Health Communication
ISSN: 1041-0236 (Print) 1532-7027 (Online) Journal homepage: http://www.tandfonline.com/loi/hhth20
The “New Public” and the “Good Ol’ Press”:
Evaluating Online News Sources During the 2013
Polio Outbreak in Israel
Anat Gesser-Edelsburg, Nathan Walter & Yaffa Shir-Raz
To cite this article: Anat Gesser-Edelsburg, Nathan Walter & Yaffa Shir-Raz (2016): The “New
Public” and the “Good Ol’ Press”: Evaluating Online News Sources During the 2013 Polio
Outbreak in Israel, Health Communication
To link to this article: http://dx.doi.org/10.1080/10410236.2015.1110224
Published online: 18 May 2016.
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Date: 19 May 2016, At: 01:23
HEALTH COMMUNICATION
http://dx.doi.org/10.1080/10410236.2015.1110224
The “New Public” and the “Good Ol’ Press”: Evaluating Online News Sources During
the 2013 Polio Outbreak in Israel
Anat Gesser-Edelsburg
a
, Nathan Walterb, and Yaffa Shir-Raza
a
School of Public Health, University of Haifa; bAnnenberg School for Communication & Journalism, University of Southern California
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ABSTRACT
The current research focuses on the 2013 polio outbreak in Israel as a case study to analyze the sources
of information used in new media platforms, examining whether the new media have changed the ways
in which we communicate about health issues. Specifically, we tracked and coded polio-related references on Hebrew news websites, blogs, forums, and Facebook posts. Overall, 24,388 polio-related
references constituted our sampling frame. The findings suggest that there is a moderate-level correlation between the platform and the type of sources chosen by users. Beyond the differences between
various platforms, we found that online information platforms rely not only on popular or pseudoscientific sources, but also on high-quality information. In fact, the analysis indicates that online news
websites, forums, blogs, and Facebook posts create a unique blend of information, including scientific
literature, medical professionals, and government representatives, as well as pseudoscientific research.
These findings suggest a more optimistic view of the Internet as a source for health-related information
in times of crises. Although the fact that members of the public are exposed to scientific sources does
not indicate to what degree this affects their actual decision making. Exposure to a wider variety of
sources may enhance health literacy, resulting in a better understanding of information needed to make
informed decisions.
The existing literature on health communication tends to
focus on the audience and the message, rather than on the
source (Hallin & Briggs, 2015). While there is a growing
interest among health agencies and academia in understanding the public’s use of online health resources (Bults et al.,
2011; Nettleton, Burrows, & O’Malley, 2005; Signorini, Segre,
& Polgreen, 2011), research examining the sources of information cited in various online platforms has been limited
(Sudau et al., 2014). This gap is perplexing in light of the
increasing variety of information sources available and the
presumed impact these sources have on health-related decision making (Johnson & Kaye, 2004).
In the summer of 2013, discourse on the polio outbreak
dominated the Israeli news. Although it was not the first time
that the threat of a large-scale epidemic dominated Israeli broadcast channels and print newspapers, it was the first time that
news about such a potential threat spread across the Internet and
social media. We consequently identify the 2013 polio outbreak
as a watershed moment in the understanding of various online
platforms as sources of information during health-related crises.
This study offers a systematic comparison of different news
platforms on the Web, in order to examine how civic journalism
and the established press discuss health-related issues in a variety
of online settings.
The scientific literature indicates that the public has become a
vocal participant in the discourse on popular science, education,
medical/health practice, risks, and technological innovations
CONTACT Anat Gesser-Edelsburg, PhD
[email protected]
Khoushy Ave., Mount Carmel, Haifa 3498838, Israel.
© 2016 Taylor & Francis
(Castells, 2008; Gesser-Edelsburg et al., 2015; Irwin, 1995;
Pavilk, 2001). In particular, online media constitute important
sources of health-related information (Tustin, 2010; Vance,
Howe, & Dellavalle, 2009), as well as a platform for discussing
and sharing personal experiences, opinions and concerns relating to illnesses and treatments (Chew & Eysenbach, 2010).
Before the digital age, laypeople depended heavily on health
organizations and official sources for health information, but
the digital revolution has now opened new alternatives and
enabled laypeople to be self-managing, exposing them to a vast
variety of additional sources (Sudau et al., 2014). Consequently,
this process has contributed to a shift in the perceived role of the
public—from passive recipient to active consumer of health
information (McMullan, 2006; Sudau et al., 2014).
In the Israeli context, analyses of global Internet use indicate that Israelis are “second among the top ten countries
worldwide in time spent online among individuals age fifteen
or above” (Israelashvili, Kim, & Bukobza, 2012, pp. 418–419).
In line with these findings, recent surveys conducted in Israel
suggest that 75% of the population (about 6 million people)
use the Internet and that 50% of the population (about 4
million people) are Facebook users. Approximately 60% of
Israeli users of the social networking site log in on a daily
basis, and this pattern of use seems to persist across age, race,
and religion (Cohen, 2013; Epstein, 2013; Internet World
Stats, 2014). Interestingly, these studies also demonstrate
that Israelis use the Internet more than Americans and
Head of Health Promotion Program, School of Public Health, University of Haifa, 199 Aba
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2
A. GESSER-EDELSBURG ET AL.
Europeans (Gordon, Rosenbloom, Greifman, & Zwillenberg,
2014), spending more time on the Internet each month than
users from anywhere else in the world (Epstein, 2013).
