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As the world’s population ages, dementia is increasingly recognised as a global public health priority.1 There are estimated to be approximately 50 million people worldwide currently living with dementia and this is projected to reach 150 million by 2050.2 The prevalence in New Zealand is currently estimated to be around 70,000 and expected to reach 170,000 by 2050.3 As a public health challenge, dementia requires a public health response4 and a major element of this response are mass media campaigns that raise public awareness and understanding about dementia. The media play an important role in not only disseminating information to the public but also shaping opinions and behaviours towards families living with dementia.

For many years dementia has been viewed as a disease driven by genetics and aging, factors over which people have no control. However, recent research indicates that approximately 35% of late-onset dementia can be attributed to modifiable risk factors, including education, midlife hypertension, midlife obesity, hearing loss, late-life depression, diabetes, physical inactivity, smoking and social isolation, whereas non-modifiable genetic risk factors, such as inheritance of the apolipoprotein E4 allele account for very little of the overall risk.5 Many of these risk factors are highly determined by individual health behaviours, which, if controlled, may mitigate or delay the onset of dementia. Dementia is also increasingly being presented as a social justice issue, as its rapid increase in prevalence, particularly in low and middle income countries, has an associated economic impact on families and society in general.2 Thus societal solutions for dementia may also start to be considered in the media. The power of media on health perceptions and outcomes in these areas is important, not only as a potential influence on our health behaviours and the chances of developing dementia, but also how we choose to attempt to address the societal challenges ahead.

The media selects which health issues and perspectives are given prominence,6 thus playing an essential role in the public’s consideration of the importance of health issues. This also shapes consideration of how problems at individual and public policy levels should be resolved.7 Media frames are a method of selecting salient information regarding health issues and creating pathways to think about the issue’s news value in terms of causality, effects and solutions.8 Frames define a problem, suggest causality and consequences of the issue, and provide solutions. Through these perspectives, frames can influence the public, and policy-makers, on how to respond to health issues.

Frames are a cultural construct and thus moral evaluations come into play when considering the responsibility attributions of causality and effects.9 When causality for an issue is attributed to individuals’ behaviours, the solution is also seen as the responsibility of those same individuals. Likewise, when causality is attributed to societal factors, the solution lies in the modification of social determinants. For instance, Iyengar10 analysed audience attributions of causal responsibility for poverty and found that when the audience was exposed to more individualised media frames depicting individuals living in poverty, the audience assigned responsibility to those people as being the cause of their poverty. However, when the audience was exposed to more societal media frames, the audience assigned responsibility for poverty to society rather than the individuals. Iyengar’s study demonstrates how audience attributions, shaped through media framing, influences political opinions and ideas. As a result, media framing of responsibility has powerful implications beyond purely the definition of the problem.

Research into dementia representation in media discourse is relatively sparse when compared to other public health issues such as cancer, obesity and HIV. While dementia coverage is positive in certain areas, such as sympathetic photographic depictions of people living with dementia,11 overall the literature suggests that the prevailing image of dementia in media is pessimistic, created through substantially negative frames, with an emphasis on stereotypically ageist depictions,12 but attribution of responsibility for the disorder has rarely been addressed.

The aim of our research is to evaluate how New Zealand newsprint media shapes discourse about dementia through its framing of the causes, effects and solutions, and who bears responsibility for the disease. We investigate this through examining i) the coverage of dementia between 2012–2016; ii) the framing of specific causes and effects of dementia; and iii) the association between specific causes and effects of dementia. Integrating the findings of the above three research questions, we discuss the moral evaluation of dementia through the lens of New Zealand newsprint media.

Methods

The study analyses dementia discourse across New Zealand’s three largest metropolitan daily newspapers: The New Zealand Herald, The Dominion Post and The Press between 1 January 2012 to 31 December 2016. Readership for the 2016 period were as follows: 423,000 for The New Zealand Herald, 159,000 for The Dominion Post and 157,000 for The Press.13 Our inclusion of the three newspapers takes into consideration geographical readership coverage: The New Zealand Herald is published in Auckland and has its largest audience-base in the upper North Island, The Dominion Post, published in Wellington, has highest readership in the lower North Island, while The Press, published in Christchurch, is the leading newspaper in the South Island.

Data extraction

We used ‘dementia’ as a search term on the academic database Newztext. Articles were restricted to those that were at least 150 words, in order to ensure articles were of sufficient length to develop themes and responsibility discussions. Articles that fell outside these criteria were: letters to the editor, advertisements, events, obituaries, duplicates within the newspaper, reports that were not about dementia in humans (as in articles discussing animal dementia) and items that mentioned dementia in passing.

Data analysis

We conducted the research in three phases of content analysis. We firstly developed thematic codes and their attributed reasoning devices of cause, effect and solution. Using Ward’s hierarchical clustering,14 we distributed codes under thematic categories. We categorised the thematic codes under the three generic frames identified as being the dominant theme in the health discourse: medical, health behavioural and societal. For each article, we also identified the dominant theme mentioned as a cause, effect or solution, and we marked it as being present once per document under that attribution regardless of how many times the theme and its associated reasoning device was reiterated within the article.

Once we had exhausted all possible codes within the cohort of news stories and the wider literature, we then developed and implemented the coding matrix.15 The coding matrix consisted of cause, effect and solution along the y-axis and medical, health behavioural and societal frames along the x-axis (see Table 1), similar to that recently developed for the framing of diabetes.16

Table 1: Coding matrix for framing of dementia by New Zealand newsprint media.

Finally, we used measures of association to examine the foremost cause-effect relationships within dementia discourse in New Zealand newsprint media.

We used MAXQDA Analytics Pro for the qualitative coding scheme development and content analysis, and its statistics module for statistical analysis to make inferences about measures of association between cause and effect themes.

Intercoder reliability

Two of the authors (FG, RS) independently coded 75 articles (20%) to assess inter-coder reliability. An acceptable level of agreement for Krippendorff’s17 alpha is α=0.8 (Krippendorff, 2004:241). Our study achieved α=0.851 across all codings. For each of the three frames, alpha scores were similar: medical frame α=0.881, societal frame α=0.861, and behavioural frame α=0.874.

Results

Framing of dementia in New Zealand newsprint media (2012–2016)

Using the word ‘dementia’ as a search term on the academic database Newztext resulted in a total of 800 articles: 242 articles from The New Zealand Herald, 285 articles from The Press and 273 articles from The Dominion Post: 439 articles did not meet the inclusion criteria; 361 articles were included in the study. All 361 articles presented the effects of dementia, 35% discussed causes and 7% mentioned solutions for dementia. Table 2 presents the frequency of media framing for the years 2012–16 and shows an increase in coverage over that time period.

Table 2: Frequency of medical, health behavioural, and societal framing of the causes, effects and solutions for dementia in New Zealand newsprint media (2012–2016).

Table 3 presents the causes and effects of dementia as reported through medical, behavioural and societal frames in New Zealand newsprint media. As solutions were rarely presented (7%) and mostly described existing medication or potential medical advances available for dementia, these were not included in the table.

Table 3: Causes and effects of dementia via medical, behavioural and societal frames in New Zealand newsprint media.

Framing the causes of dementia

Framing of causality mostly used the medical frame (83%). Within medical framing, 72% of the topics discussed were potentially modifiable causes of dementia (rugby-related head trauma and concussion, hearing loss, medication use, cardiovascular risk factors and obesity), but only nine percent of medical causes were presented as a result of lifestyle or health behaviour. One quarter of medical frames were attributed to non-modifiable causes such as biological ageing and genetic factors, and eight percent identified societal causes of dementia, for example the impact of air pollution or aluminium in the water supply.

Framing the effects of dementia

The framing of the effects of dementia were mainly represented by the societal frame (n=196, 54%). Within this frame, 70% of articles reported the adverse societal consequences of living with dementia, such as potential financial abuse, physical abuse and neglect, the effect on family relationships and caregivers’ stress and burnout. The remaining 30% in the societal frame addressed dementia’s impact on society including health and social care resources, the national economy, workforce, laws and policies.

The medical frame for effects of dementia was the second most utilised (n=119, 33%). As with the societal frame, the emphasis was on living with dementia. Within the medical frame, articles were more likely to identify dementia’s cognitive impact including memory loss, confusion and wandering, word-finding difficulties and personality changes.

