tool. The work examines the nature and functions of racial categories in the law and in broader society and explores the role of spirituality in overcoming racism.

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                                                                              • The Praxis Project. 2010. Fair game: A strategy guide for racial justice communications in the Obama era. Washington, DC: Praxis.

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                                                                                Written for social justice advocates, this book provides case studies, tools, and guidelines for communicating about racial justice. Its guidelines focus on how to develop messages that build power among communities of color, as opposed to the more commonplace practice of developing messages designed to be palatable to groups in power.

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                                                                                • Shenker-Osorio, Anat. 2012. Don’t buy it: The trouble with talking nonsense about the economy. Philadelphia: PublicAffairs.

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                                                                                  The author discusses common metaphors for talking about the economic inequality, and examines their implications for advancing a progressive economic agenda. Shenker-Osorio advocates moving away from metaphors that portray the economy as a force of nature to those that describe the economy as human-made.

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                                                                                  • Williams, D. R. 19 May 2017. Black Lives Matter for health. . . and for all of us. Lecture presented at Fourth Annual Health Law Year in P/Review in Harvard Law School, Cambridge.

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                                                                                    This lecture provides a concise overview of the prevalence and causes of racial disparities in health in the United States. The lecture includes data and graphs that compellingly illustrate how racial injustices, such as discrimination in housing and employment, lead to health disparities.

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                                                                                    News Industry Practices

                                                                                    To interact effectively with journalists so they can set the agenda and shape debate, media advocates must understand how the news operates. Framing for access requires an understanding of news structures, how to establish relationships with reporters and bloggers, and how news operations are evolving with the advent of social media and the decline of traditional journalism. This section includes classic studies of news practices: Fishman 1980, Gans 2004, Gitlin 1980, and Bagdikian 1987 assess commercial news constraints, and Iyengar and Reeves 1997 examines the news media’s influence on politics and policy discussions.

                                                                                    • Bagdikian, Ben H. 1987. The media monopoly. Boston: Beacon.

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                                                                                      Describes the dizzying consolidation of news organizations and its effect on journalism and democracy. Discusses the effects of the new media on newspapers.

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                                                                                      • Fishman, Mark. 1980. Manufacturing the news. Austin: Univ. of Texas Press.

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                                                                                        An ethnography that provides a critical examination of the news production process. Fishman examines how routine news practices exacerbated a crime wave on the elderly. He argues that the standard methods of news gathering, rather than hidden manipulations, can systematically misrepresent what is actually happening in the world.

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                                                                                        • Gans, Herbert J. 2004. Deciding what’s news: A study of CBS Evening News, NBC Nightly News, Newsweek, and Time. 25th anniv. ed. Evanston, IL: Northwestern Univ. Press.

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                                                                                          Gans’s sociological study categorizes news as either journalist-centered or event-centered, and as either organizationally or externally determined. He illuminates the role of sources, explaining how official sources influence news content by what they reveal and withhold as well as how they control access to institutions and events that journalists want to cover. First published in 1979 (New York: Pantheon).

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                                                                                          • Gitlin, Todd. 1980. The whole world is watching. Berkeley: Univ. of California Press.

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                                                                                            Using coverage on CBS and the New York Times, Gitlin analyzes the news media’s influence on Students for a Democratic Society (SDS). This work would be of value to media advocates interested in a case study of how news coverage can influence a social movement; Gitlin argues that news coverage of SDS attracted a unique crowd that eventually changed the organization, leading to its downfall. Chapter 10 offers an insightful sociological analysis of how news functions in modern society.

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                                                                                            • Graeff, Erhardt, Matt Stempeck, and Ethan Zuckerman. 2014. The battle for?“Trayvon Martin”: Mapping a media controversy online and off-line. First Monday 19.2.

                                                                                              DOI: 10.5210/fm.v19i2.4947Save Citation »Export Citation »E-mail Citation »

                                                                                              What role does social media play in influencing news media practice? This study details how advocates’ strategic use of social media and traditional community organizing elevated the salience of the killing of Trayvon Martin from a local news story to one that dominated national coverage.

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                                                                                              • Iyengar, Shanto, and Richard Reeves. 1997. Do the media govern? Politicians, voters, and reporters in America. Thousand Oaks, CA: SAGE.

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                                                                                                This collection of essays brings together the perspectives of academics, reporters and commentators, campaign consultants, and policy advocates to examine the news media in the context of American politics and news influence on the policy process.

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                                                                                                Evaluation

                                                                                                Media advocacy is difficult to evaluate. The ultimate outcome measure for media advocacy is whether or not the desired policy 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. Stead, et al. 2002 provides a comprehensive assessment of the challenges and how best to meet them. For these reasons, most evaluations of media advocacy are qualitative case studies that describe the process of conducting media advocacy (see Case Studies). In addition, measuring media effects is difficult in and of itself. Dorfman, et al. 2002 provides a framework for evaluators who want to assess media advocacy in relation to other sorts of health communications, while Major 2009 tests media advocacy concepts in an experiment. Most evaluations of media advocacy have examined efforts to enact either tobacco control policy (Niederdeppe, et al. 2007) or alcohol control policy (Harwood, et al. 2005; Holder and Treno 1997; and Stewart and Casswell 1993), likely because media advocacy was developed first in those fields. As media advocates expand their practice, we should start to see evaluations of media advocacy practiced in other public health policy arenas, such as those discussed in Schooler, et al. 1996 on heart disease, Major 2009 on lung cancer and obesity, and Gardner, et al. 2010 on health care.