Israelis report high levels of interest in science, with 62% of
the public stating that they actively seek knowledge on science
and technology on a daily basis (Dgani & Dgani, 2015).
Moreover, polls have documented that health-related news is
more popular than any other topic among Israelis (Mash,
Mano, & Tzamir, 2009). As a recent study among otolaryngology patients reveals (Segal et al., 2015), Israelis turn to the
Internet as a source for health information significantly more
than to books or newspapers (80%, 78%, and 66% respectively). More importantly, the phenomenon of e-patients in
Israel (i.e., Internet patients who see themselves as active
participants in their medical care) was found to be associated
with a variety of positive health outcomes, including starting a
diet, initiating physical activity programs, and communicating
regularly with health professionals (Mano, 2014).
Despite the apparent benefits of online health resources,
the positive outcomes associated with e-health literacy are not
equally shared by all, and socioeconomic, geographical, educational, and generational disparities in Internet access and
use continue to represent significant barriers to knowledge
gain (Neumark, Lopez-Quintero, Feldman, Hirsch Allen, &
Shtarkshall, 2013). Corresponding with the Knowledge Gap
Hypothesis (Tichenor, Donohue, & Olien, 1970; Wei &
Hindman, 2011) and concerns over the Digital Divide
(Viswanath et al., 2006; Xiao, Sharman, Rao, & Upadhyaya,
2014), studies demonstrate that literacy disparities are
enhanced in the search for health information on the
Internet (Neter & Brainin, 2012). According to a national
survey of the Israeli adult population, “Respondents who
were highly e-Health literate gained more positive outcomes
from the information search in terms of cognitive, instrumental (i.e., self-management of health care needs, heath behaviors, and better use of health insurance), and interpersonal
(i.e., interacting with their physician) gains” (2012, p. 1).
Recent years have witnessed a proliferation of research on
the use of new media during emergent situations, including
epidemics and pandemics (Bults et al., 2011; Chew &
Eysenbach, 2010; Zhang & Gao, 2014). With that in mind,
although studies have produced analyses comparing traditional and online media sources, they often tend to refer to
a monolithic concept of “new media” that fails to fully take
into account the diversity of online platforms, such as blogs,
forums, and social media. Considering that various online
news platforms are associated with unique technological and
informational characteristics (boyd & Ellison, 2007), it seems
that research on health discourse and the new media necessitates a more nuanced approach. Additionally, the comparison
between traditional and online media as a source for health
information is often limited to traditional journalism (Deuze,
2001; Matheson, 2004), overlooking the important role of
what Irwin has termed “citizen science,” in communicating
and mediating events to the public (1995). This term refers to
expertise among individuals who were traditionally seen as
ignorant laypeople (Irwin, 1995). Unlike the Deficit Model
(Dickson, 2005), which is associated with a clear distinction
between experts who have the information and nonexperts
who do not, “citizen science” is a more optimistic articulation
of the public’s knowledge. It does not view the public and the
experts in dichotomous terms, but rather as interrelated entities, each of which is associated with a unique information
needs. In particular, experts possess professional knowledge,
whereas nonexperts embody practical knowledge (Horst &
Irwin, 2010). Thus, different social groups and local communities have different and diverse understandings of scientific
knowledge. In order to advance our understanding of online
health-related practices, the current study analyzes the sources
of health information on different online platforms during the
2013 polio outbreak in Israel.
The Polio Outbreak in Israel
In 2013, Israel’s health ministry reported that Wild Poliovirus
Type 1 (WPV1) was detected in environmental sewage samples from the southern and the central districts of Israel
(Kaliner et al., 2015; Ministry of Health Israel, 2013a, 2013b,
2013c, 2013d, 2013e; Shulman et al., 2014). Although more
than 95% of Israeli infants were routinely immunized with
inactivated poliovirus vaccine (IPV), the health ministry
launched “Two Drops” in August 2013, a campaign for
immunizing all children under age 10 years (Ministry of
Health Israel, 2013f), with a bivalent oral poliovirus vaccine
(OPV) vaccine (OPV 1 and 3). The campaign was deemed
controversial among those who claimed that the OPV was
banned in Israel in 2005, after local and international health
officials had declared it dangerous, reportedly causing dozens
of children to contract polio (Even, 2013). Although the rate
of vaccination during the campaign was high, GesserEdelsburg, Shir-Raz, and Green (2014) found that parents
who tended to comply with routine vaccination programs
hesitated or even refused to vaccinate their children in this
case. The current study probed online news websites, forums,
blogs, and Facebook posts in order to examine the types of
information sources that represent each online platform. In
the following we review various online sources of healthrelated information, emphasizing their unique affordances
and constraints.
