- Email: [email protected]
The case of Norplant as an example of media coverage over the life of a new health technology
PUBLIC HEALTH
Public health
The case of Norplant as an example of media coverage over the life of a new health technology Vikki A Entwistle, Ian S Watt, Fiona Johnson
Background The contraceptive implant Norplant (levonorgestrel) had a fairly short life in the UK. This made it a convenient subject for a case study of how media coverage alters over time. We set out to produce a critical description of national newspaper coverage of Norplant over the course of its use in the UK. Methods We searched newspaper databases and pressclippings files for articles about Norplant printed between 1992 and 1996. For those that met our inclusion criteria, we extracted bibliographical data, made a standardised judgment about the “slant” of the article towards Norplant, and used qualitative techniques to analyse the content of the articles. Findings 101 national newspaper articles were included in the study. Norplant attracted media coverage over the course of its career, but the slant of articles shifted dramatically over time from a favourable to a negative presentation. This reflected the use of different story types over the course of time. Early reports presented Norplant very positively as either a clear improvement on existing contraceptive methods or a valuable addition to the range. Any disadvantages were down-played. The positive image of Norplant was reinforced immediately after its official launch by reports that it was in great demand but women might be denied access to it. Less than a year later, however, newspaper reports about Norplant were dominated by the stories of individual women who had had bad experiences with the product. Interpretation Three main reporting themes were seen. At first, Norplant was presented as a positive new development, and one that might be denied to people. In later coverage it became a flawed and damaging product. These themes recur in media reporting of health technologies, and the fact that they occur at different stages in a product’s career means that a balanced assessment of the technology is not usually feasible from media reporting at any one time. An appreciation of the forms and implications of these reporting frameworks could help health-care providers and users to appraise media reports more critically.
Lancet 2000; 355: 1633–36 Health Services Research Unit, University of Aberdeen (V A Entwistle PhD); Department of Health Studies, University of York (I S Watt FFPHM); and ICRF Health Behaviour Unit, University College, London, UK (F Johnson BSc) Correspondence to: Vikki A Entwistle, Health Services Research Unit, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen AB25 2ZD, UK (e-mail: [email protected])
THE LANCET • Vol 355 • May 6, 2000
Introduction The levonorgestrel implant Norplant is a contraceptive developed by the World Population Council in the 1970s and introduced to the USA in 1990 by Wyeth and to the UK in 1993 by Hoechst Marion Roussel. Six small silastic capsules are implanted beneath the skin of the woman’s arm, releasing the progestagen levonorgestrel into the bloodstream. Norplant is intended to provide contraceptive cover for up to 5 years. Prescription data from the UK show that after the product launch in initial surge in uptake was followed within a year by a substantial decline that cannot be fully explained by the fact that Norplant is long-acting (figure 1). The product was withdrawn from sale in the UK in 1999. Several factors may have contributed to Norplant’s demise. For example, although the insertion and removal of Norplant are skilled and time-consuming tasks, the government refused to pay general practitioners any more for providing Norplant than for prescribing oral contraceptives. As a result, professional bodies advised their members against providing the implant.1 Also, it has been suggested that adverse publicity in the professional and lay news media discouraged people from using it.2 Although media coverage can influence use of health services,3 the extent to which media coverage causes, reinforces, or reflects changes in attitudes and behaviour is difficult to establish and may vary from case to case.4 The fact that Norplant had a short life in the UK makes it a convenient subject for a case study of how media coverage alters over time. We provide a critical description of national newspaper coverage of Norplant from 1992 to 1996. The study was not designed, however, to investigate the possibility of any causal relation between media coverage and the use of Norplant.
