Hybrid mediatization and network dependencies:

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Hybrid mediatization and network dependencies:

Health interest group strategies in a hybrid media landscape

Nanna Alida Grit Fredheim

Submitted to the Faculty of Media and Communication, the University of Oslo, in accordance with the requirements for the degree of Doctor of

Philosophy of Humanities

2021

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Acknowledgements

The learning curve has been steep, and I would like to express my gratitude to all those who have helped me in completing this dissertation. First, I would like to thank all my informants. Despite your busy agendas, you generously shared your experiences, opinions and knowledge. This research could not have been done without you, and I am very grateful to you all.

I am particularly indebted to my main supervisor Espen Ytreberg, and my co-supervisor, Kjersti Thorbjørnsrud. Your guidance and calm assurance has been invaluable. I am equally grateful to my co-author Tine Ustad Figenschou, who also provided valuable advice and input throughout this process. I will miss our writing-coffees.

I would furthermore like to express thanks to my leader at the Institute for Social Research (ISF), Kari Steen-Johnsen, whose timely help was highly valued. A special thanks also to the

administrative staff at ISF for your attentive assistance, and in particular Solvor Ardem, for embodying organisational care in general.

I am most grateful to my PhD co-candidates, Daniel Arnesen and Øyvind Bugge Solheim at ISF and Liesbeth Wiering at the University of San Diego (UCSD). Thanks, in part, for commenting on my material, but primarily for your company and friendship, and for cheering me on. It means more than you can imagine.

I would also like to thank the other participants in the HeCoRe project, which I thoroughly enjoyed being a part of. Furthermore, I extend thanks to all my colleagues at ISF, where I was lucky enough to spend over two years. In particular, I would like to express my gratitude to the participants of ‘Politikkseminar’, who provided valuable comments on several occasions.

I am grateful to Professor Daniel Hallin at the UCSD, primarily for inviting me, but also for introducing me to the UCSD, for commenting on my paper and for including me in general. I would furthermore like to thank the Norwegian Research Council and the Fulbright Foundation for enabling me to visit the UCSD for nearly a year and for simultaneously providing a southern Californian adventure for my family.

I am thankful to the Political Communication (POLKOM) research group at UiO for including me as a member and for constituting a scholarly node for political communication in Norway. A special thanks also to the Society, Health and Power (SHEP) research group at the Institute of Health and Society, UiO, which also generously included me.

I am furthermore thankful to Maaike, my mother and also an English professional who insisted on proofreading much of the dissertation. An extended thanks also to Lisbeth Thoresen at the

Institute of Health and Society and Elisabeth Staksrud and Vidar Enebakk at The National Committee for Research Ethics in the Social Sciences and the Humanities (NESH) for ethical advice.

Last but not least, thank you to my beloved friends and family, for cheering me on, for your help, for keeping me grounded and for bearing with me ☺

Oslo, February, 2021

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Summary

This dissertation concerns how health interest groups use the media to advance their interests.

More specifically, it explores how different groups, representing citizen, business and medical professional interests in the Norwegian health field, perceive and strategically engage with both mass and digital media.

Through a multi-method approach, the study combines 65 in-depth qualitative interviews with media text analysis. By triangulating interview accounts, and fieldwork, it provides behind- the-scenes insights into what motivates and conditions interest groups’ practices in the hybrid media landscape, encompassing both mass and digital media.

Drawing on interdisciplinary literature, the dissertation considers how various organisational objectives, group characteristics and contextual factors affect health interest groups’ practices in the hybrid media landscape. Notably, it highlights how inter-group networks are key determinants for media opportunities, labelled network dependency. While media

visibility is not necessarily an organisational aim in itself, the ability to control media visibility constitutes a key asset that groups can exchange as a commodity. Theoretically, the dissertation aims to extend and nuance mediatization and biomediatization theories, by taking into account inter-group networks and digital media practices. The term hybrid mediatization is suggested to capture how health interest groups strategize according to a hybrid media logic.

The dissertation consists of four individual articles, along with an introductory chapter (‘cloak’). Each article illuminates different aspects of how health interest groups relate to the media, and external and internal factors that condition their ability to do so. The first article analyses interest group hybrid media practices in light of organisational characteristics, such as group type, economic resources, staff, members, media presence, and relative access to decision makers. The second article analyses how interest groups use social media, for instance in

lobbyism, and how economic resources affect their ability to do so. The third article concerns actors’ framing power in the news media. It analyses which actors’ frames are prioritised in the media coverage of a contentious health policy issue, and whether this prioritisation is affected by policy change. The fourth article explores how health interest groups coalesce as sources to influence news media coverage.

Drawing on existing theoretical frameworks on interest groups and the media, the study highlights how multiple and at times contending organisational objectives can explain how interest groups both adapt to media platforms, and choose not to. In line with the current

literature, the articles largely confirm that economic means determine what groups are able to do with both social and mass media. Nevertheless, in the hybrid media landscape, new forms of resources have become relevant, such as the ability to relay captivating, sharable stories that will thrive on multiple platforms. Due to overlapping interests, pre-existing interaction and different levels of resources, inter-group networks can enable, but also impede media visibility.

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Norsk sammendrag

Denne avhandlingen tar for seg medie-strategier på helsefeltet. Mer spesifikt undersøker den hvordan norske helse-grupper, som representerer helseindustrien, borgere og medisinske profesjoner, forholder seg til og bruker ulike masse- og digitale medier.

Avhandlingen er basert på 65 dybde-intervjuer og medieanalyse. Ved å triangulere

intervjuer, og etnografisk observasjon, gir avhandlingen et innblikk i praksiser som man vanligvis ikke kan observere, samt innsikt i hva som betinger interessegruppers mediepraksiser i det hybride medielandskapet.

Avhandlingen tar i bruk en tverrfaglige tilnærming for å vurdere hvordan organisatoriske målsettinger, ulike gruppe-karakteristikker og kontekstuelle faktorer påvirker hvordan grupper forholder seg til og kombinerer tradisjonelle og digitale medier. Studien fremhever spesielt hvordan sosiale nettverk mellom gruppene er sentrale for den enkelte gruppens muligheter i mediene. Dette omtales som nettverk-avhengighet. Mens mediesynlighet ikke nødvendigvis er et organisatorisk mål i seg selv, er evnen til å kontrollere mediesynligheten en kjerneferdighet som gruppene kan utveksle seg imellom. Ved å inkludere innsikter om gruppe-nettverk og digitale mediepraksiser, søker avhandlingen å utvide og nyansere teorier om mediatisering og

biomediatisering. Begrepet hybrid mediatisering foreslås for å betegne hvordan en hybrid medie- logikk påvirker hvordan gruppene forholder seg til mediene.

