In the early eighties, a popular prime time drama serial Zeg eens A was being broadcast in the Netherlands. Health communication professionals who saw this series regarded it as an interesting setting in which to introduce and deal with health communication messages (see for example Bouman, 1984). At that time, however, collaborating with scriptwriters of popular television programmes was a problematic issue, due to the fact that health organizations had great reservations about using a popular medium like a tabloid, a gossip magazine, a soap opera or other drama series to communicate serious health messages (Dekker, 1985 personal conversation). Apart from their unfamiliarity with popular culture, health organizations feared losing their respectable image and, as a possible ultimate consequence, their funding. Although understandable, this showed an explicit tension between the goals of health communication and the goals of public relations and fundraising. Health communication professionals however saw that the messages of health organizations have to compete with thousands of other communication messages. If the attention of the target audience is to be caught and held, and more especially if that audience is not spontaneously interested in health messages, it is no longer sufficient to rely solely on the rationality of the message: other, more emotionally appealing and popular communication methods must also be brought into play. Some health organizations acknowledged this, but did not yet accept its consequences. Zeg eens A became the most popular Dutch drama serial of the eighties, but never carried a purposively designed and eloquently interwoven health message1.
As time went by, the climate for using entertainment television for health communication purposes changed however, and worldwide a number of ways were found to incorporate health promotion messages into popular television entertainment. This approach is now known as the entertainment-education (E&E) strategy (Coleman & Meyer, 1989). In the Netherlands also, some challenging experiments were carried out in the late eighties, such as the drama series Familie Oudenrijn in 1987 (Verbeek, 1990), the Way of Life Show in 1988 (Nederlandse Hartstichting, 1988; Bouman, 1989) and Villa Borghese in 1991 (Bouman & Wieberdink, 1993).
The first experiments with E&E television programmes initiated a lively discussion and debate about norms and values in the Dutch health communication field. This provided an impetus for the creation of new and experimental ways of reaching the so-called 'hard to reach' groups. Because of the many still unanswered questions, research in the field of the entertainment-education strategy is both necessary and rewarding.
In the next four sections, some matters that need to be explicated will be touched upon. Section 1.1 defines some concepts frequently used in this thesis. Section 1.2 lists the research questions of the thesis. Section 1.3 gives a short overview of the health communication field, divided into organizations, health communication professionals and health communication strategies. Section 1.4 briefly describes the field of television in the Netherlands. Section 1.5 gives an overview of the thesis chapters, and section 1.6 summarizes this chapter.
The subject of this thesis is collaboration for prosocial change; the entertainment-education strategy on television. The concepts in the title of this thesis are defined as follows:
- In this thesis, collaboration refers to two different professional fields working together to design and produce a television programme in which entertainment and education are combined. The two professional fields concerned are the field of health communication and that of television production. In a wider sense these represent national health organizations on the one hand and broadcasting companies and independent production companies on the other; in a narrower sense they are the health communication professionals and television professionals working within these respective organizations.
- The term prosocial denotes 'that which is socially desirable'. From a critical theory perspective, questions can be raised about what is socially desirable (see also Chapter 2, section 2.4.). In this thesis, health is the object of prosocial change. Health is defined by the World Health Organization (WHO) as 'a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity' (WHO, 1986). The goals of prosocial and health communication, as referred to in this thesis, are directly derived from policy papers as formulated and formalized by national governments, and indirectly by international organizations, such as the WHO.
- In this thesis, change agencies are national health organizations. National health organizations as change agencies are defined here as either government related agencies or non-governmental organizations (NGOs) and the change agents are health communication professionals who work within these organizations. Health communication is regarded here as an essential element of the wider concept of health promotion. Some of the researched projects in this thesis also concern broader health related issues, such as environmental communication or road safety, but the term 'health communication' will be used as an overall concept for all forms of prosocial communication with which this thesis deals.
- Entertainment-education (E&E) strategy refers to the combination of entertainment and education in order to promote prosocial change. In Chapter 2 the definition of the entertainment-education strategy will be elaborated. The E&E strategy can be applied to different popular media: theatre, music, film, radio, television, etc. This thesis focuses on the use of the E&E strategy in television.
Television entertainment as a potential vehicle for health promotion is regarded as a challenging concept. A study into the use of the E&E strategy in television refers to such questions as: 'What are the characteristics of television programmes in which education has been or can be combined with entertainment?' 'How effective is the E&E strategy?' 'Which facilitating or hindering factors play a role in the collaboration between health communication and television professionals when making an E&E television programme?' 'Is it possible to develop a working model that helps practitioners to decide if and how an entertainment-education programme can be designed and produced successfully?' These - and other - questions have led to the central research question, which is twofold:
- A) What are the characteristics of entertainment-education (E&E) television programmes which are purposively designed to enhance prosocial behaviour, and what is known about their effects and conditions for success?
