Television and film are powerful tools to disseminate health information, promote health, and construct health-related narratives, said Dana March, of the Columbia University Mailman School of Public Health, and moderator of the fourth panel. Since the 1940s, television and film have played an important role in shaping Americans’ perceptions of health and disease. During the fourth panel session, two presenters described creative ways that the power of television and film could be leveraged to increase the public understanding of population health. Kate Folb, director of the Hollywood, Health & Society (HH&S) program at the Annenberg School for Communication and Journalism at the University of Southern California, described how the program helps writers and producers convey health information effectively on television. Finally, Rachel Poulain, an associate producer at California Newsreel, discussed two projects combining documentary film with public engagement campaigns to shift the public conversation about population health issues.
Consultation to Ensure Accuracy
Storytelling is an effective way to provide important health information, Folb said, in part because people often retain information better when its presented in a narrative way. HH&S is a free resource offered to
the entertainment industry with the goal of supporting accurate health-related storylines. Established in 2001, HH&S is funded primarily by the Centers for Disease Control and Prevention (CDC), The California Endowment, and The Bill & Melinda Gates Foundation. Writers, producers, and creative content makers often contact HH&S for information about health issues they plan to address in their shows. For example, writers may ask about specific diseases and treatments, the appearance of treatment rooms, and medical terminology.
HH&S has a website and provides easy-to-read tip sheets that are based on information from CDC. HH&S staff are available for quick phone and e-mail consultations and also can provide expert briefings to and in-person consultations with a show’s creative team. HH&S also holds panel discussions, screenings, and field trips—dubbed Storybus Tours—to inform and inspire the entertainment industry on a wide range of public health topics. As part of a 2013 project funded by The California Endowment, HH&S staff conducted a tour through select neighborhoods to educate writers about the social determinants of health.1 To demonstrate the challenge of creating healthy, nutritious meals on a limited budget in neighborhoods with little access to grocery stores, one tour took writers to South Central Los Angeles to learn about food deserts and about the various projects working to combat hunger and obesity. Participants visited a liquor/convenience store where they were asked to figure out how to feed a family of four with $10. When television writers personally experience these challenges, they can more effectively convey information about social determinants of health in storylines.
HH&S works with the entertainment industry on a pro bono basis, requiring no fee or credit for its services. Since 2009, program staff have helped develop more than 700 aired health-related storylines for dozens of top-rated shows, including Doc McStuffins, The Good Wife, Homeland, Grey’s Anatomy, NCIS, Body of Proof, Boardwalk Empire, and Switched at Birth, as well as Breaking Bad and Orange Is the New Black. The organization works with all major broadcast networks, including the Big Three (NBC, CBS, ABC), Fox, and CW, as well as cable channels such as HBO, Showtime, Lifetime, and Spanish language television.
Public Service Announcements Linked with Health-Related Content
Public service announcements (PSAs) aired immediately following television shows can increase the impact of health messages, Folb said. HH&S staff have worked with television writers and producers on several
1 For more on HH&S Storybus Tours see https://hollywoodhealthandsociety.org/events/?event_type=2 (accessed January 22, 2015).
projects that combine storylines with PSAs to engage audiences on important health issues. HH&S staff helped develop the storyline for an episode of the medical show Private Practice in which one of the characters became addicted to Oxycontin and others intervened to help. HH&S helped write language for a PSA directing people to an addiction hotline which aired after the show. During her presentation, Folb showed a video clip from the episode as well as the PSA.
HH&S consulted with producers of the show Extreme Weight Loss, who wanted to list resources for victims of sexual assault in a PSA following an episode about incest. The PSA provided the link to the website for the Rape, Abuse, and Incest National Network (RAINN) and the phone number for the National Sexual Assault Hotline. After the network aired the episode and the PSA, the number of calls to the sexual assault hotline increased by 200 percent, call volume for the online hotline rose by 97 percent, and visits to the website were up by 80 percent. The number of Facebook impressions2 for RAINN doubled, and the number of Twitter mentions increased by more than 100 percent. Folb showed the PSA during her presentation.
In the early days of the AIDS epidemic, many shows created storylines and PSAs about HIV/AIDS. In 2001, HH&S worked with the daytime soap opera The Bold and the Beautiful on a story about a character who learned that he was HIV positive. When the network aired the episode in which he was diagnosed, followed by a PSA listing the phone number for an HIV/AIDS hotline, calls to the hotline increased significantly. After the character disclosed his HIV positive status to his fiancée in another episode followed by the PSA, the number of calls rose to a record-high level (Kennedy et al., 2004).
