The Power of TV Dramas

Drama is more powerful than other forms of communication because it tells an engaging and captivating story (Kincaid, 2002). Through attractive storytelling, involving characters the viewer already knows, health information is more likely to be attended than traditional health campaigns (Singhal, Cody, Rogers & Sabido, 2004;

Singhal & Roger, 1999; Slater & Rouner, 2002). As a matter of fact, people are dislike of interruptions in their entertainment, for example, commercials or public service announcements (PSAs). Commercial sponsors thus turn to “product placement”

where appeals or products are embedded into popular dramas or programs directly.

When health-related contents are integrated into TV storylines, this practice is called as “entertainment-education” or E-E (Sabido, 2004; Sherry, 2002; Singhal et al., 2004;

Singhal & Roger, 1999, Murphy, Frank, Moran & Patnoe-Woodley, 2011).

E-E is a form of “intentional placement of educational content in entertainment messages” (Singhal & Roger, 2002, p.117). It has been argued to be more effective than traditional PSAs, as dramas are less “obvious,” and therefore, viewers may be less resistant to the content embedded (Brown &Walsh-Childers, 2002; Singhal &

Rogers, 1994; Slater, 1997, 2002; Slater & Rouner, 2002). Instead of using clinic brochures or PSAs, the use of narrative can lead viewers to be become transported into the story where disbelief is suspended, also, it “can overcome reactance by diminishing the viewer’s perception that the message is intended to persuade”

(Moyer-Guse, 2008, p.415).

1.2 Health Effects of TV Dramas in Global View

Originally, entertainment-education strategy began its practice in developing countries, especially across Latin America and Asia, mainly in the form of TV and radio soap operas. Serial drama, especially, often goes on TV for several months or years, is a powerful form of E-E, which can make an impact on health behaviors and related social norms. E-E serves as a social mobilizer or agenda-setter, resulting in a socially-desirable direction for public or policy initiatives (Wallack, 1990).

Some of the prominent studies included Soul City¹, launched in South Africa in 1994. The 11 series depicted various kinds of issues like domestic violence, HIV prevention, Tuberculosis, alcohol misuse, etc. It had successfully reached 80% of its target audience to raise awareness and shift in social norms within communities (Soul City, 2001). Shabuj Chhaya², aired in 2000 in Bangladesh, captured an important HIV/AIDS message: Care for the sick, do not shun or stigmatize them. In a 3-minute sequence, it conveyed a specific health message, evoked a powerful emotional response and created a lasting impression which can lead to viewers’ behavior change (Piotrow & deFossard, 2004).

In addition, a growing number of organizations in the United States have seen the successful global E-E effects, and hope to apply in the U.S.. Furthermore, they attempted to evaluate these E-E interventions more proactively than earlier efforts,

1 Soul City TV drama series was launched in 1994 as part of a multimedia health promotion and social change project by the Soul City Institute for Health and Development Communication. The drama was not only broadcasted on SABC 1 channel in South Africa, but also in many other countries to millions of viewers.

2 Shabuj Chhaya was aired in 2000 in Bangladesh. Scripted by Dr. Hamayun Ahmad, the drama

which was to analyz viewers’ responses accordingly after the storyline ended (Sharf

& Freimuth, 1993; Sharf, Freimuth, Greenspon & Plotnick, 1996). According to 2000 Porter Novelli Health Styles survey, 26% of the U.S. public referred entertainment TV shows as their Top 3 sources of health information, and over half (52%) trusted the health information contained in these programs to be accurate, and 48% took some action after hearing about a health topic in a TV show (Beck, 2004; Beck &

Pollard, 2001; Murphy, Hether & Rideout, 2008).

In order to help writers and producers for fast, correct and based-on-true-story health information, in 2002, Hollywood, Health and Society was launched in collaboration with Annenberg Norman Lear Center at the University of Southern California and the U.S. Centers for Disease Control and Prevention. This program has been conducting a TV Monitoring Project, tracking health contents depicted in TV prime time programs for years. It is found that health storylines in U.S. television shows can appear in a single episode of television drama series (in a few lines of dialogue between characters or minor storylines of two to three scenes, for example) or, it could span in an entire season for several months (Greenberg, Salmon, Patel, Beck & Cole, 2004).

Some successful E-E practices HH&S had intervened, including an episode of The Bold and the Beautiful³ featuring a young Hispanic character telling his girlfriend that he was HIV-positive. It let CDC’s AIDS hotline reached the highest

3 The Bold and the Beautiful is an American soap opera premiered in 1987. As of February 2015, it had aired 7,020 episodes on CBS channel. It has become the most-watched soap opera in the world,

spike of callers all year when the storyline showed a PSA/800 number (Kennedy, O’Leary, Beck, Pollard & Simpson, 2004).

