JOURNALISTIC USE OF EXEMPLARS TO HUMANIZE HEALTH NEWS

Abstract

Health journalists often use personal stories to put a “face” on a health issue. This research uses a sociology-of-news approach, based on data collected from 42 in-depth interviews and three surveys with health journalists and editors [national (N = 774), state (N = 55), and purposive (N = 180)], to provide a first look at how important journalists think exemplars are to their stories. Results show journalists select exemplars to inform, inspire, and/or sensationalize a health issue. Some of the strategies journalists use to locate exemplars pose ethical concerns. Further, journalists rank the use of exemplars lower in aiding audience understanding compared with the use of experts, data and statistics, and definitions of technical terms.

Introduction

Use of exemplarsⁱ in health news stories is a common, albeit contested, practice. An exemplar is an “illustrative individual case” (Brosius and Bathelt 1994, 48) that describes the experience of someone dealing with a situation and offers enough detail for audience members to envision the individual’s situation (Greene, Campo, and Banerjee 2010). Exemplars often appear alongside expert interviews and base-rate information, which typically includes statistical probabilities. In using exemplars, journalists weigh their responsibilities for providing truthful and accurate information with getting audiences interested enough to follow the story.

Because exemplars attract audiences, cultivate emotional investment, and enliven base-rate information, their use is widespread. Narratives from members of the lay public may depict unusual circumstances and relay inaccurate information about diagnosis, treatment, or recovery (Kreuter et al. 2007). By the same token, exemplars can help overcome audience resistance to public health messages, facilitate information processing, and provide social connections through identification with the person in the story (Kreuter et al. 2007).

According to critics, some exemplar-use in journalism over-dramatizes personal stories, exploiting the ways in which audience members identify with the story’s subject (Vanderford and Smith 1996). In fact, the medical community has two terms for these differing types of discourse: one is “objective language,” which includes “verifiable, measurable signs of disease conveyed in the authoritative voices of physicians and other health providers;” and the second is “subjective language,” which covers the “internal, non-verifiable experience of illness” (Sharf and Vanderford 2003, 11). Exemplars and base-rate information (the former subjective, the latter objective) do not always align factually, and message receivers have been shown to make behavioral changes in favor of an exemplar that counters that message offered in the base-rate information (Allen, Preiss, and Gayle 2006). Exemplars have been characterized as “less valid but more vivid” than base-rate information (Brosius and Bathelt 1994, 48) and have been shown to be more effective than statistical messages (Cox and Cox 2001), to affect credibility (Arpan 2009), and to foment moral panic when grouped with other exemplars (Denham 2008).

The selection of which exemplars to use in a story is “guided by the subjective sentiment of a journalist” (Brosius 2003, 180). This subjective sentiment is precisely what the present research examines. Because health news is so widely consumed (Viswanath et al. 2008; Nelkin 1995) and the use of exemplars is considered beneficial in aiding audience understanding, yet problematic in its ability to focus on the unusual instead of typical case, it is important to understand how health journalists perceive that power, how they locate individual exemplars, and how they decide which exemplars to include. To provide a theoretical framework for our analysis, this study first explores exemplification theory.

Theoretical Framework

Whether exemplars help or hinder understanding is widely discussed, but there is little question that they are persuasive. Exemplification theory (Zillmann 2002, 1999) reveals how people’s beliefs are modified by exposure to individual occurrences that represent (exemplify) a whole phenomena, condition, or issue. Research shows that exemplars aid audiences in forming enduring beliefs about health risks, even when they contradict data in the same story (Zillmann, Perkins, and Sundar 1992; Zillmann et al. 1996; Zillmann and Gan 1996). Zillmann (2006) writes: “emotion-conveying and affect-eliciting exemplars do exert disproportional influence on the assessment of safety and health risks to others and self” (p. S230). The ability of exemplars to evoke emotion and create audience connections may be why journalists use them. As to why exemplars function so powerfully in persuasion, Petraglia (2009)posits that audience members’ ability to authenticate the information within the context of their lives gives legitimacy to the information. Moreover, Brosius (2003) points to the vividness and emotional proximity of exemplars to explain their disproportionate influence over summary-type base-rate information.

