Spring 2004 Entertainment Education and Health in the United States
Many groups have come to believe that There is no single formula for getting entertainment media can play an important educational messages into a script and onto positive role in educating the public about the screen. Some messages are generated by signifi cant health issues. In the United producers and scriptwriters themselves because States and around the world, public health they have a particular interest or personal organizations are increasingly turning to connection to the issue, or by staff consultants entertainment media—from soap operas to with expertise who review scripts and suggest sitcoms to reality shows—as a way to reach the ways to make the story and characters more public with health messages. realistic. Other messages result from outreach efforts of special interest groups or health What Is Entertainment Education? agencies to deliver their message to audiences. Entertainment education, also referred to as These groups often work with Hollywood-based enter-educate, edutainment or infotainment, is a advocacy organizations that serve as liaisons way of informing the public about a social issue to the entertainment community via industry The Henry J. Kaiser or concern. The entertainment education (E-E) forums, roundtable briefi ngs, and technical 4 Family Foundation strategy involves incorporating an educational script consultations. 2400 Sand Hill Road message into popular entertainment content in Examples of Entertainment Education Menlo Park, CA 94025 order to raise awareness, increase knowledge, Phone: 650-854-9400 create favorable attitudes, and ultimately As early as the 1970s, entertainment television Fax: 650-854-4800 motivate people to take socially responsible has been recognized as a source for delivering action in their own lives.1 important messages to audiences. An episode
Washington Offi ce: of “Happy Days” in which the character Fonzie Television is the primary medium for goes to the library to meet girls and ends 1330 G Street, NW entertainment education in the United States. up getting a library card reportedly inspired Washington, DC 20005 Over the years, the E-E strategy has been thousands of young people to do the same. Phone: 202-347-5270 applied in a variety of ways and raised a number According to those involved in the effort, the Fax: 202-347-5274 of social and health issues in entertainment nationwide demand for library cards increased programming, including substance abuse, about 500 percent after the episode aired.5 www.kff.org immunization, teenage pregnancy, HIV/AIDS, cancer, and other diseases.2 In recent years, the use of entertainment media to disseminate health messages has increased Entertainment education, in which health-related markedly as more groups include entertainment storylines are incorporated into popular TV education in their strategy. Some efforts are sitcoms, dramas or soap operas, is distinct issue-specifi c and for a limited time period, from the use of public service announcements while others involve ongoing outreach to the (PSAs), which can also be an important tool entertainment industry. Following are some in public health communication. Some groups examples from American television, beginning have been effective in combining PSAs with with the earliest of these efforts: entertainment education for a wider impact.3
The Kaiser Family Foundation is a non-profi t, private operating foundation dedicated to providing information THE HENRY J. KAISER FAMILY FOUNDATION and analysis on health care issues to policymakers, the media, the health care community, and the general public. The Foundation is not associated with Kaiser Permanente or Kaiser Industries. • The Harvard Alcohol Project’s National puberty, underscore family communication, Designated Driver Campaign, developed and emphasize self-esteem in shows such as by the Harvard School of Public Health’s “Lizzy McGuire,” “As Told by Ginger,” and “The Center for Health Communication, is widely Proud Family.” The group also launched a considered to be the fi rst successful effort Spanish Media Initiative to provide resources to partner with the Hollywood community and script consulting for writers and produc- to promote health messages in prime time ers of Spanish-language television in the programming. During the 1988–1992 TV United States and Latin America.7 seasons, more than 160 prime time shows, such as “The Cosby Show,” “Cheers,” and • For more than a decade, Mediascope has “L.A. Law,” included subplots, scenes, dia- played a role in promoting health and social logue, and even entire half-hour or hour-long issues within the entertainment industry episodes devoted to the campaign theme. By through creative community roundtables, 1990, public opinion polls indicated that 9 in program briefi ngs, information forums, script 10 adults (89%), and virtually all (97%) young consultations, and online resources. The adults 18–24 were familiar with the desig- group placed anti-bullying and violence-pre- nated driver concept and rated it favorably. vention messages in storylines on shows In 1991, the term “designated driver” was such as “7th Heaven” and “Law and Order” included in the Random House Webster’s for the Youth Violence Prevention Initiative. In College Dictionary.6 addition, their efforts on behalf of the Na- tional Youth Anti-Drug Campaign, a project • Since 1980, The Media Project has of the Offi ce of National Drug Control Policy, operated in Hollywood as an ongoing, resulted in plot and character development full-time project of the Washington, D.C.