Dancing in the Dark: Source Coordination and Strategic Media Alliances in the Health Field

ABSTRACT

The news media are important for political influence, and interest groups compete for visibility. However, actors on the same policy field also tend to have close ties and cooperate when interests overlap. Existing research on sources has overwhelmingly focused on journalist-source relations, and far less on how news content is negotiated between the sources themselves. Based on triangulation of in-depth interviews with 40 representatives from Norwegian health interest groups, representing business, citizens and medical professionals, the present article unpacks how groups cooperate on media management behind, and in, the media limelight. Conceptualizing cooperation as resource exchange, the study explores the barriers and incentives that condition media cooperation and visibility, theorized as network dependencies. By exploring how interest groups reason and negotiate media cooperation and access, the study adds new insight to the field of news production, and contributes to the theorizing of source representation in the news.

KEYWORDS:

• Sources
• Health news
• Strategic communication
• News media
• Interest groups
• Lobbyism
• Alliances

Introduction

Different actors, such as corporations, experts and citizen groups, coexist as autonomous players on the same field. However, on some issues, their interests can overlap. Health actors can for instance share an interest in new treatments. Due to rising costs, health care providers increasingly need to limit the availability of expensive treatments (Sabik and Lie 2008). Innovative medical technologies are often presented as magic bullets by the media (Seale 2002), and the exclusion of apparent medical “cures” can result in highly negative media coverage, often through stories of suffering individuals (Wheatley 2020). Such human exemplars can be persuasive (Brosius and Bathelt 1994) and the media are thought to have affected the approval of particular drugs (e.g., MacKenzie et al. 2008; Gabe et al. 2012). However, only a few of the exempted medicines gain public attention.

Departing from existing findings of interest group media cooperation, this study explores in-depth how and why different health interest groups work together on media strategies, and how such cooperation can affect which interests are able to pursue their issues in the media. Seeing that media strategies for political influence are associated with secrecy, the present study analyzes and triangulates unique data to shed light on practices that are normally inaccessible to outsiders.

Mainstream media remains vital for interest group political influence (Powers 2016). Due to editorial routines and requirements, journalists are prone to prioritize a limited number of official, elite actors, presenting these as “authorized knowers” (Hall et al. 1978). In contrast, non-official sources such as business groups and NGOs struggle to become newsworthy (e.g Cottle 2003; Waisbord 2011). Increasingly professional news sources can nevertheless compensate by offering information subsidies (Gandy 1982) in exchange for coverage (Grömping 2019). Established organizations in particular can access the competence and resources necessary for compiling successful media packages (Thrall 2006). Due to increased market orientation within journalism, there is a tendency to privilege popularized and engaging content across media outlets (Karidi 2018). In accordance with prevailing media logic(s) (Altheide and Snow 1979; Landerer 2013), less powerful groups can therefore attract attention through conflict and personification (see Molotch and Lester 1974; Manning 2001; De Bruycker and Beyers 2015). In particular, the populist demand for human exemplars and personal storytelling has increased the representation of identity groups and ordinary citizens in the mainstream media (Binderkrantz, Christiansen and Pedersen 2015; Keyser and Raeymaeckers 2012; Stroobant, De Dobbelaer and Raeymaeckers 2018a).

As the proliferation of interest groups increases the competition for attention, actors with mutual aims face incentives to cooperate (Berry 1997). A vast literature in political science documents how actors form coalitions by pooling resources to increase political influence (e.g., Hula 1999). While sources have received much scholarly attention during the last thirty years, studies often focus on the interaction between journalists and official sources (e.g., Cottle 2003; Ericson, Baranek and Chan 1989; Manning 2001; Schlesinger and Tumber 1994; Maurer and Beiler 2018). Surprisingly few have explored in-depth how, and why, news sources work together (Stroobant 2019,179).

One exception is a study by Schlesinger and Tumber (1994) of crime reporting in the UK, which finds that both source competition and cooperation are frequent. Similarly, a case study by Williams and Gajevic (2013) of a biomedical coalition documents how participants pool resources and align strategies, although the tactics are not explored in-depth. Other relevant studies find that health interest groups cooperate on media strategies for political influence and medical treatment advances (Epstein 1996; Klawiter 2008; Miller and Williams 1998; Thorbjørnsrud and Ytreberg 2020; Williams and Gajevic 2013; Dumit 2012). However, the majority of these studies mainly address source cooperation through passing observations. Addressing this gap, the present study focuses on how, and why, non-official interest groups collaborate on media coverage. Drawing on unique data from 40 in-depth interviews with Norwegian health policy stakeholders, and a triangulation of their accounts, this paper asks;

How Do Different Health Interest Groups Cooperate on Attracting or Steering Media Attention?

