Health Communication

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Framing as a Concept for Health Communication:

A Systematic Review

Lars Guenther, Maria Gaertner & Jessica Zeitz

To cite this article: Lars Guenther, Maria Gaertner & Jessica Zeitz (2020): Framing as a
Concept for Health Communication: A Systematic Review, Health Communication, DOI:
10.1080/10410236.2020.1723048

To link to this article: https://doi.org/10.1080/10410236.2020.1723048

Published online: 29 Jan 2020.

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HEALTH COMMUNICATION
https://doi.org/10.1080/10410236.2020.1723048

Framing as a Concept for Health Communication: A Systematic Review

a,b
Lars Guenther , Maria Gaertnerc, and Jessica Zeitzc
a
Institute for Journalism and Communication Studies, University of Hamburg; bCentre for Research on Evaluation, Science and Technology (CREST),
Stellenbosch University; cInstitute of Communication Research, Friedrich Schiller University Jena

ABSTRACT
Over the past decades, research in the fields of both framing and health communication has grown
exponentially. However, to date, no systematic review has been conducted about how framing – as
a concept – has been used in health communication. The present study provides a systematic review of
the current research, applying a quantitative content analysis to the published literature on framing in health
communication. Articles published in peer-reviewed scientific journals (N = 316) were analyzed in order to
describe common characteristics and topics, as well as the degree to which the sociological and psycholo-
gical tradition of framing, different types of frames, and visual framing have been used. Furthermore, framing
effect studies were examined to see whether they contained covariates, competitive frames, and/or gain and
loss framing. The results reveal that the most common topics in the literature on framing in health
communication were related to cancer, nutrition, and vaccination. Most articles use quantitative research
designs, most commonly surveys with experimental designs; the majority of articles are based on the
psychological tradition of framing. Thematic and generic frames occur almost equally, while the lack of
research on visual frames is clearly noticeable. More than half of the effect studies test the effects of gain and
loss framing, whereas competitive frames are under-studied. The results of this systematic review help to
identify both current trends and research gaps on framing in health communication, and how it differs from
framing in communication science overall – valuable information that can inform future research.

Introduction different from its application in communication science overall

A vast body of literature has developed on framing, both for
communication science in general (e.g., D’Angelo et al., 2019;
Entman, 1993; Reese, 2010; Scheufele & Tewksbury, 2007) and
for health communication in particular (e.g., Guenther,
Froehlich, Milde, Ruhrmann, & Heidecke, 2015; Rothman &
Salovey, 1997). Framing is one of the most popular theoretical
approaches used in communication science (e.g., Cacciatore,
Scheufele, & Iyengar, 2016; D’Angelo & Kuypers, 2010), but
despite its popularity, it has received little attention on an over-
arching, analytical level, and even less in its application in health
communication (see also Von Sikorski & Matthes, 2019).
Despite the often-stated theoretical and conceptual weakness
of the concept (e.g., Borah, 2011; Scheufele & Iyengar, 2011;
Scheufele & Tewksbury, 2007) and the different methodological
approaches used (e.g., Kohring & Matthes, 2002; Matthes &
Kohring, 2008; Scheufele & Scheufele, 2010), research on fram-
ing has grown steadily over the years (e.g., D’Angelo et al., 2019).
However, the number of systematic reviews of research on
framing is limited in communication science (e.g., Borah, 2011;
Matthes, 2009). This is also true for the specific field of health
communication, which is surprising, as in this research field,
there are even meta-analyses available that deal with specific
aspects of framing – such as the effects of gain and loss framing
(e.g., O’Keefe & Jensen, 2006, 2007; O’Keefe & Nan, 2012). The
application of framing in health communication could be
(e.g., Von Sikorski & Matthes, 2019), but no systematic review
has ever examined how the concept has been used in health
communication. The goal of the present study is to fill this
conceptual gap. Framing is an important concept in health
communication, for instance, dealing with representations of
health information in the media and with effects of different
presentations on audiences (e.g., Guenther et al., 2015;
Guenther, Milde, Ruhrmann, & Heidecke, 2013).
The present study applies a systematic review of peer-
reviewed published literature on framing in health communica-
tion, using content analysis. This approach is significant, since
conceptual analyses can indicate where current research stands
and where its gaps are located, which might guide future
research directions (Guenther & Joubert, 2017). One of the
main aims of the present study is to compare its findings to the
findings from systematic reviews of framing in general commu-
nication science (Borah, 2011; Matthes, 2009), which might in
turn help identify the extent to which researchers in health
communication have used the concept differently from research-
ers in other fields of communication science. Some researchers
see framing as a “fractured paradigm” (Entman, 1993, p. 51);
thus, this systematic review is especially valuable for identifying
the common characteristics and topics of research in this area
(see also Kim, Park, Yoo, & Shen, 2010), as well as the degree to
which the sociological and psychological tradition of framing,

