Health surveillance in the Brazilian press: overview of the media coverage of the Brazilian health regulatory agency¹

Abstract

The article presents an overview of the Brazilian media coverage of the Brazilian Health Regulatory Agency (ANVISA). The sample consists of texts published in different print and online media throughout 2018, totaling 1,629 publications from 148 different media. Data underwent content analysis, showing that most texts on health surveillance in the press do not approach ANVISA as the main source nor as a body of the Brazilian Unified Health System (SUS). The main themes in the period were related to regulation, records, and authorizations. Among the subjects under the ANVISA responsibility, the most frequent were related to medication and pharmacopoeia. Given the national repercussion involving the death of a patient of a plastic surgeon and digital influencer due to the use of a product authorized by the agency, most publications date from July. ANVISA should review its positioning with the press, expanding its role as a protagonist of the Brazilian health surveillance in the media. The results suggest trends in national coverage and may help improving the communication strategies not only of ANVISA, but also of other health institutions.

Keywords:
Health in Mass Communication; Journalism; Health Surveillance; Press; Health Communication

Resumo

O artigo apresenta um panorama da Agência Nacional de Vigilância Sanitária (Anvisa) na imprensa brasileira. A amostra é composta por textos publicados em 2018 em diferentes veículos impressos e on-line, totalizando 1.629 publicações de 148 veículos de comunicação distintos. A partir da análise de conteúdo, observou-se que a Anvisa não é a principal fonte na maior parte dos textos sobre vigilância sanitária na imprensa, bem como não é apresentada como órgão do Sistema Único de Saúde (SUS), e que os principais temas pautados no período foram relacionados à regulamentação, aos registros e às autorizações. Dentre os assuntos sob sua responsabilidade, o mais frequente foi relacionado à área de medicamentos e farmacopeia. O mês de julho registrou uma frequência maior de textos devido à repercussão nacional do caso da morte da paciente de um cirurgião plástico e influenciador digital pelo uso de um produto autorizado pela agência. É importante que a Anvisa reveja o seu posicionamento junto à imprensa, ampliando nos meios de comunicação o seu espaço de fala como protagonista da vigilância sanitária brasileira. Os resultados da análise sugerem tendências da cobertura nacional e podem ajudar a melhorar as estratégias de comunicação não só da Anvisa, mas também de outros órgãos de saúde .

Palavras-chave:
Saúde na Comunicação de Massa; Jornalismo; Vigilância Sanitária; Imprensa; Comunicação em Saúde

Introduction

Health-related issues hold central position in the daily life of society, becoming the focus of attention of governments, businesses and communities (Paim, 2009), as well as the media. Health crises are reported by the press since, in addition to corresponding to a way of life, health is part of a sector of the economy in which goods and services are produced (Paim, 2009). Media plays a relevant role in health communication, as it can assist governments in making decisions about actions that affect people’s lives.

Communication, beyond the aspects of prevention and promotion, is also important for the relations between health professionals and the population, in the search for information, in the adherence to the sector’s recommendations, and in education of citizens regarding access to health services (Pessoni, 2007). This article seeks to reflect on how this context influences the Brazilian media coverage on sanitary surveillance, a theme present in the daily lives of ordinary citizens given its presence in various services, actions (hospitals, laboratories, offices, clinics, health centers and health posts), and goods (drugs, vaccines and equipment) of health (Paim, 2009). This relationship between communication and health aims to increase both knowledge and understanding of health-related issues, providing people with information to develop their lives with quality (Schiavo, 2007). The first specialized journal in the field, the Journal of Health Communication, in 1986, defined health communication as:

un campo de especialización de los estudios comunicacionales que incluye los procesos de agenda setting para los asuntos de salud; el involucramiento de los medios masivos con la salud; la comunicación científica entre profesionales de la biomedicina; la comunicación doctor/paciente; y, particularmente, el diseño y la evaluación de campañas de comunicación para la prevención de la salud. (Pintos, 2001)

Araújo and Cardoso (2007) have already exposed on the relations between communication and health, bringing them as fields of knowledge in dialogue with the principles of the Unified Health System (SUS) when ruling the importance of social participation and decentralization, among other aspects, as crucial for the dissemination of the voice of health professionals, but also considering traditional knowledge, individual behavior, social, economic and political determinants, with the identification of voices other than the authorized ones.