- B) How do health communication and television professionals collaborate in the design and implementation of an E&E television programme and what recommendations can be made for the management of E&E collaboration in the future?
Anderson and Meyer (1988) indicate that the motives of a researcher to investigate a certain topic can be epistemological in nature, but the results and implications of the research can be ideological and economic. In this study all these components play a part. As E&E practice is ahead of E&E theory, the aim of this research is to transpose the experiences of E&E practice into a theoretical framework and to add new concepts to the discourse of E&E communication professionals. In order to answer the questions posed in this thesis, the following research has been undertaken:
- A review of the literature on the theory and practice of health communication, mass media (television) and the entertainment-education strategy;
- An analysis of the quantitative data of Dutch E&E research;
- An analysis of E&E television programmes worldwide;
- A review of the literature on television production and collaboration;
- An in-depth qualitative study into the collaboration process between health communication professionals (N=18) and television professionals (N=12) on twelve Dutch E&E television programmes.
- As the E&E strategy is not yet widely known, let alone implemented in Dutch health communication and television practice, a rather broad scope has been chosen in this thesis. The disadvantage of this is that not all related subjects can be given an exhaustive treatment. The advantage, however, is that a solid basis is created for further analysis and research.
Conclusions and lessons learned (Summary part I)
The purpose of this section is to summarize some of the experiences and lessons of the E&E television programmes studied here in order to assist the design of E&E television programmes in the future and to answer the first part of the central research question in this thesis:
A)What are the characteristics of entertainment-education (E&E) television programmes which are purposively designed to enhance prosocial behaviour, and what is known about their effects and conditions for success?
Entertainment-education (E&E) television programmes which are purposively designed to enhance prosocial behaviour are not just regular television programmes. In order to be effective, the design of E&E television programmes (drama, comedy and soaps, or quizzes, gameshows and talkshows/magazines) should be based on the principles of vicarious learning and social modelling. The actual modelling and observational learning process is governed according to Bandura (1986) by four interrelated subprocesses: attention, retention, production and motivation (see Chapter 2, section 2.3.5). Based on these four processes, combined with the research results of the design and effects of E&E television programmes worldwide, the following characteristics can be identified as important for the design and success of E&E television programmes:
First, the socially desirable television model must catch the attention of the audience (observer). In entertainment-education television, this is achieved by using a popular programme genre. Other variables, such as the perceived credibility and attractiveness of the model, also come into play. It is important to use spokespersons (show host, stars, actors) that the audience will trust and believe. Entertainment-education television must be of high quality, using skilled and talented professionals. The production quality has to meet or exceed media standards. It is important to keep entertainment in the foreground and education in the background. First the audience has to get involved in the programme, later messages can be introduced and incorporated. It is important to cater for both the head and the heart and to be dramatic and moving. Although different kinds of programme formats have been used in E&E television studies, varying from talk and gameshows and variety shows to popular soap and drama series, realistic social drama is especially successful in involving people emotionally. There is much inconsistancy about the effectiveness of humour. Studies concluded that in order to be an effective aid to learning, humour must be at least meaningfully related to the material to be learned. The humour should coincide perfectly with the critical learning opportunity.
In order to reproduce the behaviour without the presence of the model, it is necessary to retain the image and verbal symbols that are provided. Retention of modelled information is enhanced when viewers perceive the model and the circumstances to be similar to themselves and significant in their lives. The programme has to involve a variety of problems which are eventually solved to the benefit of positive role modelling characters.
It is necessary to present role models who exchange ideas and opinions about the prosocial issue involved. In this way, different segments of the population will be able to identify with the issue at hand. Vicarious learning can best take place when viewers identify with and relate to these role models and when viewers recognize issues as relevant for their daily lives. This way, television programmes can serve as touchstones for experiences which viewers have and which they see reflected in the programme. The programme has to be realistic, set in todays world, include events in different settings (urban and rural), and depict characters who are regarded by the viewers as 'people like us'.
Depicting lifelike situations and portraying social models who are 'people like us' is an essential part of E&E television programming to create the circumstances necessary for social learning and to enhance a feeling of involvement. A realistic programme does not mean that every detail must conform to reality, but that it has a contemporary setting, that it concerns itself with secular action (human action described in exclusively human terms) and that it is socially extended, which means that it deals with the lives and experiences of ordinary people. With reference to the latter, to avoid feelings of embarassment or stigmatization, it is advised to depict positive role models with a slightly higher aspiration level. Domestic productions with outdoor scenes at well known sites, using colloquial language, make E&E television more realistic.