Avhandlingen består av fire forskningsartikler, og en såkalt "kappe". Hver artikkel belyser forskjellige aspekter av hvordan helseinteressegrupper bruker medier, og eksterne og interne faktorer som forutsetter deres evne til å gjøre det. Den første artikkelen analyserer hvordan interessegruppers bruk av forskjellige medier påvirkes av organisatoriske karakteristikker, som organisasjonstype, økonomi, størrelse, tilstedeværelse i ulike medier og tilgang til

beslutningstakere. Den andre artikkelen analyserer hvordan interessegrupper bruker sosiale medier, for eksempel i lobbyisme, og hvordan økonomiske ressurser påvirker deres evne til å gjøre det. Den tredje artikkelen vurderer ulike aktørers evne til å påvirke mediepresentasjonen.

Den analyserer hvordan et omstridt helsepolitisk tema presenteres i ulike medier og av ulike aktører, før og etter en politisk systemendring. Den fjerde artikkelen utforsker hvordan helseinteressegrupper samarbeider som nyhetskilder for å påvirke mediedekningen.

Med utgangspunkt i eksisterende teoretiske rammeverk for interessegrupper og medier fremhever avhandlingen hvordan interessegruppenes mediestrategier avhenger av flere og til tider motstridende organisatoriske målsettinger. I tråd med etablert forskning bekrefter avhandlingen at økonomiske midler i stor grad avgjør hva grupper er i stand til å gjøre med både sosiale og

massemedier. I dagens hybride medielandskap gjør likevel nye ressurs-typer seg gjeldende, for eksempel evnen til å formidle engasjerende historier som fungerer på tvers av medie-plattformer.

På grunn av overlappende interesser, eksisterende relasjoner og ulike ressurser kan gruppe- nettverk både muliggjøre, men også forhindre, mediesynlighet.

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Chapter 1. Introduction

The meeting room is intimate but modern, open and light. Seven informally dressed participants take their seats around the circular meeting table with coffees and teas in hand, chatting amicably about recent activities, their children starting kindergarten, vacations and industry news. They represent pharmaceutical companies, a patient organisation, a biomedical industry organisation and a medical science and technology cluster. A few are former journalists. The agenda for this meeting on a late morning in the spring of 2019 is to organise an upcoming event; a public symposium about medical treatment opportunities and their availability within the public health care system. The symposium is intended to place the issue on the public and political agenda and to establish a dialogue about it with central decision makers, in addition to creating momentum for subsequent meetings, symposiums and communication. The present meeting is one of several where the participants will plan the program of this and subsequent symposiums. Notably, the participants discuss practicalities, objectives, communicative aims, message control and digital promotion through social media. For example, they consider where potential speakers stand on the issue, and their communicative capacities. They discuss which of them knows a relevant speaker best, and who will coordinate the content of their talk. They reflect on who is best

positioned to invite a particular public officer to speak and who will invite the Ministry of Health.

They deliberate on the need for a patient story to capture the audience’s attention, and one of the participants suggests a potential option that suits the format and topic. Simultaneously, they plan how, with whom and when to digitally record particular talks beforehand, among other methods to control their content and length. Mass media, on the other hand, are not central for the program committee; they are hardly mentioned and not explicitly invited. This is not because the media are not considered important, but presumably because they already know that journalists will not turn up at these types of events, a fact commonly lamented by industry representatives in similar settings. Rather, they discuss how they can communicate and coordinate promotional activities through their independent platforms and social media channels. They briefly consider involving the editor of a specialist newspaper as the moderator, before deciding on someone else, continuing the discussion of relevant topics, desired perspectives, talking points and participants, who to include, and who not to.

The above snapshot from a closed meeting¹ serves to illustrate key propositions of this dissertation. Notably, it shows how interest groups can exert message control by combining

1 The meeting description originates from ethnographic fieldwork conducted within multiple closed meetings and public symposiums on biomedical innovations and availability within the Norwegian public health system.

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multiple communication platforms. Digital arenas offer new opportunities to bypass, or only indirectly target the mainstream media. Still, in many ways, the groups draw on conventional media formats: the symposium’s program mirrors news media ‘ingredients’ such as short visual soundbites, credible experts to provide legitimacy, a personalised perspective through a human- interest story and opponents debating a ‘conflict’. The meeting furthermore shows how groups can cooperate by combining resources, such as legitimacy, knowledge and contacts, to reach their mutual goal. However, because of different and partly incompatible formal roles and public identities, this cooperation is not necessarily transparent to outsiders.

What interest groups do and how they strategize is partly dependent on the structural conditions in which they operate. In the following, I provide an outline of relevant societal developments within media, politics and biomedicine, on an international scale. The specificities of the Norwegian case will be explored in chapter four.

1.2. Background: contextualizing health interest groups and their media practices.

In recent years, the number of interest groups internationally has exploded (Rommetvedt, 2014).

In contrast to the traditional centralised organisations with ideological underpinnings and broad group membership, new groups tend to be less hierarchical and spring from identity and issue politics (Arnesen, 2019; Saltman & Vrangbæk, 2009). The internet, in particular, has facilitated theincrease in small, ad-hoc sectional interest groups by connecting otherwise geographically and socially dispersed individuals (Sivesind et al., 2018).

Generally, interest groups compete for limited attention, resources and access to decision makers. The current proliferation of groups increases competition, arguably reinforced by international trends of de-corporatism, which reduce formal opportunities for involvement in policymaking and implementation (Christiansen et al., 2010; Rommetvedt, 2014). Consequently, lobbyism and strategic communication are thought to have become more central for interest groups, and many advocacy groups have become more professionalised.

In the health field, an increasing number of interest groups associated with particular medical conditions fight for medical and public legitimacy, political influence, members, funding and research means. Within public welfare states, the government is responsible for health care provision, and hence a mutual target for all interest groups seeking to affect the allocation of health care resources. In recent years, health interest groups have also fought for access to new

Observations from these closed and public arenas serve as a central interpretative background for the main data of the dissertation: in-depth interviews and media text analyses (see Chapter 4 for elaborate discussion).