In top-rated prime time medical drama ER⁴, compared to non-viewers, men who have sex with men (MSM) who watched the syphilis storyline were twice as likely (33% vs. 69% ) to say they would go for a syphilis test (Whittier, Kennedy, Seeley, Lawrence & Beck, 2005). A survey of Numb3rs⁵ indicated that 10% of the viewers who were not registered as organ donors said that the transplantation storyline made them more likely to become a potential donor (Movius, Cody, Huang & Berkowitz, 2007). In 90210⁶, a BRCA-gene breast cancer storyline motivated 11.5% of the viewers surveyed to schedule a doctor’s appointment to talk about their risk of breast cancer (Rosenthal, Buffington & Cole, 2013).

1.3 Health Effects of TV Dramas in Taiwan

According to Taiwan Communication Survey, 75% of Taiwanese audiences made a point to read and watch stories about health in media. Among TV, radio, newspapers and the internet, most people believed that health information contained in television is the most important source (TV 70%, compared to radio 61%,

4 ER is an American medical drama series aired on NBC from 1994 to 2009. The storyline follows the inner life of the fictional County General Hospital in Chicago and depicts various issues faced by the room’s physicians and staffs. The show ran for 15 seasons with a total of 331 episodes, becoming the longest-running prime time medical drama in American television history.

5 Numb3rs is an American medical drama series that ran on CBS from 2005 to 2010. It had 5 seasons with a total of 118 episodes. The show focuses equally on the relationships among Charlie Eppes and their father Alan Eppes, and on the brother’s efforts to fight crimes mostly taken places in Los Angeles. A typical episode begins with a crime, which is investigated by FBI agents led by Don and mathematically modeled by Charlie.

6 90210 is an American teen drama series that aired on CW from 2008 to 2013. The drama ran 5 seasons with a total of 114 episodes. The storyline revolved around several students at the fictional

newspaper 66% & internet 61%); regarding to trusts in source of health information, nearly 46% of Taiwanese trust TV or newspapers, 34% trusted health information mentioned in radio or the internet. (Taiwan Communication Survey first sub-topic of the first phase, 2012). In general, television is still considered as the most powerful medium to convey health messages to audiences.

As an increasing number of global E-E strategies have been practiced in promoting health topics, in 2012, Centers for Disease Control in Taiwan collaborated with Shih Shin University and launched the E-E Matchup Project. As the principal investigator Liu mentioned, if “scriptwriters are interested in integrating a disease into the script, to dramatize the content (or to meet the needs of media social responsibility), they may go through this platform to obtain free and accurate information of the disease from professionals and scholars that meet the standards of public health promotion” (Centers for Disease Control, R.O.C. & E-E Matchup Project, 2014, p. 6). In the three-year project, this platform had reached nearly a hundred scriptwriters in Taiwan, disseminating E-E effects and media’s social responsibility for the public. It had successfully helped include disease information provided by the Centers for Disease Control in six drama programs which will be broadcasted or are still under production.

Moreover, the E-E Matchup Project conducted a case study to analyze health contents contained in Taiwanese TV dramas aired from 2012 to 2014. It is found that narratives regarding health contents in Taiwanese dramas were mainly chronic illnesses, especially cancers (Centers for Disease Control, R.O.C. & E-E Matchup Project, 2014). Unlike Murphy, Hether & Rideout’s (2008) study incidated that one

fourth of U.S. health-related drama contents were about unusual or rare illnesses, leading viewers to have a wrong impression that these rare illnesses are more prevalent than they actually are, Taiwanese TV dramas actually have comparatively low percentage of storylines about rare illnesses, which in turn brings a positive influence of health education to viewers (Centers for Disease Control, R.O.C. & E-E Matchup Project, 2014).

1.4 TV Dramas in Taiwan

In Taiwan, besides trendy dramas which are mostly shown on weekend nights,

“long-running” native soap operas are wildly popular genre of prime time TV drama.

Long-running soap operas are one of the mainstream drama genres in Taiwan with the highest view rating. They are mainly Taiwanese dialogue-based, with family grudges or love triangle as main storylines. Also, they are mostly in a live-shoot system for financially advantages, because the networks can shorten the number of episodes if ratings are low and therefore allow more profitable dramas to be broadcasted sooner.

