This review represents an initial attempt to harness a body of work on interpretive policy analysis, specifically framing research, to understand more about the ways in which ideas influence the policy process. In so doing, the authors hope to bridge the health policy and broader policy studies literatures. This review aims to demonstrate the potential value of constructivist and interpretative approaches to policy analysis for the domain of health policy and practice.
It highlights the ways in which researchers outside of the health domain use theory to gain a better understanding of contestation and change in the policy process. Potential lines of enquiry are suggested to help position HPSR as an important vehicle for furthering our understanding of the policy process in the health sector. Policy scholarship on framing has evolved from a research tradition that focuses on the primacy of ideas in explaining policy dynamics and variation John This contrasts with other theories of the policy process including those oriented around interests Bachrach and Baratz ; Mills ; Dahl , institutions March and Olsen , metaphors that blend elements of each Baumgartner and Jones ; Sabatier and Jenkins-Smith a ,b; Kingdon and analytical eclecticism Sil and Katzenstein Ideas present the policy researcher with an interesting entry point for understanding policy by providing clear linkages to institutions Schmidt , conceiving of interests as social constructions Hay which leaves room to account for irrational behaviour Kahneman in the policy process, and by capably handling abstract concepts such as power and domination Fraser ; Jenson ; Lieberman Framing research gained currency through the early work of anthropologist Gregory Bateson and sociologist Erving Goffman in the s and s, respectively Bateson ; Goffman Common to most of these interpretations is the constructivist premise that an issue in society can be viewed in myriad ways and cast so as to imply multiple values and considerations Berger and Luckmann As such, framing is a dynamic process through which those who produce and receive frames make sense of ideas by interpreting them through other available social, psychological and cultural concepts, axioms and principles Fischer But frames are much more than packages of meaning.
In policy analysis, framing is largely situated in the post-positivist literature that uses interpretive and critical approaches to analyse policymaking as a contested meaning-making enterprise Fischer These concepts underscore the importance of language and symbolic representation in the policy process Edelman , , ; Elder and Cobb ; Gamson In this way, the analyst favours knowledge claims of subjective understanding over objective truths, to the extent that interpretation provides a reasonable explanation of human behaviour, including evidence use, argumentation and persuasion in the policy process Majone In the disciplines of political psychology and communication, the concept of framing is deployed to analyse public preference formation.
Within this literature, framing draws heavily on the field of behavioural economics Kahneman and Tversky ; Tversky and Kahneman to look at the cognitive basis for decision making Druckman Frames, in this context, are heuristic devices which shape our understanding and evaluation of the world around us based upon the extent to which they are cognitively available, accessible, applicable and appropriate Druckman Emphasis or issue frames represent cognitively coherent dimensions of an issue that are assigned weights in preference formation Druckman ; Scheufele and Iyengar This literature distinguishes these cognitive frames from their communicative forms, by drawing on research from the field of political communication Scheufele and Iyengar In media studies, framing effects are carefully distinguished from the related processes of agenda-setting and priming Scheufele and Tewksbury As noted, the concept of framing is used in related, yet distinct, ways in other academic disciplines.
Within these different approaches, frames are seen to function in a variety of ways. Both overtly and covertly, frames highlight certain aspects of a problematic situation, while obscuring others in order to define problems, diagnose causes, make moral judgments and suggest remedies Entman This is important in the policy world because frames determine what the actors in the policy community will consider the facts to be and how competing problem definitions lead to normative prescriptions for action Rochefort and Cobb Framing precludes certain policy responses, identifying legitimate participants through political discourse and galvanizing coalitions of interest Schattschneider Moreover, when comparing multiple perspectives on how to address a particular problem, the problem itself may change through framing Fischer As mentioned previously, frames can be classified based on whether they define, diagnose, judge or prescribe Entman Similarly, other scholars suggest that diagnostic, prognostic and motivational collective action frames are requisite for the emergence and mobilization of social movements Snow and Benford As highlighted earlier, some researchers differentiate between communicative frames and cognitive frames, which can be classified into emphasis and equivalency frames Druckman Other linguists classify the components of frames into four structural dimensions of a greater news discourse, including their syntactical, script, thematic and rhetorical structures Pan and Kosicki Together, this array of frames, framing processes and approaches to frame analysis provide a fertile body of knowledge to cultivate insights into previously unexplored policy domains.
This approach was selected because of its emphasis on flexibility, relying on an abductive logic of enquiry, and its bias towards narrative driven summation see Table 1. Like all research, and particularly qualitative research, this approach is interpretive in nature. The research question emerged gradually through the review process. Therefore, our initial decision was to include only articles that explicitly state a frame, its construction, its sponsor, and the ways in which it influenced the policy process in the health sector.
