Uses of news narratives to enhance health knowledge of the audience: an analysis of the 2009 H1N1 flu vaccination coverage

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USES OF NEWS NARRATIVES TO ENHANCE HEALTH KNOWLEDGE OF
THE AUDIENCE: AN ANALYSIS OF THE 2009 H1N1 FLU VACCINATION
COVERAGE

by

Selene C. W. Hu
____________________________________________________________________

A Thesis Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTER OF ARTS
(STRATEGIC PUBLIC RELATIONS)

August 2010

Copyright 2010 Selene C.W. Hu

ii
DEDICATION
This work is dedicated to my beloved family, my dear Dad and Mom, my
maternal granny, my parents-in-law, my sister, my brother, and my husband Han-
Chieh, without whose caring support it would not have been possible. This work is
also dedicated to the memory of my dear grandparents, who had wholeheartedly
taken care of me in my childhood and passed on a love of reading and respect for
education.

iii
ACKNOWLEDGEMENTS
Special thanks to the distinguished faculty members who served on my
committee: Professor Jennifer Floto (chair), Professor Lynn Miller, and Professor
Jay Wang. As my thesis advisor, Professor Floto provided clear guidance and
encouragement throughout the course of preparing for and conducting the research.
Her optimistic attitude and inspirations kept me going. It is a pleasure to thank Dr.
Lynn Miller for her detailed and insightful comments on the draft, which enabled me
to develop a deeper understanding of the subject and the research. I am also grateful
to Dr. Jay Wang for his helpful comments on short notice. They generously
contributed their time and expertise. I would like to show my gratitude to all my
committee members for their support, patience, encouragement, and valuable
suggestions.
My thanks also go to friends and classmates for participating in the survey
that enabled the subsequent analyses. I offer my regards and blessings to all of those
who supported me in any respect during the completion of the work. I owe my
deepest gratitude to my family for their good-natured forbearance with the process
and for their pride in this accomplishment.

iv
TABLE OF CONTENTS
Dedication ii
Acknowledgements iii
List of Tables v
List of Figures vi
Abstract vii
Chapter One: Introduction 1
Chapter Two: Literature Review 5
Chapter Three: Primary Research 25
Chapter Four: Findings 31
Chapter Five: Conclusion 57
References 68
Appendix: Questionnaire 74

v
LIST OF TABLES
Table 1: The Number of Samples Chosen from the Four Newspapers 26
Table 2: Elements of Narrative Analysis and Their Meanings 28
Table 3: An Ideal Health News Narrative Framework 63

vi
LIST OF FIGURES
Figure 1: Conceptual Model of Health Promotion Practice 19
Figure 2: Proportion of Male and Female Respondents Surveyed 44
Figure 3: Education Level of Respondents Surveyed 44
Figure 4: Proportion of Ages Groups of Respondents Surveyed 44
Figure 5: Respondents’ Understanding of Current H1N1 Influenza 45
Figure 6: Respondents’ Feeling toward the H1N1 Influenza 46
Figure 7: Respondents’ Perception of Susceptibility of Getting H1N1 47
Influenza
Figure 8: Respondents’ Perception of Consequence if Contacting the 47
H1N1 Influenza
Figure 9: People’s Attitude toward the H1N1 Flu Vaccine 48
Figure 10: People’s Likelihood to Get a H1N1 Flu Vaccine 49
Figure 11: Respondents’ Reasons for Not Get a H1N1 Flu Vaccine Yet 49
Figure 12: Perceived Amount of Coverage of the H1N1 Flu in Respondents’ 50
Daily Newspapers
Figure 13: How Well People Think Their Daily Newspapers Provided 51
Information about Vaccination of the H1N1 Flu
Figure 14: The Worst Thing People Think Newspapers Are Doing in Terms 52
of Conveying Information about Vaccination against Current
H1N1 Flu

vii
ABSTRACT
In this paper, the author examines how newspapers represent the
controversial issue about the H1N1 flu vaccination and its relation to the public’s
perception toward the health threat. It includes a survey analysis on the public’s
perceptions toward the H1N1 flu vaccine and a narrative analysis of the newspaper
coverage of it. The author focuses on how narratives of the novel H1N1 flu vaccine
are designed by reporters as narrators, and how people think about the H1N1 flu
vaccine based on some key variables that are thought to be the factors of influencing
people’s perception and attitude toward the H1N1 flu vaccine. By analyzing the
results and examining the relation between the two analyses, the conclusion suggests
a narrative framework that helps health communicators to better convey health
information and enhance the public’s health knowledge, and inform the public
without causing panic.

1
CHAPTER ONE: INTRODUCTION
Background
What is the 2009 H1N1 Influenza
The 2009 H1N1 flu, sometimes called “swine flu,” is a new influenza virus.
It was first detected in people in the United States in April 2009 and spread from
person-to-person worldwide in much the same way that regular seasonal influenza
viruses spread. It caused death and panic. On June 11, 2009, the World Health
Organization announced that a pandemic of the 2009 H1N1 flu was underway, and
raised the worldwide pandemic alert level to Phase 6.
1

Why This Issue is Important
Influenza is thought to spread mainly person-to-person through coughing or
sneezing of infected people. The government has been promoting vaccination as the
best protection to fight against flu. Initial doses of the 2009 H1N1 flu vaccine have
been available in November, with additional doses available later this year.
2

The 2009 H1N1 flu vaccines are being made to protect against the 2009
H1N1 influenza virus. There are two kinds of 2009 H1N1 vaccines being produced:
a 2009 H1N1 "flu shot" that is given with a needle, usually in the arm; and the 2009
H1N1 nasal spray flu vaccine given via a nasal sprayer. The same manufacturers

1
Center for Disease Control and Prevention. Retrieved from http://www.cdc.gov/h1n1flu/qa.htm.
2009/11/12. WHO currently has a six-phase alert system for assessing the threat level and appropriate
response to infectious diseases. Phase 1 to 3 relate to worldwide preparedness for an epidemic, while
Phase 4 to 6 focus on responses and efforts to mitigate an active pandemic disease. In Phase 6, the
virus has spread from human to human in at least two countries worldwide.

2
Center for Disease Control and Prevention. Retrieved from http://www.cdc.gov/h1n1flu/qa.htm.
2009/11/15

2
who produce seasonal flu vaccines are producing 2009 H1N1 vaccines for use in the
United States and the vaccines are being made in the same way that the seasonal
vaccines are made. The former is an inactivated vaccine containing killed virus, and
is usually given with a needle in the arm. The latter is a vaccine made with live
weakened viruses that do not cause the flu.
3

Even though the government is making efforts to get people vaccinated, there
are still many concerns about the safety of the vaccine and its side effects. In this
paper, the author examines how newspapers represent the controversial issue and
convey the information about swine flu vaccination. Specifically, the author focuses
on how reporters narrate about the novel H1N1 flu vaccine issue, and how people
think about the H1N1 flu vaccine based on some key variables, which might be the
factors in influencing people’s perception toward the H1N1 flu vaccine. By
examining the relation between the two analyses, the author is hoping to develop a
narrative approach to health communication that helps mass media to better convey
health information and that seeks to inform the public without causing panic among
them.
The Role of Mass Media in the Process of Health Communication
Health communication in the past referred to interpersonal or mass
communication activities that are directed toward improving the health status of
individuals and populations. However, advances in communication media continue

3
Centers for Disease Control and Prevention. Retrieved November 15, 2009, from
http://www.cdc.gov/h1n1flu/qa.htm.

3
to improve access to health information and add new definition to this field
(Nutbeam, 1998). One of the new forms of health communication could be the
discreet health messages incorporated into existing communication media, including
news media, advertising or popular entertainment.
As a researcher in health communication, it is essentially taken for granted
that the mass media are a source of information for individuals. Tones (1996)
indicated that the normative impact or incidental effects of mass media are a
particular concern for health promotion. Although the presentation of various
products or activities through mass media may not directly influence an audience’s
behavior, they may well influence people in a indirect or subliminal way. That is,
they can make suggestions to people that particular unhealthy or healthy practices
are common and acceptable. Because of the complex and uncertain nature of health
issues, examining health messages allows us to take a close look at mass media’s
representations of health issues, figure out the media’s focuses, and analyze the
potential impacts on the audience.

Problem Set and Research Purpose
Scholars claim that the public is poorly served by the media’s coverage of
health issues (Shuchman & Wilkes, 1997). Media is not only accused of failing to
serve the audience well with correct information, it is also blamed for providing
superficial and sensationalized coverage such as rumors and panic (Klaidman, 1991).
When it comes to health issues, previous research has pointed out the importance of

4
media in shaping people’s perceptions and attitudes. Many health issues, such as the
H1N1 flu, have a high threshold for people to access related, first-hand information,
so these issues need mass media to deliver important messages to reach the public.
However, there are many problems in communicating health information because of
the nature of health issues. Therefore, effective communication and message design
become such an important topic in health communication.
Researchers of popular health discourse have been dedicated to developing
theories that can be used to describe discursive situations, to predict possible
responses to health discourses, and to explain the relationship between health
discourse, people, and society. The ultimate goal of this paper is to prompt
improvement of the health news narratives that address the increase of information
effectiveness and the persuasiveness with regard to media’s coverage and individual
knowledge.
In addition, scholars in the health communication field have suggested that
researchers synthesize the findings from existing research on delivering written
messages to people (Bernhardt & Cameron, 2003). The goal of a synthesis is to
develop uniform standards or best practice recommendations that are rooted in health
communication theories and empirical findings. The efforts made can improve the
information quality of health issues and result in a positive influence at the reception
end. As a result, this paper focuses on the narrative analysis and is complemented by
a survey on people’s perception toward the H1N1 flu vaccination, which provides
additional insights for the best practice recommendations.