In the media presentation, actors from separate domains such as politics, medicine, science and business tend to be positioned differently. Somewhat simplified, medical professionals are often presented uncritically as neutral experts (Stroobant, Van Den Bogaert and Raeymaeckers 2018b), individual citizens and citizen groups as representing morally deserving victims (Thorbjørnsrud and Ytreberg 2020), and corporations as actors with suspicious motives (Cottle 2003). In practice, these domains are increasingly intertwined. Patient organizations provide medical services, fund research and participate in regulatory processes, scientists and pharmaceutical companies cooperate on clinical trials, and companies fund patient groups and involve them in marketing efforts (Dumit 2012). Hence, actors and groups on the same sub-domain, such as “breast cancer”, are connected in a Web of overlapping interests (Clarke et al. 2003; Gandy 1980). Due to intersecting fields, it can be hard for journalists and the public to unravel potential conflict of interests (Stroobant, Van Den Bogaert and Raeymaeckers 2018b). While related studies largely assume the convergence of the media and health domains (e.g., Briggs and Hallin 2016; Clarke et al. 2003) few have explored empirically how field intersection affects media practices. Recognizing that existing interdependencies between field actors forms a central backdrop for understanding news source activity (Schlesinger and Tumber 1994), the study furthermore asks,

How Do Groups Negotiate Interdependencies and Diverging Interests When Cooperating on Media Management?

Interest groups refer to non-government, professional stakeholders on the health policy field; physicians, corporations, medical industry organizations and patient and larger condition-specific organizations. Cooperation encompasses both explicit and implicit alliances to influence the media, both strategic collaborations and more loose coordination. Sources refer to individuals who contribute information to journalists.

News results from negotiations on multiple levels; within the media, the journalist-source relationship, and between the sources themselves (Ericson, Baranek and Chan 1989). Drawing on unique data, the study sheds light on a news production process that has received limited scholarly attention; how groups cooperate as news sources. The study's main contribution is to the larger puzzle of source-media relations and power (Schlesinger 1990). In particular, it theorizes the significance of network dependencies on source cooperation. By applying a fine-grained analytical approach sensitive to the overlapping objectives and preexisting transactions that take place between actors on a policy sub-field, it explores the effect on media strategies and the ability of groups to communicate their interests in the news. Furthermore, the study adds to the emerging literature on health news production (Briggs and Hallin 2010; Hallin and Briggs 2015; Stroobant, De Dobbelaer and Raeymaeckers 2018a; Stroobant, Van den Bogaert and Raeymaeckers 2018b).

After an initial overview over news source strategies, the paper proceeds with a presentation of the theoretical framework, the Norwegian case and the methodology, before analyzing key aspects of media-cooperation between policy actors. The paper concludes with a discussion on what affects source cooperation, and implications for the scholarly literature on news sources and source influence.

Source Strategies and Collaboration

All types of groups rely on media strategies; selectively, and in combination with other tactics (Beyers 2004; Trapp and Laursen 2017). Groups approach the media for reputation building, organizational growth, political influence and funding (see Berkhout 2013). However, media strategies partly depend on group characteristics; those representing general, public causes are more likely to approach the media than those representing sectional, narrow interests (Binderkrantz and Krøyer 2012; Dür and Mateo 2013).

Studies find that the media play a central role on the health field (Briggs and Hallin 2016). However, groups face different constraints. For patient organizations, the media are vital for funding and influence, but groups adjust their strategies according to perceived opportunities (See Fredheim and Figenschou 2020 for in-depth study). Physicians and medical experts are often key sources in health news (Stroobant, De Dobbelaer and Raeymaeckers 2018a; Van Trigt et al. 1994). While some studies find they are skeptical of journalists and prefer to respond to, rather than initiate, media contact (e.g., Williams and Gajevic 2013), others find that they use the media purposively by adapting to media requirements (Williams and Gajevic 2013; Briggs and Hallin 2016; Miller and Williams 1998). Pharmaceutical companies are generally cautious towards the media due to conflict-oriented coverage (Van den Bogaert, Stroobant and Bracke 2019), although studies also find that they can apply indirect or covert strategies, such as collaborating with patient groups (Morell et al. 2015; Dumit 2012).

