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Health Tracking

TRENDS

Communicating Health Information Through The Entertainment Media

Little is known about what information presented on television is acquired, how long it is retained, and whether and how it affects behavior.³ None of the existing research on entertainment media has specifically investigated whether these programs can alter viewers’ knowledge about health topics, whether health-related story lines can maintain viewers’ interest, or whether ongoing entertainment programs can have any impact on audiences’ actions.⁴

Some research suggests that entertainment media do play a role in shaping viewers’ conceptions of reality. Cultivation theory, from the communication literature, argues that when people are exposed to a consistent set of messages, they incorporate information from their television viewing into their understanding of the world around them.⁵ For example, television portrayals tend to under-represent older persons, which has led frequent viewers to underestimate the size of the elderly population.⁶ Other research shows similar findings about viewers’ perceptions of racial and gender composition and roles.⁷ While viewers may not consciously watch fictional programs to learn about health information, cultivation theory suggests that health information presented in entertainment media could affect their ideas about health-related issues. This raises the question of whether these programs are an appropriate venue for health information. The potential to teach the public also implies the potential to spread misinformation or create misimpressions.

This paper presents results from a unique opportunity to conduct real-world experiments on the impact of entertainment media as a health and health policy information source. Researchers at the Henry J. Kaiser Family Foundation worked jointly with a writer and producer of ER, a popular weekly television drama about the lives of medical professionals working in an urban hospital emergency department.

ER viewers were surveyed to evaluate the effect of health information communicated through an ongoing television drama. We conducted two natural experiments, with preshow, postshow, and follow-up surveys. These surveys provide insight into the actual experiences, interest, and actions of ER viewers, watching ER as they would normally, without any knowledge that they would later be surveyed.

Study Methods

 
The data for this study come from ten separate national random-sample telephone surveys of regular ER viewers. Telephone numbers were randomly generated, and adult respondents were screened based on whether they reported watching at least three out of four new episodes during the regular television season, September through May of that year.⁸ The telephone surveys were conducted between March 1997 and April 2000 with more than 3,500 regular ER viewers (300 to 500 per survey).⁹ A series of cross-sectional surveys was conducted as opposed to a panel design, to avoid sensitization effects that occur when the same person is interviewed about a given topic from one point in time to another.¹⁰

An ER writer and producer who is one of the authors of this paper provided information about general directions of story lines and, in some cases, specific health information to be presented. Using this information, we designed the surveys to assess (1) knowledge gain and retention of health information, and (2) viewers’ interest in health-related story lines and any actions taken based on these story lines. The surveys were pretested among a small random sample of viewers.

To achieve these goals, the project included two parts. The first part consisted of two experiments. The first, conducted during March–June 1997, contained a vignette on emergency contraception (preshow, post-show, and follow-up surveys). The second experiment, based on a vignette discussing the human papilloma virus (HPV), was conducted during February–April 2000, again using three surveys to assess viewers’ knowledge gain and retention.

The second part of the project involved four surveys conducted throughout the 1997–1998 television season to investigate interest in health-related story lines and personal actions taken based on these story lines. This included a baseline survey in September 1997, before the season began (wave 1), two surveys in late November/early December 1997 and in March 1998, each about one-third of the way through the season (waves 2 and 3), and a final survey conducted in late May 1998, the end of the season (wave 4).

Comparisons between groups of regular viewers were made with statistical tests of differences in the survey-derived estimates of population proportions. Each survey was weighted to be representative of all adults who watched at least three out of four new episodes of the show. Given the successful national random-digit dialing sample selection, the weights to be applied were small, resulting in small design effects for each survey. These design effects were taken into account by adjusting the standard errors for each estimate in the statistical testing for differences between two results. In interpreting these survey results, it should be recognized that all surveys are subject to sampling error (+5–±6 percentage points for these ten surveys). In addition, surveys are subject to other forms of error from nonresponse, question wording, and context effects, although every effort was undertaken to minimize these.

In using these surveys to shed light on how entertainment media can affect audiences, it is important to understand the demographics of regular ER viewers (Exhibit 1). These viewers are similar to the general adult population on many characteristics such as race, ethnicity, marital status, and geographic distribution. But they do differ in a few important ways. Regular viewers are predominantly female, younger than the general public, and slightly more educated.

Study Results

Top Study Methods Study Results Discussion NOTES

 
Knowledge gain and retention. We conducted specific tests of changes in viewers’ knowledge and awareness of the issues of emergency contraception and HPV (Exhibit 2). We were interested in determining whether a short vignette delivering factual information about these issues could increase knowledge about them, and whether any increases in knowledge would be retained beyond the weeks immediately following the episode.