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medical treatments. Biomedical innovations have revolutionised treatment opportunities for a growing number of (rare) medical conditions. The marketisation of treatment opportunities, combined with rising patient empowerment, produces patient consumer demand and patient group advocacy for individualised treatments. However, the clinical effect of new treatments such as gene and immunotherapy can be highly unpredictable, and they are often expensive compared to conventional therapies (Conrad 2005; Godman et al., 2013). Due to rising costs in health care, providers increasingly need to meet fiscal pressures to reduce health care expenditure. Within public health care systems, providers furthermore need to fulfil principles of social equity in access to medical treatments. Consequently, health care providers are increasingly evaluating the cost and effect of medical technologies, and prioritise treatments to control health care spending (e.g. Löblová, 2016; Saltman & Vrangbæk, 2009). The denial of, or unequal access to, particular expensive therapies, can result in highly contentious media coverage, often featuring individual patients or next of kin who blame government officials for refusing essential treatments.

Those who are able to attract media attention to their causes can influence how key concepts and issues are defined, thereby potentially affecting public perceptions and resource distribution (e.g. Best, 2012; Daw et al., 2014). However, the media do not cover patient groups and their demands equally; public attention to particular issues tend to reflect the relative strength and appeal of strategic interests.

Due to their varying communicative resources and capacities, interest groups with overlapping interests can be incentivised to cooperate. On the health field, new, specialised biomedical sub-segments can foster alignments between physicians, citizens, scientists and/or corporations (Clarke et al., 2003; Gandy, 1980; Hartley, 2002). For example, a cancer specialist may share more interests with a particular patient group or a pharmaceutical company running a clinical trial than for instance a general physician or an orthopaedic specialist.

Digitalisation and market pressure in the media sector have resulted in a more fragmented media agenda and a shift towards more consumer-oriented ‘soft news’, such as human-interest stories (Hinnant et al., 2013; Karidi, 2018; Eide, 1997). Rolling deadlines and lay-offs are furthermore believed to make media organisations more susceptible to professional source influence (Davis, 2002). Digital platforms are often seen as democratic alternatives for

marginalised groups seeking to challenge mass media narratives or attract attention to new issues.

Nevertheless, in practice, the majority of digital content consumption is channelled through commercial platforms, where algorithms affect who is visible for whom (Bucher, 2012). As consequence, digital visibility does not necessarily result in actual visibility, as various media affordances affect groups’ relative opportunity for visibility, communication and mobilisation (Chadwick, 2013; Bennett & Segerberg, 2013).

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The above overview serves to illuminate the centrality of strategic (media) communication for health interest groups, and the potential for interest alignment between them. Strategic use of the media by interest groups is of course nothing new; health interest groups have sought political influence though the Norwegian news media for decades (e.g. Eide & Hernes, 1987). However, in recognising how contextual conditions shape interest group motivations and opportunities for media visibility, the overview illustrates that current developments in the media, the biomedical field and the political system can both incentivise and condition strategic media practices. Broadly speaking, the media, political interests and biomedicine are increasingly segmented, and, at the same time characterised by competition for funds and attention. Competition between health interest groups may be particularly pronounced in the Norwegian context. Norway is an affluent welfare state where health care services are public and tax-funded rather than based on private or social insurance (see Chapter 4 for an elaboration of the Norwegian case). Consequently, in the overwhelmingly non-commercial Norwegian health system, interest groups compete for the same limited public means. However, as described above, overlapping interests and disparate resources likely produce consolidations between groups and actors and incentivise them to cooperate. It is in this context that the present dissertation explores the relative significance of digital and mass media for health interest group practices.

1.3 Research questions

This dissertation aims to shed light on how and why health interest groups navigate the current hybrid media landscape, in terms of available mass and digital media². ‘Health interest groups’

refers to actors with a stake in health politics, in terms of Lasswell’s ‘who gets what, when and how’ in the biomedical field (see section 2.1 for in-depth discussion). It hence encompasses a wide spectrum of group types, including those representing corporate (e.g. pharmaceutical

industry), citizen (e.g. patient groups) and professional (e.g. physicians) interests. The biomedical field (interchangeably referred to as the health field) refers to the institutional domain of health and (bio)medicine. In line with what Fligstein and McAdam (2011) label Social Action Fields (SAFs), the biomedical field can be understood as the “meso-level social order where actors […]

interact with knowledge of one another under a set of common understandings about the purpose

2 Confer Chadwick, 2013.

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of the field, the relationships on the field (including who has power and why), and the field’s rules” (Ibid, p.3).

Existing studies on interest groups’ media strategies have typically centred on either social or mass media activity rather than analysing how different media are combined in the hybrid media landscape (but see Chadwick, 2013). Furthermore, studies have often centred on public interest groups, such as non-governmental organisations (NGOs), and to a lesser extent directed attention to business groups, or the interrelations between them. Rather than a narrow focus on one specific actor or media type, the present study applies a cross-media, cross-actor approach. In line with what Couldry (2012, p.37) labels a practice approach, it focuses on how professional actors relate to media, rather than focusing on media as such. In light of this emphasis on the interrelations between Norwegian health interest groups and digital and legacy media, this dissertation asks:

RQ: What characterises health interest groups’ media strategies in the hybrid media landscape?

This overarching research question is addressed through three sub-questions. First, taking into account how digital and mainstream media affordances may condition interest group

practices, it asks;

RQ.a) How does a hybrid media logic affect health interest group media practices?

Second, although interest groups’ strategies for influence have been studied within various disciplines, insights rarely travel between scholarly fields. In particular, key insights from political science on the significance of institutional ties and policy networks are often ignored by studies on interest group media practices. Some scholars have therefore called for greater scholarly attention to the impact of the social contexts in which news sources operate (Powers, 2018).

Recognising that interest groups take part in competitive, interdependent networks that transgress conventional institutional boundaries (e.g. between science and business), a vital question is how such inter-group networks affect or relate to hybrid media practices:

RQ.b) How do inter-group networks affect health interest groups’ hybrid media practices?

According to the biomediatization thesis (cf. Chapter 3), the biomedical field is co- constructed by the media (and vice versa). However, existing approaches do not fully take into account digital and social media. Furthermore, mediatization theory seldom addresses whether media-strategies affect inter-group relations. This dissertation therefore seeks to unpack how and why health interest groups approach the hybrid media landscape, and, significantly, whether inter- group relations within the biomedical field are influenced by the media. Consequently, it asks:

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RQ.c) How do insights into hybrid media practices and inter-group networks extend and nuance existing theories on mediatization and biomediatization?

The term inter-group networks refers to the social connectedness of interest groups––that is, the interrelations and interactions between groups with a stake in the same policy arena (here, the biomedical field). ‘Networks’ in this sense hence refer to social relations, not to technological media platforms. When referencing the latter, the term networked is used. For example,

‘networked advocacy’ refers to advocacy that takes place on digital platforms³. ‘Media’ denote both professional mainstream and digital (social/network) media, including blogs, social media and websites. Together, they are referred to as the hybrid media landscape (cf. Chadwick, 2013).