Sources of Information in the New Media: News
Websites
The sheer space available online for news websites has opened
up new options for news presentation not found in traditional
sources (Fenton, 2010). In addition, multimedia formats also
allow news to be presented in innovative and interesting ways
(Kenix, 2013). Broadly speaking, there are three main types of
online news websites. First, there are newspaper websites that
are best understood as a digital extension of the paper periodical. These online platforms have provided newspapers with
the opportunity to compete with broadcast journalism by
presenting news in a timelier fashion. Second, independent
news websites often provide an alternative perspective on a
variety of issues. Although the business models of Web journalism vary, independent news websites often rely on sponsors and nonprofit organizations. Third, hyperlocal news
websites are associated with a focus on relatively small
HEALTH COMMUNICATION
communities. These news websites seek to fill perceived information gaps in public affairs coverage often ignored by mainstream media (Metzgar, Kurpius, & Rowley, 2011). Online
journalism varies considerably across this typology, but news
websites are still largely dependent on content generated by
news agencies and parent companies. As Quandt (2008) concludes, “Online journalism . . . is basically good old news
journalism, which is similar to what we know from offline
newspapers . . . [they] are still limited by their use and reporting habits” (2008, p. 735). Based on this, we hypothesize that:
H1a: News websites would focus more on Ministry of
Health (MOH) sources than Facebook, forums, and blogs.
H1b: News websites would focus more on medical
professionals than Facebook, forums, and blogs.
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Sources of Information in the New Media: Blogs
The increased access to public information and government
services has led to a rise in civic journalism in which members
of the public interact and participate (Pavilk, 2001). Citizen
journalism is exemplified by weblogs, which can be openly
subjective and highly critical, providing a space where readers
can check the validity of one news report against another. A
blog is a more dynamic version of a personal website, typically
updated at least weekly (Wall, 2005). Although all blogs share
similar characteristics, these platforms tend to have different
content. Specifically, personal blogs resemble a public diary in
which the author comments on various events, sharing a
personal perspective. In contrast, professional blogs focus on
particular subjects (e.g., health, science, media, traveling, or
music), offering commentary and often assuming the role of
the expert. As one might expect, the distinction between these
platforms is not clean-cut, and the landscape may be best
understood as a spectrum of blogging practices rather than
as discrete categories.
The main difference between online journalists and bloggers stems from the fact that blogging practices are not
guided by established editorial norms, such as objectivity
and balance (Kim & Hamilton, 2006). In fact, in this context, the traditional gatekeeper function associated with
traditional journalism is substituted by a novel dialogical
form of communication. Similarly, bloggers are not bound
by the ethical and professional standards of trained journalists. This independence makes it easier for them to discuss
issues that traditional media overlook, as the blogger often
scouts the Web for alternative sources of information, providing hyperlinks, summarizing them, and offering commentary (Wall, 2005). Without the structural and
institutional constraints of legacy journalism, blogs are
often considered more opinionated, analytical, and scientifically rigid than other more traditional forms of journalism
(Johnson & Kaye, 2004).
Walejko and Ksiazek (2010) maintain that science bloggers
often rely on information from the traditional news media,
but also link their writing to scientific sources, which provide
more in-depth explanations. Thus, bloggers tend to present
3
voices more diverse than those usually heard in traditional
journalism, thereby improving the quality of science news
reporting. In the health context, medical bloggers have been
found to be highly educated and affiliated with health care
organizations. Their writing is often characterized by links to
scientific sources and fact checking (Kovic, Lulic, & Brumini,
2008). Hence, we expect that:
H2: Blogs would focus more on scientific research
than news websites, Facebook, and forums.
Sources of Information in the New Media: Facebook
Social networks such as Facebook are used by hundreds of
millions of people to communicate about an infinite range of
topics, including health (McNab, 2009). Although Facebook is
most notable for its capacity to network between individual
people through personal profiles, it also has an undeniable
commercial aspect: namely, Facebook offers unique tools to
businesses and organizations for reaching potential consumers, often linking users with particular brands (Reed et al.,
2012). Similarly, nonprofit organizations also take advantage
of the social network, trying to cultivate relationships with
their publics (Waters, Burnett, Lamm, & Lucas, 2009). This
capacity to reach target audiences with relevant information
would seem to offer particularly promising potential in the
health context, but Facebook use also involves notable challenges, as people are often unable to differentiate between
misinformation and high-quality information. In particular,
social media can facilitate the spread of misinformation for
three reasons (Bode & Vraga, 2015; Mintz et al., 2012). First,
similar to blogs and forums, Facebook posts obviate the use of
conventional gatekeepers. Second, through mechanisms of
sharing, misinformation can be spread to the extent that it
is hard to deny or refute. Third, echoing the saying that a
picture is worth a thousand words, audiovisual content is
prominent on Facebook, and engagingly presented misinformation thus often persists despite extensive corrective efforts
(Oreskes & Conway, 2010). Based on this, we expect that:
H3a: Facebook would focus more on pseudoscientific
sources (rumors and misinformation) than news websites,
forums, and blogs.
H3b: Facebook would focus more on alternative medicine sources than news websites, forums, and blogs.
Sources of Information in the New Media: Forums
Online forums are message boards that host discussions in the
form of posts. Like other Internet platforms, online forums
are best understood not as a monolithic concept but rather as
an umbrella term that encompasses diverse practices (Bickart
& Schindler, 2001). Typically, forums enable participants to
post on their own topics and respond to posts written by
others, but certain forums have specific limitations.