Methods We searched the following sources retrospectively for Jan 1, 1992, to Dec 31, 1996, to identify national newspaper articles Prescriptions dispensed
Summary
7000 6000 5000 4000 3000 2000 1000 0 /4 /1 /2 /3 /4 /1 /2 /3 /4 /1 /2 /3 /4 93 94 94 94 94 95 95 95 95 96 96 96 96
Year and quarter Figure 1: Norplant prescriptions dispensed 1993–96 (PACT data)
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25 Negative Neutral Positive
Number of articles
20 15 10 5
92 / 93 4 / 93 1 / 93 2 / 93 3 / 94 4 / 94 1 /2 94 / 94 3 / 95 4 /1 95 / 95 2 / 95 3 / 96 4 / 96 1 / 96 2 /3
0
Year and quarter Figure 2: Number and slant of newspaper articles towards Norplant, 1992–96 about Norplant: CD-ROM versions of eight national newspapers and their Sunday equivalents. We used the search terms “Norplant” or (“contracept* and implant*”); Popular Medical Index, “contraception” and “family planning” sections; presscuttings files at the Family Planning Association and Hoeschst Marion Roussel. We included articles that contained at least three sentences about Norplant. We excluded articles that focused only on the performance of companies associated with Norplant. Decisions about inclusion were made by one researcher and checked by another. For each included article we recorded bibliographic details, newspaper type (broadsheet or tabloid), article type (news, feature, editorial, doctor’s column, letter), and whether or not Norplant was the primary subject of the article. The slant of each article towards Norplant (positive, negative, or neutral) was independently rated by three researchers by a standard set of rubrics. The majority rating was adopted except for the two articles given a different ratings by all three researchers, which were categorised as neutral. For all included articles, text related to the following aspects or issues was copied into text files for qualitative analysis: Norplant’s characteristics, including mode and duration of action, contraceptive effectiveness, reversibility, and side-effects; the provision of Norplant, including training and reimbursement of health professionals, information and counselling for women; insertion and removal procedures; patterns of uptake of Norplant and experiences of its use; social concerns and legal actions relating to Norplant. Specific statements about individual Norplant users were handled separately from general statements. We also recorded details of the people to whom comments were attributed. Once we were familiar with the articles, we grouped them into four main periods that marked key stages in the product’s life and which were characterised by different reporting themes: before the launch (Jan 1, 1992–Sept 30, 1993), during it (Oct 1–12, 1993), after (Oct 13, 1993–June 30, 1994), and later (July 1, 1994–Dec 31, 1996). The overall period was defined by our impressions about the time over which the UK media had covered Norplant. Searches of press cuttings in 1997 confirmed that there had been little coverage outside those dates.
Results 101 national newspaper articles, 51 from broadsheets and 50 from tabloid newspapers, that met the inclusion criteria. News and feature articles accounted for 90% of the articles and were present in almost equal proportions. 84% of the articles were primarily about Norplant. Of the 16 that were not, 12 were articles that covered a range of contraceptive options. The articles varied in terms of their prominence within the newspapers and their length.
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Norplant attracted newspaper coverage throughout the study period (figure 2). The number of articles peaked around the time of the product launch and when it was announced that a woman was preparing to sue the company selling Norplant in the UK. The slant of the articles shifted dramatically over time from a favourable to a much less favourable presentation. This reflected changes in the types of story that appeared over the study period. Before and around the time of the UK launch, national newspapers presented Norplant very positively as either a clear improvement on existing contraceptive methods or a valuable addition to the current range and thus as a product that would extend women’s choice. Norplant was portrayed as a new contraceptive method—although some reports stressed that it had been tried and tested in other parts of the world—that offered 5 year’s protection from pregnancy and had the potential to revolutionise women’s lives. The implant was described as effective and reliable, with the added advantage that women could not forget to take it. In these early reports, any disadvantages of Norplant were down-played. If disadvantages were mentioned, the surgery required to insert the implant and any side-effects that might occur were both described minor. While early media articles were uncritical about the product itself, several broadsheet newspapers focused on the possibility that it could be used for social manipulation. They discussed reports from America about Norplant being offered to poor (black) teenagers and forced upon women on welfare or with criminal convictions. These stories were often accompanied by reassurances from the Department of Health and others that such situations could not occur in the UK. The newspapers reported that family planning specialists were more concerned that women might be denied access to Norplant if it was deemed too expensive to be provided free by the National Health Service. After the launch, the largely positive descriptions of the product continued, although one article, triggered by an issue of Drug and Therapeutics Bulletin (a publication that aims to provide up-to-date independent evaluations of drugs and other modes of treatment) mentioned possible problems relating to the rate of drug delivery and another reported that a health authority had warned general practitioners that the side-effect of menstrual irregularity could lead to requests for early removal, thus reducing the cost effectiveness of the product. Most of the individual Norplant users who were quoted during the first 9 months after the product launch were very enthusiastic. Only one, who had experienced constant bleeding, was said to be considering having Norplant taken out if the bleeding continued. The main new reporting theme in reports after the launch was the high level of demand for Norplant and the possibility that this demand could not be met. Norplant’s popularity and the range of women asking for it was said to have surprised many doctors. The fact that not all general practitioners were trained to insert Norplant was widely reported. So was the possibility that family planning services with limited budgets would be deterred from providing it because of its high up-front cost. The indignant concerns expressed in newspaper articles that women might be denied access to Norplant still reflected a belief that the product was useful and desirable.