Zillmann (2006) offers his own suggestions for the promotion of health and safety messages. He writes that because base-rate information is largely ineffective in conveying relative risk (due to poor comprehension and delayed recall), exemplars should be used in appropriate frequency to reflect the actual quantitative distribution of risk. Kovach and Rosenstiel (2007) have supported this by arguing that “Journalists should keep the news comprehensive and in proportion” (p. 208). They also note that journalists should beware of the “pressure to hype” (p. 213) news by putting in sensational examples to lure readers.

Phenomenon of using exemplars in health journalism

In their research on magazine coverage of breast cancer, Andsager and Powers (2001) found that survivors’ stories were the most important element because of their ability to assuage anxiety. Henderson and Kitzinger (1999) found in their focus groups on breast cancer stories “human interest stories were the types of media coverage which generated conversation, thought and reflection and were most vividly recalled” (573). They later found that human interest “hooks,” in the form of patient stories, are used to draw readers into science stories, and posit that news values influence the preference for the inclusion of “real people” over “impersonal organisations” (2007, 76).

In research similar to this study, Wallington, Blake, Taylor-Clark, and Viswanath (2010) surveyed health journalists (n = 420) about how important certain priorities are when developing a story, one of them being “human interest.” They found that health journalists with a bachelor’s degree or less were more than twice as likely to say a human interest angle is important, and that those from small media organizations were 80% more likely than those from large organizations to find human interest to be a priority. This shows variation in exemplar-use among journalists.

In a review of standards for medical reporting, Vercellesi et al. (2010) found guidelines suggest avoiding anecdotal stories and emphasize that when used, exemplars should be consistent with the scientific evidence. The final recommendation from Vercellesi et al. is for journalists to “avoid reporting of anecdotal cases, unusual evidence, individual voices, even if they all have great journalistic value” (p. 57). Other authors argue that “lay narratives” or human elements are problematic because they heighten emotionality and displace scientific reason (Boyce 2006; Schwitzer 2011; MacDonald 2005). On a practical level, in-depth interviews with television journalists illustrate that due to protections of patient privacy, it is difficult to find the appropriate exemplars for stories—and that journalists will rely on hospital public relations staff for access to patients to interview (Roberts 2011). Therefore, the level of control that a journalist may have over the exemplars they use may be limited to those to whom they have access.

Based on the literature, it is clear that exemplars play a pivotal role in how much attention audiences will pay to a story and can affect whether audiences will take action on a health issue. To explore how health journalists contemplate these issues and make decisions about the use of exemplars, the following questions are posed:

RQ1: Why do health journalists say they use exemplars?

RQ2: In which kinds of stories do health journalists say they use exemplars?

RQ3: How important do health journalists say exemplars are to their stories?

RQ4: How do health journalists find exemplars for their stories and what criteria do they use?

Method

This research uses multiple data sources gathered over five years. It incorporates two sets of qualitative in-depth interviews and results from three surveys of journalists. Before describing each method, it is important to explain why this mixed-methods sequential exploratory design (Creswell 2009) is appropriate. Our approach offers methodological and data triangulation (Tashakkori and Teddlie 1998) and better enables us to understand journalistic meaning-making and work patterns. Several other sociology-of-news studies have used a multi-method approach (Witschge and Nygren 2009; Gans 1979; Tuchman 1978; Boczkowski 2004). Comparing groups, as this research does, can “improve the substance and explanatory power of our interpretations” (Christians and Carey 1989, 366). It is often helpful to precede quantitative work with qualitative observation in order to establish appropriate terms of analysis (Pauly 1991).

In-depth interviews allow researchers access to the observations of others (Weiss 1995), which is useful when exploring the specific communication technique of using exemplars. The interviews were semi-structured, and the interview protocol served the function of “grand tour” questions (McCracken 1988, 35), which allowed respondents to generate key terms through the voices of participants. Interviews were sought until patterns emerged within the obtained information. These in-depth interviews provided the foundation for survey data collection by establishing common word usage among journalists in describing exemplars, and identifying trends in how journalists locate exemplars. While in-depth interviews offer richness in data collection, surveys allow us to identify whether findings from the interviews exist in the larger population (Wimmer and Dominick 2011).