HH&S worked with a television detective show called Numbers on an episode about organ donation. At the end of the show, one of the characters, who originally did not want to become an organ donor, changed his mind and informed his family of the decision. Folb showed a clip from the episode. HH&S’s analysis found that people who had viewed the scene perceived organ donation as more important than those who had not. Furthermore, viewers of the scene were more likely to register as organ donors and to encourage others to donate (Morgan et al., 2009; Movius et al., 2007).
2 Facebook impressions are the number of times a message is displayed, for example, on a user’s wall, in a person’s newsfeed, or when it is shared.
Public Outreach Initiatives
Public outreach efforts linked with story content likewise can increase the impact of health messages on television. The Disney Junior show Doc McStuffins has engaged audiences throughout the country with health-related storylines and innovative outreach, Folb said. The show, which explores a variety of health issues from the perspective of an African-American girl whose mother is a doctor, became extremely popular among African-American female doctors whose children were watching it. These women began blogging about it, and eventually the show became a national sensation. In 2013, HH&S worked with the network to design an Airstream trailer called the Doc Mobile, which visited more than 37,000 children and families in cities across the country in August and September 2013 as a back-to-school activity. The goals were to help children feel comfortable about going to the doctor and to remind parents to bring their children to the doctor for back-to-school checkups. The Doc Mobile was a great success and will likely return in the future.
In an outreach project funded by The California Endowment, HH&S is working with television producers to incorporate accurate information about the Affordable Care Act (ACA) in storylines. As part of the project, HH&S staff consulted with producers of En Otra Piel, a show on Telemundo, to tell the story of an uninsured man who could not afford his surgery.
Evaluations to Assess Impact
HH&S frequently conducts evaluations to analyze the impact of health-related messages. Several years ago, program staff worked with the show 90210 on an eight-episode storyline about the BRCA gene. One of the characters who had a family history of breast cancer tested positive for the gene and faced a series of difficult treatment decisions. After the series aired, HH&S studied its impact on two groups, one composed primarily of American women who were frequent television watchers but who had never previously watched 90210, and the other composed of women from around the world who were enthusiastic 90210 fans and who had watched every episode. HH&S polled study participants to assess their knowledge of the BRCA gene before and after the shows aired. Folb reported that after viewing the first episode, 11.9 percent of women who had never previously watched 90210 said they subsequently scheduled a doctor’s appointment to discuss their breast cancer risk. Additionally, 13.1 percent said they talked about the BRCA gene with a woman they knew, 16.5 percent said they searched for more
information about breast cancer online, and nearly 10 percent said they watched the next episode.3
In the second study, Folb said, researchers polled viewers before they had seen any of the episodes about the BRCA gene, after they had seen the first four episodes of the series, and after they had seen five to eight episodes. According to Folb, knowledge gains correlated with the number of episodes viewed. Similarly, the percentage of women who said they were likely to research their family histories of breast cancer increased with the number of episodes watched.
HH&S is now conducting an audience impact evaluation for the popular online show East Los High, which targets Latino youth. The study is analyzing the show’s impact on audience knowledge about sexual health, reproductive health, domestic violence, advocacy, and the ACA. HH&S staff are also working with the program’s producers on a story about an uninsured character with diabetes who is thinking about traveling to Mexico for treatment.
California Newsreel, an independent nonprofit organization, produces and distributes documentary films to promote health equity and social justice. Founded in 1968, Newsreel is the oldest nonprofit, social issue documentary film center in the country, and the first to merge media production and contemporary social movements.4 In her presentation, Poulain described two California Newsreel documentaries that address population health issues: Unnatural Causes: Is Inequality Making Us Sick? and The Raising of America: Early Childhood and the Future of Our Nation. Both series were created in the context of national public engagement campaigns. California Newsreel measures the success of its films by how effectively they can be used to advance the efforts of other organizations that have long worked to advance health equity and social justice.
3 E. L. Rosenthal, S. C. Buffington, and G. Cole. Evaluation of a multiple episode television storyline on genetic risk factors for breast cancer. Manuscript is currently being prepared for publication. For a list of HH&S studies see https://hollywoodhealthandsociety.org/sites/default/files/for-public-health-professionals/research-and-evaluation/Publications.pdf (accessed January 28, 2015).