CONTACT Lars Guenther lars.guenther@uni-hamburg.de Institute for Journalism and Communication Studies, University of Hamburg, Grindelberg 7,
Hamburg 20144, Germany.
© 2020 Taylor & Francis Group, LLC
2 L. GUENTHER ET AL.
and the different types of frames (e.g., generic and thematic
frames) have been used in health communication.
Frames, framing, and framing in health
communication
Framing in communication science
For communication science in general, framing researchers
hail from a broad variety of scientific fields and disciplines,
including sociology, economics, political science, psychology,
cognitive linguistics, and communication science (e.g., Borah,
2011; D’Angelo, 2002; Reese, 2010; Scheufele & Tewksbury,
2007). This interdisciplinary diversity of fields might be one
reason for why frames are not clearly defined, conceptualized,
and operationalized (Scheufele, 2004; Scheufele & Scheufele,
2010). Frames “have at least four locations in the communica-
tion process: the communicator, the text, the receiver and the
culture” (Entman, 1993, p. 52).
While many different definitions abound as to what a frame is
(e.g., Gamson & Modigliani, 1989; Reese, 2010), Entman (1993)
provided the one that is most widely accepted: framing stresses
certain aspects of reality and pushes others into the background
through the processes of selection and salience (see also Entman,
Matthes, & Pellicano, 2009). “To frame is to select some aspects of
perceived reality and make them more salient in a communicating
text, in such a way as to promote a particular problem definition,
causal interpretation, moral evaluation, and/or treatment recom-
mendation for the item described” (Entman, 1993, p. 52). In this
definition, ‘problem definition’ refers to issues and actors, ‘causal
interpretation’ defines who (persons) or what (situations) is
responsible for a problem, ‘moral evaluation’ indicates ways to
evaluate an issue, and ‘treatment recommendation’ proposes how
best to solve a problem (Matthes, 2014). Thus, problem definition,
causal interpretation, moral evaluation, and treatment recom-
mendation have been described as the frame elements (Kohring
& Matthes, 2002; Matthes & Kohring, 2008). They systematically
organize and structure information, creating packages of inter-
pretation (see also Gamson & Modigliani, 1989); hence, frames
are more than just topics (Reese, 2010).
Although some researchers have called for a paradigm to unify
research on framing, this would not be desirable for D’Angelo
(2002, p. 871), who sees one major advantage of the knowledge
accumulation of different perspectives: a so-called “multiparadig-
matic research program.” For him, the “‘fractured’ nature of the
concept is its strength” (D’Angelo et al., 2019, p. 14). A diversity of
approaches provides an interdisciplinary quality to research on
framing (Reese, 2010). Still, a lack of clear conceptualization and
operationalization of framing has led to a high number of framing
studies that are distinct from each other, with contradicting con-
ceptual definitions of frames and framing (Scheufele & Scheufele,
2010). To this day, researchers actively discuss the definition of
what a frame actually is, and how framing is similar or different
compared to related approaches, such as agenda setting and
priming (e.g., Borah, 2011; Scheufele & Iyengar, 2011; Scheufele
& Tewksbury, 2007).
Despite all the debates around conceptualizing and operatio-
nalizing frames, researchers can still differentiate between
a sociological (e.g., Entman, 1993; Gamson & Modigliani,
1989; Goffman, 1974) and a psychological (e.g., Tversky &
Kahneman, 1981; see also Scheufele & Iyengar, 2011) conceptual
tradition of framing. The dual nature can be summarized as
frames in external texts, images, or news (sociological) and
frames in individuals’ minds (psychological) (Borah, 2011).
The psychological tradition can further be divided into equiva-
lence framing (based on prospect theory and dealing with dif-
ferent linguistic presentations of the same information; Tversky
& Kahneman, 1981) and emphasis framing (presenting a topic
differently through selection and salience of relevant facts, such
as episodic vs. thematic framing; Scheufele & Iyengar, 2011).1
Recently, some researchers have defined the application of
framing in communication studies as the communication science
tradition of framing (e.g., Matthes, 2014). If communicators are
successful in the sense that journalists or members of the public
adopt their frames, communication science researchers refer to
frame building and frame setting (Matthes, 2014; Tewksbury &
Riles, 2018). The process in which communicators or journalists
develop frames is referred to as frame production.
Current research in communication science indicates that
how communicators (such as journalists) produce frames
seems to be less important to researchers (see also D’Angelo
et al., 2019). For instance, Borah (2011) found that only 2% of
research articles deal with frame production. Furthermore,
researchers seem to focus on textual frames but not visual
ones (D’Angelo et al., 2019; Matthes, 2014). Borah (2011) also
found that communication scientists more often focus on the
sociological tradition of framing and less often on the psy-
chological tradition. This is in line with the methods being
used by researchers: most scholars who apply framing use
content analyses, distantly followed by experimental surveys
(Borah, 2011). Identifying whether these findings are also true
for research in health communication is one of the aims of the
present study.
Framing researchers also differentiate between two types of
frames. (1) Generic frames are found across themes (Iyengar,
1991), such as the differentiation between episodic and the-
matic framing (see also Scheufele & Iyengar, 2011) or frames
such as ‘attribution of responsibility’, ‘conflict’, ‘human inter-
est’, ‘economic consequences’, and ‘morality’ (e.g., Semetko &
Valkenburg, 2000). This type is also referred to as consistent
frames (Borah, 2011). (2) Thematic frames can be identified as
applicable to a specific topic (e.g., Entman, 1993; Kohring &
Matthes, 2002). Borah (2011) refers to these as unique frames.
Trends in the current research in communication science
indicate that researchers are more frequently concerned with
thematic than generic frames. Matthes (2009) found that of
the studies he analyzed, only 22% analyzed generic frames
(the conflict frame was the most-used generic frame).
Similarly, Borah (2011) found that only a third of all articles
she sampled used generic frames. These findings might be
different for the field of health communication research, due
to the dominance of gain and loss framing. Furthermore, in
communication science overall, framing effects studies have
tested single frames in experimental conditions more often
than multiple or competing frames (Borah, 2011), i.e., settings
in which participants receive a set of mixed frames.
Identifying whether this is also true for the field of health
communication is one of the aims of the present study.