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PUBLIC HEALTH
Women’s views in the headlines Post launch period (Oct 13, 1993–June 30, 1994) “I cannot afford another mistake” Daily Telegraph 15/02/94 “Worry-free way to plan a family” Daily Telegraph 15/02/94 “A qualified welcome because other methods failed” Daily Telegraph 15/02/94 Pop goes the Pill: “With the new implant I don’t have to worry about birth control” Daily Mirror 23/02/94 A success that’s under your skin: new contraceptive is safe and gives peace of mind Daily Express 14/06/94 Later period (July 1, 1994–Dec 31, 1996) A bruising experience—contraceptive implant that Kim will always find hard to forget Daily Mail 12/07/94 Implant that made my life a nightmare. Model threatens to sue doctor Daily Mail 26/12/94 “Hi tech birth control drug has ruined our love lives” People 15/10/95 Wife to sue over implant torment Daily Express 20/05/95 The missing implant: Wife sues over birth control “nightmare” Daily Mail 20/05/95 “Pill” implant mum to sue Daily Mirror 20/05/95 “Lost implant” ordeal of mum Daily Star 20/05/95 Mother sues over “lost” contraceptive implants Independent 20/05/95 Mum sues over birth control device lost in her arm. “Wonder implants” bring Caroline 12 months of misery Today 20/05/95 Implant mother’s birth control ordeal: Rod still stuck under her skin after four ops Daily Express 11/08/95 New birth control made me a monster Daily Mirror 14/09/95
From July, 1994, 10 months after the UK launch, the newspapers started to report the stories of a few individual women who had experienced problems with side-effects or the removal of Norplant, or both. These stories, which often emphasised the “innocence” of the “young mothers” who claimed their lives had been “wrecked” by Norplant, came to dominate coverage in the later period. The articles were often prominently positioned on newspaper pages, with large headlines and photographs. The setting-up of an action group that sought compensation for women and planned legal action against Norplant’s license holders were widely reported. The contrast between the types of individual experience reported in the early and later stages of Norplant’s UK career is illustrated in the panel, which shows how women’s experiences and views were summarised in headlines appearing after the launch and later. There were some counters to the negative reports that dominated the later period of coverage, but these tended to be marginalised. Some family planning providers, including those doctors who had been among the early Norplant enthusiasts, argued that a few “extreme”
THE LANCET • Vol 355 • May 6, 2000
examples had been given a “disproportionate” amount of bad publicity. A spokesman for Hoechst Marion Roussel blamed “an unholy alliance of the media, lawyers, and government bureaucracy” for killing off the product by blowing a few problems out of all proportion. The spokesman added that the unfavourable climate created for the company would probably discourage them from introducing any further contraceptive developments into the UK, with the implication that women would be unable to benefit from these. The people and organisations that were given a voice in news reports about Norplant also changed over time. Early reports quoted enthusiastic doctors (including those the company had first trained to use the product) and family planning specialists. Their voices were increasingly joined, after the product launch, by “delighted” women. In the later period of reporting, however, the voices of a limited number of dissatisfied women and lawyers dominated. A spokesperson for Hoechst Marion Roussel was quoted at most stages.
