Using a three-phase between-subjects interventional design, we investigate the effects of installing sound proofing materials and playing music during the lunch meals at a specialised ABI hospital unit. Comprising both quantitative and qualitative research approaches and data acquisition methods, this project provides multidisciplinary and holistic insights into the importance of attending to sound in hospital surroundings. Our results demonstrate that improved acoustics and music playback during lunch meals might improve the mealtime atmosphere, the patient well-being, and social interaction, which potentially supports patient food intake and nutritional state. The results are discussed in terms of potential future implications for the healthcare sector.Eating-related challenges and discomforts arising from moderately acquired brain injuries (ABI)—including physiological and cognitive difficulties—can interfere with patients’ eating experience and impede the recovery process. At the same time, external environmental factors have been proven to be influential in our mealtime experience. This experimental pilot study investigates whether redesigning the sonic environment in hospital dining areas can positively influence ABI patients’ ( Addressing disease-related malnutrition is urgent, and nutrition is key to addressing health and well-being and reducing healthcare costs ,2. MalnuPatients with an acquired brain injury (ABI) are at risk of malnutrition both in the acute and the subacute rehabilitation phase ,13,14,15Increasing the attractiveness of the care environment may include the display of art works, such as paintings, sculptures, or other installations, either as temporary exhibitions or as permanent integrations within the buildings themselves . Scarce One study concluded that images of naturalistic nature scenes compared to either abstract or representational paintings, reduced mental health patients’ anxiety and agitation during 3- to 4-day stays in a United States hospital . AnotherWell-documented evidence shows that the acoustical quality of a room greatly impacts our hearing, such as our ability to interpret acoustic communication modes, e.g., speech ,43,44,45Hard, reflective surfaces, often found throughout hospital structures , will tyAccording to Danish regulations, no specific noise exposure level thresholds exist for hospitals or other healthcare facilities, including common areas, such as dining rooms. However, in an effort to provide some guidelines for room acoustics in hospital canteens and cafeterias, the executive order on building regulations recommends to follow the acoustic criteria of the so-called sound classification C when no regulations are specified . AccordiFurther, the building code states that “it must be ensured with due consideration of the use of the building that persons in the building are not disturbed by sound” . EvidentAlthough detailed investigations into the role of the acoustic hospital mealtime environment have been largely overlooked in scientific literature, studies of the beneficial and detrimental effects of music and noise on various other health outcomes exist in abundance ,52. In pMusic is known to be an enriching emotional, cognitive, and physical experience when sought or encountered in our surroundings . The mouAlthough empirical evidence from the above-mentioned studies reveals positive outcomes related to food intake and mealtime behaviour, their general validity is somewhat limited by small and narrow study populations with severe cognitive impairments and/or exhibiting adverse behaviour. Furthermore, outcome measures of a mainly observational nature, e.g., agitation rating scales and checklists, staff surveys, patient weight, and pulse rate recordings were used, neglecting the relevance of patients’ experienced mealtime and curtailing the potential relevance to other patient groups. In addition to this, attention to individuals’ music preferences or responses were insufficiently addressed, and while some did report registrations of background noise levels ,66,69,72Other non-musical acoustic properties of the architectural structures were otherwise widely disregarded, which presents challenges for replicating results and raises concerns related to the overall increased sum of sound sources when music is added to an environment . FinallyDining areas of hospitals are patently complex, vary greatly from facility to facility, and comprise numerous elements, all of which affect the patient mealtime experience. Likewise, mealtime practices will differ according to patient groups, resources, etc. This exposes an indisputable need to at once address the nature of the perceived components in isolation while also taking into consideration the holistic multisensory experience embedded in specific environments. The current pilot study presents an exploratory approach to aestheticising a hospital eating environment. Specifically, we propose that careful attention to room acoustics and wall décor in addition to mealtime music improves nutritional care in a hospital rehabilitation context. In a collaborative effort between audio industry professionals, researchers, and clinicians, this pilot projects seeks to:Identify and resolve issues in the existing acoustic environment of a common dining area of a hospital ward.Explore how improvements to the acoustic eating environment, including music playback, affects patients’ mealtime experience, behaviour, and food intake.Examine various musical genres and their appropriateness for eating situations in hospital settings.The project followed a novel methodological interventional framework, incorporating acoustical measurements, observational studies of patients during mealtime, and individual semi-structured interviews with patients and staff. The project was designed as a between-subjects design comparing effects between the three phases, in which each intervention phase builds upon the previous see . Phase 1 was a baseline period with no interventions, the purpose of which was to provide a reference point both for the acoustic and music interventions (Phases 2 and 3) as well as a control for mealtime behaviour observations and interview data. Sound proofing materials installed in Phase 2 were chosen based on measurements at baseline, whereas the music playback equipment and volume level in Phase 3 was set according to the room acoustics data obtained from measurements in Phase 2. The study lasted approximately three months, with each intervention running for 17–18 days on weekdays during lunch (11:30–12:15). A designated project nurse was appointed to administer all project activities related to the hospital mealtime processes.Initial conversations with hospital staff revealed certain annoyances related to the acoustic parameters of reverberation time ,77 and sPrior to the baseline phase, acoustic analysis of reverberation time and speech transmission index in the empty dining room was performed. These measurements revealed an average speech transmission index of 0.604, while the average reverberation time was 0.97 s, exceeding the recommended limit values for sound Class C . Based oThe replaceable, sound transparent fabric is customisable for each use case. Keeping in mind the assumption that naturalistic images seem to be preferred among hospital patients , we inviAfter acoustic treatment of the room see , the aveFive playlists of instrumental only pieces were compiled. The music was primarily chosen from a list of validated pieces developed in a Danish clinical music therapy project ,78,79. TSeventeen patients with acquired brain injury (ABI) indicated by a median score of 99 at the Functional Independence Measure (FIM) scale  took part in the study. Of these, 15 agreed to be interviewed about their mealtime experience, and six patients, whose hospital stay spanned two intervention phases, were interviewed twice. Recruitment took place upon admission to the specialised rehabilitation ward.Criteria for recruitment in the study covered diagnosis of ABI from stroke, traumatic brain injury, anoxia etc. Common changed functional abilities following ABI included cognitive  and physical . The recruitment criteria for participating in interviews covered the ability to express oneself in Danish, having had at least two meals in the common dining area without severe eating disabilities and assistance needs, and demographic information, such as age and gender, to ensure variation and representability among the participants. The patient characteristics are shown in Patients were given a pre-determined meal plan upon admission to the hospital detailing the rotational schedule of the food options. Lunch meals would consist of a soup of the day, a warm meal, followed by open-faced sandwiches with three filling options . The food rotation scheme was three weeks, after which it would start over. Identical food options in all project phases could thus not be guaranteed throughout the duration of the study. At lunch, patients requested their desired food and drink ad libitum, which was subsequently weighed, registered, and handed out by the staff.The room was located on the fifth floor of the hospital building, and the room temperature was consistently held at 22 degrees Celsius throughout the project period, which took place during the autumn of 2020.relative loudness of perceived sound, primarily in the mid and high frequencies, as the ear is less sensitive to low audio frequencies), and dB(C), which takes into account the entire frequency range, including high and low frequencies, e.g., present in music. Note that decibels are not absolute units of measurements and follow a logarithmic scale.Overall sound pressure levels (SPL) during lunch on weekdays in all phases were recorded every minute between 11:30 and 12:15. Two different weightings of these measurements were used: dB(A), which mimics the human-ear frequency response ; overall observation of behavioural response in relation to the project interventions; the degree and type of social interaction among the patients; body mass index; and FIM were recorded on separate forms developed for the study see . DemograBehavioural response comprised estimates by the project nurse of (1) the level of social interaction exhibited by the patient, and (2) how the patient responded to the study interventions, if any . Social interaction was defined in this study as: “active, thinking people engaged in meaningful social action with each other”, described by Curle and Keller  adapted Both social interaction and behavioural influences of intervention were observed by the project nurse and rated on five-point scales; the social interaction scale was anchored by 1 = no interaction and 5 = a lot of interaction. The influence of intervention was judged from negative (1) to positive (5), with the midpoint value of 3 being a neutral “no response” point. The design of both scales was developed in collaboration between staff and researchers. Due to the design of the scales, patients received social interaction ratings during all three phases of the study; in contrast, the influence of intervention was only evaluated in the phases 2 and 3, where some form of intervention took place. The form also allowed for field notes to ensure representation of more detailed accounts of mealtime behaviour and social actions etc. See . For eacA series of semi-structured face-to-face interviews with patients were conducted by the first author at the hospital on a weekly basis, depending on patient availability/scheduling. Only the patient and the researcher were present during interviews. No prior relationship between the two existed. Interviews lasted between 10 to 30 min, and each participant signed a separate consent form before the interview. The interview guide was developed to assess themes relevant to the study objectives and the participants’ immediate perception/evaluation of the mealtime activity, including how much they enjoyed the lunch meals and the dining room atmosphere; their overall comfort before, during, and after the mealtime experience; their general attitudes towards the project, and their general mealtime and music listening practices see . ShorterTwo interviews with the project nurse were undertaken to supplement patient statements and