For the Brazilian press, in particular, different studies have already pointed out the potentialities and problems of media coverage on health. The misconceptions range from difficulty in disclosing the complexity of SUS, presenting it as something predominantly negative in nature (Silva; Rasera, 2013; Machado, 2014; Moraes; Oliveira-Costa; Mendonça, 2017), to the sovereignty of specialized knowledge to the detriment of the voices of individuals who are subjects of the reports (Oliveira-Costa et al., 2016).

The fact is that the press communicates about health. There is, thus, a need for this production to be constantly analyzed and evaluated, including to drive interventions either in the communication dynamics of health agencies to the press, or in the newsrooms themselves. It is known that the sector is undergoing downsizing, thus hindering a refined investigation. However, it is important that researchers are constantly vigilant about media communication on health.

Specifically regarding the Brazilian Health Regulatory Agency (Anvisa) (Agência Nacional de Vigilância Sanitária, Anvisa), a SUS agency with representations throughout the country, and that coordinates ports, airports, borders and customs, it has been observed that four different Brazilian newspapers do not give space for qualified speech to individuals in reports on health surveillance, portraying them as mere consumers (Ferrari; Moura, 2009).

This research seeks to observe how these themes are related to SUS in media narratives. We adopt the term media narratives because we consider journalistic texts as narrative constructions (Marques, 2016). Thus, the research question that guided this investigation was: how was the Brazilian press coverage of issues relevant to health surveillance in 2018?

In its Communications Policy (Brazil, 2014), Anvisa states that “the credibility of the Agency is built and affirmed by the way it relates to its audiences and the transparency of its actions”. However, this relationship goes through press as a mediator between the work developed in the agency and the perception of Brazilians about the agency’s work. Therefore, it is worth understanding how the Brazilian press presented to Brazilians, throughout the year, the actions performed by Anvisa based on the analysis of narratives that mention it in their texts.

Methods

The research is descriptive and exploratory (Creswell, 2010), with a sample of journalistic texts collected throughout the year 2018 from the clipping file made available on an electronic site, and used by the Brazilian Ministry of Health at the time, for interspersed weeks - seven days per month, totaling 84 days of collection in twelve full weeks.

For the sample, the texts identified that contained the keyword Anvisa in printed and online vehicles were manually included through the search tool, excluding institutional ones, including news agencies, for example Agência Brasil and Agência Câmara. Since the 1980s, content analysis has scientifically investigated people’s perceptions of health and illness, and also how messages about illness and treatment assist public health. Data were collected in a content analysis form (Bardin, 2016) containing the following categories: date, day of the week, type of media and region of the vehicle, journalistic genre, area of Anvisa’s activity to which the text refers, frequency of subjects in each of the areas of activity, sources of the texts and their reference to Anvisa, as well as a measurement of the connotation (positive, negative or neutral) of the title in relation to the image of the Agency. Likewise, data related to the relationship of Anvisa with SUS, presence of characters, accountability of the agency, and citation of local surveillance were also collected. After data collection and file cleaning, the frequency of variables was used to present the panorama of sanitary surveillance coverage in the Brazilian press.

The research instrument was tested using five different texts similar to those in the sample, with analysis performed by the research team independently. Throughout the data collection process, regular meetings were held to answer questions related to the categories. It should be noted that the research was not submitted to any ethics committee, because it is secondary data from a public domain source or restricted to journal subscribers.