In-depth Interview Data

Sample 1

The lead author conducted telephone interviews with health writers and magazine editors (N = 22) between March and June 2006. Eligible participants were in their positions for at least six months, worked at consumer publications with a total paid circulation greater than 50,000, and dealt with health content. Interviews averaged one hour and ranged between 30 and 90 minutes. Questions in the interview guide relevant to exemplars include: “What characteristics make your stories compelling to readers?” and “Is there anything you do to package a health story to make it more engaging?”

Sample 2

Four researchers conducted in-depth phone interviews (N = 20) between October 2007 and February 2008. The criteria for inclusion were that they must report, write, or edit stories about health, medicine, or health care for a newspaper or consumer magazine. Participants were found using several resources: Mastheads and editorial boards; membership list of the Association of Health Care Journalists, a partner in the study; and professional-networking Web services. Specific questions in the interview guide that elicited responses about exemplars included: “Whom do you interview in order to explain health information?” and “What elements can you include in a story that might improve your audience’s understanding of your stories?”

In the interview transcripts from both the 2006 and 2007 interviews, which are combined in the results, the researchers looked for information about the use of exemplars (for example, looking for responses about “real people,” “human interest stories,” “anecdotes,” and “reader stories”), how they were located, how they were used, and their thoughts on how exemplars function within a health article. These were then sorted into excerpt files (Weiss, 1995) to locate patterns within the responses. The researchers used the constant comparative method (Glaser 1965), which included coding and comparing incidents with previously coded incidents within the excerpt files. This method of coding enabled a grounded theory approach to determine which theoretical concepts emerged from the relationship between data and analysis(Glaser and Strauss 1967).

Survey Data

Sample 1: National telephone survey of health journalists

A cross-sectional survey (N = 774) was conducted between January and February 2008 by a professional research center and achieved a 61.9% response rate. The sampling frame was generated through partnership with the Association of Health Care Journalists and a search of Bacon’s online media directory. Journalists in the sample averaged 19 years of experience as a journalist and 10.6 years of experience as a health journalist and were mainly female (62.5%). Nearly 1 in 5 respondents had had training in health reporting. Of the total, 36% worked for national news organizations, 29.7% for metropolitan news outlets, while 18.8% worked for community media.

We measured journalists’ perceptions of the importance of exemplars by asking respondents to “Rate the importance of the following story elements in helping readers, listeners, and viewers understand health information.” Among other responses examined, “human element or someone who has experienced a health problem” was measured on a Likert-type scale with 1 (not at all important) and 7 (very important). For use in cross-tabulations, the human element variable was coded into a dichotomous variable as 1-5(less important) and 6-7 (very important). Journalists also indicated the degree to which “ability to humanize the topic” was a motivator when determining whether to cover a particular health story. To understand how journalists go about finding exemplars for their stories, an open-ended question was asked, “Where do you locate patients or other ‘real people’ to add the human element to your stories?” Response categories were provided to telephone interviewers.

Sample 2: Purposive survey

As part of an experiment about news values, health journalists (N = 180) completed a pretest questionnaire with a question relevant to the study of exemplar use. Although participants were not randomly selected for the study, researchers attempted to recruit every newspaper health journalist listed in the Bacon’s Media Directory (Bacon’s Newspaper/Magazine Directory 2009). The sampling population included those with a title that included “health,” “medicine,” “healthcare,” or “fitness & exercise.” They had an average of about 7 years experience as health journalists and were mainly female (70.9%). Of the total, 52.5% served a metropolitan audience, 42.5% served small communities, and 5% served a national audience. There was one measure in the pre-test that addressed the role of exemplars in health stories. As in the 2008 survey, journalists were asked to rate on a scale of 1 to 7 how strong of a motivator “ability to humanize the topic” is in deciding whether to cover a health story.

Sample 3: Statewide survey

This survey was conducted with newspaper journalists (N = 55) in a Midwestern state as part of a statewide health-literacy effort. A total of 273 journalists were recruited from a statewide press association directory, a university’s media list for news releases, and Bacon’s Media Directory. The response rate was 20%, and the survey was conducted over the phone (70%) and online (30%). Most respondents (79.9%) served small communities, 7.6% served suburbs/medium-sized cities, and 4.2% reported working in a metropolitan area. Journalists were asked to rank the importance of having a “human element” or “real person” to exemplify the main point of different types of health stories on a scale from 1 to 7.Journalists also reported how often they recruited exemplars from different places, such as a hospital or university PR department; friends, families, or physicians; or searching online.