Framing in health communication
Some of the tendencies described for framing as a theoretical
concept in communication science might also be true for the
specific field of health communication. Framing can be a useful
concept for health communication – describing, for instance,
how health information is presented in the media and how
different presentations of health impact audiences (Guenther
et al., 2015, 2013). Consequently, framing can be used to design
persuasive messages to influence an audience to perform desired
health-related behaviors (such as those involved in preventing
and detecting diseases) (Von Sikorski & Matthes, 2019).
Under the sociological tradition of framing in health com-
munication, a variety of health issues have been studied.
These often deal with questions such as whether individual
or societal attributions of responsibility are represented (e.g.,
Kim & Willis, 2007, for obesity); to what degree prevention,
detection, and treatment of diseases are represented (e.g.,
Atkin, Smith, McFeters, & Ferguson, 2008, for breast cancer);
and if representations reflect incidence or mortality rates (see
also Jensen, Moriarty, Hurley, & Stryker, 2010). It seems that
much research is devoted to specific health topics, such as
how cancer is represented in the media (e.g., Jensen et al.,
2010), but the content perspective of the literature on framing
has not yet been systematically analyzed.
In terms of the psychological tradition of framing, much
research in health communication is devoted to the effects of
gain and loss frames (e.g., O’Keefe & Jensen, 2007, 2008; O’Keefe
& Wu, 2012), often based on the assumptions of prospect theory
(see Rothman & Salovey, 1997). Gain frames “emphasize desir-
able consequences associated with compliance with the advo-
cated viewpoint, [whereas loss frames highlight] undesirable
consequences associated with noncompliance (O’Keefe &
Jensen, 2008, p. 52). A re-occurring question is whether gain-
framed or loss-framed messages are more effective for preven-
tion behaviors compared to detection behaviors (see also
Gallagher & Updegraff, 2012). Thus, much research has been
devoted to the question of whether one type of framing is more
effective in promoting healthy behavior than another; however,
studies have produced mixed results.
While gain and loss frames can be considered generic frames,
research in health communication has also focused on the effects
of thematic frames (Guenther et al., 2015, 2013), but it is assumed
that this has only happened to a limited degree (Von Sikorski &
Matthes, 2019). Consequently, one might assume that health
communication is dominated by framing effects studies that
deal with gain and loss framing and thus with generic frames.
Nevertheless, examples of effects of thematic frames include
research that focuses on the question of whether these frames
trigger specific health-related perceptions, knowledge, or beha-
vioral intentions (e.g., Riles, Sangalang, Hurley, & Tewksbury,
2015). Some of the dependent variables used in these studies refer
to the frame elements outlined before (Entman, 1993).
While framing seems to be used as a theoretical concept by
scholars in health communication, this kind of research has
not been systematically synthesized. To date, no systematic
reviews have been performed; hence, no overview has been
given of how the concept is applied in this specific field of
research. Based on these observations, the present study is
HEALTH COMMUNICATION 3
designed as a systematic review, exploring the current state of
the research literature and its gaps.
The present study
Since there are two broad foundations of framing – socio-
logical and psychological (e.g., Borah, 2011; Matthes,
2014) – and since scholars in health communication have
produced findings relating to both traditions, the first
research question (RQ) is interested in the extent to
which these traditions have been applied in health
communication.
RQ1: How much of the published literature on framing in
health communication focuses on the sociological or the psy-
chological tradition of framing?