Results and discussion

Over the twelve months of 2018, 1,629 texts were collected. Among digital vehicles that published the most stories mentioning Anvisa stand out: G1 - Globo (94), R7 (62), Terra Notícias (61), UOL Notícias (57), O Globo (48), Exame. (39), Folha (38), IstoÉ (34), IstoÉ Dinheiro (33) and Gazeta do Povo (32). On the other hand, printed newspapers that published most texts making reference to the agency were the following: Folha de S. Paulo (28) and A Tribuna (28) ranking 13 and 14, respectively. As for the type of media, 1,219 texts are from digital media (75%), and 410 from printed newspapers (25%). In all, 148 different vehicles published articles related to Anvisa (91 digital, and 57 printed ones). Regarding the scope, 738 texts were published in different national media (45.3%), and 891 in regional media (54.7%). Vehicles from the Northeast (271) and Southeast (260) regions published the most in the analyzed period, while the Center-West region had the fewest publications (79). The prevalence of digital vehicles and publications in this medium is characteristic of the digital era, with overabundance of information and channels, and low production costs. Such technological revolution has affected journalism and communication in a deep, radical, and comprehensive way, considered the greatest revolution in the means of production, recording, storage, processing, and transmission of information in all history (Kucinski, 2018).

Regarding journalistic genres, 607 news, 536 journalistic reports, 336 notes, 68 opinionated texts, and 37 interviews were identified. It is worth noting that, as a federal agency for health regulation and monitoring, Anvisa was mentioned in 45 advertising reports in the format of news; however, they have no commitment to the values of newsworthiness and credibility. Advertisers adopted the strategy of informing that some new product or service has Anvisa’s seal of approval. This deserves attention from the communication area of Anvisa, to verify to what extent this information is correct and does not damage the image of the public agency.

Anvisa was predominant news for actions related to regulation, registration and authorization (58.2%), followed by texts related to inspection and monitoring (30.8%). There is little room in the press for texts related to political and institutional articulation (4.4%), the Brazilian Health Regulatory Agency (Anvisa)(3.7%), education and research (2.4%), or other themes (0.5%). What is included in the media agenda corresponds to a set of news-values that help communication professionals to assess the potential of something winning the pages of the newspaper (Hohlfeldt, 2015). Considering that Anvisa is notoriously better known for regulatory and enforcement issues, this result is not surprising. It is important to understand, then, from which perspectives these themes were reported.

The media, through news-values, decides what the public should think or discuss. Among the frequent subjects in the articles of the sample analyzed, medicines and pharmacopoeia stand out (27%) as the most frequent subjects, being referenced in texts that explore new product registrations or inspections and seizures. Anvisa is mentioned as the one that approves or prohibits the most diverse regular drugs, such as antibiotics, insulin, melatonin, generic and manipulated drugs, or irregular ones, such as “good night, Cinderella”, judicialization of cannabidiol and combined therapies, as well as with fancy names, such as “intelligence pill” and “cancer pill”. The high frequency of drug-related theme may be explained by its public interest value-notice.

In sequence, texts related to health products (orthoses, prostheses, hospital materials, gloves, implants etc.) stand out, with a percentage of 12%. In this group, articles about contact lenses, surgical materials and sensors were published, being more than half related to death due to an aesthetic procedure performed by a doctor blogger known as Dr. Bumbum, using a substance authorized by Anvisa, the polymethylmethacrylate (PMMA), as mentioned at the beginning of the analysis. Furthermore, it should be noted that, due to the repercussion of Dr. Bumbum’s case, July was the month that presented the most publications about the agency in the media, as shown in Graph 1.

Graph 1
Distribution of the sample throughout 2018

Of the 310 texts collected that month, 85 texts echoed the case. After the first news about the patient’s death, publications focused on the aesthetic procedures and substances used, the details of the investigation, and the doctor’s arrest. The case gave rise to new publications with warnings about the use of substances, aesthetic procedures, and qualified professionals. Through agenda setting, the media build reality selecting topics to be reported (Lopes, 2018). According to Monteiro (2018), news determines which events are entitled to public existence and, therefore, appear on the agenda of public opinion concerns as important topics. They are also assigned with the task of defining the meanings of these events, by offering interpretations on how to understand them. Still, considering the case above, it is interesting to note a repositioning of Anvisa’s linkage to the fact. The first texts about the death of the patient, published in the first days of news coverage, mention the government-owned agency as the regulatory agency that authorizes the use of the material, bringing some legitimacy to the procedure adopted by the health professional responsible for the care. However, the subsequent texts started to present the information that the agency, despite authorizing the use of the product, did not recommend it for the purpose for which it was used, causing the death of the patient. Possibly, there may have been some intervention by Anvisa’s communication department on the media for corrections and adjustments in the texts.