Findings

The findings are organized by research question and offer data from both in-depth interviews and surveys. Integrating the data from multiple sources in answering the questions allows for a more thorough analysis on each point. Each interview is denoted by the journalist’s position and year of interview to distinguish between interview sets.

Why Health Journalists Use Exemplars

To answer the first research question, the interview data illuminate the purposes health journalists claim exemplars serve, from humanizing a rare disease to showing audiences how health policy could affect them to simply attracting readers to a story.

Educating and connecting

Using exemplars serves the purpose of “humanizing the findings” (editor-in-chief, 2006), or putting health “in the context of their lives” (editor-in-chief, 2006). More than one journalist said that readers “love” to read about other people because it offers a “connection” and causes people to understand and remember the health information better (freelance writer and editor, 2006). The affective connection audience members might feel toward an exemplar is juxtaposed with their numbers or base-rate information. “They love to hear about other people with their same problem, and the photos draw you in a lot more than some kind of drawing or abstract diagram” (newspaper reporter, 2007). Along the same lines, a journalist emphasized that personal images and stories are more desirable than “2,000 words of running text” and that such exemplars could make readers realize “these are things I could do” (freelance writer, 2007). Another journalist said that good reporters bring a human element into the story to increase reader identification with a problem and thus enhance reader knowledge (newspaper reporter, 2007).

Contained within the typification (Tuchman 1972) of readers “identifying” with a health problem is both the perceived lure for readers of connecting with people as well as helping audience members with understanding and application of information. For instance, one journalist described her award-winning story as “a perfect example of taking some serious medical lingo and […] putting a human face on it, making it understandable” (freelance writer, 2007). A “human face” diminishes the abstraction of medical science. She talked about how the audience can put themselves in the exemplar’s shoes: “Reading a dry study about HIV is much different than reading about […] a woman who could live next door to you and her struggle to […] fight off the disease while she’s raising two kids and working at the same time.” In this example, the journalist compared the abstractness of “dry” research with an exemplar’s localizing power and context. An editor-in-chief (2006) noted how her publication includes anecdotes in order to make what is “sciencey” and “full of jargon” understandable. The inclusion of exemplars’ stories was associated with the desire to add interest and appeal, help readers identify with a problem, and make health information less abstract. It is not clear whether discomfort with “sciencey” information comes from audiences or is projected onto audiences through journalists’ own discomfort.

Attention-grabbing device

In terms of getting people to engage with a story, journalists use exemplars to “rope you in” (magazine editor, 2006), with some describing an “anecdotal hook” as a “trick” to make people interested (newspaper writer, 2007) or a way to add “spice to the recipe” (writer, 2006). Another journalist described how she has to “grab their attention with a very compelling anecdote” (freelance writer and editor, 2006), equating exemplars to story “teasers.” Across the interviews, journalists noted they use exemplars to get the audience invested; “You’ve got to figure out a way to make them realize they need to read this story because it’s important for them or because there’s a very compelling personal story of somebody else” (freelance writer, 2006). Taken together, journalists say they use exemplars to help educate their audiences on health issues and they believe exemplars attract the reader’s attention and get them to care about the issue.

The in-depth interview data reveal that journalists find exemplars helpful in increasing understanding and identification. Next, data from a 2008 national survey of health journalists determines how health journalists ranked the human element exemplar in importance compared to other story elements (Table 1). All story elements were viewed as important. However, exemplars ranked fifth in a list of nine elements. According to these data, the top three story elements required in almost any situation are an expert source, baseline statistics, and definitions for technical terms.

TABLE 1.