to provide further observations from the staff point of view. All interviews were audio-only recordings, conducted in Danish, and transcribed verbatim by the first author.Sound pressure level measurements during the mealtime were analysed using a 10EaZy template for Microsoft Excel. For each meal occasion, two average decibel levels (A-weighting and C-weighting) were calculated based on the 1-min SPL recordings.t-tests were conducted on response to intervention scores against the no-intervention midpoint scale value of 3, to determine if interventions from phase two or three evoked any behavioural responses from the patients. All quantitative data analysis was carried out with SPSS 28.The food and fluid intake for each participant were averaged for all meal occasions and grouped by project phase (1–3). Due to non-standard distributions, non-parametric Kruskal–Wallis tests were used to compare mean food and fluid intake values between project phases. In terms of behavioural measures, a Kruskal–Wallis test was run to compare social interaction scores across the three project phases. Finally, one-sample Patient interviews were analysed using a phenomenological/phenomenographical approach to meaning analysis ,84,85. ISections and/or excerpts are reproduced in quotation format translated into English. Quotes are accompanied by an anonymised participant number and the project phase in which the statement was obtained.The average sound pressure levels (dB) across all phases show that the acoustic treatment reduced the overall sound level in the room from Phase 1 to 2 with −2.02 dB(A) and −2.32 dB(C), and from Phase 1 to 3 by −1.55 dB(A) and −1.12 dB(C). Note that ~1 dB change in SPL results in a noticeable change in loudness perception , indicatp = 0.908; fluid: H2 = 1.918, p = 0.383. That said, the average fluid intake increased monotonically in each phase  to Phase 2 (Mean Rank = 81.85), and subsequently increased in Phase 3 (Mean Rank = 83.62), H2 = 8.745, t-test was run to determine whether patients’ response to intervention was different from the no-change score of 3. The mean response score in Phase 2 (4.52 +/− 0.79) was significantly different from 3, with a difference of 1.52 , t49 = 13.63, p ≤ 0.001. The mean response score in Phase 3 (4.9 +/− 0.30) was also significantly different from 3, with a difference of 1.90 , t49 = 44.33, p ≤ 0.001.Finally, a one-sample Participants gave nuanced accounts of their mealtime activity at the hospital and were able to identify essential aspects related to the quality of the eating experience. Multiple themes arose from the interviews: the concept of commensality saturated the interviews and was articulated as a significant and indispensable part of the participants’ daily lives . While difficult to describe concisely, participants conceptualised commensality as a cluster of values including external/physical as well as social components. Another central theme that emerged from patients revolved around the use of music in hospital settings. In particular, patients’ views on appropriate genres for the mealtime context and the affordances that music listening provides are included in the analysis.In the following, we present these thematic categories as they relate to the project interventions. For the purpose of reporting, these themes will be presented separately; however, a certain degree of overlap exists among the topics.First, we describe the experienced benefit of the acoustic improvements on the ability to communicate and focus during the meal. Next, we introduce views on the aesthetic component of the sound-proofing panels and the evaluation of the environment following the interventions of Phase 2. Third, we expand upon the central theme of commensality, especially in terms of how the music affected emotional/psychological patient relations during the meal . Finally, we evaluate participants’ attitudes and expectations towards the use of music in a hospital setting. Staff perspectives on the above-mentioned themes are included to support the patient statements.As evident by patient statements, verbal communication was considered an essential part of facilitating the specific communal connection between patients occurring during the common meal. In addition, patients valued calmness and quiet during their lunch, in part to be able to listen and respond to each other while eating, and in part to exclude the commotion of general hospital operations. A patient in the baseline phase described how the bustle of hallway traffic and the busy kitchen area inside the dining room was distracting her from the eating activity: “I think I become disturbed. I am looking around everywhere […] It gives a frustration that it [the kitchen] is over there […]” . The same patient experienced the overlap to Phase 2, and, in the second interview, she commented on the comparable differences of the acoustic properties of the room: “It has absolutely helped. It has become more, well more tranquil in the room. The acoustics are better […] there is quieter in the head. We are better able to talk now” . Another patient agreed that the acoustics had improved to a degree that affected the inter-patient communication: “Before, it sounded very… I don’t know how to describe it, was it rumbling in there? Yes, well, it was more ringing. And that is completely gone. When you talk, you can understand everything” . Supporting the patient statements, the project nurse also indicated a noticeable effect of the sound-proofing materials. In particular, she described how being in the room became a more pleasant experience and how certain patients became more actively engaged in the ongoing conversations:I think there is a big difference in the sound […] I could clearly hear that it was easier to talk at the table…There is less “ringing” in the room […] I think you are much better able to hear what is being said around the whole table. You are taking part more. Because it is not ringing in the same way in there. It is just calmer […] You can almost feel it the moment you enter, even when you don’t speak, it is as if there is just better acoustics. It is just kind of better in a way […] it is a nice place to be (project nurse).The panels appeared to offer an additional benefit to the staff managing the lunch activity. The project nurse emphasised that communication between nurses and nutritionists also improved during the patient lunch, and that the racket from serving ware diminished:Before, it was just a bad room in which to move plates and cutlery around, but I don’t think this makes as much noise anymore […] it has also led to us speaking softer. When we’re standing at the buffet, we have not spoken so loudly I don’t think … It has this calming atmosphere (project nurse).For me, it’s the cosiness. To eat, that is cosy” . Cosiness was thought to be ascribable both to inter-personal relations and to the external, physical environment. Regarding the latter, patients emphasised that an attractive dining area was more pleasant and inspiring and had a positive influence on their mood by making the surroundings less institutional. Room descriptions in the baseline phase tended to revolve around the “lifelessness” and “coldness” of the hospital dining environment: “There is more sterile in there. There’s not that cosiness, that sort of presence that says “welcome”. I think that is missing” . Another patient stressed this point further:A recurring theme throughout the interviews related to being inside a “cosy” space. Participants frequently used the word to positively describe the holistic experience of the mealtime event. For instance, one participant said: “We are just sitting, you know, like “hospital”, and “older people”, and “it’s a bit sad” and it’s a “serious illness” […] Recovery should be a cosy place where you feel at home, because you have to be there for a long time .I have definitely noticed the pictures that have been put up in there […] So they do make it cosy for us […] It’s just a cosy place to sit and chat” , and another commenting: “It is some very nice pictures […] It is important that it is cosy […] It means that it is pleasant to be in there. You notice that someone has done something to make it feel pleasant” . One participant was especially captivated by the motives of the wall panels and illustrated their appreciation by describing a quasi-physical experience that they afforded:Compared to the baseline phase, patients in Phase 2 appeared to appreciate the appearance of the physical environment to a greater extent. Patients not only noticed the intentional efforts made to decorate the dining area with the photographs, but indeed lauded the homeliness and cosiness of the room: “[…] I think that if [the pictures] had not been there, then it would have been very hospital-like. Because there are completely white walls in there. And these pictures are fantastic. The blueberries and the cabbage and the apple. The colours, and then the mere size of them […] It seems cosy, you are almost… it grabs you, the room “hugs” you […] The colours, the deep, red apple and those blueberries and the cabbage, yes, it is a little intoxicating, because of the size. Yes, it is cosy, very cosy .it has really been much talked-about. Also by people just passing by: “you have put something in there!” These pictures are just attractive, I think” (project nurse).These statements were echoed by the project nurse who indicated that the perceived advantages of the photographs to make the environment stand out from the rest of the hospital facilities extended beyond the patients’ views. She commented that visitors to the ward, including other hospital staff and management, were enthusiastic about the images and found them extraordinary: “It works well that there is music. It is a room that you feel comfortable inside of. Music makes the room nice” . The presence of music in Phase 3 appeared to infuse the room with an aesthetic dimension similar to the effects of the wall panels mentioned earlier. However, whereas the panels provided an obvious visual beautification, the music seemed to offer an improvement to the general mood and atmosphere of the room. The patients considered the music as an integrated part of the dining area that distinguished it from others at the hospital: “Well, it sure has been cosy that there was music […] It’s not that I think about it before I enter, and then I enter and I see “oh yes, there is music”, and that is very lovely” . Related, the project nurse recalled a statement from a patient describing her experience of the room after the music had been introduced: “one of them said one day: ‘it seems like you enter into a little oasis’” (project nurse).That music was already playing when they entered the room seemed to have a positive effect as if crossing a threshold into another type of space: “It’s like this [shows an embracing gesture with her arms], like a wave, swaddling you. The music, I mean. Comforting, pleasant” , while another emphasised that it made him more relaxed: “You relax more, I think, when there is a little music” .In general, patients shared the understanding that the music had a calming effect and made them feel immediately at ease. Illustrating this point, one patient stated: “from they enter the room, it’s like they almost ‘float’ over to their seat” (project nurse).Elaborating on this aspect of calmness and pleasantness, the project nurse observed that the music may have influenced the way in which patients physically acted when entering the room, describing: “I think it has had a positive impact on the people in there […] people are sometimes listening to the music. And then we talk a little. And then we listen a little again” . Closely reflecting this statement, another patient said: “I enjoy the music when I am in there. I like that it is there. Often there will be pauses you know, and then it’s nice that there is something [the music] that takes over, and then the conversation picks up again” .In addition to providing the patients with a relaxing and pleasant atmosphere, there was a general agreement that music assumed a ventilatory role, almost calibrating the shared mood of the room. Music was described as both filling out periods of silence as well as providing a pleasant backdrop to the ongoing conversation: “It can become a bit disease-fixated, even though we try to make it less so” (project nurse). However, with the introduction of music to the room, the conversational style itself shifted towards other topics. There was an additional, somewhat surprising, effect of music playback on the conversational content and quality during lunch. Throughout all phases, having a forum in which to share their lives and everyday experiences was described as very valuable to the patients. Discussing their particular rehabilitation trajectory, in particular obstacles and setbacks along the way, were often the main focus of the talks around the table. Yet, the project nurse pointed out that conversations could tend to circle around the more serious aspects of the hospitalisation experience, sometimes exacerbating a negative mood: “You connect [a piece of music] with an experience that you’ve had […] And that made me think back on how that experience was” . More patients described how the music itself became the topic of conversations. Specifically, patients actively engaged in discussions about the music, either commenting on the pieces or guessing the names of the songs or artists as they were played:This was highlighted by several patients, who described how certain musical pieces evoked positive memories and provided a welcomed distraction from the otherwise serious nature of the hospitalisation: “I definitely think there are more conversations now. We talk about ‘this one, we know this one’, and ‘this one is by so-and-so’ […] And I think that the chatter is going better […] there was a melody from a gymnastics show I had seen, that I really liked. Then I told the others about that experience I had had with that piece of music. In that way the music leads us onto some other topics than we normally talk about .is also a conversational topic for us: ‘Is it good music today? […] Oh, it’s waltz music’ […] the music, now that I think about it, is something that we comment on every day” . One patient expressed that the mealtime music to her was a way of bonding with people with whom she would otherwise not share many commonalities:Another patient repeated the notion that “[the music] […] it is nice that there is background music […] we did not choose each other. In that way, it is nice that there is also music. Then you have something to naturally talk about […] it has definitely generated conversations about the music .There were days when we were in there an hour, and we have not done that before as far as I remember. So, it has been longer days, maybe 10–15 min more some days than before” . This notion recurred in another patient statement: “Before the music, we just ate and then we left. Now we stay almost until 12:15 every day. Otherwise, we would leave around 12, so yeah in that way, we stay a little longer I think” . Patients also shared the view that the music somehow affected their eating behaviour. Specifically, they mentioned spending more time eating when the music was playing, as well as experienced increased enjoyment from the food. One patient stated that:Finally, a number of statements by the patients who experienced the overlap between Phases 2 and 3 indicated that the pleasant and relaxing mealtime atmosphere created by the music made them want to stay in the room beyond the normal lunch duration. They noted that they stayed up to 15 min past the time when lunch would normally conclude: “I think it [the music] does that you take longer to eat. Because you are sitting and eating and enjoying […] The way that we eat the food. It is better digested than when we just quickly go in and eat and go back to our rooms. So, we sit and listen to the music and then enjoy .that thing when you sit and eat, they you take a small break to just listen. And then that thing where you just take a cup of coffee and such …” . A similar observation was made by the project nurse, who stated that the additional minutes spent inside the room also led people to reach for supplemental food items:This view was brought forth in another interview: “They have been sitting in there much longer. That has really been thought-provoking […] It was this thing where they would have a cup of coffee and talk a little. It was much more a cosy atmosphere after the meal […] and some of them actually eat more. It’s more this thing of where they grab a piece of fruit or a piece of bread with the coffee (project nurse).Well, it makes me happy […] music to me, that’s joy” , “It makes me relax and be happy” , “You become happy” , “It makes you happy. You are never angry when you listen to music” , “It gives a sort of optimism. And I think you feel good. It is a joy of life” . Throughout the interview process, most patients brought to light the ubiquitous presence of music in their everyday lives, often described as underscoring a host of activities, affording specific moods, or used to modulate emotional states. Participants also pointed out that they regularly used music as an accompaniment to eating and in general, they overwhelmingly linked their use of self-chosen music to mood-improvement and relaxation: “That [music at the hospital], I would say, I would not expect […] But I think it could be a nice thing” , “I don’t have a certain expectation about it, but I think it would be nice if there was like a quiet background [music]” .Despite their everyday habitual music listening, patients did not expect to encounter music in the hospital setting, although there was a general belief among the patients that music would improve the mealtime experience: “I think it would be a pity if the music became so loud that we almost couldn’t speak” . However, these same participants responded positively to the transition from Phase 2 to 3, explaining: “I think it has been at a suitable level. I was very worried that it would be too loud. And I don’t think it has been […] it worked well, and it has been positive” . Concerns about the prospect of music before Phase 3 were expressed by a few patients. They were mainly anticipating that the loudness of the music might interfere with the ability to talk at the table: “There has been a couple of days where it was too soft. I would have thought it would rather have been too loud, but there were days where it was too soft” . The project nurse confirmed that patients had briefly commented on the music playback volume, while at the same time noting that it did not seem to influence their ability to focus on the meal. In fact, she stressed that the overall response to the music had been overwhelmingly positive, and that the volume was ideal for both conversation and music listening.In fact, they even indicated that the music occasionally had been indistinct: “It’s like I kind of ‘cut’ out the music and say ‘well, this is not the important part’ […] You can shut off something you don’t think is good” . In terms of the music genres represented throughout Phase 3, the majority of participants emphasised variety as a positive element. Surprisingly few patients had negative opinions on the music, and there was an overall acceptance of the styles. Patients identified the playlists they enjoyed the most and were able to describe how they paid scant attention to the pieces they enjoyed less: “It [jazz] gives disquiet in the brain. It interrupts. And then it removes focus from why you are in there. It was better with something like Mozart, something like that. I mean something that swaddles nice and soft” . The project nurse made a similar observation, noting that certain patients appeared to be more sensitive to music with a higher dynamic range and/or conveying apparent emotional content. She recalled patients commenting on the “gloominess” of particular classical pieces or the “sleepiness” of certain MusiCure pieces, in addition to observing the somewhat distracting nature of the jazz playlist. She explained that the music “should not be either too jolly or too gloomy […] It needs to be ‘neutral’ in the mood” (project nurse).Only in one patient interview, the jazz playlist was specifically associated with negative outcomes, whereas the classical playlist was perceived as very comforting: “it was actually ones that we all knew […] Stuff like that you can just sit and enjoy really much, especially if it’s a good piece that you liked once” .From the five playlists, the one comprised of well-known songs in instrumental versions was often mentioned as the most preferred playlist, in particular because it was the one capable of creating associations to previous positive memories and gave rise to conversations. As previously mentioned in Suggestions that music can improve various health-related outcomes in the healthcare sector are not new, and the empirical evidence documenting the beneficial effects of music on physical and psychological disorders is rapidly mounting ,62,86. HThe first objective of the study was to identify ways of optimising the acoustic properties of the dining area. The acoustic treatment decreased the overall sound pressure level during lunch, decreased the reverberation time, and improved the intelligibility of speech from the baseline to Phase 2. Even with music playback in Phase 3, the overall sound pressure level was kept below the levels obtained in the baseline phase. These results indicate that acoustic improvements to existing hospital architecture are indeed both possible and highly effective and should be considered on a wider scale to decrease the risk of noise-related health-issues as reported by numerous studies ,55,56,57The second objective was to assess the impact of the acoustic room treatments, visual panels, and music during lunch on the nutritional status of patients in terms of intake amount, as registered by the caring staff. We found no significant effects on overall consumption of food or fluid, while we did observe a non-significant monotonic rise in beverage intake from the baseline phase to Phase 2, and from Phase 2 to 3.Of interest is the subjective accounts describing additional food or drink items being consumed in Phase 3 when music was playing. These anecdotal accounts are in line with previous studies demonstrating that dinner music is associated with longer mealtimes and higher food intake among dementia patients ,8. ThereBased on the findings by Beck and her colleagues, mealtimes can be considered as an opportunity for the patients to experience well-being when in a calming and appealing environment . We founOur results appear to be in agreement with this research suggesting the importance of “aesthetics” in mealtime settings and supports existing evidence arguing that the presence of visual art in hospitals can help reduce symptoms of stress and improve mood during hospitalisation . ResearcIn terms of the behavioural measures obtained from the registration forms, we found that patients responded significantly more positively to the music intervention than the acoustic intervention, compared to the baseline reference. Moreover, data from the registration forms revealed that the amount of social interaction decreased from the baseline phase to Phase 2, before increasing again in Phase 3. In addition, the qualitative interviews highlighted a shared understanding that the music provided calmness, relaxation, and positive mood to the group during lunch. We argue that this extends the previously mentioned notion that aesthetic properties in the surroundings promote a sense of homeliness and familiarity and affords a notion of comfort and safety during the meals ,12,13 toIn addition to providing physical calmness and enhancing the mood during lunch, patients reported that the nature of the social interactions during lunch also appeared to change in the third phase. While the presence of music may not have increased the amount of patient interaction, it contributed to more positive relations during the meals and provided new content for conversations. Our results correspond to previous research demonstrating that mealtimes are important social activities for patients, and a place where a sense of community and cohesion can be developed and maintained throughout the hospitalisation period . However, previous studies have indicated that hospital mealtimes tend to be characterised by the influence of disease, and that patients’ willingness