Media strategies are defined as actions (or non-actions) directed at, or due to, mainstream or digital media.

The overarching research question, operationalised through the three sub-questions, is based on four research articles. These are presented in Chapter 5. Table 1 below offers an overview of the relation between the dissertation’s research question(s) and the focus of the individual articles.

Table 1. Overview of the relationship between the dissertation research questions and the topics within the research articles.

Dissertation research questions

Dissertation (Introduction/

Cloak)

• Main RQ: What characterises health interest groups media strategies in the hybrid media landscape?

• RQ.a) How does a hybrid media logic affect health interest group media practices?

• RQ.b): How do inter-group networks affect health interest groups’ hybrid media practices?

• RQ.c): How do insights on hybrid media practices and inter-group networks extend and nuance existing theories on mediatization and biomediatization?

Focus within individual articles

Article 1 • Interest groups’ evaluation and prioritisation of media advocacy in the hybrid media landscape

• Factors that condition media strategies in the hybrid media landscape

Article 2 • Interest groups’ motivation to employ social media as part of lobbying and advocacy campaigns.

Article 3

• Actors’ framing power in the media.

• The impact of a policy change on source and media frames and the implications of a policy change on actor framing power.

3 The exception is the concept “network media logic” (Klinger & Svensson, 2015), where “network” rather refers to digital networks. To avoid confusion, this concept is predominantly referred to as (digital) network logic.

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Article 4

• Cooperation among health interest groups on attracting or steering media attention.

• How groups negotiate interdependencies and diverging interests when cooperating on media management.

A central underlying premise for the study is the assertion that the media are central for political influence and policy processes. Although direct media influence is notoriously difficult to document, numerous studies indicate that the media affect political agenda setting. Studies also find that media can affect public health policy perceptions (Benelli, 2003; Grilli et al., 2002), although local, political opportunity structures likely limit the extent of such influence (Beyer et al., 2020). Furthermore, several studies suggest that media coverage affects priority-setting within public health care systems, for instance pharmaceutical reimbursement (Booth et al., 2007;

Figenschou et al., 2019; Gabe et al., 2012; Harrabin et al., 2003; Hind et al., 2011; Hong, 2013;

MacKenzie et al., 2008; Nahuis & Boon, 2011; Rachul et al., 2016). However, whether media strategies result in actual influence on policies and political processes is not the centre of attention here. Rather, the dissertation focuses on actors' efforts to achieve such influence. Similarly, the related issue of media influence on public opinion represents an influential research tradition (e.g.

Iyengar, 1991) but falls outside the scope of this particular dissertation.

1.4 Contributions

This dissertation applies an interdisciplinary lens to develop new theoretical perspectives on interest groups’ hybrid media practices. It combines insights into media practices derived from media sociology with the literature on interest groups and lobbyism within political science to address factors that affect interest groups’ practices within the hybrid media landscape. More precisely, it sheds light on how organisational characteristics, system-level factors and media affordances affect how groups combine or prioritise mass and digital (social) media strategies.

Furthermore, it draws attention to a greatly understudied aspect of interest group media practices:

how inter-group networks affect groups’ abilities for media visibility, coined as network dependencies.

Empirically, the dissertation adds to the literature on interest groups by taking into account how (health) interest groups combine and prioritise between digital and mass media for political influence. Furthermore, it adds in-depth insights into media sociology by exploring how interest groups evaluate hybrid media practices, and to the emerging literature on health journalism by discussing health sources' news practices. Theoretically, it aims to broaden institutional mediatization theory (cf. Chapter 3), and the related biomediatization-thesis by taking into

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account digital (social) media in addition to mass media, and the impact of inter-group networks on health interest group media practices. It proposes how groups draw on a hybrid media logic to control visibility on multiple platforms, and how such controlled visibility constitutes a key asset that interest groups can exchange between them as a commodity. By focusing on hybrid media practices within the context of a largely non-commercial health and media system, the study furthermore illuminates the macro-drivers behind (bio)mediatization within the health field, thereby contributing to the overall discussion of what drives mediatization processes in general.

More specifically, it dissects a biomedical logic into ideal sub-types, proposing that the relative importance of the mass media for biomedical actors reflect broader tendencies of

commercialization of biomedicine and politicization of health. Moreover, the study contributes to the theorising of framing power within political communication and public relations.

Finally, the study contributes to a broader scholarly discussion on media and power. In line with the current literature (see Chapter 2), the dissertation confirms the significance of economic means for digital (social) and mass media success. Two central insights are nevertheless provided:

first, the importance of controlled visibility as a key asset for professional groups within the hybrid media landscape, and, second, the importance of inter-group networks in obtaining such controlled visibility. More succinctly, this dissertation argues that the ability to control media visibility constitutes a resource that can change the power relations between health interest groups. Consequently, resource exchange within inter-group networks is essential for accessing resources, such as (controlled) media visibility, but it is also a way to maintain and control

existing power relations between actors, such as by allowing one group to control the visibility of another. This study hence nuances existing notions of 'media influence’ by highlighting that such influence is mediated through pre-existing power relations in a given field.

1.5 Thesis outline

The dissertation consists of four individual research articles and an overarching introduction (the

‘cloak’). The introduction includes a theoretical discussion of the overall scholarly contribution of the individual research articles. This first chapter is followed by a review of existing scholarly approaches and knowledge on (health) interest groups and media. Chapter 3 discusses relevant analytical frameworks for interpreting interest groups and the media, and Chapter 4 presents the methodological approach. The individual research articles are presented in Chapter 5, article one,

“Changing priorities, hybrid campaigns: Interest groups’ perceptions of gains and risks in the new media landscape” is co-authored with Professor Tine Ustad Figenschou, and published in Interest Groups & Advocacy. Article two, “Interest groups on social media: Four forms of networked advocacy” is co-authored with Professor Tine Ustad Figenschou, and published in Journal of

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Public Affairs. Article three, “Life, Death or Drugs: Actor Framing Power on the News Media Coverage of Health Care Policy” is published in European Journal of Communication. Article four, “Dancing in the Dark: Source coordination and strategic media alliances in the health field”

is published in Journalism Studies. Chapter 6 synthesizes the theoretical contributions of the empirical articles, while Chapter 7 discusses key findings in light of theoretical concepts and concludes by outlining implications for the scholarly field.