Mean Scores of Importance of Story Elements to Audience Understanding

Element	M (N)	SD
Medical expert	6.05 (769)	1.34
Data and statistics	5.93 (771)	1.19
Definitions and rewording of technical terms	5.87 (771)	1.44
Places to go for more information	5.62 (772)	1.56
Added context	5.46 (768)	1.43
Human element exemplars	5.29 (772)	1.90
Conversational tone	5.24 (767)	1.72
Photos, illustrations or infographics	5.06 (766)	1.78
Metaphors, analogies and anecdotes	4.80 (771)	1.66

Story Types That Use Exemplars

Journalists use exemplars in certain types of stories more than others. Exemplars illustrating a particular disease are used to garner interest in a health story that is not directly relevant to the reader. One journalist illustrates this story type when she said she would have to find “some really interesting character who was a guinea pig in a clinical trial” (magazine health editor, 2006); and when a journalist said if a disease is depressing, the magazine would only cover it if they could find a woman with a “crazy awful experience” (magazine editor, 2006). As to why they use it, a journalist said that the human-interest frame “allows us to cover something that might be rarer, that we don’t necessarily want to come at from a service angle, but helps educate the public about what it’s like to live with a certain condition” (magazine health editor, 2006). In this case, exemplar-availability expands the scope of what a health journalist considers to be a viable story topic.

Along the same lines, a journalist said that with political health stories, “they definitely want to put a human face on things” (freelance writer and editor, 2006). Another journalist who writes about healthcare policy said he tries “to bring real people into the story as opposed to just experts and healthcare and government officials and academics” (newspaper writer, 2007). He looks for “patients or their families or people actually affected by these policies.” This journalist made a distinction between the “humanness” of exemplars as compared to the detachment of experts. Another journalist explained how an exemplar can “hook” readers to delve into a political story that might not normally draw them in. For example he says he will profile “average everyday women” who are “going into pharmacies just to get their regular birth control pills and they’re being refused them by right-to-life pharmacists who won’t give them birth control pills.” And once the writer has attracted readers, he said they are “willing to be educated” (freelance writer, 2006). This reiterates how the emotional strength of exemplars may be used to grab attention and increase comprehension. A newspaper reporter (2007) described her process when covering health policy as finding someone to “exemplify” an abstraction: “That way, the reader can see that, hey, […] it’s not just some policy that’s dangling out there that’s going to restrict mammograms.” Similar to anchoring abstraction from medical science, this journalist uses exemplars to make perplexing policies concrete.

One journalist also said exemplars can contribute opinions the publication cannot. For example, she covered faith-based “prayer diets” (that are backed by scientific research about lowering cortisol) with “real-life stories” but “never in the editorial voice” (magazine editor, 2006). This represents a distancing that effectively allows a publication to cover a topic without espousing a particular view.

The 2010 survey (n = 48) of journalists in one Midwestern state asked journalists to rank the importance of a “human element” or “central real person” in helping to exemplify the main point of different types of health stories. They said that exemplars were most important to service stories, e.g., those about annual events or activities (M = 5.67, SD = 1.55); maintaining wellness (M = 5.46, SD = 1.46); disease management and treatment (M = 5.12, SD = 1.58); and disease prevention (M = 5.06, SD = 1.44). Exemplars were less important to stories about health policy (M = 4.83, SD = 1.81) or breaking health news (M = 4.67, SD = 1.94).

To summarize, interview data indicate journalists find exemplar-use effective for engaging an audience in a story that may be less personally relevant to them, such as a story about healthcare policy or disease. Survey data, however, only partially supported the interview data with stories about policy, disease management, and disease prevention being lower on the scale of exemplar-importance than wellness stories.

Importance of Exemplar Availability When Weighing a Story

To answer the third research question, for some health topics, health journalists look for the availability of exemplars before considering the story, for others, they might be motivated to cover a topic because they have found an exemplar. One journalist says her publication wouldn’t cover a disease like Alzheimer’s “unless I found a 35-year old who got it” (magazine health editor, 2006).Even though she said this somewhat sarcastically, it raises the point that news organizations are concerned with representing the target demographic of their audiences. For another journalist, leading with a “first-person story” allows her to segue to more base-rate information, such as statistics and a checklist, both of which are “snowballed off of the first-person story” (freelance writer, 2007). In evaluating the editorial value of scientific research, more than one journalist described the need to find exemplars whose experiences were consistent with research results in order to legitimize the findings to the editors and have them make sense to the readers. This example is surprising because it is logical to expect that journalists would look for scientific data to weigh the value of an anecdotal story instead of weighing the value of data by the existence of anecdotal evidence.