to eat can be negatively impacted by a focus on illness during the meal . Our obsPossible explanations for the mechanism underlying this relationship are often ascribed to the theory of social facilitation , in whicThe findings from the interviews indicated that patients above all enjoyed the presence of music and the variety of the genres, and that individual music preference carried secondary importance in the overall experience of the music during lunch. This points towards the possibility of music to enhance the mealtime experience regardless of personal taste. We did find evidence of less preferred musical styles, specifically the jazz playlist and a few of the classical pieces, which seemed to be too energetic, emotional, and/or dynamically fluctuating for the mealtime situation. These results correspond to findings from existing literature arguing that mealtime music should encompass the characteristics of the existing definition of “relaxation music” found to decrease adverse behaviour of dementia patients ,74,75,79However, contrary to the existing belief that familiar music could have negative impacts on patients  and thatTo our knowledge, this is the first study to comprehensively investigate the effects of specific environmental interventions on hospital mealtime experiences and nutritional outcomes, incorporating both quantitative and qualitative data acquisition methods. However, there are obvious methodological limitations to the study design and uncertainties tied to the findings.An absolute between-subjects design could not be achieved due to the overlap of patients between phases. In addition, it should be noted that our ability to recruit patients was impacted by Covid-19 restrictions in terms of the dining room capacity. Only four patients were allowed in the room for each meal occasion, resulting in a small sample size and potential limited generalisability of the findings. However, due to a relatively homogenous study sample in terms of diagnoses and physical/cognitive characteristics, the results may be transferred to similar contexts. We must also point out that certain subjective accounts may be examples of after-the-fact intellectual speculation, rather than accounts of the actual situated effects of the interventions. All interview data were obtained and analysed by the same researcher, which could introduce the possibility of misinterpretations in the process of analysis. That said, considering the high degree of consistency across patient testimonies, this is unlikely to have played a role in the interview analysis process.Likewise, mealtime observations and staff reflections were made by the same project nurse, which increases the risk of evaluation bias. Overestimation of behavioural response and social interaction scores can, therefore, not be ruled out. However, knowing the patients’ traits and behaviours in the dining situation enabled the nurse to observe more detailed comparisons of patients’ experiences across phases, in addition to being known and trusted among the patients.Regarding food-related measurements, it could be argued that our measures of nutritional status and food intake alongside the subjective accounts could be further qualified by including more precise, yet non-invasive instrumental measures, for instance bio impedance analysis or other biochemical markers of nutrition. In addition, heed should be taken to the day-to-day variation in meals throughout the project period making comparative evaluations of the meals impossible. Furthermore, our study did not investigate the potential impact of the music on the tasting experience of the food itself. Evidence has long been indicating that background sound can influence the way we eat and how the food tastes . For exaFuture studies should first and foremost prioritise larger sample sizes and focus on employing more precise, systematic, and rigorous data collection methods to consolidate our results and expand the applicability of our findings.Our study demonstrates that a quality improvement approach of simple infrastructural modifications to the dining area can provide an important foundation for improving the mealtime experience for patients. This has obvious practical implications for the healthcare sector.First, the positive findings regarding the installation of acoustic sound absorption panels documented in this study provides hospital management with an incentive to consider installation of noise dampening materials as a cost-effective strategy to reduce potential negative outcomes related to noisy hospital eating environments.Secondly, increasing meal duration by simply playing music may provide hospital staff with an opportunity to encourage greater food intake during common lunch meals, especially among patients at risk of mal- or undernutrition. In addition, mealtime music should not be overlooked as a safe, simple, and efficient method to encourage social interaction, enhance mood and well-being during eating, and distract from stressors, which could prove helpful in encouraging more expedient food intake among those struggling with eating, including dysphagia or cancer patients, or those with disordered relationships with food, such as anorexia patients.Furthermore, the study provided the opportunity to engage patients and staff in the process of shaping the future hospital dining experience as well as identifying appropriate selections of music for a mealtime setting by asking participants about their everyday music listening practices as well as their expectations around the use of music in a hospital context. We propose that a broader range of stylistic variations than “relaxation music” alone, and even music of a more stimulating nature, may be of particular benefit to the hospital mealtime experience. It may well be that, for some patient groups, the mechanism by which music acts during meals is not solely due to the inherent musical characteristics but can also be attributed to situational factors, such as distraction from the hospitalisation experience, as previously mentioned.Finally, the project described here demonstrates the benefits of inclusive, collaborative efforts between stakeholders from state and local organisations as well as private industry professionals, opening up avenues for future research endeavours to improve the healthcare system.This exploratory project demonstrated that data-triangulation using instrumental measurements, observational quantitative, and subjective qualitative data offered nuanced insights into the relationship between the dining environment and the mealtime experience of patients during in-hospital rehabilitation following ABI. Ameliorating acoustic room properties and playing music during meals improved ability to converse, facilitated better social bonding and conversations, extended the duration of the meal, and exerted a calming influence on patients and staff.First, the positive findings documented in this study provide hospital management with an incentive to consider installation of noise dampening materials as a cost-effective strategy to reduce potential negative outcomes related to noisy hospital eating environments. Secondly, increasing meal duration by simply playing music may provide hospital staff with an opportunity to encourage greater food intake during common lunch meals, especially among patients at risk of mal- or undernutrition. In addition, mealtime music should not be overlooked as a safe, simple, and efficient method to encourage social interaction and enhance mood and well-being during eating.Taken together, the project provides a practical approach to obtain optimal acoustically conditioned hospital eating environments using attractive innovative means, i.e., acoustic wall absorption panels and mealtime music, thereby, increasing the overall quality of the patient mealtime experience.


The COVID‐19 crisis has forced researchers in Ecology to change the way we work almost overnight. Nonetheless, the pandemic has provided us with several novel components for a new way of conducting science. In this perspective piece, we summarize eight central insights that are helping us, as early career researchers, navigate the uncertainties, fears, and challenges of advancing science during the COVID‐19 pandemic. We highlight how innovative, collaborative, and often Open Science‐driven developments that have arisen from this crisis can form a blueprint for a community reinvention in academia. Our insights include personal approaches to managing our new reality, maintaining capacity to focus and resilience in our projects, and a variety of tools that facilitate remote collaboration. We also highlight how, at a community level, we can take advantage of online communication platforms for gaining accessibility to conferences and meetings, and for maintaining research networks and community engagement while promoting a more diverse and inclusive community. Overall, we are confident that these practices can support a more inclusive and kinder scientific culture for the longer term. We summarize eight insights learned from our own experience of collaborating internationally in the era of COVID‐19. The innovative, collaborative and Open Science responses that are currently being developed can serve as components of a new way of conducting international Science during and in a post‐pandemic world. Closed As the pandemic is affecting almost every aspect of our profession, the many challenges and consequences of working in academia during COVID‐19 have been thoroughly discussed , who met during an international postgraduate field course on plant functional traits,2One of the biggest challenges of the pandemic is the inability for many to either complete field campaigns or have access to laboratory facilities and equipment. For example, losing just one year of data can be damaging for the ability of many researchers, particularly ECRs who have limited timeframes to complete their training or research projects : for example, a 15‐min walk before and after work to separate the day. It is also important to take breaks—enjoy that lunch hour, or a cup of coffee. Having a designated office space, or setup, may also help maintain focus. Lastly, as we find ourselves with more online meetings, it could be advantageous to set aside meeting‐free days or afternoons, so as to reduce distractions and have blocks of time to dedicate to tasks that demand more focus.There are also ways to work together to promote productivity and focus in laboratory or research groups, many of which also support developing strong group dynamics. One option is to establish daily morning check‐ins, where all laboratory members meet virtually for 15 min to briefly discuss how everyone is doing, outline the day's plan, and share other news. These short meetings can help set the tone for the working day, and also promote focus and productivity through peer feedback and accountability. Other possibilities could take the form of “virtual pomodoros” with colleagues, where there are 25 min of work followed by 5 min to relax and chat. By hearing and seeing other people working, we are encouraged to keep focus, and we are rewarded with opportunities for conversation and access to colleagues to quickly check ideas or new developments. An extended version of this is virtual writing retreats, which can be a productive way to focus on a single piece of work , while also maintaining social contact.4Early career researchers in academia often struggle to manage competing pressures. Bielczyk et al.  provide http://www.efsa.europa.eu/; Conservation Evidence, https://www.conservationevidence.com/).An interesting option to consider when primary data collection is impeded is working on evidence synthesis, such as systematic reviews or meta‐analysis. As evidence synthesis is being more integrated into the broader research community . Interdisciplinary projects can develop in any context and not necessarily for COVID‐19, but this example highlights that these short‐term opportunities, born out of necessity, may in the future become longer term collaborations.With scientific endeavors increasingly drawing upon multidisciplinary approaches, these may open further opportunities to collaborate. Interdisciplinary research becomes especially relevant