Researchers have observed with optimism the promise of media to contribute to the elimination of health disparities (Len-Rios, 2012; Ramirez, Graff, Nelson, et al., 2014; Viswanath, 2006), since mass media are particularly trusted sources of health information for racial and ethnic minorities that suffer from information-related health disparities (Brodie, Kjellson, Hoff, et al., 1999). For example, more than 8 in 10 (83%) of US Latinos obtain health information from the media, and 79% of those who do so act on that information (Livingston, Minushkin, & Cohn, 2008). Other studies have demonstrated significant positive effects of information-seeking from the media on health behaviors (Ramirez, Freres, Martinez, et al., 2013), improved doctor-patient communication (Rooks, Wiltshire, Elder, et al., 2012), and uncertainty management (Wiltshire, Cronin, Sarto, & Brown, 2006).

The past two decades have seen a meteoric rise in the overall amount of health information available to many individuals, particularly from mass media and other non-clinical information sources (Viswanath, Nagler, Bigman-Galimore, Jung, McCauley, & Ramanadhan, 2012). Coupled with a deliberate cultural shift toward a health care model featuring patients who are active participants in their own medical decision-making process (Kelly, Hornik, Romantan, et al., 2010), access to a rich information environment – and the ability to make sense of it – is becoming an increasingly important path to health. The mass media may constitute an especially important source for information dissemination in rural regions with geographically-dispersed populations that are harder to reach through other channels, and where local community newspapers – which tell local stories and serve an especially critical role – predominate (Garferick, 2010).

However, the unequal distribution of health information is compounded in rural regions that face multiple barriers to health, and thus may contribute to rather than reduce disparities. Access to health information is socially patterned such that low-income, less-educated, ethnic minority, and linguistic minority populations – those that characterize many rural areas – have less access to health information from a variety of sources (Lee, Ramirez, Lewis, et al., 2012; Manierre, 2015; Vanderpool, Kornfeld, Finney Rutten, & Squiers, 2009; Viswanath & Ackerson, 2011; Zhao, 2010). Rural populations also suffer disproportionately from a variety of health conditions.

Health risks specifically related to information access disparities have been documented in rural regions, including low levels of media coverage of cancer risk (Krieger, Katz, Eisenberg, Heaner, Sarge, & Jain, 2013) and opportunities for health communication pertaining to food insecurity (Ramadurai, Sharf, & Sharkey, 2012). Given such evidence, access to health information has been considered a social determinant of health (Freimuth & Quinn, 2004), and one that may be especially important in rural settings.

This project contributed to mapping the health information environment by examining the availability of print health news in a rural, culturally and linguistically diverse region. California’s Merced County is located in the geographic heart of the state, in the region known as the San Joaquin Valley (SJV), a vast, largely rural region that produces more than one-third of the country’s vegetables, fruits, and nuts (Great Valley Center, 2014). Characterized by extremely high levels of poverty, unemployment, and low educational attainment, the region has been described as the “Appalachia of the West” (Cowan, 2005). Over half the county’s residents are Latinos of Mexican origin, and the county is diverse in terms of language preference and nativity: 25% are foreign-born, and their primary language may be an indigenous Mexican language rather than Spanish, while 75% are native-born U.S. citizens, who possess varying levels of English proficiency (U.S. Census, 2015). Because the current demographics of the county signal the future of the country as a whole (Colby & Ortman, 2015), this project serves as a case study that may increase understanding of media access and its implications in the broader national landscape. The overarching purpose of our study was to examine the availability of published health news and their usefulness. The research was guided by the following questions:

RQ 1: What print news sources are available in the region?

To answer the first research question, we conducted a census of all English and Spanish language publications distributed in a rural central California county (1,935 square miles; population: 266,353; U.S. Census, 2015). We compiled a list of Merced County incorporated and unincorporated communities using information from the U.S. Census Bureau on major cities and census-designated places to identify all population centers in the county. We identified a total of 19 newspapers, newsletters, and bulletins that are distributed in any of the regions; of these, 14 were available to sample online or in print for the period February 1 through July 31, 2014. We were able to obtain print copies of every issue published during the study time period for 11 newspapers; 3 had full-text news items indexed online (Table 1). The others were either no longer operating or did not have archival copies to share. To answer the second through fourth research questions, we sought to identify all health-related editorial content available during the study time period in all of the publications.

