Theoretical framework. Communication, health and gender

Studies of various media influences refer, among these effects, to the tendency of society to use them as an information system in all areas -including health- and the establishment of public agenda or selection of relevant topics in a specific context and period (^{Wolf, 1994}). The power of these media to influence the fulfillment of public health functions also stands out (^{Castiel & Álvarez-Dardet, 2007}; ^{Rojas & Vargas, 2010}; ^{Rojas-Rajs, 2016}), however, different problems are identified due to specific needs -health literacy- of the recipients of that communication to decode correctly (^{Basagoiti & Casado, 2014}; ^{Máñez, 2014}; ^{Terrón, 2012}).

Health journalism faces various tensions, such as the conditioning factors of the medium itself, which play an important role in the treatment and framing of news topics and events. The media simplify their work by collecting the most striking parts of socio-sanitary issues, building biased framing with which they influence recipients and public and political decisions (^{McCombs et al., 1991}; ^{Ruiz et al., 2005}). Among the various studies focused on the relationship between gender and health, there are some that address health care for or by women. These have focused on social perceptions, degrees of autonomy, inequalities in health with repercussions on access to health resources, and the assignment of responsibility for health care at home to women, and the manipulation of women’s decisions with moralistic perspectives (^{Cinta & Portillo, 2009}).

Research on gender and health in the media, according to ^{Ruiz et al. (2005)}, has focused on the coverage of certain pathologies, generally body image and eating disorders. The work of ^{Vives et al. (2002)}, ^{Ruiz et al. (2005)}, and ^{Perez et al. (2005)} have, firstly, indicated a greater visibility (in favor of men) in the information in press and, secondly, in relation to stereotypes, parity, empowerment and behaviors, they find notable differences in roles represented by both sexes, according to their social condition, favoring the male in the professional or personal category of subjects (as an expert).

In more recent studies, ^{Ruiz (2017)} affirms that within the social consequences of the absence of women in certain content and health information in the media, the lack of interest in solving problems stands out, underestimating “activities that are not ‘visible’, but fundamental in the management and control of diseases (like family care)” (p. 613) and hinder the development of women in the political, health and scientific fields.

If we expand the panorama on the gender perspective in health news, we observe that media would be very useful to contribute to the defense of rights, to increase plurality of sources and awareness and strategic audiences regarding health. In the second instance, media should initiate actions to “solve legislative, economic, cultural or ideological matters that affect the health of the population, and more specifically that of women” (^{Vives et al., 2002, p. 87}).

^{Artazcoz’s study (2004)}, also highlighted the relevance of public policies in social and health material, reformulated and focused on promoting gender equity in the work and family spheres. However, the lack of a correct gender perspective and sensitivity is also evident in the work of ^{Peiro et al. (2004)} and ^{Ruiz et al. (2005)}, which affects biases in the perception of the audience. Therefore, we appreciate a close relationship between a rethinking of public policies that is more consistent with the gender perspective and the role that the media should strengthen in this field, through better content and treatment of health information.

Among the most recent studies, the report of ^{Quiral 2019 Gender, health and communication} finds some progress in health coverage with a gender perspective. However, it denounces deficits in communication, unjustifiable bad practices, as well as frequent omissions (of data and topics, of women as expert sources), and undesirable uses of language or images. Another example is where lower percentages were obtained in terms of certain roles attributed to women in the treatment of HIV/AIDS (^{Terrón, 2010}). In this press analysis, significant differences between the categories of “Experts”, “News subjects” and “Testimonies” were established, which presupposes that men are still responsible for the recognition of authority.

Considering television, specifically in relation to health information, ^{Nahon’s work (1994)} highlights the influence of various conditions such as the ownership structure, the benefit to the interests of the health services administrators, and the overvaluation of the institutional dimension and a discursive homogenization of thematic diversity.

Audiovisual content (television as a priority) has an impact on social and state restructuring (^{Rojas-Rajs, 2016}), or on the construction of gender interpretation schemes and subjectivities, conditioning behavior and affecting the health and illness processes of men and women (^{Rojas & Vargas, 2010}; ^{Ruiz, 2017}). The news, advertising and fiction content on health on Mexican television have several limitations, including showing it as a consumer product, underrepresenting care models, promoting services to favor the delineation of state public functions by focusing on the economic capacity of people (^{Rojas-Rajs, 2016}).