– around the issue of substance abuse and based group Advocates for Youth (AFY), prevention strategies in shows such as “Judg- working with the entertainment industry to ing Amy,” “24,” “The Shield,” “7th Heaven,” incorporate adolescent sexual health “Boston Public,” “The Guardian,” and “All My messages into popular TV shows (the Kaiser Children.”8 Family Foundation partnered with AFY in operating the Media Project from 1997- • In 1994, the Harvard School of Public 2002). The project organizes three Health’s Center for Health Communication informational briefi ngs a year, operates a launched the “Squash It!” campaign to helpline for writers and producers, and prevent youth violence with a media initiative provides one-on-one assistance to shows targeted to urban teens. The “Squash It!” during script development. Each year, more walk-away message, which uses the phrase than 100 shows contact the helpline, and accompanied by a hand gesture based on the dozens of episodes of popular TV shows time-out signal used in sports, was incorpo- include storylines containing sexually respon- rated into scripts on shows such as “Bev- sible messages. One recent example involved erly Hills 90210,” “Dangerous Minds,” “ER,” an episode of the popular show “Felicity,” in “Family Matters,” “Hanging with Mr. Cooper,” which the lead character, a college freshman, “Living Single,” “NY Undercover,” and “South visits the campus health clinic to learn about Central.” A national survey of junior and senior birth control, gets a demonstration on using high school students conducted in 1997 in- a condom, and asks her prospective partner dicates that African American youth were the to get tested for HIV and other STDs. Other most likely (43%) to have seen the “Squash shows the project has assisted include “ER,” It!” message on TV.9 “Dawson’s Creek,” “Moesha,” “Boston Public,” “Strong Medicine,” and “Judging Amy.” The • The Kaiser Family Foundation has worked Media Project has also worked on storylines with a variety of networks and shows to for the preteen audience that demystify incorporate health messages into popular
Entertainment Education and Health Spring 2004 Page 2 in the United States entertainment programming. For example, the terminally ill. Episodes of several shows, the Foundation organizes annual briefi ngs including “ER,” “NYPD Blue,” “Homicide: Life for the writers and producers of the NBC on the Street,” and “The Guardian,” as well as drama “ER,” which have resulted in numerous the Hallmark Hall of Fame telefi lm “My Sis- storylines on topics such as rapid HIV testing, ters’ Keeper,” incorporated death and dying emergency contraception, chlamydia, insur- themes as a result of the project’s roundtable ance coverage of experimental treatments, briefi ngs and online resources.11 teen sexual activity, the working uninsured, and Medicare and Medicaid. The Founda- • Hollywood, Health & Society is a partner- tion has also partnered with the TV networks ship of the Centers for Disease Control and BET, MTV and Univision on public education Prevention and the University of Southern campaigns that have included not just PSAs, California’s Annenberg Norman Lear Center. but also a large number of full-length shows Since its inception in 2002, the group has designed to entertain and educate audiences provided the creative community with a range at the same time. For example, 19 different of health resources via story consultations, full-length shows have appeared on MTV as online tip sheets, and information briefi ngs part of this partnership, reaching an audience and interviews, including some in collabora- of over 95 million viewers. Some of the pro- tion with the Writers Guild of America West. grams include popular musicians and other Recent efforts resulted in storylines about celebrities to help draw an audience to live child injury prevention on “ER,” SARS trans- call-in shows with health experts; others are mission on “Law & Order,” and breast cancer documentary style shows chronicling the lives (with the National Cancer Institute) in “The of real young people as they grapple with Young & the Restless” and a telenovela on sexual health issues. Telemundo.12