Discussion Newspaper reporting is shaped by a variety of factors, but particularly the values and working practices of journalists and the media-relations activities of their sources.5–7 Journalists select events and issues to report by “an almost intuitive sense of what is important and what fits the bill for the paper in question”.8 Media researchers have recognised over the years that a journalist’s “sense” of what has news value is underpinned by identifiable criteria.5,9–10 Events or issues or more likely to become news the more of these criteria they satisfy. The way in which an event or issue is presented in the media is also influenced to a large extent by the way journalists see and interpret it. Journalists, like the rest of us, make regular use of convenient interpretive frameworks11 and stereotypes5 when constructing their reports. A number of studies of media coverage of health and medicine have identified commonly recurring interpretive frameworks and story types.11–13 The interpretive frameworks that we identified can be described in general terms as: ● Developments in health-care technology can benefit people ● Health-care technologies may be rationed, denying people the possible benefits ● Health-care technologies that have been presented as beneficial may turn out to be damaging ● There is potential for social misapplication of healthcare technology ● Government or professional policies may pose problems for producers and consumers of health-care technologies ● “Inappropriate” media coverage may have a damaging effect These frameworks can also be seen in media coverage of other health technologies. Early media coverage of Viagra (sildenafil), for example, could largely be described within the first two frameworks.14 We discuss the first three frameworks briefly below because we consider them to be the most significant within this case study. When Norplant was introduced in the media, it was lauded as a revolutionary new contraceptive. Media reports about new products or techniques tend to be enthusiastic about the benefits; headlines regularly announce new treatments and cures.13 The “positive new
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development” story usually occurs when experience of use of the new product or technique is limited. Enthusiastic “early adopters”15 among the medical profession are likely to be more vocal in the media than their more cautious colleagues. The promoters of new products or techniques, including those who stand to profit, want to convey messages that boost use, and journalists may be disinclined to tone down the good news message for fear of weakening their story.10 The rationing of health care within the National Health Service is currently a source of much political and public concern within the UK. It is not surprising, then, that news reports increasingly focus on the possibility that new products may not be available to all who could benefit from them. The controversy (and hence, to some extent, the news value) associated with these stories depends on the product or techniques being presented as better than the alternatives. Reports presented within this frame thus again tend to emphasise the advantages of an intervention and may serve to promote further demand. Norplant’s image in the newspapers was suddenly transformed from that of a wonderful new contraceptive into a “controversial implant” that became a “nightmare” for women who used it. Norplant’s media downfall was apparently triggered when women and solicitors started to tell the media about individual experiences of problems with Norplant—some of which involved well-known sideeffects. The news media are increasingly willing to focus on (and to sensationalise) human interest stories;16 the power of these personal narratives to attract media interest appears to have been substantial. For other technologies, the bad news might start with the publication of clinical studies that seem to reveal problems—as has been the case, for example, with measles-mumps-rubella vaccines17 or human albumin.18,19 Once the possibility of a problem has been raised, a story can be prolonged in the media by piling up evidence (anecdotal or substantial) against the product or by reports that reflect or create controversy. Our case study of Norplant highlighted how the media may tend to use different interpretive frameworks at different times. In particular, journalists may tend to focus strongly on the positive aspects of a health technology during its early states and on negative aspects later on. This tendency means that a balanced appraisal of the technology is not usually feasible from the news reports that appear at any one time. Content analyses such as the one that we have reported do not allow us to determine
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whether media coverage cause, reinforce, or reflect patterns of clinical practice. This work was done while the authors were with the NHS Centre for Reviews and Dissemination, University of York, UK. We thank the Family Planning Association and Hoechst Marion Roussell for access to their press-cuttings files. Freeth, Cartwright, Hunt, Dickens (solicitors) contributed to travel and administrative costs. At the time that the work was conducted, Freeth, Cartwright, Hunt, Dickens were bringing a legal action against Hoechst Marion Roussell on the part of women who thought they had been damaged by Norplant.