5
CHAPTER TWO: LITERATURE REVIEW
Science News Reports
Like other news, the communication of science and medical news must go
through a series of gatekeepers. Li (1985) mentioned that science and medical
reports are “related to systemized knowledge, and what sets them apart from other
news is that reporters must explain and analyze complicated facts in a simpler
manner before reporting them.” Science news is, therefore, one of the most difficult
kinds of public affairs, and among science reports medical news
4
is the most difficult
one.
In addition to communicating professional pathological information, medical
reports should also take care of and answer any question regarding social concerns
on diseases because the public relies heavily on media to receive health-related
information. As a result, during a pandemic, how the media presents the diseases is
crucial in determining the perception and reaction of the public to the disease. In
other words, people become aware of the risks due to media reports, but how the
media represents the risks also shapes people’s perceptions. This is an interrelated
process.
Although the media plays a significant role, journalists are often criticized by
scientists and policy makers for presenting risk statistics incorrectly and twisting risk
facts. Kitzinger (1999) stated that what the media often project are not objective

4
The news of H1N1 flu studied here belongs to medical science news.

6
hazards. Many theorists believe that the role of media is not a mirror that reflects
risks, but rather a filter that introduces other perspectives or opinions of risks during
the process of filtering different definitions. Murphy (1996) illustrates the
amplification feature of the media in crisis communication. That is, mass media can
spotlight a certain event, and thus turn unnoticed subjects of debate into loud noises.
Some researchers argue that the most of threats that media emphasize are
imposed. There is an imbalance in the coverage of risks when reporters focus on, for
instance, secondary hazards or place undue importance on serious but rare risks
(Singer & Endreny, 1987; Frost, 1997). Furthermore, due to competition in news
business profits, sensational, incorrect coverage is more likely to be produced and
twist the perceptions of health-threatening risks among the public
5
. News media also
pays attention to uniqueness (exclusives), commercial viability and theatricality of
science news. Science news that is more unusual, original, profitable or dramatic
usually has more coverage and leads to excessive and sensational reports. Thus, the
risk itself, however, is sometimes far less dangerous in terms of occurrence and
impact it has had on human beings than what appears on the media.
As a result, the news media are often accused of being a platform that breeds
rumors, which in turn cause irrational behavior by the public. News reporters are
further regarded as risk junkies who constantly seek stranger and scarier phenomena
to please or frighten their audience (Kitzinger, 1999).

5
For instance, news media often provide inadequate reports on smoking-related death because of
pressure from tobacco companies which often control a huge amount of advertisement budget of the
media.

7
Risk Communication
Numerous studies indicate that the media prefer “dog-bite- man” news,
therefore, risks that are serious, relatively rare, original and dramatic are considered
more newsworthy and most favored by the media over hazards that are old,
chronicled and usual (Singer & Endreny, 1993; Wilkins & Patterson, 1987; Frost,
1997; Adam, 1992). The media is reporting harm rather than risks, such as property
loss, injury and death.
Research finds that hazards (or “risks” in this study) containing news value,
prerequisites of conflict, influence and uniqueness are easier to attract news
reporters. Itule and Anderson (2003) further stated that when personal health risks
are at stake, risk events with higher casualties are more newsworthy to reporters. For
example, Chang (2004) illustrated in the research of news reports on avian flu that
the more important the poultry industry was to the economy of a country, the more
likely large scale death caused by avian flu was to receive greater media coverage.
The media are also more likely to focus their attention within the frames of loss of
lives and economy consequences.
Despite negative information presented by the media that might raise the
awareness of audiences on the seriousness of risks, no indications are given as to
how the hazards are likely to occur (Singer & Endreny, 1993). Mass media are
skilled in reminding the public of the outcome of specific hazardous incidents, but
are unable to provide other aspects of risk information such as how likely is it that
the risk would occur. In addition, mass media lacks preventative reports on risks

8
such as how to reduce property loss, diseases, injury, and death, and enhance quality
of life that allows consumers to make risk judgements (ibid, 1993; Ryan, 1991).
A number of techniques are frequently employed by mass media when
reporting risks (Adams, 1992). First, reporters habitually adopt certain institutional
sources or their familiar sources that may lead to one-sided and biased opinions
Second, news media usually lack the 5W1H concept (Who, What, Where, When,
Why and How
6
) of past events. This is important because not using the 5W1H
concept frequently results in incomplete coverage, and thus may lead to large grey
areas in understanding the risk and cause the audience’s oversimplification on the
situation. Third, reporters are inclined to personalize risk-related narratives, which
means they turn risks into personal incidents. Many experts and science and
technology sources do not tolerate such a technique which views a risk as a personal
story unrelated to the society at large, while some reporters believe it renders the
news more readable and appealing.
By the same token, successful risk disseminators always try to personalize
their situations, because personalised stories are more likely to attract the attention of
the media, even if such a situation could be a fake (Adams, 1992; Kitzinger & Reilly,
1997). News media prefer jargon-free contents, metaphors as well as comparisons
that are good, tangible and meaningful.

6
“How” refers to how things happened.

9
However, reporters often make three mistakes (Wilkins & Patterson, 1987, p.
83). Their first mistake is handling risk events as some fresh events when most of the
time they are not. A second mistake is that news reports that reporters rely on are not
able to analyze comprehensively the technology and social system within which the
risks occur, which results in a stereotypical depiction of risk outcomes without
generating any discussion on risk and its impacts on society. Third, news description
sometimes uses jargons and difficult sentences that may not be understood by
ordinary folks or less educated people.
Contemporary science and technology experts often provide excessive
information and complicated jargon to enhance certainty in order to gain credibility
for their professions, and ultimately to compete for research funds and public
support. Therefore, the so-called “exclusives” are likely to be well-designed public
stunt for the interests of certain individuals, institutions or groups (Chu, 1995, p.
206). If mass media prefers the opinions of certain experts than others, it is likely to
include them in its monopolized discourse.
According to Slovic (1987), however, risk communication is doomed to fail
unless those efforts are structured as a two-way process. Not only risk experts but
also the public need to contribute to risk communication because the public’s basic
conceptualization of risk is much richer than that of the experts and often reflects an
important but omitted part from the experts’ risk evaluation.
Furthermore, many health-related opinions which news media covers are
designed by advertising firms representing pharmaceutical companies. When

10
announcing risk information, these institutions and experts cater to the media’s
pleasure and publish what the media like. In addition to the relationship of news
sources and reporters, experts and media also form an accomplice structure, which
favors certain advantageous news. Risk news is thus largely based on politics, power
and controversy, instead of transparency. As a result, it is important to explore what
is hidden and what is highlighted in the H1N1 flu news.
The Limitations of Media Risk Reports
Medical journals are essential sources for health reporters, while many
journals are commercial enterprises. Even papers in peer-reviewed scientific journals
that were thought to be more reliable are sometimes problematic. As Levi (2001)
points out that, in some cases, editorials are actually written by public relations firms
that represented pharmaceutical companies. In addition, publication in scientific
medical journals is one of the health industry’s marketing strategies. Pharmaceutical
companies may choose journals in which study results relevant and advantageous to
their products, and choose scientists they are familiar with to have access to these
journals. Hence, only part of the truth is told on these publications. Levi (2001)
mentions that sometimes researchers are encouraged to design studies that omit
negative findings and only show desirable results due to monetary incentives.
Apart from biased sources, journalists who report on risks are frequently
accused of poor quality research, oversimplification, and being misleading and
sensational. Some scholars believe the reason is the innate limitation and difficulty of
news media when reporting risks.

11
First of all, deadline is an issue for news media. Exclusive reports have to be
done within a very tight timeframe and are limited to space. Because risk
information is highly technical and complex, news reporters are thus required to
interview experts from different fields to reinforce the creditability of their reports.
However, very few reporters are equipped with adequate background in science to
comprehend complex, chaotic and contradictory risk knowledge. When faced with
diverse statistics and data from experts in government, business, social movement
groups, academia or medicine, reporters do not have the capability to critically
question their sources. Due to insufficient knowledge and limited time, reporters and
editors often omit conditions that are significant to scientific and technological data,
including background, sequence of ideas, and limitations. As a result, statements that
science and technology experts regarded as preliminary, hypothetical, temporal, or
conditional materials are reported as strong, conclusive evidence by mass media
(Chu, 1995, p. 205). Furthermore, with the burgeoning of Internet, it may not be so
hard for reporters to search for information they need, but “the process is a matter of
controversy” (Patel, 2001). The problem that Internet brings into medical journalism
is not only excessive unreliable materials that can be retrieved from the Web, but
also the laziness of reporters due to the handy information on the Web. Hence, even
though Internet changes the processes of scientific journalism, some journalistic
problems remain unsolved and even became worse in the field of health
communication.

12
Secondly, the difference in professions between journalism and science and
technology has led to poor interaction. Journalists are generally in a hurry and on
deadline. Therefore, when reporting risks, they tend to simplify materials and extract
bits and pieces from sources. They prefer and seek for “confirmed” and “conclusive”
answers. Science and technology experts are the opposite. The more cautious an
expert is, the more likely she or he will be to express unconfirmed opinions and
temporal analysis, and acknowledge insufficient evidence or lack of knowledge in
depth. The media, however, often omit such statements and presupposition (Chu,
1995; Nelkin, 1996).
Due to the distinct difference in professions between mass media and medical
science, contradictions usually arise when the media represents medical/health
information in a sensational and commercial way.
Lastly, we know that a risk is based on the predication of future and focused
on the assessment of prospective. Thus, there is a conflict inherent with the
fundamental value of risk news – the “now” factor. News reporters are likely to
overlook threats that are distant and hypothetical until they become obvious (Chu,
1995). That is to say that news media prefer happening risks rather than prospective
ones, especially when there are decisive scientific statements, catastrophes, strange
stories or conflicts associated with risks.
In the well-known Bhopal disaster in India in 1984, the media demonstrated
their news logic in dealing with risk events. No matter print or the broadcast media,
all were event-centred and viewed this disaster as an independent and isolated

13
incident (Wilkins & Patterson, 1987, pp. 84-85). There were no report or discussion
on the social, cultural or economical influence of this incident, and no analysis on
biochemical plants. The media focused on the disaster itself, its aftermath and the
remedial tasks. The news reports on the Bhopal disaster were all very similar, with
the primary source being the experts, governmental officials, while citizens who
were able to provide richer resources were given less attention. The mass media
depicted the Bhopal disaster as an unprecedented industrial tragedy in human
history, stressing its “new” and “now” factors, instead of its being an initial sign of
problems generated from the global industry (ibid, 1987).
News reporters should therefore regard risks as a series of events instead of a
single event, and deal with them with a non-event-centred view (ibid, 1987, p. 85).
Media, Message and Health
For medical reporters in particular, they should avoid scientific languages
that are highly technical and ambiguous, and they need to acquire the ability to report
risk within their contextual frames. Frost (1997) mentions that only when reporters
work with health experts and value their concerns for health-related subjects of
debate while producing risk news would health risks receive sufficient attention and
avoid being over- or underestimated. Water et al. (2000) suggest that reporters could
help readers to assess risks, compare similar risks and focus on long-term risks.
Furthermore, news media should develop a heuristic way to report risks,
which articulates risks with a series of relevant events and decisions. There should be
social and socio-psychological viewpoints presenting to the audience. If news media