The third most frequent subject in the sample refers to the food area (10%). The texts predominantly discuss the regulation and inspection of a wide range of products, with information on meat, wheat, soy, olive oil, water, on products for specific diets, such as pink Himalayan salt, whole foods, vegan, gluten-free, lactose-free, carbohydrates including even the novelties in the sector, such as kombucha, poppy seed and banana peel hamburger. Thus, the thematization promoted by the press in relation to Anvisa may be relating health as a consumer good, and the medicalization of life. As Lefévre (1999) points out, if the message in the press does not bring an argument to the collectivity, but an individual indication about drugs and treatments for this or that public, the press presents a collective health that, however, is of individual prescription.

The other themes had a frequency of less than a tenth of the total texts, as shown in Graph 2.

Graph 2
Frequency of subjects published in the texts about Anvisa in the sample, Jan./Dec. 2018

Data regarding the presence of Anvisa in the heads of the texts present at least two relevant aspects. The first, and most evident, is that even though data collection was performed from the retrieval of the word Anvisa, that is, the sample of 1,629 texts, said term appears in only 351 titles, representing 21.5% of the total analyzed. Thus, most of the texts analyzed do not highlight the name of the Agency in their titles. The fact in itself is not surprising, since the journalistic criteria by which titles of news are constructed make these calls attract the reader’s attention to what is most emphatic in the text. Titles work, as Serra and Santos (2003) point out, “as an advertisement, they call attention, present the issues that motivate the reading and qualify the information”. The fact that it is not present in most of the titles of texts on sanitary surveillance shows a kind of absence of the agency in media coverage on the subject.

The second aspect to draw attention is that Anvisa is not always the focus of the news, even when it is mentioned on the title of the text. This was observed in 54 of the 351 publications that have the word Anvisa in the title. It is noticed that, in fact, the name of the agency may have been used to support the information provided without, however, giving more room to Anvisa in relation to other actors of the contents reviewed.

Regarding the qualifier of titles, it is noted that almost all the texts (99.5%) were classified as neutral, i.e., without the presence of expressions or words that bring adjectives or criticism related to Anvisa. Titles may determine how a reader will construct meaning about the text before a complete reading and, in this case, it was observed the construction of titles with objectivity, without perceiving the intentionality of each text just by the title (Barros-Filho; Bertolozzi, 1995). Finally, it is noted that the titles containing the word Anvisa are mostly from digital communication vehicles, totaling 306, while those from printed media totaled 45. Similarly, the same logic was observed among the 1,278 titles that did not mention Anvisa (913 digital, and 365 printed).

In this sense, the following question arises: was Anvisa the focus of the texts published? No, for 72.2% of the sample. Only 452 texts present the Agency as the core of publications. Moreover, although cited, the agency is the source of information in less than half of the texts analyzed: of the 1,629 texts, the agency had voice in only 698 (42.9%), in contrast to the 931 texts in which it does not appear in this condition, despite discussing sanitary surveillance. Correia (2011) understands source as “(...) all social agents willing to collaborate with journalists in providing informative material considered of interest by journalists”. It is known that the use of sources is a relevant journalistic resource, used both to explain a given subject and to add credibility to the information provided, whether technical or political. Mont’Alverne and Marques (2015) help to better understand the role of the source when they attest that:

In many cases, coverage is built from the statements of official agents and experts, prioritizing their perspectives, since they would be in a position to know the information, holding the position of reliable sources to which professionals should resort to validate their stories. (Mont’Alverne; Marques, 2015, free translation)

The source is used by communication vehicles as an instance capable of ensuring the exemption of the news conveyed, thus distancing the journalist’s opinion from the fact to be reported. Often, more than the role of providing clarification on various topics, the source can define the credibility that the media has as audience. Or, in the words of Strömbäck and Nord (2006), information sources, being people of great power, may have the ability to “grant legitimacy to stories”.