The health behavioural frame was referred to least in discussions of dementia effects (n=46, 13%). Within this frame, the majority addressed reduced quality of life for people living with dementia due to the loss of independence in self-care, daily activities and feelings of loneliness. A few articles also mentioned behavioural changes, such as mood swings, and increased aggression and recklessness.

Association between medical causes and societal effects in New Zealand newsprint media

Table 4 presents the medical causes and societal effects that were most frequently mentioned together in the same article (p<0.0001). Modifiable medical causes (eg, concussion and cardiovascular risk factors) were more likely to be associated with adverse outcomes for society (eg, residential care resources), and non-modifiable medical causes (eg, biological ageing and genetic) were more likely to be associated with adverse outcomes for the individual and/or their family (elder abuse, caregiver stress and burnout, and impact on social ties). Figure 1 presents examples of quotes from articles to illustrate the associations made between medical causes and societal effects of dementia.

Table 4: Significant associations between causes and effects of dementia as portrayed in New Zealand newsprint media.

Figure 1: Examples of associations between medical causes and societal effects of as portrayed in New Zealand newsprint media.

Discussion

Our study is the first to examine media framing of dementia and its associated moral evaluations using a coding matrix that consists of cause, effect and solution along the y-axis and thematic categories by medical, health behavioural and societal frame along the x-axis, extending the work by Gounder et al, 2018.16 We found that, between 2012 and 2016, New Zealand newsprint media largely attributed the causes of dementia to medical causes, whereas the effects focused on the negative impact of the disorder on individuals, families and society. Modifiable medical causes were more likely to be associated with adverse outcomes for society whereas non-modifiable medical causes were more likely to be associated with adverse outcomes for the individual and/or their family.

Causes and effects of dementia

Recent epidemiological evidence suggests that approximately 35% of late-onset dementia can be attributed to modifiable risk factors.5 Many of these are related to lifestyle choices and therefore important to target for health promotion and prevention of dementia. Between 2013 and 2016, 35% of the articles about dementia in New Zealand newsprint media emphasised the medical causes of dementia. Almost half of these described rugby-related head injuries and concussion, but medical causes were rarely presented as lifestyle choices or health behaviours. This framing might suggest to readers that there is little that they can do to prevent dementia, or that it is rugby players who are most at risk.

New Zealand newsprint media also placed great emphasis on the effect of dementia on the individual. These were often described in negative, even catastrophic terms (see Figure 1). The effects were commonly reported as a loss of personhood, judgement and autonomy, resulting in a vulnerability to abuse from others, and the likelihood of ending up in a care home. In this respect, little has changed in the last 14 years: in 2006 Kirkman18 similarly reported that New Zealand newspaper articles between 1998 and 2002 represented people living with dementia as “powerless victims of their disease, victims of their carers and victims of health and social care services”. Likewise, in the UK print media, disproportionate negative emphasis on the effects of dementia, in addition to the ageing demographic, has been described. Peel (2014) concluded that “the high level of emphasis on the lack of personal control over the cause of dementia and the widespread detrimental effects on society creates a public discourse about dementia that is pessimistic and contributes to stigma around the disease”, as well as being a significant contributor to societal “dementia-panic”.19 In a more recent examination of news articles about dementia published in the British press between 2012 and 2017, the biomedical emphasis was noted, in particular the reliance on pharmaceutical treatments as the only possible solution to prevent dementia.20

Moral evaluation

We found that non-modifiable medical causes were more likely to be associated with adverse outcomes for the individual and/or their family. These findings replicate previous research which has shown that if the frame attributes dementia to non-modifiable medical causes (or ‘fixed attributes’) such as genetics and biological aging, these are perceived as being outside the control of the individuals,21 having adverse consequences on an individual’s lifestyle resulting in ‘social death’ with loss of self and personhood, independence and quality of life.22 The person (and their family) are seen as victims of the disease.22,23 While the medical frame distances individuals from blame for their disease, it also decreases their agency to alter their health outcomes. This reinforces the idea of individuals living with dementia as blameless victims of their circumstances, and powerless to alter their prognosis, contributing to the victimhood frame.24

In contrast, we found that modifiable medical causes of dementia (such as rugby-related head injuries) were less likely to be associated with adverse consequences for the individual, and more likely to be associated with adverse outcomes for society, such as the effect on the use of scarce health and social care resources. This might suggest a shift away from victimhood and a possible move towards blaming the victims and their lifestyle choices for the impact that dementia has on society.

Victimhood or victim-blaming?

In recent years, the UK news media has begun to shift its emphasis to health-related behaviours and dementia, in areas such as diet, exercise and lifestyle, and what people can do to “stave off” dementia.19 A similar shift has been observed in Australian news media where a causal relationship between engaging in preventative behaviour and individuals’ risk of cognitive decline and dementia has been emphasised.25 While this might be construed as empowering people to have control over their disease, it might also be viewed as problematic if individuals are presented as being morally deviant in their health behaviours.26 The authors of the Australian study25 argue that health advice given in newspaper articles is often accompanied by underlying moral claims regarding audiences’ obligation to commit to dementia preventative activities. Those that do not take preventive measures might be seen as being responsible for causing their disease, and possibly for the societal consequences of dementia such as the effects on the public purse, thus shifting the frame from victimhood to victim-blaming.

The topics of lifestyle choices and health behaviours in dementia have not received the same level of attention in New Zealand media. This lack of attention may be perceived by some as problematic, as it may add to the anxiety around dementia as an incurable and untreatable disease (victimhood). On the other hand, unhelpful victim-blaming for perceived unhealthy lifestyle choices has long been recognised in various chronic diseases such as obesity and diabetes,27 and particularly so among Māori in New Zealand.28 The scarce research evidence available in New Zealand suggests that Māori and New Zealand Pacific Islanders may be at greater risk of dementia29 and that this may be due to higher rates of risk factors such as diabetes, obesity and cardio-vascular disease compared with New Zealand Europeans.30,31 Thus dementia could become yet another chronic disease that is more common in socially disadvantaged peoples, who are then made responsible for developing the disease and morally judged for their assumed unhealthy lifestyle choices and health-related behaviours having an impact on society as a whole.

Strengths, limitations and implications

This study provides a comprehensive analysis of the national media coverage of dementia, but the findings from this study are limited due to the homogeneity across mainstream New Zealand newsprint media due to merged ownership: the Australian media company APN News & Media owns The New Zealand Herald, while Fairfax owns The Dominion Post and The Press. Newspaper readership globally is on the decline but remains popular in New Zealand. In 2019 over three million (77%) of New Zealanders read or accessed newspapers in an average seven-day period via print or online (website or app) platforms,13 so New Zealand newsprint media still enjoys substantial influence on public perception and therefore policy development. However, as other media sources are increasingly used by the public to educate themselves, these will also require examination in future research in this area.

As the prevalence of dementia changes rapidly, so too does the portrayal of the disease. In addition to its recent portrayal as a potentially preventable disorder, dementia is also increasingly presented as a social justice issue. This frame represents dementia as a public and social health crisis through depiction of the effect of dementia across family, community and wider society.2 Dementia as a societal issue, with adverse social and financial consequences, will require societal solutions such as social inclusion, a public health approach to risk reduction and support for families who provide most of the care. This approach has been adopted by the World Health Organization with the production of a global action plan on the public health response to dementia, calling on its 194 member states, including New Zealand, to produce a national dementia plan or strategy for 2017–2025.4 Our study examined newspapers from 2013 to 2016 prior to the introduction of the concept of dementia as potentially preventable and/or a social justice issue. Consequently, an update of our research findings is already required to assess whether there has been change in the New Zealand media framing of dementia since 2016 which will contribute to this new public health approach.

Conclusion

Dementia is a complex issue as a result of it having both modifiable and non-modifiable origins and shaped by its multilayered effects on individuals and society and a current lack of solutions for prevention or cure. Dementia remains a highly stigmatised disorder in many countries,32 so it is important that information about the disease is disseminated accurately and responsibly. From a human rights perspective, there is perhaps a moral obligation for media to choose words carefully and to not portray people with dementia as powerless, child-like, vulnerable, dependent and a burden. By portraying people using a personhood model33 the focus is on the human being rather than the disease. From a social justice perspective, the New Zealand media has an important role to play in promoting an inclusive society that champions the rights of individuals and families living with dementia, rather than reinforcing a culture of victim-blaming and stigma. This approach would contribute to engaging the public in addressing the inevitable social and financial consequences of the expected ‘tsunami’ of dementia and help to address potential inequities for people and families living with dementia in New Zealand.