On the other hand, script can always be rearranged to comply with viewer demands.

Long-running Taiwanese soap operas are popular not only in Taiwan, but also in other Southeast Asian Chinese regions. Popular native soap operas like Feng-Shui Family《風水世家》⁷, Mother’s Home 《娘家》⁸, Taiwan Tornado《台灣龍捲風》

7 Feng-Shui Family is a Taiwanese-spoken TV prime time drama that began airing on Formosa TV in Taiwan from July 2012 to March 2014. The highest viewer rating in an episode was 8.57%, and average viewer rating was 5.66%. It was highest rated TV drama of 2012 and 2013.

8 Mother’s Home is a Taiwanese-spoken TV prime time drama aired on Formosa TV from May 2008 to December 2009. The highest viewing rate in an episode was 7.97%, and average viewing rate

9, or the 2014 to 2015 ongoing drama Love in This World《世間情》¹⁰not only offered public entertainment value but also gained much media attention. The origin of native soap operas may be traced back to 1990s, not long after the lifting of Martial Law, when TV stations began to produce Taiwanese spoken dramas and shows. Native soap operas are Taiwanese-spoken (a.k.a Minnan language) dramas, which are often related to enterprise heritage, love triangle, family grudges, violence and diseases.

They are considered to contain certain type of “formulas” and “stereotypes,” and are usually cliché. The target audiences of native soap operas are those who are prefer to stay in at night, above 55 years old, free and seeking easy-to-watch dramas (Cheng, Ko, Kuan & Tsai, 2006; Huang, 2013).

Although it is argued that native soap operas often have over-exaggerated and dragging storylines, which leave a negative impression of viewers in Taiwan. Studies have shown that native soap operas do embody an ethos and cultural identification to viewers. Thus, native soap drama shown at prime time is regarded as one of the most important and effective media tools of imbedding health messages and addressing health information (Lee, Lin & Lin, 2014).

1.5 Why Feng-Shui Family?

Feng-Shui Family《風水世家》was chosen in the study for several reasons. First, it is the most recently finished “long-running” prime time TV drama with the highest

9 Taiwan Tornado is a Taiwanese-spoken TV drama that began airing on SET Taiwan from February 2004 to June 2005, with a total of 345 episodes. The drama had generated many meme languages across youngsters in Taiwan and created a viral mimicked phenomenon.

10 Love in this World is a Taiwanese-spoken drama premiered on SET Taiwan since September 2013 till now (as of June 2015). The cliché storylines had resulted in a huge discussion on the internet and news. The average viewing rate to date is 3.72%, and ranked as the Top 2 prime time drama of

viewing rate in Taiwan, aired from July 2012 to March 2014, with a total of 426 episodes. According to Nielsen rating, the highest per minute viewing rates it had achieved was 10.2% (3.27 million viewing population), 8.57% (2.75 million viewing population) for an episode, and reached a 5.66% average viewing rate. 83% of episodes were ranked as the top rated dramas during primetime timeslots. From the first to last episode, the total viewing population reached 16.7 million, which meant over 70% of Taiwanese had watched Feng-Shui Family (Yen, 2014).

Second, this drama was broadcasted on a wireless television – Formosa TV (民 視). It is a free channel which is accessible to nearly all residents in Taiwan, whether living in urban, rural or remote areas. One study showed that for people living in rural or remote areas, television (86.9%) is most frequent channels by which health messages were received, followed by health care providers (82.2%) and family (55.4%) (Yue, 2005). Wei and Hung (2010) pointed out that some elders are illiterate, bad eye-sighted, and have knowledge gaps to access new forms of media, such as the internet. Besides health advices through family, health professionals or churches, television is an important source for them to obtain health information. Feng-Shui Family is worth studying because its target audience – middle age and above, is the age group who rely on TV the most. It would be interesting to see what kind of health contents viewers have been exposed.

Third, the E-E Matchup Project had confirmed with a script writer in this drama that there was no health authority intervened in this drama. However, there were several commercial product placements in it, from cord blood bank, chicken essence to waterproof cell phone, flat screen TV and snacks. On average, profits generated

from product placements covered more than half of the production cost per episode on average (Apple Daily News, 2013). This study will present a descriptive analysis of how commercially driven drama portrays health contents without government intervention.