when we are facing a complex problem that can be addressed from different perspectives. In the context of the COVID‐19 crisis, many of the skills or resources available to ecological researchers could be redeployed , and online communication tools that allow group messaging. Together, these can work as a “virtual office,” allowing quick and easy access to information and almost instant feedback from colleagues. An additional advantage of many messaging apps includes their capacity to integrate with a wide array of other remote collaboration tools such as shared drives, videoconferencing apps, and shared online documents. Here, with online collaborative work, finding tools that support version control can be critical.This is also a good time to build reproducible workflows that follow best‐practice standards for project and data management  too expensive, or (b) locationally difficult, that is, many southern hemisphere countries. In a similar vein, scientific workshops and resources can also be adopted, with many traditional face‐to‐face workshops already being shifted, or supported by online platforms.8In‐person meetings with informal discussions remain the main way to foster collaborations and network, especially for ECRs  with different members of the community . Such events can make important contributions to increase scientific literacy among nonscientists and raise awareness of current research issues. As these events are hosted virtually, ECRs can connect with communities from around the world and participants have the possibility to be exposed to a wide range of scientific ideas that may have previously been inaccessible to them.9In times of crisis, underrepresented groups are those that disproportionately suffer the consequences of a sudden change (Bapuji et al., As ECRs, we need the COVID‐19 crisis to be a wakeup call for institutions and agencies to develop more flexible family‐friendly policies and action to mitigate parenthood, but especially motherhood penalties (Cech & Blair‐Loy, For building a more inclusive and diverse scientific community, we must also consider that most of the new approaches for working and collaborating remotely rely upon Internet access, visual displays, and text‐based chat interactions. In this context, it is important to acknowledge the difficulties to ensure access to meetings, resources, and digital networks for everyone. For example, it is crucial to appreciate which additional challenges may be faced either by colleagues from developing countries with unequal access to technologies (Moakofhi et al., 10The pandemic has illuminated that the way we do science is changing. Indeed, we are now in a process of adapting to this new reality. During this transition, each of us first need to take care of our mental and physical health, we need to help each other, and adopt new practices to maintain our capacity to focus and to promote resilience in our research practice. Within a very short time, we have shifted from a 100 percent in‐person model to an almost completely remote one. However, in this process we have also adopted new practices that hold large potential to serve as a foundation for a more international, collaborative, and Open Science model underpinned by technological developments. The question here is: “What do we want to keep for the future, and how?” The COVID‐19 crisis presents the opportunity for researchers and institutions to transition to a new hybrid model that integrates remote and in‐person workflows, taking advantage of the new skills that have recently been developed. It also presents us multiple opportunities to address long‐lasting issues in academia, such as the lack of diversity, equity and inclusivity. To take the final steps and use the momentum, we not only individually need to take action, but need the commitment and support of our institutions and research agencies. If we succeed to transform this new workstyle into routines, it could serve as a model for a community reinvention in academia. We should not miss the opportunity to take many of the eight insights for conducting science as a foundation to design the community that we want to work in.The authors declare no competing interests.Conceptualization: JCL and SRG lead; MB, BJE, WFR, RG, AHH, SLM, JvO, SPP, TS equal. Writing ‐ Original Draft Preparation: JCL and SRG lead; MB, BJE, WFR, RG, AHH, SLM, JvO, SPP, and TS equal. Writing ‐ Review and Editing: JCL and SRG lead; MB, BJE, WFR, RG, AHH, SLM, JvO, SPP, TS, and VV equal. Visualization: TS lead; MB, JCL, BJE, WFR, SRG, RG, AHH, SLM, JvO, SPP, TS, and VV equal.


Los Angeles Times and the San Francisco Chronicle, which represented two of the largest news markets in California when the measles vaccine was released, in 1963, and during the 2015 outbreak. Measles reporting during this period displays patterns pointing to an active role for journalists in shaping public understanding of health and medical matters, especially as they recede from public memory, through the employment of available and circulating political and cultural frames. Moreover, journalistic frames in this period of reporting incorporated presentist descriptions of the disease, which imposed present values on the medical past, and which were constructed of decontextualized historical references that supported prevailing contemporary notions of the disease. Framing and the tendency toward presentism, in the context of shifting public health discourse, had the effect of communicating an increasingly severe sounding disease over time, and of shifting blame for that disease’s spread from nature to government to individuals. Journalistic framing and causal stories have much power to shape public understanding of medical matters as they recede from public memory.Language used to describe measles in the press has altered significantly over the last sixty years, a shift that reflects changing perceptions of the disease within the medical community as well as broader changes in public health discourse. California, one of the most populous U.S. states and seat of the 2015 measles outbreak originating at Disneyland, presents an opportunity for observing these changes. This article offers a longitudinal case study of five decades of measles news coverage by the  Los Angeles Times, blamed the outbreak on parents. Measles was a leading, highly contagious childhood disease that once killed millions each year, wrote Times reporter Karen Kaplan. But modern Americans no longer feared it because they “have no first-hand experience with measles or other dangerous diseases that used to be common.” The problem, Kaplan explained, was exacerbated by the influence “of the anti-vaccination movement,” which spread misinformation about measles and its vaccine and was “certainly” responsible for the outbreak’s “scope” (Kaplan 2015). Like others published at the time, the article defined measles as a social problem and identified its cause as misinformation spread by individuals. The article also implied journalism’s role in the solution: to reach a wide audience with reliable facts about measles in the present as well as pertinent information about measles’ past.In 2015, a case of measles in a Disneyland visitor sparked an outbreak of one hundred forty-five cases in seven states. In the attendant media storm, Disney’s hometown paper, the Los Angeles Times and the San Francisco Chronicle, which represented two of the largest news markets in the state at the time the measles vaccine was released, in 1963, and at the time of the Disneyland outbreak in 2015.1 Throughout this period, measles reporting displays patterns that point to an active role for journalists in shaping public understanding of health and medical matters through the employment of available and circulating political and cultural frames.As a disease that has been vaccine-preventable since the 1960s, measles has been the subject of intermittent periods of intensified media coverage for more than a half-century, with coverage usually triggered by outbreaks or vaccine issues. This essay offers a longitudinal case study of five decades of measles news coverage by two California news outlets, the Journalists also played a role in shaping public understanding of measles’ past. Because measles was a disease in decline, it was increasingly familiar through collective, not autobiographical, memory. Its collective memory was forged, in large part, through journalistic frames that lent themselves to presentist descriptions of measles’ history. Often, this history was constructed out of fragmented and decontextualized references, selected because they reflected contemporary values and supported contemporary frames. The act of framing and the tendency toward presentism had the effect, over time, of shifting responsibility for the disease’s spread from nature to government to individuals. Moreover, as this shift took place, journalists described measles as more severe than their predecessors had. As agency shifted, therefore, the individual became responsible for the spread of a more serious-sounding disease than nature had been responsible for in the pre-vaccine era. This longitudinal case study supports findings other scholars have produced regarding the episodic, decontextualized and presentist nature of reporting on social problems over time, as it demonstrates a significant role for journalists in shaping public understanding of social problems in the realm of health and medicine.Times and the Chronicle, despite the papers’ divergent politics. Moreover, as the media’s causal stories skewed conservative over time, vaccination policy skewed increasingly liberal through programs that expanded federal involvement in oversight and provision and through state policies that expanded local authority to require vaccination .Deborah Stone’s typology of causal stories offers a useful starting point for analyzing journalistic coverage of measles as a social problem. Per Stone, narratives about political problems highlight either accidental, inadvertent, mechanical, or intentional causes (1989). In the earliest post-vaccine phase of reporting, measles was, temporarily, an accident of nature, newly avoidable via vaccination. In the subsequent reporting phase, however, journalists offered causal stories that pointed to inadvertent human causes of measles’ persistence: individuals who did not know or understand the value of vaccination, or political agents who did not realize that decisions to cut budgets or programs would spread disease. In the final phase, journalists circulated a story that spoke to intentional cause: individuals who deliberately spread or believed misinformation about measles and vaccines. For Stone, the inadvertent cause is a common liberal explanation of problems and the intentional cause a conservative one, but these causal stories appear in both the Causal stories, which are often handed to journalists by policy actors, officials, and experts, are often shaped through framing. In mass communications theory, frames emphasize a particular interpretation of a problem, its causes, and its possible solutions. Journalists, frequently unaware of or insensitive to the presence of framing, may inadvertently communicate news in ways that favor a particular frame. Consequently, argues Robert Entman, “the frame in a news text is really the imprint of power”—the power of the party served by the frame . If framing provides an explanation of the forces and factors giving salience to issues, then journalists, by communicating and circulating frames, play a key role in defining the importance of social issues, their causes, and the promise of their various solutions.Mass communication theory’s definition of framing is related to but distinct from framing as understood by the discipline of history and specifically the subfield of medical history. Both theories posit framing as a phenomenon that advances problem definitions and causal solutions. Focused less exclusively on textual communication, however, framing in medical history describes a multi-sited series of events that shape human understanding of a health or medical matter, its causes, and its optimal management at a particular moment in time. Biology, language, identity, politics, economics, and contemporary scientific knowledge, for