Summary

Abstract

Aim

To evaluate how New Zealand newsprint media shapes discourse about dementia through its framing of the causes, effects and solutions, and who bears responsibility for the disease.

Method

Using New Zealand’s three largest daily newspapers, we examined i) the coverage of dementia between 2012–2016, ii) the framing of causes and effects of dementia, and iii) the most frequent associations of causes and effects of dementia. We integrated the findings to assess the moral evaluation of dementia in New Zealand newsprint media.

Results

Of the 361 articles extracted all presented effects of dementia, 35% discussed causes and 7% mentioned solutions for dementia. Medical causes dominated over health behavioural and societal causes, and effects were mostly the negative impact on the individual, family and society. Modifiable medical causes were more likely to be associated with adverse outcomes for society whereas non-modifiable medical causes were more likely to be associated with adverse outcomes for the individual and/or their family.

Conclusion

Between 2012–16 New Zealand newsprint media largely portrayed dementia from a ‘powerless victim’ frame. Further research is required to assess whether, since 2016, there has been a shift towards media framing of dementia as potentially preventable and a social justice issue.

Author Information

Sarah Cullum, Senior Lecturer, Dept of Psychological Medicine, The University of Auckland; Rachael Simpson, Psychiatric Registrar, Mental Health & Addiction Services, Counties Manukau District Health Board, Auckland; Farzana Gounder, Deputy Head of School (Research), Dept of Linguistics, Institute of the Pacific United New Zealand Tertiary Institute, Palmerston North.

Acknowledgements

Correspondence

Sarah Cullum, Department of Psychological Medicine, School of Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Private Bag 92019, Auckland Mail Centre, Auckland 1142.

Correspondence Email

sarah.cullum@auckland.ac.nz

Competing Interests

Nil.

1. World Health Organization. Dementia: a public health priority. United Kingdom; 2012.

2. Prince M, Wimo A, Guerchet M et al. World Alzheimer Report 2015: the global impact of dementia, an analysis of prevalence, incidence, costs and trends. Alzheimer’s Disease International. London; 2015.

3. Deloitte Access Economics. Updated Dementia Economic Impact Report 2016, New Zealand. Alzheimers New Zealand; 2017.

4. World Health Organization. Global action plan on the public health response to dementia 2017–2025. World Health Organization. Geneva; 2017.

5. Livingston G, Sommerlad A, Orgeta V, et al. Dementia prevention, intervention, and care. Lancet. 2017; 390(10113):2673–2734.

6. Frost K, Frank E, Maibach E. Relative risk in the news media: a quantification of misrepresentation. Am J Public Health. 1997; 87(5):842–845.

7. Altheide DL. “The News Media, the Problem Frame, and the Production of Fear”. The Sociological Quarterly. 1997; 38(4):647–668.

8. Van Gorp B. The constructionist approach to framing: Bringing culture back in. Journal of Communication. 2007; 57(1):60–78.

9. Entman RM. Framing: Toward Clarification of a Fractured Paradigm. Journal of Communication. 1993; 43(4):51–58.

10. Iyengar S. Framing responsibility for political issues: The case of poverty. Political Behavior. 1990; 12(1):19–40.

11. Kessler E-M, Schwender C. Giving Dementia a Face? The Portrayal of Older People With Dementia in German Weekly News Magazines Between the Years 2000 and 2009. Journals of Gerontology Series B: Psychological Sciences and Social Sciences. 2012; 67(2):261–270.

12. Van Gorp B, Vercruysse T. Frames and Counter-Frames Giving Meaning to Dementia: A Framing Analysis Of Media Content. Social Science & Medicine. 2012; 74(8):1274–1281.

13. Nielsen Company. Nielsen National Readership Survey. New Zealand: Nielsen Company; 2017.

14. Johnson S. Hierarchical clustering schemes. Psychometrika. 1967; 32(3):241–254.

15. Van Gorp B. Where is the Frame?: Victims and Intruders in the Belgian Press Coverage of the Asylum Issue. European Journal of Communication. 2005; 20(4):484–507.

16. Gounder F, Ameer R. Defining diabetes and assigning responsibility: how print media frame diabetes in New Zealand. Journal of Applied Communication Research. 2018; 46(1):93–112.

17. Krippendorff K. Reliability in content analysis: some common misconceptions and recommendations. Human Communication Research. 2004; 30(3):411–433.

18. Kirkman AM. Dementia in the news: the media coverage of Alzheimer’s disease. Australasian Journal on Ageing. 2006; 25(2):74–79.

19. Peel E. ‘The living death of Alzheimer’s’ versus ‘Take a walk to keep dementia at bay’: representations of dementia in print media and carer discourse. Sociology of Health & Illness 2014; 36(6):885–901.

20. Bailey A, Dening T, Harvey K. Battles and breakthroughs: representations of dementia in the British press. Ageing and Society. 2019:1–15. doi: 10.1017/S0144686X19001120.

21. Bond J. The medicalization of dementia. Journal of Aging Studies. 1992; 6(4):397–403.

22. Corner L, Bond J. Being at risk of dementia: Fears and anxieties of older adults. Journal of Aging Studies. 2004; 18(2):143–155.

23. Sweeting H, Gilhooly M. Dementia and the phenomenon of social death. Sociology of Health & Illness. 1997; 19(1):93–117.

24. Kvaale EP, Haslam N, Gottdiener WH. The ‘side effects’ of medicalization: A meta-analytic review of how biogenetic explanations affect stigma. Clinical Psychology Review. 2013; 33(6):782–794.

25. Lawless M, Augoustinos M. Brain health advice in the news: managing notions of individual responsibility in media discourse on cognitive decline and dementia. Qualitative Research in Psychology. 2017; 14:62–80.

26. Brown R. Resisting Moralisation in Health Promotion. Ethical Theory and Moral Practice. 2018; 21(4):997–1011.

27. Garry E, John D. Beyond Obesity and Lifestyle: A Review of 21st Century Chronic Disease Determinants. BioMed Research International. 2014; 2014.

28. Reid P, Paine S-J, Curtis E, et al. Achieving health equity in Aotearoa: strengthening responsiveness to Māori in health research. The New Zealand Medical Journal. 2017; 130(1465):96–103.

29. Cullum S, Mullin K, Zeng I, et al. Do community-dwelling Maori and Pacific peoples present with dementia at a younger age and at a later stage compared with NZ Europeans? Int J Geriatr Psychiatry. 2018; 33(8):1098–1104.

30. Joshy G, Simmons D. Epidemiology of diabetes in New Zealand: revisit to a changing landscape. N Z Med J. 2006; 119(1235):U1999.

31. Feigin VL, Krishnamurthi RV, Barker-Collo S, et al. 30-Year Trends in Stroke Rates and Outcome in Auckland, New Zealand (1981–2012): A Multi-Ethnic Population-Based Series of Studies. PloS one. 2015; 10(8):e0134609-e0134609.

32. Alzheimers Disease International. World Alzheimer Report 2019: Attitudes to dementia. London; 2019.

33. Kitwood TM. Dementia Reconsidered: the Person Comes First. Buckingham: Open University Press; 1997.

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As the world’s population ages, dementia is increasingly recognised as a global public health priority.1 There are estimated to be approximately 50 million people worldwide currently living with dementia and this is projected to reach 150 million by 2050.2 The prevalence in New Zealand is currently estimated to be around 70,000 and expected to reach 170,000 by 2050.3 As a public health challenge, dementia requires a public health response4 and a major element of this response are mass media campaigns that raise public awareness and understanding about dementia. The media play an important role in not only disseminating information to the public but also shaping opinions and behaviours towards families living with dementia.

For many years dementia has been viewed as a disease driven by genetics and aging, factors over which people have no control. However, recent research indicates that approximately 35% of late-onset dementia can be attributed to modifiable risk factors, including education, midlife hypertension, midlife obesity, hearing loss, late-life depression, diabetes, physical inactivity, smoking and social isolation, whereas non-modifiable genetic risk factors, such as inheritance of the apolipoprotein E4 allele account for very little of the overall risk.5 Many of these risk factors are highly determined by individual health behaviours, which, if controlled, may mitigate or delay the onset of dementia. Dementia is also increasingly being presented as a social justice issue, as its rapid increase in prevalence, particularly in low and middle income countries, has an associated economic impact on families and society in general.2 Thus societal solutions for dementia may also start to be considered in the media. The power of media on health perceptions and outcomes in these areas is important, not only as a potential influence on our health behaviours and the chances of developing dementia, but also how we choose to attempt to address the societal challenges ahead.