Interest groups cooperate on media strategies because of mutual aims and resource mobilization (Ferree et al. 2002; Schlesinger and Tumber 1994; Williams and Gajevic 2013). Thorbjørnsrud and Ytreberg (2020) for instance find that large health NGOs cooperate with smaller patient organizations to locate “media-friendly” patients. The perceived public importance of an issue is also decisive for media strategies and alliance-formation. Beyers and De Bruycker (2018) for example find that coalition-formation relates to degree of media interest. Cooperation range from formal coalitions to “tacit collusions” (Schlesinger and Tumber 1994, 72). Overt strategies involve sending joint press releases (Schlesinger and Tumber 1994), communicating a shared set of messages (Williams and Gajevic 2013), and connecting journalists with “media friendly” sources (Stroobant, Van den Bogaert and Raeyemaeckers 2018b). More covertly, groups seeking to downplay their involvement can communicate through others (De Dobbelaer, Van Leuven and Raeymaeckers 2017; Ferree et al. 2002; Van Trigt et al. 1994). Nevertheless, Schlesinger and Tumber (1994, 64-65) find that groups largely avoid sponsoring other groups’ media attention, and that ( communal action is disincentivized when one actor contributes disproportionally). As it is primarily the larger, more established groups that coordinate actions, the relative ability to influence collective efforts can be skewed (Thorbjørnsrud and Ytreberg 2020).

Theoretical Framework

Departing from the proposition that actors can align efforts to pursue mutual objectives, which theoretical approaches can be helpful in explicating this phenomenon? The analysis concentrates on two main concepts drawn from the literatures on social movements, media, and journalism; frame alliance and exchange relations. These are elaborated below.

How issues are publicly defined can affect political attention, attitudes and policy solutions (Snow et al. 1986, 464). The media can hence be seen as semantic battlegrounds where interest groups compete on how issues should be understood (Pan and Kosicki 2001). By advocating particular perspectives while ignoring or contesting other potentially relevant aspects, actors engage in strategic framing). However, actors can also advocate similar or identical frames (Pan and Kosicki 2001). Such frame alliance (Snow et al. 1986) is believed to increase the potency of these frames (Pan and Kosicki 2001). A study by Junk and Rasmussen (2019) for instance finds that when several groups promoted the same policy frames, these became more influential in the public debate.

Resources, and the exchange thereof, are believed to be central determinants for interest group action and mobilization (McCarthy and Zald 1977). Actors have access to different resources, and what counts as resources is context-dependent. Medical conditions for instance enjoy varying status (Norredam and Album 2007). Adherence to a particular social group, institution or profession can thereby constitute a form of symbolic capital. Other relevant resources are human resources, knowledge, network, credibility and finances, although the latter facilitates access to the rest (Ihlen 2007). Within the social movement literature, resource exchange is, somewhat simplified, theorized as either rational (Resource exchange theory), or relational (Social exchange theory). The first approach theorizes rational, marked-like transactions in pursuit of explicit goals. The second concentrates on personal, dyadic relationships, where social norms, trust and liking motivate exchange (cf. Chadwick-Jones 1976). Interaction is thought to foster further exchange, thereby strengthening the relation over time (Homans 1961 in Chadwick-Jones 1976, 185). However, as exchanges are inherently unequal, social exchanges both reinforce relations and create subordination (Blau 1964). Because of unspecified reciprocity, resourceful actors can accumulate the reciprocal debt of others (Blau 1986).

Nevertheless, neither of the two models adequately explain professional interactions between policy actors. As mentioned earlier, actors on the same field also tend to have overlapping aims and close connections (e.g., Gandy 1980; Schlesinger and Tumber 1994). For instance, while interactions between journalists and sources are mostly conceptualized as exchanges (e.g., Gandy 1982; Gans 1980), others find that journalists and central sources within a beat develop close, long-term relations (e.g., Reich 2009). Within such hybrid professional- personal relations, reciprocity is not necessarily immediate nor specific, but rather governed by a combination of cultural and professional (strategic) norms (Eide 1991,156).

Studies within strategic communication also highlight the importance of mobilizing resources within networks for communicative power (e.g., Ihlen 2005). Pan and Kosicki (2001, 44) suggest that actors can increase their communicative abilities by drawing on a “web of subsidies”, understood as the control of, and access to, material resources, competence and strategic alliances. However, they do not theorize how interdependencies between actors can limit or constrain visibility. The present study thus proposes the theoretical concept of network dependencies in an attempt to explain how power relations affect how news sources cooperate.

Case Background: Health Care Prioritization in Norway

Norway is a wealthy welfare state with a universal, tax-based health care system characterized by universal access to public services (Magnussen et al. 2009). Health care expenditure is increasing, but comparable to other high-income countries (Saunes, Karanikolos and Sagan 2020).¹ During the last decades, a range of reforms have pushed towards cost-control, standardization, and patient involvement. A national prioritization system, “New Methods” largely determines the availability of new treatments within the public health service based on cost-effect calculations (Saunes, Karanikolos and Sagan 2020). The system has been criticized for lack of transparency and limited stakeholder involvement.