The essence of the entertainment-education strategy is to use television characters as models of behaviour and to encourage audience members to talk each other into practising the desirable behaviour they see portrayed. Entertainment-education programmes are designed to stimulate and enhance parasocial interaction between viewers and television personalities and characters and encourage talking with neighbours, family and friends about what they have seen on television. Memorable images and the acting out of prosocial behaviour are remembered better and longer than dialogues and lectures about such behaviour. E&E television programmes have to link in with what is already part of public awareness. The influence is problably greater when a message evokes recognition and then adds an idea or concrete information to that, rather than when it is contradictory to the prevailing opinion. It is important that E&E television programmes address their objectives by associating them with pre-existing human values and dramatizing how specific role models learn to actualize these values in their lives by practising the prosocial behaviour.
The third subprocess that influences the degree of modelling is called the production process. This process addresses the ability of the individual to replicate the observed behaviour, or the translation of retained symbols into guides for future behaviour. In order to reproduce the modelled behaviour it is important to tell audiences what they can do now, referring them to sites (e.g. address, telephone, Internet page) for answers on questions or to services or service providers that are familiar, available and ready. Some ways to do this are: (1) by using several 'reality reminders' epitomizing appropriate behaviour; (2) by 'advising' viewers how to deal with specific situations; and (3) by introducing epilogues to programmes to summarize the main educational points and to provide specific information about the services and infrastructure needed for viewers to convert an intention, motivated by the television programme, into action. Direct messages work best, especially with hard to reach audiences. Researchers report that respondents with lower levels of education gained more from factual information and knowledge about health issues than from more subtle messages conveying particular attitudes from which they were sometimes unable to draw appropriate inferences. Respondents with higher levels of education, however, gained most from the inferential messages tackling prejudice and attitudes. This confirms that different audiences demand different kind of message frames. Clear cut factual information and practical advice seems to meet especially the needs of the less well educated, while implicit contextual information suits more highly educated audiences. It is also suggested that a more direct approach may be more successful in addressing issues where attitude change is likely to be particularly difficult. It is important to focus on so-called 'personal efficacy', or the extent to which people think that they have the skills to change their behaviour. Focusing on imparting skills to handle different situations seems to offer a better prospect for changing behaviour than emphasising the damaging effects for health. Another approach which does not place too heavy an emphasis on the transfer of information and does not become too serious, is to depict how ordinary people deal with dilemmas in everyday life: how they share emotions, exchange ideas and arguments about a certain issue and how they make their final choice for one or the other behaviour.
Message framing based on a 'consumer approach' supports and empowers lay people, in contrast to a 'medical approach', which underlines and supports the central role of the educated health care professional. Message framing according to a 'look after yourself' approach focuses on individual lifestyle determinants of health problems, and an 'environmental approach' stresses the socio-economic determinants and conditions of health problems.
Motivation and reinforcement process
The most important and decisive subprocess is motivation and reinforcement. An individual may observe, retain and have the ability to translate the retained symbols into specific behaviour, yet not do so unless favourable incentives are introduced. Motivational processes address incentives to exhibit modelled behaviour, including direct and vicarious rewards. There are three types of modelling characters with whom the audience needs to identify closely in order to vicariously experience the rewards (or punishment) for practising the promoted behaviour: (1) those who support the prosocial behaviour (positive role models), (2) those who reject it (negative role models), and (3) those who move from antisocial to prosocial behaviour (transition models). In entertainment-education television programmes, the observer or viewer learns vicariously by watching a television model being visibly rewarded or punished immediately after the model engages in prosocial or antisocial behaviour. These rewards or punishments must be realistic and can vary from subtle gestures to more explicit moral statements.
In general we can say that, from a social marketing perspective, the use of entertainment television formats has been very beneficial. Most programmes gratified both the need for entertainment and education and attracted a huge public, in ways that cannot be achieved by straight-forward didactic approaches. The programmes had favourable prime time slots which are never given to more conventional health education television formats. The most reported impact of E&E television programmes was at the level of exposure and awareness. Several results have also been reported in affecting knowledge, attitude and even in some cases a change of behaviour regarding the prosocial issue. The strength of E&E television programmes lies especially in social modelling, social reinforcement and interpersonal communication. Some E&E television programmes were also successful in triggering and mobilizing local communities (collective efficacy). While the direct effects of most E&E programmes were modest, the indirect effects via the encouragement of peer comunication can be substantial. Effects occur through the social psychological processes of social modelling, parasocial interaction and efficacy building which take place particularly when audience members discuss the content of an E&E message in peer communication. Although generally E&E television proved successful in raising the attention of the audience in respect of the prosocial issue and in communicating the message as intended, clearly failure has to be accepted in certain areas. The entertainment education strategy is not free of problems. Viewers did not always identify with the intended characters and it was sometimes difficult to find the right balance between entertainment and education. In addition, many summative research designs had methodological limitations.