The media selects which health issues and perspectives are given prominence,6 thus playing an essential role in the public’s consideration of the importance of health issues. This also shapes consideration of how problems at individual and public policy levels should be resolved.7 Media frames are a method of selecting salient information regarding health issues and creating pathways to think about the issue’s news value in terms of causality, effects and solutions.8 Frames define a problem, suggest causality and consequences of the issue, and provide solutions. Through these perspectives, frames can influence the public, and policy-makers, on how to respond to health issues.

Frames are a cultural construct and thus moral evaluations come into play when considering the responsibility attributions of causality and effects.9 When causality for an issue is attributed to individuals’ behaviours, the solution is also seen as the responsibility of those same individuals. Likewise, when causality is attributed to societal factors, the solution lies in the modification of social determinants. For instance, Iyengar10 analysed audience attributions of causal responsibility for poverty and found that when the audience was exposed to more individualised media frames depicting individuals living in poverty, the audience assigned responsibility to those people as being the cause of their poverty. However, when the audience was exposed to more societal media frames, the audience assigned responsibility for poverty to society rather than the individuals. Iyengar’s study demonstrates how audience attributions, shaped through media framing, influences political opinions and ideas. As a result, media framing of responsibility has powerful implications beyond purely the definition of the problem.

Research into dementia representation in media discourse is relatively sparse when compared to other public health issues such as cancer, obesity and HIV. While dementia coverage is positive in certain areas, such as sympathetic photographic depictions of people living with dementia,11 overall the literature suggests that the prevailing image of dementia in media is pessimistic, created through substantially negative frames, with an emphasis on stereotypically ageist depictions,12 but attribution of responsibility for the disorder has rarely been addressed.

The aim of our research is to evaluate how New Zealand newsprint media shapes discourse about dementia through its framing of the causes, effects and solutions, and who bears responsibility for the disease. We investigate this through examining i) the coverage of dementia between 2012–2016; ii) the framing of specific causes and effects of dementia; and iii) the association between specific causes and effects of dementia. Integrating the findings of the above three research questions, we discuss the moral evaluation of dementia through the lens of New Zealand newsprint media.

Methods

The study analyses dementia discourse across New Zealand’s three largest metropolitan daily newspapers: The New Zealand Herald, The Dominion Post and The Press between 1 January 2012 to 31 December 2016. Readership for the 2016 period were as follows: 423,000 for The New Zealand Herald, 159,000 for The Dominion Post and 157,000 for The Press.13 Our inclusion of the three newspapers takes into consideration geographical readership coverage: The New Zealand Herald is published in Auckland and has its largest audience-base in the upper North Island, The Dominion Post, published in Wellington, has highest readership in the lower North Island, while The Press, published in Christchurch, is the leading newspaper in the South Island.

Data extraction

We used ‘dementia’ as a search term on the academic database Newztext. Articles were restricted to those that were at least 150 words, in order to ensure articles were of sufficient length to develop themes and responsibility discussions. Articles that fell outside these criteria were: letters to the editor, advertisements, events, obituaries, duplicates within the newspaper, reports that were not about dementia in humans (as in articles discussing animal dementia) and items that mentioned dementia in passing.

Data analysis

We conducted the research in three phases of content analysis. We firstly developed thematic codes and their attributed reasoning devices of cause, effect and solution. Using Ward’s hierarchical clustering,14 we distributed codes under thematic categories. We categorised the thematic codes under the three generic frames identified as being the dominant theme in the health discourse: medical, health behavioural and societal. For each article, we also identified the dominant theme mentioned as a cause, effect or solution, and we marked it as being present once per document under that attribution regardless of how many times the theme and its associated reasoning device was reiterated within the article.

Once we had exhausted all possible codes within the cohort of news stories and the wider literature, we then developed and implemented the coding matrix.15 The coding matrix consisted of cause, effect and solution along the y-axis and medical, health behavioural and societal frames along the x-axis (see Table 1), similar to that recently developed for the framing of diabetes.16

Table 1: Coding matrix for framing of dementia by New Zealand newsprint media.

Finally, we used measures of association to examine the foremost cause-effect relationships within dementia discourse in New Zealand newsprint media.

We used MAXQDA Analytics Pro for the qualitative coding scheme development and content analysis, and its statistics module for statistical analysis to make inferences about measures of association between cause and effect themes.

Intercoder reliability

Two of the authors (FG, RS) independently coded 75 articles (20%) to assess inter-coder reliability. An acceptable level of agreement for Krippendorff’s17 alpha is α=0.8 (Krippendorff, 2004:241). Our study achieved α=0.851 across all codings. For each of the three frames, alpha scores were similar: medical frame α=0.881, societal frame α=0.861, and behavioural frame α=0.874.

Results

Framing of dementia in New Zealand newsprint media (2012–2016)

Using the word ‘dementia’ as a search term on the academic database Newztext resulted in a total of 800 articles: 242 articles from The New Zealand Herald, 285 articles from The Press and 273 articles from The Dominion Post: 439 articles did not meet the inclusion criteria; 361 articles were included in the study. All 361 articles presented the effects of dementia, 35% discussed causes and 7% mentioned solutions for dementia. Table 2 presents the frequency of media framing for the years 2012–16 and shows an increase in coverage over that time period.

Table 2: Frequency of medical, health behavioural, and societal framing of the causes, effects and solutions for dementia in New Zealand newsprint media (2012–2016).

Table 3 presents the causes and effects of dementia as reported through medical, behavioural and societal frames in New Zealand newsprint media. As solutions were rarely presented (7%) and mostly described existing medication or potential medical advances available for dementia, these were not included in the table.

Table 3: Causes and effects of dementia via medical, behavioural and societal frames in New Zealand newsprint media.

Framing the causes of dementia

Framing of causality mostly used the medical frame (83%). Within medical framing, 72% of the topics discussed were potentially modifiable causes of dementia (rugby-related head trauma and concussion, hearing loss, medication use, cardiovascular risk factors and obesity), but only nine percent of medical causes were presented as a result of lifestyle or health behaviour. One quarter of medical frames were attributed to non-modifiable causes such as biological ageing and genetic factors, and eight percent identified societal causes of dementia, for example the impact of air pollution or aluminium in the water supply.

Framing the effects of dementia

The framing of the effects of dementia were mainly represented by the societal frame (n=196, 54%). Within this frame, 70% of articles reported the adverse societal consequences of living with dementia, such as potential financial abuse, physical abuse and neglect, the effect on family relationships and caregivers’ stress and burnout. The remaining 30% in the societal frame addressed dementia’s impact on society including health and social care resources, the national economy, workforce, laws and policies.

The medical frame for effects of dementia was the second most utilised (n=119, 33%). As with the societal frame, the emphasis was on living with dementia. Within the medical frame, articles were more likely to identify dementia’s cognitive impact including memory loss, confusion and wandering, word-finding difficulties and personality changes.

The health behavioural frame was referred to least in discussions of dementia effects (n=46, 13%). Within this frame, the majority addressed reduced quality of life for people living with dementia due to the loss of independence in self-care, daily activities and feelings of loneliness. A few articles also mentioned behavioural changes, such as mood swings, and increased aggression and recklessness.

Association between medical causes and societal effects in New Zealand newsprint media

Table 4 presents the medical causes and societal effects that were most frequently mentioned together in the same article (p<0.0001). Modifiable medical causes (eg, concussion and cardiovascular risk factors) were more likely to be associated with adverse outcomes for society (eg, residential care resources), and non-modifiable medical causes (eg, biological ageing and genetic) were more likely to be associated with adverse outcomes for the individual and/or their family (elder abuse, caregiver stress and burnout, and impact on social ties). Figure 1 presents examples of quotes from articles to illustrate the associations made between medical causes and societal effects of dementia.

Table 4: Significant associations between causes and effects of dementia as portrayed in New Zealand newsprint media.