14
presents a risk as an independent event which is not related to other decisions,
audience members are hard to articulate relevant events and then make decisions by
themselves. Presenting health risk as a series of events and decisions can help the
audience understand the situation and figure out their best reactions and decisions.
The audience is able to weigh the outcome of choices. Even though the method of
viewing risks as a series of related decisions instead of events may not solve all the
problems in risk communication, it is feasible and of great help to convey risk
information for modern media.
Kitzinger (1999) believes people should not adopt only scientific means to
assess risks because risk cannot be solved only by science. The public must not rely
solely on the risk assessments from science and technology experts since they are not
able to solve the conflicts arising as a result of adopting a science and technology
viewpoint, and the same rule applies to the news media.
Levi (2001) suggested several principles to tell true stories when journalists
are doing their jobs. These include choosing good examples, reporting both effects
and side effects, distinguishing between associations and causes, quantifying and
comparing risks, revisiting topics, giving equal attention to equally substantiated
claims, and considering the impact on people’s lives.
Earlier researchers argue that there are more and more advanced approaches
applied in public health, includes social marketing, behavioral decision theory,
entertainment education, media advocacy, and so forth (Maibach & Holtgrave,
1995).

15
Since health is highly interrelated to mass media, however, Seale (2004)
points out that the media and sociology of health and illness seem to “stand at a
distance from one another.” People find abundant resources to decide what to think,
make decisions about health, or vote about health care policy and finance.
Audience’s behavior is formulated in large part from resources drawn from various
mass media. Nonetheless, mass media depictions are partial truths. For example,
Covello and Peters (2002) found that 80% of women relied on the general media for
health information, and only 25% received health information from doctors or
nurses.
Kasperson et al. (2003) point out that, according to the social amplification of
risk model, risk information can reach individuals through either the news media or
personal networks when individuals have no direct personal experience of risk. As a
result, public responses are “influenced by the volume, dramatization, and symbolic
connotations of the information.” Research shows that large volumes of information
can amplify the perception of risk and distract audience from other sources of risk. In
addition, Kasperson et al. find that even though the news coverage is balanced, those
reassuring claims may not counter the effects of fear or risk messages.
Berry, Wharf-Higgins, and Naylor (2007) find that health topics were
discussed in terms of risk almost three times as often as they were discussed in terms
of prevention. This is in accord with previous research which addresses the habit of
reporters that they usually focus on the possibly horrible scenes of a risk.

16
Classic tenets of journalism call for objectivity and neutrality, while a newer
generation of journalists adopts a non-objective viewpoint when writing their stories:
advocacy journalism. Simply put, it is a genre of journalism that intentionally
promotes an idea or viewpoint for some social or political purposes. When it comes
to health issue, some research indicates the value of advocacy journalism. For
example, in Australia, the successful banning smoking in workplace can be largely
attributed to media advocacy; publicity surrounding expert reports became
significant catalyst and led to each of the memorable milestones (Chapman, 2001).
By the same token, in the case of the 2009 H1N1 flu, some journalists retain
a certain angle in their stories. Since health-related issues by nature are more
complicated than other kinds of news, it would be sometimes unavoidable for
journalists to write reports with a specific angle. This is not to say that pure news is
impossible in health communication, but this veiwpoint stresses that objectivity is
reletively hard to maintain when journalists report health issues.
A widely known example is the advocacy of 1976 swine flu vaccine. A
nationwide National Influenza Immunization Program was rolled out in the fall of
1976 after an outbreak of swine flu among military personnel in New Jersey. But the
advocacy of vaccination was halted in December of that year because of an unusual
number of reports of Guillain-Barre syndrome (GBS) occurring in the weeks
following vaccination. Since it is still not clear what led to the increased incidence of
GBS in 1976, scientific research believes that it is unlikely GBS following the flu
vaccine (Floeter, 2010). Whether mass media should be responsible for the

17
consequence from the advocacy, it need to rebuild the public’s trust when advocating
an action again in the face of the 2009 H1N1 flu.
As Stewart (2003) mentions, the newly shared terrain of narrative medicine
overlaps the larger province of advocacy journalism. More and more physicians,
health professionals, and journalists employ the techniques of narrative to mobilize
people toward change in a way similar to advocacy journalism. He believes
advocacy-oriented medical journalism has nudged its way into the modern
professional medical and scientific journalism.
In this paper, the author believes that what meterials of receiving vaccination
of the H1N1 flu journalists choose and how they present the rationale reveal their
intention and news angle. It is helpful to understanding the situation by examining
how newspapers convey the information on the H1N1 flu vaccine as well as the
relationship between the news discourses and the public’s perception.
The Audience Under Risks
Communication theories and research indicate that mass media has great
influence on audience in different aspects, including perception, attitude, and
behavior. Different communication appeals and channels will have different impacts
at different levels of changes.
One of the theories that can best illustrate changes and reactions of the
audience facing health risks would be the Health Belief Model (HBM) proposed by
Irwin M. Rosenstock. When Rosenstock developed the Health Belief Model in 1966,
it was widely accepted by researchers and has been furthered and amended by the

18
following scholars in the late 1988. The model describes people’s motivation and
readiness to change their health-related behavior, and had been shown to have value
which was found useful in explaining behavior (Nutbeam & Harris, 1998).
The Health Belief Model argues that people’s behavior is influenced by their
perception of the threat and the desirable outcome which taking action will result in.
It comprises a set of variables that include the individual's perceptions of
vulnerability to a disease, severity of the disease, paths of action that can be taken to
prevent the disease, and benefits versus costs of the potential action.
Rundall and Wheeler (1979) further explain the prime determinants of an
individual’s utilization of disease prevention services. There are three distinguished
components of an individual's readiness to undertake recommended health behavior:
the individual's general motivation with regard to health care, the value of reducing
the threat of illness to the individual, and the individual's perception of the
probability that complying with the recommended behavior will actually reduce the
threat of disease. In addition, there are other variables classified as possible factors to
influence audience behavior such as an individual's demographic characteristics, the
structure of the delivery mechanism, attitudes toward the service provider, and
certain ad hoc variables such as prior experience with illness.
In other words, a person’s concern about health matters in general,
willingness to accept medical direction, perception of susceptibility and severity of
illness, and perception of the efficacy and potential danger of the recommended
behavior. These elements are proved to be fundamental factors in influencing

19
people’s health behavior in research and have been applied to a wide range of health-
related campaigns and messages. To be more specific, when people believe that they
are susceptible to a threat, the consequences of the threat can be serious, and the
benefits outweigh the barriers to take action, people are more likely to have stronger
self-efficacy
7
to take certain actions (Glanz et al., 2002).

Figure 1: Conceptual Model of Health Promotion Practice
(Source: Glanz et al, 2002, p. 52)

7
According to Bandura (1977), self-efficacy as a belief about one’s own ability to perform a
recommended action. Whether or not one will take an action depends on his/her belief about the
extent to which he/she can be efficacious in performing that action. In other words, the stronger you
perceive self-efficacy, the more effort you will be willing to exert. The stronger self-efficacy you
perceive, the more effort you are willing to exert

20
According to the Glanz’s formation of perception (2002), individuals would
be more likely to get the 2009 H1N1 flu vaccine if they believe that:
 they are at high risk of the novel H1N1 flu pandemic
 the consequences of the infection are serious
 getting a vaccination is effective in reducing the risk of infection
 the benefits of getting vaccinated outweigh the potential costs and
barriers.
The concept implies how mass media influence audience’s perception toward
a health threat with variable elements. Even though the HBM is sometimes criticized
for its limitation that health beliefs sometimes predict health behaviors to a lesser
degree than theoretically expected and its over-simplistic perspective of the relation
between the two, it is still useful for researchers to conceptualize the idea of possible
influence variables.
With this in mind, given the goal of the U.S. government is to promote the
idea of receiving the H1N1 flu vaccine and enhance people’s willingness to take
action, the mass media undoubtedly plays an important role in addressing the issue in
terms of these health behavior variables. In other words, the health messages should
include elements of evaluating risk, consequences, benefits of actions and barriers to
taking action that would better control the messages and are more effective in
influencing audience’s behavior.
In this paper, the author aims to explore the audience perception toward the
issue on the H1N1 flu and its vaccination. The Health Belief Model undoubtedly

21
renders some valuable points to researchers to break down the complex processes
into several analytical variables.
News as Narrative
Narrative analysis is thought to be best used for exploratory purposes,
sensitizing the researcher, illustrating but not by itself validating theory (Alvarez &
Urla, 2002). A common focus is the exploration of ethical, moral, and cultural
ambiguities.
Narrative theory is based on the concept that people are essentially
storytellers (Fisher, 1984). He believes storytelling is one of the oldest and most
universal forms of communication. Individuals approach their social world in a
narrative mode and make decisions and act within this narrative framework. Lule
(2001) also mentions that “journalists are part of a long storytelling tradition that
includes fleet-footed messengers, minstrels, troubadours, carriers, couriers, criers,
poets, chief priests, missionaries, rabbis, and medicine men.” He contends that
storytelling is an essential part of what makes us human. Through stories we
understand our lives and the world. In the past, news was treated as merely
information, we now should adopt a new approach to look at news as storytelling. As
Lule points, “news will be in crisis to the extent that we ignore the roots of
journalists as storytellers.” Journalists are among the most valued storytellers in
contemporary society.
Woodstock (2002) mentions that narrative structure is about two things: the
content of a story and the form used to tell the story. Story and plot are two common

22
ways to describe the narrative structure. According to narrative theories, stories
themselves provide opportunities for narrators/reporters to gain legitimacy (Zelizer,
1990). Using techniques such as direct address, repetition, selection, reordering and
time condensation, the narrator structures the telling and meanings. The way
information is gathered and the way it is reported heavily influence the resulting
representation.
Rock (1987) mentions that narratives are also based on the experience of
hundreds or thousands people. Vivid case histories evoke stronger mental images
than abstractly presented information, are easier to access from memory, and are
therefore more likely to influence attitudes when the individual is trying to decide
whether to accept message recommendations. Stories engage the imagination and
thus are “intuitively appealing to humans” because people are all “essentially
storytellers and avid story recipients” (Kopfman, Smith, Ah Yun, & Hodges, 1998,
P.21). Green and Brock (2002) also point out that narratives are more interesting
than statistical evidence in terms of news forms.
As researchers contend that narratives touch our emotions (Dal Cin, Zanna &
Fong, 2004; Oatley & Gholamain, 1997), influence what we believe (Green &
Brock, 2000), teach us new behaviors (Slater, 2002), and shape our cultural identity
(Jacobs, 2002), we recognize the role of journalists as storytellers is of significance
in shaping people’s perception, attitude and behavior. Health news narratives are
thus conveying effective and meaningful information worth analyzing by
researchers.