4
A. GESSER-EDELSBURG ET AL.
Regarding vaccination, forums may facilitate productive
scientific debate when they allow diverse perspectives on
health-related topics and encourage people to evaluate the
problems based on the arguments presented. Nevertheless,
in the context of the antivaccine movement, Kata (2012) has
demonstrated the centrality of this virtual space for promoting misinformation about vaccines. Although antivaccine
advocacy campaigns on the Internet are not limited to Web
forums, they have permeated these platforms. This is because
unlike social media, forums are not restricted to our social
network, and they are less guided by practices of gatekeeping
or evidence-based information, as are news websites and, to
some extent, online blogs (Betsch et al., 2012). In light of this,
we hypothesize that:
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H4: Forums would cite more antivaccine-related
sources than news websites, blogs, and Facebook.
This study focuses on the 2013 polio outbreak in Israel
as a case study to examine the sources used in various
online platforms, trying to understand whether the new
media have led to a new discourse on health-related
topics, or simply reproduced the traditional discourse
using new tools.
Method
Sample
In the first stage of data gathering, IFAT Business Information
Group, an Israeli monitoring media company, tracked and
coded every publicly available polio-related reference from
Hebrew news websites, blogs, forums, and Facebook posts,
beginning with the first mention of a potential outbreak (May
1, 2013) until its official containment (December 1, 2014).
Overall, 24,388 polio-related references constituted our sampling frame. Subsequently, we extracted 250 polio-related
references from each subcategory (i.e., news websites, blogs,
forums, and Facebook posts) using SPSS random sampling
application. The disproportionate stratified sampling technique had three key advantages over simple random sampling:
(a) It ensured adequate representation of every subcategory
(for instance, the ratio in the sampling frame between
Facebook posts and news articles was 24:1); (b) it provided
the opportunity to observe differences within each strata,
guaranteeing variability; and (c) it safeguarded against liberal
inferential tests, which could result from a large disproportional sample. Finally, we analyzed every polio-related reference to ensure that it related specifically to the 2013 polio
outbreak and that it was not sampled accidently by virtue of
containing the relevant letter sequence (e.g., general
Wikipedia polio entries not connected to the 2013 outbreak),
or items of less than 200 characters. Irrelevant items (23 items
from all strata) were randomly replaced with relevant items
from the sampling frame. We also ensured that our sample
did not include any duplicates.
1
The final research sample included a total of 1000 items
(250 items from each online platform). We decided to focus
on these subcategories since they had the highest representation among online sources that referenced the polio outbreak
in Israel.1 It is important to note that our sample was limited
to the public domain of social media, since sampling private
pages is restricted for practical and ethical reasons (for a
comprehensive discussion see Baltar & Brunet, 2012; boyd &
Hargittai, 2010). Facebook-related content is particularly subject to concerns about privacy, as is, to a somewhat lesser
degree, content associated with access-restricted forums and
blogs. Indeed, private pages differ in their tone, focus, and
agenda from public platforms, which may limit the generalizability of the current analysis and introduce a systematic
bias to our measurements. For instance, we might suspect that
access to content associated with the radical antivaccine lobby
might be limited to community members. Although these
concerns are undoubtedly warranted, there is also some evidence to suggest that ideologically driven groups often deliberately make their content public in order to reach broad
segments of the population. For example, the GesserEdelsburg et al. (2014) analysis of vaccination hesitancy during the 2013 polio outbreak in Israel suggests that the most
subversive antivaccine groups (i.e., “mothers say no to the
weakened virus vaccine”) used Facebook as an accessible platform to disseminate their ideology, while trying to undermine
the credibility of official health care organizations. Likewise,
Kata (2012) and Poland, Jacobson, and Ovsyannikova (2009)
maintain that similar trends are evident in most Western
countries, where antivaccination movements have largely
embraced the inclusivity of social media.
The unit of analysis for this research was the polio-related
item (i.e., single article, single log, single forum entry, and
single Facebook post). Two research assistants coded the
number and type of explicit sources mentioned in one item.
Only explicit references that cited sources were coded. For
instance, if a blog entry suggested generally that there was
scientific evidence that linked the virus with paralysis, this was
not used as a source. However, if a news item discussed the
same proposed correlation, referring to a person, providing a
YouTube hyperlink, or explicitly citing scientific studies, then
the person, YouTube, and the study were used as sources for
this particular article. The length of items in the sample
ranged from 214 characters to 6,424 words. Out of the 1,000
items coded, 7 (0.7%) had five sources or more, 4 (0.4%) had
four sources, 42 (4.2%) had three sources, 71 (7.1%) had two
sources, 274 (27.4%) had one source, and 407 (40.7%) did not
include any sources.
Coder Training and Reliability
Two coders were employed for the study. Each coder
received at least 12 hours of training. As part of their
training, they coded 150 polio-related items that were not
in the final sample until discrepancies were resolved and
initial agreement was satisfactory. Disagreements were
Initially, we also wanted to include Tweets and Talkbacks, but the former were too sparse in our sampling frame and the latter were often too short,
included many duplicates and irrelevant references.