Figure 1: Examples of associations between medical causes and societal effects of as portrayed in New Zealand newsprint media.

Discussion

Our study is the first to examine media framing of dementia and its associated moral evaluations using a coding matrix that consists of cause, effect and solution along the y-axis and thematic categories by medical, health behavioural and societal frame along the x-axis, extending the work by Gounder et al, 2018.16 We found that, between 2012 and 2016, New Zealand newsprint media largely attributed the causes of dementia to medical causes, whereas the effects focused on the negative impact of the disorder on individuals, families and society. Modifiable medical causes were more likely to be associated with adverse outcomes for society whereas non-modifiable medical causes were more likely to be associated with adverse outcomes for the individual and/or their family.

Causes and effects of dementia

Recent epidemiological evidence suggests that approximately 35% of late-onset dementia can be attributed to modifiable risk factors.5 Many of these are related to lifestyle choices and therefore important to target for health promotion and prevention of dementia. Between 2013 and 2016, 35% of the articles about dementia in New Zealand newsprint media emphasised the medical causes of dementia. Almost half of these described rugby-related head injuries and concussion, but medical causes were rarely presented as lifestyle choices or health behaviours. This framing might suggest to readers that there is little that they can do to prevent dementia, or that it is rugby players who are most at risk.

New Zealand newsprint media also placed great emphasis on the effect of dementia on the individual. These were often described in negative, even catastrophic terms (see Figure 1). The effects were commonly reported as a loss of personhood, judgement and autonomy, resulting in a vulnerability to abuse from others, and the likelihood of ending up in a care home. In this respect, little has changed in the last 14 years: in 2006 Kirkman18 similarly reported that New Zealand newspaper articles between 1998 and 2002 represented people living with dementia as “powerless victims of their disease, victims of their carers and victims of health and social care services”. Likewise, in the UK print media, disproportionate negative emphasis on the effects of dementia, in addition to the ageing demographic, has been described. Peel (2014) concluded that “the high level of emphasis on the lack of personal control over the cause of dementia and the widespread detrimental effects on society creates a public discourse about dementia that is pessimistic and contributes to stigma around the disease”, as well as being a significant contributor to societal “dementia-panic”.19 In a more recent examination of news articles about dementia published in the British press between 2012 and 2017, the biomedical emphasis was noted, in particular the reliance on pharmaceutical treatments as the only possible solution to prevent dementia.20

Moral evaluation

We found that non-modifiable medical causes were more likely to be associated with adverse outcomes for the individual and/or their family. These findings replicate previous research which has shown that if the frame attributes dementia to non-modifiable medical causes (or ‘fixed attributes’) such as genetics and biological aging, these are perceived as being outside the control of the individuals,21 having adverse consequences on an individual’s lifestyle resulting in ‘social death’ with loss of self and personhood, independence and quality of life.22 The person (and their family) are seen as victims of the disease.22,23 While the medical frame distances individuals from blame for their disease, it also decreases their agency to alter their health outcomes. This reinforces the idea of individuals living with dementia as blameless victims of their circumstances, and powerless to alter their prognosis, contributing to the victimhood frame.24

In contrast, we found that modifiable medical causes of dementia (such as rugby-related head injuries) were less likely to be associated with adverse consequences for the individual, and more likely to be associated with adverse outcomes for society, such as the effect on the use of scarce health and social care resources. This might suggest a shift away from victimhood and a possible move towards blaming the victims and their lifestyle choices for the impact that dementia has on society.

Victimhood or victim-blaming?

In recent years, the UK news media has begun to shift its emphasis to health-related behaviours and dementia, in areas such as diet, exercise and lifestyle, and what people can do to “stave off” dementia.19 A similar shift has been observed in Australian news media where a causal relationship between engaging in preventative behaviour and individuals’ risk of cognitive decline and dementia has been emphasised.25 While this might be construed as empowering people to have control over their disease, it might also be viewed as problematic if individuals are presented as being morally deviant in their health behaviours.26 The authors of the Australian study25 argue that health advice given in newspaper articles is often accompanied by underlying moral claims regarding audiences’ obligation to commit to dementia preventative activities. Those that do not take preventive measures might be seen as being responsible for causing their disease, and possibly for the societal consequences of dementia such as the effects on the public purse, thus shifting the frame from victimhood to victim-blaming.

The topics of lifestyle choices and health behaviours in dementia have not received the same level of attention in New Zealand media. This lack of attention may be perceived by some as problematic, as it may add to the anxiety around dementia as an incurable and untreatable disease (victimhood). On the other hand, unhelpful victim-blaming for perceived unhealthy lifestyle choices has long been recognised in various chronic diseases such as obesity and diabetes,27 and particularly so among Māori in New Zealand.28 The scarce research evidence available in New Zealand suggests that Māori and New Zealand Pacific Islanders may be at greater risk of dementia29 and that this may be due to higher rates of risk factors such as diabetes, obesity and cardio-vascular disease compared with New Zealand Europeans.30,31 Thus dementia could become yet another chronic disease that is more common in socially disadvantaged peoples, who are then made responsible for developing the disease and morally judged for their assumed unhealthy lifestyle choices and health-related behaviours having an impact on society as a whole.

Strengths, limitations and implications

This study provides a comprehensive analysis of the national media coverage of dementia, but the findings from this study are limited due to the homogeneity across mainstream New Zealand newsprint media due to merged ownership: the Australian media company APN News & Media owns The New Zealand Herald, while Fairfax owns The Dominion Post and The Press. Newspaper readership globally is on the decline but remains popular in New Zealand. In 2019 over three million (77%) of New Zealanders read or accessed newspapers in an average seven-day period via print or online (website or app) platforms,13 so New Zealand newsprint media still enjoys substantial influence on public perception and therefore policy development. However, as other media sources are increasingly used by the public to educate themselves, these will also require examination in future research in this area.

As the prevalence of dementia changes rapidly, so too does the portrayal of the disease. In addition to its recent portrayal as a potentially preventable disorder, dementia is also increasingly presented as a social justice issue. This frame represents dementia as a public and social health crisis through depiction of the effect of dementia across family, community and wider society.2 Dementia as a societal issue, with adverse social and financial consequences, will require societal solutions such as social inclusion, a public health approach to risk reduction and support for families who provide most of the care. This approach has been adopted by the World Health Organization with the production of a global action plan on the public health response to dementia, calling on its 194 member states, including New Zealand, to produce a national dementia plan or strategy for 2017–2025.4 Our study examined newspapers from 2013 to 2016 prior to the introduction of the concept of dementia as potentially preventable and/or a social justice issue. Consequently, an update of our research findings is already required to assess whether there has been change in the New Zealand media framing of dementia since 2016 which will contribute to this new public health approach.

Conclusion

Dementia is a complex issue as a result of it having both modifiable and non-modifiable origins and shaped by its multilayered effects on individuals and society and a current lack of solutions for prevention or cure. Dementia remains a highly stigmatised disorder in many countries,32 so it is important that information about the disease is disseminated accurately and responsibly. From a human rights perspective, there is perhaps a moral obligation for media to choose words carefully and to not portray people with dementia as powerless, child-like, vulnerable, dependent and a burden. By portraying people using a personhood model33 the focus is on the human being rather than the disease. From a social justice perspective, the New Zealand media has an important role to play in promoting an inclusive society that champions the rights of individuals and families living with dementia, rather than reinforcing a culture of victim-blaming and stigma. This approach would contribute to engaging the public in addressing the inevitable social and financial consequences of the expected ‘tsunami’ of dementia and help to address potential inequities for people and families living with dementia in New Zealand.

Summary

Abstract

Aim

To evaluate how New Zealand newsprint media shapes discourse about dementia through its framing of the causes, effects and solutions, and who bears responsibility for the disease.

Method

Using New Zealand’s three largest daily newspapers, we examined i) the coverage of dementia between 2012–2016, ii) the framing of causes and effects of dementia, and iii) the most frequent associations of causes and effects of dementia. We integrated the findings to assess the moral evaluation of dementia in New Zealand newsprint media.

Results

Of the 361 articles extracted all presented effects of dementia, 35% discussed causes and 7% mentioned solutions for dementia. Medical causes dominated over health behavioural and societal causes, and effects were mostly the negative impact on the individual, family and society. Modifiable medical causes were more likely to be associated with adverse outcomes for society whereas non-modifiable medical causes were more likely to be associated with adverse outcomes for the individual and/or their family.