23
Research Questions
By combining theories and research discussed above, the author believes that
an exploration of the public’s perception toward the H1N1 flu vaccine and an
examination of the construction of messages about the H1N1 flu vaccine should be
conducted. Guided by previous research and theories, this paper addresses the
following questions:
1. What narratives do the newspapers convey regarding the novel H1N1 flu
vaccination?
2. How are these narrative messages designed?
3. What is the current perception of general public toward the novel H1N1
flu and its vaccination?
a. What is people’s understanding of current H1N1 flu?
b. What are people’s feelings toward the H1N1 flu?
c. What is people’s perception of susceptibility of getting the H1N1
flu?
d. What is people’s perception of the consequence if contracting the
H1N1 flu?
e. What’s people’s attitude toward the H1N1 flu vaccine?
f. How likely are people to get a H1N1 flu vaccine?
g. What are people’s concerns about the H1N1 flu vaccine?
4. How do people perceive the news coverage about the H1N1 flu on their
daily newspapers in terms of the amount, advantages, and disadvantages?

24
5. Is there any relationship between newspaper coverage and the audience’s
perception, attitude, and behavior? Is there any correlation that can be
deduced from the two analyses (the narrative analysis and the survey)?
Above all, the author hopes to integrate findings on these research questions
and then prompts discussion on improvements and recommendations for health
communicators to better convey messages of health-related issues that could help
enhance audiences’ knowledge under encounters of complex health risks.

25
CHAPTER THREE: PRIMARY RESEARCH
According to the literature review, news articles that can generate higher
willingness to take action among audiences are those that convey greater severity of
the H1N1 flu, greater perceived susceptibility, higher effectiveness of vaccination,
and easier access to vaccination. However, apart from examining how newspaper
articles convey these elements, it is necessary to understand the public’s perception
about the H1N1 flu and its vaccination. By learning from the public’s point of view
and the narrative analysis of news articles, the results will become more meaningful
when they are presented together. The following sections describe the methodology
used in each portion of the primary research, followed by the findings.

Narrative Analysis
The narrative analysis examined how newspapers present the issues of
vaccination of the H1N1 flu. By analyzing the narrative structure and locating the
biases in the narratives, one can determine the news logic and the narrator’s
rationale, then prompt improvements on the narrative contents and structure which
can assist media consumers in becoming media literate and enhance their knowledge
on health issues.
Sample Selection
Four mainstream newspapers were chosen for this research in light of their
importance, scope and readership. They are The New York Times, USA Today, San
Francisco Chronicle, and the Washington Post.

26
A series of Lexis-Nexis searches performed between August 1
st
and
September 30
th
2009 produced articles about the act of vaccinating. The focus of my
research is the narrative developed in recent coverage by journalists to describe the
issue of getting vaccination of the H1N1 flu. Articles gathered for the analysis
focused on the rationale journalists chose to present about why and how people
should get vaccinated. Unless the H1N1 flu vaccine was the primary theme the
author didn’t analyze the article. My intent was to explore how journalists present
the issue of the H1N1 flu and the facts of getting vaccination. Only stories with
keywords “vaccine,” “vaccination,” or “shot” in headlines that indicated such a focus
of “H1N1” or “swine flu” were analyzed. The result of sample selection is as
follows:

Table 1: The Number of Samples Chosen from the Four Newspapers

Newspapers Number of news articles
The New York Times 9
USA Today 5
San Francisco Chronicle 4
Washington Post 13

27
Framework of Analysis
The narrative approach provides the researcher with an organizational
structure designed to be responsive to analysis. Labov (1997) claims that a fully
formed narrative may show the following structure:
i. Abstract - summarizes the events or incidents of the story.
ii. Orientation - describes the setting and character.
iii. Complicating Action - offers an evaluative commentary on events,
conflicts and themes.
iv. Evaluation – addressing the question. Narrative has point, and it is
narrators’ prime intention to justify the value of the story they are telling,
to demonstrate why these events are reportable.
v. Resolution - describes the outcomes of the story or conflict.
vi. Coda - This wraps up the action, and returns the conversation from the
time of the narrative to the present.
In this research, the author examines the headline and the lead of each news
article to record its main idea. Through out the content, the author examines the roles
of news sources to determine the story setting and characters. The
commentaries/subjective comments about the H1N1 flu vaccine in the news are
examined to figure out the narrative positioning on the issue. In addition, narrators’
judgments on the H1N1 flu vaccine issue are also examined to understand narrator’s
prime intention (i.e., encouraging mass vaccination, inhibiting the H1N1 flu vaccine,
and so forth.) Conflicts and outcomes in the context are also examined to learn how

28
narrators define the current H1N1 flu vaccine problem, with certain angle. Lastly, the
author examines the conclusion of the story to know what narrators proposed to fix
the problem defined.

Table 2: Elements of Narrative Analysis and Their Meanings

Contents Meanings
Abstract Headline and the lead Main idea of the story
Orientation Setting and character Roles; voice of participants in a
particular time, place, or setting.
Complication Evaluative commentary Positioning
Evaluation The value of the story;
Judgments of the event
Narrator’s prime intention
Resolution The outcome & conflict Narrator’s perspective and
selections of what to present
Coda Conclusion Narrator’s conclusion

After examining and recording the results of each sample news article
according to the six categories, the author presents the main narrative storyline in an
organized analysis in the Chapter Four.

Survey
A questionnaire was designed to explore the perception and attitude
regarding current H1N1 flu and its vaccination among general public. It examined

29
the relationship between their personal perceptions to media coverage on novel
H1N1 virus, and to see if some variables are related to their attitude toward the
H1N1 flu vaccine and their willingness to get vaccinated. The intent was to explore
the motivations and experiences of people whether they get vaccinated or not.
According to Lindsay & Norman (1977), perception is the process by which
organisms interpret and organize sensation to produce a meaningful experience of
the world. As a result, perception better describes one's ultimate experience of the
world.
Earlier research suggests that some non-attitudinal variables can be accounted
for behavior by inclusion of determinants such as socio-demographic characteristics
(Anderson, 1968), social influence (Kar, 1978), and past experience with medical
care (Winkelstein & Graham, 1959). Rrewer et al. (2007) further ascertain that there
are a high degree of consistency and strength of association between risk perceptions
and behavior. The research reveals that the three risk perception measures- perceived
likelihood of a disease to happen, perceived self-susceptibility to a disease, and
perceived severity of the consequence- are related to people’s vaccination behavior.
As a result, the questionnaire is designed based on basic assumptions
inducted from variables suggested by theories and models.
Sample Selection
Due to the difficulty of conducting a random sampling, convenience
sampling was conducted to reach members of the general public. Three hundred
questionnaires were distributed electronically through emails to school faculty, staff,

30
and students, and through messages on social media such Facebook and MSN
messenger to reach a wide range of people. Two hundred and six responses were
received and recorded. The response rate is 69% (n = 206).

31
CHAPTER FOUR: FINDINGS
In this chapter, the author presents the major findings of the narrative analysis
and the survey. The results are presented as follows.

News Narrative Analysis Results
Health messages usually communicate information about prevention,
detection, diagnosis, treatment, or survivorship. According to Kreuter et al (2007),
narrative forms of communication have four major functions: overcoming resistance,
facilitating information processing, providing surrogate social connections, and
addressing emotional and existential issues. Narrative is defined as “a representation
of connected events and characters that has an identifiable structure, is bounded in
space and time, and contains implicit or explicit message about the topic being
addressed” (ibid, 2007).
News articles by nature are thought to be more expository, didactic, or
straightforward in delivering messages. However, this point of view ignores the role
of newspapers as a powerful narrator in representing events and constructing the
world. In this paper, the author believes that news narratives have the functions
mentioned above, delivering more metaphor and connotation beyond the words.
Even news articles may sometimes be categorized into non-narrative contents, they
are in fact worth analyzing in terms of their social function. Below are the summaries
of storyline from each of the four newspapers.

32
General storyline taken from the New York Times.
The New York Times portrays the government’s vaccine effort as a
successful initiative that the government has been trying hard to meet the demand of
the vaccine. Vaccine safety controversy is acknowledged. The newspaper points out
that many people are concerned with the flu vaccine’s side effects on pregnancy and
its adjuvants issues. The existing problem in the current vaccination program is
identified as follows:
If there is a weak link in this chain of preparedness, it is the federal
bureaucracy’s torpor in explaining the risks of the vaccination program to the
public.

Moreover, the New York Times provides problem-solution narratives which
imply a recommendation:
The need for good safety monitoring is more important than ever in this risk-
averse age, in which a discredited link to autism has shaken confidence in
childhood vaccination. It’s equally important that officials communicate the
difference between correlation and cause.

“If you add what the public perceives as another unknown there, there’s a
concern that people would be reluctant to get vaccinated.”

“Using adjuvants is that they can increase a vaccine’s potency against a virus
to which it is poorly matched. But swine flu vaccine is well matched to the
virus, which has not mutated.”