In the 2008 national survey (n = 763), health journalists reported that the ability to humanize a topic could motivate them to pursue a story (M = 5.03, SD = 1.68). In a repetition of that question with the 2009 pretest (n = 179), respondents also ranked ability to find a human angle as motivator when choosing a health story (M = 5.69, SD = 1.16).

Locating People

To answer the first part of the fourth research question, it is difficult to find members of the “amorphous public” (Tuchman 1978, 92) who are affected by a particular health issue, and they might be disinclined to discuss private medical problems in a public forum. Journalists frequently said that they use medical experts to locate exemplars, which requires careful negotiation with regard to patient privacy rights. It takes “talking to lots of experts and explaining to them why we need the real people and saying it really helps the story come to life for our readers,” (magazine health editor, 2006). Another journalist reiterated how the expert serves as the connector: “We interview the experts first, but we need those experts to get us people and it’s hard with rules like HIPAA that are an invasion to privacy. So you have to have the doctors trust you and be willing to go out a little bit on a limb for you” (freelance writer, 2006).

In addition to using experts as a path to exemplars, one journalist noted using university public relations to find people who have been in clinical trials (freelance writer, 2007). Along those lines, a couple of journalists reported using pharmaceutical companies to find exemplars. One in particular found using pharmaceutical companies to be unethical. She said that although using an industry-supplied exemplar is an easy way to illustrate a health problem, she personally hates using exemplars because “the reason you’re getting these names is because […] you’re gonna get the people for whom the drug worked” (health editor, 2007). She pointed out that it is difficult for journalists to find exemplars on their own because of time constraints, a point that others also articulated.

News audiences can also serve as sources for exemplars, and one journalist said readers are good because they already fit their target demographic (editor-in-chief, 2006). Another journalist offered a powerful example from a story pitched by a reader about her friend who needed a liver transplant but who didn’t have insurance for a period between jobs and therefore couldn’t get on the waiting list. As the journalist followed up on the story, the reader’s friend died. She did the story anyway, and said:

it had a big impact on people because this guy was a middle-class person who worked all his life who was head of the Rotary club, who gave away a lot of his time and energy to helping people who were less fortunate. And then when he was in that position, there was nobody to help him. […] the government and the country that he loved were going to say, “Tough. You’re going to die, buddy. At age 49 or 50 or whatever he was, you’re going to die. You may as well just pack it in.” (newspaper medical reporter, 2007)

This particular example shows one reporter taking story ideas from her audience and noting how the demographics of the story subject appealed to readers.

Part of the appeal of “real people” as health news sources is that they are often unaffiliated sources who don’t profit from the story. This autonomy from official sources makes it difficult for journalists to locate “real people.” Journalists in the 2008 national telephone survey said they were most likely to locate “real people” through a hospital or private practice (44.1%). Other resources were personal contacts or friends (21.2%), readers or viewers (20.7%), and associations or organizations (20.7%). Few journalists mentioned using clinical trials (1.3%) or pharmaceutical companies (0.8%) for finding “real people.” Of the 340 respondents who named “other” sources, 65 (19.1%) mentioned individual experts, 23 (6.8%) named publicists or public information officers, 15 (4.4%) mentioned support groups, and 29 (8.5%) said listservs, Yahoo! groups, or social network sites.

Respondents in the 2010 statewide survey of journalists (n = 48) typically reported recruiting exemplars for stories through public relations professionals, such as those affiliated with a local hospital (M = 4.44, SD = 1.88). Other common routes to identifying exemplars were querying colleagues in the newsroom (M = 4.36, SD = 1.73), family and friends (M = 4.09, SD = 1.79), or local health care providers (M = 4.08, SD = 1.80). Respondents were somewhat likely to find “real people” sources via online searches or blogs (M = 3.10, SD = 1.69), but very unlikely to find them via pharmaceutical companies’ PR offices (M = 1.87, SD = 1.06).

One journalist showed disdain for exemplar-use because of how they are located, though she understands why it works as a writing device. She said she would feel less “cheap” if she talked to 50 people with gastrointestinal bypass to use as the basis of her reporting (magazine editor, 2007). Instead, she explained:

What usually happens is you write a story about gastrointestinal bypass, and you’ll talk to a lot of doctors and cite a lot of studies and then as an afterthought you think “Oh, we need a photo for this, so we need a real person. So, let me find someone who had success with it and then let me find someone who didn’t have success with it.” And there’s really no guarantee that they’re at all representative.