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Chapter 2. (Health) interest groups’ media strategies: A review of the interdisciplinary literature

A number of sub-fields within sociology, political science and media studies have explored issues related to interest groups and media strategies, notably the literatures on social movements, interest groups, journalism, media sociology and political communication. Over all, studies address how political actors and interest groups influence, seek to influence or seek influence through various media, and in turn, how the media influence actors, institutional fields and issue- presentations. However, with a few exceptions, these studies largely apply distinct methodological approaches and interpretative frameworks. For example, media studies tends to focus on how actors and institutions relate to mass or digital media, journalism studies on journalist-source relations, interest group studies on group representation and political strategies, and political communication on elite strategies for media influence. Moreover, the dialogue between different sub-fields has been limited.

In the following sections, I synthesise and critically assess existing scholarly approaches to interest groups and media practices. While recognising the predominantly interdisciplinary nature of the topic, I do not intend to provide an exhaustive account of all relevant literatures. Rather, given the particular focus on interest groups in the biomedical field, the review aims to provide a general map of the dominant orientation and insights within different scholarly traditions, while providing more in-depth discussion of studies related to organised actors in the health and biomedical field.

2.1 Interest groups: Who are they?

There is little scholarly consensus on what ‘interest groups’ refer to. The term is often applied to denote membership organisations that seek political influence, such as trade unions, business associations and citizen groups (Baroni et al., 2014; Binderkrantz et al., 2015; Figenschou, 2020).

Some definitions also include other institutional actors such as corporations, local governments and hospitals (see Baumgartner & Leech, 1998), whereas others include all agents that engage in public policy processes and debates, including individual citizens, coalitions and journalists (Salisbury, 1994 in Baumgartner & Leech, 1998, p.23). In the present study, interest groups refer to institutional actors with an interest in the distribution of public health care resources, such as access to particular medical treatments within the public health care services. These interest groups include pharmaceutical companies, medical industry associations, medical science and technology clusters (membership organisations that seek to strengthen the medical industry by

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connecting members from business, the scientific community, citizens and the bureaucracy), professional medical organisations (representing different medical specialties), trade unions (representing dentists, psychologists, physicians, nurses, physiotherapists and other health workers), patient organisations (representing individuals afflicted with various medical

conditions), large health-focused NGOs, and, to some extent, health bureaucrats. The selection is based on existing research that establishes which groups engage in policy debates related to priority setting in heath (e.g. Gabe et al., 2012; Hind et al., 2011; MacKenzie et al., 2008), in addition to field observation and media analysis. While private businesses are included, individual citizens, journalists and academics are not⁴.

Interest groups tend to be categorised in two ways: according to their policy activities or according to the type of interests they represent (Baroni et al., 2014). Scholars for example distinguish between insider groups with access to the political establishment, and outsider groups without such formal access (for in-depth discussion, see section 2.3.1).

Distinctions are also made between groups that represent public and sectional (or special) interests. Public interest groups represent interests beyond those that concern their particular members, such as environmental and humanitarian NGOs. Sectional interests groups represent the interests of specific constituencies, such as trade unions or business associations.

Some scholars, however, claim that these analytical categories do not necessarily reflect either actual policy activities or group characteristics. First, there are different levels of ‘insider’

access, as some groups have access to the bureaucracy, while others have access to politicians in parliament (see Rommetvedt, 2014). Furthermore, ‘insider’ strategies such as behind the scenes lobbyism and informal networking is not necessarily observable for researchers. Similarly, divisions between self-interested groups and public interest groups are not necessarily clear cut.

For example, increasingly professionalised citizen organisations might pursue altruistic, public interests, while simultaneously needing to secure organisational growth by meeting economic objectives (see 2.3 for discussion). Moreover, health-related NGOs working, for example, to improve cancer treatments can be said to pursue public interests (outside of their specific member- base), although these objectives (access to high-cost treatments) in effect might limit health care allocations for other patient groups. Individual group representatives can have multiple

institutional ‘hats’. For example, leaders of patient organisations can also be active politicians, and representatives of professional groups often work as both medical scientists and hospital- employed physicians. Competence and contacts obtained under one ‘hat’can be applied to pursue

4 Insurance agencies and private providers are also not included. In contrast to many other health systems (see van den Bogaert et al., 2017), neither represent key stakeholders within the Norwegian health system.

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interests under another. Relatedly, blurred institutional boundaries between groups are addressed by McCormick et al. (2003), who stress that academically imposed categorisation tends to ignore close interaction and cooperation between groups.

2.2 (Health-related) social movements and the media

Although the present study focuses on interest groups, the review starts with an initial overview of relevant insights from the literature on (health-related) social movements. This is because early health interest mobilisation started out as social movements. As health activist movements gained influence and strength, their tactics and experiences assisted subsequent movement and interests to become increasingly organised and professionalised (see Klawiter, 2008).

Social movements (SMO) are generally understood as loosely organised actors who seek collective goods through structural, that is, political, change (see e.g. McCarthy & Zald, 1977).

SMOs depend on media attention to expand issue-attention, mobilise constituencies and for image building (Gamson & Wolfsfeld, 1993; Ryan, 1991). The literature has traditionally focused on how resources, arguments and political opportunities affect social movement formation, actions and success (Cress & Snow, 1996; Jenkins, 1983; McCarthy & Zald, 1977). Scholars for instance consider how groups use frames to define issues, increase influence and mobilise collective action (Snow et al., 1986). “Frames” concern how issues are presented, by highlighting some aspects over other relevant interpretations (e.g. Entman, 1993). A study by Kolker (2004) analyses how the American breast cancer movement in the 1990's successfully drew on culturally resonant frames to redefine the disease, shifting its conceptualisation from a private condition to a public concern, thereby increasing public funding. Scholars furthermore theorise that frame alignment, understood as the congruence of values, beliefs and actions between the individual and the collective, affect mobilisation (Snow et al., 1986; Benford & Snow, 2000; Snow & Benford, 1992). Numerous studies have explored media relations and strategies specifically (see Mattoni &

Treré, 2014 for an overview). Initial studies have largely focused on the relationship between social movements and the mass media (Gitlin, 1980): according to Koopmans (2004), the media have become the main interactional platform between political authorities and social movements.

Accordingly, movements’ relative success is dependent on discursive opportunities in the media, such as degree of coverage, resonance and public support by others.

While different social movements receive different levels of media attention, they can strategically appeal to the news media through staged protests and personification (Molotch &

Lester, 1974).Andrews and Caren (2010) nevertheless find that the media tend to favour large

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established groups over voluntary or confrontational groups, or even those forwarding new issues (see also Tresch & Fischer, 2015). Movements struggling to attract attention furthermore need to balance media requirements with the often conflicting institutional policy participation norms (Jenkins, 1983). Koopmans (2004) therefore divides between different levels of media impact, as in of degrees of visibility, resonance (response, either negative or positive) and legitimacy. As agitators in the media are often not given the opportunity to forward both protests and a balanced issue frame, Gamson and Wolfsfeld (1993) find that movements can divide labour by delegating roles, where some actors attract attention, and others present solutions.