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HEALTH COMMUNICATION
resolved through group discussion with the research team
and later translated into rules and specifications for the
codebook. Two hundred and fifty-two items within the
final sample (approximately 25% distributed equally
between news websites, blogs, forums, and Facebook
posts) underwent reliability coding by the coders.
Reliability was assessed using Krippendorff’s alpha2 and
was found to be highest for medical professionals
(kappa = .82, p = .001) and lowest for pseudoscientific
research (kappa = .71, p = .001). One explanation for the
relatively low agreement regarding the coding of some of
the sources has to do with their low occurrence in the
sample, such that each disagreement had greater impact
on the assessment of reliability. Similarly, some sources
(i.e., celebrities, nongovernmental organizations [NGOs],
Twitter, YouTube, and foreign professional) were too
sparse in our final sample, which limited our capacity to
assess the reliability of their coding. Nonetheless, we
decided to code and analyze these sources since they were
stressed as relevant stakeholders. As Table 1 indicates, most
of the kappa coefficients were above or near the norm for a
good reliability test of .80 (De Swert, 2012).
Instrument
The final version of the codebook contained three pages of
specific rules for the attribution of different sources and
prominent examples of people/organizations/ data associated
with a specific source type.
Source Types
The goal in developing this variable was to establish coding
categories that were exhaustive, were mutually exclusive, and
would exhibit a high degree of intercoder reliability. The
broad coding categories were borrowed from the Borrill
et al. (2000) report on relevant stakeholders in health care;
Worsley’s (1989) work on sources for health information; and
the Lacy et al. (2013) study on radio news sources. The final
source categories were fine-tuned to conform to the current
Israeli health care context. For each polio-related item, all the
source types and source identification were coded.
These categories include Ministry of Health representatives, medical professionals and providers, stakeholder groups
of alternative medicine,3 scientific articles, pseudoscientific
information, grassroots leaders, national leaders, pharmaceutical industry representatives, international organizations, opinion leaders, celebrities, anti-vaccine sources, NGOs,
traditional media, Twitter, YouTube, foreign professionals,
and the general public.
2
5
Table 1. Krippendorff’s alpha coefficients for the reliability estimates (n = 252).
Source
MOH representatives
Medical professionals
Alternative medicine
Scientific research
Pseudoscientific research
National leaders
Grassroots leaders
Pharma companies
International organizations
Opinion leaders
General public
Celebrities
NGOs
Anti-vaccine
Traditional media
Twitter
YouTube
Foreign professionals
Other
Kappa
.81
.82
.8
.81
.71
.79
.77
.74
.75
.81
.8
—
.77
.81
—
.72
Note. A missing coefficient indicate low occurrence categories for which we were
not able to calculate intercoder reliability.
Results
Table 2 presents data collected from the content analysis.
There were 594 sources for the 1,000 items in our sample.
Of these sources, 277 (46.6%) appeared on online news websites; 146 (24.6%) were from Facebook posts; 69 (11.6%)
appeared in forums; and 102 (17.2%) were from blog posts.
Acknowledging the structural differences between various
online arenas, the descriptive differences presented in
Table 2 seem to suggest a pattern. It seems that while both
news websites and Facebook posts rely heavily on external
sources, this tendency is less prevalent in blogs and forums.
With regard to the prevalence of different sources, the dominant categories are MOH representatives (139, 23.4%), medical professionals (74, 12.5%), traditional media (60, 10.1%),
and scientific articles (51, 8.6%).
All research hypotheses were tested by examining the variance in source selection between different online platforms.
The hypotheses were assessed with chi-squared tests, and
significance was set at a two-tailed p < .05 level. As Table 2
indicates, the news websites tended to rely on MOH representatives (104, 37.5%), national community leaders (34,
12.3%), the general public (25, 9%), medical professionals
(22, 7.9%) and grass-roots leaders (15, 5.4%). As the crosstabs
suggest, for forums, the dominant sources were scientific
research (17, 24.6%), medical professionals (15, 21.7%), and
traditional media (13, 18.8%); blogs relied on medical professionals (20, 19.6%), scientific research (16, 15.7%), MOH
representatives (15, 14.7%), traditional media, (15, 14.7%),
and Twitter (11, 10.8%). Lastly, Facebook posts focused on
pseudoscientific sources (27, 18.5%), traditional communication (21, 14.4%), medical professionals (17, 11.6%), MOH
representatives (15, 10.3%), and YouTube clips (12, 8.2%).
The specific assessment was done using Hayes’s SPSS macro (http://www.afhayes.com/statistical-methods-for-communication-science.html).
By alternative medicine, we mean medical treatments not part of mainstream medicine. In the context of the polio outbreak, we defined alternative
medicine sources as sources that offered treatments other than the vaccine.
3
6
A. GESSER-EDELSBURG ET AL.
Table 2. Descriptive statistics for information sources (n = 594) by online platform (including row number, percent within platforms, and adjusted standardized residuals).