• The UCLA School of Public Health and • KNOW HIV/AIDS, launched in January Department of Film and Television, in col- 2003, is a cross-platform HIV prevention laboration with the Immunization Branch of and awareness campaign conducted by the California Department of Health Ser- the Kaiser Family Foundation and the media vices, launched an entertainment education company Viacom. One component of the campaign to raise public awareness about campaign involves incorporating HIV/AIDS the importance of immunization. During the messages in television shows and movies 1996–1998 broadcast seasons, stories produced by Viacom-owned companies or about immunization were incorporated into broadcast on Viacom-owned networks (CBS, scripts of over a dozen TV shows, including UPN, MTV, and BET, among others). Certain “ER,” “High Incident,” “Frasier,” “7th Heaven,” messages have been designed for the public “Step by Step,” “Sabrina the Teenage Witch,” at large, while others have targeted groups “Guiding Light,” “Days of Our Lives,” and most at risk, including youth, people of color, “Mister Roger’s Neighborhood.” For example women, and gay men. Episodes in numer- one episode showed the lead character of ous shows such as “Becker”, “The District,” “Frasier” overcoming his fear of needles to “Enterprise: Star Trek,” “Touched by an Angel,” get a fl u shot, and included a discussion “Girlfriends,” “Half and Half,” “One on One,” about fl u strains and how they are spread.10 “Soulfood,” “Presidio Med,” and “Queer as Folk” have included the HIV/AIDS theme, with • The Last Acts Writers Project, organized storylines ranging from educating a teen- by the Robert Wood Johnson Foundation, is ager about the risk of HIV/STDs to asking an ongoing effort to improve the accuracy a boyfriend to get HIV tested, to the impact and sensitivity of depictions of terminal illness of HIV/AIDS on family and friends.13 In 2003 and death in TV and fi lm. The project provides alone, more than 58 million viewers tuned in experts, background information, and real- to campaign-related entertainment program- life story ideas about end-of-life care, pain ming, and more than seven million visited the management, biomedical ethics, and rights of campaign’s website. Entertainment Education and Health Spring 2004 Page 3 in the United States • The Robert Wood Johnson Foundation spear- Effectiveness of Entertainment Education headed the fi rst “Cover the Uninsured Week” during March 2003 to draw attention A body of research is emerging that assesses to the millions of Americans who are unin- the impact of entertainment education as a sured or have inadequate health insurance. strategy for reaching the public about health As part of the strategy, a workshop for writers issues. was held to provide information for “issue placement” in storylines of daytime and prime Prime Time Entertainment time shows. The weeklong campaign resulted A survey of prime time TV viewers conducted by in references to the need for universal health the Centers for Disease Control and Prevention coverage in at least seven shows, including in 2000 found that: “Strong Medicine,” “Passions,” and “Law & Order: Special Victims Unit.” Subsequent • A majority of viewers (52%) report picking campaigns are planned for the same week in up health information that they trust to be ac- 14 future years. curate from prime time TV shows, and 1 in 4 (26%) say that these shows are among their top three sources for health information.15 Entertainment Education Awards
Several groups sponsor annual awards to recog- • Nine out of 10 (90%) regular viewers report nize the entertainment industry for accurate and learning something about diseases or how to socially responsible depictions of health issues. prevent them from television, and almost half For example: cite prime time (47%) or daytime entertain- ment shows (48%).16 • The Prism Award is presented by the Entertain- ment Industries Council, in partnership with • Almost half (48%) of regular viewers who the Robert Wood Johnson Foundation and the heard something about a health issue on a National Institute on Drug Abuse, for accurate prime time television show say they took one depictions of drug, alcohol, and tobacco use or more actions: told someone about the sto- and addiction in television, fi lms, music and ryline (42%); told someone to do something comic book entertainment. or did something themselves, such as use a condom or exercise more (16%); visited a • The Sentinel for Health Award for Daytime clinic or doctor (9%); or called a clinic, health Drama is presented for exemplary portrayal care facility, or hotline number for information of health issues in television soap operas by (5%).17 Hollywood, Health and Society, the Centers for Disease Control and Prevention, and Population “ER” Communications International. During the 1997–2000 TV seasons, the Kaiser • The SHINE Award (Sexual Health IN Entertain- Family Foundation surveyed 3,500 regular ment) is presented by The Media Project to viewers of the popular NBC drama “ER,” and 18 recognize accurate and honest portrayals of found that: sexuality and sexual health in entertainment programming. • Slightly more than half of regular viewers said they learn about important health issues while • The Turner Prize is awarded by the Environ- watching “ER” (53%) and talk with family and mental Media Association for the television epi- friends about these issues (51%). Approxi- sode that best deals with a population growth mately one-third (32%) said information from issue such as teen pregnancy, contraception or the show helped them make choices about abstinence, overcrowding, or empowerment of their own family’s health care, particularly women. those viewers with less education (44% with no college vs. 25% with some college educa- tion).19