Since there are two types of frames – thematic and generic
frames (e.g., Borah, 2011) – the second RQ is interested in the
extent to which these types of framing have been used in
health communication.
RQ2: How much of the published literature on framing in
health communication focuses on thematic or generic frames?
Framing effect studies in health communication seem to be
particularly interested in the effects of gain and loss frames;
a remarkable number of meta-analyses are available (O’Keefe &
Jensen, 2006, 2007; O’Keefe & Nan, 2012). Therefore, the third RQ
asks:
RQ3: What are the common characteristics of the published
literature on framing effects in health communication, and how
many of these studies focus on gain and loss framing?
Method
Sample
While many publications deal with framing in health com-
munication, the present study was focused on published lit-
erature of high quality (see also Borah, 2011). We equated
quality with peer review and thus decided that our unit of
analysis would be published articles in peer-reviewed scienti-
fic journals. We were also only interested in literature using
the concept of framing in health communication contexts.
Following the PRISMA model (Moher, Liberati, Tetzlaff, &
Altman, 2009), we used the search term “fram* ‘health com-
munication’” in Web of Science (N = 461) and on Google
Scholar (N = 1300) in August and September 2018. All 1,761
articles that were found were screened for their use of the
concept of framing in a health communication context, indi-
cated in their titles, abstracts, or keywords. In addition to our
definition of published peer-reviewed literature, we also
excluded non-English articles and ‘gray’ literature that was
listed among the findings (books, book chapters, dissertations,
theses, and conference proceedings). This resulted in a sample
of N = 307 articles.
4 L. GUENTHER ET AL.
We noted that six meta-analyses were among these articles;
consequently, we checked the reference lists of five of the available
meta-analyses2 to identify other relevant articles (N = 119) that
were not captured by the search term and the databases used. This
extended the sample size to N = 426 articles. Finally, we down-
loaded the available full texts of the articles and examined their
relevance in detail again.3 This resulted in a sample size of N = 316
articles that represent the base for our investigation. An overview
of all articles included in the sample can be obtained from email-
ing the corresponding author.
Quantitative content analysis
A systematic, quantitative content analysis helped to answer
the RQs. For the content analysis, we differentiated between
formal and content-related categories. The codebook used in
this study can be obtained from the corresponding author.
Formal categories
Formal categories were directly extracted from the title pages of
the articles. We coded the publication year, the journal the article
was published in (openly coded), and the number of authors
(also openly coded). For each author we coded their name,
affiliation, and gender. For gender identification, the authors’
names and website presence guided the coding. The affiliations
also determined whether or not authors were cooperating inter-
nationally. We also coded the country in which the study was
conducted, which was not always in line with the authors’
affiliations. The formal categories in the present study were
drawn from research studies with similar goals (Borah, 2011;
Guenther & Joubert, 2017; see also Kim et al., 2010).
Content-related categories
The content-related categories were determined by coders
reading the abstract and keywords and browsing through
the article. First, we openly coded the health topics under
investigation; at a later stage, they were categorized similar
to the classification provided by Kim et al. (2010). Often, titles
and keywords indicated the topics under study.
In line with RQ1, we first coded the methods used in the
study (e.g., content analysis, survey), whether the study
employed a qualitative or quantitative method, and the tradi-
tion (sociological or psychological) of framing (Borah, 2011).