More recent studies have focused on the impact of digital media on social movement formation, organisation and activity (Bennett & Segerberg 2013; Lievrouw, 2011; Vromen, 2017).

Bennett and Segerberg (2013) theorise how digital media create new forms of personalised collective action based on what they label “the logic of connective action”, or digital sharing of personalised content. Vromen (2017) also highlights the importance of digital storytelling as a device for new forms of digital social movements. Nevertheless, as Mattoni and Treré (2014) point out, few studies have explored how on social movements are affected by different types of media platforms, together.

Studies on the sub-field of health social movements (HSMs) typically focus on strategies for influence by groups or activists associated with a particular medical condition, notably the AIDS movement (Epstein, 1996; Miller et al., 1998) and the breast cancer movement (Brown &

Zavestoski, 2004; Klawiter, 2008; see Brown et al., 2010 for an overview). Within the health field, the AIDS movement in particular has been subject to extensive research (Epstein, 1996.).

Creating the first “media disease” (Berridge, 1991) AIDS activists campaigned for their rights, seeking to spread information and to influence the treatment of the disease (Rose, 2007, p. 144).

In general, health-related social movements are seen as highly influential on medical research agendas, funding allocations and treatment practices, and on increasing disease recognition and patient empowerment (see Brown et al., 2010; Brown & Zavestoski, 2004;

Epstein, 1996). Studies also find that different types of actors and groups with overlapping aims, such as lay activists, scientists and health professionals, tend to cooperate through informal networks (see Brown et al., 2010). In fact, blurred boundaries and overlaps between health and medical-related organisations, resulting in what McCormick et al. (2003) label “boundary

movements”, are frequently identified in the literature. Rose (2007, p. 144), for example finds that although AIDS activists and the medical community were initially hostile to each other, they formed pragmatic alliances over time, and activists exchanged insights for optimising prevention campaigns in order to increase resources and influence. Furthermore, in her study of the American

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breast-cancer movement, Klawiter (2008) finds that AIDS activists instructed breast cancer activists on effective tactics and introduced them to helpful partners. Several studies furthermore document cooperation between physicians and health activists (Brown et al., 2010; Klawiter, 2008; Miller et al., 1998). Such cooperation is not necessarily overt: in a study on abortion activism, Ferree et al. (2002) find that the Catholic Church used alliances with other actors to publicly downplay their involvement in the issue.

Overall, the health-related social movement literature consists of case studies on particular diseases and the strategies of involved actors, although there is relatively little focus on media strategies in particular (but see Figenschou & Thorbjørnsrud, 2020).

2.3 Media practices within the literature on (health) interest groups

A vast literature within political science explores the practices and societal influence of interest groups (e.g. Schattschneider, 1960; Baumgartner & Leech 1998; Berry, 1997; Hojnacki et al., 2012). Of particular interest is the relative influence and representation of different group types within various political arenas. For example, numerous studies analyse the quantitative presence of particular groups, or their discursive frames, in the media (Binderkrantz, 2005, 2008, 2012, 2019; Junk & Rasmussen, 2019). Pluralism, measured by, for example, presence in the media coverage, is seen as an indication of democratic access to the public sphere. Relevant studies overwhelmingly find that the most resourceful and established organisations are the most successful across political arenas, including the media (Binderkrantz, 2008; Thrall et al., 2014;

Thrall, 2006, but see Binderkrantz, 2012; Halpin et al., 2012). Nevertheless, these studies often resort to ‘strong’ evidence of influence, such as numerical presence or measurable policy impact (e.g. Junk & Rasmussen, 2019), often ignoring more structural forms of influence (Manning, 2001; Lukes, 1974) or the potential challenges in counting interest group populations impact (see Halpin et al., 2012 for discussion).

Some studies seek to explain what motivates interest group media strategies. Institutional context is one factor believed to affect what interest groups do (e.g. Beyers, 2004, Powers, 2018).

For example, a group’s level of inclusion in political processes is likely to influence whether that group uses the media for political influence (Binderkrantz, 2012; see also Baumgartner & Jones, 1993). Others argue that the issue context is a more central determinant (Mahoney, 2007). The importance of issue characteristics for choice of strategy, such as degree of contention, salience and importance, is confirmed in the literature (Beyers, 2008; Binderkrantz & Krøyer, 2012;

Kollman, 1998; Smith, 2000). The role interest groups take on a particular policy issue can vary dramatically according on their specific aims, and the relative salience of an issue on the general

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political agenda (Baumgartner & Jones, 1993). Group characteristics are also highlighted as being key factors for choosing a strategy (Kollman, 1998; Kriesi et al., 2007). Studies find that groups representing narrow, sectional interests are less likely to use the media than cause groups

representing public interest issues (Binderkrantz, 2008). Binderkrantz and Krøyer (2012), for example, find that groups pursuing public goals are more inclined to approach the media and parliament, whereas technical objectives are primarily directed at bureaucrats. However, as choice of tactics is also resource and context dependent, special interest groups have also been found to apply media tactics to achieve their goals (Beyers, 2004; Dür & Mateo, 2013, see also Tresch &

Fischer, 2015).

Scholars generally agree on the centrality of resources for choice of strategy. Most groups are dependent on funding from, for instance, the government, other organisations, corporations, the public or their members. For example, Miller and Williams (1998) note how dependence on government funding can constrain a group’s actions and arguments, implicitly or explicitly, and Hanegraaff et al. (2016) find that the use organised interest groups make of protests and media tactics is influenced by resource competition. Powers (2018) finds that the publicity strategies of large human-rights NGOs are shaped by expectations from “important others”, such as donors and government officials. Furthermore, he finds that choice of media outlet is partly based on funding models. For example, NGOs aiming for political impact are more likely to approach elite news outlets, whereas these who seek charitable donations tend to approach more general media (p. 15).

Consequently, resource competition, funding models and donor expectations are key determinants of interest groups’ strategies for influence in general and media practices in particular.