Entertainment Education and Health Spring 2004 Page 4 in the United States • As a result of viewing “ER,” more than one • According to the Kaiser Family Foundation’s in fi ve viewers (23%) said they had gone to National Survey of Physicians, one in fi ve other sources for additional information about doctors say they are consulted “very” or a health issue, and one in seven (14%) said “somewhat” often about specifi c diseases or they had contacted a doctor or other health treatments their patients heard about on TV care provider because of something they saw shows such as “ER.”22 in an episode.20
• Many regular “ER” viewers demonstrated sig- “Friends” nifi cantly increased awareness about specifi c In 2002 the Kaiser Family Foundation helped health issues that were addressed on the fi nance a RAND Corporation survey of teens show. After a brief vignette about emergency ages 12–17 who were regular viewers of the contraception was included in an episode, TV sitcom “Friends,” to assess the impact of the percent of viewers who were aware that a a storyline about an unplanned pregnancy. woman has options for preventing pregnancy According to RAND’s analysis, entertainment even after unprotected sex increased by 17 television can be most effective as an educator percentage points (50% to 67%). Among when teens and parents view together and those who had heard of emergency con- discuss what they watch. traception, one in fi ve (20%) said they had learned about it on “ER.” • Among teens who had viewed a “Friends” episode about the risks of sexual activity, two- • Similarly, after an episode aired about the thirds (65%) remembered that the specifi c sexually transmitted disease human papilloma storyline depicted an unplanned pregnancy virus (HPV), the proportion of viewers who caused by condom failure.23 had heard of HPV nearly doubled (from 24% to 47%), and the proportion who could cor- • Four out of 10 (40%) teens who reported rectly defi ne HPV tripled (from 9% to 28%). watching the “Friends” episode watched it Among those who had heard of HPV, one- with a parent or adult, and 10 percent of them third (32%) volunteered that they had learned talked with an adult about the effectiveness of about it from “ER.” condoms as a result of the episode. Almost half (47%) who discussed the episode with • In both cases, however, viewers’ aware- an adult recalled the characters describing ness decreased over time, as indicated by condoms as being 95% or more effective.24 separate samples of regular “ER” viewers surveyed two months later. These results un- • Compared with their peers who watched derscore that health-related messages must alone or with another youth, teens who be repeated for viewers to retain the informa- watched with a parent or adult were twice tion. as likely to say they learned something new about condoms from the episode (38% vs. • A separate study from the Harvard School of 15%), as well as to recall that condoms were Public Health compared a sample of regular said to be between 95% and 100% effective “ER” viewers interviewed the week before (40% vs. 20%).25 an episode about smallpox prevention with a sample of regular “ER” viewers who saw or • A follow-up survey six months later found heard about the episode. After viewing the that teens who watched the episode about episode, more viewers were aware (57% vs. condom effi cacy were more likely to rate 39%) of the need for getting a smallpox vac- condoms as 95% to 100% effective than cination immediately after exposure to prevent teens who did not view the episode (30% vs. the disease.21 18%).26
Entertainment Education and Health Spring 2004 Page 5 in the United States Daytime Dramas organization CARE (Cardiac Arrhythmias Re- search and Education Foundation). Similarly, A 1999 survey of soap opera viewers, when a trailer with the telephone number for conducted by the CDC, found that many the Tourette Syndrome Association followed daytime viewers also report learning about an episode of “The Practice”—inspired by the health issues from TV: co-executive producer’s children who are bat- tling the disease—the organization received • Among regular viewers of daytime drama, 500 calls.30 A rape hotline number screened almost half (48%) of those surveyed said they at the end of a “Felicity” episode on date rape learned something about a disease or how received more than 1,000 calls.31 to prevent it from watching soap operas, and 4 in 10 also reported learning about disease • With the help of the Centers for Disease and prevention from prime time television Control and Prevention (CDC), the executive shows (41%) and talk shows (38%). More producer of the daytime drama “The Bold than one-third (38%) of regular soap view- and the Beautiful” developed an HIV/AIDS ers agreed that they would like to see more storyline, and CBS aired PSAs following two health storylines on television.27 different episodes with key HIV plot points. The fi rst PSA generated a total of 1,426 calls • One-third (34%) of regular daytime view- to the CDC’s national HIV/AIDS hotline dur- ers reported that they took action in their ing the soap opera time slot, compared to 88 personal lives after hearing about a health calls the previous day and 108 calls the day issue or disease on a soap opera by telling following the episode. Ten days later when someone about it (25%), telling someone to the PSA was shown again the call volume do something to prevent the health problem