This top-down approach going from the researchers to the exemplars is not honest in her opinion, and the exemplar that is chosen may not be representative of the typical case.

In summary, exemplars are difficult to find, and using exemplars may require journalistic compromises—settling for an exemplar that is not representative of the problem or an exemplar tied to vested interests.

Criteria for Inclusion

As well as practical decisions for choosing exemplars, there are ethical ones as well. Journalists apply different criteria to see if an exemplar will work in a story for different publications, and this becomes clear in answering the second part of the fourth research question. Some journalists noted that the person featured in the anecdote needs to share the demographic characteristics of the publication’s readership, such as age, sex, religious background, or material wealth (all specifically mentioned). One journalist said she was instructed to make the real person in the anecdote “sound as real as possible; make her sound as much like the reader as possible” in order to get the reader to care about a disease (magazine editor, 2006). One journalist said they looked for exemplars “in our demo that we can start stories with and weave through stories so that people can see themselves in the story. And it becomes about a person and themselves rather than just about a disease” (magazine health editor, 2006). Another journalist highlighted how the demographic characteristics, if similar to the reader’s own, cause a reader to more closely identify with a health story. “They start with ‘Here’s Amy Sue Jones who had this amazing experience, either heartbreaking or triumphant or whatever the case may be, and she’s your age and she looked like you and this could be you, so you need to read about her’” (freelance writer, 2006). The assumption is that readers would be less inclined to sympathize with a demographically different individual.

One journalist said her publication would not include exemplars considered “negative characters” who “you can’t relate to or you can’t learn something from” (magazine editor, 2006). Even if an exemplar’s health situation is different from the readers’, they have a shared social-demographic background. The exemplar’s willingness to be identified by name or in photographs was described as “critical” by different journalists. One journalist disparages other publications that do not use real names or last names, saying they are “thinly reported” and should have higher standards.

Problematic use of exemplar criteria

One journalist recalls the challenge she faced in reporting a story on abortion where the exemplar did not match the ideal image editors imagined for the story’s protagonist. The assigning editor first saw the exemplar with blonde hair in a newspaper photograph. At the time of assignment, the journalist said she thought: “If that woman had been Black, we never would’ve run the story” (freelance writer, 2006). As the journalist learned more, her concerns about the exemplar’s lack of fit with the demographic mold of the magazine increased. In fact, the journalist deemed her to be “white trash,” and not a “redeeming character.” While the exemplar’s race and gender demographically matched the audience, her class status did not. The journalist recounted a conversation with her editor when she revealed the exemplar’s class status:

Journalist: “She’s at this shelter and I’m waiting to hear back.”

Editor: “Wait a minute. Is she not in our demo?”

Journalist (thought to herself): Do we only care about reproductive rights if she can afford a Chevy Cavalier?

Here, the journalist ridiculed the publication’s exclusive use of those exemplars who reflected the audience demographic.

Instead of killing the story because of the exemplar’s delegitimizing demographic and character traits, the publication instead concealed those traits. They photographed the exemplar in a hotel to make her appear middle-class. The journalist said she represented the exemplar as a sympathetic character when her behavior was in reality unsympathetic. The journalist described her own ethical double-bind, saying if she had not obscured the woman’s true character and actions, it would be akin to “giving someone nails to make a nail bomb” outside an abortion clinic. Both her sense of social responsibility to a public health issue and the publication’s desire to make the exemplar’s story resonate with the audience led to this misrepresentation of the truth.

The criteria for inclusion and the demographic categories are a fairly straightforward way to have audience members “identify” with the exemplars. It appears, however, that if those criteria become too rigid or idealized, they can influence the facts of a story or disqualify a potential exemplar from inclusion.

Discussion

Although the functions of exemplars are well known and widely studied in the field of public health and in persuasion more generally, the way health journalists conceive of those functions is largely unknown. Health journalists are an understudied group (Viswanath et al. 2008; Viswanath and Emmons 2006; Wallington et al. 2010), and their perceptions are important because of the broad consumption of this type of information. This research describes the common practices and rationales behind health journalists’ use of exemplars, which could help facilitate communication among media producers, public health advocates, and private citizens.