References 1 2 3
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6
7 8
9
10 11
12 13
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17 18 19
Bower H. GPs urged to shun unpaid implant work. Doctor Oct 5, 1995: 20. Bromham DR. Contraceptive implants: users lose out when misleading information limits choice. BMJ 1996; 312: 1555. Grilli R, Freemantle N, Minozzi S, Domenighetti G, Finer D. Impact of mass media on health services utilisaton. In: Cochrane Library. Issue 3. Oxford: Update Software, 1998. McCoombs ME, Shaw DL. The evolution of agenda setting research: twenty five years in the marketplace of ideas. J Commun 1993; 43: 58–67. Fowler R. The social construction of news. In: Language in the news: discourse and ideology in the press. London: Routledge, 1991: 10–24. McQuail D. Production of media culture: media institution, organization and role. In: Mass communication theory: an introduction (2nd edn). London: Sage, 1987: 135–71. Erikson RV, Baranek PM, Chan JBL. Negotiating control: a study of news sources. Milton Keynes: Open University Press, 1989. Brindle D. Media coverage of social policy: a journalist’s perspective. In: Franklin R, ed. Social policy, the media and misrepresentation. London: Routledge, 1999: 39–50. Galtung J, Ruge M. Structuring and selecting news. In: Cohen S, Yong J, eds. The manufacture of news: social problems, deviance and the mass media. London: Constable, 1973: 62–72. Entwistle V. Reporting research in medical journals and newspapers. BMJ 1995; 310: 920–23. Best G, Dennis J, Draper P. Health, the mass media and the National Health Service. London: Unit for the Study of Health Policy, 1977. Karpf A. Doctoring the media: the reporting of health and medicine. London: Routledge, 1988. Entwistle V, Shelton T. The picture of health? Media coverage of the health service. In: Franklin R, ed. Social policy, the media and misrepresentation. London: Routledge, 1999: 118–34. Berger A. Medicine and the media: the rise and fall of Viagra. BMJ 1998; 317: 824. Rogers E. Diffusion of innovations. New York: Free Press, 1983. Franklin R. Misleading messages: the media and social policy. In: Social policy, the media and misrepresentation. London: Routledge, 1999: 1–13. Anderson P. Another media scare about MMR vaccines hits Britain. BMJ 1999; 318: 1578. Offringa M. Excess mortality after human albumin administration in critically ill patients. BMJ 1998; 317: 223–24. Lawler PG, Morgan GA. Modified editorial might have restrained media response. BMJ 1998; 317: 882.
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Public health
The case of Norplant as an example of media coverage over the life of a new health technology Vikki A Entwistle, Ian S Watt, Fiona Johnson
Background The contraceptive implant Norplant (levonorgestrel) had a fairly short life in the UK. This made it a convenient subject for a case study of how media coverage alters over time. We set out to produce a critical description of national newspaper coverage of Norplant over the course of its use in the UK. Methods We searched newspaper databases and pressclippings files for articles about Norplant printed between 1992 and 1996. For those that met our inclusion criteria, we extracted bibliographical data, made a standardised judgment about the “slant” of the article towards Norplant, and used qualitative techniques to analyse the content of the articles. Findings 101 national newspaper articles were included in the study. Norplant attracted media coverage over the course of its career, but the slant of articles shifted dramatically over time from a favourable to a negative presentation. This reflected the use of different story types over the course of time. Early reports presented Norplant very positively as either a clear improvement on existing contraceptive methods or a valuable addition to the range. Any disadvantages were down-played. The positive image of Norplant was reinforced immediately after its official launch by reports that it was in great demand but women might be denied access to it. Less than a year later, however, newspaper reports about Norplant were dominated by the stories of individual women who had had bad experiences with the product. Interpretation Three main reporting themes were seen. At first, Norplant was presented as a positive new development, and one that might be denied to people. In later coverage it became a flawed and damaging product. These themes recur in media reporting of health technologies, and the fact that they occur at different stages in a product’s career means that a balanced assessment of the technology is not usually feasible from media reporting at any one time. An appreciation of the forms and implications of these reporting frameworks could help health-care providers and users to appraise media reports more critically.
Lancet 2000; 355: 1633–36 Health Services Research Unit, University of Aberdeen (V A Entwistle PhD); Department of Health Studies, University of York (I S Watt FFPHM); and ICRF Health Behaviour Unit, University College, London, UK (F Johnson BSc) Correspondence to: Vikki A Entwistle, Health Services Research Unit, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen AB25 2ZD, UK (e-mail: [email protected])
THE LANCET • Vol 355 • May 6, 2000
Introduction The levonorgestrel implant Norplant is a contraceptive developed by the World Population Council in the 1970s and introduced to the USA in 1990 by Wyeth and to the UK in 1993 by Hoechst Marion Roussel. Six small silastic capsules are implanted beneath the skin of the woman’s arm, releasing the progestagen levonorgestrel into the bloodstream. Norplant is intended to provide contraceptive cover for up to 5 years. Prescription data from the UK show that after the product launch in initial surge in uptake was followed within a year by a substantial decline that cannot be fully explained by the fact that Norplant is long-acting (figure 1). The product was withdrawn from sale in the UK in 1999. Several factors may have contributed to Norplant’s demise. For example, although the insertion and removal of Norplant are skilled and time-consuming tasks, the government refused to pay general practitioners any more for providing Norplant than for prescribing oral contraceptives. As a result, professional bodies advised their members against providing the implant.1 Also, it has been suggested that adverse publicity in the professional and lay news media discouraged people from using it.2 Although media coverage can influence use of health services,3 the extent to which media coverage causes, reinforces, or reflects changes in attitudes and behaviour is difficult to establish and may vary from case to case.4 The fact that Norplant had a short life in the UK makes it a convenient subject for a case study of how media coverage alters over time. We provide a critical description of national newspaper coverage of Norplant from 1992 to 1996. The study was not designed, however, to investigate the possibility of any causal relation between media coverage and the use of Norplant.
