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Wicked problems, difficult solutions, and unintended consequences: strengthening efficacy to enhance access to affordable drugs

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Wicked problems, difficult solutions, and unintended consequences: strengthening efficacy to enhance access to affordable drugs

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WICKED PROBLEMS, DIFFICULT SOLUTIONS, AND UNINTENDED CONSEQUENCES:
STRENGTHENING EFFICACY TO ENHANCE ACCESS TO AFFORDABLE DRUGS

by

Hyun Tae Kim

____________________________________

A Dissertation Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(COMMUNICATION)

August 2020

Copyright 2020 Hyun Tae Kim
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ACKNOWLEDGMENTS
This dissertation was made possible by support from the Annenberg School for
Communication & Journalism, and the many wonderful faculty and staff members with whom I
have worked during my time as a graduate student. First, I would like to thank my advisor
Patricia Riley, who has been an inspiring guide and mentor to me throughout graduate school.
Ever since the first day I met her, I have never ceased to marvel at how she brings together so
many different theoretical and methodological perspectives. Her enthusiasm for academic
research and its role in identifying and solving social problems has fundamentally altered my
own life for the better. I would also like thank my dissertation committee members, Sheila T.
Murphy and Robert V. Kozinets, for answering my myriad of questions and being supportive of
my research over the years. The many classes I have taken with Patricia, Sheila, and Robert have
all been valuable learning experiences for me in the context of not only research and teaching,
but also my engagement with the world.
My dissertation also stems from my experiences in classes at Annenberg and in the
Department of Psychology, as well as during the qualifying exam process. I would like to thank
also Thomas A. Hollihan and Daphna Oyserman for their insight and guidance in their courses
and in their roles as members of my qualifying exam committee. I would also like to thank all
the faculty who provided me with invaluable feedback from outside of the institutional
boundaries of the University of Southern California. I thank Lauren Feldman (Rutgers
University) for responding to my initial inquiry about her research concerning efficacy and
climate change; our subsequent conversations enabled me to create and test the relevant stimuli
for efficacy variations. Similarly, a big shout-out also goes to Olya Bullard (University of
Winnipeg), who also was a Good Samaritan of sorts, helping out a graduate student in need of
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critical yet supportive feedback on gain- and loss-framed appeals. Last, but not least, I thank my
friend Lena-Maria Schwarze, who was a highly competent second coder for one of my
dissertation chapters.
Thank you to my parents, who are also academics in an affiliated yet distinct discipline
(Linguistics); your emotional and physical support for me over the past five years got me “past
the finishing line.” I also express gratitude to members of my spiritual community at the Power
of Praise Church, particularly the Rev. Seungho Synn and his wife, Nakkeum Baik. I have lost
count of the number of times I have relied on them and other members of the church community
for spiritual comfort and replenishment. Finally, thank you to my Annenberg friends and
colleagues who have consistently been my sounding board and bedrock of support. This goes out
to every single one of my amazing 2015-2020(+) Ph.D. cohort, especially Rachel Moran, Sonia
Jawaid Shaikh, Jillian Kwong, Azeb Madebo, and Ignacio Cruz. A big shout-out also to David
Jeong, Meiqing Zhang, and James Lee; the numerous intellectual conversations I had with all of
you on issues of morality and media really helped me expand my intellectual horizons. Also, a
special mention also goes to my fellow Korean PhD students in the department; you kept me
grounded in so many different ways. Lastly, I truly thank God for having carried me through this
journey. It is He who has granted me the ideas and insights for my research. I thank Him for the
wonderfully engaged and supportive faculty, friends, and colleagues I have come across over the
past five years as a PhD student.

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TABLE OF CONTENTS
ACKNOWLEDGMENTS .............................................................................................................. ii
LIST OF TABLES ......................................................................................................................... vi
ABSTRACT ................................................................................................................................. viii
CHAPTER 1: INTRODUCTION ....................................................................................................1
Theoretical Framework: Efficacy and “Wicked Problems” ......................................................4
Broader Health, Regulatory, and Business Environments .......................................................11
Crossing Borders: Generic Drugs, the Pharmaceutical Industry, and Regulatory Regimes ....15
Why Media, Communication, and Organizations Matter ........................................................18
Bringing Organizations (Back) In ......................................................................................20
The Many Shades of Organizational Messaging ...............................................................23
CHAPTER 2: EFFECT OF GAIN- AND LOSS-FRAMED ORGANIZATIONAL APPEALS
ON PERCEPTIONS OF CREDIBILITY AND EFFICACY ........................................................27
Introduction ..............................................................................................................................27
Gain- and Loss-Framed Messaging .........................................................................................29
Organizational Messaging .................................................................................................31
Perceptions of Impact, Efficacy, and Credibility .....................................................................34
Research Design, Method, and Measures ................................................................................37
Study Design and Stimuli ..................................................................................................38
Measures ............................................................................................................................39
Data Analysis and Results .......................................................................................................41
Multivariate and Mediation Analyses ................................................................................42
Discussion and Conclusion ......................................................................................................48
CHAPTER 3: ORGANIZATIONAL INFLUENCERS? PARTICIPATORY EFFICACY,
DISCRETE EMOTIONS, AND EFFICACY PERCEPTIONS ....................................................54
Introduction ..............................................................................................................................54
Participation and Efficacy ........................................................................................................56
Efficacy in Political, Civic, and Organizational Contexts .................................................57
Organizational Identity Matters (Up to a Point!) ...............................................................61
Making Experimental Variations on Different Types of Efficacy .....................................63
Discrete Emotions, Valence, and Efficacy ........................................................................65
Research Design, Method, and Procedures..............................................................................71
Sample Characteristics .......................................................................................................72
Measures ............................................................................................................................73
Data Analysis and Results .......................................................................................................74
Effects of Valence and Organization Type ........................................................................76
Mediation Analyses ...........................................................................................................81
The “Left Behind” Sample: Additional Inquiries ..............................................................83
Discussion and Conclusion ......................................................................................................86
“Halo Effect” of Perceiving Organizations ........................................................................89
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Promise and Limitations of Consumer Participation .........................................................91
Conclusion: Participating in Solving “Wicked Problems” ................................................92
CHAPTER 4: “CAN-DO” MEDIA? FINDING EFFICACY IN U.S. NEWS EDITORIALS .....94
Introduction ..............................................................................................................................94
Attributing Responsibilities in News Media ............................................................................97
Corporations and Corporate Activity .................................................................................97
Health Promotion and Health Organizations .....................................................................99
Conceptualizing and Operationalizing Efficacy in News Media ...........................................100
Research Questions, Research Design, and Coding Categories ............................................102
Method and Coding Procedures .......................................................................................106
Analysis and Interpretation: Content Analysis ......................................................................110
Analysis and Interpretation: Qualitative Constructions of Efficacy ......................................117
Informational Efficacy .....................................................................................................119
Mobilizing Efficacy .........................................................................................................122
Consumers and Citizens: All Together Now ...................................................................125
Not Critical Enough: The Limitations of Editorial Worldviews .....................................126
Discussion and Conclusion ....................................................................................................130
Editorializing Efficacy: Effects beyond the Newsroom ..................................................131
Limitations and Directions for Future Research ..............................................................132
Concluding Remarks: Taming “Wicked Problems”? ......................................................136
CHAPTER 5: DISCUSSION and CONCLUSION .....................................................................138
Implications for Efficacy-Oriented Research and Practice ....................................................138
Addressing Timeless and Timely Challenges across Academic Fields ...........................145
An Epilogue, and Prologue, Too: A Transitional Moment in U.S. History ..........................150
REFERENCES ............................................................................................................................155
APPENDIX A: GAIN- AND LOSS-FRAMED ORGANIZATIONAL APPEALS ...................205
APPENDIX B: EFFICACY VARIATIONS ...............................................................................207
APPENDIX C: NEWSPAPER CLASSIFICATION ...................................................................210
APPENDIX D: INSTITUTIONAL AFFILIATION OF EDITORIAL AUTHORS ...................214

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LIST OF TABLES
Table 1. Mediation Regression Analysis (for Donation Intentions, DI) ........................................43
Table 2. Definition of Different Conceptualizations of Efficacy ..................................................60
Table 3. Definitions of Internal, External, and Response Efficacy ...............................................63
Table 4. ANOVA for all Dependent Variables ..............................................................................76
Table 5. Estimated Means from 2 by 2 ANOVA ...........................................................................77
Table 6. Distribution of Interpretive Codes - Entire Sample and by Newspaper Type ...............112

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TABLE OF FIGURES
Figure 1. Mean Organizational Credibility and Perceived Efficacy by Message Frame ...............45
Figure 2. Final Mediation Model ...................................................................................................46
Figure 3. Mediation Model (PE-Organization as Dependent Variable) ........................................46
Figure 4. Mediation Model (PE-Self as Dependent Variable) .......................................................47
Figure 5. Estimated Mean and Statistical Significance for Efficacy Measures .............................78
Figure 6. Estimated Mean and Statistical Significance for Discrete Emotion Measures ..............79
Figure 7. Interaction between Valence and Organization on External Efficacy ............................80
Figure 8. Publication Year Distribution .......................................................................................111
Figure 9. Breakdown by Author’s Institutional Affiliation .........................................................111

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ABSTRACT
In the U.S. in 2020, there are clearly more problems than there are answers. In the midst
of a pandemic, when everything appears out of control, people crave solutions. And the problems
that come with a pandemic, such as high unemployment, are intensified because health insurance
and other benefits are frequently connected to a person’s job. Long-standing problems such as
high prescription drug prices quickly become even more salient and pervasive, as they adversely
affect millions of American patients trying to navigate unemployment rules and other systems. A
combination of company- and industry-level practices, enabled by regulatory, economic, and
science policy profoundly influenced by market-oriented neoliberalism, has entrenched and
made practically intractable – some would say wicked or complex – the crushing costs of
prescription drugs.
What, if anything, can be done? It is in this context that I examine efficacy from both
quantitative and qualitative angles. Efficacy is the belief that a positive difference can be made
through tangible action, and it is a critical component of problem-solving at the individual,
group, and especially societal-level (Bandura, 1997). Across three interconnected empirical
chapters (Chapters 2, 3, and 4), I examine multiple variations of efficacy both quantitatively and
qualitatively. For the two quantitative chapters – Chapter 2 and Chapter 3 – I used a fictional
organization called “Civic Med” for the stimuli in experiments designed to test different efficacy
in different communicative circumstances. Civic Med is a drug manufacturer committed to
producing generic prescription drugs and selling them at below-market prices. It was inspired by
recently-founded U.S. non-profit organizations (e.g., Fair Access Medicines, Civica Rx) that are
performing a highly similar function.
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In Chapter 2, I compared gain- and loss-framed organizational appeals to see whether
there were differential effects on perceptions of credibility and expected impact (or efficacy) of
Civic Med. Testing these messages among participants recruited from Amazon Mechanical Turk,
I found that overall, the gain-framed appeal was successful in eliciting higher perceptions of
Civic Med’s credibility and efficacy. Credibility consisted of trust and motive, while perceptions
of efficacy were found to differ depending on the whether the stimulus was oriented toward the
organization or self. Both variations of efficacy of credibility were meaningfully enhanced;
however, the gain-framed appeal increased only one type of efficacy perception (organization).
Mediational analyses showed that assessments of motive positively mediated the effect of the
gain-framed message on the perceived efficacy of organizations, but not for self-efficacy. Trust,
however, did not play a mediating role.
Chapter 3 also investigated efficacy perceptions as outcomes of interest. Here, however,
variations of efficacy information were included in the experimental stimulus. And the context
for the stimulus for this study had to do with consumer participation in the decision-making of
Civic Med. Participatory efficacy in Civic Med was characterized as either high (i.e., more
effective) or low (i.e., less effective). Additionally, Civic Med was categorized as either a for-
profit company or a non-profit organization. In a 2 (efficacy valence: low vs. high) by 2
(organization type: for-profit vs. non-profit) experiment run on the Qualtrics platform,
multivariate and univariate tests showed that exposure to the high-efficacy information increased
three different efficacy outcomes – internal, external, and marketplace influence. Several
emotional responses, operationalized as discrete emotions (Nabi, 2003), were also affected;
viewing high-efficacy information led to enhanced hope, whereas viewing low-efficacy
information resulted in higher levels of sadness and anger. While variations to organizational
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type did not significantly influence any of the efficacy or emotion outcomes on their own, there
was one interaction between the two experimental conditions; reading about highly efficacious
consumer participation led to higher evaluations of external efficacy, but only within the for-
profit condition. Follow-up mediation analyses also showed that of the discrete emotions, hope
consistently and robustly mediated the effect of variations to efficacy information on internal
efficacy and marketplace influence efficacy.
Chapter 4 approached efficacy from a mixed-methods perspective, via content analysis
and follow-up inductive frame analysis. In the context of U.S. newspaper editorials published
between 2015 and 2019, content analyses identified that slightly under half of these editorials
included some reference to the efficacy of either ordinary citizens or institutions. The results also
unsurprisingly attributed responsibility for high prescription drug prices to the pharmaceutical
industry, along with attributing to legislative and policy actors the responsibility to solve this
problem. And while there were still references to market competition as a viable solution, it was
rarely mentioned on its own, but rather was invoked alongside the need for active legislative and
policy. A few differences were observed in coverage across national and regional newspapers—
regional newspapers were marginally more likely to discuss the efficacy of individual citizens
and members of the public, whereas national newspapers were more likely to discuss market
competition as offering a viable solution. Inductive frame analyses of editorials that referenced
efficacy further revealed two aggregate dimensions of efficacy – information and mobilization.
Both information- and mobilization-oriented efficacy were found to reveal deeper assumptions
about the role of transparency in engaging citizens.
Together, the chapters and studies that constitute this dissertation offer profound insights
for optimal strategic communication approaches that can be taken up by policy makers, citizens
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and organizations such as healthcare start-ups with a social purpose. Participatory decision-
making, especially when it involves external stakeholders such as consumers, may also be an
innovative approach for such organizations, not only in healthcare but also in other sectors. The
role of both national and local media is also highly important in covering innovative cases of
positive social change and the agents that are driving these initiatives. These agents encompass
institutions and organizations as well as individual citizens and consumers. Thus, perceptions of
efficacy relevant to all of these actors are critically important, and deserve to be continuously
observed and studied.

1
CHAPTER 1: INTRODUCTION
Within the discipline of communication, scholars concern themselves with the impact of
messages about social issues that are produced by a diverse array of organizations and
individuals alike. The creation, dissemination, and circulation of these messages is also
inextricably linked to broader political economic structures (McChesney, 2008). Policy
decisions, be they at the local, municipal, state, or local levels, shape the very definition and
practice of political economy; furthermore, such decisions are also responses to developments in
macro- and micro-level economics, as well as those within and across sectors, industries, and
individual firms. Such developments and decisions are embedded within the framework of
political economy, contra the neoclassical perspective that they operate in a sphere outside of it
(Stilwell, 2019).
The pharmaceutical industry is no exception to the observation that economic sectors and
industries operate within, and simultaneously reproduce, the structures of political economy.
After all, it is true that governmental policies concerning scientific innovation and competition
have profoundly influenced the institutional responses of pharmaceutical companies (Comanor,
1986). By many accounts, the U.S. pharmaceutical industry has considerable economic and
political clout. The industry as a whole enjoys the highest profit margins across all industries.
According to the General Accounting Office (GAO)’s analysis of 2006-2015 data, the largest
twenty-five pharmaceutical companies reporting profit margins of over 20% (with similar figures
reported by the largest twenty-five software companies); this is almost triple the figure for
companies that are not in the pharmaceutical, biotechnology, and software sectors (Wolitz,
2018). Such high profit margins are made possible in part due to so-called “blockbusters,” or a
drug for which its owner has a patent and can charge high prices, with many patients having to

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use it for a long time (Castellblanch, 2012, p. 3). The industry also has a longstanding, well-
documented history of lobbying, with the average annual amount of lobbying exceeding $240
million over a ten-year period between 2009 and 2019; additionally, in 2016 alone, $63.7 million
was spent as contributions to political campaigns (Center for Responsive Politics, 2019). These
for-profit pharmaceutical companies are commonly referred to as “Big Pharma”, and their
considerable influence can be traced back to the 1940s, in the aftermath of the Second World
War.
The influence of Big Pharma can be traced broadly to two factors. First, as part of an
effort to promote the production, research and development of essential medicines, the U.S.
Patent Office in 1948 began to allow domestic drugmakers to patent medicines for private profit;
over the subsequent years, patents allowed for companies to continue charging high, oligopolistic
prices (Castellblanch, 2012, p. 10). Second, prescribing drugs became legally required in the
postwar era; this had the effect of giving the medical profession a crucial, mediating role
between manufacturers and the U.S. government. Prescription itself became a tool by which the
drug industry and medical professionals, acting in alliance, constrained the reach and impact of
federal regulatory powers (Rasmussen, 2017). It is a documented fact that pharmaceutical
companies have a considerable presence in Capitol Hill (Downes, Supa, & Austin, 2017), with
the practice of ‘drug detailing’, i.e., direct visits by pharmaceutical firm representatives to
doctors that often entail the provision of free lunches and other ‘benefits’ from the former to the
latter (Guardino & Snyder, 2017).
These extensive ties between the pharmaceutical industry, political institutions, and the
medical profession have been critically analyzed by scholars across multiple disciplines; some
have even claimed that substantive parts of the U.S. government bureaucracy - most notably the

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Food and Drug Administration (FDA) - have been ‘colonized’ by the pharmaceutical firms and
medical profession (Boggs, 2015). Private pharmaceutical companies have become major sites
for decision-making about public health, ranging from not only pharmaceutical development and
distribution but also resource use, economic development, and employment standards (Zoller,
2017, p. 219). Consumers and patients have also been deeply influenced by this pervasive power
of the U.S. pharmaceutical industry. The industry has long played a key role in keeping the price
of many drugs high (particularly critical ones necessary for saving lives), enabled by the distinct
non- or minimalist-regulation of drug prices in the U.S., a pattern not observed elsewhere
(Boggs, 2015, p. 141). In real terms, drug prices increased sevenfold between 1981 and 2016
(Guardino & Snyder, 2017), with this trend also contributing to the generation of such high
profits. The current status quo with respect to both high drug prices and profits hinges on
minimal regulation of prescription drug price inflation, while simultaneously maximizing access
for those who do not have the financial ability to pay not a priority for drugmakers
(Castellblanch, 2012, p. 4).
A series of policy decisions over a roughly seventy-year period in U.S. history shaped the
current state of affairs. How the U.S. pharmaceutical industry came to possess and exercise such
pervasive and structural power may be partly explained by two related yet different concepts:
unanticipated and unintended consequences. Sociologist Robert Merton (1936) was primarily
interested in investigating the unanticipated consequences of “formally organized” action, but
not so much with those of “individuals considered distributively”; he argued the former afforded
a “better opportunity for sociological analysis” because “the very process of formal organization
ordinarily involves an explicit statement of purpose and procedure” (p. 896). Another
sociologist, Anthony Giddens, defines unintended consequences as “consequences which result

4
from behavior initiated for other purposes” (1993, p. 765); de Zwart (2015) explains that
Giddens (1976) clearly differentiates between unintended and unanticipated consequences, while
also commenting that many scholars tend to conflate the two. It is not of interest to the present
dissertation to wade into this debate, other than to acknowledge that the difference is a
substantive one. It can be argued, however, that American policies concerning the
pharmaceutical industry in the postwar era did not explicitly intend to bring about such an all-
powerful pharmaceutical industry (P. Riley, personal communication, October 7, 2019).
Furthermore, more recent policy initiatives such more aimed at controlling drug prices (e.g.,
formularies), have been found to invite such unintended consequences (Schweitzer & Lu, 2018).
Theoretical Framework: Efficacy and “Wicked Problems”
Indeed, it is possible for larger-scale legislative, policy, institutional, and organizational
actions to have unintended (if not wholly unanticipated per se) consequences; this observation
allows scholars to then inquire about the range of possible intentions, behaviors, and outcomes
on the part of stakeholders - be they individuals, public officials, or non-profit organizations -
who genuinely are motivated to offer some type of feasible solution(s). Such an inquiry into what
is perceived to be possible, in turn, benefits from a deep engagement with the concept of
efficacy. First conceptualized by social psychologist Alfred Bandura in 1977, having
expectations about efficacy refers to having “conviction that one can successfully execute the
behavior required to produce a given outcome” (p. 193). He differentiates it from expectations
about outcome, insofar as outcome expectancy is “defined as a person’s estimate that a given
behavior will lead to certain outcomes” (Bandura, 1977, p. 193). Bandura had specifically
conceptualized efficacy as self-efficacy, pertaining to expectations about changing one’s one
behavior; a multitude of scholars have operationalized, manipulated, or measured self-efficacy

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within contexts of health-related behavioral interventions to either encourage individuals to take
up healthier habits (e.g., eating fruits and vegetables) or discontinue unhealthy ones (e.g.,
smoking or eating fatty foods).
As subsequent scholarship has demonstrated, however, the ramifications of efficacy go
beyond the individual domain. Efficacy meaningfully influences attitudes, intentions, behaviors,
and learning outcomes with respect to contexts other than health (May, Luth, & Schwoerer,
2014, p. 69). Efficacy has been explored and conceptualized also in terms of morality, as it fills
the gap between possessing sound moral judgment and moral ownership on the one hand, and
actually taking moral action on the other (Hannah, Avolio, & May, 2011, pp. 675-676). In
situations where individuals are faced with moral or ethical dilemmas - e.g., one extreme
example being the classic “Trolley Problem”, although real-life situations rarely involve such
extreme choices - such moral efficacy is likely to be a much-needed cognitive and emotional
resource.
Even in the absence of such clear-cut extreme choices, there still exists a myriad of
“complex social problems for which there may be no ‘directly-traceable’ causes” (Ferraro,
Etzioni, & Gehman, 2015; Gioia, 1992, cited in Reinecke & Ansari, 2016, p. 302). C. West
Churchman, a philosopher and systems scientist, first conceptualized the term ‘wicked problems’
as a set of system-wide problems that are “ill-formulated”, with multiple clients and
decisionmakers who have conflicting values; furthermore, the ramifications for the system as a
whole tend to be “thoroughly confusing” (1967, p. 141). Churchman then proceeds to explain
that “the adjective ‘wicked’ is supposed to describe the mischievous and even evil quality of
these problems, where proposed ‘solutions’ often turn out to be worse than the symptoms”
(1967, p. 141). When engaging with such wicked problems, multiple moral and ethical concerns

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exist; yet actual solutions can only address some of them. Often finding themselves in such
imperfect situations, individuals will have to call on multiple forms of efficacy. These forms of
efficacy include, but are not limited to, efficacy in the moral and ethical dimensions, even as it
can be assumed that morality and ethics do not constitute a separate, siloed domain within
people’s decision-making processes). Efficacy can be a resource that individuals use to critically
appraise both social problems and solutions to these problems, acknowledging the complexity of
both problem(s) and solutions while not losing the will to make a meaningful difference.
High prescription drug prices can also be understood as a ‘wicked’ problem for which
such a sustained sense of efficacy based on both current and future efforts is needed. The
pharmaceutical industry, specifically the profit-seeking motivations of the industry, is the
underlying cause of high prescription drug prices (Quigley, 2017). Government policies have
further exacerbated this problem, with the lack of drug price restraints in Medicare a feature that
pharmaceutical companies have fully taken advantage of to their own benefit (Quigley, 2017).
Insurance companies and pharmacy benefit managers (PBM)s also are responsible, even as they
are also directly impacted by the actions of pharmaceutical companies. Americans have borne
the brunt of rapidly-rising health insurance premiums and deductibles, a direct result of
prescription drug price hikes (Quigley, 2017). PBMs work for insurance companies to administer
the prescription drug portion of a health insurance plan, and their role is to ensure that patients
have access to new drug therapies while also keeping in check spending for insurance companies
or employers. While PBMs do keep drug prices in check, they receive sizeable rebates from
pharmaceutical manufacturers, and as a result the retail price of prescription drugs found at
pharmacies frequently does not reflect the actual market price (Quigley, 2017; Schulman, 2019).

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As far as the causes of high prescription drug prices are concerned, multiple ‘moving
parts’ have so far been identified. In this vein, a slight departure from Reinecke and Ansari
(2016)’s definition of “wicked problems” as not having a single, traceable cause is called for; a
more useful framework is a classification of “complex” problems (Alcott & Head, 2017) that
provides further granularity to “wicked problems.” The authors identify a problem scenario
where “the nature and causes of the problem may be known, but the solution is not – and indeed,
it is difficult to find a sound solution owing to analytical or political complexities”; this scenario
belongs to an intermediate level of “wickedness,” less wicked than that in which neither the
problem nor possible solutions are known to stakeholders, but more wicked than that where both
the problem and solutions are clear (Alcott & Head, 2017, p. 403). The inherent complexity of a
problem depends on the presence of contradictions/dilemmas, as well as the degree to which the
remedies themselves can also lead to further problems (Alcott & Head, 2017, p. 406).
The problem of high prescription drugs, by these two dimensions, can be appropriately
conceptualized as a “wicked” or “complex” problem. First, it may be the case that more
Republicans have come to embrace the need for a more activist regulation of prescription drug
prices, with a spate of legislation mandating more stringent government regulation of drug
pricing and drug access passing with bipartisan support. However, there is still a high level of
disagreement between Republicans and Democrats on the feasibility and effectiveness of
solutions, e.g., the importation of prescription drugs from Canada (Jaffe, 2019). Furthermore,
Republicans and even a considerable number of moderate-leaning Democrats have long
expressed hostility to, or at least serious reservations about, Medicare-for-All (i.e., single-payer
universal healthcare). Thus, to the extent that there is consensus, there is considerably less of it
with respect to what are deemed as necessary and desirable policy solutions than with what is

8
arguably a narrowly-defined delineation of the problem (i.e., prescription drug costs and
inadequate access to affordable drugs). Dissonant ideas about solutions to wicked problems can
range from radicalism to tokenism (McConnell, 2018); policy and institutional responses in the
U.S. context can also be seen in this light, insofar as debates about whether to regulate
prescription drug prices through the Affordable Care Act (ACA) or Medicare-for-All also
contain within them different degrees of alignment with tokenism or radicalism.
This is not to take away from the promising policy developments at the federal and state
level with respect to regulating the actions of the pharmaceutical and health insurance industries,
as well as those of PBMs (discussed in more detail in the subsequent chapters of this
dissertation). At the same time, the pharmaceutical industry has not “gone gently into the night”
but rather has been actively seeking to minimize the regulatory impact of such initiatives (Jaffe,
2019). This broader, structural analysis is not incompatible with the acknowledgment that
individual chief executives of pharmaceutical companies may very well have a healthy respect
for the social responsibility of pharmaceutical companies; such intentions, furthermore, can and
do translate to actual positive social impact on the ground at a given point in time, within the
situational context of a single project or initiative. Engaging with such complexities without
embarking on an ‘easier’ cognitive and emotional decision-making pathway that leads to simply
accepting that “bad apples exist everywhere” and supporting a system-justifying worldview
(Jost, Banaji, & Nosek, 2004; Jolley, Douglas, & Sutton, 2018) is a necessary responsibility, yet
a difficult one to carry out fully with full, unwavering commitment.
It is precisely because of these inherent difficulties, however, that the challenge of
maintaining and enhancing efficacy is a worthy endeavor. Furthermore, such perceptions and
feelings of efficacy can be translated into positive action, either individually or collectively, even

9
with the awareness that the consequences of such actions cannot be wholly anticipated, and may
also come to at least partially undo the ‘good’ created through the initial positive action. Yet, in
reality, a fuller understanding about the possibility that events ‘could go wrong’ in the near or
even distant future often diminishes a sense of efficacy in the here and now. Even if efficacy
itself is not diminished, the probability that it will be actively translated to tangible action
becomes diminished. There is certainly no panacea to this dilemma; yet, just because there is no
panacea does not mean that rigorous, committed research is not feasible. For these reasons, this
dissertation specifically focuses on understanding and applying different definitions of efficacy,
with respect to the present problem of high drug prices and structural enablers and constraints
that perpetuate this problem.
As explained in detail earlier in the Abstract, the questions addressed by this dissertation
are how 1) how different variations of messages about social impact-driven pharmaceutical
manufacturers elicit different levels of civic and consumer engagement, revolving around
perceptions of consumer and organizational efficacy; and 2) the patterns of U.S. news media
coverage of citizen-, consumer-, and institutional-efficacy about engaging with, and solving, the
problem of high prescription drug prices. The epistemological approach on efficacy has been
developed based on a wide array of scholarship on efficacy, drawing upon scholarship that
conceptualizes it as a precondition for intrapersonal behavior change (e.g., health-related) as well
as scholarship that sees it as a perceptual link to meaningful action that can change broader
interpersonal, collective, and societal outcomes. It is the latter stand of scholarship with which
the studies in this dissertation identify most closely; much inspiration has been drawn from
scholars who have found meaningful differences (in not just the statistical sense of the word)
concerning perceptions of civic, economic, and political efficacy with respect to changing the

10
behavior of external actors and actants (e.g., policy, government action, industries) on critical
issues such as climate change (Feldman & Hart, 2016; Hart & Feldman, 2016; Feldman, Hart,
Leiserowitz, Maibach et al., 2017) and ethical marketplace behavior by companies (Leary, Vann,
& Mittelstaedt, 2019).
These streams of scholarship have been integrated in a problem domain - the U.S.
pharmaceutical industry, high drug prices, and social impact-driven organizations in this sector -
that has not yet been investigated from an efficacy-centered methodological and theoretical
perspective. Researchers in communication, political science, and organizational psychology
have demonstrated the linkages between citizens’ political efficacy and political participation
(e.g., Finkel, 1985; Vechionne & Caprara, 2009), consumer efficacy in response to products and
services offered by socially-conscious companies (e.g., Becker-Olsen, Cudmore, & Hill, 2006;
Lee, Haley, & Yang, 2019; Kim, Youn, & Lee, 2019), as well as employees’ sense of efficacy in
the workplace and its influence on employee well-being and organizational innovation (e.g.,
Hussain, Lei, Akram, Haider et al., 2018; Ozyilmaz, Erdogan & Karaeminogullari, 2018).
However, relatively less is known about whether including and varying information about
efficacy about direct participation in organizational decision-making influences perceptual
efficacy and other attitudinal and behavioral measures. The three main studies of this dissertation
will provide theoretical and methodological insights about efficacy as it shapes participation and
civic engagement in the context of broader U.S. public opinion about drug prices, the
pharmaceutical industry, and the possibilities of meaningful change initiated by socially-
conscious, innovative organizations in this sector.

11
Broader Health, Regulatory, and Business Environments
For the investigation of efficacy as a factor that shapes knowledge, perceptions, and
engagement with the problem of drug prices and the pharmaceutical industry, it is necessary to
understand the broader structural underpinnings of healthcare in the United States. According to
Boggs (2015), ever since the end of the Second World War, American society has been operating
within the ‘medical model’ of healthcare; this refers to a set of interlinked structures, institutions,
and practices in which there is a pronounced emphasis on medication, high-tech procedures, and
surgery, and relatively less focus on providing and supporting preventive, holistic, nutrition-
based alternatives. This healthcare model lent itself to the perpetuation of high prices of
prescription drugs, not only because of FDA regulations and policies that enable oligopolistic
practices on the part of pharmaceutical firms (i.e., granting patents for drugs), but also because
patients themselves habitually consume medicine for long periods of time (Castellblanch, 2012,
p. 10). What also has to be accounted for is the fact that American consumers, patients, and
physicians alike have access to generic versions of such prescription drugs.
What, then, are generic drugs? Generic drugs refer to those that are “chemically
equivalent to brand-name medications,” i.e., containing the same active ingredients as the
original, but are sold at a lower price. Just as their brand-name counterparts, generic drugs are
also subject to regulations that govern medication safety (Hayden, 2007). Nonetheless, there is
considerable subjectivity and complexity with respect to the specific criteria used to define, and
satisfy the conditions for, a drug to be a generic one. The case of generic Chloromycetin, which
had passed the test of chemical equivalence but nevertheless had different physical effects on the
human body, prompted the FDA to pull the generic version from the market and institute a new
proof of biological equivalence in the late 1960s (Greene, 2014). The case was not settled back

12
then; throughout the 1970s and 1980s, and even to this day, there are ongoing debates about the
level of rigor required to define and apply both chemical and biological equivalence, as well as
over which actor (i.e., manufacturer, regulatory authorities, insurance companies, prescribing
doctor, or consumer) ought to have the final, authoritative say in determining and applying
relevant criteria for equivalence (Greene, 2014).
This ongoing contestation reflects different perspectives about the point of contact
between different forms of equivalence (i.e., chemical, biological, and industrial) and the logic of
exchangeability, which has to do with defining the commodity in relation to the market; generic
medicine is both unbranded (vis-a-vis branded medicine) yet also rebranded (particular generic
products are differentiated amongst themselves, with respect also to profitability concerns of
generic medicine manufacturers themselves) (Greene, 2014, pp. 15-16). Another complicating
factor is that the distinction between branded and generic manufacturers has shown to be blurred
from time to time; historically, there have been U.S. pharmaceutical companies that produced
both generic and branded medicine (Greene, 2014). An inquiry into the organizational form and
orientation of generic manufacturers also tells a similar story. Many well-known generic
medicine manufacturers, such as Teva Pharmaceutical Industries (Israel), are for-profit entities,
constrained just like their Big Pharma counterparts by capitalist market conditions and forces
(Semigran, 2012).
Having provided an account of the complex political, economic, and technological
narrative surround generic drugs, this dissertation now turns to how the usage and perceptions of
generic drug can be situated within both macro-level economic supply and demand frameworks
and micro-level prescription and consumer patterns on the part of physicians and consumers,
respectively. Physicians either prescribe cheaper generic or more expensive, branded prescription

13
drugs; not surprisingly, such prescription choices are not random outcomes, but rather can be
attributed to broader systemic factors. Melamed and Rzhetsky (2018) have claimed that
differences in such choices, and the result differences in the drugs prescribed to patients, are
rooted in county-level wealth differences, state-level health care laws, and racial disparities.
Individual patients themselves have demonstrated less trust in generic drugs than in
branded prescription drugs; this tendency has been evident among patients who do not identify
themselves as Caucasian, as well as those who report lower socioeconomic status (Kesselheim et
al., 2016). Howard, Harris, Frank, Kiptanui et al (2018) identified several factors that influenced
use of generic drugs in the United States, such as patient sociodemographics (e.g., patient
knowledge, race, income, education levels, healthcare coverage); payment and cost control;
healthcare policies; promotional activities (e.g., frequency of communication between
pharmaceutical companies and physicians, availability of co-pay subscription options);
educational initiatives; technology; and physician sociodemographics (e.g., resident experience,
interaction with pharmacists).
Evidence suggests that more American patients are now more comfortable with FDA-
approved generic medicine than in the past (Kesselheim et al., 2016), in part due to educational
initiatives and greater communication among patients and healthcare professionals were seen as
major drivers to the uptake of generic medicines among consumers (Hassali, Shafie, Jamshed,
Ibrahim, & Awaisu, 2009). More frequent use of generic medicine by individual patients, on its
own, may not constitute a ‘worthy’ goal in and of itself (it can arguably be said that better health
conditions across more individuals, which would require less medicine use and less frequent
hospital visits overall, constitute the more desirable goal!). Rather, it would be considerably
more convincing to argue that expanded access to generic medicine, which are relatively

14
inexpensive but functionally equivalent compared to their branded counterparts, constitutes one
channel towards the pursuit of equity and social justice goals. This is aligned with the empirical
and normative goals pursued by researchers who endeavor to identify cognitive, emotional, and
behavioral interventions that fundamentally reduce health disparities perpetuated by structural,
social determinants (Major, 2018; Skurka, 2019).
At a system and structural level, the greater availability of generic drugs help healthcare
systems avoid drug shortages, and indirectly can benefit research and development (R & D)
across the board, of not only generic drug producers but also originator companies (i.e., brand-
name drug companies) (Dylst, Vulto, & Simoens, 2015). For individual consumers and patients,
generic medicines offer cost-saving potential - as much as by 95% for some medications - by
way of reduced prices; greater availability of such medicine also means a higher likelihood of
medication adherence (Dylst et al., 2015). In so doing, generic medicines can offer individual-
level solutions to patients whose decision-making choices and latitude are inexorably shaped by
structural inequalities. At the same time, the availability of such medicines to individual patients
hinges on organizational, institutional, and structural factors that shape the supply of generic
medicines. A plethora of legal and regulatory regimes also shape not only the supply of, but also
the scientific definition(s) and policy implications of generic medicine. The production,
regulation, and policy impact of pharmaceuticals also are mediated by, and situated in, intra- and
inter-national inequality patterns (Quet, 2018). The scientific effects of pharmaceuticals do not
exist in a vacuum, but rather are shaped (in some cases exaggerated, in other cases downplayed)
by not just commercial interests, but also social norms and moral concerns (Hardon & Sanabria,
2017).