The above is due to the influence of the characteristics of the television on the construction of health-related news. Therefore, most news content is characterized by their brevity, fugacity, lack of constancy and contextualization, use of statistics that are difficult to remember, spectacularization, exaggeration of risk and benefits, taking advantage of the power of images as an advantage of the audiovisual medium, criteria of newsworthiness, coverage and commercial reasons (^{Gambaccini et al., 2011}; ^{Loewy, 2011}; ^{Rutz, 2007}). In this way, a notion of health based on over-sizing assessments is promoted.

The construction of news and the adequate treatment of health information requires compliance with quality standards, such as: reliability (plural sources), relevance, proximity, adaptation (to the context), precision, clarity, independence and correspondence between media, citizen and public agendas (^{Morales & Vallejo, 2010}). These criteria have not been properly assessed in most of the research results on health issues.

We must emphasize that several of the cited studies, although valuable, are focused on specific aspects, with somewhat limited access or feasibility to carry them out. We consider, therefore, that in some of these studies there is a deficit of certain theoretical and methodological approaches, or of empirical references that reflect the inter and transdisciplinary relationship, as well as the comparison of sociocultural contexts in the complex field of health and communication. In this paper, we are going to observe some of these qualities in attributes that make up the frames.

^{Entman (1993)} highlights, among other aspects that impact on the perception of audience, the relevance of the actor responsible for the action. We conceive actors, as a category represented by the various participants and protagonists of the information, individual or collective, people, figures and central references of the news. As for the actions carried out by health-related actors, we try to identify what they do, characterize their activities, tasks and/or roles performed.

Methodology

The present work is nourished by the results obtained from a wider research into news and health frameworks in three newscasts from Mexican primetime television (public and private): El noticiero con Joaquin López Doriga (Televisa), Hechos (TV Azteca) and C7 Noticias Jalisco, during the period of November, 2014 to September, 2015. The objective of this preliminary quantitative study was to identify the frames in health news of three shows taking into account information -verbal and visual- of actors, actions, diseases, and to observe whether any reference was made to sex and gender in particular information on disease processes, institutional attention, disease monitoring and condition of exclusion due to health problems.

In the broader investigation, a content analysis was carried out taking a set of 510 health news pieces, 170 for each newscast and television company. The purpose of this proposal was to count the most frequent categories and variables to find health frames through Principal Component Analysis in SPSS, version 22 of IBM. Our research questions are, on the one hand, what are the specific characteristics that define the frames of health news in these shows and, on the other, who appears, how, what do they do, and what do they talk about.

In the study, the items containing several variables (actors, actions, actors definitions, physic spaces, places, and more) were coded and grouped to form clusters or datasets and variables that constitute or express meaningful information frames, models or informative structures of meaning and ideas that reflect the relevant and recurring health informative aspects for the news programs. From statistical calculations and reductions using Varimax rotations and, after several depurations, the most consistent frame models were selected, excluding those frames with low Cronbach’s Alpha (α), or below average and standard deviation values, leaving those that reached values within the acceptable range, or those who were the most significant to answer the research questions.

Results

The specific characteristics that define the frames of health news in these programs (see Table 1) lie primarily in the actors -who appear-, how are they shown -actor definition- and what actions they carry out. If we asses certain gender-related issues in order to verify how they were addressed by the news, it is found that, of the 510 items, in half of them women were not mentioned as information actors, 24% pointed them out on one occasion, and another 25% did it two or more times. In the case of men, they are referred to once it almost 27% and 42% twice or more. In about three quarters of the pieces, gender is not specified. While there was a wide range of health information actors/ subjects, it was necessary to make groups, i.e. categories or sub-assets by affinity of roles or responsibilities, as shown in Table 2.

Table 2 shows the numerical superiority of men over women in the identification of information actors and subjects that the news piece was about. As can be seen, the most abundant category is the number 1: ill people, patients, users of health services; followed by the one of government officials and, with a bigger difference, of almost 70 cases, the one of physicians, paramedics and specialists. Contrasting with the two groups of actors and subjects at the bottom of the table: relatives of patients or users; and nurses, technicians, social workers, brigadiers. Other relevant categories of actors in this field are researchers and academics (48), 9.4%; and the NGO’s mentioned in 32 news pieces, reaching 6.2%.