We extended this to include a third category called ‘frame
production’, added for studies that dealt with processes
through which frames are created.
In line with RQ2, we coded the types of frames, with
thematic frames defined as unique frames that are topic-
specific and with generic frames defined as consistent frames
used across studies, such as gain and loss frames (Borah, 2011;
Matthes, 2009). Furthermore, we also coded whether the
studies used visual frames or not. For all studies that were
identified as framing effects studies (see also Borah, 2011), we
coded whether participants received only one frame or a mix
of competitive frames within the experimental conditions of
the study (Borah, 2011). Moreover, we also coded whether
covariates were present. Lastly, in line with RQ3, we coded
whether framing effects studies used gain or loss frames.
Intercoder reliability was assessed using a random sample
of 15% (n = 42) of the total articles after several coder training
sessions. Using Cohen’s Kappa, the coders reached satisfac-
tory results, with all scores higher than κ = .82; thus, the two
coders independently coded the sample articles.
Results
In terms of sample characteristics, the year in which the most
articles from the study sample were published was 2016
(n = 43; 14%). Figure 1 indicates an increase in publication
output, with volatilities. Many of the articles were published
in Health Communication (n = 61; 19%), the Journal of Health
Communication (n = 24; 8%), or Health Psychology (n = 13;
4%). The average number of authors was three (M = 3.05;
SD = 2.014), with most articles having two (n = 108; 34%),
three (n = 62; 20%), one (n = 52; 17%), or four author(s)
(n = 42; 13%).
There were 965 unique authors listed. Among them, one
author was counted 19 times – the highest number of appear-
ances. However, this was an anomaly; 856 authors (89%) were
counted only once. In terms of their affiliations, most authors’
institutions were located in the US (n = 637; 66%). The UK
ranked second (n = 57; 6%), followed by the Netherlands
(n = 51; 5%), Australia (n = 39; 4%), Canada (n = 32; 3%),
and Germany (n = 24; 3%). Figure 2 displays a world map of
authors’ institutions, highlighting that only 30 unique coun-
tries were counted. International cooperation was only
observed for 28 articles (9%), which increased only slightly
over the years sampled.
In line with these findings, a majority of the studies were
set up in the US (n = 167; 53%), followed by the UK (n = 17;
5%), the Netherlands (n = 12; 4%), and Australia (n = 11; 4%).
Of the studies sampled, 20 (6%) did not clearly indicate in
which country their study was conducted, and 22 were set up
in more than one country (7%). Finally, in terms of the
author’s gender, a majority of the authors were identified as
female (n = 573; 59%). While a dominance of female authors
was evident throughout, the number of female authorships
also slightly increased over the years sampled.
The openly coded topics were classified into subcategories
(see also Kim et al., 2010). The most common topics studied
in the sampled articles were cancer (n = 68; 22%); obesity,
foods, diets, and nutrition (n = 44; 14%); vaccination (n = 36;
11%); tobacco, cigarettes, and smoking (n = 27; 9%); sexually
transmitted infections and diseases (n = 23; 7%); sport topics
(steroids, physical activity, exercise, and fitness) (n = 17; 5%);
and HIV/AIDS (n = 17; 5%). For the three most dominant
topics, Figure 1 demonstrates that cancer was important from
the beginning, while vaccination only became important later.
Topics that were not often investigated include mental health
(n = 14; 4%), alcohol and drinking (n = 11; 4%), drugs (n = 7;
2%), health policy (n = 6; 2%), diabetes (n = 2; .6%), and
allergies (n = 1; .3%)
In terms of RQ1, most articles sampled had used experi-
mental survey designs (n = 206; 65%), followed by content
analyses at a distant second (n = 60; 19%). Theoretical papers
(n = 15; 5%) and interviews (n = 9; 3%) had even lower
frequencies. Case studies (n = 3; 1%) and focus group
 HEALTH COMMUNICATION 5