Anvisa is recognized by the media as the national regulatory and health surveillance agency. However, the same vehicles resort to it in less than half of the publications (42.9%) to report contents that deal with standards, regulations and the themes and issues encompassing its performance. In a context in which a dispute for media visibility is observed, and what exists is what is in the media (Monteiro, 2018, p. 117), there is a need to thinking of alternatives that make room for the agency’s positions beyond citations, considering that:

It is in the room for mediation, mobilized by the many social fields to politically act in favor of their interests - and which is now expanded to house cyberspace - in which the discourse of public opinion circulates. Whenever one field seeks to interfere in the other, resorting to public opinion gives it the representative legitimacy of its claim. (Monteiro, 2018, p. 118, free translation)

Even though Anvisa is the agency responsible for regulation, registration and authorizations, part of the Brazilian press has chosen not to echo in line with the responsible body, the mentioned contents, attributing to Anvisa the exclusive responsibility. Buarque states that:

Hallucinated by the intermediation of the media, the population sees a world different from reality, or only small parts of it: the chosen parts of a world produced by the hands of journalists, over the computer keyboard or the focus of the camera. While offering all the advantages of transparency, without which there is no democracy, the press makes mistakes that manipulate reality, serving to blur rather than clarify reality. (Buarque, 2018, p. 14, free translation)

Authors such as Corrado (1994), cited by Monteiro (2018, p. 123), argue that legitimate and credible communication of the institution with its stakeholders becomes a business necessity, given competition in a marketplace fraught with public issues (mergers, privatization, public budgeting, minority demands, ecological concerns, public safety, etc.). Thus, institutions have to engage with the media to reach the audiences whose opinions guide national policies and political actions; the media becomes the arena or social field in which interests become visible in the battle for winning the support of public opinion (Monteiro, 2018, p. 123).

The texts analyzed resonate voices of diverse subjects beyond those linked to Anvisa. Bubnova (2011) presents the idea that voice “is identified with opinion, idea, point of view, ideological stance”. Hence the relevance of understanding the journalistic strategy of assigning power of speech to certain subjects. The research allowed us to observe that the great majority of subjects are those related to some government body, with 697 records. Next, the most recurrent voices are those of health professionals, with 424 occurrences, and those of the private sector, with 412. The population and social movements appear with 346 entries, and science with 341. Sometimes several voices appear in the same text. In that case, it is worth noting that the texts analyzed sought to reference their contents with agents linked to public power.

Moreover, it was observed that 20.5% of the sample (334 texts) disclose the presence of characters. According to Sodré and Ferrari (1986), the humanization of the report is one of the characteristics of the reportage, which offers more detail and context than news story, and chooses a character to illustrate the theme it intends to develop, as in a short story in which the dramatization of a situation collects the action around a character. The character may appear in the narrative as autonomous, with a life of their own, or accidentally, to illustrate it. Ferrari and Moura (2009) have already observed in a content analysis of four national newspapers, that reports on health surveillance do not give room for social actors, portraying individuals as consumers rather than as citizens contemplating aspects of quality of life and socio-environmental. The authors also mentioned that the press does not value the individual as a stakeholder in health issues, and emphasizes more the economic actors to the detriment of health surveillance itself and people.

Less than 3% of the total sample (43 texts) cite or make some reference to the SUS. This information, important for the Brazilian public health communication, is invisible in almost the entire sample. Moraes, Oliveira-Costa and Mendonça (2017) noticed that it is not common to use the term ‘Sistema Único de Saúde’ or the acronym ‘SUS’ in journalistic texts that deal with public health services. According to the authors, the texts that mention the acronym tend to devalue the image of the system, bringing in their titles and headlines words, expressions or phrases of pejorative meaning. There is, therefore, the problem of incoherent disclosure of a negative image of SUS, a fact already proven by research conducted in Folha de São Paulo (Silva; Rasera, 2013) and in O Globo (Machado, 2014) newspapers. It is believed that part of the negative image Brazilians have of the SUS may be strongly influenced by the information they have access to through the media. They build their agenda essentially based on the negative situations and problems of the health system, with little or no room for positive and successful experiences. In the period reviewed, Anvisa, as the regulatory space of the system, is portrayed by the press almost absolutely without any mention or connection to the SUS. From the analysis of fifteen years of Brazilian news coverage on topics of interest to collective health, it was observed that the newspapers present “a supposed inefficiency of the State, incompetence of the authorities or professionals in the area, leading to the construction of an unreflective symbolic order about the field of health policy represented by the SUS” (Langbecker et al., 2019). Given that the SUS is hardly mentioned in texts about Anvisa, it is as if the agency did not integrate the system, that is, the state would not be participating in the agency or contributing to its performance, and the communication-health interface would conform in “networks of cooperation, conflict, visibilities, invisibilities and where subjects are socially and symbolically situated” (Pitta, 1995, p. 258).