Methods We searched the following sources retrospectively for Jan 1, 1992, to Dec 31, 1996, to identify national newspaper articles Prescriptions dispensed
Summary
7000 6000 5000 4000 3000 2000 1000 0 /4 /1 /2 /3 /4 /1 /2 /3 /4 /1 /2 /3 /4 93 94 94 94 94 95 95 95 95 96 96 96 96
Year and quarter Figure 1: Norplant prescriptions dispensed 1993–96 (PACT data)
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25 Negative Neutral Positive
Number of articles
20 15 10 5
92 / 93 4 / 93 1 / 93 2 / 93 3 / 94 4 / 94 1 /2 94 / 94 3 / 95 4 /1 95 / 95 2 / 95 3 / 96 4 / 96 1 / 96 2 /3
0
Year and quarter Figure 2: Number and slant of newspaper articles towards Norplant, 1992–96 about Norplant: CD-ROM versions of eight national newspapers and their Sunday equivalents. We used the search terms “Norplant” or (“contracept* and implant*”); Popular Medical Index, “contraception” and “family planning” sections; presscuttings files at the Family Planning Association and Hoeschst Marion Roussel. We included articles that contained at least three sentences about Norplant. We excluded articles that focused only on the performance of companies associated with Norplant. Decisions about inclusion were made by one researcher and checked by another. For each included article we recorded bibliographic details, newspaper type (broadsheet or tabloid), article type (news, feature, editorial, doctor’s column, letter), and whether or not Norplant was the primary subject of the article. The slant of each article towards Norplant (positive, negative, or neutral) was independently rated by three researchers by a standard set of rubrics. The majority rating was adopted except for the two articles given a different ratings by all three researchers, which were categorised as neutral. For all included articles, text related to the following aspects or issues was copied into text files for qualitative analysis: Norplant’s characteristics, including mode and duration of action, contraceptive effectiveness, reversibility, and side-effects; the provision of Norplant, including training and reimbursement of health professionals, information and counselling for women; insertion and removal procedures; patterns of uptake of Norplant and experiences of its use; social concerns and legal actions relating to Norplant. Specific statements about individual Norplant users were handled separately from general statements. We also recorded details of the people to whom comments were attributed. Once we were familiar with the articles, we grouped them into four main periods that marked key stages in the product’s life and which were characterised by different reporting themes: before the launch (Jan 1, 1992–Sept 30, 1993), during it (Oct 1–12, 1993), after (Oct 13, 1993–June 30, 1994), and later (July 1, 1994–Dec 31, 1996). The overall period was defined by our impressions about the time over which the UK media had covered Norplant. Searches of press cuttings in 1997 confirmed that there had been little coverage outside those dates.
Results 101 national newspaper articles, 51 from broadsheets and 50 from tabloid newspapers, that met the inclusion criteria. News and feature articles accounted for 90% of the articles and were present in almost equal proportions. 84% of the articles were primarily about Norplant. Of the 16 that were not, 12 were articles that covered a range of contraceptive options. The articles varied in terms of their prominence within the newspapers and their length.