example, cofunction to frame a biological situation as a “disease” or condition in need of medical or scientific attention (Rosenberg 1992). Failure to perceive the frame, according to Charles Rosenberg, risks presentism, the imposition of present values and knowledge on the interpretation of medical situations past.The analysis in this essay draws on both theoretical frameworks to examine the framing of measles in its post-vaccine era in the single site of the news media, focusing on the form and function of those frames over time. Our analysis finds that over five decades of measles coverage, the frames for measles reporting continually shifted, as briefly noted above and described in detail below. As the frames in measles reporting shifted, the reporting itself was characterized by presentist representations of measles’ past, which supported the frames journalists used to make sense of measles in their own time. For journalists, measles’ history—the number of cases the disease formerly caused, its victims, its symptoms, and its complications—helped define measles as a contemporary problem and called up prevention as an imperative present solution.before the vaccine was introduced. But because of this decline, journalists offered historical facts about measles excised, for example, from the disease’s own recent history of treatment and management. Journalists’ construction of measles’ history from decontextualized fragments echoes a pattern that other scholars have documented regarding media coverage of historical events, applied here to a topic—infectious disease management—sometimes viewed as less politicized than others . It also echoes other patterns from social issue reporting. As the past becomes more distant, Jill Edy has argued, it may become increasingly subject to media manipulation; at the same time, the collective memory journalists help construct, itself a product of framing, can become a frame on that past . Vaccination-era measles reporting shows both patterns holding.Measles’ history was an important reference point partly because measles incidence had significantly declined in the decades Reporters who covered measles in the vaccine era constructed its past as increasingly troubled over time. Their reporting reveals a pattern of referencing increasingly larger numbers of measles cases, as well as deaths, attributable to the disease historically. They also described the disease’s symptoms and consequences in increasingly severe terms; while some of the earliest vaccination-era stories referred to measles’ reputation for being “benign,” later reports would refer to it as deadly and fatal, never mild (Nelson 1964a). As reporters constructed this increasingly collective memory of measles to replace its receding autobiographical memory, the memory itself, of a severe and deadly disease, became a resource they or other journalists used to explain the current measles-related events they were covering .Journalists, adds Edy, tend to present the past as fact carrying the “mantle of objectivity,” as opposed to selective and embedded truths open to interpretation (2006: 164). In medical or scientific reporting more generally, this mantle of objectivity may seem even more impenetrable than it might in other forms of social problem reporting . The number of measles cases, or deaths, in a particular year, for instance, reads as objective fact, but the embedded truth of that number—who was at highest risk of death, why, and how the number of deaths related to deaths from other causes, or deaths due to the same cause the previous year or decade—could greatly influence the meaning and implications the number carried and the causal stories it supported. In media reporting on measles, a collective memory of measles as severe and deadly quickly became a commonly deployed frame for journalistic stories whose message or “moral” concerned the urgency of measles prevention through vaccination (White 1987). Measles’ increasing severity also offers an example of how journalistic coverage of the past over time can “keep raising the threshold at which we begin to respond” (Zelizer 1998: 204).From the 1960s through the 2010s, journalists deployed a series of evolving frames to explain measles’ persistence. Many suited presentist ends, as noted above; all also resonated with contemporaneously circulating political and cultural stories. A public ignorance frame in 1960s measles reporting spoke to a tension over the balance between physician and lay authority over individual and family health . The urban poverty frame journalists used in the 1970s reflected President Lyndon Johnson’s Great Society ideals . The frame of national and especially urban decline in 1990s reporting supported the liberal policy goals of President Bill Clinton’s administration, especially with respect to health care . The frames of elite privilege and the science wars in 2010s reporting echoed rhetorics then gaining currency in American politics and culture . Per Rosenberg, disease has always served as “an occasion and agenda for…debate about the relation among state policy, medical responsibility, and individual culpability” (1989). Journalistic measles coverage shows how journalists, wittingly or not, weighed in on such debates with reporting that framed measles through the prisms of prevailing policy and cultural discourse of the day.Ayer Directory of Publications and Gale Directory of Publications and Broadcast Media, were consistently archived and catalogued and provided regular coverage over the entire period in question. To narrow our large dataset (more than four thousand articles mentioning measles across the two papers), we browsed state medical journals to identify years in which medical and health experts discussed significant developments in the disease’s prevalence or management; we then searched for measles news articles from these years, yielding a subset of three hundred nine articles. We used inductive and abductive approaches as well as thematic analysis to identify common threads across the data, such as references to measles’ past and reasons for non-vaccination in the present .The sections below analyze the frames and presentist themes apparent in three periods of measles reporting: the period of the measles vaccine’s introduction, 1963–1967; the period characterized by two attempts to eliminate measles from the U.S. between 1967 and 2000; and the post-elimination period, starting in 2000, when health officials declared measles no longer endemic to the U.S. We chose two newspapers that, in addition to serving large audiences per circulation numbers published in the San Francisco Chronicle’s cover declared on March 19, 1963, just a day after the U.S. government announced the imminent licensure of several new measles vaccines (San Francisco Chronicle 1963). In the following days, journalists reported the news with a set of frames that highlighted the bountiful, exciting and superior nature of American science on the one hand and corporate largesse and government cooperation on the other. The Los Angeles Times reported that the “for real” medical drama of the vaccines’ development was going to be featured in a CBS special (MacMinn 1963). The Chronicle article noted that three American companies were behind the advance and that the government was taking the unusual step of eliminating a waiting period before the vaccines could come to market (San Francisco Chronicle 1963). The reason: measles sickened an estimated four million Americans each year, causing four hundred deaths annually, making it responsible for more deaths than polio, the most dreaded childhood disease of the day .Measles was about to make its “Last Stand,” the Times reported, the numbers of children dying annually from diseases such as measles, diphtheria and scarlet fever were down to just a handful from the “hundreds” of such deaths that had taken place in the 1920s, thanks to “medical strides” and “progress” (Los Angeles Times 1961). By the late 1950s, wrote the Chronicle’s syndicated physician-columnist, Walter Alvarez, the key problems were car accidents and poisonings, which killed “four times as many children under 4 years of age as formerly were killed by all the common infectious diseases put together!” (Alvarez 1958).This framing—of American science as triumphant over a high-stakes medical problem—was familiar, as it had been used to report on the disease in the decades leading up to the vaccine. “Children will not die any more of measles,” the papers had declared in 1939 on the discovery of an antibiotic effective against pneumonia, a sometimes-fatal infection that struck children with measles (Associated Press 1939). Journalists covered the 1940s discovery of gamma globulin, an antibody-rich extraction of blood plasma treatment, with headlines that declared the “end” to “cycles of measles” . By the early 1950s, the Times reported that measles killed from 385 to 522 Americans per year; after, the paper reported that measles killed “500 U.S. children every year and permanently injures many more” . Weeks before the vaccine was released, the Chronicle had reported “upwards of 400,000 cases” of measles annually, mentioning no deaths; after the vaccines’ release it reported four million annual cases and four hundred deaths, not specifying if these were domestic or global figures . Measles, the Times reported on the occasion of the vaccines’ licensure, killed twenty-five percent of its victims (The Washington Post 1963).While the framing of measles treatment remained constant from pre- to post-vaccine reporting, the framing of the disease itself changed. Specifically, the story of measles as a vanquished foe gave way to the story of measles as a severe and ubiquitous killer, its number of cases, deaths, and associated complications all higher and more severe than previously described. Before the vaccine, the Times science reporter Harry Nelson . Others reported that measles would leave many children deaf (Hersh 1963). By the time the fifth measles vaccine made it to market, in 1965, the Times reported that twenty million children were at risk of the disease and its life-altering and deadly complications and that the disease was now the “the No. 1 killer among childhood diseases” . This framing matched the scale of the threat to the power of the current technology. The vaccine was a far more effective scientific tool than early antibiotics and gamma globulin had been. Journalistic reports that amplified the numbers of measles cases, deaths, and complications refashioned the disease into a foe worth the vaccine’s unprecedented capacity for technological disease control.Both papers also began to include details about measles complications in their reporting. Of the reported four million cases, one in one thousand would suffer “damaged brains,” and some of those would be “severely mentally retarded,” wrote Chronicle’s front-page noted (San Francisco Chronicle 1963). “Most parents and many doctors consider measles to be no more serious than a cold,” Nelson wrote in the Times (Nelson 1964b). Alvarez imagined “mothers” thinking, “why bother about measles? It isn’t much of a disease, and every child has to have it” (1965). But it was time to rethink measles, he urged, presenting the “surprising” information that in 1960 only sixty American children died of polio while four hundred eight died of measles. And “I was just reading,” he added, “that 50% of all children who have measles show some involvement of the brain” (1963). The following year, both papers carried the news that measles causes “mental retardation” for many . American scientific and medical experts, such stories communicated, were turning up new information about problems and solutions all the time; a parent’s (particularly mother’s) duty was to trust that expertise without question.As an event or reality recedes into the past, some members of any news audience will retain their own memories of it, notes Edy (2006: 13). Some journalists covering measles immediately post-vaccine therefore acknowledged—and explained—the new framing of measles in their reporting by setting the news of measles’ severity into larger frames of scientific advancement and physician authority. People tend to think of measles as “uncomfortable but harmless,” the