When prevention gets attention: News coverage of Minnesota’s Statewide Health Improvement Program

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When prevention gets attention: News coverage of Minnesota’s Statewide Health Improvement Program

Tuesday, December 03, 2013

The Minnesota Statewide Health Improvement Program in the news

In our democratic society, the news plays a key role in setting the agenda for public policy debates. News coverage raises the profile of a social issue and can influence how the public and policymakers consider the issue. Journalists' decisions about how to cover the pressing problems of the day influence the discussions that take place. In 2008, the Minnesota Legislature passed a ground-breaking health reform law that included a provision to address the root causes of poor heath, with the aim of reducing quickly rising health care costs. The program became known as SHIP, the Statewide Health Improvement Program, which began funding grants to support local community prevention across the state in 2009. The broad reach of Minnesota's SHIP provided an opportunity to assess how prevention was being framed in statewide news coverage. To this end, BMSG analyzed news coverage to understand what was said — and left unsaid — and what lessons could help public health advocates inform future discussions on the importance of prevention.

The landscape of SHIP news coverage

We systematically analyzed a broad selection of print news, television and radio transcripts, and commentary from prominent blog websites for all of the coverage of SHIP between the opening debates over the Minnesota health care reform bill through July 2012, when our study commenced. We also examined a select number of stories about SHIP from late 2012 and 2013, when SHIP was reauthorized, to see if the news coverage of SHIP changed after the initial reports (see appendix for methodological details). Overall, we found 155 news pieces that discussed SHIP. The vast majority (84%) were local news stories about one of the 51 city, county or tribal governments being funded. Far less common were commentaries, such as editorials, op-eds or letters to the editor about SHIP (8%), pieces by newspaper columnists or other feature-length stories (5%), or stories picked up by the national news wires (3%). The news centered on four main topics when discussing SHIP. The most prevalent topic discussed the local governments being funded by SHIP, often in the form of articles announcing a new grant or promoting a community activity related to a grantee. The next most frequent topic encompassed general health items that also mentioned SHIP. This included, for example, a story covering the release of the Robert Wood Johnson Foundation's County Health Rankings, which also mentioned how SHIP was aiming to improve Minnesota's position in these rankings.1Less often, we saw coverage of the legislature debating SHIP's budget or general pieces explaining SHIP to the public as the Program launched.

How is SHIP portrayed in the news?

In the in-depth coverage, news stories discussed SHIP's work across the three core public health issues addressed by the initiative: increasing physical activity, improving nutrition, and reducing tobacco use and exposure. It was most common for articles to mention multiple public health issues (34%), closely followed by articles focusing solely on nutrition (29%) or physical activity (28%) programs; 7% of articles generally discussed how SHIP addresses obesity, without citing specific nutrition or physical activity programs. Three percent mentioned SHIP's tobacco-related work. News stories almost always portrayed SHIP in a positive light: 90% of articles praised the Program, while 10% offered either a neutral or mixed perspective. Positive articles mentioned, for instance, how SHIP is enabling county governments like Anoka's to "stop obesity before it starts" by promoting healthy foods in schools and day-care centers, thus helping children improve their nutrition and reducing future health care costs.2 Similarly, when referring to the Minneapolis Healthy Corner Store Program, Blue Cross Chief Prevention Officer Marc Manley indicated that improving residents' access to healthy foods could effect long-lasting change: "Our eating habits really are habits. If you're used to having fresh produce, you will keep trying to find it."3 The few mixed articles included positive depictions and criticisms of SHIP. An article in the St. Cloud Times, for example, included both SHIP officials praising the Program for pushing community health across the state and challenges to the Program's efficacy from some state legislators.4 No articles offered an entirely negative portrayal. The news coverage of SHIP also consistently portrayed (84%) the Program as a policy-oriented approach to improving health, rather than one that relies solely on changing individual behaviors. Such descriptions by journalists were often straightforward, such as a StarTribune reporter's overview of Ramsey County's focus "on community, school, work and health care settings," and "on policies, systems and environmental changes."5 For example, the county introduced programs bringing fresh fruits and vegetables to corner stores, promoting tobacco-free college campuses, and introducing new physical activity programs in the White Bear Lake school district. Comments from SHIP officials, such as Minnesota Health Commissioner Edward Ehlinger, made the connection that changing environments is necessary to creating a healthier future: "What we can really do about health reform is change our perspective. Healthy communities are actually what creates health in individuals in those communities."6 Only 16% of articles suggested that SHIP was solely about individual Minnesotans losing weight or quitting smoking, and most often these depictions were not from SHIP officials. A journalist, for example, wrote, "Armed with a hefty new grant, Anoka County officials have a message for residents: get moving, stop smoking and eat right."7 In instances where a Program representative explained how SHIP might influence individual health choices, it was connected to the broader sorts of communitywide changes that, once in place, will make it easier for all residents to be healthy. As Laura Tiede, Minneapolis SHIP manager, phrased it, the emphasis was on "trying to change the environment so that the healthy option is the easiest option, the default option."8