Patient organizations in the Nordic countries are increasingly politically active and growing in numbers, although many are small and focus on single conditions (Winblad and Ringard 2009). Digital media is assumed to have facilitated group proliferation (Sivesind et al. 2018). In Norway, access to the internet is near universal (SSB 2019), and the large majority (84%) consume online news weekly. Offline news consumption has been declining, but is still comparatively high (Newman et al. 2019) The Norwegian media system adheres to the Northern democratic corporatist model (Hallin and Mancini 2004), characterized by high levels of press subsidies and relative low levels of political parallelism. In media systems where the media operates independently of the political field, the media is more likely to play a central role in affecting policy processes (Berkhout 2013).

Methodology

This study explores how actors on the health field cooperate on media attention. Semi-structured interviews were conducted with 40 executives and communication officers representing key health policy stakeholder groups: pharmaceutical companies (8), organizations representing industry interests (4), patient groups (10), large patient interest organizations (4), and physicians affiliated with medical specialist associations (6). (See Table 1 for overview).

Table 1. Interview sample.

Health Interest Groups	Number of interviewees	Number of organizations
Patient group	13	12
Patient Interest Organization	4	2
Physicians	6	6
Medical Industry Organization	6	4
Pharmaceutical Company	10	8
Total	40	32

Group types were identified within studies on health care prioritization debates (Gabe et al., 2012). The specific groups were chosen to include different types of medical conditions, sizes and degrees of media presence. The latter was measured with the Norwegian media database Retriever. Interviewees were executives and/or heads of communication within the selected groups. Interviewees were asked a number of open-ended questions about communication practice, media relations, and related experience. The interview guide was largely the same for all groups, except for some group-specific questions based on preceding field observations, in-depth media-analysis and existing literature. For instance, pharmaceutical representatives were questioned about industry regulations, and physicians on how they handled conflicting institutional expectations and roles. Several interviewees had experience from politics, journalism or PR. In order to reduce strategic accounts from professional communicators, interviewees were probed for examples and questioned about actual media coverage (Dexter 2006).

The interviews took place between autumn 2017 and spring 2019, including two in 2015. The interviews were semi-structured and conducted in person, except for three on the phone. Ten interviews were conducted by three other researchers within a larger research project. The majority were recorded digitally and lasted for about one hour. Media strategies can be sensitive; several interviewees expressed an uneasy incompatibility with actual media strategies and the preferred image of the group or domain they represented. Five interviews were therefore not recorded, either due to interviewee requirements or the apparent effect of the recorder on the willingness to disclose sensitive strategies. In these cases, the interviewer took notes. All interviewees signed a consent form, and all participants have been anonymized.

The data were transcribed and coded in HyperText. Codes were identified inductively through a close reading of the material, mapping central concepts and topics, and by comparing and contrasting accounts on specific issues or media coverage by multiple interviewees. In line with (Luker 2008), analytical categories and codes were developed while simultaneously scanning relevant literatures, thereby increasing the analytical sensitivity to relevant concepts in existing literatures.

Since interviews are suitable for discovering narratives that cannot otherwise be observed (Luker 2008), the data is first and foremost suitable to capture interviewees perceptions, how they reason and perceive their actions (Cramer 2015). However, by interviewing multiple stakeholders in a particular policy issue, the claims by one can indirectly be validated, if not verified, by those of others. Such triangulation of different accounts of actual media coverage provides valuable insights into how actors experience themselves, and how they experience each other. Inconsistent accounts and contradictions between interviewees informs the overall analysis as meta-data (Fujii 2010). The method does not allow for generalization, but is rather suitable for disentangling the logics behind media strategies between certain actors on a particular issue, on a specific policy field. The following presents an analysis of how health interest groups cooperate as news sources in light of shared policy concerns, and how they negotiate differences between them in light of interests and resources.

Analysis

Cooperation Through Resource Exchange

The interviews show that groups cooperate on media attention to increase policy impact. The leader of a large health interest organization explains it concisely:

We have to realize that we cannot solve everything on our own. So having collaborators, that being politicians, professionals, clinicians, … The more people who repeat a message, the greater the likelihood of something getting through (Interest Org.1 2019)

However, whether groups cooperate or not is context dependent. A representative of a large patient organization explains that while they often cooperate with other organizations on particular issues, they also need to foster their public image as a key actor with independent issue- ownership.

The groups in the study have varying access to media-relevant resources. For instance, pharmaceutical companies and large NGOs largely have financial means and expert knowledge, while small patient organizations and physicians have access to a crucial ingredient in health news; patient exemplars (Hinnant et al. 2013). In line with the human-interest economy found by Thorbjørnsrud and Ytreberg (2020), such media-resources can be exchanged to enhance media visibility. Small patient organizations for instance approach the larger groups to access media competence, funds and medical knowledge, while the larger groups in turn solicit patient cases for media input.