We initially identified a total of 838 health-related news items, then removed 191 “articles” retrieved electronically that were simply event listings with no associated news item, as well as 77 duplicate items, for a final analyzed sample of 570 health-related news items. Health stories constitute just 19.2% of all news items published in the analyzed newspapers. The average length of a health-related news story was 13.5 paragraphs (SD: 7.3).

We examined the health information environment in a rural, culturally and linguistically diverse California community whose demographic composition may reflect the future of the United States, and which suffers disproportionately from preventable chronic disease morbidity and mortality. We found a general paucity of health information, and also a lack of correspondence between the major health issues facing the community and the issues covered in the news. While health-related newspaper items in the rural county covered a range of topics, they mostly focused on the topics of access, insurance, and policy. Given the timeframe of the data collection (six months following implementation of the Affordable Care Act), and ongoing regional challenges to health care access (Joint Center for Political and Economic Studies, 2012), the overwhelming focus on such issues is not unreasonable. The region faces health burdens associated with extremely high rates of obesity and diabetes, so the abundance of items relating to physical activity and diet also makes sense, although it is less clear why obesity and diabetes were not covered as topics. Our analysis also demonstrates that stories that may have logically linked behavioral determinants of obesity and diabetes – physical activity and diet – in general did not, missing an opportunity to provide useful information to readers.

Perhaps of greater significance than the topics that were covered were those that were not mentioned. Notably absent from coverage were environmental health threats such as air quality, climate change (e.g., drought and lack of access to drinking water), and fertilizer/herbicide/pesticide usage in this agricultural area. Of the 570 health-related news items, just 40 (7.0%) were about environmental health threats, despite the significant public health challenges associated with such threats in a region that consistently ranks among the top 10 most polluted in the county (American Lung Association, 2015). Also missing was coverage of the social determinants of health, notable for its absence in a region that suffers extreme economic and educational disparities that contribute to health disparities (Joint Center for Political and Economic Studies, 2012). Previous studies have documented the news media’s failure to address social determinants of health as well as health disparities (Kim, Kumanyika, Shive, Igweatu, & Kim, 2010; Niederdeppe, Bigman, Gonzales, & Gollust, 2013).

Additionally, we found a surprising lack of print sources in Spanish, surprising in a region where over one-third of the population speaks Spanish. This could be due to low levels of literacy and education in this Spanish-speaking population (U.S. Census, 2015); however, that does not explain the lack of news in Spanish, since there are at least two small-scale monthly publications that were not included in this sample because they are primarily commercial advertising with some minimal editorial content but no formal news. A more plausible alternative is an unmet demand for Spanish-language news publications, which have been decreasing nationally, as have English-language publications (Pew, 2016). This is unfortunate because ethnically-targeted media – which usually means Spanish-language for Latinos – offer qualitatively different coverage than English-language or mainstream media (Matsaganis, Katz, & Ball-Rokeach, 2013; Villar & Olson, 2013).

We also found a lack of specifically local content, such as that focusing on local health challenges and providing information about local resources. Finally, our study demonstrated that news coverage of health issues in a rural community lacked information that would help make the news useful as a vehicle for health promotion information, suggesting that despite the promise of newspapers to serve as health communication channels, there is much opportunity to grow to realize that promise. Both of these patterns are consistent with previous content analyses of California newspapers in general (Wang & Rodgers, 2013) as well as Latino-targeted newspapers in particular (Vargas & dePyssler, 1999).

The construct of “usefulness” as employed in this study warrants additional consideration and future research that could improve its utility for communication interventions. There is substantial evidence about what makes news credible, including source, structure, and audience features (Metzger et al., 2003), as well as evidence from communication interventions about strategies to increase credibility and enhance relevance (Cohen et al., 2010; Ramírez, 2013). In addition, literature from the audience perspective (e.g., information seeking) provides evidence that individuals find utility in health information from the news and use it to make decisions about their health (cf., Ramírez et al., 2013). Missing from the literature, however, is evidence about what constitutes usefulness. If relevance is important to gain the audience’s attention to the information and credibility is importance to enhance trust, what is it that makes information useful? Certainly the answer will vary depending on the specific topic, but a set of evidence-based guidelines would provide a useful framework for interventions to increase health information in the news media.