Viewers’ awareness of emergency contraception increased seventeen percentage points in the week after the episode aired. Among those who knew that a woman has options for preventing pregnancy even after unprotected sex, the number who specifically mentioned that she could take birth control pills (the method mentioned in the show) increased by twenty-three percentage points.

To measure whether effects persisted over time, a separate sample of regular ER viewers were again asked about emergency contraception two months later. General awareness of emergency contraception and the proportion mentioning birth control pills as an option had decreased to pre-episode levels.

Human papilloma virus. A second experiment was conducted in conjunction with an episode mentioning HPV (aired 24 February 2000) to test shifts in knowledge and retention of any knowledge gain. In a short vignette, directly focused on HPV for less than a minute, nurse Carol Hathaway sees a teenage patient who is diagnosed with cervical cancer and explains that it can be related to the sexually transmitted disease HPV.

Three samples of regular ER viewers were surveyed one week before, one week after, and just over a month after the episode. As before, viewers’ knowledge rose, but the level was not sustained over time (Exhibit 2). We cannot say whether the early knowledge gains would continue to decrease to pre-episode levels, as we saw in the emergency contraception experiment.

There is evidence that many viewers surveyed increased their knowledge because of these ER episodes. Among regular viewers who had watched the emergency contraception episode and said they had heard of emergency contraception, 20 percent volunteered that they had learned about the issue from ER. Similarly, 32 percent who had watched the HPV episode and had heard of HPV volunteered that they had learned about it from ER.

It should be acknowledged that viewers may have been exposed to other sources of information about emergency contraception and HPV during the study period. Ideally, a comparison group of non-ER viewers would have been surveyed at the same time to ensure that increases and decreases in knowledge were related to ER rather than to some other event occurring around the same time. However, concerns that nonviewers differ from viewers in other significant ways that would make such a test inconclusive and concerns about budget constraints prevented this from occurring. The finding in both experiments that knowledge increased but then decreased without repetition of the messages, the consistency of this finding with other studies about the need to repeat messages for retention of any knowledge gain, and the relatively short study period during which outside exposure to other information sources could have occurred make it appear likely that much of the observed shift in knowledge is attributable to the ER vignettes.¹²

Health-related story lines. Another major research question investigated whether entertainment media can convey health and health policy information while maintaining viewers’ interest and commercial success. To answer this question, we asked respondents about their interest in health-related story lines and compared this with their interest in other types of story lines, such as those about characters’ relationships. We also looked at whether any actions were taken because of ER’s health-related story lines.

Certainly the personal lives of the characters interest ER viewers, but viewers also reported substantial interest in health-related story lines (Exhibit 3). In fact, of nine separate story lines followed during the 1997–1998 season (in waves 2–4), the story about physician assistant Jeanie Boulet and her human immunodeficiency virus (HIV) status vies for first place, in terms of the percentage of viewers who reported being "very interested" in it, with the story line about Doug Ross and Carol Hathaway’s ongoing romance, the primary romance on the show. Furthermore, more viewers said that they were "very interested" in the story line about Hathaway’s free clinic for low-income and uninsured populations than about the romance between Peter Benton and Elizabeth Corday.

Overall, 54 percent of regular viewers said that they were happy with the amount of health-related story lines on the show, and 40 percent said that they would like to see even more health issues addressed, compared with only 4 percent who wished there were fewer health-related story lines (from the 1997 follow-up survey on contraception). Young, nonwhite, and less educated viewers were particularly likely to say that they would like to see even more health issues covered on the show. Viewers under age thirty were more likely than older viewers were to want to see more health issues addressed (43 percent versus 20 percent; p < .01), as were nonwhite viewers (56 percent versus 39 percent; p < .05) and those with no college education (48 percent versus 35 percent; p < .05).

Slightly more than half (52 percent in the April 1997 preshow contraception survey and 55 percent in the June 1997 follow-up survey) of regular viewers said that in addition to being entertained by ER, they also learned about important health issues from watching the show. Older viewers were more likely than younger viewers (63 percent versus 50 percent) and less educated viewers more likely than those with a college education (62 percent versus 44 percent) to say that they gained important health information. Non-white viewers were also more likely to say that they learned from the show (74 percent of non-whites, compared with 50 percent of whites).

We also explored whether ER episodes led viewers to take any action with respect to health issues (Exhibit 4). We found that 51 percent of regular viewers said that they talked with family and friends about the health issues that were addressed on the show. A third said that they got information from ER that helped them to make health care choices. Viewers with no college education were more likely than those with at least some college to say that they got such information from the show (44 percent versus 25 percent; p <.01).

About one in seven viewers said that they have contacted a doctor or other health care provider about a health problem because of something they saw on ER (Exhibit 4). Approximately 8 percent of viewers said that they have sought additional information from sources other than a provider, such as friends, family members, books, or magazines.