Groups furthermore have varying communicative constraints. Industry interviewees describe formal regulations that limit their communicative abilities, and for physicians, proactive media strategies appear to conflict with the professional ethos (see Williams and Gajevic 2013). Furthermore, a simplified media presentation can invoke collegial ridicule. Some of the smaller patient organizations also face some communicative constraints, which will be elaborated on below. Based on interviewees’ accounts, Table 2 provides a generalized overview over how the groups in this study differ in resources and constraints, according to themselves.

Table 2. Overview over central group resources and constraints.

Actor	Financial Resources	Cultural Legitimacy	Human-interest Exemplars	Formal Communicative Constraints
Small Patient Groups	Low	High	High	Some
Large patient Interest Organizations	High	High	Low	Few
Physicians	Moderate	High	High	Some
Medical Industry Organizations	Moderate	Moderate	Low	Few
Pharmaceutical Companies	High	Low	Low	Many

Notes: Based on interviewee accounts of themselves and other actors on their field. Values are relative, not absolute.

In line with the literature, the interviews thus show that resource dependency is a central motivation for source cooperation, and that groups exchange these to obtain mutual goals.

Cooperation Between Heterogeneous Actors as Boundary Work

The interviews reveal some cooperative hurdles between actors from different fields. Several industry representatives highlight how both skepticism towards them and industry regulation can limit stakeholder contact. One pharmaceutical representative describes a situation where a patient organization made contact after the government had rejected their medicine:

A patient organization contacted us, because they wanted to know what was happening. It was a strange meeting. We sat there and said almost nothing (…): We cannot say anything due to regulations. They asked us “what can we do to help? What can we say to the media"? And we can't say that (so we just said), “yes, no, we don't know … ” And they sat there looking at us, wondering, what in the world, what a passive bunch (Company 6, 2019).

Relatedly, several interviewees stress the importance of autonomy, as industry relations can harm their image. A physician whose industry-relations had been criticized in the media said that she had advised a patient organization to leave her out of their future media efforts as not to harm their cause with her stained credibility. On the other hand, several interviewees challenge the conventional divisions between fields, highlighting the necessity of inter-field interaction for medical advances. Interviewees therefore frequently explain cooperation through common ground. A leader of a small patient organization reflects on the dilemma:

The benefit is that (the pharmaceutical companies) have lots of knowledge and resources that can help us. They have many contacts, so that we can spread knowledge about our organization, and our messages. (..) The downside is the ethical bit, they have lots of money, and there are expensive medications for which we fight for lower prices.. (but) they also want our patients to get well, and I believe they have a certain ethical standard, so we're really working towards the same goal. But of course, we have to think through what we join and don’t. So we discuss many of their suggestions in our board. We do not say yes to everything we get from them (Patient Org. 9 2018).

Exchanges between industry and non-industry actors can thus be said to be legitimized through boundary work (Gieryn 1983): by highlighting communality, the interviewees discursively conflate conventional boundaries between fields such as science, business and medicine (see Briggs and Hallin 2016). The following elaborates on different types of cooperation, before discussing conditioning factors.

Three Types of Media Cooperation

The data indicates that group cooperation ranges from explicit collaboration to more loose coordination. In essence, groups cooperate on frame alignment, information subsidies, and by delegation of public roles. While these practices can overlap in practice, they are described below as ideal types for the sake of analytical clarity.

Aligning Media Frames

Several interviewees describe how they discuss their position with other stakeholders before contacting the media. A physician explains why;

I discuss (medical issues) with colleagues, in order to discover potential counterarguments or alternative views, prior to going to the media. The other thing is the discussion with the people in the pharmaceutical companies (..). You have to work with the companies to obtain a sober media presentation when there are new medications, or when medications are rejected. Try to explain why it happened, and how one can try to get it approved next time around (Physician 2, 2019).

Similarly, some interviewees describe how they identify actors who are likely to back them, and adjust their argumentation accordingly. Others describe how they explicitly attempt to reach an agreement on key media messages. Large health interest groups for instance co-author op-eds to demonstrate unity. Similarly, an industry representative explains why collaborating with patient organizations is useful:

We have quite a bit of contact with patient organizations, because we have many joint interests, of course. In terms of the media, they often have easier access than we do. Of course, we are a commercial actor. So, when we give joint statements, they can for instance highlight the patient interest (Industry Organization 5, 2017).