Key themes conveyed in news coverage of SHIP

The news coverage of SHIP included almost one thousand (997) individual messages, which fell into five broad themes. Within these five themes, three dominated the conversation, while the two minor themes offered important insights into the full range of opinions about the Program expressed in the news.

Future benefits of SHIP

By far the most prominent theme in SHIP news coverage articulated the future benefits that the Program would bring to Minnesota, primarily about how SHIP would use important health policy changes to improve Minnesotans' health and save on health care costs. The "future benefit" in SHIP coverage was about upcoming policy changes: These messages often included promotions for upcoming SHIP events or discussed programs planned with funds from SHIP that had not yet been dispersed. Especially in regional newspapers, these articles often read like press releases from SHIP promoting its activities. The Bemidji Pioneer, for example, announced an upcoming invitation for local employers to join the Cass County Public Health Department to help create workplace wellness programs.9 Similarly, the St. Cloud Times publicized that through Sherburne County Public Health, "Six work sites will get help creating or improving wellness programs. Licensed day care centers can use both the SHIP nutrition and physical activity programs. Health care workers will have opportunities to attend breast-feeding training. And landlords will get help creating smoke-free multiunit housing policies."10 State or local SHIP officials often delivered the future benefits message, typically promoting the intent of the program, but cautiously, as there were not yet formal evaluation data. For instance, Brown County Public Health Director Karen Moritz said, "The interventions that we are implementing in these programs are making improvements, but it takes time to see a significant change in the data. I hope to see that number go down in the coming years."11 Comments from public health advocates not officially representing SHIP often eloquently made the case for the long-term potential of the Program to create a healthier Minnesota. One article cited Larry Cohen, director of the Oakland, Calif.-based Prevention Institute, who said, "With tobacco, in two years the changes might not have been apparent. In one generation we cut smoking in our state in half. What we've learned is that, to advance prevention, we need norms that support healthy behaviors, not discourage [them]. It's easy to criticize fresh fruits and vegetables, or bike racks. But they're really important catalysts to change."12 Occasionally, articles carried the message that SHIP would produce economic benefits. Most often, this view was expressed in terms of SHIP as a cost-effective "investment in future generations."13 At times, members of the state legislature, such as Rep. Kim Norton, DFL-Rochester, made this claim, saying "[T]he goal was to help save money in the long-run by making a 10-year investment in efforts to tackle obesity, tobacco use and health issues."14

The need for SHIP

About a quarter of the messages in the news coverage outlined the need for SHIP. Most of these messages highlighted the importance of using prevention to address a variety of chronic disease risk factors, such as tobacco use, poor nutrition and lack of activity.15 In some stories, the language read like a press release from the health department; indeed, in areas with smaller, regional papers, it is common for stories to rely heavily on news releases, due to limited reporting budgets. Some articles also cited the need for SHIP to foster local environments to support health. One grantee in Rosemount, for example, reflected on the critical infrastructure improvements that SHIP brought to her community: "This grant program was exactly what we needed. We're finding that more and more of our customers like to bike to our location and we didn't have an organized and secure place for them to park their bikes."16 Similar messages about the need for SHIP underscored a variety of infrastructure deficiencies that SHIP addressed, including the lack of snowshoe trails for physical activity in the winter, the lack of bike lanes for safe, non-motorized commuting, and the lack of land set aside for gardening to grow fresh produce. Sources also used statistics to explain the level of chronic disease in Minnesota when expressing the need for SHIP. An article touting the Blackduck School's attempt to foster a "culture of healthy eating" among students noted that "more than 60 percent of adult Minnesotans are overweight or obese."17 Another argument explained the importance of SHIP in providing resources for communities with the desire for community-based programs, but without the financial means. When describing an urban garden program, for example, a journalist emphasized the need for SHIP's resources: "Backyard gardens provide a cheap, organic source of nutrition-building, fat-busting vegetables. But what if you don't have a back yard — or the money to rent space? Dakota County has come up with a solution for some residents: It is providing grants to groups with excess land to start or expand community gardens."18 The news coverage praised the value of grants provided by SHIP across a variety of programs, including those that help low-income metropolitan neighborhoods initiate farmers' markets that accept Electronic Benefit Transfers, connect Rice County colleges with smoking cessation groups, and provide Hennepin County child care centers with information on how to improve their nutritional and physical activity offerings.