                                                                                                • Dorfman, Lori, Joel Ervice, and Katie Woodruff. 2002. Voices for change: A taxonomy of public communications campaigns and their evaluation challenges. Berkeley, CA: Berkeley Media Studies Group.

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                                                                                                  Examines characteristics of various communications campaigns and defines three axes of differentiation that can help evaluators assess effects: purpose, scope, and maturity. The authors argue that where communication campaigns fall on these axes affects the evaluation methods and can lead to specific evaluation challenges.

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                                                                                                  • Gardner, Annette, Sara Geierstanger, Claire Brindis, and Coline McConnel. 2010. Clinic consortia media advocacy capacity: Partnering with the media and increasing policymaker awareness. Journal of Health Communication 15.3: 293–306.

                                                                                                    DOI: 10.1080/10810731003686606Save Citation »Export Citation »E-mail Citation »

                                                                                                    Describes the media advocacy activities of nineteen community-based clinics from 2002 to 2006. The authors find that the consortia obtained media coverage that increased public and policy-maker awareness but found limited effects on policy. The study relies on interviews with participants and policymakers, and may underestimate the role of media advocacy.

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                                                                                                    • Harwood, Eileen M., Jean C. Witson, David P. Fan, and Alexander C. Wagenaar. 2005. Media advocacy and underage drinking policies: A study of Louisiana news media from 1994 through 2003. Health Promotion Practice 6.3: 246–257.

                                                                                                      DOI: 10.1177/1524839905276079Save Citation »Export Citation »E-mail Citation »

                                                                                                      An evaluation examining the relationship between newspaper coverage and legislative action restricting minors’ alcohol consumption in Louisiana. The study finds that news coverage may be most beneficial in the early stages of a campaign when the problem is being framed.

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                                                                                                      • Holder, Harold D., and Andrew J. Treno. 1997. Media advocacy in community prevention: News as a means to advance policy change. Addiction 92:189–200.

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                                                                                                        Describes the evaluation of media advocacy activities within the Community Trials Project, an intervention to reduce alcohol use. The authors find that media advocacy increased news coverage of the issue and coverage focused attention on prevention components; they conclude that media advocacy can be more effective than traditional health education campaigns.

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                                                                                                        • Major, Lesa Hatley. 2009. Break it to me harshly: The effects of intersecting news frames in lung cancer and obesity coverage. Journal of Health Communication 14:174–188.

                                                                                                          DOI: 10.1080/10810730802659939Save Citation »Export Citation »E-mail Citation »

                                                                                                          An experiment that investigates the effects of news frames (thematic/episodic and gain/loss) on the reader’s perceptions of obesity and lung cancer as individual or societal responsibilities. The results showed that people exposed to stories with thematic and loss framing attributed more responsibility to society, consistent with a public health approach.

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                                                                                                          • Niederdeppe, Jeff, Matthew C. Farrelly, and Dana Wenter. 2007. Media advocacy, tobacco control policy change and teen smoking in Florida. Tobacco Control 16:47–52.

                                                                                                            DOI: 10.1136/tc.2005.015289Save Citation »Export Citation »E-mail Citation »

                                                                                                            Evaluation of a tobacco control program to assess its influence on newspaper coverage, policy changes, and reduction in smoking among youth. Findings include increased coverage of the program’s youth advocacy organization. News coverage helped pass policies, but these policies did not lead to a reduction in smoking among youth.

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                                                                                                            • Schooler, Caroline S., Shyam Sundar, and June Flora. 1996. Effects of the Stanford Five-City Project media advocacy program. Health Education & Behavior 23:346–364.

                                                                                                              DOI: 10.1177/109019819602300306Save Citation »Export Citation »E-mail Citation »

                                                                                                              Evaluates a media advocacy program designed to reduce cardiovascular disease. Using content analysis of newspapers in treatment and reference cities, the authors find that one of the two treatment cities increased desired coverage. They suggest that maintaining frequent contact with media professionals and provision of materials lead to success.

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                                                                                                              • Stead, Martine, Gerard Hastings, and Douglas Eadie. 2002. The challenge of evaluating complex interventions: A framework for evaluating media advocacy. Health Education Research 17.3: 351–364.

                                                                                                                DOI: 10.1093/her/17.3.351Save Citation »Export Citation »E-mail Citation »

                                                                                                                Reviews the media advocacy evaluation literature and provides an evaluation framework specifically for media advocacy. Given the type of evaluation (formative, process, outcome) and objective, the authors propose research questions and methods to evaluate media advocacy. Examples include evaluating outcomes in the media, public opinion, and policy.