Such frame alignment (Snow et al. 1986) can also be less transparent, as exemplified by the following quote by a small patient organization representative:

Now that the prioritization bill has been approved, we will have to sell in stories to the media about people who can tell what it means for them that they have to discontinue a treatment because the state wants to save a little money (..). Then we have cases, and we have to work with them so that we agree on which message we want to get out (Patient Org.8 2018)

When a medical product was criticized in the media following a government procurement, the affected company coordinated their media strategy with the relevant public agency:

There was an issue in (Specialized media), which we felt was incorrect. Then we contacted (Public Agency) and asked them if they were going to do something about it. They didn't know and it was a bit blurry, so we said, “if its ok for you, we'll do it”. And they were very ok with that, so we contacted the journalist and had a dialogue, and then we informed the Public Agency afterwards. (Company.7 2017).

Frames are not necessarily coordinated explicitly. One physician explains that although the solution he advocates originates from the industry, he refutes any coordination between them; it is rather an independent position that happens to correlate with that of others.

Providing Source Subsidies

Attracting media attention can be hard, and most interviewees explain how they seek to optimize coverage by anticipating journalistic needs, such as the need for particular sources. The following quote by the head of communication in a pharmaceutical company illustrates this:

Presenting an angle, with a patient case, that is key. And the contact information to a physician, That's a minimum (..) Often we present the (patient) case as an article, so that it is nearly finished. We don’t expect it to go right in, but.. surprisingly often it is quite similar to how it ends up in print. But we don’t always get the angle we want”. (Company 11 2019)

Different types of sources serve different needs. In particular, interviewees agree that patients are crucial for achieving coverage, while expert sources are central for legitimacy and credibility. Both physicians and patient organizations can draw on each other to gain media attention. Similarly, actors consider their own relative legitimacy in a debate. The reflections by a leader of a large health interest organization are illustrative:

I believe (..) we have quite a bit of credibility in the public (..). But I think, at least in this medicine-debate, it obvious that the physicians, they have even more credibility. And that's important for us. We work for our goals, and then, if “Physician Paul” has more credibility, it's important to use him in this issue. (Interest Org. 1 2019)

Referring journalists to others is not necessarily explicitly coordinated. Several have experienced that other groups refer to them without first informing them. However, as actors generally know how others in their field stand on central issues, they can direct journalists to those with similar opinions. Nevertheless, not all actors are able to mobilize “their” central field actors, as illustrated by the following quote by the head of a patient organization:

I feel we maybe should educate the physicians on the media (…). For example when (an issue) was in the media, I called (the physicians) and said, now you must be prepared to go out (..). But they were just silent (Patient Org. 4 2019).

Interestingly, both patient organizations and physicians mention incidents where individual citizens, such as resourceful patients, have recruited them as news sources to back up their grass root campaign in the media.

Delegating Media Roles

A third way groups cooperate is by enacting different roles in the public sphere. According to the interviewees, conflict attracts media attention but can be counterproductive for political access. By cooperating, some groups can protest while others quietly lobby. The following quote illustrates such coordination between different patient groups:

It's important for us that they are one actor, and we are another. They can protest, but we have to work slower and more thoroughly before giving statements (..) But we helped them, and we contacted other organizations (… .) And we had a dialogue before (we contact the media), and we decided on the premises for our participation (Small Patient Org. 2 2018).

Similarly, groups can communicate indirectly, through others. The head of communication of a pharmaceutical company explains that he often uses a primary source between himself and the journalist, such as a patient or an industry organization. According to the leader of a large patient organization, pharmaceutical companies frequently solicit their help to create public attention:

Relatively often, we are contacted by pharmaceutical companies, that come here and present new medicines they think are significant innovations. And they want help with putting pressure to have them approved (..). It is not unusual. Several times a year. Different companies. Sometimes they already have patient cases, sometimes they want them from us. And sometimes they want help to direct attention to an area they are starting to work on, and then they of course have medicines under development (Interest Org.17 2015).

Role delegation can be highly explicit, as exemplified in the following quote by the head of a patient organization:

(The PR agency) is making a strategy (…) and we are in on it. Because (the pharmaceutical companies) can't go out (in the media) you know. We represent the patients, and (the journalists) often want a case, and we have the case. So now (…) they want to write an open editorial, and “could it be in my name"? And so on. So we are very grateful for that, because my time doesn't allow these things (Patient Org.4 2019).

However, it can also be more subtle. According to industry representatives, establishing good relations with other groups can be helpful to ensure they are “on the same page” in the event of media criticism.

Some groups provide others with media visibility and competence. A physician explains that when a pharmaceutical company once asked her to comment on a patient satisfaction report, she received media training by a PR consultant. While the report never got any publicity, the PR contact later became useful when he offered informal advice on another (non-pharmaceutical) issue: “who to join alliances with, patient organizations, which politicians to contact, how to write open editorials (Physician 6, 2019). Similarly, the representative of a small patient organization describes how they were initially unsuccessful with the media, but then a pharmaceutical company tried to help them increase their public presence through a PR company. Consequently, groups can access competence and increase visibility through their networks, while resourceful groups can potentially strengthen their own interests indirectly by providing others with this competence.