50

45

40

35

30

25

20

15

10

0
1987 1990 1993 1995 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

obesity cancer vaccinations total

Figure 1. Comparison of total publication output and publication output concerning the three most dominant topics under study.

Figure 2. A world map of authors’ institutions and their publication frequencies.

discussions (n = 2; 1%) were a small minority. In line with
these findings, most articles were based on the psychological
tradition of framing (n = 218; 69%). Almost a quarter was
based on the sociological tradition (n = 76; 24%), while three
articles (.9%) used both traditions of framing. Only four
articles (1%) dealt with processes of frame production.
Furthermore, most articles used quantitative methods
(n = 266; 84%); qualitative methods (n = 26; 8%) and
mixed-methods (n = 9; 3%) were the minority. Table 1 shows
that the methodologies used in these articles varied systemati-
cally by framing tradition and by methodological design (i.e.,
qualitative or quantitative): Studies following the psychological
tradition predominantly used experimental surveys and (to
a lesser degree) meta-analyses, which were more often than not
quantitative. Studies following the sociological tradition of
framing predominantly used content analysis, also often
6 L. GUENTHER ET AL.
Table 1. Methodologies used, in comparison to framing traditions, methodological designs, and types of frames.
Meta-analysis Content analysis
Tradition of framing
Sociological tradition / 60 (21.1%)
Psychological tradition 4 (1.4%) / /
Processes of frame production / /
Quantitative vs. qualitative designs
Quantitative 3 (1.1%) 51 (18%)
Qualitative / 6 (2.1%)
Mixed-methods 1 (.4%) 3 (1.1%)
Type of frame
Generic 3 (1.1%) 3 (1.1%)
Thematic / 55 (19.4%)
a
We excluded theoretical articles and those whose methodology included more than one methodology or did not fall under one of the categories provided here
(n = 284).
quantitatively; in some rare cases, they used interviews, focus
group discussions, or case studies – that is, methodologies for
which a qualitative design is more likely.
In terms of RQ2, the articles sampled in this study dealt
almost equally with generic (n = 151; 50%) and thematic
(n = 146; 48%) frames.4 Table 1 also shows that the use of
generic versus thematic frames varied with respect to the
methodologies used in the sampled studies: generic frames
dominate in experimental surveys and meta-analyses, while
thematic frames are more commonly used in content analyses,
interviews, focus group discussions, and case studies.
Furthermore, the analysis revealed that visual frames were
included in a minority of studies (n = 27; 9%): four studies
(1%) were solely about visual frames, and 23 studies used
a mix of textual and visual frames (7%).
In terms of RQ3, for framing effects studies (n = 213),
competitive frames were tested in only nine articles (4%).
Hence, most studies tested single frames in experimental
conditions. A sizable majority of studies tested influences of
covariates (n = 208; 98%). Furthermore, a majority 64%
(n = 137) of all framing effects studies tested effects of gain
and loss framing.
Discussion
The aim of this study was to analyze how framing is applied as
a concept of health communication, providing a systematic
review of the peer-reviewed published literature in this field.
The overarching research question dealt with how framing is
used in scientific publications and which current trends and
research gaps exist in the field of health communication
research.
The 316 articles in the sample were published between 1987
and 2018. The highest number of articles in a single year was
published in 2016. The results indicate that research on framing
in health communication has been steadily and significantly
increasing in terms of the number of peer-reviewed research
outputs. Kim et al. (2010) also observed a general tendency of
increased research output in their analysis of studies published in
the journal Health Communication. While only a few studies on
framing were published before 2006, since 2007 the number of
published articles has increased. According to the results of the
current study, the number of published articles has more than
Methodologiesa
Interview Focus group discussion Case study Experimental survey design
6 (2.1%) 2 (.7%) 3 (1.1%) /
/ / 206 (72.5%)
3 (1.1%) / / /
1 (.4%) / / 205 (72.2%)
8 (2.8%) 2 (.7%) 3 (1.1%) 1 (.4%)
/ / / /
1 (.4%) / / 143 (50.4%)
8 (2.8%) 2 (.7%) 3 (1.1%) 63 (22.2%)
doubled since 2010, compared to 2000. This fact is an indicator
of the increasing popularity of framing as a concept in health
communication.
It might be considered a positive development that the
reviewed articles were published in 147 different journals by
965 different authors. This might indicate of the breadth of
applying framing in health communication. The fact that only
12 researchers have published five or more articles over the
entire period is a possible indication that relatively few
researchers are leading framing research on health commu-
nication. Likewise, the concept of framing has been the sub-
ject of many different journals, even though almost one-third
of the articles reviewed (27%) were published in journals that
specifically specialize in health communication, such as
Health Communication or Journal of Health Communication.
Many articles in this sample (54%) were written by two or
three authors; fewer were written by a single author. This
might be interpreted to indicate that when it comes to
research on framing in health communication, researchers
seem to collaborate, although not as much on an international
level. Considering that the sample contained only English-
language articles, there seems to be a dominance of Western
countries. In this context, the trend toward international
cooperation has developed in recent years, albeit with only
a slightly significant increase. The positive shift toward insti-
tutional cooperation and internationalization are probably
good signs for the future of this discipline (see also Kim
et al., 2010). Still, the world map in Figure 2 shows that for
English-language articles on framing in health communica-
tion – as sampled here – there are less research contributions
from the southern hemisphere, in particular from Africa,
Asia, and the Middle East. This does not automatically mean
that this research does not exist, but it shows that readers of
English-language journals do not encounter many research
items from these regions. In addition, more than half of the
authors in this sample (59%) were female. This has increased
slightly over time, showing a positive trend of gender diversity
that is highly uncommon in many scientific fields.
The most frequently cited topics in the study’s sample were
cancer, obesity and nutrition, and vaccines. This is barely in line
with Kim et al.’s (2010) study on the published literature in
Health Communication, and it might indicate that researchers
who are interested in framing choose specific health-related