A review of the peer-reviewed literature was conducted for original research articles that used some form of frame analysis within the broad domain of health. No time or language restrictions were placed on any of the databases. See Table 2 for a list of databases with their corresponding search terms and number of hits. In addition to the database search, we used Google and Google Scholar search engines to identify sources not included in electronic databases.
Finally, we conducted a hand-search of four health policy journals that publish framing research on occasion, including: Health Policy and Planning, Social Science and Medicine, Health Policy, and Journal of Health Politics, Policy and Law. Articles were excluded sequentially by ADK based on their title, abstract and full-text.
Articles that alluded to framing, language, metaphor, discourse and its effects on health policy issues were included in the title review. Finally in the full-text review, all articles were reviewed to assess the extent to which frames, a frame articulator, and a contested policy process was explicitly represented. In this way, the review attempted to draw from the wider pool of non-health policy issues, to assess the various ways in which frame conflict and change shapes the policy process.
See Figure 1. A master table was created that included article details, corresponding research traditions, epistemology, theory employed, methodological approach, data sources, health and policy themes, frames, frame sponsor and the extent to which contestation had an effect on the policy process. Though this was systematic, the process of charting involved some degree of interpretation on the part of the investigators to classify various themes such as research traditions and the epistemology represented in each article.
The investigators made no claims of objectivity in judging whether or not an article presented contestation or adequately showed an affect on the policy process. The final stage of the scoping review process involved collating, summarizing and reporting the findings, as described in greater detail below. A descriptive analysis of collated articles by field was reported and general trends were identified. The findings were summarized with an emphasis on the scope of existing knowledge and an eye to what remains unclear from the body of research.
Further suggestions about the conduct and import of framing research in the health sector are discussed and limitations of such an approach are considered, below. All three authors are social scientists with experience conducting qualitative research. Though we make no claims to objectivity, we have attempted to provide a fair and balanced account of the various strands of framing research and their representation in the health policy literature.
Rather the use of the term is consistent with the principles of analytical eclecticism Sil and Katzenstein A large number of framing studies were conducted on health policy issues, predominately from the social sciences. A total of articles were returned from the initial search.
From these, a title review, supplemented with cursory abstract review, further narrowed the number of articles to See Appendix for an overview of 52 articles, which are characterized in greater detail below. The number of relevant research articles is increasing in volume and geographic coverage. Articles ranged from to Two articles represent obesity framing research Saguy and Riley ; Kwan from larger bodies of work represented in separate books Kwan and Graves ; Saguy The books themselves were not included as the peer-reviewed articles were considered sufficient.
Framing research varied across social science disciplines, epistemology and drew from multiple framing theories. To be included, an article had to draw on established framing theory as described earlier. Nearly all articles signaled Goffman as the theoretical origin, though Entman , Gamson and Benford and Snow were frequently cited as well.
Framing research relied on multiple data sources and covered a range of health topics. Nearly all articles made reference to some degree of document review. Of the studies categorized as substance misuse, In sum, a wide range of data sources and health topics were covered with some issues i. Numerous frames were presented with variable interpretations of the concept. The number of frames represented in a single research project ranged from 44 Andress to one Abraham ; Kamradt-Scott and McInnes Some articles referred to frames when describing packages of ideas that align with a particular value base Esmail and Kohler ; Parkhurst ; Oronje Similar to the multiple uses of the term frame, authors located frames at varying degrees of abstraction ranging from broad values Johnson ; Rasmussen ; Esmail and Kohler ; Reubi to specific policy positions Redington ; Fogarty and Chapman , ; Paterson and Marshall ; Parkhurst and Vulimiri This was sometimes difficult to identify, as many articles failed to specify the theoretical basis for their specific interpretation of frames.
Few articles distinguished between different types of frames or the ability of various ideas to overlap and correspond to multiple legitimate frames constructed at various levels of abstraction. Diverse policy stakeholders were identified as frame sponsors, responsible for creating, supporting, or opposing contested policy frames. Though most articles presented at least one group of frame articulators from the public sector, frame articulators lacked many unifying characteristics and were often specific to the issue or focus of the research project. Contestation was context specific, but frequently represented deeper conflicts over the size of government and its mandates.
A number of respectable framing articles from political psychology and communication were excluded from this review of the health literature for two reasons. Many of these articles did not assess how specific health policies, programmes or legislation was framed, but rather how disease or problems are socially constructed by the media. Second, these articles frequently focused on how framing affects public opinion. The authors often mentioned that public opinion affects policy, but this was not the explicit focus of these studies.
Content analysis, a method of analysing media discourse, was well-represented in 52 selected articles, but only because these showed how media constructions affected the health policy process.
To suggest that the media shapes public opinion, which in turn affects policy, was considered insufficient to address our main research question and be included in the final review. Descriptively, the results of this scoping review suggest that the research on framing in health is somewhat limited. First, compared with the large number of articles that mentioned framing, there are relatively few studies that focus specifically on the ways in which ideas and policies are framed.