Entertainment-education by itself can sometimes bring about social change, and under certain conditions (in combination with other sources of influence) it can create a climate for social change.
There are several contextual differences between non-western and western countries that may explain why some E&E televison projects are more successful than others, such as differences in infrastructure, available audiences, novelty and timing and other societal factors.
Conditions for success
As indicated earlier, the entertainment-education strategy is based on a social marketing approach, implying a strong focus on the social adoptability of prosocial messages and a consumer orientation. In order to position the 'product' and to be responsive to consumer needs, pre-production research and 'product testing' (formative research) is of utmost importance. Various techniques of social marketing are used in the design of entertainment messages (e.g. formative evaluation, audience segmentation, needs assessment, product development, pre-testing).
Research-based knowledge about the characteristics, needs and preferences of the target audiences can substantively inform and support the design of entertainment-education programmes. This may be done by having the scripts of E&E television programmes read by representatives of the target audience, by inviting audience representatives to participate in the design process, or by organizing focus groups to get actual information and feedback from the specific target group. In order to achieve realistic portrayals, visiting the sites and neigbourhoods where the target audience lives and talking with them about their day to day problems and experiences have proved to be of considerable value. In particular, establishing whether there are any rumours, myths or misinformation around the issue involved is helpful in designing the content of the programme and very helpful in choosing positive and negative role models. Besides improving the messages and materials, the process of audience analysis and pretesting also proves helpful in generating a sense of involvement in the collaboration process between television professionals and health communication professionals. Some researchers report that by attending the focus-group discussions and reflecting on the feedback from the potential audience, the collaboration partners came all the more to the realization that communication is a process, not a product.
This extensive formative research, however, demands more preparation time before and during the design of an E&E television programme than conventional television programmes. This calls for careful planning in advance and communicating with the television professionals in order to meet the demands of the production schedule. Effective implementation requires the creation of solid ground in order to optimize programme effects. The research shows that E&E television programmes that are part of a multi-media campaign and are combined with a variety of other promotional and educational activities to inform and influence target groups are the most effective. E&E television alone cannot cause change without the support of other socio-cultural and structural factors. The importance of providing adequate infrastructural services to support E&E is emphasized. In order to be effective E&E television programmes need to be well planned, researched and orchestrated, but even the most thorough planning, research and orchestration do not guarantee success. Enough time, adequate funding over a sustained period, applied by a dedicated staff of able people using strategies based on research, is also essential. Effective communication demands a high level of commitment and multidisciplinary teamwork. The way in which collaboration partners succeed in building a win-win relationship is important for success.
Conclusions and Lessons Learned (Summary part II)
In this section, an overall view of the experiences and lessons of the E&E collaboration processes as studied in Part II of this thesis will be given, and an answer will be provided to the second part of the central research question of this thesis:
B)How do health communication and television professionals collaborate in the design and implementation of an E&E television programme and what recommendations can be made for the management of E&E collaboration in the future?
In general, the E&E collaboration between health communication and television professionals was experienced as complicated. Bourdieu's general theory of practice (see Chapter 6) may be of assistance in gaining more insight into the hows and whys of the complexities of the E&E collaboration process. The key concept in this theory is that of 'habitus'. The habitus is sometimes also described as a 'feel for the game', a 'practical sense' that inclines agents to act and react in specific situations in a manner that is not always consciously calculated, but nevertheless fits the rules of its 'field' (the 'territory' of the habitus). It is clear that health communication and television professionals belong to different fields and thus employ a different habitus. In collaborations, however, where fields more or less have to integrate in order to reach a common goal, like in E&E production, it is necessary that both parties attune (make 'congruent') their habitus to that of their collaboration partner.