Present benefits of SHIP

Because this study covered the period of SHIP's legislative origins and first disbursement of funds, messages about the existing benefits of SHIP were not as common as expressions of future benefits. Nevertheless, these were still a consistent theme in SHIP news coverage. The most common way news coverage presented the immediate benefits of SHIP was by explaining the many programs and policies enacted around the state as a result of SHIP. A piece about the grant received by the Stewartville Middle School in Rochester, for example, extolled that "eighth-grade students are not only learning how to grow plants and vegetables in the 96 feet of raised garden beds behind the school, they're also getting an opportunity to share that bounty with the rest of the school by incorporating it into the daily lunch menu. 'The kids get really excited when they see things start to grow,' says Family Consumer Science teacher Katie Young. 'They're interested in it. And a lot of them also take pride in it because we've used some of the food they've grown in our school lunch line.'"19 The news also included stories about the health impact that SHIP was already beginning to have. These stories often came from residents who witnessed its benefits to their community. For example, a physical education teacher praised a Safe Routes to School walking program in Apple Valley for helping students not only stay active, but also be better prepared to learn: "When you exercise, it increases your ability to think more clearly."20 A few messages praised SHIP for producing immediate cost savings. Much like the claims of health benefits, these emerged from individual grantee success stories. The CEO of Brooklyn Park's Diversified Plastics, for example, said the "payback was astonishing" from using Hennepin County SHIP for his firm's wellness program, saving his company approximately $100,000.21

Who has the responsibility to address health?

The two remaining themes illustrated important points of contention on whether SHIP was a valid activity for the government to undertake and whether the program was effective. The first of these centered on the question of who should be responsible for addressing health: Is it a matter of individual responsibility or collective responsibility involving community and governmental action? Though the question of responsibility for health rarely appeared — it was only 5% of all messages — most of these suggested that individuals, not governments, should act to protect health. This argument was often made by doctors and other health professionals, such as Charlie Mandile, executive director of a community health collaborative in Rice County, who said, "[l]ifestyle changes, like eating habits and exercise, are just as important to treating chronic diseases as traditional medicine," leaving out the systems change perspective emphasized by SHIP.22 This claim was also made in expressly political terms, such as when Sondra Erickson, a candidate running for re-election to the Minnesota State Legislature, asked, "Why is it the government has to fund a program to dictate whether we're obese? These are individual responsibilities."23 By contrast, collective responsibility messages suggested that communities should take action to support health. Community leader Caroline Rasmussen, for instance, concluded that SHIP's engagement of local residents was important, saying, "I saw the need for people to open their eyes and see what is happening in their communities. I want people to have a shared vision of doing things together."24 Least frequent among responsibility messages was the insistence by SHIP officials and others that it was the responsibility of government to support individuals' capacity to live healthful lives. In a commemoration of National Public Health Week, Brown County Director Karen Moritz framed SHIP as one aspect of public health activities that are "what we, as a society, do collectively to assure the conditions in which people can be healthy."25 A StarTribune editorial suggested that responsibility is not a zero-sum situation and that effective health prevention involves all sectors of society; the editors made the case for SHIP by saying, "Better for government, communities and families to invest in reducing youth obesity now — starting with preschoolers — than to pay billions later."26

Criticisms of SHIP

The least frequent theme in the news coverage involved criticisms of SHIP. Most criticisms came from legislators who questioned whether SHIP was worth its budget or suggested it was an inappropriate role for government. One of the most prominent critics, Sen. David Hann, R-Eden Prairie (who at the time chaired the Health & Human Services Committee), said, "I don't believe, and have not seen, any evidence that the money being spent has any measurable effect on anything. Is it the duty of the state government to provide bike racks to people?"27 Less often, speakers criticized the actions undertaken by local governmental agencies. An editorial in the Post-Bulletin, for example, stated, "The fact is, the county can't shop for us. It can't cook our meals or pack our lunches. It can't make decisions for us at the drive-thru. And it can't make us turn on the treadmill that's been collecting dust for six months."28

Who speaks in coverage of SHIP?