Conclusion

Between 2012–16 New Zealand newsprint media largely portrayed dementia from a ‘powerless victim’ frame. Further research is required to assess whether, since 2016, there has been a shift towards media framing of dementia as potentially preventable and a social justice issue.

Author Information

Sarah Cullum, Senior Lecturer, Dept of Psychological Medicine, The University of Auckland; Rachael Simpson, Psychiatric Registrar, Mental Health & Addiction Services, Counties Manukau District Health Board, Auckland; Farzana Gounder, Deputy Head of School (Research), Dept of Linguistics, Institute of the Pacific United New Zealand Tertiary Institute, Palmerston North.

Acknowledgements

Correspondence

Sarah Cullum, Department of Psychological Medicine, School of Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Private Bag 92019, Auckland Mail Centre, Auckland 1142.

Correspondence Email

sarah.cullum@auckland.ac.nz

Competing Interests

Nil.

1. World Health Organization. Dementia: a public health priority. United Kingdom; 2012.

2. Prince M, Wimo A, Guerchet M et al. World Alzheimer Report 2015: the global impact of dementia, an analysis of prevalence, incidence, costs and trends. Alzheimer’s Disease International. London; 2015.

3. Deloitte Access Economics. Updated Dementia Economic Impact Report 2016, New Zealand. Alzheimers New Zealand; 2017.

4. World Health Organization. Global action plan on the public health response to dementia 2017–2025. World Health Organization. Geneva; 2017.

5. Livingston G, Sommerlad A, Orgeta V, et al. Dementia prevention, intervention, and care. Lancet. 2017; 390(10113):2673–2734.

6. Frost K, Frank E, Maibach E. Relative risk in the news media: a quantification of misrepresentation. Am J Public Health. 1997; 87(5):842–845.

7. Altheide DL. “The News Media, the Problem Frame, and the Production of Fear”. The Sociological Quarterly. 1997; 38(4):647–668.

8. Van Gorp B. The constructionist approach to framing: Bringing culture back in. Journal of Communication. 2007; 57(1):60–78.

9. Entman RM. Framing: Toward Clarification of a Fractured Paradigm. Journal of Communication. 1993; 43(4):51–58.

10. Iyengar S. Framing responsibility for political issues: The case of poverty. Political Behavior. 1990; 12(1):19–40.

11. Kessler E-M, Schwender C. Giving Dementia a Face? The Portrayal of Older People With Dementia in German Weekly News Magazines Between the Years 2000 and 2009. Journals of Gerontology Series B: Psychological Sciences and Social Sciences. 2012; 67(2):261–270.

12. Van Gorp B, Vercruysse T. Frames and Counter-Frames Giving Meaning to Dementia: A Framing Analysis Of Media Content. Social Science & Medicine. 2012; 74(8):1274–1281.

13. Nielsen Company. Nielsen National Readership Survey. New Zealand: Nielsen Company; 2017.

14. Johnson S. Hierarchical clustering schemes. Psychometrika. 1967; 32(3):241–254.

15. Van Gorp B. Where is the Frame?: Victims and Intruders in the Belgian Press Coverage of the Asylum Issue. European Journal of Communication. 2005; 20(4):484–507.

16. Gounder F, Ameer R. Defining diabetes and assigning responsibility: how print media frame diabetes in New Zealand. Journal of Applied Communication Research. 2018; 46(1):93–112.

17. Krippendorff K. Reliability in content analysis: some common misconceptions and recommendations. Human Communication Research. 2004; 30(3):411–433.

18. Kirkman AM. Dementia in the news: the media coverage of Alzheimer’s disease. Australasian Journal on Ageing. 2006; 25(2):74–79.

19. Peel E. ‘The living death of Alzheimer’s’ versus ‘Take a walk to keep dementia at bay’: representations of dementia in print media and carer discourse. Sociology of Health & Illness 2014; 36(6):885–901.

20. Bailey A, Dening T, Harvey K. Battles and breakthroughs: representations of dementia in the British press. Ageing and Society. 2019:1–15. doi: 10.1017/S0144686X19001120.

21. Bond J. The medicalization of dementia. Journal of Aging Studies. 1992; 6(4):397–403.

22. Corner L, Bond J. Being at risk of dementia: Fears and anxieties of older adults. Journal of Aging Studies. 2004; 18(2):143–155.

23. Sweeting H, Gilhooly M. Dementia and the phenomenon of social death. Sociology of Health & Illness. 1997; 19(1):93–117.

24. Kvaale EP, Haslam N, Gottdiener WH. The ‘side effects’ of medicalization: A meta-analytic review of how biogenetic explanations affect stigma. Clinical Psychology Review. 2013; 33(6):782–794.

25. Lawless M, Augoustinos M. Brain health advice in the news: managing notions of individual responsibility in media discourse on cognitive decline and dementia. Qualitative Research in Psychology. 2017; 14:62–80.

26. Brown R. Resisting Moralisation in Health Promotion. Ethical Theory and Moral Practice. 2018; 21(4):997–1011.

27. Garry E, John D. Beyond Obesity and Lifestyle: A Review of 21st Century Chronic Disease Determinants. BioMed Research International. 2014; 2014.

28. Reid P, Paine S-J, Curtis E, et al. Achieving health equity in Aotearoa: strengthening responsiveness to Māori in health research. The New Zealand Medical Journal. 2017; 130(1465):96–103.

29. Cullum S, Mullin K, Zeng I, et al. Do community-dwelling Maori and Pacific peoples present with dementia at a younger age and at a later stage compared with NZ Europeans? Int J Geriatr Psychiatry. 2018; 33(8):1098–1104.

30. Joshy G, Simmons D. Epidemiology of diabetes in New Zealand: revisit to a changing landscape. N Z Med J. 2006; 119(1235):U1999.

31. Feigin VL, Krishnamurthi RV, Barker-Collo S, et al. 30-Year Trends in Stroke Rates and Outcome in Auckland, New Zealand (1981–2012): A Multi-Ethnic Population-Based Series of Studies. PloS one. 2015; 10(8):e0134609-e0134609.

32. Alzheimers Disease International. World Alzheimer Report 2019: Attitudes to dementia. London; 2019.

33. Kitwood TM. Dementia Reconsidered: the Person Comes First. Buckingham: Open University Press; 1997.

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As the world’s population ages, dementia is increasingly recognised as a global public health priority.1 There are estimated to be approximately 50 million people worldwide currently living with dementia and this is projected to reach 150 million by 2050.2 The prevalence in New Zealand is currently estimated to be around 70,000 and expected to reach 170,000 by 2050.3 As a public health challenge, dementia requires a public health response4 and a major element of this response are mass media campaigns that raise public awareness and understanding about dementia. The media play an important role in not only disseminating information to the public but also shaping opinions and behaviours towards families living with dementia.

For many years dementia has been viewed as a disease driven by genetics and aging, factors over which people have no control. However, recent research indicates that approximately 35% of late-onset dementia can be attributed to modifiable risk factors, including education, midlife hypertension, midlife obesity, hearing loss, late-life depression, diabetes, physical inactivity, smoking and social isolation, whereas non-modifiable genetic risk factors, such as inheritance of the apolipoprotein E4 allele account for very little of the overall risk.5 Many of these risk factors are highly determined by individual health behaviours, which, if controlled, may mitigate or delay the onset of dementia. Dementia is also increasingly being presented as a social justice issue, as its rapid increase in prevalence, particularly in low and middle income countries, has an associated economic impact on families and society in general.2 Thus societal solutions for dementia may also start to be considered in the media. The power of media on health perceptions and outcomes in these areas is important, not only as a potential influence on our health behaviours and the chances of developing dementia, but also how we choose to attempt to address the societal challenges ahead.

The media selects which health issues and perspectives are given prominence,6 thus playing an essential role in the public’s consideration of the importance of health issues. This also shapes consideration of how problems at individual and public policy levels should be resolved.7 Media frames are a method of selecting salient information regarding health issues and creating pathways to think about the issue’s news value in terms of causality, effects and solutions.8 Frames define a problem, suggest causality and consequences of the issue, and provide solutions. Through these perspectives, frames can influence the public, and policy-makers, on how to respond to health issues.