spiked even higher to 1,840 calls originating (13%), visiting a clinic or doctor (7%), or do- during and shortly after the episode. In com- ing something to prevent the problem (6%). parison, there were 94 calls the day before More than 4 in 10 regular soap opera viewers and 234 calls the day after the HIV episode.32 (43%) say they have asked their doctor about something they heard or read in the media.28 • A PSA tied to a character’s diagnosis of breast cancer on the soap opera “The Young • Black women (69%) were most likely to cite & the Restless” displayed a toll-free number soap operas as a source of health informa- for the Cancer Information Service (CIS) tion, as well as to report taking action in their sponsored by the National Cancer Institute. own lives about the health issue, followed by A survey of viewers who called the hotline Hispanic (56%) and White (48%) women.29 found that compared to regular CIS callers, inquiries stimulated by the PSA were twice Entertainment Education and PSAs as likely to come from a minority group (18% vs. 9% were Hispanic, and 21% vs. 9% were A public service announcement (PSA) linked African American) and were more likely to be to a health storyline in a television show can interested in prevention (15% vs. 6%) and motivate viewers to seek information by calling a screening (11% vs. 7%), and less likely to be toll-free telephone hotline. interested in treatment (14% vs. 30%).33
• PSAs aired at the end of a show have gener- ated a substantial number of hotline inquiries. For example, after an episode of “Chicago Hope” that included a storyline about a car- diac disorder that can cause sudden death in children and young adults, a PSA was broadcast that resulted in 1,500 calls to the
Entertainment Education and Health Spring 2004 Page 6 in the United States Entertainment Education and News Pegs Key Organizations • The Kaiser Family Foundation and the Johns Hopkins University Bloomberg School of American Academy of Pediatrics Public Health, in collaboration with the NBC Media Resource Team—Pediatricians on Call News Channel and the prime time drama www.aap.org/mrt “ER,” developed a new model that linked Entertainment Industries Council health messages in the show “ER” with 90- www.eiconline.org second news segments broadcast after the episode in local newscasts. On the air from Harvard School of Public Health 1997 until 2001, “Following ER” was pro- Center for Health Communication www.hsph.harvard.edu/chc/ duced by NBC affi liate WBAL in Baltimore and featured interviews with medical experts The Henry J. Kaiser Family Foundation and real people who had experienced the www.kff.org/entmedia/index.cfm www.kff.org/entpartnerships health issue addressed in the show. Each segment also offered access to additional Hollywood, Health & Society information via a toll-free telephone number or USC Annenberg Norman Lear Center www.entertainment.usc.edu/hhs online resources displayed on-screen. 34 Last Acts Writers Project • The “Following ER” news series, which www.lastacts.org/writers reached an average of one million viewers nationwide each week, addressed a range of The Media Project—A Program of Advocates health information and prevention strategies, for Youth www.themediaproject.com including teen pregnancy, violence preven- tion, gun safety, fetal alcohol syndrome, organ Mediascope donation, doctor-patient communication, can- www.mediascope.org cer, HIV/AIDS, eating disorders, vaccinations, nursing home care, and health insurance. The National Youth Anti-Drug Media Campaign White House Offi ce of National Drug Control Policy success of the series spawned a partnership www.drugstory.org and www.MediaCampaign.org between Johns Hopkins Medical Institutions and CBS for a similar news segment called Population Communications International “Living with Hope,” based on the drama www.population.org/programs.htm (select U.S.) “Chicago Hope,” which is reported to have reached an estimated 30% of the American UCLA School of Public Health Health and Media Research Group 35 public. www.ph.ucla.edu/hmrg
Entertainment Education and Health Spring 2004 Page 7 in the United States Endnotes 15 Centers for Disease Control and Prevention, “Prime Time 1 Arvind Singhal and Everett Rogers, Entertainment-Education: Viewers and Health Information,” 2000 Healthstyles Survey A Communication Strategy for Social Change (Mahwah, NJ: Executive Summary, October 24, 2001. Lawrence Erlbaum Associates, 1999). 16 Ibid. 2 For an overview of the fi eld and a discussion of early E-E 17 Ibid. efforts, see Arvind Singhal, Michael Cody, Everett Rogers, and 18 Mollyann Brodie, Ursula Foehr, Vicky Rideout, Neal Miguel Sabido (Eds), Entertainment-Education and Social Baer, Carolyn Miller, Rebecca Flournoy and Drew Altman, Change: History, Research and Practice, (Mahwah, NJ: “Communicating Health Information through the Entertainment Lawrence Erlbaum Associates, 2003); Michael Suman and Media,” Health Affairs (Jan/Feb 2001): 192–199; Henry J. Gabriel Rossman, Advocacy Groups and the Entertainment Kaiser Family Foundation, “Survey of ER Viewers:Viewers: Summary Industry (Westport,(Westport, CT:CT: Praeger Publishers, 2000); Kathryn of Results,”
Entertainment Education and Health Spring 2004 Page 8 in the United States