Cooperation, Power and Network Dependencies

As seen above, groups belonging to the same policy field can be said to comprise a form of ecology of interdependence, where groups with overlapping objectives provide mutual support. Due to frequent interaction, actors appear to develop informal connections based on trust and reciprocity, as illustrated by the following quote by an industry representative:

Over time, as we have established a relation, and they know us. I notice for instance that (patient organization), if there is something they are wondering about, or know that we have competence on, they'll call us or send us an e-mail. It goes both ways, it does. But I believe you have to have a relation first, then you know what you can help each other with. (Company.7 2017)

In accordance with social exchange theory, actors who know each other are likely to engage in exchanges, and exchanges persevere if they are mutually beneficial (Salisbury 1969). The head of communication of a small patient organization explains how he can solicit free advice from his contacts, in return for help when they need it:

We haven’t spent lots on communication strategies or anything. But, I have a quite an extensive network with people who are communication advisors, politicians, and the like. I usually call them and ask for advice, recommendations and so on (..). They are sort of friends of mine. And maybe some of the PR agencies have clients with an interest in (my field), right, so it goes both ways, since I am also a professional and I have a network, right, everywhere. So I also help, it goes both ways really (Patient Org. 5 2017).

Nevertheless, as conflicts of interest and power discrepancies hover in the background, groups continuously evaluate the material and social cost of exchanges. When differences surface, the boundaries between them re-appear, and the exchanges can break down. The leader of a patient organization provides an example where this happened:

That's something I would have liked to write an article about, right, but then I run short on working hours. And then a pharmaceutical company comes along and they have written an article for me, but it's not quite right the way I see it, so I say they have to fix this and this and this and this, and then they probably think it's too much, because they don’t (laughs). And then I don’t use it (Patient Org. 4 2019).

In cases where power differences between them emerge, thereby disrupting the premise of autonomy, the relation itself can break down, as described by the following quote by a patient organization representative:

I have cooperated with some pharmaceutical companies. (..) That cooperation I have terminated, actually, because I thought they became a bit (..) I mean, it’s a very positive issue, and they cooperate with many other organizations, but I felt they became too pushy. (… ..) This person from the company recommended that we should write an opinion piece (..). And I didn’t agree with the strategy (…). But I said, ok, since everyone else seems to think this is a good idea, I'll write it. And I did, and it got in (the newspaper). (explains that it had no effect). Then the company started sending lots of emails, with many exclamation points; “now we have to do this! Now we have to do that"! And then I said maybe this was not the right strategy. We haven’t spoken since (Small Patient Org.5 2017).

As the quote above illustrates, actors can be inclined to compromise on their own concerns by adjusting to the larger groups (see Thorbjørnsrud and Ytreberg 2020). Exchanges can in other words reflect underlying dependence and power discrepancies. The only interviewees who mention incidents of undue exchanges, and active resistance thereof, are all well connected, experienced professionals, and likely less dependent on the larger groups. Furthermore, cooperation in itself requires resources. Smaller groups struggle to cooperate even when they recognize the benefits of doing so, because they lack the competence, people and time to coordinate activities.

The degree of autonomy within exchanges thus appears to be contingent on both the ability to mobilize resources within a network, and the degree of dependence on others. Such network dependencies can both enable groups to gain media visibility by drawing on network resources, but also potentially limit it due to lacking resourceful partners, or through dependency and submission to larger groups. For example, established groups can secure exclusive issue ownership by controlling the media visibility of others who are dependent on them. A representative of a small patient organization describes the following dilemma:

The benefit of (other organization) is that they have a lot, they are well known, and big, and have a large apparatus, a lot bigger than ours. They have a lot of knowledge. And they have many full-time employees, it is a completely different organization than little us. So we benefit from that, we get a lot of information, knowledge; they really help us build our organization. They're a great support in many ways. (..) on the other hand, we become very small in comparison. (…) we feel we don't really succeed in communicating our organization (..), they don’t really lift us up (in the media) the way we had wanted (Patient Org.9 2018).

Nevertheless, the independent media appeal of one particular small patient organization has enabled it to collect funds independently and therefore to break out from such dependency relationships.

Discussion and Conclusion

This study has explored how interest groups cooperate on news media access and management. Through in-depth accounts of media practices by Norwegian health interest groups, and comparing and contrasting related accounts, the study sheds light on how interest groups liaison for political influence through the media. The main contributions to the scholarly literature are discussed below.