Second, this lack of framing research is accentuated when looking geographically and thematically. The bulk of framing research has historically been conducted in North America and Europe on a small set of health issues such as infectious disease control and the regulation of harmful substances. Third, most framing research has been conducted by social scientists, with considerably less situated within health policy departments or published by health policy journals.
This skew, in geographic, thematic and disciplinary focus, is possibly explained by rationalist hegemony in industrialized countries as much as by simple disciplinary capture. In addition to a descriptive overview of the scope of framing research, this review generated many analytical insights. The central goal of this review was to determine what is known from the existing literature about the influence of frames and framing on the policy process. The short answer is that quite a lot is known about a few issues in a few contexts.
A more nuanced interpretation of the findings; however, points to several areas that require in-depth explanation to identify strengths and shortcomings of the existing research. First, it is important to revisit the underlying purpose of framing research. Much framing research operates from a constructivist epistemology that contests the view that knowledge is an objective, knowable and measureable entity which exists independently of the researcher and the research process.
The theoretical basis of a discursive mode of policy analysis associated with framing research is derived from Critical Theory and Post-modernism. Similarly, Foucault emphasized that power cannot be possessed but is exercised through knowledge and discourse, which serve as a form of social control Foucault Although Habermas and Foucault differed significantly in their understandings of the social world, their work provides the intellectual foundation of interpretive policy analysis Fischer As such, interpretive research on framing looks at how actors create meaning in the policy process and how they package these meanings for instrumental and expressive purposes.
In this way, a frame emerges, interacts with others and helps shape the terrain of the debate. Framing research does not predict change or advocate for a particular way of seeing the world. Instead, it seeks to provide an explanation for human behaviour in the policy process and how this collectively structures subsequent interactions. The scoping review was partially successful in answering the original question of what is known about the way frames and framing influences the policy process in the health sector. On the one hand, a great deal is known about highly contextualized debates over a narrow set of health issues.
On the other hand, the body of scholarship on framing research offered relatively little internal coherence. This suggests that the interdisciplinary nature of framing research presents a challenge for both the reviewer and a review methodology native to biomedicine.
Media Messages and Public Health : A Decisions Approach to Content Analysis
Nevertheless, a few strong themes emerge and are reflected in Appendix , which surveys the 52 included articles. This raises questions about the exclusivity of the health policy process. Many articles illustrate that policymaking is an expansive process that transcends issue domains and involves deliberation from multiple segments of society.
Second, a variety of theories and methods can be used to interpret the influence of frames on health policy. Although a variety of methods were employed for analysis, most articles relied on a similar set of data sources, including some combination of interview transcripts, media transcripts and an array of different documents from legislative briefs to organizational position articles. Third, articles that presented multiple frames provided a more convincing assessment of its influence on policy than articles that described the evolution of a single frame over time.
The reviewers, who were uniformed about the substantive issues in the identified articles prior to conducting the review, found it much easier to identify the interplay of ideas in the policy process, when there was a moderate amount of organized frames. But, in framing as in life more is simply not better. More important than the quantity of frames, was the way in which the authors organized them either hierarchically or based on established theory.
Even when a larger number of frames were represented, as in Roth et al. On the other hand, work on the social determinants of health that identified 44 different frames, proved cumbersome and raised as many questions as it answered Andress This finding, that organization is possibly more insightful than revealing minute distinctions, underscores the significance of incorporating theory into framing research.
Fourth, research that embedded and internalized a range of framing research proved more insightful than research that gave little attention to theory.
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Similarly, a neo-institutionalist article Inoue and Drori provided a sound theoretical basis for a sociological study, but an unconvincing analysis of how frames influenced the policy process. Furthermore, these studies illustrate the value of abductive reasoning, to move iteratively between empirical findings and framing theory. Fifth, research that presented multiple actors, contested policy arenas and highly charged ideas proved to be useful in furthering our understanding of framing in health.
This finding may be attributable to the fact that some disciplines, such as policy studies and political sociology, are inherently better positioned to capture the contested field than others, such as linguistics or cognitive psychology. This suggests that the highly contextual nature of framing research, combined with a qualitative analysis of the often-opaque forces that shape policy, is difficult to present within the confines of the journal format.
This might provide a partial explanation as to why concise, coherent and comprehensive framing research appears to be in short supply in the health policy literature given the restrictive word counts of journal articles in the field. Based on the insights of this review, we propose a list of considerations for framing research on the policy process see Table 3.
Although this list is by no means exhaustive, nor does it favor a disciplinary approach to framing research, it should serve as an adequate launch point for discursive investigations into the role that ideas play in health policy. Furthermore, because this list has been developed based upon the evidence presented in this review, the strength or weaknesses of proposed research can be assessed based on the extent to which the endeavor accounts for these broad considerations.