Online platform
Source
MOH representatives
Medical professionals
Alternative medicine
Scientific research
Pseudoscientific research
National leaders
Grass-roots leaders
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Pharma companies
International organizations
Opinion leaders
General public
Celebrities
NGOs
Antivaccine
Traditional media
Twitter
YouTube
Foreign professionals
Other
New sites
104
37.5%
7.6
22
7.9%
–3.1
—
–3
12
4.3%
–3.5
5
1.8%
–4
34
12.3%
5
15
5.4%
3.5
8
2.9%
2.1
8
2.9%
–0.8
8
2.9%
2.1
25
9%
3.9
3
1.1%
1.9
4
1.4%
1.5
11
4%
–1.1
11
4%
–4.6
1
0.4%
–4.4
1
0.4%
–3.5
1
0.4%
–2.5
4
1.4%
2.1
Facebook
15
10.3%
–4.3
17
11.6%
–0.3
7
4.8%
3.4
6
4.1%
–2.2
27
18.5%
7.4
3
2.1%
–26
2
1.4%
–1.2
1
0.7%
–1.1
1
0.7%
–2.1
2
1.4%
–0.3
2
1.4%
–2.4
—
Forums
5
7.2%
–3.4
15
21.7%
2.5
1
1.4%
–0.2
17
24.6%
5.1
—
–1
1
0.7%
–0.2
11
7.5%
1.6
21
14.4%
2
12
8.2%
4.2
12
8.2%
4.2
8
5.5%
3.7
—
–1.1
–2.2
1
1.4%
–1.9
—
–1.5
—
Blogs
15
14.7%
–2.3
20
19.6%
2.4
2
2%
0.2
16
15.7%
2.8
3
2.9%
–1.4
2
2%
–2.1
—
–1.2
6
8.7%
2.5
—
–1.9
1
1%
–0.6
6
5.9%
1.4
—
–1.2
1
1.4%
–1.5
—
1.5
3
2.9%
–1.1
—
–0.6
—
–0.8
—
–0.8
4
5.8%
0.3
13
18.8%
2.6
1
1.4%
–0.8
1
1.4%
–0.8
2
2.9%
0.7
—
–1
4
3.9%
–0.6
15
14.7%
1.7
4
3.9%
0.6
4
3.9%
0.6
—
–0.7
–0.9
–0.9
—
Note. The post hoc test for the variance in the distribution of sources based on
online platforms was assessed with Gardner’s (2001) test. In order to suggest
that a cell value is significantly different from other cells, its adjusted standardized residual should exceed the Z score (adjusted residual) = 3.2 (based on
the total number of cells and the desired alpha level).
N = 594) = 324.84, Rc = .43, p < .05].4 Although there is a
significant association in the cross-tabulation between our
research variables, we still need to examine whether the specific
differences support our research hypotheses (Lu, 2010).
Gardner’s (2001) post hoc test was used to specify which
media platform and source types were significantly associated.5
In order to support H1a, we needed to establish that news
websites focused more on sources officially associated with the
Ministry of Health. As the adjusted residuals demonstrate, our
data seems to support this hypothesis (adjusted residual = 7.6).
Conversely, we were not able to find support for H1b, which
suggests that news websites would tend to cite more medical
professionals as sources than other platforms. In fact, although
the post hoc tests did not exhibit any significant difference in the
use of medical professionals as sources across different online
platforms, relative to other media, the forums tended to include
more medical professionals (21.7% out of all sources used), following blogs, Facebook, and news websites (19.6%, 11.6%, and 7.9%,
respectively).
The same statistical procedure was used to test H2, suggesting
that blogs would focus more on scientific research than news
websites, Facebook and forums. The data failed to support this
hypothesis (adjusted residual = 2.8). Contrary to our prediction, it
seems that forums cite more scientific sources than other platforms (adjusted residual = 5.1), as 24.6% of all sources cited in
Israeli forums were associated with scientific research. H3a predicted that Facebook would rely more on pseudoscientific information than news websites, forums, and blogs. In our sample,
Facebook posts directly referred to pseudoscientific material 27
times (18.5% out of all sources used), which was significantly more
than other online information platform (adjusted residual = 7.4).
Interestingly, our content analysis did not find any reference to
pseudoscientific sources within forums and found a low number
of references in blogs and news websites (3 and 5, respectively).
Regarding H3b, the data support the hypothesis, suggesting that
Facebook cited more sources on alternative medicine. Although
the 250 Facebook entries analyzed in this study referred to promoters of alternative medicine only 7 times, this was significantly
more than any other online platform (adjusted residual = 3.4). Yet
the paucity of items in the sample citing these sources suggests that
these results should be evaluated with caution.
Finally, H4 suggested that forums would cite more antivaccine movement speakers than would news websites, blogs,
and Facebook posts. This tendency was not supported by the
data. In fact, news websites and Facebook posts tended to cite
antivaccine movement representatives more (although not
significantly more), with 11 references on each platform.
Discussion
These differences were also reflected in a moderate correlation between online platforms and source types [χ2(72,
4
The coupling of citizen journalism with e-health has revolutionized the ways in which people are exposed to health-
In order to ensure that the correlation between online platforms and source type does not stem from inflated degrees of freedom, we ran an identical test,
which included only the sources relevant to our research hypotheses. The results demonstrated a significant relationship χ2(20, N = 340) = 163.53,
Rc = .35, p < .05.