In the sphere of actions carried out in the transmitted messages, given the dispersion and high quantity, it was necessary to group actions according to similarities and situations shown, highlighting the activities carried out by public officials at the three levels of Mexican government, followed by the medical-patient or hospital-user assistance set, and the rest of the action categories given in Table 3.

The results of these eight action categories in Table 2 show that, in all of these, the mention of men exceeds that of women. Particularly in six of these actions, the difference ranges from 10% to 26%. The sets of actions where we observe smaller differences in the presence of the term women or men in the narrative are, mainly: health care or provision of health services; prevention of physical and physiological diseases; and showing statistics and information about diseases, with differences of 3.9%, 6.9% and 5.3%, respectively.

There is an extensive list of missing actions in the table above, due to them representing a very low percentage of the total sample. These include: disseminating a person’s particular story (with or without relatives) with a specific disease; anomalies with individual or organizations in health service provisions; research in medical genetics, biological, nuclear and radiological medicine, and more. It should be clarified that sometimes several actions were mentioned at once, that is, they are not mutually exclusive.

The relevant topics and aspects found in the news on private and public channels included: various public health measures (policies) and programs, representing 28%; health promotion and disease prevention (chronic-degenerative and seasonal) make up about 35%; symptoms and treatments of various physiological/biological diseases, 24%; reports of accidents in health institutions, 28%; and 16% goes to other actors and public and private, scientific, academic and technological entities. The sum exceeds 100%, given that categories are non-exclusive.

Regarding specific health problems, a total of 13 diseases of various kinds were recorded. These were classified by eight systems of the human body: digestive, with 14.5%, are the ones with the highest incidence; cancer reached 11.8%; circulatory (hypertension) and respiratory systems represented 8.6% and 8.3%, respectively; mental disorders barely represented 4% of the sample. It should be noted that only in some cases (and with different sequence and hierarchy) the news covered diseases corresponding to the actual prevalence in Mexico during that period, since the five principal ailments registered by the health system were: acute respiratory infections; intestinal by other organisms and the poorly defined ones; urinary tract ones; ulcers and gastritis; gingivitis and periodontal disease (^{Secretaría de Salud, 2014}).

Other aspects of the agenda should be added to these matters, namely: public health policies and programs (federal, state and municipal); economic issues (health service costs, investment in medicine, among others), which are mentioned in 19.6% of the sample; medical procedures and treatments appeared in 16% (in which the presence of men was higher than that of women by 14%); addictions, with 7%; science advances, biological, medical genetics, nuclear medicine, 5.1%; discrimination arising from health conditions, 4.7%, where the mention of women was half that of men; and negligence and abuse of power, 2.6%.

Particularly, only 6% of the total news segments reported on women’s health care. When talking about health problems it is done without differentiating by sector or group or classifying according to gender, age or social condition. Men had a higher presence than women as sources, reaching 68%, compared to 41% for women. Finally, as for visual content, the presence of male actors exceeded 92%, and female were present a little less than 80% of the time, emphasizing the prominence of men in the images that accompanied the news and, of course, in the newscasters.

The sets of variables that made up the frames are another element that allows us to study some gender aspects. Only eight frames (F) were chosen from the previous study, the ones with the highest intensity and representativeness, that complied with the corresponding statistical and theoretical criteria (see Table 1).

An initial approach at these frames with a gender perspective allows us to appreciate certain preferences for referring to men as subjects of information or actors in the news. Also, we found it difficult to identify the presence of the female gender due to the widespread use of general terms to allude to the actors, this is: “physicians and public officials”, “the citizens”, “health system representatives”. The most striking differences in the averages obtained over the number of mentions of both genders in the news are concentrated in the F2 frame, which refers to accidents or hospital disasters, were nurses (female nurses implied in Spanish) played a key role in patient care and rescue; they got an average of 1.20 against 0.28 for men. The opposite happens in the F4 frame, which refers to public authorities, where men have an average of 1.28, against the 0.98 of women. In any case, the difference is bigger because there are fewer women government officials.