There are several important findings from this review that further our understanding of frames and point to directions for strengthening their analysis across disciplines. First, there was a lack of clarity between framing analysis as theory and method in the health literature. In fact, frame or framing analysis seems to mean different things to different researchers, depending largely on their disciplinary focus.
Many articles drew on the concept of framing as the basis for an empirical research project in which various themes were identified, labeled as frames, and contradictions between frames were described. Other articles, used a range of analytical techniques, identified as frame analysis, to systematically work through the discursive elements of a given text or speech act. Though the indiscriminate use of framing as both theory and method might seem problematic for defining the boundaries of a research paradigm, it also represents a potential strength of framing research.
To be fair, many articles did make mention of some type of framing theory and implied that the methods were a form of frame analysis, but the most insightful studies were those that used abductive reasoning to move iteratively between empirical findings and framing theory.
Epub Media Messages And Public Health A Decisions Approach To Content Analysis
Second, despite attempts to develop frame analysis as a research paradigm, the health policy literature suggests a lack of consensus exists across disciplines. Efforts to bring conceptual clarity to framing research have come from the fields of political communication Entman ; Pan and Kosicki ; Scheufele ; Scheufele and Iyengar , political psychology Druckman and policy studies Van Hulst and Yanow This review suggests that these endeavours have yet to produce a coherent and unified corpus of framing research in the health policy literature. We contend that researchers interpret and deploy the concept of frames and the process of framing in particular ways.
Yet, this contention is in keeping with a constructivist epistemology. One goal of this review was to use framing research as a vehicle to marry the health policy literature with the wider policy studies scholarship. The rationale for using frames, as an ideational approach, is that by nature framing is interdisciplinary and its use as both theory and method is gaining credence. This review suggests the same is true both quantitatively and qualitatively in the health policy literature. This indicates that some ideas are beginning to enter mainstream modes of policy analysis in the health sector, but it also points to some differences.
Although the two forms of discourse in institutionalist scholarship are integrated into a highly contextualized way of looking at the discursive interplay of policy ideas, in the health policy framework, they are positioned as 2 variables amongst 12 that must be considered in explaining why something happens Shiffman and Smith The policy studies literature on framing emphasizes the primacy of ideas and an adequate analysis of them would take into account other salient aspects included in the Shiffman and Smith framework such as actor power, political context and issue characteristics.
This shift in emphasis is manifest in the applications of the health policy framework, which is biased in favor of a deductive mode of proving or testing theories about why some things happen Walt and Gilson A mode of analysis that focuses to such a limited degree on frames often raises more questions, particularly with respect to the irrational nature of decision making, than it actually answers. By looking at the way in which the articles included in this review are structured, the intentions of the researchers writing them, and what they are trying to achieve, we shift the nature of the discussion around policy analysis in health.
Similarly, by looking at the scope of framing research in one issue domain, such as health, insights may be generated to further broader policy studies scholarship on framing.
The limitations of this review are multiple. The body of evidence proved difficult to corral given the abstract nature of the subject material and the systematic nature of the scoping review framework. This ranged from the relatively simple tasks of defining categories for strains of disciplinary background, theory and methods to distinguishing amongst more abstract characteristics of the articles such as epistemology, evidence of contestation and demonstrated affect on the policy process.
Further, by including articles with a strong theoretical basis, we excluded various strands of relevant framing research, including experimental findings germane to behavioural economics and media analyses from political psychology, discourse studies and communications research. These articles were largely excluded because they showed little or no direct bearing on the policy process.
Still, they remain important and under-represented dimensions of framing research. This scoping review demonstrates the potential of framing research as a means of understanding the influence of ideas and human behaviour in the policy process. Despite a relative paucity of data for many health issues, demonstrable policy struggles occur in a variety of contexts for a few health issues such as tobacco control and pandemic influenza preparedness. By framing ideas in a particular way, actors evoke deeply held values that shift the terrain of the debate, transforming social phenomena into problems, implying a set of solutions, forming coalitions of interest and mobilizing specific policy responses.
More research should be conducted, particularly in LMICs, to gain a better understanding of the complex policy terrain in the health sector. The scoping review was a useful approach for harnessing the diverse pool of evidence located on the periphery of traditional health policy research.
As a relatively new methodology and perhaps an unfamiliar body of theory, framing research has yet to receive adequate attention in the health literature. The analytical insight generated by the 52 articles included in this review was quite variable with framing approaches reflecting distinct research traditions.
This article contributes to the wider non-health policy literature on framing by identifying several features of insightful framing research. Funding for open access publication was provided by the London School of Hygiene and Tropical Medicine. Oxford University Press is a department of the University of Oxford.
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