What health lessons could viewers learn from television? The high viewing rate proved that Feng-Shui Family offered an engaging and captivating story to the viewers. This drama involved characters viewers knew and cared about, thus, health information is more likely to be attended than traditional health campaigns. Since E-E is a relatively new concept in Taiwan health communication research field, this study starts with discussing and reviewing behavioral and social science theories in health communication. Health communication research domain, diffusion of innovation, health belief model, social learning theory (Bandura, 1977), cultivation theory of reasoned action, stages of behavior change model, and social marketing will be discussed. As background, this research will also look back at the development of health communication and explain how Entertainment-Education functions as a way of intervention. More modern concepts behind E-E, “a model of effects of narrative as cultural-centric health promotion” (Larkey & Hecht, 2010), “entertainment overcoming resistance model (EORM)” (Moyer-Guse, 2008, 2009) and drama theory (Kincaid, 2002) are also introduced as to support the discussion section.

2. Literature Review

2.1 Defining Health Communication

2.1.1 Health Education

It is known about individual’s lifestyle can influence their health, if one can maintain healthy life styles, it may further help prevent chronic diseases. In the early days, people learned about health in their communities, schools or patient care settings. Health education is aimed at “bringing about behavioral changes in individual, groups, and larger populations from behaviors that are conductive to present and future health” (Simonds, 1976). No matter how it’s conveyed to the public, the importance of communicating information with individuals about benefits of maintaining a healthy lifestyle and risks of continuing an unhealthy lifestyle is highly valued. Thus, health education is the greatest hope to reduce the burden of preventable diseases and death around the world (Glanz et al., 2002).

A common assumption in health education efforts is that people continue an unhealthy lifestyle because they do not know the harm and consequences of these acts.

Thus, ignorance is the problem and information would be the solution (Kerr et al., 2000). Although conveying educational health content is necessary, sometimes it still cannot create meaningful change (Wallack, 1990). People often see health education flyers or campaigns as “old school” advertisement with no fun. The rise of various forms of media gives more platforms to spread health content messages, e.g. dramas or social networks with health promotion messages. How to perform a correct,

eye-catching and interesting message to audience has gained much discussion in research and entertainment field.

2.1.2 Health Communication

According to Rogers (1995), if there’s health related content in human communication categories, it’s regarded as health communication. It is an increasingly distinguished field not only in public health but also in non-profit or commercial sector. The constitution of health communication is consisted of areas including health education, interpersonal and intrapersonal communication, mass and speech communication, marketing, social marketing, psychology, anthropology, and sociology, furthermore, it has increasingly been considered as an integral part of most public health interventions (Bernhardt, 2004; Institute of Medicine, 2003; World Health Organization, 2003; Schiavo, 2007).

Some of the commonly used key words to define health communication include the following: “inform or influence individuals or communities decisions” (New South Wales Department of Health, n.d.; CDC, n.d.; Freimuth, Linnan & Potter, 2000;

Smith & Hornik, 1999; Maibach & Holtgrave, 1995), “motivate target audiences or individuals” (Ratzan et al., 1994; Tufts university Student Services, n.d.), “change of benaviors” (Clift & Freimuth, 1995), “increase knowledge and understanding of health-related issues” (Muturi, 2005; Agunga, 1997), “empowers people” (Muturi, 2005), and “exchange & interchange of information” (Exchange, n.d.; Bernhardt, 2004).

Similar as stated above, the U.S. Center of Disease Control and Prevention (CDC) define health communication as “the study and use of communication strategies to inform and influence individual and community decisions that enhance health” (U.S.

Department of Health and Human Services, 2005). Also, the Health People 2010 defined it as “ the art and technique of informing, influencing and motivating individual, institutional, and public audiences about important health issues,”

moreover, it “links the domains of communication and health” (U.S. Department of Health and Human Services, 2005, p. 11-13).

In mass communication field, health communication is focused on effective message dissemination for health promotion, disease prevention, and health-related messages transmitted through mediated channels, including health marketing and policy-making (Jackson, 1992; Payne et al., 1989). Thus, health communication is a bridge to connect medical science, health communication and public health. The practical functions of health communication in the public health domain include

“disease prevention, health promotion, health care policy, and the business of health care as well as enhancement of the quality of life and health of individuals within the community” (Ratzan, 1994, p. 544). The use of different forms of medium in health promotion communication can enhance individuals or communities’ awareness of health knowledge, whether they’ve been notified before or not.

According to Schiavo (2007), one of the key objectives of health communication is to make influence and support in individuals, communities, health care professionals, policy makers, or special groups by improving their health related knowledge and sharing useful health information. It helps to adopt or sustain a

behavioral practice or social or policy change that will ultimately improve health outcomes.

Another role of health communication is that it has to create a favorable

Another role of health communication is that it has to create a favorable