Empirically, the study finds that media cooperation constitutes a form of resource exchange. In line with previous findings, groups pool resources to pursue communal policy objectives, through cooperation ranging from strategic lobbying coalitions to implicit coordination due to overlapping concerns. Moreover, the study confirms that groups cooperate through frame alignment, journalistic subsidies and by communicating through others. More generally, the findings contradict assumptions in the literature concerning which group types proactively approach the media: most of the groups in this study can be said to represent sectional, including corporate, interests (Dür and Mateo 2013). Furthermore, while previous studies have found that groups do not wish to spend resources on directing valuable media attention to others (Williams and Gajevic 2013), the present study finds that actors seeking to hide their involvement are incentivized to sponsor both long and short term media capacities of those who will forward their interests, directly or indirectly.

A key contribution of this study is the unraveling of factors that condition groups’ abilities to engage in, and benefit from, media cooperation. In contrast to the existing literature, which predominantly focuses on how groups can benefit from their network (see Ihlen 2005), the present study finds that cooperation can both enable and impede interest groups in becoming news sources, theorized as network dependencies. Marginalized groups coalescing with powerful groups willing to share their time, resources and competence appear to experience more media opportunities. Nevertheless, the interviews indicate that due to underlying dependencies and relations, groups can potentially feel compelled to oblige with more powerful partners, or refrain from criticizing them (see also Thorbjørnsrud and Ytreberg 2020). In other cases, cooperation with resourceful others can help facilitate public awareness about common causes, but simultaneously constrain the organizational visibility of less-resourceful groups. This is due to conscious efforts to secure exclusive public issue ownership and funding by the more resourceful group. Groups that lack resourceful or elite media-assertive partners are likely to remain unable to attract public attention towards themselves, or the issues they represent. Furthermore, as cooperation in itself is resource demanding, in terms of time, coordination and competence, less resourceful groups appear to largely fail to coordinate efforts among themselves, despite recognizing the inherent benefits of resource pooling. The interviews also show that group representatives with an extensive, professional network appear to be less dependent on their powerful partners. By drawing on their professional contacts, they can access alternative means to pursue their organizational interest, without having to compromise on content or visibility. The study thus documents how resources and dependencies are both potentially liberating and constraining on how groups negotiate cooperation.

The findings yield interesting perspectives on the larger issues of source access, democratic participation and interest group representation in the media. While media cooperation potentially can provide marginal actors access to the public debate, it can also disguise underlying interests, both for the public and the journalists themselves (see Clarke et al. 2003; De Dobbelaer, Van Leuven and Raeyemaeckers 2017; Stroobant, Van den Bogaert and Raeyemaeckers 2018b). One might therefore ask whether journalists always know with whom they are dancing. In line with Jones (2008) the study finds that controlling others’ media participation is a central media strategy. By enabling some groups and actors, and not others, to become media participants, powerful groups can exert macro-level influence over which stories and issues receive public attention. Moreover, most marginal groups likely lack the support of resourceful partners. In other words, regardless of source diversity within the Habermasian public sphere, there can be an implicit slant towards powerful interests, even without any form of explicit or conscious, coercion. These insights questions established truths of source representation in the media.

Despite valuable insights, the study has a number of limitations. First, rather than providing the complete picture of source cooperation, the study attempts to unravel pieces of what are largely secret media management practices (Gandy 1980,114; Schlesinger 1990, 72). Also, the study does not consider actual influence on media content, but rather media practices and relations as experienced by the interviewees. Furthermore, the data is limited to accounts of practices, and the experiences thereof, which likely diverges from actual practices.

Lastly, the data concerns groups on a particular field, in a specific context (Norway). Arguably, the Norwegian institutional context represents some particularities, such as being a small country, which potentially produces tighter networks across institutional fields than in other countries. Furthermore, the peculiarities of the health care prioritization system might increase the political significance of the media for relevant stakeholders (e.g., Binderkrantz 2005). However, cooperation and overlapping interest on the health field is not confined to Norway (e.g., Gabe et al. 2012; Miller and Williams 1998), and studies have documented the existence of news source cooperation on other fields (e.g Ericson, Baranek and Chan 1989; Schlesinger and Tumber 1994). Insights from political science show that political coalitions tend to unite “strange bedfellows” and that media strategies often form part of other lobbyism tactics (see Baumgartner et al., 2009). The extent to which media cooperation is equally relevant for other fields is hence largely an empirical question. Future studies are therefore warranted to unravel whether the results found here diverge from other fields or national contexts.

Disclosure Statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by The Research Council of Norway (Norges Forskningsråd) [grant number 258993].

Notes

1 In terms of percentage of the GDP. Total spending on health care is among the highest worldwide due to the high Norwegian GDP (cf. Saunes et al. 2020).