topics for their studies. Only occasionally did studies in the
present sample examine other health issues, such as health policy
or dental health. As a result, while a great variety of thematic
references was identified, most of the studies focused on only
three topics. What is in line with Kim et al.’s (2010) results is that
studies related to cancer seem to be a major contributor to
research in health communication, and to research on framing
in health communication. Therefore, future research should
expand to a broader variety of health topics.
In terms of the methods used in the studies sampled, more
than half of the articles used a survey with experimental
design, while only 19% of the studies carried out a content
analysis. Furthermore, most research was based on the psy-
chological tradition of framing and employed quantitative
methodologies. This contradicts the findings of Borah
(2011), where most framing studies followed the sociological
tradition. Hence, this finding of the present study might
indicate a unique fingerprint of the application of framing
to health communication that deserves further elaboration.
The finding mentioned above might be caused by the high
proportion of framing effect studies in the present sample – studies
that predominantly deal with gain and loss frames. This finding
probably also explains why the articles sampled almost equally deal
with generic and thematic frames. This finding also contradicts
those of Matthes (2009) and Borah (2011), again indicating
a unique characteristic of the application of framing to health
communication that future research should explore further.
What matches previous work on the overall application of
framing in communication science (e.g., Borah, 2011) is the fact
that very few studies in research on framing in health commu-
nication seem to focus on frame production. However, investi-
gating how frames are developed is needed for a more complete
understanding of the framing concept. Therefore, future inves-
tigations could focus more on this topic, for instance, analyzing
how frames are developed in different communicator contexts,
such as how health journalists, general journalists, and campaign
strategists develop frames and what goals they try to achieve.
Furthermore, the findings of the present study indicate a strong
focus on text-based frames, while only a minority of studies
concentrate on visual framing. D’Angelo et al. (2019) stressed
that the analysis of visual framing remains a challenge for com-
munication science. They also confirmed that studies on visual
framing tend to be rare and that it is more common to observe
a mix of text-based and visual frames. Indeed, 92% of all studies
in the present sample focused solely on text-based framing. As
a result, further research might be required in visual framing.
In terms of the framing effect studies, only a small minority of
the present sample tested competitive frame conditions. This
result confirmed Borah’s (2011) finding. So far, it seems that little
research has attended to mixed frames in health communication
effect studies. Future research could therefore focus more on
understanding the effects of mixed frames in experimental set-
tings. Although research on competitive frames has increased over
the last decade, many open questions remain. The fact that most
framing effect studies in the present sample deal with gain and loss
frames might indicate a gap in the research dealing with the effects
of thematic frames. The findings of this study indicate a slight
correlation between the two foundations of framing: while
researchers with a sociological foundation seem to identify
HEALTH COMMUNICATION 7
thematic frames, researchers with a psychological foundation
seem to test generic frames.
The findings emphasized so far, and their discussion and
implications, need to be taken into account against the backdrop
of this study’s limitations. While sampling and data collection were
done systematically, in terms of sample, we only used one search
string in a small number of databases. In addition, we were only
able to include the studies to which we had access; hence, we
cannot guarantee the representativeness of our sample. We also
only included peer-reviewed research articles and thus missed the
broader gray literature. We also only considered English-language
articles, although framing in health communication is a research
