News Framing Analysis of the Health Crisis of 2017 in Turkey

Crises pointing to a situation that creates confusion in normal living conditions have the potential to adversely affect people and societies. Health, which is one of the areas with high probability of crisis due to its structure, is a matter of concern to almost all members of society. The media, the primary source of the public in crisis situations, has an important role in defining and framing health problems. The news frames preferred by the media can affect public opinion about who will be responsible for the crisis, from whom to expect solution. In this study, which aims to show how the crises in the health field are reflected in the newspapers in the example of Turkey in 2017, news contents have been analyzed according to the news frames revealed Valkenburg et al. (1999). The study results show that the most preferred frame for health crisis news is the responsibility and the least preferred frame is the economic frame.


Introduction
Crises are chaotic situations that create confusion in the lives of organizations and societies. According to Coombs and Holladay a crisis is "an event for which people seek causes and make attributions" (Coombs and Holladay, 2004). Crises are "abnormal, dynamic, and unpredictable events" (Seeger, 2006). In its simplest form, crisis situations that have emerged unexpectedly and express the developments that have the potential to adversely affect individuals, organizations, groups and societies make it necessary to use communication strategies in place. Crisis is the name of the situation in which public interest is completely directed to the organization, group or society. In this way, in times of crisis, it is needed to be managed more effectively (Bulduklu and Karaçor, 2017).
Crisis management has increased its importance in all sectors, especially in health services. It is because health is an area where the possibility of a crisis is always high due to its service intensive structure, the need to be presented in multilayered orm, asymmetry between the information and received service as a result of the predominance of its economic side, the strict adherence to technology and other reasons. By its structure, health services contain many unexpected situations during its presentation. Presentation of the service at all levels can reveal unexpected results based on various factors.
What needs to be done in crisis communication is to be ready in advance of the crisis and its consequences, take the necessary measures and manage the chaotic situation created by the crisis, that is, to overcome the crisis with the least damage. Here, the important point is how the crisis is reflected on the public, or rather how it is reflected by the media. Today, as in all areas, the media has an important role in defining and framing health problems for the public. The media not only draws attention to a topic but can also provide reasons and solutions and may affect readers about on what issues to think and how through framing (Kim et al., 2002). Media events can change the meaning of news when it is placed in specific frames (Auerbach and Bloch-Elkon, 2005). As the conceptual tools used by the media and individuals to communicate, interpret and evaluate information (Neuman et al., 1992), news frames in case of crisis, especially if the institutions/organizations where the crisis is experienced or held responsible remain silent, serve as a kind of interpretation guide for different segments of the public (Coombs, 2007). This means that news frames which journalists use for a crisis may have an impact on the public's evaluation of issues, institutions and social actors. In crisis situations, the news frame of the media can highlight some aspects by ignoring some aspects of the subjectand, therefore, may affect the public's assessment of the person responsible for the crisis.
This work is to analyze how the crisis in the health sector in Turkey in 2017 is framed in the newspaper news. For this purpose, the news contents were analyzed according to the news frames revealed by Valkenburg et al. and it has been looked at whether there is a relationship between the type of crisis and the news frame.
context, in recent years, it has become more prominent on the agenda than before and has become a subject gaining importance.
The crisis is an important problem that occurs suddenly or over time and should be resolved immediately when it occurs. The most important symptom of the crisis is that the decision-making mechanisms of the organization become inadequate and their plans become unworkable (Tutar, 2007). With the traditional approach, a crisis is seen as an unusual situation that may threaten the work, reputation, image and relationship of an organization, or in any way harm its social stakeholders (Falkheimern and Heidenn, 2006).
Common characteristics of crises can be expressed as follows:  Adversely affected, organizational structures, values and norms,  The emergence of unexpected situations,  Inability to predict the crisis environment,  Inadequate preventive mechanisms,  Organization's purpose and the existence being threatened by the crisis,  Lack of adequate information and time for measures to be taken to prevent the crisis,  The necessity of the rapid implementation of the measures taken and  Increased tension in organization management (Aykac, 2001). Coombs classifies the crises as "victim cluster", "accidental cluster" and "preventable cluster" (Coombs, 2006). In victim cluster, the organization is also a victim of the crisis such as natural disaster, rumors, workplace violence, product tampering/malevolence; in accidental cluster the organizational actions leading to the crisis were unintentional such as challenges, technical breakdown accidents; in preventable cluster the organization knowingly placed people at risk, took inappropriate actions, or violated a law/regulation such as human breakdown accidents, organizational misdeed with injuries.
It is possible to make a distinction between crisis types by looking at the sources and causes of crises. Accordingly, crises are divided into two as internal and external sources. From the point of view of organizations, the crisis may arise from the organization as well as from external environmental factors. It is possible to divide external crises into types such as natural disasters and environmental crises, crises from terrorism, economicpolitical crises and public health crises.
If we look at the causes of possible crises in the field of health; reasons such as appropriate and unethical conduct by a professional health care provider, harm to the patient as a result of inadequate and negligent behavior in professional practices, incomplete service and not meeting the expectations of the patient may be considered. It is possible to talk about human errors such as fatigue, insufficient education, not showing enough care, not taking precautions, carelessness, lack of communication; and inadequacies that may be the source of crises, depending on institutional factors such as insufficient/incomplete devices, misrepresentation of personnel, insufficient automation, administrative/financial structure of the workplace.
Each crisis has the potential to create unique communication needs and demands. In this respect, the crisis will require a special communication as it requires a special management. This particular communication work is crisis communication. Crisis communication is described as: in a broad sense gathering, processing and sharing the information necessary to cope with a crisis situation (Coombs, 2007), expressing a specific event to stakeholders affected by the crisis with an honest, fast, accurate approach, (Reynolds and Seeger, 2005), effective communication and follow-up of communication channels that enable the detection of information before the acute stages of the crisis to determine the possible consequences and to reduce the damage caused by the crisis (Kirdar and Demir, 2011), verbal, visual and/or written interaction-dialogue before and after the event, before and during a negative event between the organization and stakeholders (usually through media) (Fearn-Banks, 2007). Coombs suggests that in general, each crisis can pose three major threats and these are; public safety, financial loss and loss of reputation. And effective crisis management requires managing threats in a priority order (Coombs, 2007). In crisis, the first priority should be given to public safety. An error in providing public safety will further exacerbate the effects of the crisis. After all, crisis management is designed to protect the stakeholders of an institution and organization from threats and/or to reduce the impact of threats. Crisis management does not consist of only one process. Crisis management can be divided into three stages: pre-crisis, crisis response and post-crisis period. Precrisis period is related to prevention and protection. The crisis response stage is the period in which management must virtually respond to the crisis. The post-crisis period is getting better prepared for the next (possible) crisis.
Crisis communication; it is related to communication strategies and tactics to be followed during crisis periods. Taking measures to prevent possible crises, the elimination of elements that may cause a crisis, production of communicative solutions, sharing of crisis solutions and developments with the target audience constitute the subject of crisis communication (Peltekoglu, 2009). Crisis communication requires strategic (communicative) responses for victims, employees, stakeholders, those indirectly affected and the media (Lukaszewski, 2001). Forthe media may influence the public perception of the crisis with its preferred discourses and frames in communicating crises.
People watch the media more in times of crisis to learn, explain and interpret (Graber, 1980). In general, public learns many events from the media and therefore largely dependent on the viewpoint of the media. For most people, news media is the most popular and credible source of public health information (Coleman et al., 2011). Crisis periods in the health sector are the times when there is most intense communication between the parties to the crisis. Since it is about human life / health, the need and perception of all stake holders to the information and advice reach the highest level. Therefore, communication process during the health crisis has a structure that is different, more critical, more comprehensive, intense, transparent and requires attention.

News Discourse and Framing
News, with a large number of definitions but with no agreed, is information about a new, sudden, unexpected and interesting event, situation or phenomenon. Developments in various stages of life, such as birth, development, change, failure, tension, conflict, crisis, disaster, disaster, death (Demir, 2010). In this respect, everything that concerns the public can be news; however, the news provided in the mass media is not actually the event itself, but a rearranged version of it. News is the work of communicating an event, idea or problem to the public by summarizing, through storytelling (Tokgoz, 2000). According to Tuchman, who describes news as "a frame that tells us what we want to know, what we need to know and what we have to know," the news is a window that looks at the world and depicts reality from a certain point of view (Tuchman, 1981). Therefore, the direction, view of the window changes. Events, ideas, problems are made news either by reporting or summarizing. During this process, the important point to be considered is that while news is being made, event, problem, idea are built into the actual frame and fictionalized (Rigel, 2000).
Erwin Goffman, the first to use the concept of framing as an interpretation practice, has defined the frame as the meaning schema. According to him, frames; it helps people to "find, understand, define and label information" flowing in their environment (Goffman, 1974). Reese gives a more general definition; for him, the frames are "the permanent and culturally shared regulatory principles that symbolically construct the social World" (Reese, 2001). Although Hertog and McLeod participate in this definition, notes that frames point to more than a set of principles (Hertog and McLeod, 2001). They say that even if not expressed orally, they provide cultural construction of the meanings shared by the members of a society. Since frames shape people's viewpoints of the world, framing is a vital phenomenon in the construction of social reality (Johnson-Cartee, 2005). Framing is a process of defining and constructing a political or public subject or discussion and in this process, frames determine the basic parameters that citizens discuss public events (Nelson et al., 1997).
Framing is based on the assumption that how a subject is approached can affect how people understand the subject (Scheufele and Tewksbury, 2007). Framing basically works with inclusion and exclusion. An event or subject can be understood and described in many ways. The news media consciously or not, refer to various frames when communicating news to the reader/viewer. A media frame, also called a news frame, is created to make the news about an event or problem meaningful; a general context that determines what will be left out in the news; an emphasis different aspects of a subject to attract attention (Atabek and Uztug, 1998). Gamson and Modigliani define media frames as "a central organizing idea or story line that provides meaning to an unfolding story" (Gamson and Modigliani, 1989). Gitlin defines frames as persistent patterns of cognition, interpretation, and presentation, of selection, emphasis, and exclusion, by which symbol-handlers routinely organize discourse, whether verbal or visual (Gitlin, 1980). While some researchers prefer the media frames (Carragee and Roefs, 2004;Reese, 2001;Tankard, 2001;Wicks, 2005), some of them prefer news frames (D'Angelo, 2002;Semetko and Valkenburg, 2000), in studies, they have been classified in various ways such as "thematic and episodic" (Iyengar, 1991) or "subject-oriented" and "generic" (de Vreese, 2004) frames. Neuman et al. (1992) described four dominant news frames that could be applied to different news contexts such as conflict, economic consequences, moral and human impact. Valkenburg et al. (1999) renamed the human impact frame as human interest frame and adding responsibility as a new frame. Accordingly, the dominant news frames are: 1. Attribution of responsibility frame: This frame is used to describe the responsibility of a person, group or institution in the problem or solution. Hallahan (1999) defined this frame as the most important frame for health issues. This is partly due to the fact that the government is responsible for health issues and has the greatest potential for solving problems.
2. Human interest frame: This frame adds an emotional perspective to the presentation of a subject or problem with personal stories. through individual examples, it transmits subjects or problems by focusing on individual problems and responsibilities.
3. Conflict frame: This frame is used to reflect conflicts between individuals, groups or institutions. d 'Haenens and de Lange (2001) state that conflict frame is used to reduce complex social and political problems to simple conflicts in which one party opposes anotherand that this may make it difficult to see the various sides or causes of the issue. It is seen that in crisis situations conflict frame can lead to charging offense on one side (Nijkrake et al., 2015).
4. Morality frame: This frame reveals events, facts or problems in the context of ethics, social rules and religious principles (Semetko and Valkenburg, 2000). The stories directed by this frame tends to include moral messages about how to behave. According to the journalistic principle of objectivity, journalists use this frame more indirectly, such as citation (Neuman et al., 1992). Four other frame of moral crisis news frame less used but avoidable crisis more heavily in the news for the preferred (An and Gower, 2009). 5. Economic frame: This frame describes the effects of an event, subject or problem on the economic situation of individuals, groups, institutions or countries. This frame emphasizes the profit or loss produced by the issue or problem (de Vreese, 2004). Economic impact is an important news valueand media use this frame to make a topic or issue relevant to the public (d' Haenens and de Lange, 2001).
Framing is the process of integrating some elements of a perceived reality into the construction of a particular interpretation. Some parts of the subject can be highlighted when drawing a frame. In other words, the feeling that these parts are more important is provided by selecting some parts of a topic. Some ideas can be made invisible by drawing attention to some thoughts in the text, data incompatible with the story can be covered up by repeating the meaning frames, which are mainly intended and therefore made noticeable, connotations of words and visual materials associated with this frame (Pan and Kosicki, 1993). In other words, a perspective on how the event/action should be understood can also be imposed with frames. Van Dijk and Kintsch (1983), who points out that understanding or expressing sentences as part of a discourse is different from understanding them separately, say that framing is a powerful tool in determining the context of public debates. People seek information in order to assess the responsibilities of institutions in the crisis of public matters. Today the source of information is largely the media and framing is one of the effective ways in which mass media can shape and direct the public. Therefore, it is important to analyze the news frames of the media.

Methodology
In this study, the way that the events, occurred in 2017 in the health sector in Turkey and characterized as crisis, reflected to newspaper news as a matter of public concern and in which frame they were presented have been examined. The main aim of the frame analysis is to understand how certain thought elements are actually related to each other within the hidden meaning of discourse (Creed et al., 2002). In this study, a framing analysis, supported by the content analysis frequently referred to Wimmer and Dominick (2006), was used in framing. A code table has been created for content analysis including the newspaper in which the news is published, the date (in months), the subject, the types of crises and the definitions of the news frames. Wimmer and Dominick (2006) recommended that intercoder reliability be tested on a 10 to 25 percent overlap of articles when conducting a content analysis and randomly selected 56 news stories (19% of all news) were used for pretest. Later, all news is then coded separately by two different encoders, there is a 85% confidence rate among them. This ratio is within the acceptable level of (Miles and Huberman, 1994).
The answers to the following questions were sought with the analysis of the expressions in the analysis form.  How is the distribution of news according to the crisis type?  What news frames are used in the news?  What difference is seen in the frame used according to the subject of the news?  What difference is seen in the frame used according to the type of crises? LexisNexis Academic News Index database was used to access news content. In the database where search ca be carried out based on various options such as the name, language of the newspaper, the title of the news, their full text, their history, searching was carried out with the following keywords and the news texts reached were examined and the unrelated ones were eliminated: "health", "patient relatives", "attack", "violence", "doctor", "health personnel", "beating up/assault" "hospital", "scandal", "diagnose/treatment", "death", "patient", "victim", "Ministry of Health", "public health", "crisis", "medicine", "price" and "repayment". In the study, only the news were examined and the reader letters and columns were not included in the study. After downloading full text of news from LexisNexis and saving in MS Word format, 10 of them were randomly selected; then it was checked whether they were in the printed copy of the relevant newspapers. As a result of a total of 19 keywords, 605 results have been reached, as a result of the elimination of intersecting and unrelated news, a total of 334 news articles were examined. The news reviewed; were classified under 4 headings in the first reading as, "violence to health personnel", "wrong treatment and sick victimization", "public health" and "medicine shortage and medicine price". The subject of 114 of these reports is the violence against health personnel; the subject of 58 is wrong treatment and patient victimization; the subject of 14 is public health and the subject of 148, is the medicine shortage and medicine price.
This study is based on the study of Semetko and Valkenburg (2000) used by many researchers (An and Gower, 2009;d'Haenens and de Lange, 2001;Nijkrake et al., 2015) to examine media representations about crises. In study, news frames were evaluated according to the five classification of Valkenburg et al. (1999) as responsibility, human interest, conflict, moral and economic frame. However, since only the texts of the news from LexisNexis can be reached, the statement of the news photos was removed; adding three statements of crisis types, the use of a total of 21 statements were examined. In the coding of the form, Coombs (2006) three classifications as "victim cluster, "accidental cluster" and "preventable cluster" were used. Whether news frames used in health crises news differ depending on the news topic and the type of crises was analyzed with Chi-square test.

Results and Discussion
In 2017, the distribution according to the subject of news about the crises in the health sector in Turkey are as follows:44.3% of the news (148 news) are news about medicine shortage, 34.1% (114 news) consisted of violence reports against health personnel. While the news about the wrong treatment consisted of 17.4% of total news (58 news), news about public health consisted 4.2% of the total news (14 news).
Looking at the distribution of news according to crises types 67.7% (226 news) of the crises mentioned in the news can be preventable crisis, 29.9% (100 news) of them is victim crisis and only 2.4% (8 news) is considered as an accidental crisis.
Values of each framing scale were coded as 0 (no frame used) or 1 (frame used). Each news frame is summarized separately and the points of the frames are created. In 98.8% of health crisis news, at least one item of responsibility frame, in 92.2%, at least one item of the conflict frame was used. In 64.7% of the crisis news in the sample, at least one item related to the humanitarian frame was used. In the crisis news, the use of economic frame in at least one article was 31.1%, the use of moral frame was 26.9%. .62 Does the story suggest that some level of government is responsible fort he issue/problem? 72% Does the story suggest that some level of government has the ability to alliviate the problem? 88% Does the story suggest solution(s) to the problem/issue? 55% Does the story suggest the problem requires urgent action? 90% 2. Human Interest Frame (Frequency = .64) .97 Does the story provide a human example or human face on the issue? 51.8% Does the story employ adjectives or personal vignettes that generate feelings of outrage, empathy-caring, sympathy, or compassion?

50.9%
Does the story emphasize how individuals and groups are affected by the issue/problem?

64.4%
Does the story go into the private or personal lives of the actors? 53.0% Does the story contaion information that might generate feelings of outrage, empathy-caring, sympathy, or compassion?

54.5%
Does one party individual-group-country reproach another? 79.6% Does the story refer to two sides or to more than two sides of the problem or issue?

86.8%
Does the story refer to winners and losers? 87.4% Does the story refer to the reason of the crisis/conflict? 80.2% 4. Morality Frame (Frequency = .27) .98 Does the story contain any moral message?
26.3% Does the story make reference to morality, God, and other religious tenets?

26.0%
Does the story offer moral prescriptions about how to behave? 25.8% Does the story offer specific social prescriptions about how to behave?
24.7% (Frequency = .31) .99 Is there a mention of financial losses or gains now or in the future? 29.3% Is there a mention of the costs/degree of expense involved? 31.1% Is there a reference to economic consequences of pursuing or not pursuing a course of action?

29.3%
The Cronbach's Alpha value of each news frame was calculated to test the internal consistency of the five frames and each value was greater than 0.60. The frequency of using news frames in health crisis news is shown in Table 1. According to this, health crisis has been the responsibility frame with 98% of the most use in news. Responsibility leads people to perceive the crisis as serious, urgent or dangerous (An and Gower, 2009;Cho and Gower, 2006). In the 90% of the news coverage of the responsibility frame, the expression that the problem requires urgent action/measure is used. While 88% of the news includes statements that the government/public institution may reduce or resolve the issue/issue, in 72% of them, the statement that the government/public institution is responsible for the matter is used. However, in only 55% of health crisis news, a proposal for the solution of the crisis took place. The frame of responsibility is the most used frame and shows that the news media focuses on putting responsibility on government and public institutions.
In 92% of health crisis news published over a year, it was seen that conflict frame was used. While mentioning a winning or losing side, in 86.8% of the reports using the conflict frame, in 79.6% of them, it was seen that a party/person/group was held responsible or accused of the crisis. With the conflict with frame, the news media are directed towards the winners and losers, who are responsible for the crisis.
Within the scope of the research, in 64% of the health crisis news, a human interest frame was used. In 64.4% of reports using this frame, the people or groups affected by the problem are mentioned. In 53.9% of the news, the expressions of emotions were involved. The human interest frame is primarily used to provide a personal example to the story. As the third frame, the human interest frame shows that it is tried to we make news noticeable featuring the stories of the victims in the news, using personal expressions and emotions. While the rate of use of the economic frame in health crisis news was 31%, the use of moral frame was 27%. In this part of the study, the relationship between health crisis news subjects and the use of news frames was examined. The Chi-square test results obtained to analyze whether there is a meaningful relationship between the use of news frames and health crisis news topics are presented in Table 2. According to this, there was no significant difference between the responsibility frame and the news subjects (χ2 = 5,265, df=3, p ˃0,05). At least one article on the responsibility frame is used in all public health and medicine shortage news, violence to health personnel (98%) and false treatment (96%) were also used at a high rate in news. There are significant differences between human interest, conflict, moral and economic frame and news topics (p˂0,001). While the humanitarian frame is most commonly used in healthcare (97%) news; it was used the least in the news related to medicine shortage (31%). In general, the conflict frame has been used extensively in all news types. The news, in which the conflict frame was used the most, are false treatment (100%) and violence to health personnel news (98%). The moral frame was mostly used in the news of violence to health personnel (47%). The economic frame was mostly used in public health (85%) and medicine shortage (58%) news. Chi-square test was performed to determine whether there is a meaningful relationship between the frames used in health crisis news and the types of crises. According to Table 3, there is no significant difference (p˂0.05) between the responsibility frame and the types of crisis. Responsibility frame was highly used in all three types of crisis. There are significant differences (p˂0,001) between human interest frame and crisis types. In the context of human interest, the most used crisis are victim crises (95%), preventable crises (53%) and least accidental crisis (25%). There are differences between the conflict frame and the three types of crisis (p˂0,05). The conflict frame was most commonly used in the accidental crisis (100%) and the types of victim crisis (98%). There are also significant differences between the moral frame and the economic frame and the three types of crises (p˂0,001). While moral frame is most commonly used in victim crises (45%), it has never been used in accidental crisis types. While the economic frame is mostly used in accidental crises (88%), it has not been used in the victim crisis.

Conclusion
Crises in health area are important events whose results are likely to adversely affect the health care institution and health personnel as well as patients, their relatives, and society at large. Especially, discourses and frames preferred by the media, which is the first information source of people in crisis periods, when communicating events may affect the public's view of the problem. In health news often negative, sensational, personalized and emotional language is used (Harrabin et al., 2003). In this regard, frames of the news are important. As An et al. (2011) have shown in crisis situations, institutions and organizations should consider to whom the news media places the blame of the crisis and how it may affect people's perception positively or negatively.
With this work, it has been aimed to show which news frames are used more in newspapers in the news of health related crisis in 2017 and whether the use of these frames varies according to the types of crisis and the subject of health news.
According to the findings of the study, frames used in the news related to health crisis are responsibility, conflict, human interest, economic and moral frame, respectively. This result, as Semetko and Valkenburg (2000) and An and Gower (2009) stated in their studies, confirms that in the news the most common frame used is responsibility, the least used one is moral frame. However, the order of the other three frames is different from; ranking of Semetko and Valkenburg (2000) in the form of responsibility, conflict, economic, human interest and moral frames; ranking of of An and Gower (2009) in the form of responsibility, economic, conflict, human interest and moral frames. The difference between the work of An and Gower (2009) may be due to the fact that this study only deals with crises in health area. It is because the humanitarian aspects of health-related crises are more important than their economic consequences.
Studies on the reflection of the institutions facing the crisis in the news shows that (An and Gower, 2009;Semetko and Valkenburg, 2000;Valentini and Romenti, 2011), in the case of preventable crises, placing blame on is used predominantly, while in the victim crises humanitarian frame is used predominantly. The findings of the study partially confirm that the frame of responsibility in preventable crises is the most widely used frame. The responsibility frame was used in all of the victim crises. However, conflict, and human interest frames were also used at high rates.
Research category have been created extensively as much as possible, however, like every research, this study has some limitations. First of all, only the news of the newspaper, in other words the press, have been included, however, it is important to consider visual strength and prevalence of the internet as well as the television that has importance in the news transmission. The similarities and differences of the frames between the printed media and in other mass media can also be compared.
Content analysis is mainly a descriptive method. It reveals the current situation but it doesn't say much about the reasons for this. There is need for researches to understand the causes of news frame choices in health crises of media.