Discussion

Top Study Methods Study Results Discussion NOTES

 
This study documents that viewers are interested in health-related story lines, and some learn about health topics and have been motivated to seek additional health information, even engaging in discussions about health issues with their friends and families, and sometimes their doctors. Importantly, this first-of-its-kind natural experiment highlights that repetition of messages is the key to increased comprehension and longer-term retention among audiences.¹³ When specific health information is presented only through a brief, one-time mention, viewers’ long-term retention of the information is questionable.

This study has implications for those involved in the delivery of health information to the public. Dramatically depicting health-related issues through entertainment television may be a mechanism to inform the public about key health topics. Entertainment television provides access to a wide audience, tuning in week after week. Few other dissemination channels guarantee such ongoing access to the public.

On the other hand, fictional depictions could lead to viewers’ obtaining inaccurate information or taking away critical misperceptions about health topics. Some might reasonably worry that much public health or health policy information may be considered value-laden—for example, information on controversial issues such as abortion. Therefore, even the communication of "factual" information in entertainment media, as in other health education forums, produces both the potential for real disagreements or outright abuse by parties with a particular interest or point of view.

This raises two important questions. First, is entertainment television an appropriate mechanism for communicating information to the public? Second, is there any role for policymakers or public officials to play?

An appropriate medium? Some might argue that fictional television is an inappropriate mode of information dissemination, especially given the potential pitfalls discussed above. Further, many in the entertainment industry itself may resist the suggestion that their goals should go beyond entertaining in an artistically rewarding and commercially successful way by also seeking to educate viewers. Nevertheless, health information is going to be depicted in the entertainment media anyway, and it seems desirable that it be communicated as accurately as possible and that health and health policy experts play a role in this process.

In addressing questions about potential abuses, we would argue that viewers are unlikely to blindly accept all information presented to them, particularly information that goes against their real-world experiences or their own values and belief systems. While early research on the effects of mass media typically characterized audiences as passive recipients of information, as the field has evolved, researchers have shifted to view audiences as more active and critical consumers of media messages.¹⁴ Information that viewers find offensive or misleading might cause them to stop watching a particular show, search out more information about the topic, or simply ignore the reference altogether. Advertisers also might choose to stop supporting a show that presents misleading information or takes a viewpoint on a topic that they feel is out of step with the public or is too sensitive or controversial.

A role for government? This issue raises difficult questions about the role of government and the First Amendment freedom of the creative community. Few would argue that it would be bad for the government to encourage the entertainment industry to play a positive role in information dissemination. But whether the government should be involved in monitoring content, providing financial incentives, or directly dictating or encouraging specific content is a broader and highly controversial question that lies beyond the scope of this analysis.

Entertainment television reaches a wide audience, and in the end, whether one feels that entertainment television does more good or more harm, it will continue to convey health information to its audience whether by design or by default. This study shows that the content has an impact on that audience. It seems, therefore, worth the effort to try to make the content as accurate and science-based as possible, and to take advantage of opportunities to convey public health messages that can improve health and sometimes save lives.

Editor's Notes

 
Mollyann Erodic is vice-president and director of public opinion and media research at the Henry J. Kaiser Family Foundation in Menlo Park, California. Ursula Foehr is a graduate student in the Stanford University Department of Communication. Vicky Rideout is vice-president and director of entertainment media and public health at the Kaiser Family Foundation. Neal Eaer, former executive producer of ER, is now executive producer of Law and Order: Special Victims Unit. Carolyn Miller is an independent survey research consultant from Princeton, New Jersey. Rebecca Flournoy is a research associate at the foundation, and Drew Altman is its president and chief executive officer.

NOTES

Top Study Methods Study Results Discussion NOTES

 