Frames are a cultural construct and thus moral evaluations come into play when considering the responsibility attributions of causality and effects.9 When causality for an issue is attributed to individuals’ behaviours, the solution is also seen as the responsibility of those same individuals. Likewise, when causality is attributed to societal factors, the solution lies in the modification of social determinants. For instance, Iyengar10 analysed audience attributions of causal responsibility for poverty and found that when the audience was exposed to more individualised media frames depicting individuals living in poverty, the audience assigned responsibility to those people as being the cause of their poverty. However, when the audience was exposed to more societal media frames, the audience assigned responsibility for poverty to society rather than the individuals. Iyengar’s study demonstrates how audience attributions, shaped through media framing, influences political opinions and ideas. As a result, media framing of responsibility has powerful implications beyond purely the definition of the problem.

Research into dementia representation in media discourse is relatively sparse when compared to other public health issues such as cancer, obesity and HIV. While dementia coverage is positive in certain areas, such as sympathetic photographic depictions of people living with dementia,11 overall the literature suggests that the prevailing image of dementia in media is pessimistic, created through substantially negative frames, with an emphasis on stereotypically ageist depictions,12 but attribution of responsibility for the disorder has rarely been addressed.

The aim of our research is to evaluate how New Zealand newsprint media shapes discourse about dementia through its framing of the causes, effects and solutions, and who bears responsibility for the disease. We investigate this through examining i) the coverage of dementia between 2012–2016; ii) the framing of specific causes and effects of dementia; and iii) the association between specific causes and effects of dementia. Integrating the findings of the above three research questions, we discuss the moral evaluation of dementia through the lens of New Zealand newsprint media.

Methods

The study analyses dementia discourse across New Zealand’s three largest metropolitan daily newspapers: The New Zealand Herald, The Dominion Post and The Press between 1 January 2012 to 31 December 2016. Readership for the 2016 period were as follows: 423,000 for The New Zealand Herald, 159,000 for The Dominion Post and 157,000 for The Press.13 Our inclusion of the three newspapers takes into consideration geographical readership coverage: The New Zealand Herald is published in Auckland and has its largest audience-base in the upper North Island, The Dominion Post, published in Wellington, has highest readership in the lower North Island, while The Press, published in Christchurch, is the leading newspaper in the South Island.

Data extraction

We used ‘dementia’ as a search term on the academic database Newztext. Articles were restricted to those that were at least 150 words, in order to ensure articles were of sufficient length to develop themes and responsibility discussions. Articles that fell outside these criteria were: letters to the editor, advertisements, events, obituaries, duplicates within the newspaper, reports that were not about dementia in humans (as in articles discussing animal dementia) and items that mentioned dementia in passing.

Data analysis

We conducted the research in three phases of content analysis. We firstly developed thematic codes and their attributed reasoning devices of cause, effect and solution. Using Ward’s hierarchical clustering,14 we distributed codes under thematic categories. We categorised the thematic codes under the three generic frames identified as being the dominant theme in the health discourse: medical, health behavioural and societal. For each article, we also identified the dominant theme mentioned as a cause, effect or solution, and we marked it as being present once per document under that attribution regardless of how many times the theme and its associated reasoning device was reiterated within the article.

Once we had exhausted all possible codes within the cohort of news stories and the wider literature, we then developed and implemented the coding matrix.15 The coding matrix consisted of cause, effect and solution along the y-axis and medical, health behavioural and societal frames along the x-axis (see Table 1), similar to that recently developed for the framing of diabetes.16

Table 1: Coding matrix for framing of dementia by New Zealand newsprint media.

Finally, we used measures of association to examine the foremost cause-effect relationships within dementia discourse in New Zealand newsprint media.

We used MAXQDA Analytics Pro for the qualitative coding scheme development and content analysis, and its statistics module for statistical analysis to make inferences about measures of association between cause and effect themes.

Intercoder reliability

Two of the authors (FG, RS) independently coded 75 articles (20%) to assess inter-coder reliability. An acceptable level of agreement for Krippendorff’s17 alpha is α=0.8 (Krippendorff, 2004:241). Our study achieved α=0.851 across all codings. For each of the three frames, alpha scores were similar: medical frame α=0.881, societal frame α=0.861, and behavioural frame α=0.874.

Results

Framing of dementia in New Zealand newsprint media (2012–2016)

Using the word ‘dementia’ as a search term on the academic database Newztext resulted in a total of 800 articles: 242 articles from The New Zealand Herald, 285 articles from The Press and 273 articles from The Dominion Post: 439 articles did not meet the inclusion criteria; 361 articles were included in the study. All 361 articles presented the effects of dementia, 35% discussed causes and 7% mentioned solutions for dementia. Table 2 presents the frequency of media framing for the years 2012–16 and shows an increase in coverage over that time period.

Table 2: Frequency of medical, health behavioural, and societal framing of the causes, effects and solutions for dementia in New Zealand newsprint media (2012–2016).

Table 3 presents the causes and effects of dementia as reported through medical, behavioural and societal frames in New Zealand newsprint media. As solutions were rarely presented (7%) and mostly described existing medication or potential medical advances available for dementia, these were not included in the table.

Table 3: Causes and effects of dementia via medical, behavioural and societal frames in New Zealand newsprint media.

Framing the causes of dementia

Framing of causality mostly used the medical frame (83%). Within medical framing, 72% of the topics discussed were potentially modifiable causes of dementia (rugby-related head trauma and concussion, hearing loss, medication use, cardiovascular risk factors and obesity), but only nine percent of medical causes were presented as a result of lifestyle or health behaviour. One quarter of medical frames were attributed to non-modifiable causes such as biological ageing and genetic factors, and eight percent identified societal causes of dementia, for example the impact of air pollution or aluminium in the water supply.

Framing the effects of dementia

The framing of the effects of dementia were mainly represented by the societal frame (n=196, 54%). Within this frame, 70% of articles reported the adverse societal consequences of living with dementia, such as potential financial abuse, physical abuse and neglect, the effect on family relationships and caregivers’ stress and burnout. The remaining 30% in the societal frame addressed dementia’s impact on society including health and social care resources, the national economy, workforce, laws and policies.

The medical frame for effects of dementia was the second most utilised (n=119, 33%). As with the societal frame, the emphasis was on living with dementia. Within the medical frame, articles were more likely to identify dementia’s cognitive impact including memory loss, confusion and wandering, word-finding difficulties and personality changes.

The health behavioural frame was referred to least in discussions of dementia effects (n=46, 13%). Within this frame, the majority addressed reduced quality of life for people living with dementia due to the loss of independence in self-care, daily activities and feelings of loneliness. A few articles also mentioned behavioural changes, such as mood swings, and increased aggression and recklessness.

Association between medical causes and societal effects in New Zealand newsprint media

Table 4 presents the medical causes and societal effects that were most frequently mentioned together in the same article (p<0.0001). Modifiable medical causes (eg, concussion and cardiovascular risk factors) were more likely to be associated with adverse outcomes for society (eg, residential care resources), and non-modifiable medical causes (eg, biological ageing and genetic) were more likely to be associated with adverse outcomes for the individual and/or their family (elder abuse, caregiver stress and burnout, and impact on social ties). Figure 1 presents examples of quotes from articles to illustrate the associations made between medical causes and societal effects of dementia.

Table 4: Significant associations between causes and effects of dementia as portrayed in New Zealand newsprint media.

Figure 1: Examples of associations between medical causes and societal effects of as portrayed in New Zealand newsprint media.

Discussion

Our study is the first to examine media framing of dementia and its associated moral evaluations using a coding matrix that consists of cause, effect and solution along the y-axis and thematic categories by medical, health behavioural and societal frame along the x-axis, extending the work by Gounder et al, 2018.16 We found that, between 2012 and 2016, New Zealand newsprint media largely attributed the causes of dementia to medical causes, whereas the effects focused on the negative impact of the disorder on individuals, families and society. Modifiable medical causes were more likely to be associated with adverse outcomes for society whereas non-modifiable medical causes were more likely to be associated with adverse outcomes for the individual and/or their family.

Causes and effects of dementia

Recent epidemiological evidence suggests that approximately 35% of late-onset dementia can be attributed to modifiable risk factors.5 Many of these are related to lifestyle choices and therefore important to target for health promotion and prevention of dementia. Between 2013 and 2016, 35% of the articles about dementia in New Zealand newsprint media emphasised the medical causes of dementia. Almost half of these described rugby-related head injuries and concussion, but medical causes were rarely presented as lifestyle choices or health behaviours. This framing might suggest to readers that there is little that they can do to prevent dementia, or that it is rugby players who are most at risk.