While health journalists would not be expected to know the empirically established functions of exemplars, their interview and survey responses indicate they match. When health journalists described getting readers to “identify” with a health problem, their mission goes beyond simply informing a reader. More specifically, they spoke of getting the readers to see that health problem as authentic and to locate the issue within the scope of their own lives. This echoes Petraglia’s (2009) point that information in narrative form imparts authenticity in its consumption because the information is “relevant to” and “consonant with” (p. 176) the audience members’ realities. This is not to say that exemplar use is the main tool health journalists use to promote audience understanding. Three other story elements came up consistently as needed in almost any situation (expert source, baseline statistics, and definitions for technical terms). However, exemplars are important for telling particular kinds of stories and for making stories newsworthy when they might not otherwise be covered as news. Furthermore, some types of health journalists find exemplars to be more important than others.

Health journalists also use exemplars to represent the types of stories they want to tell. From the interviews, finding an exemplar was less about finding someone who is ideally representative of a disease, condition, or situation and more about finding someone whose personal story can be a catalyst for a story type, be it illustrative, inspirational or sensation-oriented. And, just as Zillmann (2006) discusses exemplar-use for tailoring health messages and making them suitable to audience members with certain “known characteristics” (p. S233), several health journalists look for exemplars with characteristics that match those of the target reader. That said, research from Zillmann (2006) would also lead us to expect journalists to choose exemplars for their emotional conveyance or affect arousal since those are the most influential characteristics. Instead, finding an exemplar with certain demographic characteristics appears to take precedence over other sensationalized qualities. Another unexpected finding was that journalists sometimes evaluate the worth of base-rate information based on whether they can find an exemplar to support it (instead of vice versa).

A few points in the findings specifically indicate obstacles in providing an accurate reflection of health information through exemplar-use. Some health journalists in this research revealed that, in the hunt for fitting exemplars, they might compromise the information they are communicating. Two journalists raised ethical concerns about methods they had used, and those two instances in particular, as well as the journalists’ stated use of public relations practitioners to find exemplars, do beg the question of how much an exemplar’s narrative is manipulated at every stage (even before the journalist gets it). Furthermore, much of the health communication and exemplification theory literature treats objective sources as superior to subjective sources. We recognize, however, that health and science information from objective official sources can also be inaccurate and manipulated by vested interests. Also, it is clear that a person’s individual risk may not be the same as the population-based risk assessments (Edwards, Elwyn, and Mulley 2002). One final contribution of this research concerns the practice of journalism more generally. The health journalists’ willingness to discuss how their conceptions of the audience influence their use of exemplars is refreshing. These health journalists permit themselves reflexivity, whereas Ettema (2005) writes, “Journalism, supposing that it would lose itself in self-contemplation, is characteristically hostile to the mere mention of reflexivity” (146). Because health journalists were not hostile to reflecting about how notions of the audience shaped their work, we can better understand how those assumptions directly inform what becomes news.

The limitations for this study are three-fold. First, the statewide survey had a small sample size (N =55). Second, the terminology for referring to the phenomenon of exemplar-use evolved along with our understanding of the health journalists’ work. Survey measures were refined based on new understandings and made them more sensitized to the participants. Third, health journalists in the present study reported surprisingly low use of social media for locating exemplars in the 2008 and 2010 samples. Whether this is a matter of the present data not accounting for massive shifts in technology-driven reporting or whether there is an actual reluctance on the part of health journalists to use social media to locate exemplars should be examined. One recent study found that business journalists did not use social media for sourcing (Lariscy et al. 2009), but massive social media growth has occurred even since 2009. In short, this surprising finding deserves more probing. Future research should also examine how social media exemplars function (e.g. an individual posting about a health status to his or her own network), and what would lead exemplars to share their stories via journalistic outlets.

For many health journalists, exemplars serve the purpose of bringing health issues into the life-context of audience members and validating the relevance of issues, at least until education occurs. Journalists’ goal of getting audience members’ attention in order to impart information is important for public health practitioners to consider. Are health journalists allies in the quest to advocate for public health; are they unreliable sources of information who threaten to over-sensationalize and stymie accurate understanding; or do they serve an entirely different function? There is no straightforward answer to these questions, but these findings indicate that journalists grasp the power of exemplars to inform and connect with audiences.