1. Henry J. Kaiser Family Foundation/National Association of Black Journalists, National Survey on Blacks, Media, and Health (Menlo Park, Calif.: Kaiser Family Foundation, July 1998); M. Brodie et al., Whit’s the Diagnosis? Latinos, Media, and Health (Menlo Park, Calif.: Kaiser Family Foundation, June 1998); and M. Brodie et al., "Perceptions of Latinos, African Americans, and Whites on Media as a Health Information Source, "Howard Journal of Communications 10, no. 3 (1999): 147–167.
2. K. Marder, "Real Lives Being Saved by ER," Los Angeles Daily News, 24 November 1997, L.A. Life section, 3.
3. J. Bryant and D. Zillman, eds., Perspectives on Media Effects (Hillsdale, N.J.: Erlbaum, 1986).
4. W.J. Brown, "The Use of Entertainment Television Programs for Promoting Prosocial Messages," Howard journal of Communications 3, nos. 3 and 4 (1992): 253–266; A. Huston et al., Big World, Small Screen: The Role of Television in American Society (Lincoln, Neb.: University of Nebraska Press, 1992); J.A. Winsten, "Promoting Designated Drivers: The Harvard Alcohol Project," American journal of Preventive Medicine 10, supplement 1 (1994): 11–14; R.E. Rice and C.K Atkin, eds., Public Communication Campaigns (Newbury Park, Calif: Sage Publications, 1989); and Kaiser Family Foundation, The Use of Mainstream Media to Encourage Social Responsibility: The International Experience (Menlo Park, Calif: Kaiser Family Foundation, 1995). One qualitative study with a small group of thirty something viewers assessed the effects of that television program on viewers’ knowledge and actions: B. Sharf et al., "Confronting Cancer on thirty something: Audience Response to Health Content on Entertainment Television," Journal of Health Communication 1, no. 2 (1996): 157–172.
5. G. Gerbneret et al., "Growing Up with Television: The Cultivation Perspective," in Media Effects: Advances in Theory and Research, ed. J. Bryant and D. Zillman (Hillsdale, N.J.: Erlbaum, 1994).
6. Ibid.
7. N. Signorelli, A Content Analysis Reflections of Girls in the Media (Oakland and Menlo Park, Calif: Children Now and Kaiser Family Foundation, April 1997).
8. Interviewing dates and sample sizes of each of ten Kaiser Family Foundation surveys to assess the impact of watching ER on regular ER viewers are as follows: For the three surveys conducted around the episode with the emergency contraception vignette: Preshow, n = 400, 31 March to 9 April 1997; Postshow, n = 305,11–16 April 1997; Follow-up, n = 301,25–30 June 1997 For the four surveys conducted over the course of the 1997–1998 season: Baseline, wave 1, n = 505,11–23 September 1997; wave 2, n = 502,21 November to 3 December 1997; wave 3, n = 500, 7–16 March 1998; and wave 4, n = 501, 20–31 May 1998. For the three surveys conducted around the episode with the HPV vignette: Preshow, n = 400, 8–16 February 2000; Postshow, n = 301, 25–29 February 2000; and Follow-up, n = 299,3–16 April 2000.
9. Response rates for each of ten Kaiser Family Foundation surveys to assess the impact of watching ER on regular ER viewers are as follows: For the three surveys conducted around the episode with the emergency contraception vignette: Preshow, 41 percent; Postshow, 27 percent (36 percent recruit x 76 percent Postshow); and Follow-up, 54 percent. For the four surveys conducted over the course of the 1997–1998 season: Baseline, wave 1, 58 percent; wave 2, 56 percent; wave 3, 57 percent; and wave 4,57 percent. For the three surveys conducted around the episode with the HPV vignette: Preshow, 28 percent; Postshow, 24 percent (34 percent recruit x 72 percent Postshow); and Follow-up, 27 percent. Response rates were calculated by using the American Association for Public Opinion Research standard definition RR3 as described in Standard Definitions: Einal Dispositions of Case Codes and Outcome Rates for RDD Telephone and In-Person Household Surveys (Ann Arbor, Mich.: AAPOR, 1998). The experimental survey component presented challenges for response rates given the incidence of regular ER viewers (only one in four households had a regular ER viewer) and the short period available (one week between episodes) for testing the immediate impact of the specific vignettes. This latter fact prompted us to use a presurvey recruitment phase for the postshow portion of the surveys (reflected in the breakdown of the response rates for the postshow surveys above). With regard to the response rates, several things are worth noting. First, we do use a standard and fairly conservative measure for calculating response rates as proposed by AAPOR. Second, response rates alone should not be taken as a guide to the reliability of survey data. Also, any systematic bias that might have resulted from nonresponse on the natural experiments would likely persist across all three surveys, which mitigates concern about nonresponse having an effect on retention rates among the groups surveyed.
10. M. Brodie, "Sensitization Effects in a Study of the Impact of a Nationally Broadcast Special on Health Care Reform," in Doctoral Thesis: Political Institutions, Participation, and Media Evaluations— Influences on Health CarePolicy (Boston, Mass.: Harvard University, 1995).
11. Kaiser Family Foundation/Harvard University, Health News Index (May/June 1998); and Health News Index (January/February 2000).
12. R.E. Petty and J.T. Cacioppo, Attitudes and Persuasion: Classic and Contemporary Approaches (Dubuque, Iowa: William C. Brown Company Publishers, 1981), 79.
13. Ibid.
14. B. Reeves and R Hawkins, Effects of Mass Communication (Chicago: Science Research Associates, 1986).

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