Times story dubbed measles the “No. 1 killer,” neglecting to mention that this was true in foreign countries, not in the U.S. (Nelson 1964a). Other stories in the paper reported on deadly epidemics in India, Iran, and “some African countries,” where measles was responsible for a quarter of all deaths . Such news, in addition to supporting narratives of measles as severe, supported the framing of the measles vaccine as an American scientific success story. In African countries such as Upper Volta, where the measles vaccine had been tested years before, the Times reported that the “U.S. vaccine” was now saving the lives of hundreds of children (Toth 1964). The history that Alvarez shared, meanwhile, turned on a “great American pathologist’s” discovery of the culprit virus (Alvarez 1963). This process of selection, again witting or not, allowed the dual frames of severe measles and American scientific superiority to support one another.Framing involves selection and omission, and in framing measles as severe, journalists did both—wittingly or not. Stories offered selective information about measles’ toll in poor, foreign, and historic settings. Alvarez wrote of how the disease had killed thousands of “American Indians” and “grown natives” in the South Seas “in the old days” (Alvarez 1963). A Measles began this period seen as an act of nature. But human action in the form of vaccination began to reconfigure measles into a social problem with a specific solution. That problem was defined through reference to poor, foreign, and historic contexts, and the frame of American scientific triumph pointed to the solution: wide use of the American vaccine. Narratives in this first phase of reporting thus upheld a very particular relationship between the present and the past: one in which the past showed the scale of the threat posed by nature, a threat matched only by the power of contemporary American technological capacity.The second phase of reporting on measles—1967 to 2000—was characterized by repeated efforts to widely vaccinate U.S. children against the disease through two national eradication campaigns. During this period, the causal story in news reports shifted decidedly away from nature; the problem of measles’ spread now had inadvertent causes, including an innocently ignorant public and irresponsible government. These causes were buttressed by a strengthened severity frame, reinforced by the frames of American scientific superiority, middle class values, and government responsibility.San Francisco Chronicle 1967). Journalists—now describing an infection that “often has serious long term effects,” including pneumonia, deafness, encephalitis, “mental retardation and death”—reported that measles would very soon “join the ranks of the conquered diseases of childhood” (Sell 1967). Headlines called measles “a crippler” (San Francisco Examiner and Chronicle 1967). Reporters broke down the four million cases into jarring statistics: one in six would have “serious complications,” five hundred would die of encephalitis and pneumonia, and sixteen hundred would become “mentally retarded” (San Francisco Examiner and Chronicle 1967).In 1967, President Lyndon Johnson announced that the Surgeon General would vaccinate up to ten million children and four million infants in order to eradicate measles by 1968 . Cases fell significantly during the first few years after the eradication goal was declared, but then they began to climb again in the early 1970s. As they did, news reports described parents who didn’t vaccinate their children as “confused” about measles’ true dangers . Journalists offered stories from the burgeoning middle class that proved measles’ threat. “Pretty” hazel-eyed Kim Fisher from Fort Wayne, Indiana, had become a burden on her hardworking parents since measles encephalitis had left her “handicapped” (San Francisco Examiner and Chronicle 1967). Scotty Whitmire from Sacramento had to relinquish his dream of becoming the “world’s fastest runner” because a “rare measles virus” had left him unable to sit upright or speak (Los Angeles Times 1971). Fair-haired Paul House, pictured on his rocking horse on the Chronicle’s front page, threatened to delay Apollo 13’s launch when a backup pilot and astronaut were exposed to his measles (United Press and Associated Press 1970).In the papers, the cause behind the shocking figures was not just measles itself but the parent who was unaware of measles’ severity, whose blameless ignorance posed a threat to middle-class stability and American technological achievement. It was true, said a physician in the Times, had forced the district to cut the nurses who had vaccinated eighty thousand children the previous year; those shots would now “have to be obtained through a county clinic or a private doctor” (Thompson 1978). But that causal story faded when President Jimmy Carter announced a new eradication campaign, late in 1978. The allotted $45 million in federal funds, California reporters explained, would help states detect outbreaks and “crack down” on unimmunized children (Associated Press 1978).In 1976 and 1977, measles cases reached epidemic heights, and the causal story of the naively ignorant parent was supplanted by a causal story pointing to ineffective government. A state vaccination law was not working because officials were not enforcing it (Birkinshaw 1978). When a revision gave the law more teeth, the papers reported that with limited resources, schools and counties could only do so much (Nelson and Kistler 1977). California’s Proposition 13, said a school health director in the San Francisco Chronicle 1989a). Scientists were “surprised” to learn that measles was more contagious and spread more easily through the air than previously thought; some children had become infected in doctors’ offices more than an hour after a measles patient had left (San Francisco Chronicle 1989b). Measles was proving “so transmissible that even groups with complete immunization circumstances may result in outbreak,” said a health official in the Chronicle (San Francisco Chronicle 1989e). This new scientific knowledge strengthened, once again, the disease severity frame.As it had in the wake of the previous eradication campaign, measles fell and then climbed again in the 1980s. As it did so, two new causal stories emerged in quick succession. The first placed blame on nature within a frame of evolving scientific knowledge. Journalists explained “continuing outbreaks” by covering weakly protective older vaccines, poorly timed vaccines, vaccine failure, and measles’ tenacity. The measles virus outwitted vaccines six to forty percent of the time, reporters noted . A front-page story told of “poor ethnic minorities” without access to medical care who feared American institutions and the discovery of their immigration status (Spiegel 1989). When measles struck the Samoan community in Los Angeles, the Times described a group “hit disproportionately with poverty, high unemployment and school dropout rates and youth crime” (Ford 1989). “These populations” needed higher immunization levels, said a health worker in the Chronicle (San Francisco Chronicle 1989d). Health officials had “been able to vaccinate only about 50 percent of children in poor urban areas,” the paper reported (San Francisco Chronicle 1989b). The problem was a statewide “money crunch,” explained the Times, caused by budget cuts and rising vaccine prices. Public clinics with short hours, long lines, and too little vaccine were “turning [children] away” . The situation was so “desperate” that California was borrowing vaccines from neighboring states .The second causal story to emerge placed blame on government neglect of urban and particularly poor people of color and immigrant communities. Measles, the Times about a plan to make government the sole purchaser and provider of all vaccines (Fuetsch 1993). Supporting this notion (if unconsciously), journalists again invoked foreign, poverty-stricken contexts. This time, these contextual stories were brought in not to show how bad measles was in the past but to show how bad it had become in the modern U.S. “Measles has permanently established itself here in much the same way that it has in developing countries,” a Times writer wrote (Spiegel 1989). “It’s the kind of measles you see in Third World countries,” said a state health director in the paper (Spiegel 1989).This causal story called, as it had a decade before, for more and bigger government. Reporters covered a new policy approach to vaccinating children, a “universal” plan in which the federal government would assume the cost of vaccinating every child. “The nation that sold Coca-Cola to the world…can figure out a way to sell universal immunization,” said a doctor interviewed in the Times noted, “as many as 500,000 children in the United States caught measles each year” before the 1960s (Spiegel 1989).  But the past was also now a reminder of how effectively measles had previously been controlled. California had enjoyed its “all-time low” of one hundred seventy-six measles cases in 1983 (Gaw 1989). Los Angeles hit a low of forty cases in 1986 (Spiegel 1989). As Edy notes, journalists engage in the process of creating pasts that “also become the resources we use to make sense of current events” (2006: 16). Presentism, in this case, shifted the moral of measles reporting. The moral of earlier reporting was that measles was too serious not to vaccinate against; by the late 1980s, the moral was that it was important to remember that this serious disease was controllable via widely accessible vaccination, which had been achieved in the past.References to the past remained an aspect of measles reporting in this period, but the relevant past changed. The past still proved measles’ severity: as the Chronicle editorial, for example, pointed back to California’s fifty child measles deaths during the 1989 epidemics as a reminder that measles was deadly. But that was not the editorial’s main message. The deaths were “abhorrent” and a “stern reminder” that it was everyone’s business to make sure every young child was vaccinated, especially now that “vaccines are never denied to people who lack funds” (San Francisco Chronicle 1996). With the entitlement in place, anyone who failed to make the necessary “trip to a clinic or physicians’ office for a swift immunization” was personally responsible for any cases of disease that ensued (San Francisco Chronicle 1996).In 1993, President Bill Clinton signed a budget creating a partially universal vaccination program, which guaranteed childhood vaccines to low-income and uninsured children. Subsequently, the framing of measles’ persistence shifted again. If nature was the responsible agent in the first phase of reporting and government the primary responsible agent in the second, the third phase saw the culpable individual emerge, as a personal responsibility frame came to dominate. A 1996 The final phase of reporting was characterized by a pronounced narrative shift with what would come to be known as the “Disneyland outbreak.” The phase’s commencement was marked by measles’ elimination, declared in 2000, a time when the accidental story reigned. When measles returned in the form of a multi-state outbreak originating in California in late 2014 (which was when the Disneyland outbreak began), that accidental causal story was quickly replaced by an intentional one. As this shift took place, the disease severity frame persisted, upheld once again by presentist representations of measles’ past.Times readers that “long ago, many families would have 10 to 15 children to have only a few survive” (Qaqundah 2000). Health officials, reporters noted, had to remain vigilant to ensure that “foreign” measles didn’t gain a “domestic toehold” .2In 1999, the U.S. saw an all-time low of one hundred measles cases; California had just nine (Cimons 1999). Reporters shared the “news,” for the third time, that measles was poised to join “the ranks of…diseases that have been effectively wiped out in the United States” (Bynum 1999). By the following year, 2000, the few measles cases in the country were all imported from abroad, a fact that led federal health officials to declare the disease eliminated from the U.S. Measles, occurring in isolated instances in this