Interest groups need to balance numerous and at times contradictory organisational needs and aims, such as demonstrating advocacy impact towards their members, signalling efficiency towards their funders and building an image as a reliable policy partner. According to Schmitter and Streek (1999), business groups are driven by two distinct organisational logics, the logic of membership (funding) and the logic of influence (policy influence). Building on their approach, Berkhout (2013) suggests that media visibility has also become an essential organisational motivation, formulated as the logic of reputation. Empirical studies confirm that organisational practices are determined by numerous organisational concerns. For example, a study by Powers (2014) illuminates how human rights NGOs’ publicity strategies are conditioned by a mixture of funding models, government relations and organisational dynamics, which together produce several target groups: policymakers, members or donors. Different organisational logics and target groups can be hard to balance. For example, the need to demonstrate advocacy through demands and criticism in the media may misalign with pragmatic policy contributions and partnerships

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with decision makers. Interest group (media) strategies are hence affected by their relations to various powerful others, such as journalists, funders and policy makers (Berkhout, 2013, Powers, 2014). Jenges et al. (2013) furthermore find that interest groups use media to monitor other actors on their field, driven by what they label a logic of reciprocity. Consequently, Hojnacki et al.

(2012, p. 389) claim there is “solid evidence that organisations’ advocacy behaviour is very much affected by their interaction with others and the nature of the associations that they share”.

2.3.1 Media as a lobbyist-tactic

The present study focuses in particular on interest groups’ strategies for gaining political influence. Such strategies are referred to in the literature as lobbyism, public affairs, political public relations, and, advocacy (see Ihlen et al., 2021, p. 307). Here, media strategies for influence include all media-related activities carried out aiming to gain either short-term policy influence or long-term relationship-building with decision makers. As with social movements, interest groups are generally seen as being dependent on the media for issue-attention (Baumgartner & Jones, 1993). The literature on lobbyism has traditionally seen media as an indirect strategy for

influence, where “outsider” groups seek influence through public pressure in the media, whereas

“insider” groups would rather have direct dialogue with decision makers (Grant, 2004). Initially, then, according to the compensation hypothesis, the media was seen as a weaker form of influence applied by marginalised groups to compensate for lacking direct access to decision makers

(Beyers, 2004; Binderkrantz, 2012). However, in line with Baumgartner and Leech (1998, p. 155), who claim lobbyism is most effective when it involves multiple tactics, empirical studies have found that all group types combine media tactics with more direct forms of influence (Kollman, 1998; Kriesi et al., 2007; Baumgartner & Jones, 1993). In a study on European interest

associations, (Beyers, 2004) find that groups combine inside and outside lobbying extensively.

Similarly, Trapp and Laursen (2017) find that established groups apply media strategies as a supplement to on-going insider lobbying efforts to strengthen relations with decision makers and motivate them to address their issues. However, there is still limited knowledge about which tactics are used when, and how groups choose between them (Baumgartner & Leech, 1998, p.

162).

When and how groups apply media for lobbyism hence depends on the complex interplay between the characteristics of the issue in question, the institutional setting and policy stage, group type, strategic objectives, policy involvement and resource levels (Beyers, 2004, 2008; Dür

& De Bièvre, 2007; Kollman, 1998; Kriesi et al., 2007; Baumgartner & Jones, 1993). While all group types combine different strategies, there is a general preference for insider channels when

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they are available, and resourceful groups are generally better able to successfully apply publicity strategies (Kriesi et al., 2007).

The literature disagrees on whether media tactics are actually beneficial for advocacy success. According to an extensive study by Baumgartner et al. (2009), drawing on media tactics is not necessarily an efficient lobbyism strategy, while de Bruycker (2019) finds that within the EU such tactics can be both beneficial and negative for interest groups’ policy success. While Smith (2000) finds that the success of corporate coalitions is dependent on public opinion, and hence the media, Baumgartner et al. (2009, p. 121) claim that since media coverage increases issue salience, contending sides mobilise and expand, which can result in a loss of control.

Established groups are thus thought to lose control when more actors engage in an issue-debate.

As the presence of other stakeholders affects viable strategies, coalition formation is a common tactic (Hojnacki et al., 2012). An interest group coalition exists “whenever two or more interest groups collaborate in advocating their public policy agendas” (Heaney & Lorenz, 2013, p. 252).

In the literature, coalitions range from formalised, long-term alliances to loose ad-hoc issue networks with marginal formalization (Berry, 1997; Mahoney, 2007). Coalition formation is thought to strengthen actors' influence by signaling unity across groups (Mahoney, 2007), and can unite groups that are not normally associated with each other.

Numerous studies confirm the tendency of interest groups to cooperate when their interests align on particular policy issues (e.g. Baumgartner et al., 2009; Weiler & Reißmann, 2019). Hartley (2002) notes that scholarly attention has often concentrated on contention between health actors, thereby ignoring the frequent interrelations between them. Whether groups

cooperate is nevertheless context dependent. Beyers and de Bruycker (2018), for instance, find that coalitions between business and non-business interests are more likely to form on salient policy issues with extensive media coverage.

Notably, groups cooperate by pooling resources, such as expertise and information (Berry, 1997; Chalmers, 2013; Hula, 1999; Mahoney, 2007; Hojnacki, 1998, p. 439). A study on health- coalitions in the U.S., for example, finds that groups prioritise establishing strong inter-

organisational ties when there is a lack of available policy information (Carpenter et al., 2003).

While Baumgartner et al. (2009, p. 211) suggest that groups primarily cooperate with other groups with equal resource levels, groups can sometimes choose to coalesce with groups that offer

different types of resources. Several studies for example find that pharmaceutical companies cooperate with patient activists because the latter have a more positive public image (ibid, p. 205;

Dang & Bn, 2016; Dumit, 2012). Baumgartner et al. (2009) furthermore find that elite government allies constitute a key resource for policy influence (p. 209).

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In general, large, established groups are better able to successfully access political arenas (Binderkrantz, 2005; Binderkrantz et al., 2015; Kriesi et al., 2007; Thrall, 2006). Although some claim that resources are inconsequential for lobbyism success in terms of policy outcomes (Baumgartner et al., 2009; Mahoney, 2007), resources are nevertheless central when measured in terms of the total amount of resources of a policy ‘side’; that is, the sum of actors advocating the same policy solution (Baumgartner et al., 2009, p. 204). The crucial issue, in other words, comes down to who cooperates, and the sum of their resources.

Although media visibility is recognised as a key strategy for political influence, remarkably few studies in the interest group literature have explored cooperation on media lobbying specifically (but see section 2.4 for relevant studies in the media literature). In one exceptional study, Wolfsfeld (1984) explores the collective (mass) media strategies of Israeli

"political action groups", concluding that collective action in relation to the media demands different forms of resources than do other forms of political collective action. Furthermore, with a few notable exceptions (Brown, 2016; Chalmers, 2013; Obar et al., 2012; Karpf, 2010; van der Graaf et al., 2016; Vesa et al., 2020), studies related to media lobbyism overwhelmingly focus on mainstream media, largely ignoring social and digital media platforms. For an in-depth discussion on the literature on digital media and lobbyism, see section 2.6.