15
As indicated earlier in this chapter, the issue of prescription drug production, availability
and access thus constitutes a “wicked” or “complex” problem. This dissertation focuses
predominantly on the American context, investigating American residents’ efficacy responses to
experimental stimuli (Chapters 2 and 3) and American news media editorials’ framing of
efficacy (Chapter 4). Thus, the bulk of the Introduction (Chapter 1) was focused on providing a
detailed overview of the American context. The subsequent sections, however, will also do
justice to the global influence and repercussions of the pharmaceutical industry.
Crossing Borders: Generic Drugs, the Pharmaceutical Industry, and Regulatory Regimes
There exists a myriad of instances where global pharmaceutical companies have
prioritized profit over health. For instance, these companies have been accused of not doing
enough for HIV/AIDS treatment. GlaxoSmithKline (GSK), Pfizer, and Gilead have been sued by
HIV/AIDS (most notably Michael Weinstein, who has been controversial for going against the
medical consensus that individuals at high risk of HIV ought to take the PrEP drug for
preventing HIV). Weinstein’s non-profit organization, AIDS Healthcare Foundation, was also
one of the key drivers behind the unsuccessful push for Proposition 61 in California, which
would have prohibited state agencies from buying any prescription drug from a drug
manufacturer at any price over the lowest price paid for the same drug by the U.S. Department of
Veterans Affairs (Robbins, 2016).
An added complication, providing another piece of evidence for the ‘wicked problem’
argument, is that while generic drug manufacturers often are separate legal and business entities
from ‘Big Pharma’ companies, they have also been guilty of committing similar ‘sins’ as their
counterparts in the latter category. Generic drug manufacturers in developing countries have also
been mired in controversy; their products have been recalled for posing a high cancer risk to

16
patients, and also were shown to be willingly produced out of adulterated content (Becker,
2019). Such recalls, furthermore, have occurred also in the U.S, as a high proportion of generic
drugs consumed by Americans are manufactured in such lower-income, developing countries;
the FDA’s negligence in inspecting overseas plants of such foreign companies has also come
under intense scrutiny and criticism in 2019 (Eban, 2019).
To reiterate the analysis by Hardon and Sanabria (2017), the therapeutic, societal, and
political effects of generic drugs do not exist in a vacuum, independent of subjective cultural,
political, and economic influences; the willingness of such companies in developing countries to
engage in the production of such faulty medicines cannot be understood properly without also
accounting for the policy paradigms within those countries. In not only India (where the recent
controversies about unsafe generic drugs consumed by American consumers originated from),
but also other countries such as Mexico, Russia and Israel, policymakers viewed the goal of
increasing the production of generic drugs as a priority for national development; such
policymakers frequently framed this policy pursuit as support for strengthening domestic,
national economic capacity as a counterweight to European and American multinational
pharmaceutical companies (Hayden, Callon, Ecks, Pagán et al., 2007). Regulatory authorities
across the developing world have not been passive victims; on multiple occasions, they have
been able to reject Big Pharma patent claims in their jurisdictions) (Bonadio, 2015). At multiple
points in history, U.S. policymakers and pharmaceutical companies have sought to push back
against such efforts at economic nationalism. As early as 2000, the U.S. government filed a
World Trade Organization (WTO) claim against the Brazilian generic pharmaceutical industry,
accusing it of unfairly undercutting the price of antiretroviral (ARV) AIDS medication (the claim
was later dropped) (Hira, 2009).

17
Therefore, a certain narrative of “Third-World generic manufacturers vs. First-World Big
Pharma” can be identified. There are historical and contemporary accounts to support this
narrative, including but not limited to the evidence offered in this chapter. However, an even
closer inspection reveals that the boundaries between the two categories of drug manufacturers
are blurrier than they seem. Purdue Pharmaceutical, for instance, had illicitly owned Rhodes
Pharma, a producer of generic opioids (Crow, 2018). At a structural level, a less expensive
generic medicine can be manufactured only if there is a branded version of it in place, with the
patent for the latter having already expired; in a sense, then, the generic drugs industry is thus
reliant on Big Pharma. And with respect to the much-maligned ‘Big Pharma’, there is also more
than meets the eye, thus providing yet more difficulties for informed citizens to conceptualize
and put into practice workable solutions.
Large, globalized pharmaceutical companies do engage in acts of social responsibility.
Since 2008, an independent initiative called Access to Medicines Index has been ranking the top
20 global pharmaceutical companies every year, using the following criteria: general access to
medicine; influence on public policy & marketplace behavior; pricing, manufacturing &
distribution; patents and licensing; capability advancement in product development &
distribution; and product donations and philanthropic activities (Hogerzeil, 2013, p. 897). In
recent years, two companies in this Index - GlaxoSmithKline (GSK) and Gilead - have made
concessions on Hepatitis C treatments, so that patients would have access to less expensive
versions of the treatments. These very concessions, however, were notable also for their
selectiveness and conditionality (e.g., licensing agreements that authorize such concessions are
applied only to low-income countries, not middle-income ones) (Bonadio, 2015; Quet, 2018).
The interactions among national and global regimes of pharmaceutical regulation, ‘Big Pharma’

18
and generic drug manufacturers, and mobilized patients and their representatives (e.g., consumer
associations) offer a rich landscape for identifying, and strengthening, various types of efficacy
perceptions; this is so because of a multitude of wicked problems, unintended and unanticipated
consequences that cause, exist within, and are produced by such interactions.
Why Media, Communication, and Organizations Matter
For a certain system to be maintained and sustained, it relies on multiple institutions and
organizations that (re-) produce certain ideological worldviews, via discourse and action. A
critical factor that perpetuates the hold of the ‘medical model’ in not only the U.S. but also in
many other parts of the world that operate in a capitalist system is news media, specifically but
not limited to advertising and commercials. Media images about well-being and health are
circulated around the world; those of massive health ‘crises’ (e.g., AIDS, tuberculosis, etc.)
heighten people’s fears, whereas advertisements on news and digital media explicitly celebrate
the role of pharmaceutical companies, as they are the ones that provide the latest blockbuster
drug for a range of illnesses (Petryna & Kleinman, 2006, p. 1). The media thus has played an
important role in perpetuating and expanding individuals’ reliance on pharmaceuticals, and, at
least in the U.S., likely has also abetted the high prices of drugs maintained by the
pharmaceutical industry.
Scholars have demonstrated that advertising campaigns, notably Direct-to-Consumer
(DTC) advertising in the U.S., have considerably succeeded in neutralizing “public awareness
and outrage over price gouging [on the part of pharmaceutical corporations]” (Boggs, 2015, p.
141). The decision by the Food and Drug Administration (FDA) to relax the requirement that
drug companies and advertising companies explicitly include information about risks associated
with a given drug in 1997 led to an exponential increase in the number of DTC advertisements in

19
the popular media (Hartley & Lou-Coleman, 2007; Parekh & Shrank, 2018). Analyses of U.S.
news media coverage of DTC advertisements have suggested an outsize (and excessive)
influence played by the pharmaceutical industry in shaping favorable media coverage, reflecting
also changes in relationships among relevant stakeholders (i.e., increased power of
pharmaceutical industry vis-a-vis consumers, government, and healthcare providers) (Coleman,
Hartley, & Kennamer, 2006; Hartley & Lou-Coleman, 2007).
Experimental and survey research has identified perceptions of drug advertisements in
the American context (Kim & Park, 2010; Ju & Park, 2013; Chung, Berger, & DeCoster, 2016);
the assumptions underlying their research were rooted in media environments that encouraged
continued individualized consumption of drugs, above other alternative possibilities, be they
alternative treatments (e.g., preventive therapies) or a much more public health-oriented
approach to health and illnesses. These media environments have also been intimately shaped by
the regulatory latitude accorded to pharmaceutical companies’ DTC advertising, often via
popular media (Ventola, 2011). Such constraints, however, have not meant pervasive passivity
on the part of citizens and organizations. Indeed, activist and legislative initiatives have
succeeded in containing the price of prescription drugs, thereby putting brakes on the influence
of the pharmaceutical industry. Throughout the late 1990s and early 2000s, grassroots activists
won major legislative victories over the Pharmaceutical Research and Manufacturers of
American (PhRMA) in Maine and California (even though a similar effort was defeated in
Vermont) (Castellblanch, 2012). Activism and advocacy have continued into the present decade,
in response to continued price hikes by Big Pharma. In February 2019, a lawsuit was brought
against Purdue Pharmaceutical, based on the allegation that the company engaged in deceptive

20
marketing of Oxycontin and deliberately downplayed its addictive potential (Joseph, 2019); this
lawsuit was made possible largely because of committed activism.
Bringing Organizations (Back) In
The role of organizations in the enactment of such reforms and fundamental challenges to
the status quo cannot be discounted. Committed individuals may engage more robustly in civic
and political action through explicit membership in activist organizations (van Stekelenburg,
Klandermans, & Akkerman, 2016), although others have found little difference between active
and passive membership in voluntary organizations (Wollebæk & Strømsnes, 2008). More
passive, ‘looser’ forms of organizational membership have become more, not less, conducive to
collective actions in part because of the role played by digital technologies (Bennett &
Segerberg, 2012).
How, then, can we define organizations? Organizations can be defined as “a group of
people who coordinate activities to achieve individual and collective goals” (K. Sereno, personal
communication, April 17, 2019). Scholars have distinguished organizations from other similar
yet different concepts, such as institutions (Lammers & Barbour, 2006). Particular
understandings of a specific organization or an organization as a concept tend to be based on
both objective and subjective features; there are also several approaches - i.e., social
constructivism, social identity, and social actor - to understanding how an individual incorporates
such objective and subjective features to form a sense of organizational identity (Haslam,
Cornelissen, & Werner, 2017).
In the field of healthcare more broadly, it goes without saying that many organizations
are currently active; they have varying areas of emphasis and regional reach. For instance, the
World Health Organization (WHO), Center for Disease Control (CDC), and the National

21
Institutes of Health (NIH). Narrowing the scope somewhat to focus only on pharmaceuticals,
prominent players include the Pharmaceutical Research and Manufacturers of America
(PhRMA) and Consumer Healthcare Products Association (CHPA). On the side of consumer and
patient advocacy exists a particular organization type called patient advocacy organizations
(PAO). In the realm of healthcare more broadly, organizations American Cancer Society (ACS),
American Heart Association (AHA), and the National Organization of Rare Disorders fall into
this category. Concerning access to affordable medicine, currently organizations such as Patients
for Affordable Drugs and the Treatment Action Group are key players. These organizations not
only advocate on behalf of patients, but also fund or directly undertake medical and health
research, as well as influencing funding allocation decisions by legislatures and government
agencies (Rose, Highland, Karafa, & Joffe, 2017).
What can be inferred from this organizational landscape is a considerable degree of
symbiosis, not adversarialism. Indeed, over two-thirds of U.S. consumer organizations receive
support from the pharmaceutical industry, with over ten percent of consumer organizations
reporting that over half of their funding comes from industry sources (Fabbri, Swandari, Lau,
Vitry et al., 2019; Rose et al., 2017). In addition to these organizations, there exist also nonprofit
and activism-oriented organizations that are specifically committed to expanding access to
generic medicine by way of advocacy or direct production. In 1999, Médecins Sans Frontières
(MSF) initiated a campaign for increasing the availability of essential medicines (i.e., medicines
that satisfy individuals’ priority health needs, according to the WHO), active to this day; the
Health Global Access Project also operating on a global scale, but specifically for the purpose of
increasing access to antiretroviral medicines for individuals living with the human
immunodeficiency virus (HIV).

22
Organizations such as the Universities Allied for Essential Medicines (UAEM) and
Patients for Affordable Drugs Now commit themselves to raising awareness of high prescription
drug prices, as well as engaging in activism that support lower drug prices and improving
citizens’ access to such lower-priced (yet equally effective) drugs. Recently, in 2018 an
organization called the Alliance to Protect Medical Innovation (APMI) was founded, for the
purpose of giving favorable attention to medical innovations and providing a counterpoint to
what it perceives as the dominant, prevailing discourse that the pharmaceutical industry is largely
responsible for the excessively high price of prescription drugs (King, 2018; O’Connor, 2019). It
appears that APMI places greater emphasis on highlighting the positive aspects of what the
pharmaceutical industry does (e.g., successful medical innovations that save lives), even as it
does not dispute per se the phenomenon of high drug prices; however, it does place the blame on
the pharmacy benefit managers (King, 2018).
On the manufacturing side, the Association for Accessible Medicines (AAM) is
comprised of U.S.-based manufacturers producing the bulk of prescription drugs used by
Americans. Distinct from such for-profit companies, there exist also non-profit organizations
founded to manufacture generic medicine. Founded in 2017, Fair Access Medicines have been
manufacturing affordable versions of insulin for both consumers in the U.S. and other parts of
the world. And in September 2018, several prominent U.S. healthcare systems such as the Mayo
Clinic, Trinity Health, and Providence St. Joseph Health joined forces to form a collaborative
venture called Civica Rx. As of January 2019, 750 U.S. hospitals are participating in this
collaborative venture (Kacik, 2019). In addition to non-profit healthcare providers, Civica Rx is
also a recipient of $30 billion worth of funding from research and philanthropic foundations, i.e.
the Gary and Mary West Foundation, the Peterson Center on Healthcare, and The Laura and

23
John Arnold Foundation (Pulsinelli, 2018). The self-identified purpose of Civica Rx is to bring
14 hospital-administered generic drugs to the market in 2019, most likely via sub-contracting
with an FDA-approved manufacturer (Pulsinelli, 2018; Kacik, 2019).
The mission of organizations such as Fair Access Medicines and Civica Rx arguably
lends itself to a broader social justice agenda (i.e., ensuring adequate, low-cost supplies of
critical drugs for patients), with the likelihood of Civica Rx being a meaningful ‘solution’
contingent at least partly on whether it can produce drugs whose prices remain stubbornly high
even after the expiration of patents, such as cancer and rare diseases (Dusetzina, 2018).
Considering these real-world developments with respect to drug pricing and organizations that
are mobilized to either engage in advocacy or manufacturing, it therefore becomes important to
understand public engagement with a) drug pricing and b) relevant organizations. What acquires
added importance, therefore, is a review of scholarship on organizational messaging, which will
be the focus of the subsequent section.
The Many Shades of Organizational Messaging
How a message is articulated therefore matters, particularly if it is coming from
institutions and organizations for a specific purpose of altering perceptions of a given issue or
increasing support for a given course of action. Organizational appeals or mission statements can
serve as ‘cues’ to readers in a way that changes cognitive and affective perceptions; scholars
have also claimed that the cognitive and communicative dimensions of evaluating organizations
can be situated within institutional theory more broadly (Cornelissen, Durand, Fiss, Lammers &
Vaara, 2017). Scholars housed in the sub-discipline of public relations have sought to analyze the
effects of different messaging within the theoretical context of organizational-public relationship
(OPR). OPR has been categorized as being constituted of professional, personal, and community

24
relationships (Bruning & Ledingham, 1999). Hon and Grunig (1999) identified the following six
dimensions: control mutuality, trust, satisfaction, commitment, communal relationship, and
exchange relationship; later work found that perceptions of satisfaction and control mutuality
most strongly predicted positive attitudes towards a given organization, with such attitudes also
positively mediating supportive behavioral intentions toward the organization (Ki & Hon, 2007).
Across these different approaches, there is arguably a consensus that organizational
messaging plays a key role in eliciting “‘approval from critical publics’ for specific policies or
actions” (Boyd, 2000, pp. 348-349, cited in Barbour, Doshi, & Hernandez, 2016). Specifically
comparing a narrative with a non-narrative version of a Center for Disease Control (CDC)-
produced message about a public health initiative, Barbour and his colleagues (2016) found that
a narrative form elicited more positive assessments of agency reputation. It should not come
across as a surprise that these messages are subjective; the mission statements of health advocacy
organizations have revealed a bias that emphasizes an individual patient’s responsibility to
overcome diseases (e.g., diabetes) (Chaufan & Saliba, 2019; Kirkland & Raphael, 2018).
Fewer studies have specifically investigated generic medicine; the studies that have,
furthermore, have mostly shown mixed results. The attribution of human characteristics generic
drug advertisements did not make a difference to patients’ intention to seek information about,
and switch to, generic drugs; varying the narration style of a given advertisement also failed to
have an impact (Muzumdar, Schommer, Hadsall, & Huh, 2013; Howard et al., 2018). And while
surveys did note the positive influence of the role of media and education in increasing generic
medicine use (Hassali et al., 2009), at least one experiment showed that exposure to educational
videos about generic medicine yielded more positive evaluations, yet the same consumers
actually reported more severe side effects upon a subsequent intake of a generic drug (which was

25
actually a placebo) (Colgan et al., 2016). Pharmaceutical industry insiders and their affiliates
have tried to re-orient the discourse on ‘Bad Pharma’, which they see as judging drug companies
by an excessively high moral standard while neglecting the ‘good’ that they provide in terms of
innovations and news discoveries (Van den Bogaert, Declerq, Christiaens, Jacobs, & Bracke,
2018).
As a counterpoint, the discourse around generic medicines has been framed, at least in
part, as a “critique of the corrupt marketing practices associated with Big Pharma” (Greene,
2014, p. 38). Hassoun (2016) articulated a legal and philosophical justification for consumers to
purchase medicine from drug manufacturers that have an explicit, empirically-supported
commitment to producing and supplying affordable and effective medicine (in some cases,
ideally, being certified by rigorously and widely-accepted standards such as the Global Health
Impact); this acknowledgment of responsibility is also predicated on a recognition that access to
medicine is a fundamental human right, according to international law (Cohen-Kohler, 2007).
Hassoun (2016)’s argument provides further justification for an efficacy-centered approach that
focuses on engaging with organizations that produce generic drugs, as opposed to simply greater
consumption of such drugs.
A holistic investigation of efficacy, as found in media coverage of, and engagement with,
the problem of high drug prices and messages of both non-profit and for-profit organizations
endeavoring to address the said problem also lends itself to insights about broader tensions
between consumerism and citizenship (Barnett, Clarke, Cloke, & Malpass, 2005). Prior research
findings have identified positive associations between socially conscious and responsible
consumption on the one hand, and on the other hand political action or civic participation (Willis
& Schor, 2012; Cho, Keum, & Shah, 2015). Individual and collective action, undertaken as

26
either a consumer or as a citizen, requires belief that the impact of such action is not irrelevant,
but rather is impactful and relevant (otherwise it becomes less likely for a given individual to
take action in the first place). Furthermore, repeated experience of individual and/or collective
action is also likely to enhance that sense of relevance. Support for organizations seeking to
make a positive difference to at least some ‘wicked problems’ is important; to increase the
likelihood of meaningful social change, such support must be undergirded by a strong sense of
efficacy, with respect to both how it is manifested in quantitative and qualitative contexts.
Enhancing individual-level support for such organizations, when aggregated and aligned with a
sense of efficacy, may have positive implications for the pursuit of societal healthcare access and
justice objectives more broadly. The next chapters provide a series of earnest and rigorous
endeavors to achieve these objectives.

27
CHAPTER 2: EFFECT OF GAIN- AND LOSS-FRAMED ORGANIZATIONAL
APPEALS ON PERCEPTIONS OF CREDIBILITY AND EFFICACY
Introduction
In recent years, there has been a considerable, ongoing shift in the extent to which
legislators and policymakers have embraced the possibility that the public sector and government
can, and should, play a more interventionist role in the production of prescription drugs. The key
aim is ensuring access to affordably-priced prescription drugs, which typically are generic
versions of brand-name prescription drugs. One of the key proposals of the Affordable Drug
Manufacturing Act (ADMA), re-introduced by Sen. Elizabeth Warren (D-MA) and
Representative Jan Schakowsky (D-Ill.) in 2019, one year after their initial effort in 2018, is to
authorize public sector manufacturing of generic insulin, an expensive treatment for diabetes
(Rifkin, 2018). In 2020, two legislative bills went into effect, accelerating U.S. Food and Drug
Administration (FDA) approval of generic drugs, and putting further curbs on the pharmaceutical
industry’s practice of blocking lower-cost generic drugs from entering the marketplace (Creenan,
2020). Furthermore, the state of California has embarked on a novel form of policy innovation;
Governor Gavin Newsom recently proposed that the state of California contract with one or more
generic drug manufacturers in order to manufacture specific generic medications (Antrim, 2020).
This turn of legislative and policy interventions, both proposed and actualized, provides
one attempt to solve one chronic problem, or feature, of the U.S. healthcare system – the lack of
availability of affordable prescription drugs. It is also true that, preceding these interventions,
advocacy organizations such as the Association for Affordable Medicine (AAM) and Patients for
Affordable Drugs have been around for a considerably longer time, engaged in advocacy for
greater access to affordable medicine on behalf of American consumers. Moreover, on a global

28
scale, organizations such as the Universities Alliance for Essential Medicine (UAEM) and the
Right to Health Campaign have been particularly active in not just the U.S. but also in
developing, low-income countries. Their focus has been confronting the practices of the global
operations of large pharmaceutical companies (“Big Pharma”), many of whom are headquartered
in the U.S., Japan, and several European countries, in light of the (justified) role played by these
companies in perpetuating health inequalities on a global scale (e.g., because of their focus on
maximizing profits over ensuring access to medicine) (John & Legge, 2011).
More recent entrants to this current organizational landscape have integrated both
advocacy and actual production of medicine into their portfolios. Non-profit organizations such
as the Open Insulin Project, Fair Access Medicines, and Civica Rx (Waters, 2017; Terry, 2018)
fall into this category. They purport to offer meaningful alternatives to both the individual
practice and structural dominance of global, for-profit pharmaceutical companies. Shifts in
public opinion towards even greater mistrust of the motives and behavior of such global
pharmaceutical companies arguably facilitated the development of these organizations (Betz,
2018). It may be possible to give these non-profit organizations the benefit of the doubt, at least
as far as the alignment of their organizational mission with that of more established advocacy
organizations.
Messages originating from organizations matter, with some variations of messaging more
effective than others in bringing about desired outcomes. The mission statement of a given
organization is one demonstration of such organizational communication; it serves as an identity
cue, expressing the ‘personality’ and shaping the reputation of an organization over time (Spear,
2017; Meijer, 2009). A company’s mission statement in which the prosocial element (i.e.,
serving the broader societal good, beyond profit) was emphasized, compared to one that was pro-

29
corporation, elicited higher levels of hypothetical organizational commitment among business
school students (Ersner-Hershfield, Galinsky, Kray, & King, 2010). Similar findings were
identified with respect to evaluations of entrepreneurial pitches; Lee and Huang (2018) found
that a venture whose mission statement included a message about its social impact resulted in
more positive evaluations for ventures led by female founders; the effect of social impact
framing also weakened the influence of negative stereotyping, i.e., perceived incongruity
between women and being an entrepreneur.
Relatively less, however, is known about the influence of variations of organizational
messaging on people’s perception of the impact of their own efforts, as well as those of the
organization in question. The current study builds on the body of research in gain- and loss-
framed messages, situated within prospect theory (Tversky & Kahneman, 1979); furthermore,
the influence of these messages on perceived impact, or perceived efficacy (Bandura, 1977) will
be measured. The aims and findings of the current study also will contribute to research on how
media frames non-profit organizations it is news coverage (Hale, 2007), and the impact of
engagement with news stories about non-profit organizations, as opposed to those about
government agencies or individuals, eliciting different patterns of responsibility attribution
(Sisco, 2012; Bhalla, O’Boyle, & Haun, 2018).
Gain- and Loss-Framed Messaging
Gain- and loss-framed messages each emphasize the positive consequences of an action
and the negative consequences of a lack of action; the desired outcome of both messaging,
however, is the increase in the action itself. The use of this specific messaging variation has been
observed in a variety of contexts. Its use has been documented in health communication research,
for instance with respect to detecting health problems (Rothman & Salovey, 1997; Salovey &

30
Williams-Piehota, 2004; Rothman & Updegraff, 2011), encouraging the intake of fruits and
vegetables (Latimer, Williams-Piehota, Katulak, & Cox et al., 2008) and encouraging healthy
behavior such as flossing (Sherman, Mann, & Updegraff, 2006). This specific framing method
has also been used in conjunction with other types of framing strategies, e.g., thematic/episodic
frames (Major, 2018, 2009) and responsibility attribution (Shah, Kwak, Schmierbach, & Zubric,
2004). Gain-loss frames have also been used to encourage public participation in new
digitization initiatives (Mak & Cho, 2019) or public investments in the environment (Arbuthnott
& Scerbe, 2016).
Such variations in advertisements of prescription drugs have also elicited different
consumer attitudes. In a study on direct-to-consumer (DTC) advertisements of select drugs, Kim
and Park (2010) found that the loss-framed advertisement of a medication improved attitudes
towards the drug, as well as enhancing intentions for information-seeking intentions and actual
drug use; this effect was observed for an emergency contraception medicine, but not an allergy
medicine. For another type of disease - sleeping disorder - a gain-framed advertisement led to
more favorable evaluations of the message (Ju & Park, 2013). Consistent with the findings from
health communication that varied the framing of the illness (rather than the medicine used to
treat the illness), gain- and loss-framed messages about a drug, be they news stories or
advertisements, depends at least in part on what type of illness it treats. Different diseases elicit
different levels of risk appraisals from people, and risk appraisals often significantly interact with
gain- and loss-framed messages so as to change the directionality of the effects of messaging
(Rothman & Salovey, 1997; Salovey & Williams-Piehota, 2004; Rothman & Updegraff, 2011).

31
Organizational Messaging
Several studies have also examined the use of gain- and loss-framed messages in
organizational settings, be they related to health or otherwise. Lewis (2019) identified gain- and
loss-framed messaging as one message variation to consider for effectively implementing
organizational change. While the context for Lewis (2019)’s findings of the relevance of gain-
and loss-framing strategies was arguably with internal stakeholders (i.e., employees of the
organization in question), other findings also show that exposure to a gain- or loss-framed
message on the part of external stakeholders each resulted in different outcomes. Gain- and loss-
framed appeals each elicited highest donation intentions, when coupled with abstract and
anecdotal information, respectively (Das, Kerkhof & Kuiper, 2008). Cao (2016) compared
exposure to each of gain- and loss-framed charitable advertisements of a non-profit organization
(a hospital), and found that individuals who considered themselves easily swayed by
organizational pitches were more likely to respond to the loss-framed appeal for donations, even
though there were no main effects of the messaging condition itself.
Kogen and Dilliplane (2017) adapted prospect theory and gain-loss framing to
manipulate the solvability of malaria as either high or low, finding that cognitive and emotional
pathways each led to high donation intentions to an organization seeking to eradicate malaria.
When reading about an explicitly gain- and loss-framed appeal by an organization seeking to
build water wells in Africa, Bullard and Penner (2017) found that an individual’s regulatory
focus (i.e., promotion- or prevention- focus) also matters: a loss-framed appeal elicited stronger
support for the organization, as well as higher perceived impact of the organization’s work, for
individuals primed with a promotion focus.

32
What is relatively under-explored is the comparison of gain- and loss-framed messages
produced by an organization with a healthcare focus, with the production (as opposed to the
advertisement of) prescription drugs. As indicated earlier in this manuscript, there were several
reasons to contextualize messaging around the provision of generic drugs. Generic drugs are
medications “created to be the same as an existing approved brand-name drug in dosage form,
safety, strength, route of administration, quality, and performance characteristics” (U.S. Food
and Drug Administration, 2018). The use of generic drugs saved the U.S. healthcare system
$1.67 trillion between 2007 and 2016 (Association for Accessible Medicines, 2017); researchers
have also demonstrated that the use of generic medicines can directly or indirectly increase
access to pharmacotherapy, provide a stimulus for innovation by both originator companies and
generic companies, and even positively influence patients’ medication adherence (Dylst et al.,
2015).
The commercial reality on the ground, however, has not necessarily been titled in favor
of such lower-cost generic medicine. Pharmaceutical companies tend to benefit from greater
sales of branded drugs, rather than generics. Furthermore, health practices by doctors also skew
towards prescription of more expensive branded drugs, even in cases when they are not more
effective than generic drugs; such biases, moreover, intersect with and exacerbate health
inequities across race/ethnicity, region, and income (Melamed & Rzhetsky, 2018). It is likely
that the constant lobbying efforts by pharmaceutical companies towards not only politicians and
policymakers, but also physicians and pharmacists, have played at least some role in the
continued privileging of branded over generic medicine (CVS Health, 2017). Patients and
consumers have also often betrayed a preference for brand-version drugs, even when they know
that generic drugs are identical in quality (Colgan et al., 2015).

33
Investigation into messaging strategies of generic drug-producing organizations thus can
contribute to a better understanding of what messages can elicit more robust support by citizens
and consumers for addressing health inequities. At the same time, the findings in the preceding
paragraph also suggest that there may very well be a ‘default’ preference for branded
prescription drugs; it is thus not wholly surprising that media interventions revolving around the
perception and use of generic medicine have produced mixed results. Experiments that exposed
consumers to educational videos about generic medicines resulted in more positive evaluations
of generic drugs. Yet, in the same study, those very consumers also reported more side effects
when they knowingly took a generic drug, even though this drug was a placebo (Colgan, Faasse,
Pereira, Grey, & Petrie, 2016). Changing perceptions of generic drugs for the better is one thing,
more easily done; enabling people to feel safe (or at least not in more danger) when consuming
generic medicine is a separate issue, and considerably more difficult. Even when testing the
influence of advertisements for generic drugs, making variations with respect to the attribution of
human characteristics and narration styles did not noticeably increase patents’ information-
seeking about, and intentions to switch to, generic drugs (Muzumdar et al., 2013; Howard et al.,
2018).
Acknowledging such mixed findings about perceptions of the drug specifically as it
relates to actual use by patients, there is one study that showed more promising findings, albeit
on the organizational side of the spectrum. Tian and Zhou (2015) had tested and compared the
effect of accounting information framing (costs vs. profit margins) and subject identity (branded
drug vs. generic drug) on evaluations of generic drug manufacturers vis-à-vis their for-profit

34
counterparts.
1
The results showed that the most positive evaluation occurred among people who
saw a combination of profit information and branded drug as the subject, with the next highest
evaluation observed among those exposed to the combination of cost information and generic
drug as subject.
These findings by Tian and Zhou (2015) lend themselves to additional considerations. In
the said study, there was no explicit consideration of making a difference to public support of a
specific organization; the stimulus material the authors tested mentioned generic or brand-name
drug manufacturers more generally. In other words, organizational identity, and specifically
attributes of organizational identity (Haslam, Postmes, & Ellemers, 2003; Falk, 2014) and how
those attributes are viewed by the public were not measured. The authors’ findings thus opened a
new line of inquiry, namely that the objective of generic medicine producers may indeed be
viewed as more aligned with serving the broader social good. Consistent with the research design
adopted by studies that tested framing strategies of non-profit organizations with a socially-
desirable purpose such as global development (Bullard & Penner, 2017) or campaign against
counterfeiting (Septianto et al., 2019), this study varies an appeal made by a fictional non-profit
manufacturer of generic medicine along gain- and loss-framed dimensions, to see whether these
frames influence perceived credibility of the organization and perceived efficacy of individual
engagement with such organizations as well as of the organizations themselves.
Perceptions of Impact, Efficacy, and Credibility
Concerning attitudes or attractiveness, related to but separate from perceptions of impact,
efficacy, or credibility, it may be possible that gain-framed messages have the upper hand. In a

1
Within the subject condition, the variations were as follows: brand name as subject was written as “in general,
brand name drugs are more expensive than generic drugs”, whereas generic as subject was written as “in general,
generic drugs are less expensive than brand name drugs” (Tian & Zhou, 2015, pp. 60-61).

35
study comparing gain- and loss-framed job advertisements, the gain-framed advertisement
elicited higher ratings of the organization’s attractiveness, with stronger associations with
positively-valenced adjectives (e.g., hopeful, positive, confident) positively mediating this effect
(Thorsteinson & Highhouse, 2003). Given also the parallels between on the one hand gain- and
loss-framed messages, and positive-valenced and negatively-valenced information on the other,
what is also noteworthy is the fact that a cause-related marketing (CRM) message that referenced
positive information about a given cause (i.e., cancer survival rate) elicited more favorable
attitudes towards the campaign for this cause – helping bone cancer patients – than an equivalent
message that referenced negative information (i.e., death rate) (Grau & Folse, 2007).
More positive attitudes or appraisals go hand-in-hand with higher credibility ratings, e.g.,
the relationship between website credibility and attitudes towards a given website (Long &
Chiagouris, 2006), as well as between the credibility of a corporation and intentions to purchase
goods or services from that corporation (Goldsmith, Lafferty, & Newell, 2000). In a factorial
design that tested three conditions - gain/loss framing, expert/non-expert, and high/low social
endorsement - Borah and Xiao (2018) found that the most positive credibility ratings came from
those who read a gain-framed social media news article written by an expert source with a high
level of social endorsement (i.e., “likes”). Gain-framed appeals for organ donation were found to
elicit more favorable reactions towards the message (Reinhart, Marshall, Feeley, & Tutzauer,
2007). In light of research that show positive associations among organizational credibility,
message effectiveness, and author credibility in public health advocacy campaigns (Worthington,
NussBaum, & Parrott, 2015), the following hypothesis is thus posited:
H1. Gain-framed appeal will elicit more favorable organizational credibility assessment.

36
Credibility assessments of electronic Word of Mouth (eWOM) marketing source helped
lower perceptions of risk associated with the product being marketed (Hussain, Ahmed, Jafar,
Rabnawaz et al., 2017). Credibility also is a constitutive element of efficacy information that is
used for persuasion purposes (Bandura, 2009), and other research also supports the impact of
gain- and loss-framed appeals on perceptions of the effectiveness of one’s own efforts (i.e.,
efficacy). Framing a specific problem as highly solvable, which aligns with the gain-framed
message creation, increased intentions to help solve that problem via enhancing an individual’s
own sense of perceived efficacy (Kogen & Dilliplane, 2017). News stories that contain
information about solutions to a given problem, a feature that corresponds to the gain frame,
have also shown exert a positive influence on engagement intentions (Curry & Hammonds,
2014).
H2. Gain-framed appeal will elicit more positive perceived efficacy.
H3. Organizational credibility assessment will positive mediate the effect of gain-framed
appeal on perceived efficacy.
Concerning the effects of gain - and loss-framed messages on donation intentions and
behavior, the findings present a mixed picture. Compared to a control message, high-solvability
message did elicit higher donation amounts, although the low-solvability message also had an
identical effect; Kogen and Dilliplane (2017) find that this is because the low-solvability
message increased a sense of sympathy with the victims (as opposed to enhanced self-efficacy).
Research on gain- and loss-framed appeals on donations either shows that this framing condition
by itself is insufficient (i.e., there has to be interaction with another type of framing condition)
(Das et al., 2007), interacts with an individual’s prior regulatory foci (Bullard & Penner, 2017) or

37
susceptibility to persuasion (Cao, 2016). Thus, we posit the following open-ended research
questions in this respect:
RQ1. What are the effects of gain- and loss-framed appeals on donation intentions?
RQ1-1. Does organizational credibility assessment mediate the effects of gain- and loss-
framed appeals on donation intentions?
RQ 1-2. Does perceived efficacy mediate the effects of gain- and loss-framed appeals on
donation intentions?
Research Design, Method, and Measures
Respondents were recruited from the Amazon Mechanical Turk (MTurk) platform in
June 2019. A total of 171 participants were recruited; as 29 responses were deleted because they
failed an attention check embedded in the survey, the final sample size was n = 142. The average
participant age was 34.78 years old, with over 60% of participants self-identifying as male.
Slightly under two-thirds (64.1%) of the sample reported their race/ethnicity as Non-Hispanic
White, with Asians, Hispanics, and African-Americans constituting a little under one-third of the
final sample (32.4%). Median annual income was in the range of $40,000 to $49,999, and over
90% of participants reported incomes lower than $100,000. More than two-thirds (67.6%) of the
participants reported as being employed and working 40 or more hours a week. The median
education was at the bachelor’s degree/four-year college level (47.8% of all participants).
While the final sample is not a representative sample of the U.S. population (i.e. U.S.
Census data), it nevertheless is likely to more closely approximate representativeness than other
samples, such as college student samples (Buhrmester, Kwang, & Gosling, 2011; Berinsky,
Huber, & Lenz, 2012). Participants were instructed to take a research survey titled “Attitudes
towards non-profit organizations in healthcare”, with each participant compensated $1.80 for

38
taking part in the study. They were randomly placed in one of two experimental conditions, i.e.,
gain- and loss-framed appeals, respectively. After answering several questions related to
healthcare, they were exposed to one of the two appeals; subsequently they responded to a series
of attitudes- and evaluation-related questions. Basic demographic questions were asked in the
last part of the survey.
Study Design and Stimuli
This study was a one-factor experiment that compared gain- and loss-framed appeals of a
fictional non-profit pharmaceutical manufacturer (“Civic Med”). While fictional, it nevertheless
is situated within the recent growth of non-profit pharmaceutical firms such as Civica Rx and
Harm Reduction Therapeutics in the U.S. (Betz, 2018). In the appeal, Civic Med is a non-profit
organization that is in the process of being formed, with its mission being the production of less
expensive, generic versions of prescription drugs. It is in need of funds in order to start the actual
production of drugs, and as it does not want to be potentially compromised in its mission by
receiving funding from for-profit pharmaceutical companies and consumer associations (with the
latter often under the influence of the former), it is directly appealing to individual Americans
(i.e., survey participants) for donations and/or purchases. This appeal for donations accounts for
the fact that non-profit organizations cannot sell equity shares to raise initial funds; and the
reason for its appeal - i.e. setting up manufacturing facilities - is also a realistic course of action
recommended for nonprofit generic-drug manufacturers (Liljenquist, Bai, & Anderson, 2018).
It is true that non-profit manufacturers such as Civic Med have the option of
subcontracting the manufacturing to other manufacturers, with this taking somewhat less time
than the alternative of setting up their own manufacturing facilities (Koons, 2019); nevertheless,
there are benefits to a non-profit drug manufacturer directly overseeing its manufacturing

39
facilities, in part because this would reduce potential accountability concerns associated with
having another company as the entity responsible for manufacturing the drugs. The stimulus used
for our study is specified in Appendix A.
Measures
The main variables for analysis were analyzed on a six-point Likert (1: Strongly
Disagree, 6: Strongly Agree), with a higher score (i.e. score closer to agreement than
disagreement) corresponding to a more positive appraisal. Organizational Credibility (OC), a
nine-item measure, was adapted from Worthington et al (2015) [M = 4.28, SD = .80, Cronbach’s
Alpha = .788]. Principal Component Analysis through varimax rotation identified two separate
components: Organizational Credibility - Motive (OC-Motive) [M = 4.41, SD = .85, Cronbach’s
Alpha = .802] and Organizational Credibility - Trust (OC-Trust) [M = 4.12, SD = 1.26,
Cronbach’s Alpha = .873]. For OC-Motive, the following items were included: Civic Med is
even-handed in presenting information”, “Civic Med has my interests at heart”, “Civic Med is
ethical”, “Civic Med appears to have experts on the topics discussed”, “Civic Med is ethical”,
and “Civic Med appears to be a leader in its area of specialty”. OC-Trust was consisted of the
following items, all reverse-coded: “Civic Med is not trustworthy”, “Civic Med provides
information that is not balanced”, “Civic Med does not provide in-depth information” and “Civic
Med is biased in the information it provides”.
Measured also was Perceived Efficacy (PE). Adapted from Kogen & Diliplane (2017),
this ten-item measure [M = 4.35, SD = .76, Cronbach’s Alpha = .824] included two different
types of survey items: individual- and organization-directed. Survey items that were directed
towards the individual included the following: “Average citizens can make a real difference in
providing affordable prescription drugs”, “By purchasing generic drugs, I can effectively help

40
individuals get adequate access to affordable prescription drugs”. Organization-directed survey
items focused on each of non-profit organizations, for-profit corporations, state government, and
federal government separately (e.g., “For-profit corporations can make a positive difference in
providing affordable prescription drugs”). In line with initial expectations, Principal Component
Analysis using varimax rotation identified two separate components: Perceived Efficacy- Self
(PE-S) [M = 4.11, SD = .95, Cronbach’s Alpha = .84] and Perceived Efficacy - Organization
(PE-O) [M = 4.73, SD = .87, Cronbach’s Alpha = .751]. And on a sliding scale (from $0 to
$100), participants were asked if and whether they’d be willing to donate a certain amount of
money if they were given $100 for giving to non-profit organizations (Donation Intentions, or
DI); this measure was also used in research that used fictional social entrepreneurial companies
in stimuli to assess public responses to organizational appeals for donations (Smith, Cronley, &
Barr, 2012). The average amount (hypothetically) donated was $38.28, with the standard
deviation being $29.82.
For the manipulation check, participants were instructed to respond to three separate
questions. Consistent with its use in other research on gain- and loss-framed message effects (Ju
& Park, 2013), one question asked participants about the “focus of the test you just read”, with
the answer options corresponding to whether the message focused more on gains or losses,
respectively.
2
The other two questions were constructed as semantic differential scales,
consistent with the use of this specific survey question format for manipulation checks for gain-
and loss-framed messages (Cho & Sands, 2011). Constructed on a six-point scale, a lower score
corresponds with greater agreement with the perception that the message was focused on gains

2
The answer choices were the following: “Positive consequences that would result from Civic Med being able to
produce affordable generic drugs” and “Negative consequences that would result from Civic Med not being able to
produce affordable generic drugs.”

41
(and a higher score aligning with greater agreement with the perception that the message was
focused on losses).
3
The order of exposure to the manipulation check questions was randomized.
And before answering the basic demographics questions (but after responding to the dependent
variable scales), participants were asked to evaluate the quality of organizational appeal that they
had read (Message Quality); the three items focused on the extent to which the message was
persuasive, informative, and clear [M = 4.81, SD = .896, Cronbach’s Alpha = .776].
Data Analysis and Results
Statistical analyses were carried out using SPSS 25 software. First, preliminary analyses
were conducted concerning message exposure (0: loss-frame, 1: gain-frame) and message
quality. The results of the manipulation check showed that participants indeed understood the
gain-framed message as focused more on achieving positive consequences than avoiding
negative ones, X
2
(1, N = 142) = 24.648, p < .01. Phi and Cramer’s V measures were also
significant at p < .01, at -.417 and .417, respectively. The results for the other two manipulation
checks also showed successful manipulation, with the following independent sample t-test
results: t (141) = 4.827, p < .01 and t (141) = 4.083, p < .05, respectively. An averaged two-item
index of the two continuous manipulation check questions also produced identical differences, t
(141) = 4.978, p < .01 and F (1,140) = 24.780, p < .01.
4
The averaged response for exposure to

3
Both questions were phrased in the following way: “In your opinion what is the message from Civic Med
ultimately focused on?” The two statement pairs were as follows: “‘The positive outcomes of Americans’ support
for production of affordable generic prescription drugs’ and ‘The negative outcomes of Americans’ withholding
support for production of affordable generic prescription drugs’”; “‘Achieving a positive outcome of being able to
improve access to affordable health treatments’ and ‘Avoiding a negative outcome of not being able to improve
access to affordable health treatments.’”
4
The averaged response for exposure to the gain-framed message was M = 2.26 (SD = 1.38); for exposure to the
loss-framed message, M = 3.45 (SD = 1.47). As indicated in the ‘Methods’ section of the paper, a lower score
corresponds to agreement with the perception that the message focused on gains (i.e. positive consequences of an
organization’s action), a higher score with the perception that the message focused on losses (i.e. negative
consequences of the lack of action on the part of the organization).

42
the gain-framed message was M = 2.26 (SD = 1.38); for exposure to the loss-framed message, M
= 3.45 (SD = 1.47).
As indicated in the ‘Methods’ section of the paper, a lower score corresponds to
agreement with the perception that the message focused on gains (i.e., positive consequences of
an organization’s action), a higher score with the perception that the message focused on losses
(i.e., negative consequences of the lack of action on the part of the organization). The Cohen’s d
effect size (d = .836) for the averaged differences in message manipulation, suggests high
practical significance. Lastly, exposure to one of gain- and loss-framed conditions did not result
in a meaningful difference in message quality appraisal, t (141) = -.1433, p > .10. Therefore, the
possibility that differences in perceived persuasiveness or informativeness of the message led to
statistically significant differences in outcome measures was ruled out.
Multivariate and Mediation Analyses
The current study draws on the classification of mediation types and effects as identified
by Zhao, Lynch, and Chen (2010). The authors had classified mediation along the following five
types: no effects, direct-only, indirect-only, competitive, and complementary. Mediation was
said to be statistically significant only for indirect-only (i.e., no significant main effects, only
significant mediating effects), competitive and complementary mediation.
5
Throughout this
paper, where appropriate references to these five different types of (non-) mediation will be
made. Individuals who read the loss-framed appeal indicated, on average, a willingness to donate
a higher amount ($41.35) than their counterparts in the gain frame condition ($35.02); this

5
The criterion for distinguishing between competitive and complementary mediation, according to Zhao et al
(2010), is the valence of the product of a * b * c, with a = effect of X on M, b = effect of M on Y, and c = direct
effect of X on Y. If the product is positive, then it is complementary; if negative, competitive. What differentiates
indirect-only mediation from competitive and complementary mediation is that with the former, there is no
significant main effect of the independent variable on the dependent variable. It is likely that there is at least one
omitted mediator for competitive and complementary mediation, but unlikely for indirect-only mediation.

43
difference, however, was statistically non-significant, F (1, 140) = 1.603, p = .208, η
2
= .011
(RQ1). Table 1 shows the results of the specific path analysis within mediation for donation
intentions as the outcome variable.
Table 1. Mediation Regression Analysis (for Donation Intentions, DI)
Step
(X → M → Y)
Paths Estimates
1 (X → Y) G/L Frame → DI B = -7.252, SE = 4.967, 95% CI [-17.075, 2.571]
2 (X → M) G/L Frame → OC-Trust
G/I Frame → OC-Motive
G/L Frame → PE-Self
G/L Frame → PE-Org
B = .402, SE = .21, 95% CI [-.013, .817]
+

B = .291, SE = .141, 95% CI [.012, .57]*
B = .011, SE = .161, 95% CI [-.308, .33]
B = .415, SE = .143, 95% CI [.132, .698]**
3 (M → Y) OC-Trust → DI
OC-Motive → DI
PE-Self → DI
PE-Org → DI
B = -1.302, SE = 1.944, 95% CI [-5.146, 2.542]
B = 7.177, SE = 3.295, 95% CI [.66, 13.693]*
B = 7.528, SE = 2.851, 95% CI [1.89, 13.165]**
B = -1.744, SE = 3.071, 95% CI [-7.817, 4.329]
**p <.01, * p <. 05,
+
p < .10

Hayes Model 4 was applied, so as to be able to enter mediator variables either
simultaneously in parallel mediation or individually, one mediator at a time; this was done to
address RQ1a and RQ1b, investigating the potential mediating effect of each or all of the
following variables - OC-Trust, OC-Motive, PE-Self, and PE-Organization. Figure 1 shows the
results of each of the paths when all four mediators were entered simultaneously, in parallel. For
each path, it was found that exposure to the gain-framed message positively increased three out
of four mediator variables, with one variable (OC-Motive) also positively increasing donation
intentions. However, the results of indirect effects show that no significant mediation occurred
for each of the four proposed mediator variables when they were entered simultaneously: OC-
Trust, B = -.523, SE = 1.018, 95% CI [-3.304, 1.002]; OC-Motive, B = 2.089, SE = 1.715, 95%
CI [-.121, 6.291]; PE-Self, B = .082, SE = 1.284, 95% CI [-2.624, 2.781]; and PE-Org, B =

44
-.724, SE = 1.429, 95% CI [-3.934, 1.896]. Additionally, when entered as individual, separate
mediators, identical patterns were observed for three of the four variables
6
, except for OC-
Motive, B = 2.927, SE = 1.757, 95% CI [ .175, .6.951].
Thus, framing did not meaningfully induce different amounts of hypothetical donations
(RQ1), and neither type of perceived efficacy exercised a significant mediating effect (RQ1-2;
however, one type of credibility assessment, i.e., of the organization’s motive, likely
demonstrated statistically-significant mediating influence. RQ1-2 was thus able to be answered
in a partially affirmative manner. This demonstration of significant mediation, however, may not
necessarily be understood as having exercised an ‘indirect-only’ mediation (Zhao et al., 2010).
This is so because this instance is not a case where there was a significant direct effect of the
independent variable on the dependent variable, only for a mediator to fully ‘absorb’ the
statistical significance of the independent variable. As shown in the earlier analyses, there was no
direct effect of gain- and loss-framing on donation intentions.
Multivariate analysis of variance (MANOVA) results were run on organizational
credibility-motive, organizational credibility-trust, perceived efficacy of self, and perceived
efficacy of organizations. There was a statistically significant difference in these credibility and
efficacy measures based on message framing, F (5, 136) = 3.173, p = .01, Wilk’s Λ = .896.
Discriminant analysis results showed the Box’s Test of Equality of Covariances (Box’s M
Statistic) to be F = 11.799, p = .728; it was thus concluded that univariate ANOVA results did
not differ significantly from the MANOVA results. Univariate analyses revealed robust
statistical significance for each of OC-Motive, F (1,140) = 4.250, p < .05, ηp
2
= .029, and PE-
Organization, F (1,140) = 8.411, p < .01, ηp
2
= .057, as well as marginal significance for OC-

6
The indirect effect results are as follows: OC-Trust, B = .029, SE = .987, [-2.208, 1.953]; PE-Self, B = .105, SE =
1.607, [-3.079, 3.302]; and PE-Org, B = 1.443, SE = 1.38, [-.939, 4.578]

45
Trust, F (1,140) = 3.66, p = .058, ηp
2
= .025. However, no meaningful significance was observed
for PE-Self, F (1, 140) = .005, p = .946, ηp
2
= .000. Figure 1 shows the differences in the average
mean scores across the outcome variables.
Figure 1. Mean Organizational Credibility and Perceived Efficacy by Message Frame

Note: Pairwise comparisons for each of the following variables: OC-Motive, OC-Trust, PE-Organization, and PE-
Self. Means for each of the pairwise comparison rows that do not share a common letter differ at p < .10.

Thus, results show full support for H1 and partial support for H2; there was at least a
marginally significant effect of the gain-framed appeal on increasing perceptions of both types of
organizational credibility measures (H1 supported), while only one type of perceived efficacy
assessment (of organization) was meaningfully enhanced by exposure to the gain-framed
message. To test for mediation (H3), the following mediation model was developed (Figure 2).

a
a
a
a
b
b
b
a
0
1
2
3
4
5
6
OC-Motive OC-Trust PE-Org PE-Self
Credibility & Efficacy Mean Scores
Loss-frame Gain-frame

46
Figure 2. Final Mediation Model

Hayes Model 4 was used as the template for statistical mediation analyses, the model
described in Figure 1 was separately run for each of PE-Organization (Figure 3) and PE-Self
(Figure 4).

Figure 3. Mediation Model (PE-Organization as Dependent Variable)

**p <.01, * p <. 05,
+
p < .10

Framing
(0: Loss, 1: Gain)
OC- Trust
OC-Motive

Perceived
Efficacy (PE)
Framing
(0: Loss, 1: Gain)
OC- Trust
OC-Motive
PE-Organization
.402(.21)
+

.291(.141)*
.301 (.138)*
.345 (.082)**
n.s.

47
As shown in Figure 2-1, there is a significant direct effect of framing on the perceived
efficacy of organizations, B = .301, SE = .138, p < .05, 95% CI [.028, .574]. A significant
indirect (i.e. mediation) effect was identified for OC-Motive, even as it did not result in indirect-
only or full mediation, in that the direct effect of framing remained statistically significant.

Figure 4. Mediation Model (PE-Self as Dependent Variable)

**p <.01, * p <. 05,
+
p < .10

Identical analyses on the other component of perceived efficacy, i.e. of self, yielded
different results (Figure 2-2). The direct effect is non-significant, B = -.143, SE = .149, 95% CI
[-.437, .151], with the mediating effect of OC-Trust also non-significant, B = .006, SE = .031,
95% CI [-.056 .070]. However, identical to what was observed for the PE-Organization model,
OC-Motive again emerged as a significant mediator, B = .148, SE = .074, 95% CI [.013, .302].
With respect to H3, partial support was thus provided; credibility assessments of an
organization’s motive positively mediated the effects of the gain-framed appeal on both types of
perceived efficacy measures. Here, once again there has to be a certain degree of caution
exercised in interpreting mediation observed for OC-Motive on perceived efficacy of individual
Framing
(0: Loss, 1: Gain)
OC- Trust
OC-Motive

PE-Self
n.s
.

.402(.21)
+

.291(.141)*
n.s.

.509(.089)**

48
actions, in light of the fact that univariate analysis of variance did not produce a significant,
direct effect of message framing.
Across all the models, there was consistent support for the impact of the gain-framed
appeal, either on its own or via mediating variable(s), on the perceived efficacy of organizations,
even as the equivalent perception of efficacy for one’s own (i.e., individual) efforts was not
meaningfully affected. Additionally, there was a distinction between two forms of organizational
credibility – trust and motive. Perceptions of the motive (distinct from trust) of organizations
positively mediated the gain-framed appeal’s effect on the perceived efficacy of organizations.
Discussion and Conclusion
Emphasizing the positive consequences of an organization’s proposed action was found
to meaningfully improve positive attitudes towards organizational entities such as for-profits,
non-profits, and government (both federal and state), insofar as attitudes are defined and
operationalized as the perception that such entities can positively contribute to an action, or
actions, identical to the proposed action in the stimulus. To an extent, then, it may be suggested
that the use of gain-framed appeal may have positive implications for enhancing organizational
efficacy, i.e., a sense that relevant organizations can meaningfully bring about positive change. It
must also be cautioned that this specific finding of the current study is relevant for the effect of
gain-framed messaging on would-be external stakeholders, i.e. individuals who could
hypothetically, and plausibly, use generic drugs themselves and also can be exposed to messages
about drug manufacturers. Other studies (e.g., Bohn, 2002; Wombacher & Felfe, 2017; Günzel-
Jensen, Jain, & Kjeldsen, 2018) had also measured the perceived impact of an organization, but
they had been carried out among internal stakeholders, most notably employees of the
organization in question.

49
Another contribution of this study has to do with identifying the distinction between
perceptions of motive and trust (or trustworthiness). The fact that there was little significance
associated with the trust variable may have to do with the fact that three of the four items for this
specific component were about the transparency and quality of information associated with, and
emanating from, Civic Med. Had the stimulus included information about a novel treatment, or
about the role played by this organization in tackling a little-known social problem, the
perceptions of trust or trustworthiness may have played a more salient role. The significant
findings with respect to perceived motive are likely to be related to both perceptions of
competence (i.e., two items in this specific scale assessments evaluations of expert presence and
organizational leadership in the healthcare sector) and of goodwill or good intentions (i.e., two
items about the ethics and empathetic concerns demonstrated by the organization at hand).
Scholars have identified the differential role played by specific motive attributions, such as
willingness to affirm certain values, strategic planning outcomes, and a desire to satisfy a wide
range of stakeholders (Groza et al., 2011). A combination of perceived competence and goodwill
on the part of an organization may very well be a positive mediating factor for strategic
communication messages that emphasize the positive consequences of an organization’s
behavior.
While not part of the final set of hypotheses and research questions, in the initial,
exploratory stages of data analysis, political ideology and perceptions of generic drug risk were
each ‘vetted’ as potential moderators. This decision was reached based on relevant findings in
gain- and loss-framing research about the role of risk perception (Rothman & Salovey, 1997;
Salovey & Williams-Piehota, 2004; Rothman & Updegraff, 2011) and political ideology
(Septianto et al., 2019). Neither political ideology nor perceptions of generic drug risk

50
significantly moderated the influence of either of the message variations. Tentatively, the non-
findings for these two variables as moderators may be understood with respect to the following
insights. First, people’s evaluations of generic drugs tend to be positive (or at least not markedly
negative), but such evaluations may not necessarily hold when they make a conscious decision to
use branded drugs for actual use for treating their illnesses. Second, as far as generic drug risk
perceptions are concerned, partisanship or political ideology is likely not relevant in the current
day and age; this is likely explained by the considerable degree of bipartisan convergence
(particularly in the aftermath of the 2016 Presidential Election) about the need to lower
prescription drug prices, often through increasing access to lower-cost generic equivalents.
In light of the fact that the scale used in our study had also asked participants about
whether they believe that their donations to, or purchases from, some of these organizations can
make a difference, it can be argued that there is at least some degree of overlap also with how
other scholars have defined ‘expected effectiveness’ of consumer action, e.g., donations
(Erlandsson, Nilsson, & Västfjäll, 2018). Erlandsson and his colleagues (2018) had also found
that more positive attitudes towards the appeal predicted expected effectiveness in increasing
donations, although arguably it did not meaningfully predict actual donating behavior across
multiple contexts. In this vein, in hindsight it is perhaps not too surprising that the hypothetical
donation amount a given participant was willing to give to Civic Med, a hypothetical non-profit
organization, was not meaningfully influenced, either directly by framing manipulation or
indirect via mediating influences of credibility and perceived impact evaluations. This may have
occurred at least in part because the survey question asked participants under the assumption that
they had, hypothetically speaking, $100 to donate. Other studies have phrased the question, in
more realistic (i.e. less hypothetical) terms (e.g., Kogen & Diliplane, 2019; Lee, Bolton,

51
&Winterrich, 2017), as these studies were about real-life organizations, be they combating
malaria (Against Malaria Foundation) or supplying libraries in developing nations
(Books4Cause).
Additionally, this study accounted for Institutional Review Board (IRB)
recommendations that because Civic Med is a hypothetical rather than an actual organization,
phrasing the question about donations in such a way as to imply that Civic Med actually exists
would amount to deception, in turn requiring a heightened level of scrutiny on the part of the
IRB (M. Burgett-Moreno, personal communication, May 21, 2019). The use of a donation
questions phrased in hypothetical terms was justified based on IRB and prior literature that
revolved around testing different versions of vignettes or frames about a hypothetical
organization (Smith et al., 2012). Provided that the organization in question exists in real life,
future studies may also benefit from operationalizing question(s) on donation in such a way that
it elicits actual donations (e.g., lottery ticket donations), consistent with scholarly value in
measuring actual (rather than simply intended) donation behavior when comparing the effects of
negative and positive appeals (Erlandsson et al., 2018).
The fact that no significant results were observed for perceived efficacy of individual (i.e.
one’s own) actions also deserves deeper scrutiny, with more profound implications for
scholarship than the lack of findings for generic drug risk assessment and political ideology. This
may be, at least in part, be attributed to the fact that the stimulus used for our study mainly
discussed organizational action (or inaction). Researchers who test the model identical to that
used in our study would do well to see whether a stimulus that is written in such a way that
references an individual actor (i.e., in the form of ‘you’, rather than ‘the organization’)
meaningfully alters perceptions of individual efficacy. This also raises the question of the

52
challenges of mobilization through the deployment of gain- and loss-frames on their own. One
study indicated earlier in this manuscript found that the loss-framed organizational appeal had
elicited a more positive appraisal of one’s own efficacy, but this effect was only observed among
people who had a certain dispositional tendency (i.e., being more promotion-focused, rather than
prevention-focused) (Bullard & Penner, 2017).
In this vein, future studies may benefit from paired-message designs, i.e., testing not only
gain/loss frame variations, but at least one another type of experimental variation. In a
crowdfunding context, Moradi and Das (2019) had found that a negatively-framed description of
a project raised higher backer funding compared to a positively-framed one; the effect of the
negatively-framed message was further enhanced by another type of message – i.e., positively-
framed public updates about the project at hand. Public updates may count as a form of
additional media information about a project or the organization that is sponsoring the said
project.
Additionally, it is also possible to conceptualize research designs in which the other
experimental variation is not necessarily about message frames per se. Certain aspects of a
message, for instance advertisements for products (which also serve as communication for the
company that produces such products), can ‘cue’ specific elements of consumer identity
(Oyserman, 2009; Kirmani, 2009); engagement in written exercises, furthermore, can also prime
people to be a certain mindset, e.g., a mindset of self-affirmation (Walter, Demetriades, &
Murphy, 2017). In this vein, researchers have recently found that engaging in active future-
thinking, coupled with exposure to a loss-framed message, produced stronger anticipated regret
of not having taken HPV vaccination (Kim, Kim & Murphy, 2020). Future-thinking
manipulations could possibly enhance the relevance of broader societal actors’ actions to

53
individual ones, or rather to conceptualize individual action as the prerequisite for societal
action. Linking one’s own future behavior with one’s own identity is feasible (Soliman, Buehler,
& Peetz, 2017), and future paired-design studies in the area of organizations’ strategic
communication would benefit from interventions that either cue identity or change the mindsets
of participants; this may enjoy greater success in increasing individual- and self-level efficacy
perceptions.
The current study thus made a unique contribution to research on gain- and loss-framed
appeals, and highlighted distinctions within broader umbrella concepts of credibility and
efficacy, and how the above variations differentially influence certain types of credibility and
efficacy. Individuals take part in helping organizations achieve objectives, be they fundraising,
cause-related marketing (CRM), or lobbying governments; it is also the case that individuals can
play a meaningful role in the incipient formation of organizational initiatives and organizations
as a whole (e.g., crowdfunding). It is easier to effectively increase perceptions that organizations
and institutions are effective at solving societal problems; what remains a thornier challenge is
convincing individuals that their own direct efforts also matter.

54
CHAPTER 3: ORGANIZATIONAL INFLUENCERS? PARTICIPATORY EFFICACY,
DISCRETE EMOTIONS, AND EFFICACY PERCEPTIONS
Introduction
Organizations, as representatives of activists, consumers, or patients (with these
representations not necessarily mutually exclusive), influence government healthcare policy
making from the outside. There are also instances of how public involvement occurs more
directly within government institutions. For instance, in Ireland, citizens were invited to take part
in Expert Advisory Groups (EAG), a mechanism in which laypersons would have a say in
developing and monitoring the implementation of health policies (O’Donovan, 2011, pp. 97-98).
Similar initiatives have also been found in the American context, even though the relative “lack
of systematic, even everyday avenues for consumer participation” in healthcare delivery is a
structural problem across the United States (Tritter & Lutfey, 2009, cited in Daw, Truong, &
Rosenau, 2011, p. 223). Consumers and patients can take part in Food and Drug Administration
(FDA) advisory committees; members of the public also take part in Health Systems Agencies
(HSA), which are mechanisms set up in the mid-seventies to evaluate capital expenditures on
healthcare-related items (e.g., oversupply of beds) (Daw et al., 2011).
There are also instances of public involvement within the pharmaceutical industry.
Representatives of consumer groups sit on advisory committees to pharmaceutical companies,
with one of their roles the assessments of research proposals or ethical issues with respect to drug
development. This type of participation was coterminous with the mobilization of specific
‘disease constituencies’ that influenced both the allocation of funding for, and direction of,
research and development (Vitry & Lofgren, 2011, p. 247). It is also the case that the
participatory influence observed within other organizations is oriented less towards patients, and

55
more towards advocacy for industry (Koivusalo & Tritter, 2011). The case of how a
controversial drug gained regulatory approval is an apt case. In 2013, a U.S. drug manufacturer,
Sprout Pharmaceutical, repeatedly failed in its attempt to get regulatory approval for flibanserin,
a drug for the treatment of female sexual dysfunction, because of the negligible benefits in
comparison to the prevalence and severity of side effects. Two years later, Sprout
Pharmaceutical ultimately did succeed in getting approval, and this was attributed largely to the
company’s strategic mobilization (aided also by the efforts of professional public relations’
firms) of citizens working on women’s health (Cassels, 2016). One form of mobilization was a
workshop involving such citizens, where a pro-flibanserin argument was made on the grounds of
gender equity (Cassels, 2016). But one can question whether making a relatively ineffective
product widely available is, in fact, in the public good.
As the prior example shows, public involvement in decision-making processes within
healthcare contexts may have to be evaluated on a moral and ethical continuum, rather than
being placed in either side of a strict binary between ‘good’ and ‘bad’. Healthcare has both civic
and political dimensions, insofar as it is closely intertwined with community-level well-being
and multiple levels of policy. Therefore, a user-centric design of healthcare decision-making
processes (Tritter, 2009) would better approximate ideals of public participation that emphasize a
combination of citizens’ roles in ensuring accountability and problem-solving (Schudson, 1998;
Bang, 2005; Li & Marsh, 2008; Choi & Kwon, 2019). When actually translating the ideals of
participation into specific practices within organization(s), however, it should not be a surprise
that challenges and complications arise. By the highest standards of a normative adherence to the
notion of participation, an organization cannot claim to “speak for the consumer” unless it has
“reached out to the users of the system in a way that listens to and documents their unique

56
opinions” (Fox & Lambertson, 2011, p. 214). Realistically, however, what also deserves to be
considered is the perceived effectiveness of the perspectives of such users, or the extent to which
those opinions and perspectives are substantively voiced and taken up in organizational-,
institutional, and system-level decision-making. The current study engages with this challenge
through an experimental approach; it does so by incorporating, and expanding upon, relevant
research on participation and efficacy.
Participation and Efficacy
Researchers have shown that, in experimental settings, people respond differently to
messaging about products that involves consumers at different stages of product development.
Specifically, a distinction can be made between a product that involved consumers as originators
of a product idea or as selectors of products to be produced and/or marketed (Lijedal & Dahlen,
2018). Such research has taken place within the broader body of work on consumer involvement
in new product development (NPD) (Hoyer, Chandy, Dorotic, Krafft, & Singh, 2010), and can be
situated also as a quantitative approach to operationalizing “consumer work” (Dujarier, 2016).
Thus, there is some knowledge about how the differing role of the consumer in product
development influences attitudes and behavior differently. However, less is known about how, or
whether, message variations with respect to the outcome of participating in the development of
entire organizations (as opposed to specific products or services) make a difference to those
outcomes. Bitterl and Schreier (2018) found that a higher degree of consumer identification with
the venture that they are supporting in a crowdfunding context made an individual contributor
perceive one’s own financial contribution to the venture as more meaningful. Such enhanced
perceptions, in turn, increased consumption of the products offered by the venture. These
findings suggest new possibilities for variations in depicting individual participation in

57
organizations. One possibility is that exposure to variations to how consumer participation is
communicated can bring about different assessments of, and engagement with, a given
organization. An inquiry into this possibility is made possible by the fact that similar real-life
examples exist, for instance consumers’ role in decision-making within the non-profit arms of
for-profit restaurants (Houck, 2019; Eckhardt & Dobscha, 2019). The subsequent sections will
make a case for the inclusion and testing of different types of efficacy information for this
purpose.
Efficacy in Political, Civic, and Organizational Contexts
Self-efficacy (or efficacy in the general sense) can be defined as the belief that one’s
actions matter and can make a difference to a given process or outcome, for instance with respect
to solving a problem or perceived injustice via individual action (Bandura, 1997). Distinct from
an individual sense of efficacy, collective efficacy refers to the shared belief that a group of
people (e.g., organizations, social groups) can successfully organize and execute the courses of
action (Bandura, 1997, p. 477, cited in Gully, Incalcaterra, Joshi, & Beaubien, 2002, p. 820).
Collective efficacy has shown to positively influence access to health resources (Matsaganis &
Wilkin, 2015), with media interventions (e.g., positive role models depicted in a media program)
also enhancing collective efficacy with respect to the belief that peace can be achieved in post-
conflict regions (Bilali, Vollhardt, & Rarick, 2017). Collective and individual (or self) efficacy,
while they overlap, are nonetheless separate variables; research findings suggest that collective
efficacy more strongly predicts people’s capacity for problem coping (Chen, 2015), even as there
is a positive relationship between the two (Jugert, Greenaway, Barth, Büchner et al., 2016).
Individual efficacy, however, more strongly influenced collective efficacy, as opposed to vice

58
versa (even though the relationship was also a statistically significant and positive one in the
latter) (Fernández‐Ballesteros, Díez‐Nicolás, Caprara, Barbaranelli et al., 2002).
Enhanced efficacy is one pathway towards collective action (Van Zomeren, Postmes, &
Spears, 2008). Relatedly, scholars have also defined group efficacy, which can be defined as the
belief that the ingroup is able to achieve social change through unified action (Cohen-Chen &
Van Zomeren, 2018). Such variations of efficacy have been measured in a variety of contexts,
e.g., health promotion (Hinyard & Kreuter, 2007; Murphy, Frank, Chatterjee, Moran et al.,
2015), political activism (Halpern, Valenzuela, & Katz, 2017), and environmental conservation
(Walter et al., 2017). Across these multiple dimensions, efficacy is thus intimately linked to
participation and active engagement. Participation and engagement are similar yet also different
concepts (for a detailed review, see Barrett & Brunton-Smith, 2014).
7
In this manuscript, we err
on the side of participation and engagement interchangeably, given that both are desirable or
expected outcomes of enhanced efficacy. After reviewing relevant literature on the influence of
efficacy on political and civic participation, greater focus will be placed on research that
identified the influence of efficacy in organizational contexts.
Political participation is a set of actualized/ongoing behaviors, or behavioral intentions, to
influence government personnel or policies, with direct (or indirect) implications for public
policy and lawmaking (Carpini, 2004; Vitak et al., 2011; cited in Oh, 2016, p. 14). Higher levels
of political efficacy enhance political participation (e.g., making campaign contributions,
contacting officials, and taking part in protests) (Pollock, 1983). The relationship between
political efficacy and political participation, furthermore, is reciprocal (Finkel, 1985). More

7
According to Barrett and Brunton-Smith (2014), participation is behavioral in nature, and thus encompasses a
range of participatory behaviors. On the other hand, engagement is construed primarily in psychological terms,
denoting interest in, attention to, or possession of knowledge, beliefs, opinions, attitudes, or feelings about either
political or civic matters (p. 6).