period, was framed as foreign and historic, temporarily assigned, once again, to a causal story that placed blame on nature. Journalists reminded the public that measles “still kills a million children a year” in the “developing world,” and that the 1989–1991 outbreaks, when “Los Angeles was hit particularly hard,” proved measles’ might (Allen 2000). A local pediatrician told But measles’ causal stories shifted back to the realm of human agency during the 2015 Disneyland outbreak. The causal stories in news reporting on the outbreak emphasized the intentional acts of individuals and were supported by the persistent severity frame. At the same time, the set of collective memories about measles—constructed with selective fragments of information about measles’ pre-vaccine past and its post-vaccine outbreaks and control—now served as frames for stories addressing both measles’ severity and the uniquely egregious nature of the current outbreak.Like Kaplan, journalists reporting on the Disneyland outbreak invoked measles’ pre-vaccine days to prove measles’ contagion and deadly capacity and to offer commentary on the present. In pre-vaccine days, journalists reported, measles infected forty thousand Californians a year, killing more than 2.6 million—worldwide . Even in post-vaccine outbreaks, like those of 1989–1991, measles “ravaged California” (Lin II 2015). Journalistic references to the past in this period carried clear moral implications. The story of fifty thousand students suspended for lacking vaccines in 1977, who were back in school, vaccinated, “within days,” spoke to the sufficiently measles-fearful obedience of parents past, who quickly immunized their children once apprised of the disease threat (Lin II and Xia 2015). The 1989–1991 outbreaks were chalked up to “lax vaccination policies,” which, when strengthened, drove measles cases firmly down; this spoke to a call for stricter vaccination policies in the present—even as it omitted the circulating explanation of the invoked past, namely health services beyond reach of the poor and undocumented (Allday 2015a).Times story reported that measles caused one death for every five hundred cases, and two cases of encephalitis for every five hundred cases, “many of those” resulting in “permanent brain damage” (Lin II 2015).  Other journalists reported a figure of one or two deaths per thousand, not five hundred; but even in these cases, the reporters failed to specify that the figure represented measles’ death rate globally, where it was most prevalent, and fatal, in countries with poor health outcomes overall. The Times conflated the nation’s one hundred fifty thousand cases in the 1989–1991 outbreaks with those in California alone (Lin II 2015). The Chronicle, by contrast, reported that measles had spread from Disneyland before, causing a fourteen-person outbreak in 1982 and a five-person outbreak in 2001, numbers juxtaposed with the one hundred thirty-two cases connected to Disneyland by March 2015. Such past outbreaks were described as “small and self-contained” in comparison to the present one (Allday 2015a). But this representation of the past was made possible only by omitting the outbreaks of 1989–1991. The framing of measles’ historic severity and control, even if inconsistent across the two papers, consistently points to the media’s growing ability to manipulate the past as that past became increasingly remote.As in the earliest phase of measles reporting, numbers, especially historical figures, proved fungible, adapted to suit the persistent severity frame. A Times editorial described “her” as an unvaccinated person with a highly contagious disease who traveled in the “tight confines of two airliners” before visiting “a tourist destination that draws people from throughout the world,” where she was “packed in with others at the theme park, including babies too young to have been vaccinated.” The editorial offered no explanation for her lack of vaccines but offered a causal story that pointed to the anti-vaccine movement with its “ignorant and self-absorbed rejection of science” and “anti-science stubbornness” (Los Angeles Times 2015).In a new pattern in this period, however, reporters invoked the histories of other epidemic infectious diseases in order to illustrate measles’ severity through metaphor, and in doing so, they offered a causal story that placed epidemic blame on the negligent individual (Lupton 1995). Reporters described measles as more contagious than SARS and Ebola, likened it to smallpox, and in calling the index case “Patient Zero,” conjured up the early days of AIDS . As in that epidemic, a reckless individual was held culpable (Allday 2015a). Though numerous reporters said health officials would not identify the person who sparked the outbreak, a Times and the Chronicle included, in their mix of outbreak coverage, stories on a new study that found the highest rates of under-immunization in two types of northern California communities: those with more graduate degrees and those with incomes below the poverty line . But in outbreak reporting itself, the low-income individual was omitted as reporters focused on “upscale” and “affluent and coastal” communities where parents believed in “myths” and succumbed to “hysteria” . The Chronicle reported that non-vaccinating individuals “clustered” in communities with “tony private schools”; their decision not to vaccinate was positioned as a luxury born of privilege (San Francisco Chronicle 2015a). The Times portrayed these parents as a threat to others: “I feel surrounded by women here in Santa Monica, where I live, who have chosen to not vaccinate their children for personal reasons,” said a quoted parent, “and…put their children at risk to infect others” . “Score one for science,” read a Chronicle editorial later, after a state Senate panel voted to tighten California’s school vaccination law in response to the outbreak (San Francisco Chronicle 2015b).Coverage of the outbreak reveals a common synecdoche for the movement, a negligent individual consistently described as a privileged, white, anti-science parent, usually female, who did not vaccinate her children . Both the The severity frame in measles reporting persisted for decades partly because of measles’ own fade into memory and partly because it was complementary to other frames and adaptable to multiple causal stories. In the sixties, measles’ severity frame spoke to the need to place trust in experts and American scientific achievement; in the seventies, it spoke to a call for social uplift; in the late eighties and nineties, it supported the cause of greater government involvement in health care; in the 2010s, it resonated with frames of elite privilege of anti-science citizens. As measles’ framing shifted consistently in one direction, its causal story moved in and out of the realm of nature, from there to realms of human agency during outbreaks and back again when outbreaks or prevalence declined.Stone (1989) suggests no teleology among causal stories, but a number of scholars have demonstrated the emergence of a neoliberal ethic, incorporating an emphasis on personal responsibility, in public health discourse, including the narratives employed to describe public health problems and their underlying causes . By the time of the Disneyland outbreak, personal responsibility  in health was widely seen, as Nike Ayo notes, “as a willful obedience to the duties and obligations imposed by citizenship” (101). The “good” health citizen, adds Rose Galvin, is responsible, makes rational decisions, and participates in social life (2002). By placing blame on the irresponsible, anti-science individual, the emergence of a causal story identifying intentional blame for the 2015 measles outbreak fits into a broader shift in public health discourse across modes of communication. Journalists who reported on the outbreak by framing the story as one about non-vaccinating individuals deliberately rejecting science framed them as disobedient citizens. These were individuals who deserved sanction, not largesse. Indeed, what followed was a modification to California vaccination law that removed a clause granting a right to object to vaccination on the basis of personal belief.Chronicle featured a story about a former sitcom actress reportedly “furious” that a show she once starred in, “The Brady Bunch,” was being shared on social media as proof that measles was once not considered serious. “If you have to get sick, sure can’t beat the measles,” the actress’s character said in a 1969 episode in which the Brady children were delighted that measles kept them home from school. As the meme spread online, the actress told reporters she was “really concerned” about the show’s transformation into a pro-measles meme and that “as a mother” she had vaccinated her own daughter (Sippell 2019).When Governor Jerry Brown signed that bill, the move gave California one of the most stringent school vaccination laws in the nation. Vaccination rates increased; measles outbreaks stayed at bay; and measles receded from journalistic attention. But five years later, in 2019, U.S. measles cases exceeded levels not seen since prior to elimination (Ingraham 2019). California was spared more than a few isolated cases (a fact attributed to the 2015 law), but the nationwide cases still made local news, as did a cultural dispute over measles’ severity. A different California institution—Hollywood—featured in media coverage of this dispute. The Reporters following the story held to the frame that presented measles as serious: back in the 1960s, health officials “didn’t think measles was funny, given that the virus could lead to pneumonia, encephalitis and even death,” one journalist wrote (Ross 2019). But individuals opposed to the politics of California’s new vaccine law rejected this version of collective memory, reinterpreting primary evidence from the past for themselves. “Remember when the entire Brady Bunch was wiped out by measles?!!” read one sarcastic meme (Ross 2019). Traditional news media had played a role in creating and sustaining collective memory of measles over a half-century during which, even as the disease’s past was subject to modifications and omissions, its severity was consistently amplified. But in this instance of measles reporting, the new media environment offered space for media producer-consumers to create and share the specific, partisan social memory that most aligned with their preferred vaccination ideology (Edy 2014).Michael Schudson argued that monolithic and all-powerful versions of the past won’t triumph in pluralistic societies where conflicting views can emerge, find audience, and survive (1992). With measles, the Brady Bunch story and the trend it represents suggest a monolithic past may now be giving way. This possible shift follows five decades of reporting in which journalists firmly shaped public understanding of measles as a severe disease in urgent need of prevention via vaccination. Journalists did so using familiar and available frames, which supported a set of causal stories that shifted responsibility for measles’ spread from nature to the inadvertent party, government or individual, and then to the intentional culprit, the privileged, science-rejecting individual. Journalists also did so by communicating a past, constructed of decontextualized fragments, that supported the frames and causal stories transmitted through their reporting.This presentist project was realized in part through a pattern that Edy has documented: as the proportion of the public able to check public memory against personal memory declines over time, journalistic authority over the past expands (2006: 105–106). This may be giving way, but as our analysis shows, for more than five decades of post-vaccine measles reporting, it held. This holds potential significance for journalistic coverage of other vaccine-preventable diseases, which move from autobiographical to collective memory at their own pace. The most recent disease to become vaccine preventable, Covid-19, was framed as such even before its vaccine was developed. As this disease shifts from its pre- to post-vaccine phase, journalistic reporting will likely have just as powerful and lasting effects on public understanding of its present—and its past.