Overall, news coverage of SHIP included a variety of voices, but the majority of messages did not directly quote particular spokespeople or community members. Among those directly quoted, local and state SHIP officials were among the most prevalent speakers, promoting local grantee efforts and making the case for SHIP as a valuable statewide investment. While a number of voices appeared only sporadically in the SHIP news coverage, they nevertheless made important contributions. For instance, school officials including food service and physical education staff members spoke with authority about the impact of SHIP on their students. And parents and other adult community members praised the Program for making a difference in their children's lives.

Conclusion & recommendations

News coverage of SHIP from its inception through mid-2012 emphasized benefits of the Program and consistently focused on SHIP as attempting to create a healthier, more cost-effective future for the state.
  • SHIP received a decisively positive depiction in the news. Overall, 90% of the news coverage carried only positive messages about SHIP, and no articles carried only critical viewpoints. When people talked about SHIP in the news, they focused on the benefits of, and need for, SHIP in creating a healthier Minnesota. These conversations overwhelmed the two viewpoints that offered critical perspectives on the government's responsibility for health and SHIP's effectiveness as a health program.
  • Almost all of the news coverage highlighted local grantee work, pointing to the benefits that would accrue to local communities and families. Few stories contained criticism of SHIP, except for a few articles reported during budget negotiations in the metro-area news.
  • SHIP officials articulated a clear and consistent message about the program being a new prevention-based, policy-driven, systemic change approach to health in Minnesota. While state officials appearing in the metro-area news media carried this message most often, local representatives in New Ulm, Rochester, Bemidji, and elsewhere across the state communicated that a new, community-level approach was critical to investing in the state's health and financial future.
Some gaps in the news coverage point to ways public health advocates could strengthen future discussions of prevention.
  • Use opinion pieces to create different forms of stories about prevention. During the study period, only 8% of the coverage came from opinion pieces, such as op-eds. Residents engaged with SHIP locally can contribute op-eds, letters to the editor and social media posts (where permitted), as can colleagues in the field, such as researchers, business leaders, parents, teachers, clergy, and others who experience SHIP at the local level. In many community newspapers, the letters to the editor are the most widely read section of the paper. These are excellent venues not only to promote prevention programs, but also to help community members see how their local government is acting to promote health and support local economies.
  • Emphasize prevention programs in terms of present and future benefits. This helps explain the program's importance during periods of intense competition for scarce resources, even if the program carries important long-term health improvement goals. This analysis revealed that the primary message communicated the future benefits of SHIP, while comments touting the present benefits occurred far less often. While, of course, state officials must not overstate the impact of SHIP without appropriate data, naming the 53 original grantees and their work, quantifying the policies and programs they put in place, and sharing the powerful stories of youth and adults affected by the programs can be valuable pieces of the public narrative to build support for the Program. As seen throughout this report, communication about SHIP is most powerful when it offers concrete details about the communities that benefit from the projects enabled by SHIP, rather than using public health jargon that has less resonance in this context.
  • Establish new, and build on existing, relationships with journalists covering health. Clearly some journalists in both Minnesota metro and regional papers regularly covered SHIP, and this is a credit to the SHIP officials who have reached out to the media so far. Maintaining strong relationships with journalists pays dividends in two ways: Prevention advocates will be more likely to be called upon as sources in future articles about the health issues that their programs address, and they will be better able to pitch ideas for stories about prevention and public health. Maintaining an up-to-date journalist contact list can help support this work.
  • Look for relevant, creative events to use as news hooks to generate reporters' interest in stories about health. Local papers provide excellent opportunities for continued prevention coverage. Health is a popular topic in local news, and programs like SHIP offer a variety of local stories that can present health as a shared community issue, rather than solely an individual issue. News hooks may vary somewhat between the larger metropolitan papers and regional sources: Metro hooks might include the release of reports; anniversaries, such as the passage of health care reform; or political angles, such as ongoing budget negotiations. Local hooks might include festivals, health fairs, anniversaries of grantees' programs, annual events like "back to school" nights, and other angles to encourage journalists to see prevention in the local context.
  • Broaden the range of voices used to discuss prevention. Many articles reporting on SHIP grantees' efforts lacked quotes from local actors involved in the work, and allies may be in a better position to tout a program's existing achievements. Especially where grantees have the ability to regularly pitch stories or suggest stories in the local paper, prevention advocates can collect quotations from valuable, authentic voices in the community to make the case for prevention. These voices can also acknowledge the efforts of funders, such as the Minnesota state government, while not representing that group. As Dr. Marc Manley of Blue Cross and Blue Shield of Minnesota put it, "To take on issues like obesity and really help people move more and eat better ... has made a huge difference. We couldn't possibly have the reach that the state health department has. It's been a long time since we've seen a program this powerful."29 They can also include allies in sectors not normally associated with health programs, such as business owners like Brooklyn Park's Diversified Plastics who saved an "astonishing" $100,000 due to wellness programs. Be sure to prepare staff and community members ahead of time so they are comfortable talking with reporters. Ultimately, these stories allow SHIP spokespeople to highlight policy successes and maintain a broad frame that includes the importance of changing environments, not individuals.
  • Reconsider phrases such as "making the healthy choice the easy choice" when discussing efforts to improve community health. Program coordinators often want to broaden the conversation from focusing on individual behavior to showing the impact of an individual's surroundings on his or her health. It is easy for the conversation to settle on the concept of "choice," or "making the healthy choice the easy choice." The danger is that the more Program staff talk about choice — even when related to the absence of choice — the more staff unintentionally reinforce the dominant frame of individualism. So, when asked about choice, use the opportunity instead to discuss the policy solutions that improve the places people live, learn, work, and play. For example, the quote referenced above from Prevention Institute Director Larry Cohen does this well: "In one generation we cut smoking in our state in half. What we've learned is that, to advance prevention, we need norms that support healthy behaviors, not discourage."
  • Reuse the news. As a majority of the coverage on SHIP programs was positive, these are opportunities for SHIP administrators and local coordinators to reuse news articles in their future outreach efforts. Especially since many policymakers are looking for examples of how SHIP is effective, showing news coverage with positive highlights can emphasize the good that the Program is doing. Also, showing that news outlets are paying attention gives the Program an extra level of legitimacy that decision-makers value.
  • Explain that success breeds success. Describe the many successes the Program has already seen to counter opponents' obsession with the urgency of showing results in two years' time. For example, Lara Tiede, Minneapolis manager of SHIP funding, put it well: "So much momentum has been developed, and it would be shame to lose all of that. If we want to realize the full potential of these programs, we need to give them time."30