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Norplant attracted newspaper coverage throughout the study period (figure 2). The number of articles peaked around the time of the product launch and when it was announced that a woman was preparing to sue the company selling Norplant in the UK. The slant of the articles shifted dramatically over time from a favourable to a much less favourable presentation. This reflected changes in the types of story that appeared over the study period. Before and around the time of the UK launch, national newspapers presented Norplant very positively as either a clear improvement on existing contraceptive methods or a valuable addition to the current range and thus as a product that would extend women’s choice. Norplant was portrayed as a new contraceptive method—although some reports stressed that it had been tried and tested in other parts of the world—that offered 5 year’s protection from pregnancy and had the potential to revolutionise women’s lives. The implant was described as effective and reliable, with the added advantage that women could not forget to take it. In these early reports, any disadvantages of Norplant were down-played. If disadvantages were mentioned, the surgery required to insert the implant and any side-effects that might occur were both described minor. While early media articles were uncritical about the product itself, several broadsheet newspapers focused on the possibility that it could be used for social manipulation. They discussed reports from America about Norplant being offered to poor (black) teenagers and forced upon women on welfare or with criminal convictions. These stories were often accompanied by reassurances from the Department of Health and others that such situations could not occur in the UK. The newspapers reported that family planning specialists were more concerned that women might be denied access to Norplant if it was deemed too expensive to be provided free by the National Health Service. After the launch, the largely positive descriptions of the product continued, although one article, triggered by an issue of Drug and Therapeutics Bulletin (a publication that aims to provide up-to-date independent evaluations of drugs and other modes of treatment) mentioned possible problems relating to the rate of drug delivery and another reported that a health authority had warned general practitioners that the side-effect of menstrual irregularity could lead to requests for early removal, thus reducing the cost effectiveness of the product. Most of the individual Norplant users who were quoted during the first 9 months after the product launch were very enthusiastic. Only one, who had experienced constant bleeding, was said to be considering having Norplant taken out if the bleeding continued. The main new reporting theme in reports after the launch was the high level of demand for Norplant and the possibility that this demand could not be met. Norplant’s popularity and the range of women asking for it was said to have surprised many doctors. The fact that not all general practitioners were trained to insert Norplant was widely reported. So was the possibility that family planning services with limited budgets would be deterred from providing it because of its high up-front cost. The indignant concerns expressed in newspaper articles that women might be denied access to Norplant still reflected a belief that the product was useful and desirable.
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PUBLIC HEALTH
Women’s views in the headlines Post launch period (Oct 13, 1993–June 30, 1994) “I cannot afford another mistake” Daily Telegraph 15/02/94 “Worry-free way to plan a family” Daily Telegraph 15/02/94 “A qualified welcome because other methods failed” Daily Telegraph 15/02/94 Pop goes the Pill: “With the new implant I don’t have to worry about birth control” Daily Mirror 23/02/94 A success that’s under your skin: new contraceptive is safe and gives peace of mind Daily Express 14/06/94 Later period (July 1, 1994–Dec 31, 1996) A bruising experience—contraceptive implant that Kim will always find hard to forget Daily Mail 12/07/94 Implant that made my life a nightmare. Model threatens to sue doctor Daily Mail 26/12/94 “Hi tech birth control drug has ruined our love lives” People 15/10/95 Wife to sue over implant torment Daily Express 20/05/95 The missing implant: Wife sues over birth control “nightmare” Daily Mail 20/05/95 “Pill” implant mum to sue Daily Mirror 20/05/95 “Lost implant” ordeal of mum Daily Star 20/05/95 Mother sues over “lost” contraceptive implants Independent 20/05/95 Mum sues over birth control device lost in her arm. “Wonder implants” bring Caroline 12 months of misery Today 20/05/95 Implant mother’s birth control ordeal: Rod still stuck under her skin after four ops Daily Express 11/08/95 New birth control made me a monster Daily Mirror 14/09/95
From July, 1994, 10 months after the UK launch, the newspapers started to report the stories of a few individual women who had experienced problems with side-effects or the removal of Norplant, or both. These stories, which often emphasised the “innocence” of the “young mothers” who claimed their lives had been “wrecked” by Norplant, came to dominate coverage in the later period. The articles were often prominently positioned on newspaper pages, with large headlines and photographs. The setting-up of an action group that sought compensation for women and planned legal action against Norplant’s license holders were widely reported. The contrast between the types of individual experience reported in the early and later stages of Norplant’s UK career is illustrated in the panel, which shows how women’s experiences and views were summarised in headlines appearing after the launch and later. There were some counters to the negative reports that dominated the later period of coverage, but these tended to be marginalised. Some family planning providers, including those doctors who had been among the early Norplant enthusiasts, argued that a few “extreme”
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examples had been given a “disproportionate” amount of bad publicity. A spokesman for Hoechst Marion Roussel blamed “an unholy alliance of the media, lawyers, and government bureaucracy” for killing off the product by blowing a few problems out of all proportion. The spokesman added that the unfavourable climate created for the company would probably discourage them from introducing any further contraceptive developments into the UK, with the implication that women would be unable to benefit from these. The people and organisations that were given a voice in news reports about Norplant also changed over time. Early reports quoted enthusiastic doctors (including those the company had first trained to use the product) and family planning specialists. Their voices were increasingly joined, after the product launch, by “delighted” women. In the later period of reporting, however, the voices of a limited number of dissatisfied women and lawyers dominated. A spokesperson for Hoechst Marion Roussel was quoted at most stages.