In second place, cross-checking the values from different frames can confirm this lack of equity and even virtually an exclusion in some cases (by type of frame), because by calculating figures by number of mentions of gender in the actors, we see that men exceeded the references to women in 100% of the frames. For example, in frame 1 “Doctors and public health officials as Mexican health promoters and health services providers”, male obtained a 68% (348 occasions) and women 48% (249 times).

Discussion

With these results it is possible to see, first, that in health-related news it is not surprising that the largest category of information actors/ subjects corresponds to people with ailments and patients or users of services. Nor that the third position is about health professionals - physicians, paramedics and specialists-. However, we are struck by the marked tendency to give prominence or relevance to the institutions of the political system, located in second place, or the authorities of the Mexican health system, which appeared in fifth place. In this matter, we agree with ^{Nahon (1994)} on presence and institutional conditioning, but also its influence on the agenda. In any case, unfortunately, even when the category of actors is ill people and users, the problem is that the health conditions or problems involved are not distinguished by sex in a large percentage of news, this aligns with the findings in ^{Ruiz (2017)} and ^{Vives et al. (2002)}.

Considering the category of diseases with a gender perspective, we need to highlight that only 7% of the pieces, that is, 36 news pieces of the total (510), provide particular information and/or differences in causes, symptoms or consequences of diseases by gender; and 4% of the pieces talk about differences in access and/or institutional health care. The same percentage indicates particularities in terms of health care and prevention in both genders; and only 3% referred to situations of social exclusion (stigmatization and/or discrimination). This suggests health information on television in Mexico is still limited to a few topics and not differentiated by gender, so health inequities studied by ^{Ruiz (2017)} and ^{Vives et al. (2002)} could increase. There are some ethical problems when giving health promotion a marketing emphasis -as a consumer good- instead of addressing it as a social right and prioritizing the figure and institutional role of the representatives of the public authorities, to the detriment of the intervention and visibility of the affected people, family members, assistants and caretakers, patient associations, and civil society groups as a whole.

The emphasis of both the institutional dimension and the smaller number of the female population versus the male population is reflected in the most frequent information actors/subjects and also in the frames found (F1, F3, F4). This confirms the lack of a gender perspective in health news and a persistence in showing a partial or biased view on the role of health actors and health managers, generally giving preponderance to men, just as it was established by ^{Ruiz (2017)}, ^{Perez et al. (2005)}, ^{Rojas & Vargas (2010)}, ^{Rojas-Rajs (2016)} and ^{Terrón (2010)}. At the same time, men retain hegemonic control by obtaining a higher average presence in public powers (F4 and F5), in contrast to women, who have a prevalent representation that assigns them the role of caregivers, both as health service providers and as citizens responsible for health risks (F1 and F8). However, an average reflecting current socio-political changes, places women with a higher average in legislative scenarios (F5).

In addition, in most frames there is an omission of actors, activities and relevant events in the health field, such as the work of patient associations, or other research and intervention groups, collectives or NGO’s, which are not visible or referenced. In fact, official sources are prioritized well over the narratives and experiences of the family or relatives of patients themselves, who do an important job in caring for the sick -relatives, partners or children, nurses, technicians, social workers-.

This upholds the exclusion of what is happening with certain associations, people -mainly women-, support groups for follow-up care, service and, above all, prevention of suffering (^{Ruiz, 2017}). Coverage of developments and consequences for controversial topics -on social media or other platforms- is also not included in a consistent manner. These topics include diversity of access to health information services, risks, technology, ethical aspects, conflicts of interest, job insecurity, progressive dehumanization, and more.

The aforementioned limits and biases come from, among other causes, the tendency of the television media towards spectacularization and strong politicization of information -with the task of offering an ideology in line with the dominant hegemonic model (^{Castiel & Vasconcelos Silva, 2005}; ^{Gambaccini et al., 2011}; ^{Roskelley, 2007})-. The presence of public authorities and their representatives in health news, due to the type of frames and actions identified, does not provide sufficient participation to promote a model of care commensurate with the differentiated needs of the population, contrary to ^{Rojas-Rajs (2016)}. Therefore, the media partially performs public state functions, weakening the social function of the media itself, which in turn has a cost in the credibility that the audiences give them. The picture is aggravated by adding the lack of gender sensitivity in public policies in general (Artazcoz, 2002) and in health policies (^{Peiro et al., 2004}) in particular.