Unnatural Causes: Is Inequality Making Us Sick?
Broadening Public Perceptions of Health
Released in 2008 on video and for national PBS broadcast, Unnatural Causes is a seven-part documentary exploring racial and socioeconomic inequalities in health. The film was created as a tool to help reframe the debate about health equity, and it is now being used by various organizations as part of a broad public engagement campaign around the country. California Newsreel created a companion website, discussion guides, action tool kits, and other resources to help organizations use the film to shift public dialogue on the issue.5
Traditionally, Poulain said, health is discussed in the context of access to health care, genes, and health-related behaviors such as healthy eating and exercise. The film’s introduction sets the stage for stories intended to broaden public perceptions of health. Poulain showed a video clip of the opening. The narrator begins by acknowledging that people carry their health histories in their bodies and states that human biology is shaped by constant interactions with the world. As the storyline unfolds, the film repeatedly returns to the question of what constitutes health.
Using Stories to Convey Population Health Messages
Each episode of the film is designed to convey a message, Poulain said. The opening episode, called In Sickness and Wealth, blends storytelling with facts to illuminate the social determinants of health. The episode focuses on three neighborhoods associated with different socioeconomic and health statuses, different educational attainment levels, and different longevity rates. As the story continues, it becomes clear that life expectancy is longest in the most affluent neighborhood and lowest in high-poverty neighborhoods. To help audiences relate to the episode’s message on a personal level, writers tell the story from the perspective of people who work in a hospital. The goal, said Poulain, is to prompt viewers to think about their places within broader social structures and to recognize that people’s opportunities vary depending on the neighborhoods in which they live.
The episode called Place Matters explores why zip codes matter to our health. It examines the history of Richmond, California, from the end of World War II to the present by focusing on two neighborhoods. When shipyards closed after the war, many people lost their jobs, said Poulain. Because the federal government provided housing loans on a
racially restricted basis, white soldiers returning from World War II had the opportunity to become home owners, and black soldiers did not. As the community was left behind during a period of social and economic progress, health conditions worsened. The once-vibrant community declined, and it is now characterized by high rates of poverty and unemployment. In contrast, said Poulain, Seattle was transformed over the years from a low-income community into a thriving city where people have opportunities to improve their lives. The episode shows deteriorating neighborhoods being rebuilt and tells the story of a Seattle family that moved to a home with better air quality to help a child with asthma. The message behind these stories is that community change is not a random act of God but rather the result of specific policy decisions, thus demonstrating the links between housing and health policies.6
An episode called When the Bough Breaks is based on research suggesting that racism is associated with socioeconomic disparities in preterm birth and infant mortality rates. Poulain commented that studies have shown that among whites, the rates of preterm birth and infant mortality correlate with socioeconomic status but that African Americans at all socioeconomic levels have higher rates of preterm birth and infant mortality than their white counterparts. The episode describes a study that found that preterm birth and infant mortality rates among African women that immigrated to the United States are similar to those of whites with the same socioeconomic status.7 But researchers found evidence of disparities in the next generation: Rates of preterm birth and infant mortality among children of the African immigrants are similar to those of their African-American peers. These findings, said Poulain, suggest that racism has long-term effects on health outcomes.
The episode called Bad Sugar explores the impact of federal government policy on the health of Pima Indians. For many years, scientific research has focused on genetic factors associated with the tribe’s high rates of obesity and diabetes. However, the research has ignored important public policy factors. As the federal government implemented policies to divert water from Native American communities to white landowners, tribes that had relied on the water for crops became dependent on the federal government for food subsidies which did not include fresh fruits and vegetables until the early 1990s. The story’s message is that policies of the past have enduring effects, but policies can be changed.
6 For a more detailed description of this episode see http://www.unnaturalcauses.org/episode_descriptions.php?page=5 (accessed February 18, 2015).
7 The study was conducted by neonatalists James Collins and Richard David. For more information see http://www.unnaturalcauses.org/episode_descriptions.php?page=2 (accessed January 26, 2015).
The next episode, Becoming American, tells the story of a Mexican-American immigrant family and shows how although they arrived in the United States poor, they also had better health than the average American. However, after 7, 10, 12 years in the United States, their health declined, raising questions about the long-term impact of relentless, chronic stress as people work to feed their families and pay their bills. Another episode, Collateral Damage, explores the global forces associated with health inequities on the Marshall Islands. The film portrays living conditions on two islands 3 miles apart. On one island, American families enjoy a middle-class lifestyle on a military base. On another island, Marshallese citizens live in overcrowded conditions, and rates of tuberculosis are high. The film shows that when Marshallese people come to the United States to work, their health status improves somewhat, but disparities remain.