In the same sample, in almost half of the texts (805), the non-responsibility of Anvisa in health surveillance issues is worrisome. However, in the articles where it appears as responsible, there are decontextualized complications of the content of this accountability, as in the case of Dr. Bumbum, in which the texts express that the substance used by the doctor is authorized by the agency, but do not explain that it is not recommended for that purpose used by the health professional in question. In addition, it is worth noting that only 4.7% of the sample cites the local health surveillance agencies, which is probably due to the use of the term “Anvisa” as a keyword in the data collection, perhaps one of the limitations of the research. It is also important to consider that the collection was performed from a specific database provided to the researchers by the Brazilian Ministry of Health, and based on keywords.

Final considerations

The research presented an overview about Anvisa in the Brazilian press throughout the year 2018. From the randomness in data collection, trends were observed that reveal how the media have presented the agency to Brazilians, with greater focus on regulation and medicines, detaching it from the SUS, and not identifying it as the main source when it comes to health surveillance. Regarding the issues and themes most presented by the press, it is up to the manager to check if the picture obtained with the research corresponds to the management priorities for incidence in the press. If not, it is suggested to produce positive agendas around the themes that had less visibility in the period reviewed.

It is worth pointing out a question: why Anvisa is not considered as a source for journalists, although it is mentioned in the texts? Any more assertive answer to this question, at this moment, would constitute speculation, since the investigation in question did not intend to explain such phenomenon. However, as for titles, it would not be strange to deduce that the name Anvisa carries technical respectability to the point of being cited as a legitimizing element of the information provided, especially due to its normative or regulatory character of various sanitary practices and procedures. The same logic may be transposed to the analysis on the focus of the texts investigated. In this sense, it is recommended a closer approach of Anvisa with the press and, in particular, with news agencies like those mentioned in the study, to ensure its voice in texts whose theme refers to its areas of activity, since, from the repetitions in the titles collected, it is possible to assume the use of texts from news agencies and other content replicators, and their potential for dissemination and capillarization of information. However, since this is not the purpose of this research, this analysis was not deepened; it only points out relevant issues for future studies on this possible relationship.

It is also worth mentioning that Anvisa should make an effort to present itself as an agency of the SUS. In the sample analyzed, it is noticeable that this relationship is not direct or explicit in most texts. Since the press is one of the responsible for the communication on the Unified Health System, it is essential that agencies such as Anvisa, which have regular media room, and produce topics directly related to the daily lives of citizens, be recognized by the press as an agency that is also part of the public health system.

Data were collected in a specific sample of texts, and cannot be generalized to other public administration agencies or other periods of analysis, but suggest trends of national coverage that can guide the decision-making of Anvisa’s communication managers.

The study is important for the area of health communication and collective health, and may be the basis for comparative investigations with other periods and samples of analysis. This panorama may be the starting point for advancing in specific investigations on the vehicles that most published texts about the agency in the period, as well as on other media such as the social networks of the agency, and contribute to the development of analyses that include the speeches by Anvisa’s communication professionals.

Acknowledgment

To undergraduate students Italo Maximiliano Freitas, Carolina Magalhães de Souza Silva, and Public Policy Management resident Rianna Moraes for their support in data collection.

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• 1
  Termo de cooperação entre a Fiocruz Brasília e a Anvisa.

Publication Dates

• Publication in this collection
  17 Jan 2022
• Date of issue
  2022

History

• Received
  18 June 2020
• Reviewed
  28 July 2021
• Reviewed
  13 Sept 2021
• Accepted
  21 Sept 2021