topic that is addressed in many different countries with articles
published in many different languages. If more languages were
included, maybe the observed dominance of the US would be
slightly different. Despite the study’s goal to provide a general
overview on the studied topic, not all of the conducted research
work could be taken into account, such as research items that are
not published. Hence, like many systematic reviews, the present
study contains bias in that sense that it only included published
articles in English-language journals. Future research could
broaden the scope of the present study by including more litera-
ture in different languages. Finally, a qualitative analysis of the
research articles sampled here could identify issues of framing in
health communication in even greater detail (see also Borah,
2011), but this was beyond the scope of the present investigation.
For instance, future research could take into account the different
definitions, conceptualizations, and operationalization of frames
across studies, which would help working toward a clearer defini-
tion of frames and delineating conceptual confusion regarding
framing, agenda setting, and priming (e.g., Scheufele & Iyengar,
2011; Scheufele & Tewksbury, 2007). Furthermore, the present
study used categories developed in other systematic reviews, such
as traditions and types of framing (e.g., Borah, 2011; Matthes,
2009); however, in health communication, additional categories
might be worth exploring. Hence, analyzing further categories
beyond the ones of the present study remains a task for future
research.
In sum, based on the outcomes of the present study and
keeping its limitations in mind, framing in health communication
seems to show similarities with how framing is applied in com-
munication science overall, especially in terms of the lack of
research focusing on frame production, visual frames, and com-
petitive frames in effect studies (Borah, 2011). However, there also
seem to be some unique features, such as the dominance of
psychological studies and the equal attention given to generic
and thematic frames. Consequently, further research could focus
on existing research gaps, in order to develop a broader under-
standing of the framing process and framing effects in the domain
of health communication. Until this is accomplished also in health
communication, “framing research remains robust and troubled”
(D’Angelo et al., 2019, p. 24).
Notes
1. It should be highlighted that some researchers rather prefer
a narrow definition of framing and framing effects, in which
they only refer to equivalency framing as the definition of frames
derived from psychology (Cacciatore et al., 2016; Scheufele &
8 L. GUENTHER ET AL.
Iyengar, 2011). The present study uses a broader definition that is
more in line with Borah (2011) and Matthes (2014), who rather
relate the psychological tradition of framing to the fact that
individuals’ minds are being analyzed. Both equivalency and
emphasis framing can be used to analyze individuals’ minds, as
well as potential effects of framing.
2. We only had access to five of the six identified meta-analyses.
3. Availability relates to the fact that in many cases, the authors of
the current study did not have access to some of the articles. In
these cases, we used ResearchGate and emailed the authors, but in
more cases than not this process was unsuccessful. Articles to
which we had no access had to be excluded from the sample.
4. In this case, we excluded theoretical papers, leading to a sample
size of 301. Additionally, for four articles (1.3%), it could not be
determined whether they used thematic or generic frames.
Acknowledgments
The authors would like to thank both editors and anonymous reviewers
for providing helpful feedback to their work. The authors would also like
to thank Daniela Mahl for commenting on an earlier version of the
manuscript and all authors who provided access to their articles in
cases in which we had no institutional access.
Disclosure of potential conflict of interest
There is no conflict of interest.
Data availability statement
The data that support the findings of this study are available from the
corresponding author [LG], upon reasonable request.
ORCID
Lars Guenther http://orcid.org/0000-0001-7760-0416
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