5
According to Gardner (2001), cell value is significantly different if the adjusted standardized residual in the cell exceeds the Z score required for the
Bonferroni-adjusted alpha level calculated by dividing the desired alpha level (i.e., .05) by the number of cells. For the 19 * 4 table in this study, the
adjusted alpha is .05/ 76 = .000657, and the Z score at this level is 3.2 (two-tailed).
Downloaded by [62.90.178.185] at 01:23 19 May 2016
HEALTH COMMUNICATION
related information (Mair et al., 2012). If for many years the
principal concern was whether people could make sense of
medical jargon (i.e., patient–doctor communication), the
focus now has shifted to ensuring that people are exposed to
quality information disseminated by knowledgeable sources
(Rimal, Ratzan, Arnston, & Freimuth, 1997; Sharf & Street,
1997). In the current study, we tried to understand what
characterizes the health discourse that takes place on various
online platforms between journalists, laypeople, and health
professionals. In particular, we focused on the selection of
sources as an element that shapes the discourse.
In concurrence with the theoretical prediction, we found that
during the polio outbreak in Israel, news websites were more likely
to rely on MOH representatives than were Facebook, forums, and
blogs. This finding implies that despite using a new platform,
health journalists working in mainstream media still prefer official
information sources and especially officials in government organizations—similar to how they operate in traditional news platforms (Altheide, 2006; Sallot & Johnson, 2006; Seletzky &
Lehman-Wilzig, 2010). This may be because the journalists themselves have not changed their fundamental approach to writing on
health issues. In other words, while the Internet has enabled
journalists to make their writing more accessible, to distribute it
more quickly and to a broader audience, it has not altered their
approach to and use of external sources (Davies, 2009). In fact, as
Quandt (2008) claims, the transition to new online platforms
might have increased journalists’ dependence on external sources
of information, such as governmental representatives, due to the
constant pressure of deadlines, which allows them little time to
validate data. Clearly, the reliance of online news websites on
traditional information sources is not an indicant of superficial
reporting. Yet these results do suggest that the Internet has gradually eroded the level of journalistic reporting in terms of the
type and diversity of sources cites (Davies, 2009; Fenton, 2010;
Lowrey & Anderson, 2005).
Another plausible explanation relates to the fact that health
journalists (both those who write for newspapers and those
who write for news websites) use their personal connections
with government officials in order to receive exclusive information that the public cannot readily obtain. In this regard,
the journalist–source relationship might represent a clash
between different interests, as sources work to further their
preferred interpretation of the events by capitalizing on the
credibility usually associated with the traditional press
(Berkowitz & TerKeurst, 1999).
In terms of medical professionals, we found that news
websites did not cite more experts than other platforms did.
Ostensibly, this finding seems to contradict conclusions from
studies on health journalists working in the traditional media,
which concludes that they often cite medical professionals and
academic centers as sources (Lariscy, Avery, & Sohn, 2010;
Len-Ríos et al., 2009). Yet these discrepancies can be
explained by the nature of the situation. Journalists routinely
do tend to rely on physicians and other healthcare professionals, whereas in a crisis their first inclination might be to
turn to decision makers rather than to medical professionals.
Thus, we might speculate that during a potentially deadly
outbreak, government officials are perceived as more accountable and better informed than medical professionals.
7
Although previous studies indicate that science blogs tend
to use diverse sources and often provide scientific references
(Kovic et al., 2008; Walejko & Ksiazek, 2010), the current
study did not find that blogs focused on scientific research
more than other platforms. Indeed, online forums cited scientific research more frequently than other sources of information. This finding could be explained by a fundamental
difference between blogs and forums. While blogs are usually
written by one person, forums are an arena for broad public
participation and debate. They call for a more argumentative
discourse that may necessitate scientific facts and evidence.
Furthermore, because bloggers are often health care professionals or individuals with health care or scientific background (Kovic et al., 2008), they may believe that they do
not need to support their conclusions with further data. In
contrast, laypeople without formal medical education may feel
more compelled to cite evidence in support of their claims.
Furthermore, as we hypothesized, Facebook users focused
on pseudoscientific sources and alternative medicine sources
more than users of other online platforms. Taken together,
these findings reflect Facebook’s unique characteristics and
format, as a combination of entertainment, marketing, and
public discourse. However, the discourse on social media does
not solely rely on pseudoscientific sources: Facebook users
also relied on other sources, such as traditional news media,
medical professionals, and MOH representatives. To this end,
the study reveals a slightly more balanced image of Facebook
as a platform for disseminating information. Simply put,
although misinformation is more salient on Facebook, the
platform also contains pages associated with official organizations and experts, who utilize this tool in order to communicate with the public. Yet this finding also stresses the need
for health care organizations to take on a greater role as an
active player on social networks, given that currently many
pages function only as upgraded message boards, with few
interactive features (Lev-On, 2011).
Based on the Sudau et al. (2014) finding, we hypothesized
that online forums would give more prominence to antivaccine sources than to other information platforms.
Nevertheless, we found that forums did not rely more than
other platforms on antivaccine movement representatives.