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                                                                                                                • Stewart, Liz, and Sally Casswell. 1993. Media advocacy for alcohol policy support: Results from the New Zealand Community Action Project. Health Promotion International 8.3: 167–175.

                                                                                                                  DOI: 10.1093/heapro/8.3.167Save Citation »Export Citation »E-mail Citation »

                                                                                                                  Presents the evaluation activities and results of using media advocacy to increase public support for alcohol-related policies. Findings show increased newspaper coverage on alcohol policy, and the qualitative evaluation activities suggest that the project had a positive effect.

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                                                                                                                  Case Studies

                                                                                                                  Case studies document how media advocacy is practiced in the high-pressure and contentious policy context. The case studies collected here describe media advocacy in various public health realms. DeJong 1996 and Seevak 1997 provide examples in alcohol control, while Jernigan and Wright 1996 also discusses tobacco control and Woodruff 1996 couples alcohol control efforts with violence prevention. Other case studies of media advocacy include violence prevention among youth, described in Wallack 1999, international case studies in injury prevention and tobacco control, in Chapman 1994, and examples that link local campaigns to national efforts, in Shaw 1999.

                                                                                                                  • Chapman, Simon. 1994. Case studies in public health media advocacy. In The fight for public health: Principles and practice of media advocacy. Edited by Simon Chapman and Deborah Lupton, 96–126. London: BMJ.

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                                                                                                                    Describes two case studies in New South Wales, Australia: one on preventing childhood drowning with fences around residential swimming pools, and the second on the tobacco industry’s attempt to defeat the Tobacco Advertising Prohibition Bill. Discusses opponents’ and proponents’ strategies and framing in media advocacy.

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                                                                                                                    • DeJong, William. 1996. MADD Massachusetts versus Senator Burke: A media advocacy case study. Health Education Quarterly 23.3: 318–329.

                                                                                                                      DOI: 10.1177/109019819602300304Save Citation »Export Citation »E-mail Citation »

                                                                                                                      Describes how Mothers Against Drunk Driving (MADD) used media advocacy to lobby for a bill that would permit a drunk driver’s refusal to take a breathalyzer test to be used as criminal evidence. Discusses how the conflict and schisms within a media advocacy group can weaken longer-term policy advocacy efforts.

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                                                                                                                      • Jernigan, David H., and Patricia A. Wright. 1996. Media advocacy: Lessons from community experiences. Journal of Public Health Policy 17.3: 306–330.

                                                                                                                        DOI: 10.2307/3343268Save Citation »Export Citation »E-mail Citation »

                                                                                                                        The authors document the experiences of controversial alcohol- and tobacco-related media advocacy campaigns. They organize lessons for health advocates into five sections: shaping the campaign, choosing spokespeople, relating to the media, handling confrontation and controversy, and finding and using resources.

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                                                                                                                        • Seevak, Allison. 1997. Oakland shows the way. Issue 3 (December).

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                                                                                                                          Describes how the Coalition on Alcohol Outlet Issues in Oakland, California, used media advocacy to impose a moratorium on new alcohol outlets located in low-income areas. Includes examples of media advocacy strategies and devices to redefine the problem as one of crime and loitering.

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                                                                                                                          • Shaw, Randy. 1999. Reclaiming America: Nike, clean air, and the new national activism. Berkeley: Univ. of California Press.

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                                                                                                                            Two case studies showing how to link local problems to national solutions. The book describes activists battling Nike’s labor practices; environmental battles for the Clean Air Act; and the “role of community-based nonprofit organizations (CBOs), the media, and the Internet in building grassroots mobilization in national campaigns” (p. 7).

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                                                                                                                            • Wallack, Lawrence. 1999. The California Violence Prevention Initiative: Advancing policy to ban Saturday night specials. Health Education & Behavior 26.6: 841–857.

                                                                                                                              DOI: 10.1177/109019819902600607Save Citation »Export Citation »E-mail Citation »

                                                                                                                              An initiative combining efforts among community, media, research, and policy advocates to reduce access to guns and to prevent violence among youth. Advocates use media advocacy to change public policy and “shift society’s definition of violence to include a public health perspective” (p. 843).

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                                                                                                                              • Woodruff, Katie. 1996. Alcohol advertising and violence against women: A media advocacy case study. Health Education Quarterly 23.3: 330–345.

                                                                                                                                DOI: 10.1177/109019819602300305Save Citation »Export Citation »E-mail Citation »

                                                                                                                                Describes the media advocacy strategies and outcomes of the Dangerous Promises campaign aimed at preventing violence against women by pressuring the alcohol industry to change the portrayal of women in its advertising.

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                                                                                                                                Practical Resources

                                                                                                                                Several organizations provide handbooks, training and technical assistance, and other resources to help practitioners use media advocacy. All have materials that can be accessed online. The Berkeley Media Studies Group, Communications Consortium Media Center, Community Media Workshop, FrameWorks Institute, Praxis Project, and the Green Media Toolshed all offer consultation services in addition to online resources for advocates. The American Public Health Association and the Community Tool Box provide media advocacy manuals for practitioners.

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