Continuing to communicate for prevention

News coverage can remain an important component of communicating with policymakers and the public about the benefit of SHIP's investments. In 2012, the Minnesota Legislature renewed the Program's funding, but only at one-third of level of the previous year, severely limiting the scope of SHIP to maintain its health benefits across the state. Since that time, SHIP funding has been renewed again at $15 million. Ongoing financial commitment to SHIP indicates a commitment from the Legislature to keep everyone in the state healthy.

Appendix: Methodology

We examined 155 pieces of news coverage about the Minnesota State Health Improvement Program, from the beginning of the debate over funding the initial SHIP program in 2007 through the onset of BMSG's analysis in July of 2012. This time frame allowed us to analyze the news coverage of initial responses to the program passage through the legislature, the first round of funds distributed to grantees, and the execution of grantees' programs.

Study sample

We examined five data sources: 1    The publicly available archives of the St. Paul-Minneapolis metropolitan area newspapers: the St. Paul Pioneer Press and the Minneapolis StarTribune; 2    The local newspaper from each SHIP training site: the New Ulm Journal, the St. Cloud Times and Bemidji Pioneer, and the Eagan Sun this Week; 3    A selection of regional news papers balanced from across Minnesota: the Duluth News Tribune, Mankato Free Press and Rochester Post-Bulletin; 4    Transcripts from the four metropolitan television news casts: KSTP, WCCO, KARE, and KMSP; 5    Content from prominent web blog news sources, including Minnesota Public Radio (online at mpr.org) and MinnPost.org.

Coding development and testing

After collecting the sample, we developed the coding protocol by reading a sub-set of articles selected for this analysis. We read these pieces to gain a preliminary understanding of the current coverage and catalogue the news frames we expected to see in the broader sample. After establishing a preliminary set of codes, multiple coders read the same set of articles to ensure that the coders had an acceptable level of agreement (inter-coder reliability). Using Krippendorf's alpha, a statistical test specifically designed for three or more coders, we achieved an acceptable level of agreement on all measures, ranging from .725 to 1.0 (perfect reliability). With intercoder reliability established, we coded the official sample and entered the coded information about each article into a customized database. We resolved any coding disagreements during this process by consensus discussion.

Acknowledgments

This report was written by Andrew Cheyne, CPhil, Lori Dorfman, DrPH, and Ingrid Daffner Krasnow, MPH. We thank the Minnesota State Health Improvement Program for supporting this study and William "Bill" Burleson for his many contributions to its development. Pamela Mejia and Laura Nixon conducted the data collection to inform this analysis. Thanks to Heather Gehlert for copy editing. © Berkeley Media Studies Group, a project of the Public Health Institute, 2013

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