Rather, arguments associated with the antivaccine movement
were more salient on news websites and Facebook posts. The
explanation in this case may not be related to the platform,
but rather to the specific Israeli context: namely, the leading
antivaccine group during the polio outbreak, “mothers say no
to the weakened polio vaccine,” was founded and managed on
Facebook (Even, 2013), followed by other antivaccine movements that utilized Facebook as the main channel of communication (Gesser-Edelsburg et al., 2014). Keeping in mind that
online forums were also the primary platform for discourse
associated with scientific sources, our results seem to paint a
relatively positive picture of online forums as a platform for
distribution and consumption of health-related knowledge.
Still, we must keep in mind that there is extreme variability
within this broad category, and that not all forums offer
accurate information and adhere to scientific principles.
Altogether, the findings suggest that the platform is somewhat associated with the selection of the sources of information.
Downloaded by [62.90.178.185] at 01:23 19 May 2016
8
A. GESSER-EDELSBURG ET AL.
In contrast to blogs that are usually run by a single person, often
an expert, and to formal media websites, in which the journalists
rely heavily on MOH representatives, the discourse in forums
tends to be more balanced, open to broad participation, and
maintained by laypeople as well as experts. The fact that online
forums provide this unique combination of expertise and personal experience may contribute to their capacity to provide high
quality medical information.
In general, the Internet is regarded as an important
source of information on health-related topics (Walter,
Böhmer, Reiter, Krause, & Wichmann, 2012). Therefore, it
is not surprising that recent research on risk communication during epidemics raises significant concerns about the
quality of the information available online (Rains, 2014).
For instance, Tausczik, Faasse, Pennebaker, and Petrie
(2012) assessed Web-based information seeking in response
to the 2009 H1N1 outbreak to suggest that blogs mentioning “swine flu” used significantly “higher levels of anxiety,
health and death words and lower levels of positive emotion words” (2012, p. 179). In the context of the 2011
enterohemorrhagic Escherichia coli (EHEC) outbreak in
Germany, a qualitative analysis of perception of information provision revealed that while the Internet appeared to
be the most popular medium for passively receiving EHECrelated information, participants were dissatisfied with the
level of its credibility, the amount of contradicting messages, and the lack of closure (van Velsen, van GemertPijnen, Beaujean, Wentzel, & van Steenbergen, 2012). More
recently, Squiers (2015) found that those who closely followed Ebola coverage on Facebook were more likely to
agree that the media had exaggerated the seriousness of
the threat, as compared to audiences of broadcast and
print news. As claimed by Ratzan and Moritsugu (2014),
“What we really need is a trusted source for both the public
health community, and the public at large, that answers
basic questions and updates us for how we engage” (2014,
p. 1214). The current study did not examine the public’s
risk perceptions or its decision-making processes, but there
seems to be cause for cautious optimism. Keeping in mind
that information seeking affects our health-related decisions
(Niederdeppe et al., 2007; Ramírez et al., 2013), the fact
that the public is exposed to scientific sources may indicate
that laypeople are guided not only by intuitions and emotions but also by reason and analytical considerations.
Although our method was designed to reduce potential
biases, this study has several limitations. The first limitation
is the emphasis on four online platforms (i.e., news websites, forums, blogs, and Facebook posts), which may overlook other relevant information resources available online
(e.g., wikis, health care organization official websites, or
digital libraries). Moreover, the aggregate approach
employed in this study might suggest that news websites,
blogs, forums, and Facebook posts are monolithic terms
that represent clear-cut categories. Obviously, this is not
the case, as there is almost as much diversity within each
category as there is between the categories. Indeed, personal
profiles on Facebook tend to use sources different from
those of Facebook pages associated with official organizations. Likewise, we anticipated that professional blogs
would be written with a different intent than personal
blogs. This study may seem to downplay these important
differences by focusing on the prototypical representative of
each category, but it also offers important insights into
user-generated content as an avenue for health-related
information.
Similarly, the fact that our sampling frame did not include
private pages limits the generalizability of this study. Yet we
also need to consider the fact that the inclusion of private
pages would have introduced technical and ethical limitations
that could outweigh the advantages associated with analyzing
private content. Furthermore, our sample included only information presented in Hebrew, despite the fact that Israeli
subpopulations also speak other languages. With that in
mind, in the initial stages of this study, our sampling frame
included references to polio in Arabic. However, during the
period of the Israeli polio outbreak, some Arab countries (i.e.,
Syria, Iraq, and Oman) also faced a polio crisis, making it
impossible to distinguish references from within Israel. Lastly,
this study systematically categorized types of sources on different online platforms used but did not focus on the content
of the information. Hence, we cannot suggest that citing
Israeli MOH representatives is equivalent to supporting
these sources or their policy. Referencing a specific source
can also be carried out in order to refute it. We hope that
future studies will adopt our typology but also include a
sentiment analysis to establish the relative valence of each
reference.
Acknowledgments
The authors gratefully acknowledge the thoughtful comments
and suggestions provided by Stefanie Demetriades. The
authors gratefully acknowledge the thoughtful comments
and suggestions provided by Stefanie Demetriades.
Funding
The research leading to these results received funding from
the European Union Seventh Framework Programme (FP7/
2007-2013) under grant agreement 278723 (TELL ME).
ORCID
Anat Gesser-Edelsburg
0000-0003-4467-8799
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