59
recent research suggests that the type of political action also needs to be considered; political
efficacy positively enhanced ‘normative’ political action (i.e., action that conforms to the norms
of the wider social system), yet diminished levels of ‘non-normative’ types of political action
(i.e., action that violates widely-shared social norms) (Tausch, Becker, Spears, Christ et al.,
2011).
While certainly not wholly distinct from participation in political contexts, civic
participation or engagement can be understood as the involvement of individuals in efforts that
change “problematic conditions in communities,” also influencing “policies and programs that
affect the quality of their lives” (Ohmer, 2007, p. 109). Collective efficacy positively influences
civic engagement, and in other findings this particular form of efficacy was found to be one
constituent of civic engagement, alongside neighborhood belonging and civic participation (Kim
& Ball-Rokeach, 2006). In the organizational context, higher levels of efficacy reported by
employees, or internal stakeholders more broadly, were shown to positively influence acceptance
of organizational change, as well as enhancing the positive effects of such change on the
organization (Armenakis, Harris, & Feild, 1999; Armenakis & Harris, 2002; Tan & Yoo, 2015).
Self-efficacy also strengthened individual employees’ propensity to engage in internal
whistleblowing of organizational wrongdoing (MacNab & Worthley, 2007).
Even in the absence of organizational wrongdoing and faults, self-efficacy was still found
to play multiple meaningful roles in the organizational context. Not only did self-efficacy
positively influence job satisfaction, task performance, and organizational citizenship behaviors
(e.g., taking care of company property in a respectful manner), but it also mitigated intentions to
leave one’s job; the latter effect, however, was conditional upon higher levels of trust in the
organization (Ozyilmaz et al., 2018). Similar to the influence of trust, organizational

60
commitment also increased a sense of efficacy among members of an organization, specifically
with respect to the tasks performed by the organization in question (Wombacher & Felfe, 2017).
In addition to the body of research that documents the influence of efficacy on internal
stakeholders, such as employees, there is also the positive impact of efficacy on stakeholders
external to the organization, such as donors or consumers (Lewis, 2019). This area, however, is
relatively underexplored, especially concerning the effects of experimental variations of efficacy
messages created by organizations on potential and probable external stakeholders, as well as on
unaffiliated members of the general public. Notably, Leary, Vann, and Mittelstaedt (2018)
operationalized the concept of efficacy with respect to one’s own perceived marketplace
influence (PMI), which focuses on an individual’s ability to change the behavior of not only
consumers, but also of organizations (e.g., companies). Their research findings, however, had
relied on a series of non-experimental surveys.
For the purpose of clarity, Table 2 below provides a definition of the definitions of
efficacy provided thus far in this section.

Table 2. Definition of Different Conceptualizations of Efficacy
Conceptual Term Definition and Explanation
Self-Efficacy Perceptions of self-efficacy constitute “a key factor in a
generative system of human competence” and they are These
“concerned not with the number of skills you have, but with
what you believe you can do with what you have under a
variety of circumstances” (Bandura, 1997, p. 37).
Collective Efficacy “The strength of groups, organizations, and even nations lies
partly in people’s sense of collective efficacy that they can
solve their problems and improve their lives through concerted
effort. Perceived collective efficacy will influence what people
choose to do as a group, how much effort they put into it, and
their staying power when group efforts fail to produce results”
(Bandura, 1982, p. 143).

61
Group Efficacy Including but not limited to social movement and activism
contexts, this definition of efficacy refers to the belief that the
“ingroup is able to achieve social change through unified
action (Bandura, 2000, cited in Cohen & Van Zomeren, 2018,
p. 50). While group efficacy and collective efficacy largely
overlap, there is a greater pronounced emphasis on the
distinction between ingroups and outgroups for
conceptualizing and applying group efficacy.
Perceived Marketplace
Influence (PMI) Efficacy
PMI efficacy can be distinguished from self-efficacy and
collective efficacy in that it has an explicit focus on a)
changing the behavior of other marketplace actors, and b)
influencing the behavior of a large group of consumers (Leary
et al., 2019, p. 1120).

The present study addresses this gap in theoretical and methodological application,
concerning itself with investigating the effects of different messages about consumer
participation in the decision-making of organizations.
Organizational Identity Matters (Up to a Point!)
In people’s minds, organizations are recalled and (re-)constructed based on certain
“stereotypic attributes” that have been conferred upon by individuals for whom a given
organization is “relevant and meaningful” (Haslam et al., 2003, p. 360). Such attributes shape the
conditions for organizational identification, informing behavior and defining individuals as
“members or nonmembers of a particular group or organization” (Falk, 2014, p. 698). Even in
experimental settings using hypothetical stimuli and/or vignettes, an organization is understood
differently from an individual, with people tending to attribute greater blame to an unethical
organization than an equivalent individual (Jago & Pfeffer, 2019).
Public- and private-sector differences have also elicited differences in perceptions.
Scientists who received funding from, and worked in, the private sector elicited lower trust from
citizens, in comparison with scientists in the public sector; public-sector scientists were also
perceived to be motivated more by benevolence, and more likely to produce benefits that will be

62
accessible to the public (Critchley, 2008). Similarly, the non-profit/for-profit distinction has also
shown to be the cause of differences in perceptual outcomes. Compared to a non-profit, a
hypothetical for-profit organization elicited higher perceptions of organizational wrongdoing
(Bhattacharjee, Dana, & Baron, 2017). And a study that compared the effects of using deceptive
recruitment techniques for hypothetical non-profit and for-profit organizations revealed that
people made more severe moral judgments about the former, partly because of different moral
expectations (Greitemeyer & Sagioglu, 2018).
Other scholars have also found similar findings, namely that non-profits are viewed as
warmer, but less competent (Aaker, Vohs, & Mogilner, 2010; Lee, Bolton, & Winterrich, 2017).
The orientation of non-profit organizations may thus be seen to better aligned with, and more
supportive of, issues of equity, equality, and social justice more generally, than that of for-
profits. What also matters is how people evaluate not only organizations as entities, but the
specific activities or initiatives undertaken by those organizations. Corporate social responsibility
(CSR), which refers to a set of activities undertaken by for-profit companies for the broader
social good, in alignment with but separate from the pursuit of profit, offers a rich context for
how people evaluate such corporate actions.
The presence of a CSR initiative enhanced warmth attributions to the company in
question (Bolton & Mantilla, 2015). Relatively less is known about whether variations made to
either organizational identity (for additional insights about specifically the construction of the
identity of organizations from a stakeholder perspective, see Scott & Lane, 2000) or the prosocial
orientation of a specific organizational initiative makes a difference to perceptions of efficacy.
The subsequent section will review recent scholarship on efficacy manipulations in

63
communicative settings and outline the potential interactions between organizational identity and
efficacy variations.
Making Experimental Variations on Different Types of Efficacy
Social psychologists have primed an individual’s sense of group efficacy through
exposure to short vignettes (Cohen-Chen & Van Zomeren, 2018). Efficacy has also been
manipulated in the context of health information. Exposure to self-efficacy information yielded
higher willingness to change health behavior, although evaluation of the risk posed by a disease
also shaped behavioral intentions via perceptions of one’s own vulnerability (Dahlstrom, Dudo,
& Brossard, 2012). Additional variations in the threat levels in a given message also made a
difference in compliance levels with a given health behavior recommended by the said message,
with high levels of both threat and efficacy generating the highest impact (Morman, 2000;
McKay, Berkowitz, Blumberg, & Goldberg, 2004).
Environmental communication scholarship also provides relevant precedents about
variations of different types of efficacy in messages. Concerning specifically climate change,
message variations were made with respect to each of three different types of efficacy (Feldman
& Hart, 2016; Hart & Feldman, 2016) (Table 3).

Table 3. Definitions of Internal, External, and Response Efficacy
Conceptual Term Definition and Explanation
Internal Efficacy This concept refers to the ease with which an individual
perceives his or her ability to take part in political or civic
action.
External Efficacy This concept refers to the perception of the impact that
individual participation or involvement can have on actors
external to one’s own self, such as policymakers or politicians.
This form of efficacy encompasses perceptions that one’s

64
opinions are being listened to by those external actors.
Response Efficacy This concept refers to the perception of the likely impact of
policy actions and proposals in achieving desired outcomes,
with those actions and proposals based substantially on part of
individual participation or involvement.

The two studies by Lauren Feldman and P. Sol Hart found that several, but not all, of
these types of efficacy message variations brought about more robust levels of political and civic
engagement intentions. Specifically, Hart and Feldman (2016) varied the valence of a given
message about climate change, so that one version revealed ineffective (or negative) efficacy and
the other effective (or positive) efficacy. Exposure to a news story with positively-valenced
internal efficacy information enhanced an individual’s own perceived internal efficacy, whereas
a negatively-valenced external efficacy story decreased perceived external efficacy. In the
context of addressing another environmental issue – recycling – a positive relationship was
found between organizational evaluation and perceived consumer effectiveness (Lee et al.,
2019). It is likely that the inclusion of efficacy information will have a similar effect to that of
including “mobilizing information” on reader engagement with victims of mass violence (Maier,
Slovic, & Mayorga, 2017), also on how different combinations of frames in organizational
appeals positively influence ‘micromobilization’ of the public on behalf of human rights causes
(McEntire, Leiby, & Krain, 2017). This effect is likely to hold when the message in question is
about the activities of an organization, specifically revolving around the perceived effectiveness
(or efficaciousness) of ordinary laypeople’s participation in the decision-making of an
organization.
In addition to internal and external dimensions of efficacy, the present study is also
interested in the perceived effectiveness of organizations, and how citizens’ and consumers’ own

65
efforts are perceived to meaningfully alter organizations’ actions and the impact of such actions.
Research on CSR initiatives find that consumer identification with the CSR-engaged company
positively influences attitudes towards it (Deng & Xu, 2017). Exposure to a news story about a
CSR initiative, furthermore, elicited more positive evaluations of both the company and its
product (von Sikorski & Müller, 2018). More positive perceptions of the effectiveness of an
organization go hand-in-hand with attitudes towards the said organization more generally. In the
current study, the manipulation of efficacy as either high (i.e., effective) or low (i.e., not
effective) concerns itself with the participatory outcomes of a specific group of people - ordinary
consumers/citizens - in an organization. Exposure to variations along these dimensions will make
a difference to an individual’s perception that his or her own actions can influence organizations.
Therefore, the following hypothesis is articulated with respect to three of the perceived efficacy
outcomes of interest to the present study:
H1. Exposure to high-efficacy information leads to higher a) internal efficacy, b) external
efficacy, and c) organizational influence efficacy, compared with exposure to low-
efficacy information.
RQ1. Is there any interaction between efficacy variations (i.e., high- vs. low-efficacy) and
organizational type variations (i.e., non-profit vs. for-profit)?
Discrete Emotions, Valence, and Efficacy
When comparing the effects of different types of efficacy information, distinct emotional
pathways and evaluations play a meaningful role in translating messaging effects into behavioral
intentions. Discrete emotions have the capacity to “selectively affect information processing,
recall, and judgment” (Nabi, 2003, p. 228), with emotions also functioning as distinct frames that
differently influence heuristic and systematic processing (Kim & Cameron, 2011). Lu and Huang

66
(2018) categorized emotions as ‘high-certainty’ (e.g., anger, happiness) or ‘low-certainty’ (e.g.,
sadness, fear, hope), with these two types each promoting heuristic and systematic processing,
respectively.
These emotional pathways are also closely intertwined with efficacy. The inclusion of
information corresponding to internal, external, and response efficacy of political actions to
address climate change influenced some, but not all, types of discrete emotions (Feldman &
Hart, 2016). All three efficacy types significantly increased hope relative to the control condition
in which no efficacy information was presented, although the impact differed slightly depending
on the self-reported political ideology of the respondents. These effects were also different across
political liberals, moderates, and conservatives. Among liberals, internal and response efficacy
messages increased hope, whereas for moderates internal and external efficacy conditions had
the identical effect; for conservatives, only the response efficacy condition enhanced hope.
Concerning fear, another discrete emotion, there was no main effect of the efficacy conditions on
fear, although a significant interaction emerged with political ideology. Internal and response
efficacy conditions reduced fear among moderates, whereas the response efficacy condition only
marginally diminished this emotion among conservatives (Feldman & Hart, 2016). No effects
were observed for two other discrete emotions - fear and sadness.
Efficacy manipulations thus impact emotions, albeit conditionally. Research also shows
that the valence (i.e., negative vs. positive) of information also matters for discrete emotions.
Discrete emotions are also sensitive to gain- and loss-framed messages, which are theoretically
based on prospect theory (Kahneman & Tversky, 1979). A gain-framed message about solutions
to climate change led to more robust support for relevant advocacy behaviors; one specific type
of discrete emotion - hope - positively mediated this pathway (Nabi, Gustafson, & Jensen, 2018).

67
Hope also positively mediated the effects of a gain-framed anti-counterfeiting advertisement on
compliance intentions, but only for political liberals; in contrast, fear played an identical role
among political conservatives (Septianto, Northey, & Dolan, 2019). Moreover, sadness, when
operationalized as a distinct message frame in the context of an appeal for supporting a specific
cause, elicited stronger policy support for addressing that cause, even as this effect was
conditional on being paired with prior exposure to a gain-framed news article about the identical
topic (Lu, 2016). Feelings of sadness encouraged donations encouraged donations to an
organization whose charitable appeal emphasized treating (as opposed to preventing) a problem
identified as a cause by the said organization (Fajardo & Salerno, 2017).
Gain- and loss-framed messages focus on the positive consequences of taking action and
the negative consequences of not taking an action, respectively. High- and low-efficacy
information can thus be understood to correspond to gain-framed and loss-framed messages,
respectively. H2 is thus posited:
H2. Exposure to high-efficacy information will elicit higher hope than exposure to low-
efficacy information.
As indicated earlier in the paper, people are likely to have different mental attributes
associated with certain organizations or sectors more broadly. The impact of reading about
negative efficacy of participating in organizational decision-making is thus likely to be different
depending on the organizational type. People tend to have higher moral expectations for non-
profit organizations, with media coverage also reflecting such a positive slant (Hale, 2007);
participation in non-profit organizations may also be perceived as beneficial to democratic
practices and norms (inherently more democratic and participatory (King & Griffin, 2019).
When responding to policy threats, however, researchers found a meaningful mediating role for

68
anger, but not fear (Valentino, Gregorowicz, & Groenendyk, 2009). Thus, low efficacy in the
non-profit context is likely to elicit greater anger. The following set of hypotheses are thus
formulated:
H3. Exposure to low-efficacy information will elicit greater anger, compared to exposure
to high efficacy information.
H3-1. Among participants in the low-efficacy information condition, those exposed to the
non-profit organization will report greater anger compared to those exposed to the for-
profit organization.
H4. Exposure to low-efficacy information will elicit greater fear, compared to exposure
to high-efficacy information.
H4-1. Among participants in the low-efficacy information condition, those exposed to the
non-profit organization will report greater fear compared to those exposed to the for-
profit organization.
And while research points to positive relationships between internal and external efficacy
across diverse contexts, relatively less is known about the relationship of both internal and
external efficacy to perceptions of consumer-specific efficacy (i.e., perceived marketplace
influence (PMI) efficacy (Leary et al., 2019). Higher evaluations of one’s own response efficacy
enhanced donation intentions to the organization in question, with perceived competence of the
organization positively mediating this effect (Lee, Heinze, & Lu, 2018); this is consistent with
findings that show how efficacy more generally increases donations (Anker, Feeley, & Kim,
2010), with donations potentially being understood as a way of participating in an organization’s
initiative or activity. A perception that one can influence the activities of organization(s) thus

69
overlaps with the assumptions that constitute response efficacy. We thus ask the following
research question:
RQ2. How do a) internal and b) external efficacy relate to perceived marketplace
influence efficacy?
The current study not only varies efficacy within textual information, but also measures
different types of efficacy perceptions on the part of respondents. Thus, it is equally important to
also examine how discrete emotional reactions in turn influence efficacy perceptions, in addition
to inquiring about the direct effects of textual efficacy manipulation on efficacy perceptions and
discrete emotional reactions. As explained in depth earlier in the paper, hope and fear have
shown to exert a positive mediating effect on activism intentions more robustly, compared to the
effect of anger and sadness (Feldman & Hart, 2016). Research findings in other contexts also
provide additional support for the role of hope. And inducing a sense of group efficacy did
positively predict robust collective action intentions to solve social and political problems;
however, this was found only when hope about the possibility of resolving a given problem was
high (Cohen-Chen & Van Zomeren, 2018).
Earlier, it was noted that discrete emotions could also as separate, distinct frames (e.g., a
sadness-framed news article can elicit a greater psychological state of sadness). In a study on
comparing different types of emotion frames on perceptions of a corporate crisis, anger-framed
news (vs. sadness-framed news) induced more negative attitudes towards the company in
question; sadness-framed news elicited higher credibility evaluations of the company, but this
was conditional upon this news article being paired with a highly emotional (vs. none) appeal
from the company (Kim & Cameron, 2011). The role played by anger in inducing greater
negativity towards the responsible organizational actor in question is also enhanced by a higher

70
level of interest in the crisis itself, with higher levels of empathy reported for the victims in the
crisis (Kim & Jin, 2016). And as Kim and Cameron (2011) observed; sadness as a discrete frame
unto itself did not make a difference. The relative ineffectiveness of sadness-framed messages
versus anger-framed messages and no-emotion messages was also found in research on
antismoking advertisements (Kim & Niederdeppe, 2014). Yet, when the sadness-frame was
combined with an emotionally intense manner of communication, it actually led to higher
credibility perceptions compared to its emotionally-intense, anger-framed equivalent (Kim &
Cameron, 2011). When comparing emotional and rational messages about an organization in
crisis, a similar sadness-framed message was more effective at improving the post-crisis
reputation of an organization (Claeys, Cauberghe, & Leysen, 2013). Acknowledging the
possibility that the mediating effect of discrete emotions depends, and differs, partly based on
context, we pose the following three hypotheses and one research question:
H5. Hope positively mediates the effect of high-efficacy information on a) internal efficacy
b) external efficacy and c) perceived marketplace influence efficacy.
H6. Anger positively mediates the effect of low-efficacy information on a) internal efficacy
b) external efficacy and c) perceived marketplace influence efficacy.
H7. Fear positively mediates the effect of low-efficacy information on a) internal efficacy b)
external efficacy and c) perceived marketplace influence efficacy.
RQ3. Does sadness mediate the effect of efficacy information variations on a) internal
efficacy b) external efficacy and c) perceived marketplace influence efficacy?
Correlational analyses will be conducted for investigating H5 and RQ4; mediational
analyses will be carried out only if there is statistical significance observed for one experimental

71
condition, with neither significant direct effects of the other condition nor interactions between
the two conditions.
Research Design, Method, and Procedures
This study is a 2 (Organization Type: For-Profit vs. Non-Profit) * 2 (Efficacy Message:
Low vs. High) factorial design. The stimulus is based on a scenario in which consumers
participate in the decision-making of a fictional drug manufacturer (Civic Med); variations are
made to the identity of the drug manufacturer (i.e., non-profit organization vs. for-profit
company) and the valence of the efficacy of consumer participation (i.e., positive vs. negative)
(See Appendix B). It was created partly in reference to the internal and external efficacy stimuli
used in recent research on climate change, adopting also the Associated Press (AP) News format
used in research on climate change and efficacy (Feldman & Hart, 2016; Hart & Feldman, 2016).
Media coverage influences the direction of strategic change by organizations (Bednar, Boivie &
Prince, 2013); as media shapes public opinions with respect to the actions of organizations, news
coverage of organizations that are embarking on altering their practices is therefore a domain that
justifies experimental research.
Individual citizens take part in the decision-making of non-profit organizations,
participating in advisory board meetings, project-specific work groups, and Boards of Directors
(LeRoux, 2009). Exact equivalents in the for-profit setting are arguably more difficult to find.
That said, instances of employee ownership of companies are not unheard of, and politicians
such as Senator Bernie Sanders and Representative Alexandria Ocasio-Cortez have introduced
relevant legislation to expand such ownership (Schneider, 2019). Scholars have called for a
“broadened imaginary” about organizational democracy (King & Griffin, 2019, p. 1), Thus, it is
not inconceivable to think that individuals who are not employees, could plausible take part in

72
the decision-making of some for-profit companies, particularly those that strive to create positive
social impact, or experiment with participatory approaches to decision-making.
For this study, textual elements that reflected internal and external efficacy stimuli were
combined so that a given news story would reflect aspects of both internal and external efficacy.
Internal efficacy information demonstrates the perceived ease of consumers in taking part in the
organization’s decision-making, whereas external efficacy information demonstrates the tangible
effects of such consumer participation. In the positive efficacy condition, consumers find
participation easy (internal efficacy), and their participation is reflected in the outcomes of the
organization’s decision-making (external efficacy). On the other hand, in the negative efficacy
condition, consumers find participation difficult (internal efficacy), and their participation is not
reflected in the outcomes of the organization’s decision-making (external efficacy).
Sample Characteristics
This study was carried out on the Qualtrics platform, a national paid opt-in online survey
panel. Quotas were used to recruit participants, with quotas for race, ethnicity, gender, and age in
the survey approximating U.S. Census estimates (Feldman & Hart, 2016). Initially a total of 439
respondents were recruited; however, slightly under one-third (n = 131) technically did not pass
a factual instructional manipulation check (FMC) question (Kane & Barabas, 2019) about the
organizational type (i.e., non-profit organization or for-profit company) of Civic Med. After
further removing four outliers based on calculation of the Mahalanobis Distance, which is the
removal of responses with probability value below 0.001), statistical analyses for our paper were
conducted only on the subset of the entire sample (n = 304), i.e., only respondents who selected
the organization type specified in the stimulus to which they were exposed.

73
Approximately 47% of the respondents were female, with the average age of the sample
in the mid-forties range (M= 45.79, SD = 17.28). Approximately 55% of the respondents
reported to be employed. Over 80 percent of respondents had at least some exposure to college-
level education, with the median respondent reporting at least some degree of college education.
Non-Hispanic Whites accounted for 60.5% of the sample, followed by Hispanics (16%),
African-Americans (12.5%), and Asian-Americans (6.6%); the rest identified themselves as
American Indian/Alaskan Native (1.0%) or Other (3.0%). Both the median and mean income
was in the $60,000 - $69,999 range.
Measures
Internal efficacy and external efficacy were both adapted from two studies that measured
the identical variables, but for a different topic (i.e., climate change) (Hart & Feldman, 2016;
Feldman & Hart, 2016). Internal efficacy was comprised of five items (e.g., “I consider myself to
be well-qualified to participate in a drug manufacturer’s decision-making”; “I feel confident that,
if I wanted to, I would have the ability to contact a drug manufacturer about its decision-
making”) [M = 3.56, SD = 1.09, Cronbach’s Alpha = .863]. The three-item External efficacy
scale included the following statements: “People like me do not have any say on what drug
manufacturers do with respect to prescription drugs” (reverse-coded); “Drug manufacturers do
not care much about what people like me think about prescription drugs” (reverse-coded); “Drug
manufacturers pay attention to what people like me think when they decide what to do about
prescription drugs” [M = 2.65, SD = 1.05, Cronbach’s Alpha = .714].
Leary et al (2018) had distinguished between organization - and individual consumer-
oriented components within the Perceived Marketplace Influence (PMI) scale. The survey items
were adapted to fit the purpose of the current study; the revised items included the following:

74
“The choices I make can persuade drug manufacturers to offer specific product and/or service
offerings to consumers”, “I feel what I buy can encourage drug manufacturers to make and sell
affordable prescription drugs”, and “my behavior does not guide other drug manufacturers to
provide similar products” (reverse-coded) [M = 3.36, SD = 1.03, Cronbach’s Alpha = .886].
Lastly, the items for discrete emotions were largely identical to those used in Nabi et al (2018).
A total of eight items (in parentheses) were included for measuring discrete emotions, with these
items categorized in a way consistent with that in Nabi et al (2018): Hope (hopeful, encouraged,
enthusiastic, inspired) [M = 3.55, SD = 1.68, Cronbach’s Alpha = .940], Sadness (upset and
distressed) [M = 2.17, SD= 1.41, r = 688, p < .01], Anger (angry) [M = 2.07, SD = 1.57], Fear
(anxious) [M= 2.20, SD = 1.51].
Lastly, four variables were considered as covariates for preliminary statistical analyses
(but were dropped from the main analyses): Ethnicity (0: Caucasian White, 1: Other Ethnicity),
Employment Status (0: Not Currently Employed, 1: Currently Employed), Subjective Health
Status (1: Poor, 5: Excellent), and Age.
8
These variables were identified as covariates for
preliminary analyses because of their statistically significant correlation with at least one of the
variables of interest to this study.
Data Analysis and Results
Three manipulation check questions had been included to assess whether participants
accurately perceived the valence of the stimulus. Created in the form of a six-point semantic
differential scale, a lower score on an item corresponded to a stronger perception of high efficacy
(with a higher score corresponding to a stronger perception of low efficacy). Responses to each

8
60.3 % of all respondents identified as non-Hispanic White, and the average reported assessment for subjective
health status was 3.25 (SD = .95).

75
of these items were statistically significant.
9
After averaging the responses to these three items,
the assessment in the high-efficacy condition [M = 2.19, SD = 1.18] was significantly different
from that in the low-efficacy condition [M = 4.49, SD = 1.49], F (1, 302) = 215.33, p < .001.
Furthermore, the difference in the mean manipulation check assessment was almost equivalent to
two standard deviations [Cohen’s d = 1.711].
In addition to covariates and multiple dependent variables, there are two experimental
conditions - valence (low-efficacy vs. high-efficacy) and organizational type (non-profit vs. for-
profit). Therefore, a two-way multivariate analysis of covariance (MANCOVA) was initially
conducted. The assumptions for multivariate analysis were thus satisfied. The value for the
Box’s M Test was 95.348, at p = .279; this was interpreted as satisfying the criteria posited by
Huberty and Petoskey (2000), namely that the probability value for the Box’s M Test should be
above .005 for the researchers to assume that the covariance matrices are equal across the
conditions. And for each of the dependent variables of interest to this study, the Levene’s Test
statistic was non-significant, p > .05, indicating equal variance across the experimental
conditions. For the main analyses, however, control variables were excluded, based in part on the
need to investigate solely the effect of the experimental variations.

9
The survey items were as follows, with the wording inside the bracket corresponding to the negatively-valenced
perception: 1) Can [cannot] effectively influence Civic Med’s decision-making; 2) Have [do not have] a sense that
they have enough knowledge to effectively participate in Civic Med’s decision-making; and 3) Have [do not have] a
sense that they have enough experience to effectively participate in Civic Med’s decision-making. For 1), positive M
= 2.13, SD = 1.32 vs. negative M = 4.27, SD = 1.74, Cohen’s d = 1.38; for 2), positive M = 2.18, SD = 1.29 vs.
negative M = 4.69, SD = 1.52, Cohen’s d = 1.77; and for 3), positive M = 2.28, SD = 1.32 vs. negative M = 4.51, SD
= 1.69, Cohen’s d = 1.468.

76
Effects of Valence and Organization Type
For our study, there were unequal cell sizes, given that a substantial number of responses
had to be deleted from the original dataset.
10
A two-way multivariate analysis of variance
(MANOVA) was conducted. For the purpose of detecting the significance of multivariate tests,
our study used Pillai’s Trace rather than Wilk’s Lambda; this decision was made because Pillai’s
Trace is more robust against violations of the assumption of equal cell size (Tabachnick & Fidell,
1989, cited in Andersson & Bateman, 1997, p. 461). Multivariate effects were statistically
significant for valence, Pillai’s Trace = .172, F = 8.754, df = (7, 294), p < .001. However, there
was no statistical significance for organization type, Pillai’s Trace = .027, F = 1.178, df = (7,
294), p = .315; multivariate results for the interaction between the two experimental conditions
similarly show statistical non-significance, Pillai’s Trace = .025, F = 1.094, df (7, 294), p = .367.
Then, separate analysis of variance (ANOVA) was conducted for each of the dependent
variables (Table 4).

Table 4. ANOVA for all Dependent Variables
Dependent Variables Independent Variables N df F p η2
Internal Efficacy Valence
Organization
Valence * Organization
304

1
1
1
4.914
.686
1.677
.027*
.408
.196
.016
.002
.006
External Efficacy Valence
Organization
Valence * Organization
304

1
1
1
4.604
.026
4.302
.033*
.873
.039*
.015
.000
.014
Perceived
Marketplace Influence
Efficacy
Valence
Organization
Valence * Organization
304

1
1
1
3.226
1.243
.575
.073
+

.266
.449
.011
.004
.002

10
Of the deleted responses, considerably more responses were deleted because a respondent incorrectly answered
that they had selected “Non-Profit Organization” when actually the stimulus to which that person was exposed
indicated that Civic Med was a for-profit company (as opposed to the other way around).

77
Fear Valence
Organization
Valence * Organization
304

1
1
1
1.697
.492
1.751
.194
.483
.187
.006
.002
.006
Anger Valence
Organization
Valence * Organization
304

1
1
1
7.682
.019
.320
.006**
.891
.572
.025
.000
.001
Hope Valence
Organization
Valence * Organization
304

1
1
1
46.346
2.553
1.363
.000**
.111
.244
.134
.008
.005
Sadness Valence
Organization
Valence * Organization
304 1
1
1
13.477
.038
.429
.000**
.846
.513
.043
.000
.001
**p < .01, * p < .05,
+
p < .10

The results in Table 4 demonstrate that the exposure to the valence condition elicited
significant differences across three of the four discrete emotion variables; similar patterns were
observed also for each of the efficacy variables. Consistent with the results of the multivariate
tests, there was no main effect of the organization type condition for each of the variables, yet
there was one interaction effect observed for external efficacy, F (1,300) = 4.302, p < .05, η2
= .014. The estimated marginal means for each cell are shown in Table 5, with a bar chart for the
corresponding variables show in Figures 5 and 6.

Table 5. Estimated Means from 2 by 2 ANOVA
Valence
0: Low-Efficacy (above)
1: High-Efficacy (below)
Organization Type
0: For-Profit (above)
1: Non-Profit (below)
Internal Efficacy M = 3.45, SE = .08
M = 3.74, SE = .09
M = 3.65, SE = .09
M = 3.54, SE = .08
External Efficacy M = 2.54, SE = .08
M = 2.81, SE = .09
M = 2.67, SE = .09
M = 2.69, SE = .07
Perceived Marketplace Influence M = 3.25, SE = .08 M = 3.30, SE = .09

78
(PMI) Efficacy M = 3.47, SE = .09 M = 3.43, SE = .07
Fear M = 2.33, SE = .11
M = 2.10, SE = .13
M = 2.28, SE = .13
M = 2.15, SE = .11
Anger M = 2.30, SE = .11
M = 1.81, SE = .13
M = 2.07, SE = .13
M = 2.04, SE = .11
Hope M = 2.96, SE = .12
M = 4.22, SE = .13
M = 3.43, SE = .14
M = 3.73, SE = .11
Sadness M = 2.46, SE = .10
M = 1.86, SE = .12
M = 2.14, SE = .12
M = 2.17, SE = .10

Figure 5. Estimated Mean and Statistical Significance for Efficacy Measures

Note: Pairwise comparisons for each of the following variables: Internal Efficacy, External Efficacy, and PMI
Efficacy. Means for each of the pairwise comparison rows that do not share a common letter differ at p < .05.

a
a
a
b
b
a
0
0.5
1
1.5
2
2.5
3
3.5
4
Internal Efficacy External Efficacy PMI Efficacy*
Low-Efficacy High-Efficacy

79
Figure 6. Estimated Mean and Statistical Significance for Discrete Emotion Measures

Note: Pairwise comparisons for each of the following variables: Fear, Anger, Hope and Sadness. Means for each of
the pairwise comparison rows that do not share a common letter differ at p < .05.

Looking at Table 5, exposure to high-efficacy information elicited higher levels of all
three forms of efficacy, at either p < .05 or p < .10. H1a and H1b were fully supported, while
H1c was partly supported. As predicted by H2, viewing high-efficacy information enhanced
perceptions of hope, p < .001. It is also noticeable that the magnitude of difference between the
two levels of the valence condition was the largest for hope (1.26). We had also predicted that
the low-efficacy condition would lead to higher reported anger (H3); this hypothesis was also
fully supported.
It is true that the mean reported anger of respondents who read about low-efficacy
information in the non-profit organization [M = 2.30, SE = .11] was somewhat higher than that
reported by those who read about positive efficacy in a for-profit context [M = 1.81, SD = .13];
however, this difference was not statistically significant. There was thus no support for H3-1. No
a
a
a
a
a
b
b
b
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
Fear Anger Hope Sadness
Low-Efficacy High-Efficacy

80
statistically significant results, be they for either experimental condition separately or the
interaction between the conditions, were identified for fear, thus justifying the rejection of H4
and H4-1. As shown in Table 5, the solitary interaction effect between the experimental
conditions occurred for perception of external efficacy (RQ1); this is visualized in Figure 7. The
highest level of external efficacy was observed in the high-efficacy/for-profit condition [M =
2.93, SE = .14], whereas the low-efficacy/for-profit condition elicited the lowest external
efficacy responses [M = 2.41, SE = .11]; across the low-efficacy conditions, exposure to for-
profit [M= 2.68, SE = .11] and non-profit [M = 2.69, SE = .10] variations brought about
indistinguishable evaluations.

Figure 7. Interaction between Valence and Organization on External Efficacy

Previously, analysis of the data showed that for evaluations of external efficacy, a
significant interaction effect was identified, F (1,300) = 4.302, p < .05, η2 = .014. Figure 3 more
clearly visualizes the meaning of this interaction effect; exposure to high-efficacy information
0
0.5
1
1.5
2
2.5
3
3.5
Forprofit Nonprofit
Low-Efficacy High-Efficacy

81
brought about significant differences in external efficacy evaluations in the for-profit condition
(but not in the non-profit condition). Exposure to high-efficacy information in the for-profit
condition resulted in the most positive assessments of external efficacy. The effect of efficacy
valence was different across the non-profit and for-profit versions, but only for one specific
efficacy outcome. Thus, RQ1 was answered in the affirmative, but with only one interaction
effect observed.
Mediation Analyses
Several of the research questions and hypotheses also inquired into potential mediating
roles played by each of the discrete emotions and efficacy perceptions. Hayes PROCESS Model
4 was used, as it allows for up to six parallel mediating variables to be incorporated into a given
mediation model. Mediational analyses were conducted on only the efficacy condition, as there
was neither a main effect of organizational type condition nor an interaction between efficacy
valence and organization type. Prior scholarly work has also run mediational analyses based on
this rationale (Belavadi & Hogg, 2018), although others appear to have justified their decision
based only on the observation that there was no significant interaction between the two
conditions (Sarıçam & Çetinkaya, 2018). Given that there was significant interaction for one
variable - external efficacy - we excluded this variable from the main mediational analyses; only
internal efficacy and PMI efficacy were deemed as dependent variables of interest.
11

There was no significant direct effect on PMI efficacy was when internal efficacy
mediated the effect of valence condition, B = .186, SE = .118, 95% CI [-.045, .418]; also, no
significant indirect effect was observed, B = .034, SE = .023, 95% CI [-.002, .086]. When the
mediator and outcome variable were switched (i.e. PMI efficacy as mediator, and internal

11
Thus, H5b, H6b, H7b, and RQ3b were all not addressed.

82
efficacy as dependent variable), there was a marginally significant direct effect, B = .207, SE
= .125, p = .099, 95% CI [-.039, .452]; however, mediation was not significant, B = .035, SE
= .025, 95% CI [-.004, .092]. Addressing RQ2a, neither external efficacy nor PMI efficacy
exerted a meaningful mediation effect, and these variables also appear to have weakened the
statistical significance of the direct effect of efficacy valence, when compared with what was
observed in the multivariate analysis results. The lack of significant mediation is consistent with
one aspect of the earlier multivariate analyses, namely that exposure to positive efficacy only
resulted in marginally higher evaluations of PMI efficacy, F (1,300) = 3.226, p = .073.
Equivalent analyses were conducted for three of the four discrete emotions (i.e., anger,
sadness, and hope) as hypothetical mediators, to address each of H5, H6, H7, and RQ3. H5a was
fully supported, B = .261, SE = .063, 95% CI [.146, .390]; hope also fully mediated the effects of
efficacy valence condition on internal efficacy, as the main effect of valence was no longer
significant, B = -.019, SE = .129, 95% CI [ -.273, .235]. Regarding H5c, a similarly strong
mediation effect also emerged. Hope fully mediated the effects of valence condition on PMI
efficacy, B = .285, SE = .061, 95% CI [.170, .441], with the direct effect of valence condition no
longer significant, B = -.064, SE = .120, 95% CI [ - .300, .172]. H5c was thus also fully
supported. Anger did not exert a mediating effect on either internal efficacy, B = -.015, SE
= .023, 95% CI [ -.064, .029], or PMI efficacy, B = - .01, SE = .023, 95% CI [ -.056, .037] (H6a
and H6c not supported). There was also a lack of support for H7a and H7c, as fear also was not a
meaningful mediator for internal efficacy, B = -.002, SE = .014, 95% CI [-.033, .026], and PMI
efficacy, B = -.026, SE = .021, 95% CI [ -.072, .006].
12
Lastly, addressing each of RQ3a and

12
While not directly addressed as a research question or hypothesis, PROCESS results also showed that the direct
effect of fear was either marginally significant, at p = .054 (for internal efficacy as the outcome variable) or
significant, at p = .038 (for PMI efficacy as the outcome variable). This stands in contrast to the non-significant

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RQ3c, sadness did not exert a mediating effect on internal efficacy, B = -.035, SE = .029, 95%
CI [ - .098, .016] or PMI efficacy, B = -.010, SE = .028, 95% CI [ -.066, .049].
When these three discrete emotions were simultaneously entered as parallel mediators, a
similar pattern emerged. When internal efficacy was entered as the dependent variable, only
hope exercised a significant mediating influence, B = .28, SE = .065, 95% CI [.161, .414].
Within simultaneous, parallel mediation model, the direct effect of the experimental condition
was also not significant, B = .01, SE = .131, p = .941, 95% CI [-.248, .264]. Identical analyses,
but with PMI efficacy as the dependent variable, yielded a significant mediation effect only of
hope, B = .272, SE = .059, 95% CI [ .155, .385]; similarly, there was no direct effect, B = -.052,
SE = .123, 95% CI [-.293, .189].
The “Left Behind” Sample: Additional Inquiries
It was mentioned earlier that 131 respondents technically did not pass the knowledge
check question about organizational type. Thus, some comments about the full sample, as well as
the sub-sample of respondents who did not pass the knowledge check, are likely to be useful.
When multivariate analyses were run on the full sample (n = 439), the patterns of multivariate
test results were identical to those of the reduced final sample (n = 304) in that the Wilk’s
Lambda and Pillai’s Trace results were significant for valence but not organizational type. As for
the effect of efficacy valence on each of the dependent variables in question, the patterns of
statistical significance were identical for the discrete emotions. Concerning the efficacy
variables, the level of statistical significance (or the lack thereof) was identical for the discrete
emotions across the two samples. For the efficacy variables, in the full sample statistical

finding for fear in the ANOVA outcomes, p = .194 (see Table 1). The improvement in statistical significance for the
PROCESS results is likely due to bootstrapping effects.

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significance levels for PMI efficacy were more robust (i.e., p <. 05 as opposed to p < .10), while
those for external efficacy were less robust (i.e., p < .10. as opposed to p < .05).
Other researchers have also had to grapple with a portion of their participants not
accurately identifying the organization type of the stimulus they used. In Greitemeyer &
Sagioglu (2018)’s study, the authors proceeded to use the full sample, deciding against excluding
respondents who gave an incorrect answer; their reasoning was based on their observation that
patterns of statistical significance were identical across both the inclusive and reduced samples
(p. 69). For the present chapter, the decision was made to primarily use the reduced sample
because of methodological concerns about respecting the results of knowledge checks.
Considerably more respondents incorrectly identified the for-profit version of Civic Med
as a non-profit (86) than those who erred in the opposite direction (i.e., identifying the non-profit
version as a for-profit one) (45). One partial explanation lies in insights generated by research on
organizational identity. There may be certain attributes associated with Civic Med; these
attributes, in turn, shape people’s social and conceptual categorization of organizational identity
(Ran & Duimering, 2007, p. 163). The name of an organization reflects agency in the context of
institutionalization processes; in so doing, “symbolic actions of individual organizations produce
and reproduce patterns in the aggregate” (Glynn & Abzug, 2002, p. 267). When real, identifiable
words are found in an organization’s name, such words can facilitate mental processing on the
part of external audiences, and also carry “well-established sociocultural meanings because they
draw from culturally meaningful and widely understood toolkits” (Glynn & Marquis, 2007, p.
18). In people’s minds, the word ‘civic’ may very well be associated with attributes that evoke
“contributions to the common good and public interest” (Brewer, 2011, cited in Winter & Thaler,
2016, p. 764). The type of activity that Civic Med engages in – the manufacturing and provision

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of prescription drugs at below-market prices – arguably was more likely to be aligned with
people’s mental attributes about non-profit organizations.
In hindsight, there is a possibility that a different name for the hypothetical drug
manufacturer in question could have reduced the number of respondents who did not pass the
knowledge check question about organization type. An organizational name that was not
constituted of real, identifiable words might not have caused concern about a potential ‘priming’
impact of the word “civic”, even though this alternative name also could have increased
ambiguity, as predicted by Glynn and Marquis (2007). The inclusion of additional detailed
information could have functioned as a more explicit dividing line between non-profit and for-
profit organizations. Winter and Thaler (2016) draw upon an extensive body of research on how
people perceive the motivations of different type of organizations. The authors argue that for-
profit organizations might be perceived as “attributing higher importance to objectives that are
linked to self-related motivational factors” as a stronger focus on profit and innovation may be
associated with opportunities to satisfy self-related motivations (p. 767). The authors also claim
that for-profit organizations are correctly viewed as unencumbered by non-distribution
constraints (i.e., a ban on surplus transfers to the people who are in control of the organization, in
particular shareholders, members and managers) (Mori, 2018), in contrast to their non-profit
counterparts.
The substance of Civic Med’s organizational mission most likely precluded including
variations about the public interest, since producing low-cost prescription drugs and involving
consumers in the said process in of themselves reflect a strong public service orientation. That
said, in hindsight, including textual variations around non-distribution constraints, or in other
words, the presence of absence of such constraints, could have reduced the number of incorrect

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responses with respect to organizational type. Such hindsight is further corroborated by a closer
examination of the words used by Greitemeyer and Sagioglu (2018) in describing their for-profit
and non-profit organization narratives. According to the authors, a for-profit organization has
competitive market goals and distributes surplus revenues as profit to its owners; however, a
non-profit organization uses surplus revenues to achieve its goals, and the funds are used to
serve the general public, rather than benefit any owners [italics for emphasis, not in original]
(Greitemeyer & Sagioglou, 2018, p. 69).
Granted, other studies did not provide such additional contextual information about non-
profits and for-profits; furthermore, there was no explicit knowledge check question in the
survey instruments within them (Aaker et al., 2010; Lee et al., 2017). Nevertheless, there is a
positive case to be made for ‘erring’ on the side of including additional contextual information
about non-profits and for-profits, respectively. Especially for enhancing ecological validity,
designing and conducting surveys that measure the public’s knowledge of factual details about
non-profit organizations and for-profit companies would go a long way towards the said purpose.
The results of such surveys are likely to be useful in approximating the ‘optimal’ type contextual
information that best help readers distinguish between these two types of organizations.
Discussion and Conclusion
The findings of the current study showed that messages that show effective input by
consumers in organizational decision-making increase perceptions of three different forms of
efficacy – internal, external, and marketplace influence. There was a significant correlation (r
= .483, p < .001) between the following two efficacy variables: external and marketplace
influence efficacy. External efficacy measured the perception of the extent to which one’s
opinion supposedly is being listened to by drug manufacturers. The focus of marketplace

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influence efficacy was on how one’s own actions could shape the actual actions of drug
manufacturers. Thus, measuring efficacy in shaping marketplace outcomes was equivalent to
evaluating the efficacy of the broader institutional responses to individual action, i.e., response
efficacy. These two forms of efficacy, in turn, were more clearly distinguished from internal
efficacy, which measured individual participant’s perceptions of their own knowledge or
competence.
The current study also had two experimental conditions, with variations made to the
valence of efficacy information and organizational categorization. The data did not show any
direct effect of variations made to organizational type (non-profit vs. for-profit), but there was
one interaction effect for external efficacy. One possible reason behind this outcome is that
because known instances of such participatory decision-making in for-profit companies are
relatively rare, participants may have been more “pleasantly surprised” by this possibility,
resulting in the highest level of external efficacy evaluations across all four conditions. With
respect to the governance of for-profit pharmaceutical companies (and arguably for-profit
companies more generally), there may be a widespread assumption that there is less appetite for
involving consumers in decision-making. When reading about consumer participation in non-
profit organizational decision-making, this may have been more aligned with the public’s prior
assumptions about external stakeholders’ involvement in non-profit decision-making.
Emotions were also accounted for as mediating variables, and the robust, consistent
significance of one type of discrete emotion – hope – was another noticeable finding. When
discrete emotions were included as either a solitary mediator or parallel, simultaneous mediators,
hope was the only discrete emotion for which it significantly mediated the effect of high-efficacy
information exposure on internal efficacy and marketplace influence efficacy. The mediational

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influence of hope was such that the direct effect of efficacy valence variations ceased to be
significant on each of the aforementioned two types of efficacy perceptions; this demonstrates
full mediation, i.e., a type of mediation where the direct effects cease to be statistically
significant (with the mediation being statistically significant instead). According to Zhao, Lynch,
and Chen (2010), full mediation provides support for a complete theoretical framework. Thus,
hope as a discrete emotion can thus be understood as a critical, verified outcome of reading about
messages that demonstrate positive efficacy; the impact of this specific type of hope is also seen
in applications of positive psychology (e.g., Sander, 2011, pp. 309-326), specifically in
workplace and organizational settings (Youssef & Luthans, 2007). Positive psychology has also
shaped the practice of solutions journalism (Benesch, 1998; McIntyre & Gyldensted, 2018), a
specific journalistic approach that strives to cover not just a host of social problems, but also
solutions to those problems. As the stimulus used in the present study imitated a news article, the
findings about hope and efficacy also offer profound insights to those who want to practice
journalism that leads to a more engaged citizenry.
Building on earlier discussions towards the end of the previous section of this chapter, the
manipulation of organizational type in our current study was only partially successful, in light of
both the lack of statistical significance associated with this condition, as well as the act that over
one-third of the sample did not accurately identify the organization type in a way that
corresponded to that in the stimulus they read. The knowledge check question for organizational
type was a binary one, in that people were given two answer choices (non-profit, for-profit). It is
thus also possible, if not probable, that even some of those who successfully passed this
knowledge check screen did so by chance. This possibility is one methodological limitation of
the current study. The weak (or non-) findings with respect to variations in organizational type

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are consistent with some studies where little difference was found between the evaluation of non-
profit and for-profit hospitals (Meier & An, 2020). What may matter more are people’s
motivations; Winter and Thaler (2016)’s study carried out in Germany found that prospective
employees’ preference for working at non-profit, for-profit, or public hospitals hinged on
heterogeneous motivations (e.g., altruism and commitment to the public interest, financial
security). While the current study was not about hospitals per se, it is true that it was about
organizations in the healthcare sector, specifically about prescription drug manufacturing).
Follow-up research may benefit from future investigations into whether there are certain mental
attributes that individuals hold in their minds about healthcare organizations that diminish
differences in perceptions of non-profit and for-profit entities. Additionally, if, and when, people
do see little difference in non-profit and for-profit organizations (including but not limited to the
healthcare sector), it may also be possible that this either consciously or subconsciously mirrors
convergence in manifest behaviors of non-profits and for-profits (Ramirez & Janiga, 2009).
“Halo Effect” of Perceiving Organizations
People’s perceptions of one type of organization may influence those of another type of
organization. Perceptions of one type of organization are likely to constitute a mental model,
which in turn influence perceptions of other types of organizations. This ‘halo effect’ of sorts
may also manifest itself when exposure to new information about one specific organization type
or sector shapes interpretations of new information about other organizations and sectors (P.
Riley, personal communication, March 25, 2020). Partnerships between organizations that are
situated in different industries or sectors may evoke such halo effect-shaped responses on the
part of readers. In the real world, numerous partnerships between have been established between
for-profit corporations on the one hand, and non-profit organizations and non-governmental

90
organizations (NGO) on the other; these partnerships often seek to address a specific social
problem (e.g., child poverty, homelessness, starvation). Shumate and O’Connor (2010)
conceptualized the term ‘NGO-corporate alliance’ as a form of inter-organizational
communication relationship, symbolized in order to shape mobilization and draw funding; the
authors also claim that stakeholders (e.g., consumers and citizens) “communicatively co-
construct the economic, social, cultural, and political value of cross-sector alliance” (p. 578).
Case studies that demonstrate the ‘pay-what-you-want’ business model show both the
innovative potential and realistic constraints associated with consumer participation and
partnerships between non-profit and for-profit organizations for pursuing a social good.
Restaurants have operated on this model, with the provision of services requiring donations of
any amount, rather than a fixed price that explicitly accounts for both profit and cost. The
example of PaneraCares, hinted at the beginning of the current chapter, is one such case study.
Initiated in 2010 as the non-profit arm of its namesake bakery chain, PaneraCares offered meals
at a suggested donation price, with the goal being increasing awareness about food insecurity
(Houck, 2019). At a PaneraCares restaurant, homeless individuals were able to eat free of charge,
with other consumers (i.e., those who are not homeless) making additional donations to cover the
meals of the homeless individuals (Eckhardt & Dobscha, 2019). Interestingly, when asked to not
simply provide additional donations, but also provide direct into the operational side of an
individual PaneraCares franchise, these same consumers expressed considerable discomfort; this
was arguably one factor that led to the discontinuation of the PaneraCares experiment in 2019
(Houck, 2019).

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Promise and Limitations of Consumer Participation
Consumer participation in organizational decision-making is not invariably an
unqualified solution; one potential reason is that there is most likely a distinction between
external and internal evaluations. Reading about PaneraCare’s involvement of consumers in its
decision-making, in either in a news article by a news media outlet or a news release produced
directly by PaneraCare or a third party organizations, is likely to be different from being directly
involved as an internal stakeholder in PaneraCare’s decision-making. The research design of the
current study was focused on external stakeholder perceptions of efficacy; one limitation is that it
did not account for the possibility that as internal stakeholders, in actual lived, non-experimental
contexts, consumers may very well experience participation in decision-making in a real-life
pharmaceutical producer, be it non-profit or for-profit, as a considerably greater ordeal.
These constraints with respect to consumers’ participation as internal stakeholders
nevertheless do not diminish the possibility that there may be positive, ‘empowering’ effects for
external stakeholders; some of them, in turn, could plausibly become, over time, more favorably
disposed to playing more active decision-making roles in the organizational contexts of their
everyday lives. Within the pharmaceutical industry, the sustained push by NGOs – an external
stakeholder – resulted in company insiders being persuaded to successfully expand the concept
of corporate social responsibility (CSR) for Novo Nordisk, a major multinational pharmaceutical
company (Girschik, 2018). Another angle for future research is to make variations on the
participative efficacy of the employees within an organization, non-profit or for-profit; these
studies would evaluate how people who are external stakeholders (for instance, citizens and
consumers) respond differently to messages about the impact of the voice of employees, i.e.,
internal stakeholders, of a given organization.

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This specific research direction is also based on real-life examples. Through the
Employee Stock Ownership Plan (ESOP), some companies are wholly owned by the employees
themselves, and some commentators have made a case that such companies can offer one
corrective solution to rampant wage inequality (Schneider, 2019). Whether or not a company is
wholly owned by employees itself may very well constitute an experimental factor, in addition to
variations in the efficacy of employee voice. This would be a useful addition to the findings
identified in the current study, which looked at the effect of variations to consumer voice.
Conclusion: Participating in Solving “Wicked Problems”
The reference to the ESOP and how organizations can be managed in a way that both
empowers individuals who may otherwise not have as much influence, with policy mechanisms
one pathway through which such organizations can become more of a rule than an exception.
One fundamental assumption of the current study was that a specific form of “market failure”
(Geiger & Gross, 2018), i.e., the inadequate provision of affordable prescription medicines for all
members of the public, can be remedied through the efforts of organizations and consumers. This
specific instance of market failure constitutes a “wicked” or “complex” problem mentioned
earlier in the dissertation (Alcott & Head, 2017). Just as the causes are complex, it is also often
the case that there is no simple, singular solution; another layer of complication is that relevant
stakeholders invariably perceive these problems differently, often from divergent and contrasting
perspectives (Elia & Margherita, 2018).
News coverage and narratives about organizations that purport to offer one solution to
such a market failure-cum-wicked problem will have to not only strengthen perceived efficacy of
citizens themselves and organizations in the field, but also lead to more vigorous and sustained
information-seeking about the solutions and problem. When engaging with media narratives

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about the participation of ordinary citizens and consumers in such problem-solving
organizations, people might come away with the idea that such participation is an inherent,
normative good in and of itself. Organizational outcomes either do not adequately account for
such participatory input (Graham, Kessler, Kim, Ahn, et al., 2018), or even when they do, the
ultimate outcomes are not necessarily positive for the stakeholders involved.
This dilemma can be observed in examples of participation in decision-making of non-
profits, for-profits, as well as government policy mechanisms; it is likely to be further amplified
when the current outcomes of participation are likely to be transient, with a slew of unanticipated
and unintended consequences (Merton, 1936; Giddens, 1976, 1993; de Zwart, 2015). At the time
of writing (June 2020), there is a global crisis caused by COVID-19, a novel form of the
coronavirus. The current study is a narrative that emphasizes the critical importance of hope and
continued participation, as well as the need to incorporate sustained, effective voice on the part
of average citizens. This is especially relevant when uncertainty reigns supreme with respect to
the consequences of individual and collective decision-making in the short-, medium- and long-
term horizons. This chapter concludes with a vigorous call for reimagining how ‘things are
typically done’ in our everyday lives, not the least how organizations are run.

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CHAPTER 4: “CAN-DO” MEDIA? FINDING EFFICACY IN U.S. NEWS EDITORIALS
Introduction
In the United States, net spending on pharmaceuticals reached $324 billion in 2017, with
spending on pharmaceuticals per capita between 20% and 54% higher than that in other
industrialized countries; total U.S. spending is expected to increase by 2% to 5% annually over
the next five years (Wineinger, Zhang & Topol, 2019). This is largely because of the high price
of prescription drugs, as well as steep increases in the price of such drugs. Between 2012 and
2017, the prices of 48 out of 49 brand-name drugs reported regular price increases of more than
50% observed for 36 such drugs (Wineinger et al., 2019). For-profit manufacturers of branded
drugs, known in popular parlance as ‘Big Pharma’, have largely been responsible for these price
hikes. As repeatedly emphasized throughout the chapters of this dissertation, the impact of legal
and policy developments with respect to the pharmaceutical industry, and the pricing and
production of prescription drugs has been felt by patients, consumers, and physicians.
Additionally, such developments have also shaped the institutional power of different
stakeholder groups in medicine and healthcare. Pharmaceutical companies fall within the
category of corporate sellers (i.e., service producers and manufacturers of healthcare-related
products), one of the five groups identified by Hafferty and Light (1995) in their identification of
tensions, or countervailing pressures, in the field of medicine and healthcare. Media scholars
have shed light on how news media covers these groups differently, with some groups enjoying
considerably more positive media coverage in terms of frequency and tone (Hartley & Coleman,
2007). The pharmaceutical industry was one group that received more positive and extensive
coverage, compared to healthcare providers, government agencies, and consumers. A salient
feature of U.S. media coverage of the pharmaceutical industry revolved around the issue of

95
direct-to-consumer (DTC) advertising. DTC advertisements in newspapers, television and other
media directly serve the interests of for-profit drugmakers, highlighting the commercializing
influence of industry on media coverage of health issues more broadly (Crosswell & Porter,
2016). Indeed, specifically on the issue of DTC advertising, news media showed a pattern of
conspicuous under-reporting of individuals and organizations critical of DTC advertisements
(Coleman et al., 2006).
These scholars’ work on how the institutional landscape is reflected and reproduced by
media coverage, in turn, has justified a consideration of the role of not only the pharmaceutical
industry and government policy, but also patient advocacy and non-profit organizations, health
insurance companies and pharmacy benefit managers (PBM). PBMs function as third-party
administrators of prescription drug programs for a variety of health plans, including those for
commercial health, self-insured employers, Medicare Part D, and federal/state government
employees. These PBMs operate within integrated healthcare systems (such as Kaiser
Permanente), retail pharmacies (e.g., CVS Pharmacy, Rite-Aid), as well as insurance companies
(Feldman, 2016). PBMs also have a role in the pricing of prescription drugs, and they especially
contribute to high drug prices when they are owned by a pharmacy, as that removes incentives
for price negotiation (Feldman, 2016). Indeed, PBMs “negotiate rebates from drug manufacturers
in exchange for giving the manufacturers’ drugs preferred status on a health plan’s formulary”;
as these rebates are typically a percentage of a drug’s list price, drug makers are pressured to
increase list prices in order to satisfy PBMs’ demands for higher rebates, even as a portion of the
rebate money does reach ordinary consumers in the form of lower co-payments (Shepherd, 2019,
p. 2).

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Even as these other organizational and institutional forces are relevant, the power of the
pharmaceutical industry itself looms the largest. News media favorably cover the pharmaceutical
industry’s actions, with particular attention paid to new drug development. This pattern
showcases an inherently pro-capitalistic bias in news coverage, with market actors and their
actions amplified to audiences. Other countries’ media coverage demonstrates similar kinds of
bias (and neglect). For example, research findings indicate that Australian newspapers obscured
the identity of individuals and organizations that would gain most from the privatization of
healthcare, intentionally or subconsciously, effectively concealing the state of power relations in
the healthcare sector from the Australian public (Lewis, Collyer, Willis, Harley et al., 2018.).
Similarly, Canadian media outlets have tended over-report benefits and under-report risks of new
prescription drugs, respectively (Cassels, Hughes, Cole, Mintzes et al., 2003).
Returning to the U.S. context, what is relatively less known is how news media
specifically covers the role of the pharmaceutical industry with respect to the pricing of
prescription drugs. Indeed, few studies have analyzed how news media construct attributions of
responsibility with respect to the degree of ‘blame’ that can be placed on the pharmaceutical
industry and/or other organizational and institutional actors (such as the state or federal
government). Additionally, few studies have looked at the ways in which news media frame how
the possibility of meaningful change to the status quo (i.e., high prescription drug prices and lack
of affordable medicine). The focus on news media coverage and framing of the pharmaceutical
industry is particularly apt, in light of the highly publicized scandals of recent years involving
many well-known pharmaceutical companies, such as Turing Pharmaceutical, Mylan, and
Purdue Pharma. The subsequent sections provide a review of relevant literature.

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Attributing Responsibilities in News Media
Corporations and Corporate Activity
The current study situates itself within research on media frames and their relevance to
shaping public opinion (Gamson & Modigliani, 1989). Media frames can also serve as a resource
through which people make connections with their own personal experiences in agitating for
social change. Framing involves both “selecting some aspects of a perceived reality and making
them salient in a communicating text,” serving also the following functions: defining problems,
diagnosing causes, making moral judgments, and suggesting remedies (Entman, 1993, p. 52).
Within this process, either explicitly or implicitly, responsibility attributions have to be made.
Scholars have distinguished episodic (i.e., focus on individual-level incidents) from thematic
(i.e., focus on broader context, such as policy) frames (Iyengar, 1991). Different patterns and
content for episodic and thematic attributions are constituted in shared, pervasive assumptions
about society (Pan & Kosicki, 1993). However, contests between different perspectives arise
when there is a tension between which of these shared assumptions ought to be given greater or
lesser priority. On issues that elicit, and are defined by, such contestation, the political
orientation of a news media outlet also matters: conservative-leaning newspapers were more
likely to make individual-level responsibility attributions for poverty, in comparison to their
liberal counterparts (Kim, Carvalho, & Davis, 2010).
Another related area of contestation, where political ideology shapes people’s perceptions
to a considerable degree, is the role of corporations within our society. Those who espouse a
free-market, libertarian perspective posit that corporations are entities that exist to maximize
profit and returns to shareholders (narrowly defined), however, the average middle-of-the-road
citizen is more likely to hold the view that corporations also have a responsibility to stakeholders

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and society more broadly defined. It can be argued that these tensions are manifested very
acutely in the pharmaceutical industry, perhaps more so than other industries. After all, average
profits of pharmaceutical companies are much higher than those in other industries, even though
large research investments are needed to develop new drugs. Furthermore, people depend on
pharmaceuticals for literally life-and-death issues, which sets the industry apart from other
industries as access to effective and affordable medicines for those who need them can be seen as
a core social responsibility of the pharmaceutical industry (Leisinger, 2005; DeAngelis, 2016).
Responsibility attributions can vary also with respect to the type of societal actor in
question, e.g., individuals, groups, or governments (Semetko & Valkenburg, 2000). Corporations
constitute a unique form of societal actor (Banerjee, 2010), and the news media make attributions
generally about corporations and corporate activities but often focus on crisis situations.
Research by An and Gower (2009) identified three distinct crisis categories, based on Coombs’
(2006) framework: victim (e.g., a company impacted by natural disasters), accidental (e.g.,
technical error recalls), and preventable (e.g., company misdeeds). Responsibility attributions
were made most frequently in news stories characterizing preventable crisis situations;
furthermore, victim- and accidental- crisis news each showed a greater tendency to make
organizational-level as opposed to individual-level attributions (An & Gower, 2009). Clearly
there is a higher degree of perceived agency associated with preventable situations (e.g., “More
could have been done on the part of the company to prevent such an incident from happening”).
These findings also hold in news coverage of situations where a corporation is explicitly
involved in a conflict with another organization, particularly a non-corporate one. For example,
news coverage of the conflict between British Petroleum (BP) and Greenpeace in the aftermath
of the 2010 Gulf of Mexico oil spill incident, found that positive frames were more associated

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with the coverage of Greenpeace (Garcia, 2011). That study also found that BP’s current actions
were often framed with reference to a prior incident – the 1989 Exxon Valdez oil spill – that was
widely perceived as an instance of a preventable organizational wrongdoing (Palmer, 2012). The
actions of for-profit corporations at times are framed as being connected to broader industry-
wide behavior; alternatively, their actions may be ‘compartmentalized’ as exceptions and one-off
incidents. Across German news media’s coverage of the 2015 Volkswagen recall scandal, one
newspaper - Die Süddeutsche Zeitung - identified a contextual frame, describing the scandal as
occurring at the “intersection of the company and the car industry” (Clemente & Gabbioneta,
2017, p. 296). On the other hand, a different newspaper (Die Wolfsburger Allgemeine Zeitung)
primarily utilized a scapegoating frame referencing a few individual managers who caused the
scandal and stating that the “actions of a few should not be confused with the good work done by
the majority of employees” (Clemente & Gabbioneta, 2017, p. 297). The contrast between these
two frames corresponds to worldviews that are either more skeptical or more trusting of the
impact of corporations in society.
Health Promotion and Health Organizations
Public health receives considerable attention from the news. For instance, the analysis of
Chinese news coverage of depression by Pan, Liu, and Kreps (2018) showed that state-owned
media most frequently made individual attributions, whereas citizen journalists and citizen
groups tended to make societal-level attributions. Similarly, press releases originating from
patient advocacy organizations such as the American Diabetes Association (ADA) surprisingly
made greater reference to individual behavior, rather than societal conditions, as the primary
driver of diabetes (Chaufan & Saliba, 2019) instead of systemic issues such as larger food
portions in restaurants or the almost ubiquitous use of corn syrup in American processed food.

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Consistent with the findings by Chaufan and Saliba (2019), as well as earlier research (Hartley &
Coleman, 2007; Coleman et al., 2006), a longitudinal content analysis study of U.S. media
coverage over an 18-year period (1993-2010) revealed that the pharmaceutical industry was the
least attributed of all actors for its role in causing healthcare costs to rise. Not surprisingly,
individual patients were the most frequently attributed for their causal role in the increasing costs
of healthcare (Foster, Tanner, Kim, & Kim, 2014; Kim, Tanner, Kim, Foster, & Oh, 2017).
Frames, including but not limited to those found in news media, can help mobilize people
to engage in collective action (Gamson, 1995; Snow & Benford, 1992). A given media ‘unit’,
such as an excerpt in a news article, can reference both causes and solutions for salient social
problems (Kensicki, 2004). In news media, frames about health focus on individually-oriented
causes and solutions. Stories about both policy and society-level solutions exist, but they are not
as prevalent (e.g., Zhang, Jin, Stewart, & Potter, 2016).
All these findings regarding how responsibility for various problems are more likely to be
attributed in news media coverage to individuals instead of corporations and corporate activity,
support an inquiry into news media coverage of the pharmaceutical industry, especially given
concerns over the high price of prescription drug prices. Although not all problems have
solutions, the subsequent section will provide a review of the concept of efficacy and its potential
application to news media coverage of the industry.
Conceptualizing and Operationalizing Efficacy in News Media
Efficacy can be defined as a sense that one’s actions matter and can make a difference to
a given process or outcome (Bandura, 1997). Efficacy is positively associated with mobilization
and collective action, as documented in numerous instances of experimental research across a
variety of contexts (e.g., Murphy et al., 2015; Walter et al., 2017; Halpern et al., 2017). Across

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both health and non-health contexts, scholars have identified different ways in which journalists
have constructed particular definitions of efficacy in news media coverage. For example, in a
study of efficacy as a type of call to action message (e.g., urging people to quit a harmful health
behavior), Blake, Kaufman, Lorenzo and Augustson (2015) found that less than five percent of
U.S. local and national television news coverage of tobacco included such messages. Efficacy
messages, however, were more frequently observed in media coverage of two infectious
diseases, i.e., West Nile Virus and avian influenza (Evensen & Clarke, 2012).
Efficacy framing has been observed in news coverage of climate change. A comparison
of The New York Times, The Wall Street Journal, The Washington Post, and USA Today over a
six-year period (2006-2011) indicated that the majority of news articles discussed actions related
to climate change, yet, climate change impact was more likely to be discussed without reference
to actions (Feldman, Hart, & Milosevic, 2017, p. 490). The authors also found that The Wall
Street Journal was the least likely to discuss the impacts and threats of climate change, and
where the news coverage included efficacy information, it was primarily negatively-valenced,
i.e., emphasizing the difficulty, cost, and even impossibility of proposed actions (Feldman et al.,
2017). These findings may be related to the pro-corporate editorial policies of The Wall Street
Journal but they are also broadly consistent with those from a study that focused on how U.S.
network television news outlets framed climate change issues during a roughly identical period
(2005-2011). This study found that efficacy information was included inconsistently and dwarfed
by coverage of threats (Hart & Feldman, 2014).
Studies have also coded news coverage to determine both attributions of responsibility
and efficacy. A comparative analysis of American, Chinese, and Canadian television coverage of
the 2009 U.N. Climate Change Conference showed that American television outlets were

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significantly more likely to emphasize their own country’s national efficacy (i.e., indicating that
their own country has the ability to mitigate climate change) (Liang, Tsai, Matthis, Konieczna et
al., 2014). As indicated earlier, efficacy is closely intertwined with, and influences, mobilization
across multiple social problems, including those that are predicated on political participation
(Van Zomeren et al., 2008; Cohen-Chen & Van Zomeren, 2018). The issue of high drug prices is
a multifaceted problem that has a political dimension. There has been some recent increase in
bipartisan recognition that policies to address the costs of prescription drugs are needed but the
parties maintain divergent perspectives about the extent to which pharmaceutical companies
ought to prioritize public needs over the profit motive.
Research Questions, Research Design, and Coding Categories
The current study specifically analyzes newspaper editorials. Newspaper editorials have
been investigated by numerous media scholars on a variety of issue topics: affirmative action
(Richardson & Lancendorfer, 2004), the War on Iraq (Mitman, Nikolaev, & Porpora, 2012),
China as an emergent global power (Golan & Lukito, 2017) and many others. Editorial content is
interesting because it is less constrained, is a space where editors and other invited writers can
voice their opinions, and the perspectives can reflect multiple segments of American society
(Richardson & Lancendorfer, 2004). In-depth analyses of editorial pages of select newspapers
have shown that diversity of sources fall short of expectations (Day & Golan, 2005) and the tone
of coverage on certain aspects of an issue (e.g., the morality of war) indicates that editorial biases
are evident (Mitman et al., 2012).
Even as these limitations are acknowledged, editorials nevertheless constitute a worthy
site for research for the following reasons: First, editorials reflect subjective opinions and
perspectives, revealing socially-constructed notions about a given topic or issue. Second,

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editorials encourage citizens’ communication with policymakers (Golan & Lukito, 2017), albeit
often in an asynchronous way, such as comments and replies to editorials posted in online news
portals. The editorial discourse about the pharmaceutical industry is likely to be complex and
include competing ideas about market innovations and failures with respect to patient access to
pharmaceuticals (Geiger & Gross, 2018). It will also likely include broad issues such as whether
the aims and practices of for-profit corporations can be content with being ‘merely’
compensatory (i.e., engaging in compensatory action to mitigate the conditions of absolute and
relative capitalistic inequality) or if organizations need to change from for-profit to not-for-profit
in order to be substantively transformative (i.e., seeking to transform capitalistic structures
altogether so as to realize substantive equity and equality) (Newey, 2018). The controversies
over the pricing of prescription drugs correspond to differing levels of expectations about the
intentions and behavior of for-profit companies more generally, as well as those of affiliated
institutions and organizations such as government (local/state/federal), insurance companies, and
patient advocacy organizations.
It is therefore expected that one element of the news media, editorial content, will make
responsibility attributions for the actors involved in the pharmaceutical industry, whether it is for
causing the problem or solving it (e.g., Gounder & Ameer, 2018; Zhang et al., 2016; Zhang, Jin,
& Tang, 2015). The current study examines whether the editorial segment of the news invokes
causal or solution responsibility of particular organizational or institutional entities. Prior media
and journalism scholarship have identified efficacy frames as just one type of framing device.
Liang et al (2014) f significant statistical correlations between treatment responsibility and
national efficacy frames in their three-country content analysis of climate change coverage by
the media. Thus there is reason to investigate another issue of interest to the current study - high

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prescription drug prices – to explore whether similar relationships emerge. Thus, the following
research questions are considered:
RQ1. How do the editorials attribute causes and solutions to the problem of high
prescription drug prices?
RQ2. How do the editorials discuss pharmaceutical advertisements, and what kind of
relationships can be identified between discussions of pharmaceutical advertisements on
the one hand, and coverage of causes and solutions on the other?
Efficacy is understood as encompassing a range of argumentative claims and information
concerning the impact of present and future action(s). Appeals for mobilization and activism are
included as well, as there is an assumption that they can make a difference when and if enacted.
This somewhat broad-based definition and conceptualization of efficacy is supported by prior
research, in which efficacy was conceptualized as a sub-dimension of impact and action
(Feldman et al., 2017). Thus, the following research question was also posed:
RQ3. How do the editorials discuss efficacy with respect to the problem of high
prescription drug prices?
Media coverage of certain issues can also differ based on national origin (e.g., Yang,
2003; Liang et al., 2014; Su & Borah, 2019) or newspaper ownership (e.g., Zhang et al., 2015;
Baum & Zhukov, 2019). Local and national newspapers have shown differences in their
coverage of sensitive, polarizing political issues, albeit on a case-by-case basis. Local and
regional newspapers may very well devote more coverage to organizations operating in local and
regional contexts, and this speculation has been supported in research on local media coverage of
locally-based nonprofits and businesses (Nah, 2009; Gurun & Butler, 2012). The geographic
location of a newspaper can lend itself to certain class biases in coverage of regional problems

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(e.g., opioid crisis, Appalachian poverty). Indeed, researchers have shown that the concentration
of elite media (with national and international audiences) in coastal cities has led to the creation
of a ‘media bubble’ that privileges the perspective of economic and cultural elites (Friedman-
Rudovsky, 2017; Shafer & Doherty, 2017, cited in Schrader, 2018, pp. 1-2).
Another example is coverage of the construction of the Keystone Pipeline, where there
was little difference in media coverage among business newspapers (e.g., The Wall Street
Journal), major metropolitan newspapers (e.g., The New York Times), and local papers (e.g.,
Lincoln Journal Star). For other issues, however, statistically significant differences between
local and national newspapers have been seen in the coverage of the Iraq War (Carpenter, 2007)
or stories about the Zika virus (Jerit, Zhao, Tan, & Wheeler, 2019). Additionally, information
sources differed between these two types of newspapers: in writing about storm-related power
outages, a key national newspaper (New York Times) were found to have interviewed residents
more frequently than local newspapers (Kloster, Morzillo, & Volin, 2019). Thus, the following
research question is also of interest:
RQ4. What differences exist in media coverage of high prescription drug prices across
local/regional newspapers and national newspapers?
The issue of prescription drug prices is, on the surface, arguably less geographically-specific
than, for instance, the opioid crisis or structural poverty in Appalachia. That said, geographical
location plays a part in the type and quality of treatments patients receive, with patients also
prescribing different treatments in quality for the same disease; furthermore, racial composition,
as well as wealth and state-level healthcare laws all indirectly shape inequality in drug
prescriptions (Melamed & Rzhetsky, 2018). These findings thus provide further support for

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accounting for regional variations, as well as variations in the newspaper type of ‘status’ in the
American news media landscape.
Method and Coding Procedures
Editorials were searched on the ProQuest database, covering a four-year period (17 Sep
2015 ~ 17 Sep 2019). On September 17th 2015, Martin Shkreli and Turing Pharmaceutical raised
the price of Daraprim from $13.50 to $750 per tablet. It has been suggested by media
commentators that this had the impact of spurring national conversations about the complexity of
drug pricing and inefficiencies in the generic drug market (Tirrell, 2018). Other pharmaceutical
industry-related scandals have also occurred during this time period. It was in August 2016 that
Mylan’s price hike of EpiPen started garnering attention by news outlets and politicians (notably
Senator Bernie Sanders). In September 2019, Purdue Pharma, the manufacturer of Oxycontin,
declared bankruptcy following many news reports of its culpability in the opioid crisis. This
period is also notable for the election of Donald Trump to the presidency (November 2016) and a
noticeable shift from free-market orthodoxy on the part of the incumbent Republican Party, as
evidenced by bipartisan support offered to legislative initiatives such as the Right to Try Act
(2018) and Ensuring Timely Access to Generics Act (2019). Much of this period overlaps with,
and reflects, the post-2016 American political landscape, one that is characterized by growing
poverty in the ‘Rust Belt’ and promises by the incumbent president to help the bring back jobs
through a shift to more protectionist policies. In this environment, these editorials are likely to
reveal rich, and sometimes contradictory insights.
In light of the salience and relevance of generic drugs to the conversations about drug
prices, the following search terms were applied on ProQuest database: “(generic drug prices
AND generic companies) OR (generic drug pricing AND generic companies).” The search for

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articles was supplemented with nearly-identical search terms - “(drug prices AND company) OR
(drug pricing AND company) OR (drug price AND pharmaceutical industry) OR (drug pricing
AND pharmaceutical industry.” Excluded from analysis were articles that had a predominantly
international focus (e.g., global development or global trade), as well as those that were primarily
or exclusively about Medicare or medical insurance. Also excluded were those that offered
commentaries about each of the following elections and political campaigns: a) 2016 Presidential
Election; b) 2018 Midterm Election; and c) 2020 Presidential Election. Katherine Fink and
Michael Schudson (2014), in their longitudinal analysis of U.S. news coverage on the emergence
of ‘contextual reporting’ excluded election years so as to minimize the likelihood of political
campaign-related news crowding out other types of news.
The research questions pursued by this study made it virtually impossible to exclude
those election years; nevertheless, the exclusion of election - and campaign- related news (if not
at the publication year level) was still deemed to be a beneficial approach. The final sample was
reduced to under one hundred seventy editorials. As shown by Appendix A, the editorials were
published in either a national newspaper (i.e., The Wall Street Journal, Chicago Tribune, Los
Angeles Times, The Washington Post, The New York Times, Boston Globe) or regional/local
newspapers across the United States. The criteria for categorizing these newspapers were based
on prior research, which had identified these newspapers as either national or elite newspapers
(Smith, 1993; Izadi & Saghaye-Biria, 2007; Elmasry, 2009; Trevino, Kanso, & Nelson, 2010;
Marcel, 2013). For the current study, such newspapers are categorized as national, as it serves as
a clearer contrast to regional newspapers. A total of 44 editorials were from these seven national
newspapers, and 126 editorials were published in 53 regional newspapers, across 29 U.S. states.
The papers included in the sample included Mercury News (San Jose, CA), Pittsburgh Post-

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Gazette (Pittsburgh, PA), Austin-American Statesman (Austin, TX), Savannah Morning News
(Savannah, GA), and others. The full list of newspapers and more detailed information about
each of these newspapers are provided in Appendix A.
The sampling of regional newspaper editorials reflected the emphasis placed on local
journalism (e.g., Kim et al., 2017; Mitman et al., 2012). For the current study, a quantitative
content analysis was conducted, based in part on deductive coding categories identified in prior
research about efficacy (Evensen & Clarke, 2012; Hart & Feldman, 2014; Feldman et al., 2017;
Liang et al., 2014) and attributions of causal responsibility (Kim et al., 2010; Kim et al., 2017;
Zhang et al., 2016). For the editorials in which some type of efficacy message was identified,
additional qualitative frame analyses were carried out, using specifically the Gioia method for
identifying inductive themes from qualitative data (Gioia, Corley, & Hamilton, 2012). A
combination of two or more methods in analyzing news media data is not unprecedented, e.g.,
Kogen (2015)’s use of both frame analysis and critical discourse analysis in analyzing American
news media’s coverage of hunger. A more detailed explanation of the Gioia method, and the
rationale for adopting the said method for follow-up inductive analyses of the data, will be
provided later in the study.
The present study differentiated between two types of coding categories - descriptive
codes (DC) and interpretive codes (IC). For the descriptive codes, the first coder was solely
responsible for coding, as the information sought out by these codes was arguably more
descriptive. With respect to the interpretive codes, coding was conducted independently, yet
iteratively, with a second coder. Two types of information were categorized as descriptive codes:
newspaper (i.e., whether a newspaper is local or national) (Appendix C) and author affiliation
(Appendix D), even though only the former was directly accounted for in the analysis of the

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editorials. With respect to interpretive codes, there were four broad categories: advertising,
causal responsibility, solution responsibility, and efficacy. For the interpretive codes, coding was
conducted using a binary present/not present, with the primary unit of analysis corresponding to
a single editorial, with specific attention paid to the experts mentioned within the editorial. The
following are the interpretive codes used for the current study.
Advertising & Commercials. Each article was coded for whether there was reference to
DTC advertisements specifically and drug advertisements and commercials more generally.
Causal Attribution of Responsibility (CR). Each article was coded for whether it made
an attribution for high prescription drug prices to any of the following causes or actors:
Government & Policy, Insurance Industry, Pharmacy Benefit Managers (PBM), and
Pharmaceutical Industry. These causes were identified and incorporated into the coding scheme
based on popular mass media, as well as academic research in health communication (Coleman
et al., 2006; Hartley & Coleman, 2007).
Solution Attribution of Responsibility (SR). Here, each article was analyzed with respect
to whether there was mention of either a specific solution being proposed, or an invocation of the
responsibility to offer a solution to the problem of high prescription drug prices. The following
solution factors were considered and coded for: legislative & policy (i.e., reference to specific
remedial actions in legislative and policy arenas), market competition (i.e., acceptance and
promotion of broader market forces and enhanced, fair competition between companies as a
solution) and nonprofit & advocacy (i.e., acknowledgment of nonprofit drug manufacturers and
advocacy organizations as providers of solutions). Attribution of solution responsibility to
nonprofit & advocacy organizations was considered because of an array of consumer and patient
advocacy organizations that have historically been active with respect to efforts to lower

110
prescription drug prices, as well as nonprofit drug manufacturers such as Civica Rx and Fair
Access Medicines founded in recent years.
Efficacy. If an article mentioned either a present action that was having an impact, or a
mobilizing appeal for action, the authors differentiated between whether this mention was geared
towards constructing efficacy on the part of individual consumers and citizens, or the public
(individual & public efficacy) and whether it did so with reference to specific organizations and
broader institutions (organizational & institutional efficacy).
A given article could be coded for multiple sub-dimensions or sub-categories such as
causal responsibility, solution responsibility, and efficacy frame categories. For instance, an
article may have multiple causal and solution responsibility attributions, and both types of
efficacy sub-categories may be coded within the same editorial.
Analysis and Interpretation: Content Analysis
Quantitative content analysis was conducted using SPSS 26, with the findings of content
analysis reformatted from coding by the first and second coder respectively on Dedoose and
Atlas.Ti. Intercoder reliability, measured in Cohen’s Kappa (k), was considered satisfactory for
each of the interpretive categories, ranging from .685 to .926. Figures 8 and 9 provide an
overview for the following types of information about the editorials: year of publication and
author institution.

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Figure 8. Publication Year Distribution

Figure 9. Breakdown by Author’s Institutional Affiliation

* ‘Anonymous’ authors were wholly from the Wall Street Journal.
** ‘Other’ included authors who did not display a unique institutional or organizational affiliation.

Figure 1 shows a roughly even distribution of editorials from four of the five years in the
time period of interest. And according to Figure 2, it perhaps is not surprising that almost two-

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thirds of all editorials were written by self-identified journalists, either writing as a member of
the Editorial Board of the newspaper in question or as an invited columnist from a separate paper
that may be either unaffiliated or affiliated with the newspaper in which the editorial was
published. Public officials - i.e., legislators and policymakers at the federal, state, and
local/municipal levels - constituted the second largest bloc of authors, at little over a tenth of all
authors. Several of these editorials also had multiple authors; the specific steps through which
authors’ institutional and organizational affiliations were identified are indicated in Appendix D.
Table 6 shows the distribution of interpretive codes for both for the entire sample and by
newspaper type, addressing RQ1 and RQ2, respectively.

Table 6. Distribution of Interpretive Codes - Entire Sample and by Newspaper Type
Total
(n = 170)
National
(n = 44)
Regional
(n = 126)
Chi-square
Advertising/Commercials
(k = .926)
13.5% 11.4% 14.3% .238
Causal Responsibility (CR)
(k = .924)
74.1% 65.9% 77.0% 2.085
CR - Pharmaceutical Industry
(CR-Pharma) (k = .924)
62.4% 52.3% 65.9% 2.57

CR - Insurance Industry
(CR-Insurance) (k = .876)
10.0% 6.8% 11.1% .668
CR - Pharmacy Benefit Manager
(CR-PBM) (k = .965)
8.8% 9.1% 8.7% .005
CR - Government & Policy (CR-
Gov) (k = .827)
22.9% 22.7% 23.0% .002
Solution Responsibility (SR)
(k = .737)
79.4% 79.5% 79.4% .001
SR - Legislative & Policy
(k = .685)
70.0% 63.6% 72.2% 1.145
SR - Market Competition 34.1% 47.7% 29.4% 4.892**

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(k =. 760)
SR – Nonprofit & Advocacy
(k = .886)
2.9% 0.0% 4.0% 1.799
Efficacy (k = .807) 58.2% 45.5% 62.7% 3.987**
Individual/Public Efficacy (k
= .796)
25.9% 15.9% 29.4% 3.078
+

Organizational/Institutional
Efficacy (k = .823)
48.2% 38.6% 51.6% 2.191
*p < .10, ** p < .05, + p < .01
Overall, almost three-fourths of all editorials included at least some causal attribution,
and causal attribution to the pharmaceutical industry was present in almost two-thirds of the data.
Causal attributions to government and policy were found in a quarter of all editorials, with fewer
causal attributions made to the insurance industry and PBMs. The role of government and
legislatures as solutions providers, in contrast, was observed across seventy percent of the
editorials. In a departure from media researchers who have identified news media emphasis on
the activities of nonprofit organizations (Hale, 2007; Olofsson, Weible, Heikkila, & Martel,
2018), less than five percent of all editorials included a reference to the ‘solution-generating’
activity of advocacy organizations or nonprofits. There was little evidence that causal
responsibility attributions were different depending on newspaper type, although for specifically
causal responsibility attributions to the pharmaceutical industry, statistical significance for the
chi-square tests approximated marginal significance, p = .109.
While not directly within the scope of the research questions, identical analyses were also
run as to whether there were statistically significant differences across the publication years. In
2019, newspapers were marginally less likely to attribute causal responsibility to PBMs than in
other years, with 18.9% of newspapers that year making such an attribution, X
2
(1, N = 170) =
9.275, p < .10. In the same year, newspapers were also less likely to make causal attributions to

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the pharmaceutical industry, X
2
(1, N = 170) = 10.998, p < .05, even though the difference was
arguably minimal (45.9% of editorials made attributions, versus the 54.1% that did not). The
opposite, however, was true for 2015; for this year, newspaper editorials were actually far more
likely to attribute causal responsibility to the pharmaceutical companies (86.7%) than not
(13.3%).
It may be the case that the eruption of major pharmaceutical industry scandals in 2015
sparked an increase in causal attribution to the pharmaceutical companies, even though the
relatively small sample size for 2015 (15 editorials in total) lends itself to caution against
drawing firmer conclusions. A similar type of caution is also advisable when drawing insights
about editorials published in 2019 (37 editorials in total), although one common denominator is
that both 2015 and 2019 were years preceding a Presidential Election, with presidential
campaigns underway. Research has shown that news readers tend to pay greater attention to
media coverage of policy issues compared to non-policy issues (e.g., non-political entertainment,
such as celebrity gossip) during election cycles (Boczkowski & Mitchelstein, 2013). It is not
unreasonable to speculate that awareness of such changes in news readers’ attention may have
played a part in differences in causal attributions to the pharmacy benefit managers and the
pharmaceutical industry, respectively.
What insights can we draw specifically from editorials where at least one type of efficacy
information was identified? In this respect, significant differences were found between local and
regional newspapers on the one hand, and national newspapers on the other. Local and regional
newspapers were more likely to indicate some type of efficacy information than their national
counterparts. There was a marginal association between newspaper type and reference to
individual/public efficacy, X
2
(1, N = 170) = 3.402, p < .10, suggesting that overall, it was

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slightly less likely for an editorial to have included this specific type of efficacy information or
claim. A more pronounced difference between the two types of newspapers was found with
respect to SR-Market Competition, i.e. attributing solutions to market forces and competition,
X
2
(1, N = 170) = 4.892, p < .05, local and regional newspapers were significantly less likely to
include an excerpt or mention of market competition as either demonstrating a viable solution or
demonstrating a responsibility for solving the problem of prescription drug prices. This may be
partly attributable to how a newspaper that arguably has been traditionally more pro-free market
- The Wall Street Journal - was categorized as a national newspaper.
Potential correlations between code pairs were also investigated. Consistent with prior
research that used the content analysis method (Greer & Ferguson, 2011; Li & He, 2018), phi
coefficients were compared for all possible pairs, given that the coding categories were binary
(0: absent, 1: present). Statistical significance was observed only for the following three pairs: a)
CR-Pharma and SR-Market Competition (φ = -.183, p < .05); b) Individual/Public Efficacy and
SR-Market Competition (φ = -.170, p < .05); and c) Organizational/Institutional Efficacy and
SR-Legislative & Policy (φ = .239, p < .05). Making causal attributions to the pharmaceutical
industry for high prescription drug prices is negatively associated with claiming that market
competition offers solutions to solving the said problem. Making such a claim about the benefits
of market competition was also negatively associated with referring to a notion of efficacy on the
part of individuals or the public.
Having a positive opinion of the actual or potential influence of markets as a corrective
mechanism may lend itself to views that are conservative (with a lower-case ‘c’); research on
tendencies to understand the world as fundamentally just (i.e., Just World Beliefs; Lerner, 1980)
and to justify existing power structures based in part on optimism that existing societal

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institutions and frameworks can address problems of tomorrow, with problems understood as
exceptions rather than the rule, as well as diminished inclination to question the status quo (i.e.,
System Justification; Jost et al., 2004). Higher levels of Just World Beliefs and System
Justification have tended to be associated with, or directly diminish efficacy (Osborne, Jost,
Becker, Badaan, & Sibley, 2019) and weaken attributions of problems to societal and structural
causes (Godfrey & Wolf, 2016; Jolley et al., 2018).
As indicated above, there was a pair for which positive statistical association was
observed - Organizational/Institutional Efficacy and SR-Legislative & Policy. Acknowledging
the potential for legislatures and policy to offer solutions that occurred in close conjunction with
mentions of information or a claim oriented towards the efficaciousness of organizations and
institutions. In one editorial, an argument is made that Oregon lawmakers “should be paying
close attention to drug pricing” with one idea to allow the Oregon state Board of Pharmacy to
import drugs from Canada” (The Skanner, 13 March 2019). The authors, in the next paragraph,
then urge “legislators to work closely with diverse groups, and to aim for a transparent pricing
system and a fair deal for consumers.” This claim can be understood as a ‘call to action’ type of
message for members of a specific institution - the Oregon Legislature - to make a difference,
and to closely coordinate with “diverse groups.” Examples offered by two other editorials lend
further support to this pattern:
As demand for naloxone continues to escalate, Maine should take a cue from its New
England neighbor, Massachusetts, the first state to negotiate lower prices for the
antidote…Our state should push the makers of naloxone for a better deal, and our U.S.
representatives and senators should press for action on a national level (Portland Press
Herald, 25 May 2016).

Badgered by angry citizens, members of Congress are demanding answers - not just for the
soaring cost of EpiPens, but for other outrageous prescription drug prices (Santa Fe New
Mexican, 26 August 2016).

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The top excerpt demonstrates a claim about the supposed institutional efficacy of state-level
policies, i.e., their positive impact on other states’ policies and legislation; this, in turn, is
presumed to have mobilizing potential for making a difference in national, or federal,
policymaking and legislation. A similar assumption about the ‘virtuous cycle’ of efficacy can
also be found in the bottom excerpt. Citizens can and do pressure congressional members, who
in turn endeavor to acquire information about not just one specific problem, but a host of other
problems that are largely identical.
Analysis and Interpretation: Qualitative Constructions of Efficacy
The above excerpts constitute a larger sub-sample of the editorials: over 57% of the
editorials (n = 99) included some type of reference to efficacy. Approximately 27% of all
editorials (n = 27) included both individual/public and organizational/institutional efficacy
information. The first coder engaged in a deeper analysis of such efficacy claims identified in
these editorials, i.e., mainly those that were coded as reflecting both types of efficacy. Several
excerpts will be analyzed in more depth, consistent with the inductive qualitative analysis
approach advocated by Gioia et al. (2012). The following excerpt was identified in an editorial
written by Maggie O’Neill, a Maine state representative:
We must do more to help those who have already fallen victim, and this tax will generate
the funding to do just that. (Morning Sentinel, 7 June 2019)
Presumably in her capacity as a public official, she used the editorial to explain an effort to
enshrine at the state level legislation that would create an “excise tax paid by pharmaceutical
companies manufacturing opioids dispensed in Maine.” Immediately prior to this excerpt, which
was coded as reflecting both individual/public efficacy (as evidenced by the invocation of ‘we’)
and organizational/institutional efficacy (primarily the reference to a policy innovation - the
excise tax - having the potential to be an effective tool), O’Neill provided a detailed explanation

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as to why opiate medication is a critical component of healthcare. She reasons that companies
that manufacture opiates should be mandated to pay their share of the costs to address Maine’s
opioid epidemic.
Other example excerpts provided further evidence of alignment between claims about
efficacy and those about the responsibility of governments and legislative bodies to provide
solutions.
In the absence of national action to control the high price of prescription drugs, California
is considering a small state rule that could make a big difference. It targets a game that
pharmaceutical companies play to keep people spending more than they need to on
medicines. (Portland Press Herald, 29 September 2017)

The California rule could bring real savings in health care spending without compromising
patients’ health. California should adopt this rule and other states should follow suit.
(Portland Press Herald, 29 September 2017)
In the top excerpt, there is a connoted sense of state policy action to provide a solution (“in the
absence of national action”) to the specific problem discussed in the editorial, i.e., of co-pay
coupons that may appear to help consumers “cover the cost of co-payments for any brand-name
drugs for which there is a generic alternative that works as well.” And the bottom excerpt reflects
an assumption that state-level policy can have a ripple effect of sorts, with positive implications
for other states. A plurality of editorials had discussed some type of state-level policy measures,
and critical evaluations of such measures were published in local, rather than national,
newspapers. This observation is consistent with what media researchers have found with respect
to local media placing greater emphasis on reporting about locally based groups and companies
(e.g., Nah, 2009; Gurun & Butler, 2012).
These qualitative observations offer deeper insights into the construction of efficacy
information and claims. Two categories of efficacy information and claims were also generated -
informational efficacy and mobilizing efficacy. These categories are largely distinct, with some

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minimal overlap. Examples will be provided with detailed explanations for each. These efficacy
categories were generated based on an adaption of the Gioia method. This particular method is
predicated on qualitative data analysis across three stages: first, 1st-order concepts are identified;
second, emergent themes are identified based on a grouping of typically two or more 1st-order
concepts; third, aggregate dimensions are extracted from groupings of 1st-order concepts (Gioia
et al., 2012). This methodological approach originates from qualitative organizational studies,
yet scholars have also used this method to show how news media frame organizational events
(Clemente & Gabbioneta, 2017). As an inductive approach, it offers flexibility as it does not
require predetermined frames, and allows researchers to extract novel frames not identified in
prior research (Clemente & Gabbioneta, 2017, p. 291).
Informational Efficacy
In these editorials, an individual claim within an editorial, as well as the editorial itself
more generally, assumes that individuals’ efforts to acquire information can make a positive
difference with respect to expected and actual outcomes. One editorial mentioned the positive role
caregivers can play in helping consumers acquire competence in the marketplace:
Working together, caregivers can help those patients to become savvy healthcare
consumers by encouraging them to:
Shop around, because prices vary by pharmacy.
Always ask whether a generic or lower-cost alternative is available.
Use the cost-saving tools their insurer offers online.
Consider subscribing to home delivery or obtaining a 90-day supply at retail for
long-term medications used to treat chronic conditions.
Review their health insurance company’s drug formulary to become
familiar with the various pricing tiers available. (Buffalo News, 29
September 2017)
This excerpt was coded as constituting information that demonstrates both
individual/public efficacy and organizational/institutional efficacy, in light of the fact that
references are made to the possibility that feasible and effective actions are possible on the part

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of consumers (i.e., members of the public) and caregivers, (i.e., a specific occupational category,
which overlaps with organizations and institutions). There is little evidence offered here that the
purported benefits of such information-seeking extends beyond the well-being and health of
hypothetical consumers and patients, even as parts of the excerpt suggest that physicians have a
tendency to prescribe higher-cost brand name prescription drugs, even when they are aware that
the generic version of such drugs offer equal therapeutic value and are made of identical
elements (in both composition and quality) (Kesselheim et al., 2017; Howard et al., 2018).
In other editorials, however, informational efficacy goes beyond such ‘technical’
instructions that are predicated on the effective potential of consumer and patient knowledge. In
one editorial, the following claim is made:
Start by talking to your doctor. Saving money on prescriptions can be as simple as asking
about cost-saving measures. More often than not, doctors are unaware of the cost of
prescription drugs. Understanding that the cost is a burden may help your doctor help you.
Sunshine will prove to be the best medicine. (Portland Press-Herald, 28 June 2017)
What can also be detected in the above excerpt is an assumption that knowledge about ‘truth’ –
or in other words, the reality of the high cost of prescription drugs - can be discoverable by
relevant agents, and that once they realize this, they can and will act in a way that achieves more
equitable and optimal outcomes. The editorial board of a Maine newspaper wrote that “If we can
get clearer information from drug companies, we too can get an inside look at the industry and
better protect the many Mainers who depend on their life-saving pharmaceuticals” (Portland
Press-Herald, 1 June 2017). It is feasible and possible for individual citizens and members of the
public to request such information from organizations. Experimental and survey research can
provide additional quantitative information for potential connections between knowledge and
efficacy (Jung, Kim, & De Zúniga, 2011). Knowledge about policy as well as specific

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corporations animates political discussion in personal networks, which in turn heightens
intentions to engage in activism (Saffer, Yang, & Qu, 2019).
The last sentence in the above excerpt - “sunshine will prove to be the best medicine”
reflects a somewhat naïve reliance on transparency, particularly as it is predicated on faith in the
good intentions of medical professionals (“Understanding that the cost is a burden may help your
doctor help you”). Transparency as constructed in this excerpt aligns with, or rather errs on the
excessively optimistic side of, Schudson (2001)’s definition of transparency as a “moral
prescription for social behavior” (p. 151). The construction of citizen- and consumer-led
knowledge-seeking as a constitutive element of transparency speaks also to the broader concept
of citizens being ‘monitorial’, or “informed enough and alert enough” (Schudson, 2000, p. 16).
One of Schudson’s arguments is that “if democracy requires omnicompetence and omniscience
from its citizens, then it is a lost cause” (1998, p. 310). Not everyone can be actively seeking out
information on all issues. Moe (2020) argues that “while the informed citizen gathers
information, the monitorial citizen supervises, and can multitask while being watchful” (p. 8).
This is not to say that Schudson diminishes the importance of the state or quality of being
informed; he draws explicit connections between access to information (a “Right to Know”) and
empowered consumers who not only make the most optimal choices for themselves, but can also
apply pressure for greater accountability (Schudson, 2015). Consumer movements have
historically championed the value of information about specific products (for instance, with
respect to labeling), as well as generalized education about nutrition and health that gave
consumers the ability to make good use of labelling information and thus exercise sound
judgment in consumption choices (Gabriel & Lang, 2006, p. 180). Evidence from these editorials

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suggest that media constructions of efficacy frequently reflect and reproduce the instrumental
value of information for consumers.
We need to increase transparency, so consumers are able to make informed decisions. Any
information behind price increases, or alternative treatments, should be shared with
patients upfront. (Austin-American Statesman, 28 April 2019)
Providing advanced notice of rising drug prices will help reduce costs in a number of
ways. It allows consumers the time they need to find alternatives to costly drugs, to hold
third-party purchasers accountable and to negotiate lower costs. (Orange County Register,
11 August 2017)
The top excerpt, coded as constituting an individual/public efficacy claim, is from an editorial by
Senator John Cornyn (R-TX). In the preceding paragraphs, he makes what could be understood
as a more ‘traditional’ Republican argument about the role of policy, i.e., that the optimal
solution ought not to be a “government-run, one-size-fits-all approach.” In the bottom excerpt,
there are indications of both types of efficacy information, in light of claims made about the
effectiveness of an institutional initiative - i.e., California Senate Bill 17 that mandates drug
companies should provide 60-days’ notice when they dramatically increase drug prices - and
how individual consumers can leverage such legislation to their advantage. Not unlike what was
identified in Cornyn’s editorial, the bottom excerpt is also preceded by an explanation of a
legislative initiative. The California state legislation also is rooted in the assumption that
mandating the disclosure of such knowledge constitutes a public resource.
Mobilizing Efficacy
The pursuit of greater transparency entails disclosure, or successful efforts to realize
disclosure of a body of information that had hitherto remained undisclosed. The tension around
disclosure can be understood as a series of “social processes through which secrecy is
challenged, defended, and mobilized” (Kinchey & Saffer, 2018, p. 1013). It is also possible for
struggles for information to “give way to secondary conflicts over presentation and interpretation
of information, the design of disclosure infrastructures, and the credibility of the various experts

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and agencies involved” (Kinchey & Saffer, 2018, p. 1013). For these “secondary conflicts” to be
sustained, perceptions of efficacy or positive impact continue to be relevant. Efficacy can be a
mobilizing resource, leading to stronger intentions for consumer activism (Saffer et al., 2019).
Social psychologists have identified efficacy as one mediator of collective action more generally
(Van Zomeren et al., 2008; Cohen-Chen & Van Zomeren, 2018). As mentioned above, there is
evidence that within informational efficacy claims, a ‘call to action’, or mobilizing information,
can be embedded. In this vein, editorials that decry the pervasive, negative influence of drug
advertisements also offer a similar combination of information and activism.
In a New York Times editorial, columnist Kathleen Sharp sharply denounces the ubiquity
of “30-second TV commercials about name-brand medications to treat just about everything,”
and falsely promise people “painless lives with our diseases under control” (3 September 2019).
Explaining that consumers and their doctors have become “adept” at ignoring the obligatory
disclaimers about a drug’s side effects which are included in drug advertisements, the editorial
proceeds to argue that, “We clearly can’t count on regulators or the drug companies themselves
to protect us” and consumers need to “realize that every drug comes with both risks and rewards”
so we need to abandon “our faith in miracle cures.”
The contents of this next excerpt can be appropriately understood within the context of
the growing ‘biomediatization’ of health news more generally. The “co-production of medical
objects and subjects through complex entanglements between epistemologies, technologies,
biologies, and political economies;” pharmaceutical companies are co-producers of subjective
realities about healthcare (Briggs & Hallin, 2016, p. 5). This particular construction of a claim
that presupposes, and is predicated on, the supposed untruthfulness of information generated
directly by pharmaceutical companies is found in multiple editorials where the word

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‘misinformation’ is used to describe “false claims by the pharmaceutical industry.” One example
is a false claim that proposed state-level legislation shifts liability to brand-name drug
manufacturers (The Sun Journal, 23 June 2017). In the following excerpts, the ‘agents’, which
can also be understood as an informed public - must actively demand transparency from the
pharmaceutical companies.
We can continue to expose their unscrupulous tactics and publicly demand that they
provide explanations for increasing prices, not just sly marketing ploys meant to appease
public outcry and repair their falling stock prices. We must also call on Pennsylvania’s
congressional representatives to explore mandatory drug pricing transparency as a
solution. (Pittsburgh Post-Gazette, 4 September 2016)
This excerpt was coded as constructing both individual/public efficacy (‘We’ refers broadly to
the public as a whole) and organizational/institutional public efficacy (there is an exhortation on
Pennsylvania’s congressional legislature to take meaningful action), as well as to display the
need to provide a meaningful solution. The construction of this particular claim is noteworthy
also because transparency of institutions can increase the perception that such institutions are
more responsive to citizens’ actions (Cicatiello, De Simone, & Gaeta, 2018). It can also be
understood, then, that a sense of response efficacy is at play here, insofar as calls for
transparency made by ordinary citizens can elicit a response from politicians and policymakers.
As indicated in the previous paragraphs, the pursuit and (fullest possible) approximation
of transparency both require, and are enabled by, efforts at information-seeking and information-
sharing. The following excerpts showcase such efforts as constitutive of consumer, citizen,
patient, and legislative action:
You can help ensure the Prohibition Against Price Gouging for Essential Off-Patent or
Generic Drugs law remains in effect. If you have had a bad experience with price gouging,
tell your story. Attorney General Frosh needs to know how prescription drug price
gouging is affecting you. You can share your story anytime at
healthcareforall.com/hearmystory. You may also call Suzanne Schlattman of the Maryland
Citizens’ Health Initiative at 410-235-9000. (The Daily Times, 3 January 2018)

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Here, the editorial included both website and landline contact information of a consumer
advocacy organization - Maryland HealthCareForAll Coalition - that is leading the Maryland
Citizens’ Health Initiative. The inclusion of such contact information by organizations in
messages and news media have been given attention by a variety of scholars (e.g., Waters &
Lord, 2009; Choi & McKeever, 2019). On contested issues, whether for local or national media,
information is frequently included to aid in mobilizing readers (Nicodemus, 2004; Clarke, 2011).
The fact that these editorials included both types of contact information - digital and
analog - may speak to the diversity in the presumed reader audience with respect to the use of
information and communication technologies (ICT). The inclusion of such information speaks
also to the role of digital storytelling about health issues (Michie, Balaam, McCarthy, Osadchiy,
& Morrissey. 2018), and is likely to also encourage health activism (Zoller, 2005, 2017). In the
two examples, efficacy helps influence policy and legislation, enables advocacy organizations,
and shares information with fellow consumers and citizens. This observation must be understood
alongside the finding that only four editorials in total were coded as constituting the “Solution
Responsibility - Nonprofit/Advocacy Organizations”. It suggests that the problem of high
prescription drug prices is perceived as one that requires solutions necessitated by broader
policy- and legislative-level solutions, rather than those offered by individual organizations.
Consumers and Citizens: All Together Now
The editorial excerpts reveal the difficulty of making strict demarcations along consumer-
and citizen-oriented manifestations of efficacy information and claims. The blurry lines between
consumer and civic dimensions in the editorials speak to the ‘unmanageability’ of the consumer
(Gabriel & Lang, 2006, 2008). This is so partly because “no-one can pin it down to one specific
conceptualization at the expense of all others” (Gabriel & Lang, 2008, p. 322). A clear-cut

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distinction between citizenship and ‘consumership’, if there was one, had been blurred for quite
some time (Benn, 2004), with both the political Left and Right conflating the two terms, albeit in
different ways (Gabriel & Lang, 2006, pp. 185-186). The editorials analyzed for the current
chapter suggested the possibility that journalists, politicians, lawyers, academics, and other elites
(for the most part) did not clearly distinguish citizenship from consumership, and vice versa. An
analogous pattern may also be observed among news audiences, as shown by Mellado and van
Dalen (2017).
The excerpts identified in the current study demonstrated also that, at least concerning
medicines, patient- and consumer-oriented understandings were shown to overlap on several
occasions. In these editorials, efficacy assumes that knowledge about medicine and the
healthcare system more broadly, either as a consumer or hypothetical patient, can make a
difference in outcomes for an individual. That said, in the same editorial, claims about
organizational/institutional efficacy were also made and the broader context in which such
efficacy claims were identified (at the editorial level) also demonstrated concerns about policy
developments and broader political decisions.
Not Critical Enough: The Limitations of Editorial Worldviews
Overall, the content analysis of editorials revealed systemic, consistent patterns with
respect to the discursive construction of causal responsibility, solution responsibility, and
efficacy. Media coverage, according to prior research, privileges certain sectors over others
Lewis et al. (2018). That study of Australian media’s coverage of healthcare demonstrated a
pronounced bias in favor of private sector initiatives over public sector institutions. What also
deserves consideration are topics from the editorial content that did not play a role in the efficacy
research. While not explicitly incorporated into the coding categories, across the editorials there

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were references to issues like importing drugs from Canada. The editorials mentioned importing
Canadian prescription drugs and suggested support for a ‘hybrid’ solution, i.e., government
policy interventions that empower solutions outside the U.S.’s labyrinthine set of laws protecting
drug patents and protectionist policies that masquerade as drug safety rules. Yet, at the same
time, the editorials by and large did not offer a more substantive analysis of the Canadian
healthcare system.
The fact that editorials tend to have word limits of 500 to 1000 words may likely have
precluded in-depth, comparative policy analysis. That said, this particular omission is potentially
a meaningful one, because readers were not given the contextual information that could have
helped them engage in a more critical and informed evaluation of policy options. Canada’s
healthcare system, for example, offers universal comprehensive public health insurance, yet its
coverage does not extend to prescription drugs (Kassam, 2017; Daw, Morgan, Collins, &
Abelson, 2014). It is true that the presence of a national, comprehensive healthcare system
distinguishes it (positively) from its American counterpart. Nevertheless, the Canadian
healthcare system is also a site where an “organic” conception of citizenship that undergirded
direct public funding and oversight of public and private not-for-profit hospitals gave way to a
more “individualistic” notion of citizenship that is focused on individual empowerment,
purchasing power, and accessibility (Church & Armstrong, 2011, pp. 194-195). Discussions of
Canada’s healthcare system and context were found wanting, and a similar absence was observed
for the systems and contexts of other countries whose healthcare systems can be described as
superior to the American one in terms of health equity and access.
It can also be argued that the worldviews of the writers, and the construction of the
problem and solutions offered in these editorials, reflect the limits of functionalist perspectives.

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According to Collyer (2018), a functionalist perspective sees the healthcare system as an enabler
for individuals to return to regular social roles after recovering from illness (a form of deviance).
In so doing, healthcare contributes to the “stability and sustainability of the social system” as a
whole (p. 113). Situating her argument within the context of health sociology research, Collyer
advocates for a fuller application of Pierre Bourdieu’s theory, as it enables a more robust and
fuller theorization of the relationship between system and action (p. 116).
While a full, detailed exploration of Bourdieu’s ideas are beyond the scope of this
dissertation, nevertheless efforts must be made to provide an explanation of the constituent parts
of his theoretical framework. Collyer (2018) accurately summarizes three constituent concepts –
capital, habitus, and field – as the deployment of power, subjective element of practice, and the
objective network of relations that is both structuring and structured. These three forces are
“mutually constitutive and always interpenetrating” (p. 117). With respect to capital, Bourdieu
distinguishes between economic (i.e., money or assets that can be turned into money) and
cultural (i.e., educational credentials, technical expertise, general knowledge, verbal
abilities, and artistic sensibilities) capital. While economic capital is more powerful, the role of
cultural capital is indispensable in “transforming good fortune into ‘legitimate’ fortune” (Benson,
2006, pp. 189-190). Bourdieu’s insights have thus been applied to not only a sociological inquiry
into healthcare, but also into media studies and journalism. The spaces of production and
reception are “homologous,” meaning simply that they constitute distinct but parallel social
spaces, organized around the same basic divisions between economic and cultural capital
(Bourdieu, 1984, cited in Benson, 2006, p. 190).
Within the context of journalism and the media industry, Benson interprets Bourdieu so
as to claim that it is “very weakly autonomous” caught between cultural and economic power,

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with the latter generally being more powerful than the former (Bourdieu, 2005, cited in Benson,
206, p. 195). Against such Bourdieusian criteria, the limitations of the editorial writers’
worldview with respect to how they see consumer and citizen empowerment can be better
understood. Neoliberal discourse, after all, encourages the rejection of the “very possibility of
structural constraints on our individuality and the choices we make as modern subjects” (Collyer,
Willis, Franklin, Harley, & Short, 2015, p. 4). Individuals’ intentions do matter, as do their
agency; their active actions shape the current and future trajectories of organizations and
institutions (Schoeneborn, Morsing, & Crane, 2020). However, it is equally important to also
acknowledge the structural constraints that shape, either in a more expansive or limiting
direction, what is considered as ‘having a choice’ and ‘making a difference’ with respect to not
only drug pricing and access, but healthcare more broadly.
The editorials that offered thoughtful analyses and suggestions about different
possibilities of positive choice and efficacy were able to acknowledge some form of ‘system
knowledge’, which is comprised of two forms: acquired system knowledge (i.e., formal
knowledge, experience, and research capacity) and assumed system knowledge (i.e., networks of
social and economic privilege) (Willis et al., 2016). They were predicated, in general, on readers
having some form of both acquired and assumed system knowledge. Yet, following up on what
was identified in the additional analyses about efficacy claims, the writers for the most part
situated their arguments in a benign, virtuous relationship between action and system, in which
individual, organizational, and institutional actors act in good faith. From their perspective, there
are presumably few hurdles between good-faith intentions and optimal outcomes for individual
consumers and patients. It cannot be ruled out that the worldview presented in the editorials may
very well be an incomplete reflection of what the authors “truly” think about the issue at hand.

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That said, the “wicked” or “complex” problem of high prescription drug prices is also sustained
by individual and collective practices of consumers and especially physicians, many of whom
might not even be conscious of their susceptibility to the explicit and implicit influence wielded
by large for-profit pharmaceutical companies (Busfield, 2010). The agency and intentions of
individuals representing institutionalized professions (e.g., doctors and pharmacists) were
assumed, somewhat one-dimensionally, as sufficient enablers of efficacy across a portion of the
editorials. Such limitations in the worldviews that are engaging with a social problem are
compounded by the constraining space of an editorial, thereby heightening the importance of
critical media literacy on the part of readers.
Discussion and Conclusion
The editorials analyzed in this study predominantly attributed causal responsibility for
high cost drugs to the pharmaceutical industry, with additional causal attributions given to
government policy, insurance companies, and PBMs. The results of the quantitative content
analysis also showed that some of the editorial authors identified certain types of efficacy
information; however, overall there were considerably fewer articles that included some type of
reference to efficacy information, relative to the invocation of causal responsibility. On certain
topics, such as depression, journalists articulated a more even balance between individual and
societal responsibility (Jin, Zhang, Lee, & Tang, 2018). However, news discussions of
particularly high drug prices in the U.S. context, show a less clear-cut difference between
competing ‘poles’ of causal responsibility attribution. Researchers have shown that the focus of
news media coverage can be oriented primarily towards a given initiative or project implemented
by individual organizations, such as corporate social responsibility (CSR) initiatives (Lunenberg,
Gosselt, & De Jong, 2016; Lee & Kim, 2010), or by specific industries or sectors (Budd, Kelsey,

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Mueller, & Whittle, 2018) or through an umbrella category of organizations (Hale, 2007). In
contrast, the findings of the present study do not appear to indicate relatively well-defined
demarcations between what an individual organization does, or organizations in aggregate, or the
sector to which an organization belongs, and broader categories under which such organizations
are subsumed.
As far as causal responsibility attributions are concerned, then, apart from isolated
examples from the Wall Street Journal and a few other news media outlets that demonstrated a
clear pro-free market bias, these results suggest a certain degree of consensus on the part of
journalists and policymakers about the cause of high drug prices. Indeed, even those Wall Street
Journal editorials uniformly acknowledged that there was some degree of culpability on the part
of the pharmaceutical industry, especially individual for-profit manufacturers. However, those
articles tended to articulate their argument in such a way that either attributed fundamental causal
responsibility to government policies and legislative action (or inaction) or made references to
the benefits accrued by the investments in medical innovations on the part of large
pharmaceutical companies. Conceptually, causal responsibility attributions that lean towards
(partial) support for pharmaceutical companies are aligned with claims about market competition
offering a solution to the problem of high drug prices (i.e., Solution Responsibility - Market
Competition frame). Furthermore, the invocation of market competition as offering such
solutions was not necessarily restricted to editorials that showed a pro-pharmaceutical company
bias.
Editorializing Efficacy: Effects beyond the Newsroom
The quantitative analysis of efficacy was carried out initially under the assumption that
there would be two different types of efficacy information (individual/public and

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organizational/institutional). To an extent, the quantitative analyses did lend support to this
distinction, although there were few statistically significant differences in mentions of efficacy
information around newspaper type and author affiliation, respectively. A deeper, qualitative
dive into those efficacy codes, however, generated two distinct, albeit overlapping aggregate
dimensions of efficacy: informational and mobilizing.
The quantitative and qualitative insights generated about efficacy in U.S. news editorials
are important because they offer promise with respect to the ecological validity of experimental
research on efficacy. There is ample room for readers of U.S. newspapers- local and national
alike - to have their own sense of efficacy influenced by mentions of efficacy in not only
editorials, but also letters to the editor, and regular news articles. Such enhanced efficacy, in turn,
may very well lead to higher levels of political participation (Jung et al., 2011).
And as one important function of news media is to provide readers with objective
knowledge and informed perspectives, reading about efficacy in the news can also have positive
implications for enhancing self-perceptions of media literacy. Textual efficacy is comprised of
both information and mobilizing elements, with overlap between the two also noticeable; the
findings of the current study thus may have useful implications for educators of media literacy,
particularly as it trains individuals to engage with social problems on the ground through reading
about textual constructions of these problems.
Limitations and Directions for Future Research
The current study acknowledges the limitations of efficacy and knowledge (a related
concept to efficacy); indeed, they are by no means any ‘silver-bullet’ solutions to the problem of
high prescription drug prices, an outcome of both intentional and unintentional actions on the
part of the pharmaceutical industry, insurance companies, PBMs, the FDA, legislatures and

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policymakers at the federal and state levels. With respect to intentionality, there is reason also to
have a healthy skepticism of editorial claims. Earlier, when analyzing what was left unsaid or
underdeveloped in the editorials, the lack of knowledge about superior health systems in other
countries and a missing ‘critical’ lens regarding the peculiar brand of U.S. capitalism that allows
inequitable access problems to flourish and alternative approaches to be investigated highlighted
the need for critical media literacy. Authors who write editorials in newspapers likely have
salient public identities, engaging in a balancing act between aspirational critique and
professional voice (Kozinets & Cerone, 2014). That said, it is far from given that readers will
necessarily be ‘duped’ by such biases, given that readers have their own agency. The ‘decoding’
process on the part of audiences, after all, often can be quite different from the ‘encoding’ part of
content producers and writers, even though audience interpretations can adhere too closely to
hegemonic and dominant discourses (Hall, 1973; Morley, 1980).
Researchers have analyzed the (partial) autonomy of audience reception specifically in
editorial contexts (e.g., Törrönen, 2001). Editorials “comment on earlier ‘turns’, the already
existing formulations of the issue under consideration.” Törrönen (2001) also explains that “the
narrators of the editorials, as well as the recipients, participate in the negotiation concerning our
values, goals and points of view in regard to the action in a certain situation” (p. 175). What also
needs to be considered with editorials is the fact that the writers are not physically present for the
readers, resulting in a “disjunction between the context of production and the context of
reception” (Kress & van Leeuwen, 1996, cited in Törrönen, 2001, p. 176). An analysis of online
comments and replies to editorials published online, where appropriate and observable, would at
least partially enable researchers to account for such different contexts of reception, to the extent
what is revealed by an individual reader. Future research on editorials may benefit from a more

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‘triangulated’ approach of interpreting editorial text, conducting audience interviews (Törrönen,
2001), and analyzing online comments and threads. These online comments and threads may
very well generate insights akin to those provided by online consumer reviews and ratings,
which, according to Kozinets (2016), showcase the “diversity of consumers and the multiplicity
of their needs” and themselves reproduce “complex social conversations embedded in
consumers’ multifaceted communicational repertoires” (p. 834).
Different contexts are thus likely to influence both audience and media producers. In this
vein, whether a given newspaper is regional or national thus reflects differences in context, with
respect to both subjective (e.g., perceptions and reach of newspaper brand) and objective (e.g.,
readership, revenue) measures. With respect to the extent to which framing differences were
observed between regional and national newspapers, it is true that, statistically speaking, only a
few significant differences were observed. Nevertheless, in further support for identifying the
influence of reading about efficacy in news on actual political participation, scholars have found
that exposure to local newspapers heightens political participation (Hayes & Lawless, 2015).
Future research would benefit from specifically investigating whether among regional (or
local/municipal) newspapers, coverage of efficacy, causal responsibility, or solution
responsibility frames differs with respect to other external factors at play: these factors may
include, but are not be limited to, the proximity of large pharmaceutical companies’ headquarters
or operations to a given local newspaper, paid advertisements, or financial contributions by the
pharmaceutical and healthcare industry.
Extending an analysis made earlier in the present study, local media provided more
coverage to local versus non-local actors (Nah, 2009), with local media coverage of local
companies demonstrating a more positive tone than that of non-local ones and the authors

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identified one cause as local companies’ media advertising expenditures through those local
newspapers (Gurun & Butler, 2012). In light of what many perceive as divergent responses on
the part of state and federal governments, respectively, to the ongoing Covid-19 pandemic at the
time of writing, the intensity of emotions and deliberative depth identified in online comments
may very well differ depending on especially whether a given news article covers critique of
local, state, or federal-level policy and legislative actions, specifically with respect to healthcare
and public health topics. Online users and commenters, categorized as “interventionist
respondents” by Løvlie, Ihlebaek and Larsson (2018), are likely to have a higher trust in
community managers that regulate online comment sections of newspaper websites (Frischlich,
Boberg & Quandt, 2019). This particular trust, in turn, can also be extended to public health and
medical professionals, who can co-produce health news (Hallin & Briggs, 2015).
On the other hand, there are, in likelihood, online readers or users who have lower trust in
media, public health, and medical professionals. It is plausible to think that a subset of such
readers are opposed to, or skeptical of, vaccination as opposition to vaccination is likely to be
identified in American online comments in the event that a vaccine for Covid-19 is developed
and distributed. Both pro- and anti-vaccination opinion is likely to be magnified in a variety of
online settings (including not only online comment spaces, but also Twitter, Facebook,
Instagram, etc.) as a reflection of the extreme importance attached to the Covid-19 vaccine. Even
though online comments to news articles are likely to be dwarfed by shares and (re-)tweets of
these articles (Almgren & Olsson, 2016) in volume, researchers are likely to derive considerable
insights from analyzing how users reveal their own worldviews in online commenting contexts,
in addition to their deliberative tactics, engagement with journalists, and use of technological
interactivity afforded by online news websites.

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Concluding Remarks: Taming “Wicked Problems”?
The problem of high cost prescription drugs is more pronounced in some countries than
others, and it cannot be solely explained by whether, or the extent to which, a given country is
considered as a ‘developed’ economy. This specific problem, for instance, is considerably more
problematic in the U.S., than in other countries with similar levels of economic and
infrastructural development (such as Canada and the United Kingdom). And at the time of
submission (June 2020), there does appear to be a greater consensus on the part of legislators and
policymakers, across the political Left and Right to the notion of more interventionist federal and
state governments, not only for the regulation of for-profit drug companies but also for the
production of cheaper, generic versions of prescription drugs.
However, the problem of drug pricing and drug supply, when viewed from a global
perspective, is still a vast and complex one with multiple moving parts, with the real possibility
of unintended or unanticipated consequences (Merton, 1936; Giddens, 1993; de Zwart, 2015).
The current Covid-19 pandemic shows that if countries that produce ingredients of key drugs
cease economic activity (“lockdowns”), there is the real possibility of global supply chains being
disrupted, with consequences for the supply (and thus the pricing) of drugs in multiple countries.
Even before the pandemic, it was also shown that prescription drug prices in one country depend
on those in other countries, based in part on divergent national-level regulatory frameworks and
global strategies of pharmaceutical companies that took advantage of such differences (Quet,
2018). The complex interplay between global/national and policy/business dimensions
concerning this specific problem at hand justifies it being called a ‘wicked problem’
(Churchman, 1967; Gioia, 1992; Ferraro et al., 2015; Reinecke & Ansari, 2016).

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Knowledge is a precondition for solving at least parts of wicked problems, yet is often
inconclusive and fragmented (Daviter, 2019). The current study similarly showed how
knowledge and information are textually constructed, revealing both the possibilities and
limitations of civic and consumer efficacy. Specifically concerning healthcare, knowledge may
be understood as a form of consumer sovereignty in healthcare more generally, yet this concept
can also be closer to fiction than fact, as “consumers may not have ability, motivation, and
opportunity to choose high quality healthcare products at lower prices” (Sirgy, Lee, & Yu, 2011,
p. 470). These authors, however, also make the argument that “when consumers better
understand their options, they may be in a position to choose wisely” (Block & Keller, 1995,
cited in Sirgy et al., 2011, p. 470). As fragmented and inconclusive as it may be, knowledge is
still a meaningful constituent of efficacy (and vice versa), even with respect to ‘wicked
problems’ that are correctly and appropriately understood as complex and pervasive.
Researchers have shown that the particular political slant of editorials can influence
voting patterns (Druckman & Parkin, 2005); editorials that frame certain ‘wicked problems’ in
ways that make salient or accessible different interpretations of efficacy can also have an impact
on actual behavior, whether for supporting particular policy measures designed to either promote
active solutions or prevent the problem from becoming worse (Garbarino, Henry, & Kerfoot,
2018) or, alternatively, involvement in initiatives by individual organizations to address those
problems at local and community levels. This chapter ends with a continued call for engaging
with media from both the creators’ and audiences’ perspectives.

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CHAPTER 5: DISCUSSION and CONCLUSION
Implications for Efficacy-Oriented Research and Practice
The findings of this dissertation provide support for continued research into efficacy-
building interventions as a means to enhance the capacity of individuals to effect organizational
outcomes. These outcomes have to do with manifest, observable outcomes of organizational
behavior (e.g., pricing, sales, profits, employment, etc.), as well as latent motives and structures
of organizations. The strength of an organization’s commitment to creating positive social
impact and actually making resources available to internal and external organizational
stakeholders constitutes an organization’s capability for innovative reforms. A robust sense of
efficacy can increase the likelihood of organizational interventions which provide meaningful,
efficacious solutions to social problems (in this case, specifically, lower drug prices and
enhanced access to affordable and effective medicine). As mentioned in Chapter 1 and
throughout the three studies within this dissertation, considerable attention has been given to the
emergence of innovative non-profit pharmaceutical manufacturers such as Civica Rx and Fair
Access Medicines. The inspiration for the name of the hypothetical generic drug manufacturer -
Civic Med - used in the experimental stimuli for Chapters 2 and 3, after all, closely mirrored
Civica Rx. These studies have demonstrated the potential for (repeated) engagement with
messages from, and news about, such organizations to enhance different types of efficacy on the
part of readers, albeit across slightly different contexts.
Going into more detail into the constitutive studies, Chapter 2 varied message features in
a strategic communicative appeal of a hypothetical non-profit generic drug manufacturer with an
orientation towards social impact along gain- and loss-framed variations; it found that the gain-
framed appeal succeeded in positively enhancing the perceived efficacy of organizations, but not

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perceived self-efficacy. Chapter 3 varied fictional news stories about an identical social impact-
driven drug manufacturer; here, however, the primary issue of concern was making variations
around participatory efficacy in organizational decision-making as either high (i.e., more
effective) or less (i.e., less effective), with the other variation around the type of organization as a
for-profit or non-profit. Chapter 3 also found that one type of discrete emotion - hope - positively
mediated the effects of the high-efficacy news story about participatory efficacy on three distinct
types of perceived efficacy on the part of survey respondents, be it with respect to their own
ability (internal), the receptiveness of others to their opinion (external), and the actual changes
their opinions have on the behavior of organizations (perceived marketplace influence). While
the stimulus was created as a news story, the fact that it was about the internal workings of an
organization means that it also functioned as a vignette about an organization (e.g., van Gerwen,
Buskens, & van der Lippe, 2018; Jago & Pfeffer, 2019; Mazepus & van Leeuwen, 2019).
In contrast to Chapters 2 and 3, Chapter 4 deployed a mixed-methods approach in
identifying efficacy claims and information in U.S. news editorials about prescription drug
prices. This chapter initially started out with a quantitative content analysis before continuing
with a qualitative frame analysis that allows for extracting novel frames and aggregate
dimensions (Gioia et al., 2012). Chapter 4 found that a portion of U.S. editorials contained
reference to efficacy claims and information concerning the positive difference that can be made
by either consumers and citizens (in both the individual and collective sense), or organizations
and institutions. A deeper qualitative take on the efficacy-coded editorials generated two
aggregate dimensions - informational efficacy and mobilizing efficacy. These two efficacy
dimensions cut across distinctions among internal, external, and response efficacy, as well as
distinctions between consumer- and citizen-oriented conceptualizations of efficacy.

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All three studies also address the linkages between efficacy and organizational legitimacy
(Hasbani & Breton, 2012). What all three studies have shown is that efficacy can be experienced
or identified as being closer in form to a perception or behavior, be it competence perceptions
(e.g., Gil de Zúñiga, Diehl, & Ardévol-Abreu, 2017) or a stronger sense of direct behavioral
change, as is the case in research on health interventions, e.g., text messages (Head, Noar,
Iannarino, & Harrington, 2013) or smartphone applications (Firth, Torous, Nicholas, Carney et
al., 2017). The experimental studies in this dissertation (Chapters 2 and 3) operationalized
efficacy, whether response efficacy (Chapter 2) or internal, external, and marketplace influence
efficacy (Chapter 3), as a perceptual outcome. Perceptions of efficaciousness and competence
may not be wholly distinct from each other. This may be one reason why in Chapter 3, when
identical sets of analyses were run after controlling for respondents’ assessment of organizational
competence, the results for three forms of efficacy – internal, external, and marketplace influence
– showed weaker levels of statistical significance. Higher competence evaluations often do lead
to, and are associated with, positive attitudes towards the organization, even as Chapter 2 and
Chapter 3 did not directly incorporate attitudes as a measured variable in the hypothesized
models. The implications of these findings are likely to be positive for non-profit generic drug
manufacturers such as Civica Rx and Fair Access Medicines, and likely applicable only to the
U.S. context.
In the time period covered by Chapter 4, there were few references to these non-profit
organizations, even as there were arguably adequate levels of efficacy information included in
U.S. news editorials. As these non-profit manufacturers become more active players, media
coverage is likely to increase, not only in editorials but also in non-editorial news. The relative
advantage of the gain-framed appeal vis-a-vis the loss-framed equivalent in eliciting higher

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response efficacy (Chapter 2), as well as the fact that hope as a discrete emotion positively
mediated the effects of high-efficacy news on different forms of perceived efficacy (i.e., internal,
external, and marketplace influence) (Chapter 3), suggest that there may be benefits to positivity
in either the messaging or in the evoked emotion(s). These findings lend support to practitioners
of solutions journalism (Benesch, 1998), and also provide insights into the intersection between
solutions journalism and positive psychology (McIntyre & Gyldensted, 2017; McIntyre &
Gyldensted, 2018).
Pointing the “Efficacious” Way Forward for Research and Practice
The findings of each of these studies complement each other in useful theoretical and
methodological ways. The relative non-success of the gain-framed appeal made a difference to
perceived self-efficacy that can be partly attributed to how the strategic communication messages
used for Chapter 2 did not sufficiently emphasize the agency of the individual who is asked to
help, or donate to, the non-profit drug manufacturer in question. In Chapter 3, engaging with a
news story/vignette about positive participatory efficacy (i.e., the successful uptake of consumer
feedback into shaping actual outcomes of organizational decision-making) meaningfully
enhanced a sense of perceived internal efficacy. This is a form of efficacy that overlaps with
perceived self-efficacy. In this regard, one implication for enhancing the appeal of strategic
communication would be to engage in real-life piloting of inclusive organizational design, in
which the voices of internal and external stakeholders are positively taken up. Engaging with
such stories about inclusive and effective organizations, broadly speaking, may in turn bolster
the belief that individuals, organizations, and institutions can make a positive difference. The
benefits of such an approach have been emphasized in the literature on strategic communication,
one that is grounded in a “strategic repositioning of power” conducive to citizens’ participation

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in the “creation of information used in governance” (Riley, Thomas, Weintraub, Noyes, &
Dixon, 2015, p. 203). Enhanced efficacy with respect to the public’s perception that they can
meaningfully alter the practice of individual organizations, which in turn can, in aggregate, shape
change throughout multiple organizations as well as institutional contexts more broadly. This is
arguably a pathway for building up communication capital, or the capacity to spread information
through sustainable networks and advocate for social change (Riley et al., 2015, p. 203).
Knowledge constitutes such communication capital; in this vein, it is worth mentioning
that knowledge and mobilization were identified as aggregate dimensions of efficacy in Chapter
4. While based on a small subset of the entire spectrum of news stories available to Americans
(i.e., editorials from national and local newspapers), this specific finding lends further support
for including efficacy-oriented information and claims in media coverage, particularly when
covering one or more “wicked problems.” Media outlets such as the Stanford Social Innovation
Review are already giving voice to such individuals and organizations; that said, further research
is still needed to see how reading about news stories and vignettes about organizations that are
committed to solving the wicked problem(s) of our day influences actual behavior of readers. In
this way, innovative definitions of efficacy can be better developed, either in the context of
theoretical frameworks in the field of communication or in other allied fields. For instance,
scholars have measured the positive influence of community storytelling networks on collective
efficacy and knowledge about local affairs, with these variables in turn enhancing local
community engagement (Burgess, Walter, Ball-Rokeach, & Murphy, 2019; Kim et al., 2019).
It would be possible to identify and bring about more explicit bridging between
community storytelling and social impact-creating individuals and organizations, particularly
those that are operating at the local and regional levels. The impact of such storytelling can be

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assessed across at least two dimensions - a) the messages themselves; and b) the interpersonal
communication that occurs about them (and by extension the organizations and the initiatives
mentioned in those messages) via current and new social networks of respondents. Readers can
become motivated to seek out new information about such social value creators, which in turn
leads to subsequent efforts to identify and fund them through either more conventional routes
(e.g., online donations through the organization’s website) or online crowdfunding. The efforts
of such social value creators, in turn, can also be covered more frequently and extensively by
media outlets. Media websites such as Upworthy arguably already fulfill this function, yet more
can be done; there may yet be feasible pathways for local and regional newspapers to increase
coverage of such individuals and organizations, accomplishing both the spirit and letter of the
objectives of solutions journalism (Benesch, 1998), as well as greater financial viability for not
only the news outlets themselves but also for the social value creators. Local and regional media,
and other content-specific niche media outlets, are therefore highly relevant to the conversations
about translating knowledge and information into efficacy, and efficacy into active engagement.
The act of having helped such social value creators may very well enhance efficacy on
the part of the funders. Researchers have shown that there is a positive relationship between
efficacy and user learning in digital environments (e.g., Xu, Park, & Baek, 2011; Koc-Michalska,
Lilleker, & Vedel, 2016; Ohme, de Vreese, & Albaek, 2018), and this is relevant to
crowdfunding because it occurs on digital platforms. Management and organizational behavior
researchers have found the influence of self-efficacy as one factor that boosts intentions to
engage in social entrepreneurship, with this in turn mediated by positive assessments of
perceived feasibility (Hockerts, 2017; Maier & Noboa, 2006). Whether or not, or the extent to
which, individuals make the decision to enable such social value creators may also depend on

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their perceptions of the feasibility of both the organizational mission and their independent
assessments of how ‘solvable’ the problem a given individual or organization is endeavoring to
solve. Throughout these processes, the would-be funders’ own sense of efficacy can be
positively altered, either concerning simple information-seeking, their own ability to make a
meaningful difference to the given problem and related challenges, and their assessments of
organizations in the arena of social impact, social change, and social value creation.
There are also relevant insights specifically concerning medical and healthcare
crowdfunding. Digital and technological advances in healthcare, intersecting with developments
in organizational innovation, provide opportunities for continued efficacy-focused research.
Crowdfunding for a variety of health innovations therefore constitutes one context where
perceptions of individual and organizational efficacy continue to gain greater relevance and
prominence. With respect to the development of new drugs and healthcare innovations, there
have been numerous crowdfunding and crowdsourcing initiatives in recent years. Crowdfunding
campaigns, for instance, have been initiated to elicit financial support for (unproven) stem cell
interventions (Snyder & Turner, 2018). A French crowdfunding platform, My Pharma Company,
is devoted exclusively to funding medical and healthcare innovations (Bassani, Marinelli, &
Vismara, 2019).
Engaging in crowdfunding activity can be foreseen in part because of intentions to make
financial contributions and share information (Shneor & Munim, 2019) are identified, and it also
enhances efficacy for funders of a given project—those individuals who are motivated to satisfy
others’ needs, help to those in need, and share enjoyment (Gerber, Hui, & Kuo, 2012; Gerber &
Hui, 2013). Further research is thus warranted on how message variations for organizations in
the crowdfunding context can differentially influence funder motivation and efficacy, using

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Renwick and Mossialos (2017)’s typology of crowdfunded health projects. This typology would
constitute another factor from which experimental variations can be conceptualized and
operationalized.
13
Research on crowdfunding organizations’ message variations should not just
be the ‘how’ of communicating organizations’ visions, but also the content, or the ‘what’ (van
Balen, Tarakci, & Sood, 2019, pp. 329-330). Hypothetically, if a study were to be conducted on
different crowdfunding messages of an organization that is promoting an innovative healthcare
solution, the actual level of scientific innovation of the solution would likely make a difference,
as innovation has predicted the likelihood of actual funding in other crowdfunding contexts
(Aleksina, Akulenka, & Lubloy, 2019).
Addressing Timeless and Timely Challenges across Academic Fields
The studies that constitute this dissertation offer insights into innovative approaches that
help researchers and practitioners understand the influence of efficacy on achieving beneficial,
real-world outcomes, specifically as they pertain to the development, growth, and action of
individual and organizational changemakers. They also offer relevant insights for the research
questions and challenges that scholars have long grappled with across a variety of academic
disciplines, including communication but also marketing, social psychology, management, and
organizational studies. One dilemma highlighted by marketing scholars Campbell and Winterrich
(2018) offers a useful starting point for conversations in this regard. The dilemma is as follows:
if a firm or a non-profit organization does not directly harm a customer, but explicitly harms or

13
Renwick and Mossialos (2017) identified the following four types of crowdfunding projects: Health Expenses
(i.e. donation-based campaigns to fund out-of-pocket expenses for patients unable to afford particular medical
services or products); Health Initiatives (i.e., fundraising for medical institutions or charitable organizations, patient
education programs, disease awareness campaigns, and global health missions); Health Research (i.e., not-for-profit
scientific research undertaken by health scientists); and Commercial Health Innovation (i.e. operations of
pharmaceutical and biomedical small - and medium-size enterprises that typically involve selling equity stakes in
return for capital on platforms such as Crowdcube and ShareIn).

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helps either: a) its own employees, or b) society more generally, what type of moral judgments
would consumers (have, or ought to) make? An extension of this dilemma may be found in a
pharmaceutical company making a decision to lower prices of a critical prescription drug in the
U.S., but not in another country where its citizens, as a result of having much lower purchasing
power, arguably are in greater need of lower prices for that drug.
The example of Gilead’s selective pricing of Hepatitis C treatment to only low-income
countries to the exclusion of middle-income ones (Quet, 2018), demonstrated in Chapter 1 is one
real-life example. Hypothetically, consumer and citizen engagement with such companies would
pose several dilemmas. Do we err on the side of emphasizing the ‘good’ that Gilead has done,
such as the provision of affordable drugs to patients in lower-income countries)? Alternatively,
do we focus more on the ‘bad’ or ‘duplicitous’ actions--the fact that it simultaneously excluded
approximately 49 million patients from middle-income countries” (Quet, 2018, p. 72) from those
same affordable treatments? Critically-minded consumers and citizens ought to realize that both
of these facts constitute a broader corporate strategy on the part of Gilead, that is a mixture of
“high-tiered pricing, patent application, licensing agreements, and anti-diversion practices”
(Quet, 2018, p. 73). Nevertheless, even when armed with this essential information about the
company, it may require significant, deliberative evaluation to judge whether the former or latter
tactic plays a more prominent role in the ethical assessment of their leaders’ decision-making.
As emphasized earlier in the preceding paragraphs of this chapter, knowledge and
information constitute one form of efficacy, particularly if conscious, motivated effort was put
into acquiring these two elements. An overlapping but separate dimension of efficacy is
mobilization, or the actual feasibility of, and pathways for, action. When confronted with such
dilemmas that revolve around critically perceiving and evaluating such organizations and their

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activities, communication scholars Tully and Vraga (2018) stress that individuals need to
perceive that they can appropriately and confidently process the knowledge and information
acquired through media (i.e., media literacy). In turn, such confidence positively predicted higher
levels of political efficacy. There is also a justified need to acknowledge and measure
individuals’ sense of their own influence over the behavior of organizations and the context in
which such organizations behave (e.g., marketplace or business environment) (Leary et al.,
2019).
These findings lead us to consider another form of efficacy relevant to morality and
ethics. Moral, or ethical, efficacy refers to a sense that one can, either individually or
collectively, make decisions that closely approximate both universal and context-specific
standards of morality and ethics. Considering this form of efficacy is even more salient as the
substantive issues investigated by this dissertation – i.e., access to affordable yet effective
medicine, situated within the broader context of healthcare justice - have moral and ethical
implications. Researchers have shown that mandating the completion of an ethics course for
business schools resulted in a higher sense of moral efficacy, in comparison with equivalent
scores among students who did not take the course (May et al., 2014). Ethical and moral
dilemmas, as an experimental intervention (e.g., in the form of discussion or contemplation),
increased the likelihood of the development of more robust morally sound intentions (Salvador,
2019). Ron Tamborini and his colleagues (2018) found that media content that reflects certain
discrete types of moral foundations and/or intuitions may influence actual donation behavior to
one type of organization versus another. Such research in the field of media and communication
is predicated in work done by social psychologists on moral foundations and intuitions (e.g.,

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Graham, Haidt, & Nosek, 2009; Graham et al., 2013; Federico, Weber, Ergun, & Hunt, 2013;
Kugler, Jost, & Noorbaloochi, 2014).
These studies show there are multiple domains of morality and moral foundations.
Individuals’ sense of moral or ethical efficacy is thus also likely to be at least equally, and more
likely considerably more, diverse, considering other factors at play such as education level,
political orientation, worldview, gender, and personality traits. Concerning healthcare and public
health issues, messages that successfully mobilize people via enhanced moral or ethical efficacy
may have to be tailored to the different moral foundations of different individuals (Kidwell,
Farmer, & Hardesty, 2013). Framing a public health issue as one of racial or geographical
inequality has different effects on responsibility attributions and tendency to argue against a
given frame (Skurka, 2019). Organizations that demonstrate and operate on the need to solve a
social problem may emphasize a specific dimension of a social problem (e.g., racial or
geographical inequality) at a given moment; future research concerning access to
pharmaceuticals and healthcare justice would benefit from investigating the individual and joint
effects of framing around issue salience or moral dimensions.
The possibility that efficacy is a finite resource is also a real one, consistent with social
psychologists’ findings that motivation and self-control are limited psychological resources
(Muraven & Baumeister, 2000). Communicative interventions might not necessarily be able to
enhance efficacy because of other individual- and societal-level factors. American consumers
responded more favorably to a corporate social responsibility (CSR) initiative that occurred in
the U.S. versus a foreign country (Russell & Russell, 2010). And re-visiting the ethical dilemma
posed by companies such as Gilead, it is not beyond one’s imagination to think of the possibility
that at least some individuals would prefer a company that errs on the side of prioritizing

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domestic consumers and their priorities. Their levels of efficacy may (or may not) differ
depending on whether an organization is ‘doing good’ either here or abroad. Regardless of that,
however, there will likely be meaningful differences in the attitudes towards, and levels of
support for, that organization.
Messages that circulate around us, to which people are exposed, and with which people
actively engage, can and do make a difference when evaluating an organizations’ impact and
their actions. Scholars also need to vigilantly assess whether organizations or institutions are
trusted. This concern is particularly acute when accounting for the role of trust in government
institutions. Shepherd and Kay (2012) found that higher levels of uncritical, or minimally
critical, trust in government institutions led to higher rates of avoidance of critical information
about relevant issues; such trust also heightened a sense of dependence on the system. Trust in
institutions and organizations therefore can pose a risk to efficacy with respect to knowledge and
information, as well as seeing individual and collective capabilities that critically appraise the
endeavors of relevant organizations and institutions. It is also possible for higher trust to lead to
more positive assessments of the perceived impact, of efficacy, on the part of those very
organizations and institutions.
At the same time, human organizations and institutions are fallible, even with good
intentions. Giridharadas (2018) notes that many entrepreneurs and philanthropists are unaware
that their accumulation of wealth and generation of profit contribute to the very social problems
that they genuinely, and effectively at times, endeavor to solve. Perceiving that social impact-
focused entrepreneurs and philanthropists (or government institutions) are effective solutions for
public problems, may thus diminish individual- and internal-level efficacy as citizens and
consumers. This is particularly the case when perceptions of impact lean more towards the

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uncritical rather than critical. Efficacy-enhancing communicative interventions that vary some
type of information about an organization - similar in design and concept to Chapters 2 and 3 of
the current dissertation - will thus benefit from extra vigilance against the possibility that higher
trust in organizations or institutions can lead to some type of uncritical or complacent acceptance
on the part of the public. Future research can thus build on the linkages identified between
informational efficacy and critical media literacy (Kellner & Share, 2007), with special emphasis
on how readers build on their own perceived efficacy to critically engage with problem-solving
organizations as depicted in the media.
It was mentioned earlier that efficacy is potentially a finite resource, just as easily
depleted as replenished. That said, education about critical media literacy can be more effective
when acknowledging that individuals who have certain beliefs and dispositions can also have the
potential to replenish efficacy. Buchan, Jeong and Ward (2017) found that those with a higher
concern for others were better able to translate their already-high social identification with the
local community into identification with the global collective. Such higher concern for others,
then, mitigated what may be inherent preferences for ingroups. Helping build concern and
empathy for neighbors and communities has intrinsic value in and of itself, constituting a key
component in a virtuous circle with multiple forms of efficacy.
An Epilogue, and Prologue, Too: A Transitional Moment in U.S. History
Lastly, the policy context also matters, as individual- and society-level definitions and
applications of even seemingly-universal concepts such as neighborliness, civic-mindedness, and
morality can vary substantially depending on the prevailing policy paradigms of a given time (it
goes without saying that applications of efficacy are no exception to this). As the review of U.S.
policies and legislative decisions that are related to the pharmaceutical industry and the cost of

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prescription drugs demonstrated in Chapter 1, a neoliberal, free-market ideology has profoundly
shaped policy logic and outcomes since roughly the late 1970s, if not earlier. Indeed, the Food
and Drug Administration (FDA)’s policy responses to drug shortages, compared to how
counterpart institutions operate in other countries, have been distinctly more laissez-faire (Beck,
Buckley, & O’Reilly, 2019).
Events of the past two years, however, are providing enough evidence to suggest that the
dominance of neoliberal ideology may be eroding. As indicated at the beginning of Chapter 2, at
the federal level Senator Elizabeth Warren (D-MA) and Representative Jan Schakowsky (D-Ill.)
have renewed their efforts to pass the Affordable Drug Manufacturing Act, which aims to “lower
prices and increase competition in the generic pharmaceutical market by establishing an Office
of Drug Manufacturing within the Department of Health and Human Services (HHS). This unit
will be tasked with manufacturing select generic drugs and offering them to consumers at a fair
price that guarantees affordable patient access” (U.S. Senate, 2019). With Senator Gary Peters
(D-MI) as a co-sponsor in the Senate, the Affordable Insulin Approvals Now Act and the
Creating and Restoring Equal Access to Equivalent Samples (CREATES) Act have both been
passed. These two pieces of legislation focus on expediting FDA approval for low-cost generic
drugs and combating anti-competitive practices that restrict lower-cost generic drugs from
entering the marketplace (Creenan, 2020). Lastly, there has also been legislative movement at the
state level that echos the spirit and letter of the Affordable Drug Manufacturing Act. In January
2020, Governor Gavin Newsom proposed that California create its own generic drug label –
negotiating contracts with drugmakers to manufacture selected medications for California (Lin &
Aguilera, 2020).

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Such policy and legislative initiatives arguably do not begin without considering public
opinion trends. The topic of enabling the government to manufacture insulin, for example,
continues to find the ‘age-old’ division between Republicans and Democrats, where 84% of
Democrats support this measure, in contrast to only 29% of Republicans, with overall support
across Democrats and Republicans at 58% (Zenilman, 2020). There is, however, growing
evidence of cross-party support. In a January 2020, a Kaiser Family Foundation (KFF) Health
Tracking poll found that the No.1 public health concern for Democrats, Independents and
Republicans alike was “lowering prescription drug costs for as many Americans as possible”
(Lopes, Hamel, Kearney, & Brodie, 2020). The results of this poll are consistent with those
found in an identical KFF Health Tracking poll released in February 2019. In the latter poll, it
was found that 79% of all respondents believed that the cost of prescription drugs is
unreasonable, and that the profits of pharmaceutical companies were the most important drivers
behind prescription drug prices (Kizinger, Lopes, Wu, & Brodie, 2019).
Granted, traditional partisan differences are still more pronounced with respect to issues
relating to “Medicare for All,” or making available a public option for health insurance; as
shown in the 2020 Democratic Presidential Primaries. Even within the Democratic Party,
progressives and moderates are still unable to reconcile their differences. And while Americans
are favorably disposed towards the possibility of Medicare being able to negotiate directly with
pharmaceutical companies, this support falls considerably short when people are reminded that a
drop in drug prices may lead to cutbacks in research spending on the part of the pharmaceutical
companies (Kodjak, 2019). The new ‘consensus’ on solutions to controlling prescription drug
prices is thus a fragile one, even as there is sufficient movement on the policy and public opinion
front to think that “business as usual” no longer is applicable.

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The contestations around the wicked problem of high prescription drug prices and the
solution(s) to the problem can be situated in unequal social and economic structures, as well as
convergent and divergent understandings of responses to such social and economic inequality. In
her recent work on inequality, social psychologist Hazel Markus (2017) similarly identified how
individuals are part of a “multilayered dynamic” consisting of ideas, interactions, and institutions
(pp. 212-213). Markus posits that this perspective “assumes that all levels of the cycle contribute
to and constitute each other...none are theoretically prior or more significant”; in other words,
she cautions against both “overpsychologizing” (i.e., locating the most important causes and
effects only inside the individual) and “oversocializing (i.e., locating the important causes and
effects only at the collective or institutional level) (Markus, 2017, p. 212).
The current dissertation accounted for not only intrapersonal psychological processes of
ordinary citizens, but also message- and content-level variations of organizational messaging,
and latent news media frames that reflect institutional biases and worldviews. This holistic
approach, it is hoped, at least partially satisfied the criteria set out by Markus’ perspective. While
not explicitly stated, conceptualizing and operationalizing efficacy in multiple forms but around
an identical set of ‘wicked problems’ (i.e., high prescription drug prices and inadequate access to
affordable prescription drugs) cannot be siloed from broader conversations about, and
substantive engagement with, the problem of inequality. It takes a village, yes, but within that
village individuals, organizations, and institutions all need to retain a sense that a positive
difference can be made. It is in this respect that messages generated by not just journalists, but
also by other types of message- and content - producers continue to be highly critical and
relevant.

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The efficacy of a medicine refers to the degree to which it yields promised therapeutic
benefits (Mandal, n.d.). Throughout this dissertation, a social psychology-driven definition of
efficacy was applied and tested, from both quantitative and qualitative perspectives. These two
definitions of the same word - efficacy - are indeed different. Nevertheless, overlap between
these two definitions can be found when medicine is understood as not simply a medication, but
also as a ‘bundle’ of commercial interests, social norms, and moral concerns (Hardon &
Sanabria, 2017). Each of these additional factors - commercial interests, social norms, and moral
concerns are not only interwoven with one another, but also are constantly reproduced by human
actors, be they individuals, organizations, institutions, societies, and entire countries, and so
forth. I would like to conclude the entire dissertation by quoting media historian and social
theorist John Durham Peters (2001):
Numbers pay tribute to our desire to be more than human; stories help us make sense both
of that yearning and its impossibility. Since democracy suspends us between personal and
the public interest, between human attachment and god-like detachment, we are fated to
continue to count and recount all our day (p. 447).
Quantifying the influence of such factors while also generating cogent, actionable
narratives about how making a positive difference are indeed possible across the multiple layers
of human existence. We are indeed “fated to continue to count and recount”; the iterative,
multidimensional process of finding the willpower to come up with effective solutions to
tackling the “grand challenges” (Ferraro et al., 2015) thus continues, developed and re-
developed, critiqued and re-critiqued, and constantly (re-) evaluated in light of new quantitative
and qualitative evidence.

155
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205
APPENDIX A: GAIN- AND LOSS-FRAMED ORGANIZATIONAL APPEALS
If You Contribute, You Can Help Civic Med be a Solution to the Prescription Drug Crisis
[If You Do Not Contribute, You Cannot Help Civic Med be a Solution to the Prescription Drug
Crisis]*
*For the title and the main text, loss-framed variation is in italics, within brackets. The bold-
faced parts correspond to the gain-framed variation.
The problem of excessively expensive prices of brand-name prescription drugs is well-
known to the American consumer. For instance, Turing Pharmaceuticals raised the cost of
Daraprim, a drug for treating infections, from $13.50 to $750 per tablet in 2015. Another for-
profit drug manufacturer raised the price of insulin, used by over six million Americans with
diabetes, by 49% in 2014 alone. Such instances are not isolated examples; on average,
Americans spend around $1,200 on prescription drugs annually, and the average cost of brand-
name oral prescription drugs increased by 15.1% each year between 2008 and 2016.
As one solution to solving the problem of out-of-control drug prices, concerned graduate
students, biomedical researchers and entrepreneurs are in the process of forming a new non-
profit organization. Provisionally named Civic Med, our organization intends to manufacture less
expensive, generic versions of select branded prescription drugs. It will cap the maximum price
of the drugs it produces at 25% of the price of the least expensive version of a given drug
currently available in the market. The first step for Civic Med is to acquire manufacturing
capacity to produce generic drugs here in America. At this point Civic Med does not have the
initial funds for setting up manufacturing facilities. Civic Med made the conscious decision to
decline funding from not only for-profit drug manufacturers (both branded and generic), but also
from patient advocacy organizations as well as consumer organizations. This is so because of the

206
high likelihood that patient advocacy and consumer organizations receive support from for-profit
drug manufacturers, and therefore may not be independent of the for-profit companies’
influence.
However, we also realize that this is an approach is not risk-free, as we are indeed
forgoing not one, but multiple, sources of guaranteed funding for our organization. This is why
we, as the founders of Civic Med, are reaching out to ordinary Americans like you. With your
financial support, Civic Med will be able to begin the production of generic drugs
independently of the influence of for-profit drug manufacturers, patient advocacy and
consumer organizations [Without your financial support, Civic Med will not be able to begin
the production of generic drugs independently of the influence of for-profit drug manufacturers,
patient advocacy and consumer organizations]. If Civic Med can start producing generic
drugs, then it will improve American citizens’ access to affordable health treatments more
generally [If Civic Med cannot start producing generic drugs, then it will not be able to improve
American citizens ’ access to affordable health treatments more generally]. Improving access to
affordable health treatments, in turn, saves lives [Not improving access to affordable health
treatments, in turn, leads to loss of life].
Please donate to Civic Med! With your donations, Civic Med can strengthen
healthcare justice [Without your donations, Civic Med cannot strengthen healthcare justice].
Lastly, with your contributions to the production of generic drugs here in the United
States, we can expand Americans’ access to safe generic drugs [Lastly, without your
contributions to the production of generic drugs here in the United States, we cannot expand
Americans ’ access to safe generic drugs].

207
APPENDIX B: EFFICACY VARIATIONS
Consumer Participation Showing Signs of Effective Influence [Little Signs of Effective
Influence] over New Non-Profit [For-Profit] Drug Manufacturer’s Decision-making*
June 15, 2019
by Sarah Reynolds
Associated Press

*For the title and the main text, the low-efficacy variation is in italics, within brackets. The bold-
faced parts correspond to the high-efficacy variation. Additionally, non-profit organization
information is also boldfaced, with the for-profit company information in parentheses.

A new non-profit organization (for-profit company) called Civic Med has been recently
formed. As is widely known, prescription drugs are too expensive for a majority of American
consumers. To address this problem, Civic Med will manufacture more affordable, generic
versions of prescription drugs, capping the maximum price of the drugs it will produce at no
more than half of the price of the least expensive version currently available to consumers. Civic
Med has drawn up an extensive list of drugs that have undergone steep price increases over the
past five years. However, it cannot produce every drug on the list, as the funds currently
available to Civic Med are not enough to cover the costs of producing every drug on the
provisional list. Therefore, Civic Med has to make some tough choices on which drugs it actually
can produce. The selected drugs will be included in Civic Med’s final product portfolio, and
production of these select drugs will begin in March 2020. The product portfolio is also available
on Civic Med’s website, reflecting the latest updates with respect to the selected drugs.

208
In a move without precedent in the pharmaceutical industry, Civic Med has decided to
rely on consumer involvement to decide its final product portfolio. It has been convening
biweekly meetings, made available to anyone and everyone, in person and virtually. Consumer
advocate Melissa Gunter has attended every single one of the meetings up to this point. Gunter is
a longstanding observer and critic of the pharmaceutical industry. So far, she has seen some
evidence of effective consumer impact from these meetings [little evidence of effective
consumer impact from these meetings]. Many of the drugs endorsed by consumers who took
part in the meetings were added to Civic Med’s final portfolio [None of the drugs endorsed
by consumers who took part in the meetings were added to Civic Med ’s final portfolio].
According to Gunter, this suggests that Civic Med is listening to consumers’ opinions. “Civic
Med is being responsive to consumer input,” she noted [Civic Med is not listening to
consumers ’ opinions. “Civic Med is not being responsive to consumers ’ input, ” she noted].
Consumers have found participation not difficult [Consumers have found
participation difficult]. Laurie Felt, a 56-year old restaurant owner, felt that she had “enough
knowledge and insight from my own experiences” to make comments during the meetings
[felt that she did not have “enough knowledge and insight from my own experiences ” to make
comments during the meetings]. Another attendee, a 32-year old dairy farmer named Kevin
Meyer, said that “I felt that I had a reasonable grasp of the decision-making process” [said
that “I did not feel as if I had a reasonable grasp of the decision-making process”]. It may be
early days, but this new non-profit organization [for-profit company] so far appears to be
succeeding in supporting meaningful consumer involvement [does not appear to be
succeeding in supporting meaningful consumer involvement]. It also appears to be helping
ordinary consumers themselves realize that they have the ability and knowledge to make a

209
real difference [does not appear to be helping ordinary consumers themselves realize that they
have the ability and knowledge to make a real difference].

210
APPENDIX C: NEWSPAPER CLASSIFICATION
Newspaper Publication
Frequency
Headquarters Location Geographic
Region
Ownership Classification
Advocate, The Daily Newark, OH Midwest Public
1
Regional
Albuquerque Journal Daily Albuquerque, NM Mountain Private Regional
Asbury Park Press Daily Ashbury, NJ Mid-Atlantic Public
1
Regional
Asheville Citizen-Times Daily Asheville, NC South Public
1
Regional
Austin-American Statesman Daily Austin, TX South Public
1
Regional
Boston Globe Daily Boston, MA New England Public National
Buffalo News Daily Buffalo, NY Mid-Atlantic Public Regional
Chicago Tribune Daily Chicago, IL Midwest Public National
Cincinnati Enquirer Daily Cincinnati, OH Midwest Public
1
Regional
Clarion Ledger Daily Jackson, MS South Public
1
Regional
Concord Monitor Daily Concord, NH New England Private Regional
Courier Post Daily Cherry Hill, NJ Mid-Atlantic Public
1
Regional
Courier-Journal Daily Louisville, KY South Public
1
Regional
Courier-News Daily Bridgewater, NJ Mid-Atlantic Public
1
Regional
Daily Record, The Daily Morristown, NJ Mid-Atlantic Public
1
Regional

211
Daily Times Daily Salisbury, MD South Public
1
Regional
Florida Today Daily Melbourne, FL South Public
1
Regional
Greenville News Daily Greenville, SC South Public
1
Regional
Jackson Sun Daily Jackson, TN South Public
1
Regional
Jacksonville Daily News Daily Jacksonville, FL South Public
1
Regional
Journal News Daily White Plains, NY Mid-Atlantic Public
1
Regional
Lima News Daily Lima, OH Midwest Private Regional
Los Angeles Times Daily Los Angeles, CA Pacific Private National
Marion Star Daily Marion, OH Midwest Public
1
Regional
Mercury News Daily San Jose, CA Pacific Investment Regional
Messenger Inquirer Daily Owensboro, KY South Private Regional
Newsday Daily Long Island, NY Mid-Atlantic Public Regional
New York Times Daily New York, NY Mid-Atlantic Public National
Ocala Star Banner Daily Ocala, FL South Public
1
Regional
Orange County Register Daily Anaheim, CA Pacific Private Regional
Palladium-Item Daily Richmond, IN Midwest Public
1
Regional
Patriot-News, The Weekly Harrisburg, PA Mid-Atlantic Private Regional
Pittsburgh Post-Gazette Daily Pittsburgh, PA Mid-Atlantic Private Regional

212
Press Democrat Daily Santa Rosa, CA Pacific Private Regional
Press of Atlantic City Daily Atlantic City, NJ Mid-Atlantic Investment Regional
Press & Sun-Bulletin Daily Binghamton, NY Mid-Atlantic Public
1
Regional
Public Opinion Daily Chambersburg, PA Mid-Atlantic Public
1
Regional
Record, The Daily Bergen County, NJ Mid-Atlantic Public
1
Regional
Rochester Democrat &
Chronicle
Daily Rochester, NY Mid-Atlantic Public
1
Regional
Salt Lake Tribune Daily Salt Lake City, UT Mountain Private Regional
Santa Fe New Mexican Daily Santa Fe, NM Mountain Private Regional
Savannah Morning News Daily Savannah, GA South Investment Regional
Skanner, The Weekly Portland, OR Pacific Private Regional
St. Cloud Times Daily St. Cloud, MN Midwest Public
1
Regional
St. Louis Post - Dispatch Daily St. Louis, MO Midwest Public Regional
St. Paul Pioneer Press Daily St. Paul, MN Midwest Investment Regional
Star Tribune Daily Minneapolis, MN Midwest Private Regional
Statesman Journal Daily Salem, OR Pacific Public
1
Regional
Sun Journal Daily Lewiston, ME New England Private Regional
Sun Sentinel Daily Ft. Lauderdale, FL South Public Regional

213
Tallahassee Democrat Daily Tallahassee, FL South Public
1
Regional
Tampa Bay Times Daily Tampa Bay, FL South Private Regional
Washington Post Daily Washington, DC South Private National
Wall Street Journal Daily New York, NY Mid-Atlantic Public National
Source: Abernathy (2018). The Expanding News Desert.

1
Gannett Media
Pacific: AK, CA, HI, OR, WA
Mountain: AZ, CO, ID, MT, NV, NM, UT, WY
Midwest: IL, IN, MI, OH, WI, IA, KS, MN, MO, NE, ND, SD
South: DE, DC, FL, GA, MD, NC, SC, VA, WV, AL, KY, MS, TN, AR, LA, OK, TX
Mid-Atlantic: NJ, NY, PA
New England: CT, ME, MA, NH, RI, VT

214
APPENDIX D: INSTITUTIONAL AFFILIATION OF EDITORIAL AUTHORS
Description Examples Frequency
(Relative %)
Media &
Journalist
Author is a journalist,
and is affiliated with
either the newspaper
that published a given
editorial or an
external media
outlet/organization
Ms. Finley is a member of the Journal’s Editorial Board
(“Medical Miracles from FDA Inefficiency: The economist
behind the ‘priority review voucher’ which advances treatments
for neglected diseases”, Wall Street Journal, January 26, 2018)

Ronald Bailey is science correspondent for Reason magazine
(“California’s New Prescription Drug Law won’t lower prices”,
Orange County Register, October 24, 2017)

106
(62.4%)
Public Official Author is an elected
representative, or a
government official
(local, municipal,
state, and federal)
Joseph E. Miro is a Republican member of the Delaware House
of Representatives, representing the 22nd District (“How much
is too much?”, The News Journal, April 10, 2016)

Trinidad Navarro, Insurance Commissioner, Delaware
(“Insurance Commissioner: Here are some tips to lower drug
prices”, The News Journal, February 13, 2019)
19
(11.1%)

Advocacy/
Non-Profit
Author is affiliated
with a non-profit or
advocacy
organization either
directly or indirectly
relevant to healthcare
Peter Pitts, a former FDA associate commissioner, is president
of the Center for Medicine in the Public Interest in New York
City (“Maine’s new generic drug legislation has good
intentions, bad execution,” Sun Journal, June 17, 2017)

Teresa Arnold is the state director for AARP South Carolina
(“Why Senate must pass prescription costs legislation”, The
11
(6.5%)

215
Greenville News, August 25, 2019)
Academic Author is an
academic researcher,
affiliated with an
academic or research
institution (including
think-tanks)
Marcia Angell is a senior lecturer in social medicine at Harvard
Medical School and a former editor in chief of the New
England Journal of Medicine (“Drug companies charge so much
because they can”, Press of Atlantic City, September 30, 2015)
9
(5.3%)
Medical Author identifies as a
doctor, physician, or
nurse and/or is
affiliated with a
medical institution
(e.g., hospital or
healthcare provider)
Dr. Ed Weisbart is a family physician in Olivette and chair of
the Missouri chapter of Physicians for a National Health
Program (“Trump’s proposal could drive drug prices even
higher”, St. Louis Post-Dispatch, November 25, 2018)
7
(4.1%)
Insurance Industry Author is affiliated
with a health
insurance company,
or a trade association
representing the
health insurance
industry
Eugene Sun, M.D., is vice president and chief medical officer of
Blue Cross and Blue Shield of New Mexico (“Step therapy
provides appropriate care”, The Santa Fe New Mexican, January
15, 2018)
3
(1.8%)

Pharmacy Author identifies as a
pharmacist, and is
affiliated with a
pharmacy, or has
expertise in
Brian Pinto is the owner and pharmacist in charge of Tiffany
Natural Pharmacy in Westfield. Anil Datwani is the owner and
pharmacist in charge of AR-Ex Pharmacy in Fords (“Pharmacy
Benefit Managers Drive up Cost of Drugs”, Courier Post, April
21, 2017)
2
(1.2%)

216
pharmacy-related
areas
Pharmaceutical
Industry
Author is affiliated
with a pharmaceutical
company, a trade
association
representing
pharmaceutical
companies and/or
industry
Wayne Roper is president of the South Carolina Biotechnology
Industry Organization (“Let the free market guide drug prices”,
The Greenville News, February 20, 2016)
1
(0.6%)
Lawyer Author is a practicing
attorney and is
affiliated with a law
firm or judicial
branch
William B. Schulz is a partner at the law firm Zuckerman
Spaeder, which represents generic drug companies and other
clients (“The Wrong Prescription”, The Washington Post,
August 6, 2017)
1
(0.6%)

Anonymous
*
Neither the name nor
the institutional
affiliation of the
author is provided;
rather, the author is
simply listed as
‘Anonymous’.
Anonymous (“The People vs. Martin Shkreli”, Wall Street
Journal, December 19, 2015)
5
(2.9%)
Other Authors whose
professional
affiliation is not
evident or who claim
Susan Olsen lives in Cambridge (“Prescription Drug Prices
Must be reined in”, Daily Times, January 8, 2018)

6
(3.5%)

217
themselves
Total: 170 (100%)
*All five editorials whose authors were identified as ‘Anonymous’ were published in The Wall Street Journal.

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Creator Kim, Hyun Tae (author)

Core Title Wicked problems, difficult solutions, and unintended consequences: strengthening efficacy to enhance access to affordable drugs

School Annenberg School for Communication

Degree Doctor of Philosophy

Degree Program Communication

Publication Date 07/16/2021

Defense Date 04/30/2020

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

Tag content analysis,editorials,efficacy,experiments,medicine access,OAI-PMH Harvest,strategic communication

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Riley, Patricia (committee chair), Kozinets, Robert V. (committee member), Murphy, Sheila Theresa (committee member)

Creator Email hyuntae@usc.edu,hyuntae0820@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-332097

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