In the E&E collaboration processes under study, health communication and television professionals experienced a lot of incongruency because they had different interpretations of the habitus the collaboration required. Television professionals talked about 'viewers' and 'viewers satisfaction', and health communication professionals about 'target groups' and 'behaviour change'. With regard to programme content, television professionals looked at potential topics in terms of visualization and gaining the attention of the audience, seeing these as goals in themselves. Health communication professionals were interested in the topics' potential for vicarious social learning and influencing audiences' awareness, attitude and behaviour. What was an end in itself for television professionals was a means for health communication professionals. Consequently, both wanted to obtain and maintain steering power during the whole E&E collaboration process. Health communication professionals wanted to work along the principles of behaviour change theories and to have influence on all programme aspects: content, form, angle, context. Television professionals, however, expected a clear division of tasks: health communication professionals to deliver and to take care of the content of the message, and television professionals to design the format in which the health message could be best televisualized. So it appears that instead of creating common ground (or habitus), both fields first just employed their own habitus. Then almost automatically the question arose as to whose habitus was the strongest and could force the other to comply with its rules.
According to Bourdieu, in order to be accepted by a field (to be 'consecrated'), one must possess the habitus which predisposes one to enter that field. Without full recognition of the habitus, a field will always reject or try to exclude new 'players'. Although television organizations often took the initiative for the E&E collaboration, and in that sense were the requesting party with regard to health organizations, practice showed reversed positions. Besides paying an entrance fee (delivering economic, cultural and/or social capital), health communication professionals were more or less forced (not always conciously) to incorporate the televison field's habitus in order to be 'consecrated' and allowed to 'play along'. For health communication professionals, especially when they were newcomers to the television field, this proved to be a complex and demanding task that often made them feel they were drifting away from their own field. In their eyes, working along the television professionals' frame of reference caused an asymmetry of power. This was not what they had in mind when they started the collaboration. Moreover, this acquisition of the habitus of the television field jeopardized their relations with their own organization. By 'going native', they put not only the backing of their organization at risk, but also its symbolic capital (fear of misrepresenting their health message, losing their respectable image, damaging their networks). Health communication professionals, knowing this, became hesitant to assimilate the television field's habitus, and experienced difficulties in shifting between the two fields.
Differences in field mechanisms also played a significant role in the complexity of the collaboration. According to Bourdieu, the field with the greatest economic and commercial interests will (try to) dominate other fields. Ultimately, the competition for high viewing rates always determined the way the E&E television programme was designed. In this case, the television field dominated the health communication field. Health communication professionals had to prove that an effective E&E television programme could not be made without their professional input and expertise with regard to behaviour change. That burden of proof was additionally complicated by the fact that the collaboration motives of national health organizations ranged from raising money, creating publicity and selling products to influencing behaviour change. In cases where behaviour change was not an aim, specific behaviour change expertise indeed was not needed. Television professionals in such situations could just follow their own knowledge and expertise. To design E&E television programmes, however, their knowledge and expertise are not sufficient, and there is a requirement for the specific expertise of health communication professionals about the way the programme can be attuned to the goal of prosocial behaviour change, and therefore the merging of professional cultures becomes inevitable. Because of all this, combining entertainment and education in the television field means working within a high risk context.
Conditions for success
The nature of the habitus will in almost all cases militate against fields easily merging and working together in harmony. Specific measures have to be taken to stimulate the fusion of one habitus with the other and to build an E&E collaborationship based on symmetry of power. What is required is a joint frame of reference which incorporates elements of the habitus of both professional fields. Both partners have to acquire a new 'E&E habitus' that materializes in an E&E television programme with specific genre features and working principles, and which is consecrated by both constituting fields. The next important question is how both types of professional can be convinced of the advantages of collaborating on common ground. The answer to this question is not yet fully clear, but engaging in some informed speculation may provide a few clues. When health organizations experience the asymmetry of power in the collaboration as a crucial factor hindering success, they may find ways to exert their power to exclude: 'if the television field does not collaborate on our terms, they cannot have our money or expertise'. This will certainly help health communication professionals to gain self-esteem, and maybe even stimulate the expansion of their habitus. It would be an antagonistic strategy however, which in the long run probably would result in unwanted adverse effects on the power balance.
The designing of new incentives to create a joint frame of reference can be expected to have more, and positive, effects. Probably the best incentive will be the attraction of a new television genre which is both challenging and promising. Health organizations as well as television organizations, therefore, are recommended to invest in establishing the features for this genre and to stimulate the formation of capital relevant to an 'E&E habitus'. Cultural, social and symbolic capital can be formed by establishing professional standards and by achieving success. Cultural and social capital originate where a body of knowledge and expertise is acknowledged and distributed by a core network of professionals. Symbolic capital is ultimately confirmed by success. In order to achieve this, a substantial investment is inevitably required from both fields: health organizations must become more television literate, television organizations must combine commercial interest with social accountability, and both must move from a production-centred to a truly audience-centred attitude.