In sum, the interest group literature provides valuable insights into how economic means, group characteristics and organisational drivers condition media strategies among interest groups.

Furthermore, it sheds light on how media strategies are motivated by different objectives, and how they constitute one of several strategies for influence. A central insight from this literature is hence that media strategies are conditioned by different organisational needs, institutional context, and by relations with important others. However, few studies explore in-depth what factors

condition the strategic combination of different digital and mainstream media platforms.

2.4 (Health) news sources in journalism studies

A significant body of literature within the field of journalism has explored the relative impact of different sources on the news production process (see Carlson, 2009 and Berkowitch, 2009 for overviews). Journalists are dependent on sources, both to gather information, and to publicly authorise the veracity of facts (Ericson et al., 1989; Tuchman, 1978, Sigal, 1973.). The source- journalist relationship is characterised as a struggle for power, or as a mutually beneficial

relationship between two powerful actors, metaphorically described as a tango dance (Gans, 1979;

see Maurer & Beiler, 2018, Allern, 1997). Others describe it as a competition over access and issue-framing, or as a tug-of-war in politics (Gans, 1979), and interactions have also been

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theorised in terms of exchanges (Chibnall, 1977; Sigal, 1973). Several recent studies on the health field have concluded that health news is co-produced between health actors and health journalists (Briggs & Hallin, 2016; Stroobant, Van den Bogaert, et al., 2018).

Due to organisational routines, deadlines and journalistic norms, journalists are prone to prioritising a limited number of established and credible sources (Sigal, 1973; see also Hall et al., 1978, Schudson, 2003; Philips, 2010). Reporters tend to seek accessible sources known to offer easily available and credible information, such as public officials (Berkowitch, 2009, p. 188). In a study on beat journalism, Reich (2009) finds that journalist tend to establish close, long-term relationships with a limited number of elite sources, such as public relations (PR) officers (see also Davis, 2002). This tendency, he notes, enables particular elite sources to influence media coverage implicitly (Reich, 2009, p. 89).

Scholars (and practitioners) generally disagree about the relative power of sources and journalists. Some posit that journalists have become secondary definers (Davis, 2002) and that powerful PR dominates the public sphere (Ericson et al., 1998). While Larsson (2009) finds that PR agents claim to succeed in planting news, he also finds that journalists deny such an influence.

Others argue that journalists can limit source influence through journalistic choices such as presentational frames (Ericson et al., 1998; Strömbäck & Nord, 2006, Gandy, 1982; Schnell, 2001), or by editorial rejection of source material (McNair, 2000). According to Terkildsen et al.

(1998), group representation in the media relates more to journalistic norms than to the strength of particular groups. In light of growing market pressure and the increasing professionalism of some sources, others claim journalists have become more dependent on sources (Benelli, 2003; Carlson, 2009; Len-Ríos, et al., 2009). However, several studies on journalist-source interaction on the health news beat find that journalists are critical to public relations material and that they are conscious of untoward influence in their interaction with sources (Len-Ríos, et al., 2009). Health journalist are said by Morrell et al. (2015) to be both dependent on, and critical to industry- interaction, aware of potential industry influence. Furthermore, a study by Stroobant, Van den Bogaert, et al. (2018) notes that journalists are skeptical of the underlying motives of biomedical sources, including scientists. However, there are differences in source reliance between news outlets; smaller and local outlets are generally more reliant on press releases than other types of media (Tanner et al., 2015: Wallington et al., 2010). According to Hestvik (2007), internet access to alternative information can result in increased journalistic independence from elite (scientific) sources. Nevertheless, although digital technologies and the democratization of media content production was initially thought to overthrow traditional source dependencies, studies largely find that existing inequalities between sources are largely reproduced within the hybrid media system

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(Phillips, 2010). A study by Deprez and van Leuven (2018) for instance highlight that digital sourcing through Twitter does not significantly alter source representation.

Traditionally, studies have found that medical experts such as scientists and physicians dominate health news. However, in the last decades, lay citizens have become increasingly prevalent in health news (De Dobbelaer et al., 2018; Eide & Hernes, 1987; Hallin et al., 2020;

Hinnant et al., 2013; Hong, 2013; Saglie & Bay, 2003, 2003; Seale, 2002; Stroobant, De

Dobbelaer, et al., 2018; Thorbjørnsrud & Ytreberg, 2020; Wheatley, 2020). For instance, a study on health sources in Dutch television news concludes that expert sources have declined, whereas citizen representation has increased (Verhoeven, 2008). While one study on health journalism in news magazines finds that elite sources, notably academic and medical experts, prevail (De Dobbelaer et al., 2017), another Flemish study on news sources finds an increase in lay persons in the quality press (Keyser & Raeymaeckers, 2012). A US study finds that NGOs and businesses have also become more prevalent in health news (Hallin et al., 2013), while several studies on health journalism in Belgium find few sources representing the pharmaceutical industry (De Dobbelaer et al., 2017; Stroobant, De Dobbelaer, et al., 2018). However, pharmaceutical industry influence has been found to 'creep' into the coverage through more covert PR strategies (De Dobbelaer et al., 2017; see also van Trigt et al., 1994). One reason for these discrepant findings, other than national differences, can be that different sources tend to dominate different platforms.

For example, in a comparative study on Belgian health news, Stroobant, De Dobbelaer, et al.

(2018) find that while ordinary citizens and academic experts are most prevalent in the coverage, medical experts dominate on web news and citizen representatives on television.

News sources vary not only in terms of access but also in how they are positioned, that is, which roles they are given in the news story (Seale, 2002). While officials often become “primary definers” (Hall et al., 1978), and scientists and medical experts are often positioned as neutral experts (Benelli, 2003; Forsyth et al., 2012), other groups, such as corporations, are often met with skepticism (Cottle, 2003). However, Stroobant, Van den Bogaert, et al. (2018) find that although elite medical sources dominate health news, they are not necessarily treated with reverence. De Dobbelaer et al. (2018) find that although lay patient sources are prevalent both online and in print news, they are positioned differently within different media. Similarly, a study by Wheatley (2020) on news media coverage of health policies finds that although there are high representation of lay citizens in the press coverage, many of these are simply 're-used' across outlets. Furthermore, these citizens are predominantly positioned as ‘victims’ rather than rational actors with policy input.

Hybrid mediatization and network dependencies: