Authorization, rationalization, and moral evaluation: legitimizing acupuncture in Hong Kong' newspapers

Hong Kong has always been regarded as a critical region of Cultural China. Surprisingly, traditional Chinese medicine has not yet been accepted as legitimate in the city. This study uses acupuncture as a case study into the way media texts work to organize a field of knowledge and practices about health in a post-colonial society where contrasting perspectives and hybrid ideas rooted from the East and the West clash and intermingle. Acupuncture is conceptualized as socially constructed health knowledge that gains its legitimacy through media discourses. Through a mixed-method approach that combines discourse and content analysis, a total of 666 news articles related to acupuncture published in two Hong Kong newspapers over a ten-year period were analysed. Three major forms of discursive construction of legitimation—authorization, rationalization, and moral evaluation—were identified and elaborated in association with the texts and the social contexts. This study found a complex process of producing legitimacy for health knowledge through news narratives. Legitimizing acupuncture in Hong Kong’s newspapers 1 Authorization, rationalization, and moral evaluation: Legitimizing acupuncture in Hong Kong’s newspapers Acupuncture is a widely used therapeutic technique of traditional Chinese medicine (TCM). It involves the insertion of fine needles into subcutaneous connective tissue and muscle at certain points in a human body’s surface (see a detailed historical review by Lu & Needham, 2002). Estimated to have existed for more than 2,500 years, like all other TCM, the idea of acupuncture is rooted in logic, philosophy, and beliefs that are alien to Western medical sciences and are regarded as “complementary” to conventional medicine (Barrett et al., 2003). In mainland China in the early 1950s, in fear of being superseded by the “modern” biomedicine, the Communist government officially reformulated all Chinese medicine into TCM, promoted systematic assessments of its effectiveness, and declared TCM has having an equal status with Western biomedicine in mainland China’s healthcare system. Such efforts continue today (Griffiths, Chung, & Tang, 2010; Hesketh & Zhu, 1997). In the Greater China Region, acupuncture is often regarded as having an equal status to biomedicine. For example, in Taiwan, acupuncture has been adopted into the compulsory health insurance scheme. Almost 23 percent of the total 1.3 million Taiwanese were treated with acupuncture between 1996 and 2002 (Chen, Kung, Chen, & Hwang, 2006). However, in Hong Kong, which has been one of the most critical regions of Cultural China (Tu, 1991) and a crowned colony of Britain for over 150 years, the legitimacy of acupuncture and all other practices of TCM have been in constant question. Before its handover to China in 1997, Hong Kong did not embrace TCM as a formal part of its healthcare system. There was no registry regulation on, institutionalized education and Legitimizing acupuncture in Hong Kong’s newspapers 2 training for, or even control over the quality of practice provided by TCM practitioners (Griffiths et al., 2010). TCM was marginalized and was relatively unpopular in Hong Kong. After the handover in 1997, the integration of Hong Kong and mainland China started to emerge and accelerate on multiple aspects. At the policy level, TCM became officially professionalized after the passing of the Chinese Medicine Ordinance in 1999. Established in the same year, the Chinese Medicine Council of Hong Kong began to implement regulations on the practice of TCM, including acupuncture. TCM education programs were developed in various universities. More than two thousand TCM practitioners were granted formal recognition in 2002. The consequence of the formalization and institutionalization of TCM is obvious. While in the past the majority of TCM adopters had been middle-aged females from lower socioeconomic backgrounds who had chronic illnesses and a lower quality of life (Chung et al., 2011; Chung, Wong, Woo, Lo, & Griffiths, 2007), the popularity of TCM among the higher socioeconomic groups in Hong Kong has been rising in recent years. According to a household survey by the Hong Kong government in 2007, around 61.7% of the Hong Kong population consulted a TCM practitioner at some time (Chung et al., 2011). Against the background outlined above, the focus of this study is to reveal the process and strategies of legitimizing acupuncture through Hong Kong’s new media over the last ten years. What is lesser known is how the knowledge about acupuncture and related practices are “incorporated into a pre-given structure” as well as “how a pre-given structure is interpreted in concrete situations of action” (Zelditch, 2001, p. 51). In other words, we treat media coverage of acupuncture as a discursive construct that transforms the knowledge and practice of acupuncture into discourses about them and becomes a symbolic source for their legitimation. Legitimizing acupuncture in Hong Kong’s newspapers 3 Literature Review Health Knowledge and the Media Scholars have recently proposed using the concept of “knowledge economy” as a useful theoretical lens to study health. This approach conceptualizes health systems as “ways of organising access to expert knowledge or expertise” (Bloom & Standing, 2008, p. 2070). Health expert knowledge is defined as information, interpretation, and the best judgement about illness, treatments, and other health related issues. The embodiment of health knowledge is people, such as doctors, as well as products that circulate in the health market, such as treatments and medicine. The construction and the maintenance (or abolishment) of such health knowledge have to involve the interplay among multiple types of power relations (Bloom & Standing, 2008, p. 2070). Any health system, such as biomedicine or alternative and complementary medicine, can be conceptualized as a type of “knowledge economy” (Bloom & Standing, 2008; Bloom, Standing, & Lloyd, 2008; Cross & MacGregor, 2010). On the one hand, they are regarded as “complex technical systems for organising specialised services (prevention, diagnostics, and treatment) and goods (pharmaceuticals and equipment)” (Bloom & Standing, 2008, p. 2070). On the other hand, they define and produce the objects of our knowledge on health and medicine, as well as organising different ways of accessing the “expert knowledge and the technologies that derive from it” (Bloom & Standing, 2008, p. 2070). Due to the special nature of health care, such as its strong component of public goods, markets alone cannot guarantee efficient production and fair distribution of health knowledge in society. It has been argued that non-market institutions, such as the press, play critical roles in producing and disseminating knowledge (Schudson, 1995). Empirical studies have Legitimizing acupuncture in Hong Kong’s newspapers 4 demonstrated that media representation of health knowledge can significantly influence health-related perceptions, attitudes, and behaviours at both a personal and public level (Brown & Walsh-Childers, 2002). The media do not simply convey health knowledge as impartial brokers. They act as agents in the social construction of reality (Gamson, Croteau, Hoynes, & Sasson, 1992; Tuchman, 1978). Hence, health knowledge is not merely mirrored but is also reconstructed in and through the media. If health knowledge is, first and foremost, a type of “expert knowledge,” then the media construction of health knowledge cannot avoid engaging with one crucial foundation that health expertise is based on—legitimacy. Legitimacy is “a generalized perception or assumption that the actions of an entity are desirable, proper, or appropriate within some socially constructed system of norms, values, beliefs, and definitions” (Suchman, 1995, p. 574). The embodiment of legitimacy often appears in two ways: people show voluntary compliance either to the legitimacy of a claim (or the action, policy, demand, or request that reflects the claim) or to that of a claimant (i.e., the person, group, organization, or larger social system that makes or supports the claim) (Kelman, 2001, p. 55). Therefore, the legitimacy of health knowledge is comprised of two elements: first, the acknowledgment of the health profession’s claims to health-related knowledge and practice; and second, the extension of authoritative power of the profession to the claimants to whom it is granted (i.e., health professionals such as doctors, nurses and therapists). In other words, the media construction of health knowledge can be understood and analysed from the perspective of a power struggle over the legitimacy of both claims related to the profession, its theories and practices, as well as that of the professionals. The Legitimation of Health Knowledge through the Mass Media Legitimizing acupuncture in Hong Kong’s newspapers 5 As we elaborated above, legitimacy, broadly speaking, refers to the voluntary compliance with the authority of certain institutions (Zelditch, 2001). Legitimation, the process of establishing legitimacy, inevitably involves “communicative action” (Habermas, 1987) in which the mass media play a vital role. On the one hand, claims related to the authority of an institution, such as the theories and methods of acupuncture, rely on an efficient and acceptable way to reach the public (including existing and potential adopters of health knowledge and associated practices). On the other hand, the claimants of authority, such as doctors and therapists who practice using acupuncture, need a channel to send their voices out and make their own images perceived (preferably in a positive way). No other communication method can be more effective and more economical than the mass media in the mediation of the “relational definition” (Beck, 1992) between health knowledge and the public. However, media representation of health knowledge only helps establish and maintain its legitimacy at the symbolic level (as opposed to at the substantial level). That is because the media, for example, only present the “real, material change” of health expertise and provide accounts (excuses and justifications) for such change (Ashforth & Gibbs, 1990). The media do not alter the values and norms that the health profession complied with nor do they directly bring in “the structural transformation” (Richardson, 1985, p. 145) to health knowledge and related practice. In other words, the legitimation of health knowledge via the media should be thought of as a discursive construction (van Leeuwen, 2008). The legitimation of health knowledge can be examined by analyzing “media discourse” for two reasons: (1) media production is considered as a dynamic and on-going process and media content is the outcome of negotiations among many different power Legitimizing acupuncture in Hong Kong’s newspapers 6 players in a defined social context (Peterson, 2001), and (2) the understanding and interpretation of the content created by the media are not derived from their “abstract or dictionary” meanings but from their “situated use” (Wetherell & Potter, 1992, p. 90). Therefore, unveiling the legitimation of health knowledge through media discourse must involve analyses at two dimensions: (1) the “patterned system of texts” (Lupton, 1992) decoded from media contents; and (2) the recontextualization of social practice; that is, how the media texts being appropriated to the “specific social contexts” where they were developed and constructed (van Leeuwen, 2008, p. 6). This study posits the media coverage on acupuncture in Hong Kong as a discursive practice, which delimits “a field of objects” for knowledge and practice related to acupuncture, defines “a legitimate perspective” for the agents who provide and receive acupuncture as a treatment, and fixes the “norms for the elaboration of concepts and theories” on the treatment (Foucault, 1977, p. 199). More specifically, we investigate how knowledge and practice on acupuncture gain their legitimacy through media discourse. We attempt to reveal media construction on three forms of legitimation discourses: authorization, rationalization, and moral evaluation (van Leeuwen, 2008). We ask: What are the major discourses related to the legitimation of acupuncture constructed and represented in major newspapers in post-1997 Hong Kong? How do the news stories evaluate acupuncture? How do they justify it? Who are the major power players selected by the newspapers to endorse the legitimacy of acupuncture? Are there any competing discourses? If yes, what are they and how should they be interpreted? Research Methods Sample Legitimizing acupuncture in Hong Kong’s newspapers 7 Two major Chinese language newspapers in Hong Kong, Ming Pao and Apple Daily, were selected for analysis. Ming Pao is an elite-oriented newspaper first published in 1959. It has a historical reputation of being neutral and objective, and thus is regarded as one of the most trusted newspapers in Hong Kong. In comparison, Apple Daily, a tabloid founded in 1995, gained its popularity through its bold and aggressive reporting style. Apple Daily is one of the most circulated newspapers in Hong Kong, with an average daily circulation of more than 250,000. We chose both newspapers to provide a relatively complete sample of news stories that target a wide readership. News stories on acupuncture covered by the two newspapers were collected through the WiseNews electronic news database. The Chinese character of acupuncture, 針灸, was used as the only keyword to search the database in both the “title” and “content” sections. For the purpose of comparison, two specific time periods were employed: (1) between 1 June 2001 and 31 May 2003 and (2) between 1 June 2011 and 31 May 2013. By doing so we expected to compare and identify the differences and changes occurring in the news construction of acupuncture within the last ten years. In total, 666 stories were found and collected. Two hundred sixty-six stories were written between 2001 and 2003, and 145 of them were published by Ming Pao. Four hundred stories were published between 2011 and 2013, among which 154 were in Ming Pao (see Table 1). It is interesting to see that, within the last ten years, while Ming Pao barely 1 Based on a long-term survey on the credibility of newspapers among adult residents in Hong Kong since 1997, Ming Pao received the highest score on credibility among all Chinese language newspapers. Its rate declined slightly only in 2013 and became the second most trusted press in Hong Kong. Retrieved from http://www.com.cuhk.edu.hk/ccpos/images/news/PressRelease_140102_credibility.pdf 2 The number is calculated based on the data provided by the Hong Kong Audit Bureau of Circulations Ltd. Retrieved from http://www.hkabc.com.hk/en/index.htm Legitimizing acupuncture in Hong Kong’s newspapers 8 increased its attention to acupuncture, Apple Daily nearly doubled its coverage on the topic. The apparently growing interest of the tabloid press in reporting on acupuncture may have revealed the mounting visibility of the treatment within the “alternative public sphere” (Ornebring & Jonsson, 2008). --------------------------------Insert Table 1 about Here --------------------------------Discourse Analysis and Content Analysis To analyse and interpret the 666 stories, we employed a “mixed methods” approach, combining discourse and content analysis. Analyzing media discourse requires a focus on both the texts and the social contexts in which “meaning is constantly negotiated and constructed” (Laclau, 1988, p. 254). In this research, first, the method of critical discourse analysis (Fairclough, 1995; van Leeuwen, 2008) was adopted to reveal the construction of the legitimacy of acupuncture in Hong Kong’s media discourse. Both the news texts on acupuncture and the recontextualization of acupuncture in the news were analyzed. In the texts, we focused on the structural organization of and actors quoted. When analysing the dimension of recontextualization, three dominant discursive constructs emerged from the news, manifesting the specific strategies utilized by the two Hong Kong newspapers in legitimizing acupuncture. In this article, we adopt the three categories of discursive legitimation developed by van Leeuwen (2008), authorization, rationalization, and moral evaluation to label these strategies. Legitimizing acupuncture in Hong Kong’s newspapers 9 Next, an ad hoc content analysis was employed to manifest the particularly quantified information that can provide solid evidence of the major textual and recontextualized discourses identified from the total 666 news stories. The coding scheme was created based on repeated and careful readings of the news texts. In other words, a discourse analysis was conducted prior to the formulation of any quantifiable schemata. Of course another round of reading news texts was employed after all quantitative messages were coded. But for the second round of discourse analysis, the main purpose was to examine and identify specific language and symbols used for illustrating the patterns that emerged from the content analysis. By and large, nine variables were created and used for content analysis. They can be grouped into two categories. The first category of variables helped provide a general outline and some background of the news on acupuncture in Hong Kong. They include: (1) whether acupuncture was the main subject covered in the news; and (2) the place(s) where the news mainly occurred, whether it was in Hong Kong, mainland China or other countries or regions. Second, the remaining seven variables were all related to the question of the legitimacy of acupuncture as knowledge and practice. These variables include: (3) the news section, the particular section of the newspaper where the story was published, such as local news, health news section, supplement or commentary section, etc.; (4) primary news sources who talked about acupuncture, whether they are medical professionals, ordinary acupuncture receivers, or 3 Due to their differences in political stance, target market and reporting style, the two newspapers might have shown significant differences in their coverage on acupuncture. However, Hong Kong is only a city, and the internal variation of newspaper readers is relatively small when compared with the variation of readers in a country, such as China. Also, the topic of acupuncture is rarely politically related, and hence it does not seem to be able to manifest the different political stance that Ming Pao and the Apple Daily possesses. The coding results also show that the two newspapers displayed quite similar trends of change on each coded items over the two time periods. Therefore, we combined the results from the two newspapers together and report them as a whole. Legitimizing acupuncture in Hong Kong’s newspapers 10 celebrity receivers; (5) the purpose of acupuncture, that is, whether it was used under common conditions such as pain relief or control, or as a treatment for particular illness, or for certain peripheral purposes such as to quit addiction, for weight-loss, or for mixed reasons; (6) the effectiveness of acupuncture, whether it was portrayed as having beneficial effects, limited effects, or with no effect and even leading to bad consequences; (7) whether acupuncture was the only medical treatment technique reported in the news, and if not, whether it was reported with other TCM or biomedicine treatments; (8) whether the news story explained the mechanism of acupuncture; and (9) the overall tone of the reporting on acupuncture, whether it was positive, neutral, or negative. Two coders were recruited and trained to code the content of the stories. Overall, 60 news articles (about 10% of the sample) were coded by both coders and were used for a reliability test. An online software, ReCal, was used to calculate Krippendorff’s Alpha for examining the inter-coder reliability. The test results showed relatively high reliability between the two coders; the coefficients were: news section (α = 1.00), place of news (α = 0.95), primary news source (α = 0.82), purpose of acupuncture (α = 0.88), effectiveness of acupuncture (α = 0.78), acupuncture as the main subject of report (α = 0.86), acupuncture as the only medical treatment technique (α = 0.87), explanation of the mechanism of acupuncture provided (α = 1.00), and the tone of reporting (α = 0.83). Results Two Background Factors Among all 666 news stories that contain some information related to “acupuncture,” only a little more than one fifth covered it as the main subject, and there were no significant 4 ReCal is available to public at http://dfreelon.org/utils/recalfront/ Legitimizing acupuncture in Hong Kong’s newspapers 11 changes shown across the ten years (23.7% between 2001 and 2003 versus 20.3% between 2011 and 2013, see Table 2). We found that a large number of stories mentioned acupuncture casually, or even by accident, when they covered issues unrelated to the treatment. For example, entertainment celebrities told the press that they had been using acupuncture to lose weight when they were asked about recent activities during a movie or TV premiere (e.g., “Heung Hoi-Lan: My New Role is Just Like Sammi,” Apple Daily, September 21, 2002;“Shek Wing-Lee’s Makeover”, Apple Daily, June 3, 2011). However, despite that, we included all 666 articles in our subsequent analyses because, as media effects studies based on information processing theories have demonstrated, news audiences might be more attentive to peripheral cues, such as the social group affiliation of news sources (Igartua & Cheng, 2009) or the degree of accordance with their prior beliefs and values (Chong & Druckman, 2007). Hence, we argue that even when acupuncture was not the main subject covered in the news, some readers, if not all, would still pay attention to information related to it, especially among those who held a strong interest in the treatment or those who were easily affected by celebrity or authoritative sources. --------------------------------Insert Table 2 about Here --------------------------------Although acupuncture did not often constitute the major focus of Hong Kong’s newspapers, some structural changes in the news construction of acupuncture still seem interesting. In previous research on the everyday operation of the two newspapers under examination, it was found that both of them had paid considerable attention to issues in mainland China. For example, in 2007, about 16% of Ming Pao’s and about 14% of Apple Legitimizing acupuncture in Hong Kong’s newspapers 12 Daily’s news articles covered issues and incidents taking place in mainland China (Guo, Huang, Du, & Chen, 2008). In our study, news articles from the same two newspapers displayed a similar pattern between 2001 and 2003 (see Table 2). In total, around 15% of the articles related to acupuncture occurred in mainland China, and 77.1% in Hong Kong. However, ten years later, between 2011 and 2013, only 5% of the stories took place in mainland while 83.8% took place in Hong Kong. This somehow demonstrates that the Hong Kong press has become more attentive and more willing to cover acupuncture from a local perspective. It may also demonstrate that during the last ten years acupuncture and actors related to it have become more and more active in attracting the spotlight from the local media. However, the constitution of main reporting subjects in the news and the place of occurrence do not inform us about the specific angles the journalists used to look at acupuncture; nor can they tell us the particular discursive strategies employed in legitimizing acupuncture. The other seven indicators can tell us more about them, which are grouped into three forms of legitimation discourses: authorization, rationalization, and moral evaluation. Legitimizing Acupuncture through Authorization Legitimation impels people to ponder the question of “why.” The news stories on acupuncture published in the two Hong Kong newspapers repetitively tackled one central question: why should we accept acupuncture as health knowledge and a medical treatment. However, the mechanism of acupuncture is always entangled with traditional Chinese philosophy and cannot be explained by modern science. Clinical research on the effectiveness of acupuncture sometimes show conflicting results and cannot be distinguished from bias (see Madsen, Gøtzsche, & Hróbjartsson, 2009), but the question of why was rarely asked directly Legitimizing acupuncture in Hong Kong’s newspapers 13 in the news, nor was it answered straightforwardly. Naturally, we identified from the news texts, the representation of authority, such as, “because someone says so,” as one of the most basic and concrete forms of legitimation. We label this “who says so” type of legitimizing strategy as “authorization,” through which the legitimation of acupuncture in the news is established “by reference to the authority of tradition, custom, law, and/or person in whom institutional authority of some kind is vested” (van Leeuwen, 2008, p. 105). As van Leeuwen further explains, authority can be vested in person, whether s/he is an expert, a role model, or someone who occupies a certain status in a particular institution; it can also be vested in impersonal attributes, such as laws, tradition, or conformity. For this particular study, we focus on two locations in the news to anchor discourses of authorization: the section of the newspaper where the story was published and the primary sources directly or indirectly quoted in the news. The news section mainly functions as a division of attention. Categorizing news stories into different parts and publishing them on different pages provides a convenience to most readers in finding the information in which they are most interested. Over the last ten years, the specific news sections publishing stories related to acupuncture in Hong Kong’s newspapers have displayed quite a dramatic change (see Table 3). --------------------------------Insert Table 3 about Here --------------------------------Between 2001 and 2003, the largest proportion of acupuncture news was published in the local news section (22.6%), most of which was spot news or news on important policy issues, social problems and contingent criminal reports. The second largest proportion Legitimizing acupuncture in Hong Kong’s newspapers 14 appeared to be news related to entertainment, sports and education (21.8%). Only 14.3% of the stories were treated as “health or medical news” and were published in the section to which interested social groups, such as patients and their relatives, would most likely pay attention. A decade later, as Table 3 shows, some notable changes occurred. First, the number and proportion of acupuncture stories increased significantly in the health and medical news desk (from 14.3% to 22.3%). Second, acupuncture seemed to be covered less frequently as “soft” news in paper sections like entertainment, sports and education (from 21.8% to 16.0%). The proportion of “hard news” related to acupuncture published in the local news section also declined significantly (from 22.6% to 18.0%). Third, more interestingly, acupuncture seemed to grow into a topic of interest in the non-news sections. The proportion of acupuncture stories reported in the supplement of the newspapers, many of which were actually written in the form of advertorial, almost doubled over the ten years (from 6.8% to 12.0%). A similar increase was also observed in the commentary section (from 4.9% to 8.8%). The changes that emerged from news sections indicate that stories related to acupuncture have become more covered from a medical perspective. It can also be interpreted as reflecting the changes in reality. As we reviewed in the introduction, the formalization and institutionalization of acupuncture has become a more prioritized health policy agendum in Hong Kong, and therefore, individuals and organizations pertaining to the treatment, especially those from the healthcare arena, have become more active in conveying messages to the press. This speculation can be further confirmed through analysing primary news sources used in the 666 stories. Table 3 shows that the proportion of medical professionals quoted in the acupuncture news increased from 29.7% to 36.5% during the last decade. The voices of acupuncture receivers were also heard more often after 2011. More importantly, the Legitimizing acupuncture in Hong Kong’s newspapers 15 proportion of ordinary acupuncture receivers quoted in the news exhibited a sharp growth, from 6.8% between 2001 and 2003 to 16.8% between 2011 and 2013. Celebrity patients still occupy a considerable proportion among all news sources, but the frequency of their voices being heard seem to increase to a lesser extent. The increased visibility of medical professionals and acupuncture receivers in the news not only reconfirms the shift of covering acupuncture from a medical perspective, it also helps amplify the voices of the acupuncture receivers and allows their “testimonies” to be heard more clearly and easily. Although not all testimonies necessarily support acupuncture, the fact that “people like us” (ordinary receiver) and “people I want to be” (celebrity receiver) are using the treatment is persuasive enough. As a result, the legitimization of acupuncture through authorization is realized. Legitimizing Acupuncture through Rationalization Authorization, in a sense, only provides readers a certain direction to look for reasons why they should comply with the authority of a profession and its practitioners. As rational beings, many readers’ perceptions and attitudes toward acupuncture are very likely to involve the process of rationalization, which functions as legitimation “by reference to the goals and uses of institutionalized social action and to the knowledge that society has constructed to endow them with cognitive validity” (van Leeuwen, 2008, p. 106). In general, there are two types of rationality: instrumental and theoretical. Instrumental rationality often focuses on “purposes.” It is constructed through discourses that “legitimize practices by reference to their goals, uses, and effects” (van Leeuwen, 2008, p. 113). Theoretical rationality, by contrast, is founded on “some kind of truth” or “explicit representations of ‘the way things are’” (van Leeuwen, 2008, p. 116). For example, assigning acupuncture news stories to the Legitimizing acupuncture in Hong Kong’s newspapers 16 section of “health or medical news” is itself a production of discourse on “scientific rationalization” which defines “knowledge” on acupuncture as “medical” and differentiates it from other non-scientific ones. As a result, acupuncture might gain its legitimacy through such types of rational “explanation.” In this study, however, we mainly focus on news discourses used for instrumental rationalization. More specifically, we try to decode four types of instrumental orientations from the coverage of acupuncture in Hong Kong: purpose or goal orientation, effect orientation, means orientation, and mechanism orientation. As Table 4 shows, all of the four different types of instrumental orientations presented significant changes over the last ten years. --------------------------------Insert Table 4 about Here --------------------------------The purpose of using acupuncture was often constructed in terms of the specific illness or symptoms that acupuncture could be used to treat or alleviate. Four specific purposes were identified through the news texts: (1) common use—certain typical use of acupuncture such as in pain control, sprains, strains, and other light to moderate physical injuries; (2) peripheral use, which includes using acupuncture for infertility, quitting smoking or other addictions, losing weight, and so on; (3) illness treatment, which mainly refers to use acupuncture to treat common and rare diseases, such as cold, asthma, allergies, or even stoke, cancer, etc.; and (4) mixed purposes that explicitly indicate acupuncture can be used for various conditions. Legitimizing acupuncture in Hong Kong’s newspapers 17 From Table 4 we can see that more news stories clearly pointed out the purpose of using acupuncture in their texts between 2011 and 2013. Ten years ago, less than 60% of all stories stated the purposes; while ten years later, almost 75% of the news did so. However, the increase did not occur in all of the four major purposes. Only the number of stories that indicated using acupuncture for common purposes (from 21.1% to 34%) and illness treatment (from 9% to 16.5%) increased over the last ten years. The amount of news talking about peripheral usage declined (from 18% to 14.5%), as did the news on mixed purposes (from 9.4% to 6.8%). Such changes imply a changing focus on acupuncture practices from something more related to everyday use to something more identified as “scientific” or “medical.” Pains and illness are medical symptoms that must be attended by medical professionals; whereas, within the Chinese contexts, things like infertility, addiction relief, losing weight and so on, traditionally are not regarded as “diseases” and can be handled through non-medical ways, such as consoling, prayers, or diet. To legitimize acupuncture as a type of “health knowledge,” non-scientific usage apparently does not seem compatible with such orientation and might even become part of the counter-discourse—discourse serving to delegitimize acupuncture and thus discourses related to that usage must be phased out. The direction of legitimizing acupuncture through constructing it as “scientific” seems to be more salient if we examine the discourses on the other three instrumental orientations. When discussing the effectiveness of acupuncture, the press in Hong Kong grew to be more “objective” and “balanced” in the last ten years. Between 2001 and 2003, almost 20% of the news described acupuncture as having “beneficial effects”; while ten years later, the percent dropped to about 15% (see Table 4). Meanwhile, there was a significant increase in the percentage of stories talking about the limitations of (from 13.2% to 22.3%), no effect (2.6% Legitimizing acupuncture in Hong Kong’s newspapers 18 to 6%), or even negative effects caused by acupuncture (from 2.3% to 8%). For instance, we found that the newspapers tended to use less affirmative words to describe the effectiveness of acupuncture in 2012 and 2013. When covering news related physical injuries, the Apple Daily used “considerably improved” in its 2002 coverage (“Tony Cruz urges Hong Kong people to be strong”, June 23, 2002) and “somewhat improved” in 2012 (“Bun Scrambling Champion paralyzed in a car accident last month”, January 6, 2012). With the effectiveness of acupuncture still maintained as the dominant discourse in the news texts (38.1% in total), the supplement of discussing non-effects or negative effects, both of which only constituted a very small share (14% in total), did not necessarily challenge the news representation of acupuncture as an effective method of treatment. Rather, the seemingly balanced way of reporting, such as talking about both the effectiveness and the limitations of acupuncture, or if you consider all the stories as a whole, created an analogy between TCM and biomedicine, since the social construction of the latter always emphasized being “objective,” “scientific,” and being honest with its positive as well negative impacts. An implicit analogy does not seem to be enough. Juxtaposing acupuncture directly with biomedicine can further enhance the impression that these two are similar or even the same means of medical treatment. We found that, only a little more or less than a quarter of the news stories reported acupuncture as the only medical treatment method (27.4% between 2001 and 2003, 24.3% between 2011 and 2013, see Table 4). The percentage of reporting acupuncture with other TCM increased very slightly over the last ten years (from 16.9% to 17.3%). However, the embracement of biomedicine, whether with TCM (from 15.8% to 20.3%) or without it (from 11.3% to 19.8%), became a highly visible trend in Hong Kong’s acupuncture coverage. Legitimizing acupuncture in Hong Kong’s newspapers 19 Legitimation through rationalizing on means orientation often focuses on constructing an action as a means to an end (van Leeuwen, 2008, p. 114). In the case studied here, it is obvious that the press in Hong Kong became more intent to putting acupuncture and biomedicine side by side. For example, when treating minor health problems, such as torn vocal cords (e.g., “Luo Xiaoyong surprises, Lin Xingtong smiles”, Ming Pao, August 4, 2012), the Hong Kong newspapers often emphasized that both Chinese medicine, acupuncture included, and Western biomedicine were sought, as if these were standard procedures of treatment. The consequence of such increased juxtaposition —no matter what kind of conclusions the readers would have drawn from such comparison —was to construct acupuncture as a legitimate means of treatment that can be compared and “put together” with biomedicine, the legitimacy of which will hardly be challenged by any Hongkongers. At last, analogy and juxtaposition seem to be quite implicit and hiding underneath the texts. A more direct and explicit rationality must be provided. News discourse on mechanism orientation serves that purpose. Even though the mechanism of acupuncture is often based on the logic of Chinese medicine that is very alien to westerners, only by talking about it, the action of explanation itself has already become a source of legitimation. Over the last ten years, the percentage of news stories that explained the mechanism of acupuncture soared from 1.5% to 10% (see Table 4). Among these stories, the mechanism was not confined to the language, terms, and theories derived from TCM. Rather, a considerable proportion of the stories used ideas and introduced research following the logic of biomedicine or western science, such as results from clinic trials or scientifically designed studies (e.g., “Scholars reveal the principles of acupuncture,” Ming Pao, August 23, 2011; “Acupuncture helps Parkinson’s patients,” Apple Daily, October 24, 2012). Persons who delivered the explanation Legitimizing acupuncture in Hong Kong’s newspapers 20 about mechanism were not always traditional acupuncture practitioners. Sometimes they were researchers affiliated with research institutions or universities; sometimes they were licensed doctors of TCM. Therefore, as a result, the four types of instrumental rationalization worked together and provided diversified but coherent discourses to legitimize acupuncture. Legitimizing Acupuncture through Moral Evaluation The last form of legitimation discourse falls into the scope of moral evaluation, which often establishes or maintains legitimation by reference to “value systems” (van Leeuwen, 2008, p. 106). Moral evaluation is often linked to specific discourses of moral values, even though these discourses may not explicitly contain words like “good,” “bad,” “evil,” or “virtuous.” As van Leeuwen (2008) argues, moral evaluation can only be identified on the basis of analysts’ “commonsense cultural knowledge” (p. 110). That is because discourses on moral values are “only hinted” at through adjectives that “transmute” moral discourses into commonsensical motives such as health, hygiene, benefit, normality, and so on (ibid). In our study, the tone of reporting does not refer to the general tone of the whole news article. We only coded the tone associated with acupuncture. In other words, we looked for specific language used to describe or being articulated with acupuncture. For example, acupuncture might be described as the “prioritized” option for the patient, which obviously presents a “positive” tone. Some news stories cover “accidents” resulting from acupuncture 5 To decode the discourses on moral evaluation legitimation, it is critical to have coders who are native language speakers of the texts and who are sensitive to the language and rhetoric that often make the moral evaluation covert, rather than salient. Both coders for this study are native Hong Kong residents who majored in communication studies. As native Cantonese speakers and professionals who were trained to use language for communicating ideas, they are highly sensitive to the culture of Hong Kong society, as well as the language and rhetoric employed by local media. Moreover, during the training process, both coders were asked to read the news stories repeatedly. Particular linguistic anchors were also discussed among the researchers and the coders to uncover the moral codes disguised by adjectives that had no obvious moral meanings, such as novel, natural, healthy, scientific, and so on. It is based on the logic and process outlined above that the last part of quantitative information of our research—the tone of acupuncture news—was coded. Legitimizing acupuncture in Hong Kong’s newspapers 21 therapy, such as a partial collapse of the lung, or complaints about acupuncture as “ineffective” by patients. These articles were coded as presenting a “negative” tone. Stories that did not particularly use any words to make judgments on acupuncture were coded as “neutral.” As a result, we found that both the percentages of the “positive” (from 25.2% to 32.3%) and the “negative” tone (from 4.9% to 12%) emerged from the news coverage increased significantly over the last ten years. In comparison, the percentage of the “neutral” tone nevertheless declined (from 44.4% to 36.5%, see Table 5). --------------------------------Insert Table 5 about Here --------------------------------However, the general description of tones does not provide us sufficient information to analyze how legitimation through moral evaluation works. We further divided the three reporting tones based on news sections where authorization legitimation was located. As Table 6 reveals, the percentage of positive tone of reporting increased more dramatically in the “health/medical news” section (from 14.9% between 2001 and 2003 to 43.4% between 2011 and 2013), while the negative tone used in the same news section only showed a relatively much slighter increase (from 15.4% to 18.8%). Such a change may influence the readers’ perceptions of acupuncture greatly, since the newspapers were more inclined to represent the treatment as positive, effective, and scientifically approved method. We noticed that, across the ten years, more scientifically designed studies on the effectiveness and principles of acupuncture were reported by the Hong Kong press between 2011 and 2013, many of which were conducted by research institutes in Hong Kong. However, the news stories dominated by a negative tone were most likely to be associated with medical accidents Legitimizing acupuncture in Hong Kong’s newspapers 22 caused by illegal practices of TCM or individual negligence of the TCM practitioners. Hence, to compare these two types of reportage, it seems easy for the readers to conclude that acupuncture has received quite positive evaluations from the medical community and the “bad” issues associated with it were mainly caused by individual practitioners. --------------------------------Insert Table 6 about Here --------------------------------When acupuncture was mentioned in the news sections that were not related to medical sciences, it was represented less negatively. For example, the percentage of news with negative tone decreased most drastically in the “Hong Kong news” section that mainly covered local spot news or policy issues (from 76.9% to 31.3%). For newspapers in Hong Kong, it is most likely that unexpected accidents or policy changes occurred in the city would be published on front page. Hence, the “Hong Kong news” section often overlaps with the front page. As a result, readers were less likely to be exposed to “negative” stories on acupuncture after 2011. This argument can be further supported by the change appeared in the “others” section of Table 6. The negative tone increased the most noticeably, from 7.7% to 35.4%, in news sections such as finance and economics, foreign news, etc. (all of which were included in the group of “others”). However, acupuncture rarely became the main topic in these news sections. It is hard to expect that readers interested in the treatment would seek information on it from these news sections. Therefore, the negative tone seemed to be attenuated since the once concentrated negative representation of acupuncture in the local news section became Legitimizing acupuncture in Hong Kong’s newspapers 23 dispersed across the newspapers, especially to the sections where readers would not expect to read about acupuncture. From Table 6 and the analyses above, it is clear how the legitimation technique of moral evaluation works. Even though both positive and negative tones became more perceptible over the last ten years, they did not work evenly for the purpose of legitimation. Since the percentage of positive tones increased by more than double in the news section on health and medical news, we undoubtedly argue that the moral evaluation discourses employed by the Hong Kong press was for the purpose of establishing and reinforcing the legitimation of acupuncture. For readers who are particularly interested in the treatment, they would be more likely to be exposed to those “positive” tones and become convinced. Moreover, the neutral tone also played a role in strengthening legitimation. There was a relatively significant increase in terms of reporting acupuncture with a neutral tone in both the “news supplement” (from 6.8% to 13.7%) and “commentary” (from 4.2% to 10.3%) sections. In journalism practice, these two sections were most likely to convey “biased” opinions, from example, through “advertorials” or “readers’ letters.” The significant increase of “neutral” reporting in these sections may imply that the opinionated news was trying to conceal its bias and disguise its opinion or purpose with the appearance of “neutrality.” As a result, “news,” “advertorials,” and “opinions” on acupuncture would not be easily differentiated by the readers. Those who could tell the difference would be more willing to view acupuncture as legitimate since even those supposedly “biased” reports covered acupuncture in a neutral way. Discussion Legitimizing acupuncture in Hong Kong’s newspapers 24 Whether acupuncture is actually effective or should be regarded as legitimate medical knowledge is not the concern of this study. As Max Weber and many other scholars have argued, legitimation is established based on “a collective construction of reality,” a process during which individuals presume others accept and share the same framework of norms, values, and beliefs (Johnson, Dowd, & Ridgeway, 2006, p. 55). Mass media undoubtedly constitute one of the most critical domains for individuals to form such types of “presumption” and to achieve a cognitive consonance when accepting the legitimation of certain objects. Therefore, what we are interested in here is the way media texts work to organize a field of knowledge and practices about acupuncture in a post-colonial society (i.e., Hong Kong) where contrasting perspectives and hybrid ideas rooted from the East and the West clash and intermingle. We conceptualize acupuncture as socially constructed health knowledge that gains its legitimacy through media discourses. Guided by the legitimation discursive framework developed by van Leeuwen (2008), we analyzed the contents of 666 news articles related to acupuncture published in two Hong Kong newspapers over a ten-year period. “The establishment of legitimacy is a contested process that unfolds over time” (Johnson et al., 2006, p. 59). We found that, the legitimacy of acupuncture has gradually been established and greatly strengthened, at least in the media landscape, over the past ten years. The legitimation discourses produced by the two Hong Kong newspapers can be categorized into three main forms. First, the Hong Kong press more and more intended to attribute and associate acupuncture with medical and health authorities. Second, the coverage on acupuncture intended to contain more discourses on instrumental rationalization, which Legitimizing acupuncture in Hong Kong’s newspapers 25 provide substantive reasons for the readers to accept the treatment. Third, the moral evaluation on acupuncture by the press tended to be (1) more visible when positively evaluating it in the medical and health news section, (2) more dispersed when conveying negative messages, and (3) more disguised with neutrality when actually trying to be persuasive. The three legitimation forms or discursive strategies—authorization, rationalization, and moral evaluation—mutually disclose a complex process of producing legitimacy for acupuncture through news narratives. We must admit that, from the news coverage alone, it is hard to conclude that the Hong Kong press was intentionally to legitimize acupuncture. However, associating the legitimation constructs identified from the news with the changes in government’s policies that greatly encouraged the development of TCM and the increased acceptance rates of TCM among the Hong Kong residents, it seems that the effort of legitimizing acupuncture was carried out at many different aspects of Hong Kong society. The Hong Kong press apparently could not resist the trend. It reflected the reality, while participated in reproducing it as well. Limited by the length of the article, many detailed linguistic indicators and examples cannot be elaborated. What needs to be studied in future research is the influence of media’s legitimation of acupuncture on the general public. For example, longitudinal agenda-setting effects at the societal level, the framing effects at the cognitive level or the behavioral changes induced by the legitimation discourses, such as whether the general public is more willing to actually receive acupuncture treatment after reading the news. Moreover, in our previous studies on the perceptions of acupuncture among Hong Kong residents through a survey (**, forthcoming) and focus-group interviews (***, forthcoming), we found that there is a significant difference of attitudes toward acupuncture between the users and the nonLegitimizing acupuncture in Hong Kong’s newspapers 26 users. Among the user group, acupuncture was perceived as being effective, having few side effects, and generating a lasting impact. Whereas the non-users perceived acupuncture as lacking clinical evidence, being high risk, and being non-standardized; and thus they had less confidence in acupuncture than biomedicine. Linking these findings to the present study suggests we think more about the complicated process of legitimation in reality. We must admit that the mass media is a place for legitimation and delegitimation discourses to coexist. As Kelman (2001) argues, the process of legitimation often operates in tandem with delegitimation. Hence, media discourse on the legitimacy of acupuncture only provides discursive repertoire, a “tool kit of habits, skills, and styles from which people construct strategies of action” (Swidler, 1986, p. 273). The understanding and interpretation of the legitimation discourses created by the mass media are not derived from their “abstract or dictionary” meanings but from their “situated use” (Wetherell & Potter, 1992, p. 90). For that reason, the actual practice of media discourse on acupuncture deserves more attention from future research. Legitimizing acupuncture in Hong Kong’s newspapers27 ReferencesAcupuncture helps Parkinson's patients. (2012, October 24). 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Apple Daily.** (forthcoming). Hong Kong consumers’ attitudes toward acupuncture? InternationalJournal of Pharmaceutical and Healthcare Marketing.*** (forthcoming). Perception of acupuncture among users and non-users: A qualitativestudy. Health Marketing Quarterly. Legitimizing acupuncture in Hong Kong’s newspapers32 Table 1: Number of stories on acupuncture published by the two newspapers in Hong Kong2001-20032011-2013Ming Pao145154Apple Daily121246Total N=266400 Table 2: General outline of stories on acupuncture in Hong Kong’s newspapers2001-20032011-2013Acupuncture as main reporting subjectYes23.7%20.3%No76.379.8Place of newsHong Kong77.1%83.8%Mainland China15.05.0Other places7.911.3Total N=266400Note:1. Acupuncture as main reporting subject: χ =1.11, df = 1, p = n.s.2. Place of news: χ = 20.56, df = 2, p<.001 Legitimizing acupuncture in Hong Kong’s newspapers33 Table 3: Legitimizing acupuncture through authorization2001-20032011-2013News sectionLocal News22.6%18.0%Entertainment/Sports/Education21.816.0Health/Medical News14.322.3Supplement/Advertorial6.812.0Commentary/Op-Ed4.98.8All others29.723.0Primary sourceMedical professionals29.7%36.5Celebrity acupuncture receiver14.316.5Ordinary acupuncture receiver6.816.8Other49.230.3Total N=266400Note:1. News section: χ = 20.44, df = 5, p<.0012. Primary source: χ = 30.40, df = 3, p<.001 Legitimizing acupuncture in Hong Kong’s newspapers34 Table 4: Legitimizing acupuncture through rationalization2001-20032011-2013Purpose of acupunctureCommon use21.1%34.0%Peripheral use18.014.5Illness treatment9.016.5Mixed purposes9.46.8Other2.32.0Inapplicable40.226.3Effectiveness of acupunctureBeneficial effect19.5%15.8%Effective but with limitations13.222.3No effect2.66.0No effect and lead to bad results2.38.0Not mentioned62.447.5Inapplicable--0.5If acupuncture was the only medical treatment reportedYes27.4%24.3%No: reported with other TCM16.917.3No: reported with other TCM and biomedicine15.820.3No: reported with biomedicine11.319.8Inapplicable28.618.5If the mechanism of acupuncture explainedYes1.5%10.0%No98.589.5Inapplicable--0.5Total N=266400Note:1. Purpose of acupuncture: χ = 28.45, df = 5, p<.0012. Effectiveness of acupuncture: χ = 29.53, df = 5, p<.0013. If acupuncture was the only medical treatment reported: χ = 16.57, df = 4, p<.0054. If the mechanism of acupuncture explained: χ = 20.18, df = 2, p<.001 Legitimizing acupuncture in Hong Kong’s newspapers35 Table 5: Legitimizing acupuncture through moral evaluation2001-20032011-2013Tone of reporting acupuncturePositive25.2%32.3%Negative4.912.0Neutral44.436.5Inapplicable25.619.3Total N=266400χ = 16.95, df = 3, p<.001 Table 6: Tone of reporting across news sectionsPositiveNegativeNeutral2001-2003 2011-2013 2001-2003 2011-2013 2001-2003 2011-2013Health/MedicalNews14.9%43.4%15.4%18.8%14.4%14.4% Entertainment/Sports/EducationNews28.415.5--4.228.025.3 Hong Kong News14.911.676.931.316.913.7Supplement/Advertorial9.09.3--4.26.813.7 Commentary/Op-Ed7.58.5--6.34.210.3 Others25.411.67.735.429.722.6Total N =671291348118146 View publication stats