Discussion Newspaper reporting is shaped by a variety of factors, but particularly the values and working practices of journalists and the media-relations activities of their sources.5–7 Journalists select events and issues to report by “an almost intuitive sense of what is important and what fits the bill for the paper in question”.8 Media researchers have recognised over the years that a journalist’s “sense” of what has news value is underpinned by identifiable criteria.5,9–10 Events or issues or more likely to become news the more of these criteria they satisfy. The way in which an event or issue is presented in the media is also influenced to a large extent by the way journalists see and interpret it. Journalists, like the rest of us, make regular use of convenient interpretive frameworks11 and stereotypes5 when constructing their reports. A number of studies of media coverage of health and medicine have identified commonly recurring interpretive frameworks and story types.11–13 The interpretive frameworks that we identified can be described in general terms as: ● Developments in health-care technology can benefit people ● Health-care technologies may be rationed, denying people the possible benefits ● Health-care technologies that have been presented as beneficial may turn out to be damaging ● There is potential for social misapplication of healthcare technology ● Government or professional policies may pose problems for producers and consumers of health-care technologies ● “Inappropriate” media coverage may have a damaging effect These frameworks can also be seen in media coverage of other health technologies. Early media coverage of Viagra (sildenafil), for example, could largely be described within the first two frameworks.14 We discuss the first three frameworks briefly below because we consider them to be the most significant within this case study. When Norplant was introduced in the media, it was lauded as a revolutionary new contraceptive. Media reports about new products or techniques tend to be enthusiastic about the benefits; headlines regularly announce new treatments and cures.13 The “positive new
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development” story usually occurs when experience of use of the new product or technique is limited. Enthusiastic “early adopters”15 among the medical profession are likely to be more vocal in the media than their more cautious colleagues. The promoters of new products or techniques, including those who stand to profit, want to convey messages that boost use, and journalists may be disinclined to tone down the good news message for fear of weakening their story.10 The rationing of health care within the National Health Service is currently a source of much political and public concern within the UK. It is not surprising, then, that news reports increasingly focus on the possibility that new products may not be available to all who could benefit from them. The controversy (and hence, to some extent, the news value) associated with these stories depends on the product or techniques being presented as better than the alternatives. Reports presented within this frame thus again tend to emphasise the advantages of an intervention and may serve to promote further demand. Norplant’s image in the newspapers was suddenly transformed from that of a wonderful new contraceptive into a “controversial implant” that became a “nightmare” for women who used it. Norplant’s media downfall was apparently triggered when women and solicitors started to tell the media about individual experiences of problems with Norplant—some of which involved well-known sideeffects. The news media are increasingly willing to focus on (and to sensationalise) human interest stories;16 the power of these personal narratives to attract media interest appears to have been substantial. For other technologies, the bad news might start with the publication of clinical studies that seem to reveal problems—as has been the case, for example, with measles-mumps-rubella vaccines17 or human albumin.18,19 Once the possibility of a problem has been raised, a story can be prolonged in the media by piling up evidence (anecdotal or substantial) against the product or by reports that reflect or create controversy. Our case study of Norplant highlighted how the media may tend to use different interpretive frameworks at different times. In particular, journalists may tend to focus strongly on the positive aspects of a health technology during its early states and on negative aspects later on. This tendency means that a balanced appraisal of the technology is not usually feasible from the news reports that appear at any one time. Content analyses such as the one that we have reported do not allow us to determine
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whether media coverage cause, reinforce, or reflect patterns of clinical practice. This work was done while the authors were with the NHS Centre for Reviews and Dissemination, University of York, UK. We thank the Family Planning Association and Hoechst Marion Roussell for access to their press-cuttings files. Freeth, Cartwright, Hunt, Dickens (solicitors) contributed to travel and administrative costs. At the time that the work was conducted, Freeth, Cartwright, Hunt, Dickens were bringing a legal action against Hoechst Marion Roussell on the part of women who thought they had been damaged by Norplant.
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