In these news segments, the roles of authority (officials or experts) are often attributed to men, considering the type of actors, actions and health frames. Therefore, the low presence of women in the performance of strategic roles or functions prevails (^{Terrón, 2010}), except for the science and technology sector. The partial assessment of health information on television is confirmed, based on visual criteria (^{Roskelley, 2007}; ^{Rutz, 2007}), such as the spectacularity of the event, illness or problem, as reflected in the second frame (F2) for victims of hospital accidents, with immoderate and repetitive uses of situations and scenarios.

In short, the types of framing and handling of health information in news programs in Mexico uphold significant control by the establishment not only over the limited public and political health agenda, but also, largely, by influencing even the perceptions and behaviors of audiences regarding the process of health-disease-care, which in turn influences the reproduction of gender roles unfavorable for either of the sexes. Said audiences are represented in the newscasts by audiovisual media as an undifferentiated whole, promoting a certain conformity or passivity of the spectator and citizen. Those representations of people and problems invisibilize groups of actors, sectors, functions, and topics related to complex technological and problematic mediations -such as mental health- or other difficulties or complications not any less delicate or valuable for being quotidian.

Conclusions

The framing results show, among other things, the limited political and public health agenda conditioned by the interests of government authorities and of the actors in the Mexican health system, as indicated by various gaps in thematic diversity, ailments, attention to or visibility of activities, formats, journalistic genres and, in particular, of certain social actors and protagonists such as patients’ relatives, patient associations and other civil organizations, public, private and academic groups of experts and other corporate groups. Neither is the work of a large proportion of health personnel sufficiently considered (unless it is about managers and specialists from second or third level clinics). In particular, news segments usually omit the experiences and contributions of those with lower ranks, who perform service functions in top-level hospitals. They understate various processes, including communication, doctor-patient interactions, work routines and dynamics in the clinics and hospitals. These are increasingly characterized by a growing precariousness of work and health, with all the implications and psychosocial, economic and political costs that have worsen in contexts like the current COVID-19 pandemic.

The differences that prioritized the presence or role of men in the various health frameworks were notable. This suggests that, for the journalists of these news segments, it is not a frequent practice to distinguish, first, how men and women participate in health-disease-care actions and processes, whether to avoid risks, promote health or in their professional training, depending on their geographical location or regional context, among other issues. Second, it does not appear to be a strong interest on the part of the subjects involved in the construction of the news in the social costs and psycho-political effects of certain constructs or health frameworks, contrasting the health discourses of different actors, or the diversified use of sources and other media. It is evident that Mexican television journalism has a weak commitment to health during triple audience hours.

The evidence gathered during this period on what the broadcasters of these television companies select and show about the health-disease-care process, that is, their limited coverage of topics and little connection to the country’s epidemiological information five years ago, suggests needs under several topics that we describe below as proposals.

First, the imperative task of creating mechanisms and synergies to enhance media literacy and critical audiences. Demanding and promoting a better job from editors, writers, reporters and executives -not just in these contents and media formats, but for other media, platforms and genres, including fiction- through the intervention of a political figure or defender of these audiences.

Second, in line with that task, considering media trends, gaps and gender biases in the treatment of health content, it is essential to create conditions, resources and measures within strategic actors -citizens, academics, journalists, health professionals and political authorities- to take measures to prevent stereotypical, obsolete, partial, imprecise or ambiguous media representations of human ailments, of health needs -both traditional and emerging- in the general population as well as in health personnel or caregivers.

Doing this hard work will require, as in any major project, a group of efforts, creativities and commitments to mobilize awareness and actors towards gender equality and equity in health. This includes policies and initiatives -even at the micropolitical level- oriented toward the well-being and improvement of quality of life, not only of the entire Mexican population, but especially of the growing vulnerable or impoverished groups, in view of differences in age, socio-demographic status, culture, access to health information services, and changes in the epidemiological and geopolitical conditions in this country.