In addition, the New York Times largely uses statistical descriptions to portray
the consequence of the H1N1 flu:
It’s statistically inevitable that some of the millions of people vaccinated this
fall will become ill or die. And there is a high risk that the vaccine will be
blamed for any coincidental health problems… But about one in seven
pregnancies ends in miscarriage, so nearly 1500 of 10000 women in early
pregnancy will miscarry this fall.

33
“…98 percent of those flu cases were the new H1N1 swine flu.”
“But there are a lot of ifs.”
“Overall, virologists say, of every 100 people who faithfully get flu shots,
only about 70 are fully protected every year. But even the other 30 are partly
protected by previous shots and by ‘herd immunity.’”

The New York Times also describes people who decline to get vaccinated as
they give up “ a far better defense.” Vaccination is implied as the best way to keep
one healthy during the H1N1 flu pandemic. The narratives point out people’s
unwillingness to get vaccinated, but attributes the problem to the government’s
failure to clearly explain the concerns and unknowns on the vaccine issue. This
implies that as long as the government explains well to the public about the logic of
the H1N1 flu vaccination, it could significantly reduce concerns and unknowns and
make the program successful. The vaccine issue is thus defined as an incomplete
communication instead of a flaw or risk coming from the vaccine itself. Examples
are as follows:
“…but she still does not want the one thing that would give her a far better
defense.”

“I want to defend the rights of other people not to get it. It’s not an easy
choice.”

“A vaccine campaign would be a successful program if it is clearly explained
by the authority to reduce concerns and unknowns.”

The New York Times also describes the H1N1 flu as a looming and global
threat. The narratives frequently compare the novel H1N1 flu to historical flu events
such as 1918 Global Influenza Epidemic or 1947 Asian flu, but these narratives all

34
point out the difference among the three: the novel H1N1 flu poses less threat than
its counterpart: ‘” It’s more like a bad seasonal flu than the 1957 Asian flu…”
Many other narratives were talking about the vaccine supply with a hopeful
tone. These narratives described those who oppose the H1N1 flu vaccine as “poorly
educated workers.” It also claims that the concern “flu shots cause flu” is a “myth.”
Anti-vaccine thoughts and behavior are implied as unscientific and uneducated.
General storyline taken from the Washington Post
The metaphor is that getting a shot is a socially correct thing. Vaccine is the
only solution to the H1N1 flu. The current problem lies in the number of “dose” and
vaccine supply shortage. Although the H1N1 flu virus appears to be causing
relatively mild disease so far, experts think that many more people will become
infected because most of them have no immunity against it. Government makes
efforts hardly so the vaccination campaign became the most ambitious one in the
U.S. history. The narratives emphasize that providing people with access to the flu
vaccine is an urgent global issue. Although the number of people who could be
protected again the H1N1 flu by the vaccine is uncertain, help is on the way for the
H1N1 flu. Mild fear appeal is used and optimistic solution is provided:
“Although the swine flu appears no more dangerous than the typical seasonal
flu, the new virus-- known as H1N1-- is likely to infect many more people
because most have no immunity against it.”

“As soon as a vaccine is available, try to get it for everyone in your family.”
“…there was some good health news for a member of the team in the past
few days: Help is on the way for the swine flu.”

35
Statistical descriptions of the effectiveness of vaccination are frequently used
to defend the vaccine:
“The study involved a standard dose of 15 micrograms of vaccine and found
that the vaccine produced a strong immune response in more than 96 percent
of the subjects.”

“Many people rush to be volunteers of vaccine trial.”
“It’s just another flu vaccine.”
The narrative logic is that the H1N1 flu is a looming but preventable threat if
people get vaccinated. There are already many states, hospitals, and local
organizations that require mandatory shots. There is a mistaken fear that vaccine
itself can cause the flu; the vaccine appears to be safe. The narratives also stress that
the pandemic is “materialized” so the benefit of vaccine outweighs its risks. Per the
concerns of vaccine safety, reassurance is made to address the improvements on
surveillance mechanisms today. The general storyline of the Washington Post is a
risk-benefit analysis that addresses the benefits from getting vaccinated but
underplays the unknowns and risks.
General storyline taken from the USA Today
The H1N1 flu is a “fearful killer” that could kill healthy children. There are
many pregnant women support the H1N1 flu vaccine trials. Parents who did not get
their children vaccinated in time led to lose their children and they now feel
regretted. Emotion-evoked narratives are used by presenting individuals’ experience
of loss of life of their family members:

36
“I didn’t know flu kills healthy children. That’s what’s so scary.”
“Flu can kill.”
Individual stories as testimonials are used to prove that getting vaccinated is a
right choice:
For McGowan, who expects her sixth child around New Year’s, volunteering
for the trial of the H1N1 flu vaccine was a no-brainer. A stay-at-home mom
in St. Louis who holds a doctorate in psychology, has read about how
pregnant women are among the high-risk groups for complications from
H1N1.

Female subjects in the storyline are categorized into three characters. One
category is educated women who have higher education level (i.e., a doctorate
degree, etc.) and are pro-vaccination; another category is pregnant women who are
about to deliver their babies and are pro-vaccination under family doctors’
recommendation; the other category is mothers with little children who are active to
have themselves and their children vaccinated. Almost all women characters are
examples of active participants in the vaccine trials or supporters of the vaccination
program. The positioning is that participating in vaccine trials is a good way to
protect pregnant women.
Government authorities are represented as experts who have been dedicated
to protect pregnant women in the H1N1 flu pandemic. They are also the supervisor
of vaccine manufacture and are in charge of surveillance. Doctors are represented as
endorsers of vaccination. College students and teachers are active participant
volunteering for vaccine trials. The H1N1 flu is portrayed as a “fickle” and

37
especially dangerous flu virus which differs from every other known flu virus, and
most people are defenseless against it.
Narratives stress that flu vaccines which had histories in harming pregnant
women or the public in the past were all medication that was not approved by the
FDA. Since the current H1N1 flu vaccine is under approval of the FDA, it is safe.
The current problem is defined that the H1N1 flu vaccine is being viewed as a
frightening specter, and thus trepidation in testing still happens. Narrative rationale
argues that the H1N1 flu vaccine is safe in non-pregnant women, so is it in pregnant
women:
“Though there’s no guarantee, pregnant women are reassured that H1N1 flu
vaccine is ‘pretty safe’ in non-pregnant women.”

In addition, optimistic reports on the results of vaccine trials are addressed.
Positive results are frequently mentioned, leaving out the unknowns and
uncertainties. Statistical data is often used to sustain the statements:
“The federal government approved four pandemic flu vaccines, saying each
one triggers ‘robust’ protection in most healthy adults within 10 days after a
single dose…”

The narratives also depict getting vaccination as a trendy thing. The rationale
here is that there may be uncertainties such as vaccine dosage, yields, and timing
issues, but there are still many volunteers participating in the vaccination program,
and people are even clamoring to take part of it. Moreover, since there was a limited
vaccine supply in early production, there will be prioritization of vaccinations. The
current vaccine issue is identified as vaccine shortage, instead of vaccine safety.

38
People of high-risk groups are encouraged to receive vaccination as soon as possible.
Prioritization is a solution to vaccine shortage.
General storyline taken from the San Francisco Chronicle
The metaphor is that the H1N1 flu vaccine is a solution for the H1N1 flu.
Statistical evidence is used. It was estimated that the H1N1 flu could infect 60
million to 120 million people in the U.S this fall and winter. The current vaccine
issue is identified as “uncertainty.” Government has been making efforts to monitor
the vaccine manufacture process. The narratives acknowledge the public’s
skepticism about the flu's danger and the safety of immunization. However, the
H1N1 flu could be reduced to a dangerous but manageable health threat as long as
public health officials push hard to produce “their strongest weapon,” the vaccine.
The public must also do its part, starting with taking the flu seriously. The
presumption here is that the public did not take the H1N1 flu seriously so that they
do not want to receive vaccination which is the best way to protect themselves:
“The worry here is twofold. A scare-weary public, especially the vulnerable
groups, won't bother getting a protective shot. Or they'll seek treatment and
won't be able to find a vaccine.”

“…the real battle probably will be convincing people in the high-risk groups
to get the vaccine.”

The narratives stress that the H1N1 flu vaccine is safe and effective, but the
delay in producation is a problem. Manufacturers should speed up the production.
Narratives argues that the risks associated with the illness are much higher than the

39
risk associated with the vaccine, so the real “battle” for the government is to
overcome the skepticism about the H1N1 flu vaccine:
“It’s crucial that people who are at risk know that seasonal and H1N1 are
serious and that they take it seriously.”

Uncertainty is addressed in the narratives. Optimistic statistical data shows
the good results of the H1N1flu vaccine trials, but acknowledgement of risks is also
mentioned in the narratives. The rationale is that the H1N1 flu vaccine is being made
using the same process as the seasonal flu vaccine, so it is safe even though the virus
is different. The narratives acknowledge the existence of uncertainties, but argue that
people should not worry about it because the government will halt the vaccine
program once side effects are detected. As a result, these optimistic, one-sided
narratives leave the uncertainties to remain unsolved:
“If serious side effects appear during clinical trials, the vaccine program will
be halted immediately.”

“If there are rare, severe adverse events, it will only be after wide-scale use
that we'll see them.”

“The swine flu vaccine should be just as safe as the seasonal flu shot, CDC
officials said. The new vaccine is being manufactured using the same process
as the seasonal vaccine, but with a different strain of influenza.”

“Demand is uncertain depending on people’s awareness of danger.”

40
Summary
1. Justification of the vaccination program
All four newspapers portray receiving the H1N1 flu vaccine as a right
decision, a socially correct thing. They all depict the government’s mass
vaccination program as an unprecedented story, and, no matter what
setbacks happened, it is literarily a successful and meaningful action.
Governmental authorities are making efforts to combat an infectious
disease.
2. Personal experience narratives (vivid case histories)
All four newspapers are presenting individual cases to share ordinary
people’s stories of fighting flu. The gist of these stories emphasizes the
individual’s neglect of vaccination and the resulting loss of lives of their
family members. That is, loss-frame messages are frequently used to
address the importance of receiving vaccination. A loss-frame message is
a message presenting the costs of not performing the behavior,
emphasizing what people may lose from not adopting an action (Salovey
& Wegener, 2002).
Personal experience narratives also include pregnant women and mothers
who actively participated in the vaccination program. These cases serve
as reminders to the audience that getting vaccinated against the H1N1 flu
is a necessity and is proved to be a trendy activity even among pregnant

41
women and children whom we may think to be weak and resistant to the
flu vaccine.
3. Narratives with fear appeal
Relevant to the last finding, fear appeal is also frequently used in the
news coverage of the four newspapers. According to Perloff (2008), fear
appeal refers to “a persuasive communication that tries to scare people
into changing their attitudes by conjuring up negative consequences that
will occur if they do not comply with the message recommendations” (p.
265). The four newspapers all argue that people may not have immunity
against the H1N1 flu by emphasizing the “newness” characteristic of the
virus and vivid cases of deaths. Death cases and live-loss stories are
frequently cited to justify the necessity of receiving vaccination.
Statistical data on projected number of infections is also frequently used
to present the possibly horrible consequence.
4. Problem-solution narratives
The four newspapers provide problem-solution narratives to achieve
persuasion attempt. Through the narratives of problem identification, the
newspapers give an idea to the audience about the current situation of the
H1N1 flu, which is also supported by the statistical data about the
probability of the risk. Then, these narratives introduce the advantages
(e.g. avoid loss of lives, etc.) from receiving vaccinations to motivate
people to get vaccinated. Optimistic statistical data is used to show the

42
good results of the H1N1flu vaccine, but the untold risk implied in the
words is still tangible and can lead to concerns and skepticism.
5. Narratives with one-sided arguments
A one-sided message presents only one perspective on an issue (Perloff,
2008). In this paper, the author finds that the four newspapers to some
extent acknowledge concerns about vaccine safety. However, they
provide information that is “technically correct” can be misleading to
receivers. First, the four newspapers are all pro-vaccination and report
positive things about the H1N1 flu vaccine. We see personal stories in
which parents lost their children because they failed to get them
vaccinated in advance, and we see how they have become activists in
promoting the H1N1 flu vaccine. We also see in the narratives that the
H1N1 flu vaccine is endorsed by the government agencies,
manufacturers, experts, doctors, and scientists. The only problem
acknowledged is the delay of vaccine production and the following
vaccine shortage. Other concerns such as vaccine usage in pregnant
women are mentioned in biased rationale and explained by one-sided
arguments. The H1N1 flu vaccine is thus represented as a must in the
current situation.
Moreover, analogy is used to stress the fatality of the H1N1 flu. The
H1N1 flu is frequently analogized to the 1976 Asian flu and the 1918
Global Influenza Epidemic to remind audience of its potential

43
consequences. But the public is then assured that the possible
consequence can be minimized by modern medical improvements, better
surveillance systems, faster (and accurate) communication, and
preventative vaccines. One-sided arguments dominate the narratives
about the H1N1 flu vaccine that fails to provide both the narrator’s
position and opposition. This would be misleading to the public and
hindering the discussion of the truth.

Survey Results
The statistical data was computed using the statistical analysis on a survey
software Qualtrics. Apart from single variable frequency analyses, the author also
uses cross-tabulation with chi-square (X
2
) analysis to test statistical independence
between categorical variables. The chi-square statistic is the means of determining if
the relationship between categories is statistically significant. The author used an
alpha level of .05 for all statistical tests. The results are presented as follows.
Characteristics of the Sample
Among 206 respondents, 53% of respondents are female and 47 % are male
(see Figure 2). Regarding education, 59 % have graduate degrees or up, 29 % have
college degrees, and 12% have high school degrees (see Figure 3). With respect to
age, as indicated in Figure 4, 71% of respondents are 21 to 40 years old; 14% are age
41 to 64 years old; 8 % of are under 21; and 7 % are 65 years old or above (see
Figure 4).

44
Figure 2: Proportion of Male and Female Respondents Surveyed

Figure 3: Education Level of Respondents Surveyed

Figure 4: Proportion of Ages Groups of Respondents Surveyed

45
The third research question posed in the current work is that what the current
perception of general public toward the novel H1N1 flu and its vaccination are.
Below are the single variable findings presented in the order of each sub-question.
With regard to people’s understanding of current H1N1 flu, as indicated in
Figure 5, 45% of respondents have modest knowledge about H1N1; 26% know the
most about H1N1; 17% know little about H1N1; 10% of respondents are very
familiar with H1N1; and only 2% of respondents don’t know anything about H1N1.

Figure 5: Respondents’ Understanding of Current H1N1 Influenza

Regarding to people’s feeling toward the H1N1 flu, 54% of respondents are a
little concerned about the H1N1 flu; 25% don’t have particular feelings toward the
H1N1 flu; 13 % are very worried about theH1N1 flu; and 8% don’t care about the
H1N1 flu (see Figure 6).

46
Figure 6: Respondents’ Feeling toward the H1N1 Influenza

As to people’s perception of susceptibility of getting the H1N1 flu, 45% of
respondents think they are at little risk of getting sick with the H1N1 flu; 27% don’t
know if they will get sick with the H1N1 flu or not; 17% think they are at high risk
of getting sick with the H1N1 flu; 11% think they won’t get sick with the H1N1 flu
(see Figure 7).
With regard to people’s perception of the consequence if contracting the
H1N1 flu, as indicated in Figure 8, 46% of respondents perceive the consequence is
severe but curable; 31% perceive the consequence is as mild as seasonal flu; 16%
perceive the consequence is fatal and might result in death; 6% perceive the
consequence is no big deal.

47

Figure 7: Respondents’ Perception of Susceptibility of Getting H1N1 Influenza

Figure 8: Respondents’ Perception of Consequence if Contacting the H1N1
Influenza

48
Regarding to people’s attitude toward the H1N1 flu vaccine, as indicated in
Figure 9, 41% of respondents hold a neutral attitude to H1N1 vaccine; 33% hold a
positive attitude to H1N1 vaccine; 27% hold a negative attitude to H1N1 vaccine.

Figure 9: People’s Attitude toward the H1N1 Flu Vaccine

As to how likely people are to get a H1N1 flu vaccine, 26% of respondents
are unlikely to get vaccinated; 24% are undecided; 23% have already gotten
vaccinated; 21 % won’t get vaccinated; 7 % are likely to get vaccinated (see Figure
10).
Lastly, regarding people’s concerns about the H1N1 flu vaccine, among those
who have not gotten vaccinated, 69% are concerned with “vaccine safety”; 19% are
concerned with “physical condition concerns”; 15 % have “other concerns” such as

49
they think getting vaccinated is unnecessary; 12% have budget concerns; 10% have
psychological concerns; 10% have social concerns (see Figure 11).

Figure 10: People’s Likelihood to Get a H1N1 Flu Vaccine

Figure 11: Respondents’ Reasons for Not Get a H1N1 Flu Vaccine Yet

50
The fourth research question posed in the current work is to know how
people perceive the news coverage about the H1N1 flu on their daily newspapers in
terms of the amount, advantages, and disadvantages. Analyses indicate that 52% of
respondents rate the coverage of the H1N1 flu in their major/daily newspapers as
modest/ appropriate; 31% rate the coverage of H1N1 in their major/daily newspapers
as too much. 14% rate the coverage of H1N1 in their major/daily newspapers as
insufficient; 3% rate the coverage of H1N1 in their major/daily newspapers as no
coverage whatsoever (see Figure 12).

Figure 12: Perceived Amount of Coverage of the H1N1 Flu in Respondents’ Daily
Newspapers

As to how well people’s daily newspapers provided information about
vaccination of the H1N1 flu, 34% of respondents think newspapers provided
opinions; 20% think their daily newspapers provided valuable information; 20%
think their daily newspapers appeased anxiety; 16% think their daily newspapers

51
fostered discussion; 11% have other comments, and many of them (6 out of 20
respondents) pointed out that they don’t read newspapers (see Figure 13).

Figure 13: How Well People Think Their Daily Newspapers Provided Information
about Vaccination of the H1N1 Flu

Regarding to the worst thing people think newspapers are doing in terms of
conveying information about vaccination against novel H1N1 flu, as indicated in
Figure 14, 46% of respondents think they are increasing anxiety; 21% think they are
providing one-side opinions; 16% think they are providing sketchy information or
rumors; 14% think they are providing overloaded information; 2% have other
comments.

52
Figure 14: The Worst Thing People Think Newspapers Are Doing in Terms of
Conveying Information about Vaccination against Current H1N1 Flu

Cross Tabulation Analysis
The fifth research question posed in the current work is to know if there is
any relationship between newspaper coverage and the audience’s perception,
attitude, and behavior. Cross tabulation analyses indicate that there is a relationship
existing in the following between-category analyses.
First, people’s perception of how well their daily newspapers are doing is
related to their attitude toward the H1N1 flu vaccine, X
2
(8, 206) = 17.84, p = .02.
Among those who think newspapers provided valuable information, 58% hold a
positive attitude toward the H1N1 flu vaccine. Among those who think newspapers
provided opinions, 52% hold a neutral attitude toward the H1N1 flu vaccine. On the
other hand, the majority of people who hold a positive attitude toward the H1N1 flu
vaccine think their newspapers provided valuable information (34%), while the

53
majority of people who hold neutral attitudes and negative attitudes toward the
H1N1 flu vaccine think their newspapers provided opinions (43% and 30%
respectively). Combined with result from Figure 14 (e.g., “What is the worst thing
you think the newspaper is doing in terms of conveying information about
vaccination of the novel H1N1 flu?”), 46% think newspapers increase anxiety and
21% think newspapers provide one-sided information. Base on the findings, one-
sided opinions may be related to people’s negative attitudes toward the H1N1 flu
vaccine.
Second, people’s degrees of understanding of current H1N1 flu issue is
related to their likelihood to get a H1N1 flu vaccine, X
2
(16, 206) = 28.95, p = .02.
Research finds that 58 % of people who are very familiar with the H1N1 flu have
already gotten vaccinated; 88% of people who have already gotten vaccinated are
those who at least have modest knowledge about the H1N1 flu; 80 % of people who
won’t get vaccinated are those who at least have modest knowledge about the H1N1
flu.
Third, people’s feelings toward the H1N1 flu are related to the likelihood
they are to get a H1N1 flu vaccine, X
2
(12, 206) = 41.67, p = .00. Sixty-two % of
people who are very worried about H1N1 flu have already gotten vaccinated; 60% of
people who don’t care about H1N1 said they would not get vaccinated.
Fourth, the degree of people’s self-susceptibility of H1N1 flu is related to
their attitude toward the H1N1 flu vaccine, X
2
(6, 206) = 25.20, p = .00. There are
63% of respondents who perceived they are at high risk of getting sick with the

54
H1N1 flu hold positive attitude to the H1N1 flu vaccine, while 53 % of respondents
who don’t know if they will get sick with the H1N1 flu hold a neutral attitude toward
the H1N1 flu vaccine; 32% of people who think they won’t get sick with the H1N1
flu hold a negative attitude toward the H1N1 flu vaccine.
Fifth, people’s feelings toward the H1N1 flu is related to their attitude toward
the H1N1 flu vaccine, X
2
(6, 206) = 26.58, p = .00. There are 81 % of people who are
a little or very worried about the H1N1 flu have a positive attitude toward the H1N1
flu vaccine; 55% people who don’t have particular feeling toward the H1N1 flu hold
a neutral attitude toward the H1N1 flu vaccine; 46% of people who don’t care about
the H1N1 flu hold a negative attitude to the H1N1 flu vaccine.
Sixth, people’s attitude toward the H1N1 flu vaccine is related to gender
differences, X
2
(2, 206) = 11.30, p = .00. Males are more likely to hold a positive
attitude toward the H1N1 flu vaccine than women. It’s possible because pregnancy is
one of the controversial elements in deciding whether to received vaccination or not
that women are more skeptical or worried.
Implications of the Survey Results
The findings support the Health Belief Model, suggesting that people’s
feeling about the H1N1 flu, their perceived self-susceptibility of the H1N1 flu, their
attitude to the H1N1 flu vaccine and their likelihood to get vaccinated are
interrelated.
As a result, if health communicators want to mobilize people to get
vaccinated during a pandemic, they could increase the awareness of self-

55
susceptibility and create a feeling of being threatened by the flu virus. When people
feel threatened, they are more likely to form a positive attitude to the vaccine as a
solution or more likely to get vaccinated.
In addition, research indicates that understanding of the H1N1 flu helps
people make decisions during a pandemic. Research found that people who have at
least modest knowledge of the H1N1 flu are more strong-minded when being asked
to get vaccinated or not. This means that the amount of knowledge about the H1N1
flu may not predict a preference of people in receiving vaccination, but it can predict
a high rate of decision-making on whether to get vaccinated or not. Thus,
newspapers that convey more information about the H1N1 flu vaccine could help
people to make decisions by themselves.
Interestingly, the research also finds that males are more likely to hold a
positive attitude toward the H1N1 flu vaccine than females do. One possible reason
is that many controversial issues regarding the H1N1 flu vaccine are about its impact
on pregnancy. As a result, females have more concerns than males do because the
perceived problems with the vaccine.
Another item worth noting: among people who haven’t received the H1N1
flu vaccine, no matter whether they hold a positive attitude or negative attitude
toward the H1N1 flu vaccine, their major reason is that they are concerned about
vaccine safety. This illustrates the important role of newspapers to make more efforts
to explain and clarify the issues of vaccine safety to enhance people’s confidence
about the specific H1N1 flu vaccine.

56
Furthermore, a majority of people thinks that newspapers provide opinions,
and more people think newspapers increase anxiety. There are even one-tenth of
respondents said that they don’t read newspapers, which indicates the urgency and
necessity of newspapers to rethink their narrative strategies to attract these non-
readers. It also implies that health communication cannot rely only on newspapers;
alternative channels must be identified and utilized to maximize the effectiveness of
communication.

57
CHAPTER FIVE: CONCLUSION
Discussion and Conclusion
The media’s role is of utmost importance when a looming threat is uncertain.
There are a couple of journalist’s responsibilities in delivering health information,
such as creating awareness to mitigate the loss of life, reducing panic, directing
people about how and where to get essential services, providing an outlet for grief
and counseling, ensuring two-way communication between assistance provider and
the public.
There is a major reason to use narratives as a health communication tool. A
narrative is a story that is created in a constructive format as a work of writing and
speech that describes a sequence of events. It’s storytelling that is absorbed faster,
and can be remembered longer by audience. Storytelling is representation of social
information and social experience, and it can also help reduce resistance against
persuasion attempt due to its relatively subtle form of persuasion. A narrative style
messages may raise less resistance among audience than ordinary news articles in
delivering health risks and health recommendations. To be more specific, individuals
may not actively avoid a narrative with a pro-vaccine subplot in the same way that
they might avoid a pro-vaccine pamphlet. As a result, the author believes narratives
function as an effective way of communicating health information.
As a public relations professional, achieving the goal in communication and
facilitating the communication process is the top priority. According to the survey
result, there are people intentionally or unintentionally ignore health messages on

58
mass media because they don’t read newspapers and stay uninformed. There are also
people who are unable to process health messages on newspapers so that they won’t
be persuaded by messages sent. We have to realize that a comprehensive framework
of delivering health messages plays a crucial role in empowering people facing
health threats.
To conclude, based on previous findings and analyses, the author suggests
some elements which should be incorporated into the narrative message design that
will enhance the quality of health information and increases persuasiveness of the
messages.
First, a good health message should include two-sided arguments. The four
newspapers under examination in this paper lower their persuasiveness by presenting
only pro-vaccination rationale and ignoring counterarguments. O’Keefe (1999) and
Allen (1998) concluded that two-sided messages influence attitudes more than one-
sided messages. Perloff (2008) also pointed out that a fair communicator can change
attitudes when they mention both sides, and offer cogent arguments in support of
their position. Health issues, especially infectious disease like the H1N1 flu, are
often high in personal involvement, and thus people would pay more attention to
what are being said by mass media and think deeply about them. Two-sided
arguments are necessary components in the health narratives.
Second, helpful and persuasive health narratives should adopt a gain-frame
structure to increase preventative behavior. Salovey, Schneider and Apanovitch
(2002) proposed that gain-frame messages are more effective in promoting health-

59
affirming (prevention) behaviors where benefits are obvious. A gain-frame message
is telling people to take an action that helps them gain something (i.e., a healthy life,
body, etc.). The positive outcome is more compelling than a negative outcome (i.e.,
lose something) when they consider whether to take an action or not. What is gain
serves as an incentive or lure in promoting preventive actions.
Third, personal experience narratives (or testimonials, as they are called in
the public relations profession) are very helpful to increase understanding of a health
issue. Personal experience narratives, or vivid case histories, refer to those
emotionally engaging stories of an individual‘s experience with a problem in life. As
we see in the four newspapers’ articles, there are some interesting anecdotes of
people who fought on the H1N1 flu or dealt with the H1N1 flu vaccine dilemma.
Those stories engage us into the situation and arouse personal involvement.
According to Taylor and Thompson (1982), vivid case histories have particularly
strong effects on attitudes because they are gripping anecdotes engaging the
imagination that tug at our heartstrings and influence our beliefs. Audiences may
gain more knowledge from referencing to others’ experiences, and generate more
emotional reactions that help them make decision. Testimonials are useful in a
variety of public relations tools, ranging from opinion-editorials to brochure content
and video programming.
Fourth, to be persuasive, health narratives must get rid of the myth that
statistical data is everything. Traditionally, mass media only draws attention by
presenting numbers in communicating risks. Sometimes, it pays attention to personal

60
cases which may not be representative of the population underscored. In the risk
communication, probability and statistical date are frequently used because they are
ways to present the risk. A risk by nature is a probability thing, which may or may
not happen. Therefore, health threats, being risks by nature, are often described by
statistical data. However, no matter how optimistic the data of a health threat is, there
is the probability that the worst thing may happen. A big problem from the four
newspapers is that they all underplayed the possibility of side effects of the H1N1 flu
vaccine based on some optimistic scientific research data. Those who are concerned
about the vaccine safety would only view these articles as useless because they are
not helpful in understanding the H1N1 flu vaccine issue. Moreover, social
psychologists believe that people are frequently more influenced by concrete,
emotionally interesting information than by “dry, statistical data that are dear to the
hearts of scientists and policy planners” (Nisbett, Borgida, Crandall, & Reed, 1976,
p.132). As a result, it is clear that statistical data is not as helpful as we thought in
delivering health information. A piece of interesting narratives may be more helpful
to engage audience and to enhance their knowledge about a health issue.
To be more specific, when uncertainties remain, mass media should
incorporate both statistical versions of narratives and parallel versions of narratives
to better deliver the information and attain the persuasion goal. As we see, the
unknowns and concerns regarding the H1N1 flu vaccine remain unsolved, and were
simplified in the four newspapers. Concerns and unknowns are based on
uncertainties. Previous research has shown that, for mass media, it is no longer

61
enough to communicate risk by only presenting statistic data or probability because
this will ignores audience’s psychological and emotional conditions. Even many
health threats are proved to be of low risk, the risk nonetheless still exists. It is
human nature to avoid risks which are thought to be statistically insignificant or of
low probability. Hence, computational presentation alone is not sufficient in
informing health risks. It must be complemented by parallel narratives. A narratives
plus computational news style is thought to be a better way to convey health
information. That is, combination of multiple personal experiences and
computational data that construct a clearer picture of health issues.
Fifth, fear appeal that addresses severity and susceptibility should be
adequately and appropriately added into the health narratives. Fear appeal is proved
to be effective in persuading people to take action by many researchers, and there are
two things should not be excluded: severity and susceptibility. Fear appeal should
contain severity information that tells the audience the seriousness and magnitude of
a health threat, and it should also contain susceptibility information that tells the
audience the likelihood a threatening outcome will occur (Perloff, 2008). In addition,
solutions following the fear appeal must be provided in the narratives to tell the
audience how effective these suggested actions are and how they can effectively deal
with the threat. When these conditions are met, fear appeal could work very well
among the audience. For example, H1N1 flu narratives could position that the H1N1
flu is a real and serious health threat, but is survivable by taking certain actions.

62
Nonetheless, audience may sometimes resist messages due to fear. They do
not want to think about the possibility of a life-threatening illness, so they avoid the
topic altogether rather than experiencing an unpleasant emotional response. In this
sense, a storytelling narrative is thus less threatening, less likely to throw audience
away and engender avoidance or selective exposure among audience (Kreuter et al.,
2007).
Above all, when these important elements are incorporated into health
narratives, these health messages can be very helpful in both increasing personal
evolvement and communication effectiveness, and thus enhancing audiences’
knowledge on the issues. The narrative framework of an ideal health message is
presented in Table 3.
Besides, there is a note for health communicators. In light of the pervasive
characteristics of audience and persuasion effects, it would be better to have at least
two different narratives regarding a health issue targeting at 1) general audience and
2) specific audience. Take the 2009 H1N1 flu for example, there is not a narrative
that would be regarded as persuasive and helpful by every audience member. An
informative and persuasive narrative to one may be another’s poison. As a result,
based on audiences’ different needs and concerns, health narratives are better to be
tailored by segmenting audience into different targets. Even a comprehensive
narrative framework is not a panacea; personalized narrative messages would be
helpful and right tug at audience’s heartstrings.

63

Table 3: An Ideal Health News Narrative Framework

Message components Function
Frame  Gain-frame This is useful in promoting
preventative health behaviors
Opening  Multiple personal
narratives
Personal experiences increase
audience’s emotional involvement.
While a vivid case may be
unrepresentative of a health issue, so
multiple personal experiences would
be better if covered in the message.
Body  Two-sided arguments
- Self-efficacy
- Response
efficacy
 Fear appeal
- Susceptibility
- Severity
 Computational data
(statistical data)
Narratives could first acknowledge
problems or concerns of a health
issue, then present evidence of
counterarguments with computational
data to increase the sense of self-
efficacy and response efficacy to the
issue. Appropriate fear appeal should
be used to support arguments that
increase self-susceptibility and
awareness of severity of the health
threat. Computational data can be
added in the section to enhance
credibility.
Conclusion  Problem-solution
narratives
 Conclusion-drawing
Solutions are given in this section.
There should be not only one solution
to the problem or concerns. Instead,
multiple solutions or alternatives have
to be listed before conclusion is draw.
Conclusion is important to ascertain
an action promoted. A clear
conclusion following the components
listed above can be more effectively
persuade a health concept.

64
Nonetheless, there are also ethical concerns about health narratives. As we
see that newspapers often cover personal experiences as they are real cases
happening around us. According to Kreuter et al. (2007), personal experience
narratives from members of lay public may “inadvertently contain inaccurate
information about diagnosis, treatment, or recovery” about a disease because the
narrator anchors “important social, environmental, and cultural references that make
the narration ‘real’ for the audience” (p.231). To be more specific, Kreuter et al.
argue that stories that accurately present one person’s experience with a health issue
may not reflect known base-rate information such as true population risk for certain
disease or the probability of survival once diagnosis. Baker (2007) also mentions
that, despite convincing scientific evidence confirming the safety of vaccination,
sometimes the public has decided that they know better and they do not need to
follow the advice of the expert sources.
As a result, we all know that audience’ perception, attitude and behavior are
elusive and fickle, newspapers thus have think and act strategically to make the best
use of their influence on enhancing the public’s knowledge about health issues. The
author holds an optimistic attitude toward the role of newspapers in conveying
helpful health information by incorporating both personal experience narratives and
statistical data to make health narratives more appealing and effective to evoke
emotions and personal involvement which are essential to catch the audience’s
attention and reach the communication goal. The audience will be better informed
and empowered by health knowledge.

65
Research Limitation and Future Research Recommendations
There are some limitations in this research. First, this research analyzed only
newspaper texts (narrative analysis), so the impact of images and voice tone cannot
be assessed. Television and radio have been also considered important media in
people’s daily lives, so it would be helpful if images and oral narratives associated
with health topics could be further analyzed.
Another limitation is about the theories applied to the research. As we know
that, there are plenty of models and theories discussing different aspects of message
design, such as audience factors, message factors, source factors, channel factors,
and so forth. It is difficult and impossible to take all of them into consideration to
develop a narrative framework. Instead, this paper focuses on elements which are
thought to be most relevant to health narratives based on previous research to
develop the framework and draw the conclusion. The author examines news
narratives within a framework consisting of both narratives and persuasion,
understates the roles of details such as content grammar and source counts. Further
research can fully conceptualize the definitions of message characteristics, and
explore their functions on message design and their influences on the audience’s
perception toward a health issue.
Third, due to limited resources to an unbiased sampling population, the
author uses convenience sampling as a way to survey general public, trying to reach
people of different education levels, age groups, and life styles via emails and social
network messages to get responses from them. Though the survey is not conducted

66
by random sampling, the author tried hard to maximize the validity of the survey and
make sure the samples are diverse and representative of the general public.
It is also important to note that some research highlighted that the variables
that influence message effectiveness (or persuasiveness) depend on the nature of the
audience (Petty & Cacioppo, 1986; Pornpitakpan, 2004). This research was intended
as a preliminary examination on the H1N1 flu news narrative and the public’s
perception toward the H1N1 flu vaccine, and hopefully the relevance between the
two. Further research could investigate how they might interact with each other. It
would be meaningful to explore whether an audience member who consumes certain
health narratives are more likely to be persuaded by the content than an audience
member who read a different one. It is also interesting to explore the audience’s
perception or attitude changes after reading health narratives of different news-
telling frameworks.
This research highlights how the health issue- the H1N1 flu vaccine- is
presented in the newspapers. We know that the mass media plays a positive role in
promoting public health, facilitating debates regarding health issues, and increasing
audience’s knowledge about health issues. Most often, health messages are framed in
terms of risk by expert sources using strong language that may mislead the audience
and generate fear (Berry, Wharf-Higgins & Naylor, 2007), This paper provides a
integrated news narrative framework for mass media, and recommends further
research to explore health narratives in different media channels in conjunction with
reactions of audience members who consume them.

67
The use of narratives in health communication is growing and promising,
while there is still much to learn about its effects and the conditions under which
they may be optimized (Kreuter et al, 2007). Apart from being delivered by mass
media, health narratives can also be tailored for more specific audience groups and
use specific channels to increase effectiveness. In addition, the interplay between
narratives and audience is undoubtedly a rich area for future studies.

68
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APPENDIX: QUESTIONNAIRE
The following questions were posed in a survey of 206 people:
Dear respondents,

Thank you for taking the time to complete this short survey. I am writing a thesis
about how health information can be improved to enhance the health knowledge of
audience. This survey will provide me with valuable information for improvements
based on your perception toward H1N1 influenza and vaccination.

There is no right or wrong answer. All of your answers will be kept confidential and
anonymous. As a result, please feel free to answer these questions according to your
own experience and thoughts. I appreciate your time and help. Thank you! 

 Gender:  Female  Male
 Age:  Under 21 years old
 21-40 years old
 41-64 years old
 65 years old and above
 Education:
 High school or below
 College
 Graduate schools or up

1. Please rate your understanding of current H1N1 influenza (also known as swine
flu).

 Very familiar
 I know most of it
 Modest
 I know little about it
 I don’t know anything about it

75

2. Please rate your feeling toward the H1N1 influenza.
 I am very worried about it
 I am a little concerned about it
 I don’t have particular feelings to it
 I don’t care about it
3. Please rate your perception of susceptibility of getting H1N1 flu.
 I am at high risk of getting sick with it
 I am at little risk of getting sick with it
 I don’t know if I will get sick with it or not
 I won’t get sick with it
4. Please rate your perception of the consequence what would happen if you got
H1N1 flu.

 The consequence is fatal and might result in death
 The consequence is severe but curable
 The consequence is mild, just like seasonal flu
 The consequence is no big deal
5. Please rate the coverage of swine flu in your major/daily newspapers?
 Too much
 Modest /appropriate
 Insufficient
 No reportage
6. Please rate your attitude toward swine flu vaccine?
 Positive (i.e., it helps to protect me from getting sick)
 Neutral (i.e., I don’t know whether it works or not)
 Negative (i.e., I don’t believe in its effectiveness; I am worried
about side-effects)

76

7. How likely are you to get a swine flu vaccine?
 I won’t get vaccinated
 Unlikely
 Undecided
 Likely
 I have already gotten vaccinated (either a shot or nasal spray).
Please jump to Q9.
8. Following up the last question, please point out you reason(s). Check all that
apply:

 Budget concerns (i.e., lack money to get vaccinated; can’t afford
to take time off)
 Vaccine safety concerns
 Physical condition concerns
 Psychological concerns (i.e., fear of needles, pills or treatment)
 Social concerns (i.e., lack of support from significant others)
 Other, please specify__________________________________
9. Following up the last question, please point out your reasons(s). Check all that
apply.

 Budget factor (i.e., the H1N1 vaccine is free)
 Health awareness
 Psychological factors (i.e., being vaccinated is trendy, etc.)
 Social supports (i.e., encouraged by significant others)
 Other, please specify_________________________________
10. How well has your daily newspaper provided information about vaccination of
the H1N1 flu?

 Provided valuable information
 Provided opinions
 Appeasing anxiety
 Fostered discussion
 Other, please specify____________________________________

77

11. What is the worst thing you think the newspaper is doing in terms of conveying
information about vaccination of the novel H1N1 flu?

 Providing sketchy information or rumors
 Providing overloaded information
 Providing one-side opinions
 Increasing anxiety
 Other, please specify____________________________________

I greatly appreciate your time and help. This information is valuable to me. Thank
you. 

Abstract (if available)

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Creator Hu, Selene Chih-Wei (author)

Core Title Uses of news narratives to enhance health knowledge of the audience: an analysis of the 2009 H1N1 flu vaccination coverage

School Annenberg School for Communication

Degree Master of Arts

Degree Program Public Relations

Publication Date 08/10/2010

Defense Date 06/02/2010

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag H1N1,health communication,narratives,news coverage,OAI-PMH Harvest,vaccination

Place Name USA (countries)

Language English

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Advisor Floto, Jennifer D. (committee chair), Miller, Lynn Carol (committee member), Wang, Jian (Jay) (committee member)

Creator Email huchihwe@usc.edu,vestamomo@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-m3311

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Rights Hu, Selene Chih-Wei

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