New Zealand newsprint media also placed great emphasis on the effect of dementia on the individual. These were often described in negative, even catastrophic terms (see Figure 1). The effects were commonly reported as a loss of personhood, judgement and autonomy, resulting in a vulnerability to abuse from others, and the likelihood of ending up in a care home. In this respect, little has changed in the last 14 years: in 2006 Kirkman18 similarly reported that New Zealand newspaper articles between 1998 and 2002 represented people living with dementia as “powerless victims of their disease, victims of their carers and victims of health and social care services”. Likewise, in the UK print media, disproportionate negative emphasis on the effects of dementia, in addition to the ageing demographic, has been described. Peel (2014) concluded that “the high level of emphasis on the lack of personal control over the cause of dementia and the widespread detrimental effects on society creates a public discourse about dementia that is pessimistic and contributes to stigma around the disease”, as well as being a significant contributor to societal “dementia-panic”.19 In a more recent examination of news articles about dementia published in the British press between 2012 and 2017, the biomedical emphasis was noted, in particular the reliance on pharmaceutical treatments as the only possible solution to prevent dementia.20

Moral evaluation

We found that non-modifiable medical causes were more likely to be associated with adverse outcomes for the individual and/or their family. These findings replicate previous research which has shown that if the frame attributes dementia to non-modifiable medical causes (or ‘fixed attributes’) such as genetics and biological aging, these are perceived as being outside the control of the individuals,21 having adverse consequences on an individual’s lifestyle resulting in ‘social death’ with loss of self and personhood, independence and quality of life.22 The person (and their family) are seen as victims of the disease.22,23 While the medical frame distances individuals from blame for their disease, it also decreases their agency to alter their health outcomes. This reinforces the idea of individuals living with dementia as blameless victims of their circumstances, and powerless to alter their prognosis, contributing to the victimhood frame.24

In contrast, we found that modifiable medical causes of dementia (such as rugby-related head injuries) were less likely to be associated with adverse consequences for the individual, and more likely to be associated with adverse outcomes for society, such as the effect on the use of scarce health and social care resources. This might suggest a shift away from victimhood and a possible move towards blaming the victims and their lifestyle choices for the impact that dementia has on society.

Victimhood or victim-blaming?

In recent years, the UK news media has begun to shift its emphasis to health-related behaviours and dementia, in areas such as diet, exercise and lifestyle, and what people can do to “stave off” dementia.19 A similar shift has been observed in Australian news media where a causal relationship between engaging in preventative behaviour and individuals’ risk of cognitive decline and dementia has been emphasised.25 While this might be construed as empowering people to have control over their disease, it might also be viewed as problematic if individuals are presented as being morally deviant in their health behaviours.26 The authors of the Australian study25 argue that health advice given in newspaper articles is often accompanied by underlying moral claims regarding audiences’ obligation to commit to dementia preventative activities. Those that do not take preventive measures might be seen as being responsible for causing their disease, and possibly for the societal consequences of dementia such as the effects on the public purse, thus shifting the frame from victimhood to victim-blaming.

The topics of lifestyle choices and health behaviours in dementia have not received the same level of attention in New Zealand media. This lack of attention may be perceived by some as problematic, as it may add to the anxiety around dementia as an incurable and untreatable disease (victimhood). On the other hand, unhelpful victim-blaming for perceived unhealthy lifestyle choices has long been recognised in various chronic diseases such as obesity and diabetes,27 and particularly so among Māori in New Zealand.28 The scarce research evidence available in New Zealand suggests that Māori and New Zealand Pacific Islanders may be at greater risk of dementia29 and that this may be due to higher rates of risk factors such as diabetes, obesity and cardio-vascular disease compared with New Zealand Europeans.30,31 Thus dementia could become yet another chronic disease that is more common in socially disadvantaged peoples, who are then made responsible for developing the disease and morally judged for their assumed unhealthy lifestyle choices and health-related behaviours having an impact on society as a whole.

Strengths, limitations and implications

This study provides a comprehensive analysis of the national media coverage of dementia, but the findings from this study are limited due to the homogeneity across mainstream New Zealand newsprint media due to merged ownership: the Australian media company APN News & Media owns The New Zealand Herald, while Fairfax owns The Dominion Post and The Press. Newspaper readership globally is on the decline but remains popular in New Zealand. In 2019 over three million (77%) of New Zealanders read or accessed newspapers in an average seven-day period via print or online (website or app) platforms,13 so New Zealand newsprint media still enjoys substantial influence on public perception and therefore policy development. However, as other media sources are increasingly used by the public to educate themselves, these will also require examination in future research in this area.

As the prevalence of dementia changes rapidly, so too does the portrayal of the disease. In addition to its recent portrayal as a potentially preventable disorder, dementia is also increasingly presented as a social justice issue. This frame represents dementia as a public and social health crisis through depiction of the effect of dementia across family, community and wider society.2 Dementia as a societal issue, with adverse social and financial consequences, will require societal solutions such as social inclusion, a public health approach to risk reduction and support for families who provide most of the care. This approach has been adopted by the World Health Organization with the production of a global action plan on the public health response to dementia, calling on its 194 member states, including New Zealand, to produce a national dementia plan or strategy for 2017–2025.4 Our study examined newspapers from 2013 to 2016 prior to the introduction of the concept of dementia as potentially preventable and/or a social justice issue. Consequently, an update of our research findings is already required to assess whether there has been change in the New Zealand media framing of dementia since 2016 which will contribute to this new public health approach.

Conclusion

Dementia is a complex issue as a result of it having both modifiable and non-modifiable origins and shaped by its multilayered effects on individuals and society and a current lack of solutions for prevention or cure. Dementia remains a highly stigmatised disorder in many countries,32 so it is important that information about the disease is disseminated accurately and responsibly. From a human rights perspective, there is perhaps a moral obligation for media to choose words carefully and to not portray people with dementia as powerless, child-like, vulnerable, dependent and a burden. By portraying people using a personhood model33 the focus is on the human being rather than the disease. From a social justice perspective, the New Zealand media has an important role to play in promoting an inclusive society that champions the rights of individuals and families living with dementia, rather than reinforcing a culture of victim-blaming and stigma. This approach would contribute to engaging the public in addressing the inevitable social and financial consequences of the expected ‘tsunami’ of dementia and help to address potential inequities for people and families living with dementia in New Zealand.

Summary

Abstract

Aim

To evaluate how New Zealand newsprint media shapes discourse about dementia through its framing of the causes, effects and solutions, and who bears responsibility for the disease.

Method

Using New Zealand’s three largest daily newspapers, we examined i) the coverage of dementia between 2012–2016, ii) the framing of causes and effects of dementia, and iii) the most frequent associations of causes and effects of dementia. We integrated the findings to assess the moral evaluation of dementia in New Zealand newsprint media.

Results

Of the 361 articles extracted all presented effects of dementia, 35% discussed causes and 7% mentioned solutions for dementia. Medical causes dominated over health behavioural and societal causes, and effects were mostly the negative impact on the individual, family and society. Modifiable medical causes were more likely to be associated with adverse outcomes for society whereas non-modifiable medical causes were more likely to be associated with adverse outcomes for the individual and/or their family.

Conclusion

Between 2012–16 New Zealand newsprint media largely portrayed dementia from a ‘powerless victim’ frame. Further research is required to assess whether, since 2016, there has been a shift towards media framing of dementia as potentially preventable and a social justice issue.

Author Information

Sarah Cullum, Senior Lecturer, Dept of Psychological Medicine, The University of Auckland; Rachael Simpson, Psychiatric Registrar, Mental Health & Addiction Services, Counties Manukau District Health Board, Auckland; Farzana Gounder, Deputy Head of School (Research), Dept of Linguistics, Institute of the Pacific United New Zealand Tertiary Institute, Palmerston North.

Acknowledgements

Correspondence

Sarah Cullum, Department of Psychological Medicine, School of Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Private Bag 92019, Auckland Mail Centre, Auckland 1142.

Correspondence Email

sarah.cullum@auckland.ac.nz

Competing Interests

Nil.

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