The film’s final episode, Not Just a Paycheck, tells the story of two towns—one in the United States and the other in Sweden—each affected by the closure of a refrigerator factory.8 After the plant closed in the American town, middle-aged people who previously had middle-class lifestyles did not have access to vocational training and could not find jobs. Their stress levels rose, and rates of depression and heart attack increased. The town was unable to recover. In Sweden, the refrigerator company was required to pay the community $3 million to foster economic development, and people who lost their jobs received 80 percent of their salaries. They were able to afford additional education and start new careers, and the town continued to thrive.
Not Just a Paycheck helps audiences understand the link between social structures and personal aspirations for health and well-being. The stark differences in the towns’ experiences raise questions about the future of the American way, Poulain said. Some Americans prefer European approaches to promoting economic opportunity, and others do not. Poulain noted that the resources available in her neighborhood—including supermarkets, recreational facilities, public transportation, and a variety of restaurants—enable her to make healthy choices. Her health is affected not only by her actions, but also by her environment. By using herself as an example during discussions of the episode, Poulain helped audiences understand social and economic determinants of health.
Changing the Language of Population Health
Changes in terminology have helped reframe the public conversation about population health, Poulain said. The term “health disparities,”
8 Both sites were closed by Electrolux Corporation. See http://www.unnaturalcauses.org/episode_descriptions.php?page=7 (accessed January 26, 2015).
while accurate, only describes differences among population health outcomes. Using the term “health inequity” implies that the differences in health outcomes are a result of injustice and unfairness in our structures and systems. By moving to a language of “health equity,” which has become prevalent more recently, we begin to foster a sense of hope and an aspirational goal to move toward health equity.
Finding New Ways to Engage Audiences
As public engagement efforts have evolved, Poulain said, public health organizations are focusing less on the dissemination of written materials and more on engagement with community members. Organizations were invited to use the series. As public engagement evolved, those groups were able to give audiences opportunities to participate in the campaign.
More than 400 organizations partnered with California Newsreel on the campaign.9 The number of participating organizations grew as the production timeline was extended. Many organizations included the film in their training programs. Screenings ranged from community events to conferences, training sessions, policy briefings, classroom screenings, and more. For example, local health departments across the country arranged screenings for staff and community members. The film was featured in policy forums on Capitol Hill and in state capitals. Poulain has heard that policy makers in Rhode Island created a health equity commission partially in response to the film.
An important lesson learned from the project, Poulain said, is that planning and organization are critical to success in the engagement process. When the film was released, community members were energized and ready to join the campaign. Health departments organized community screenings and people were asking what they could do to help.
The Raising of America
Changing the Conversation About Child Health and Development
The Raising of America, which will be completed in 2015, explores the issue of health inequity from a child’s perspective.10 Whereas previous research and communication projects related to child development have taken a siloed approach, the film focuses on the big picture. It seeks to shift the public conversation about child development to emphasize the
9 More than 25,000 screenings were organized during the first 18 months after release.
need for action to provide all children with a solid foundation for growth and development. The documentary’s primary message is that providing children with a strong foundation can help build a healthier, more prosperous, and more equitable nation. In other words, “It is easier to build strong children than repair broken men,” Poulain said, quoting Frederick Douglass. California Newsreel is conducting a public engagement campaign in conjunction with the film’s release and has provided a companion website with discussion guides, action toolkits, and other resources to support organizations using the film.
The Raising of America counters many of the messages that have dominated previous discussions of child development. Conventional wisdom suggests a link between babies’ development during the first 2 years of their life and the quality of parenting, without considering other factors. Thus, children’s success depends on the quality of parenting they receive and on parental choices. If parents work hard enough they can provide everything their children need.
The documentary seeks to provide a broader perspective. While we may not remember our earliest years, research has shown that the period from age 0 to 3 is a critical time for brain development, which builds a foundation for future development. During this time, the environment shapes the way that the brain is wired. The film describes how environmental factors can increase or reduce stress. Because parental stress affects children’s brain development, growing social inequities ultimately affect parents’ ability to create safe, secure, and nurturing environments. All public policies should be considered as child development policies, Poulain said, because public policies affect people’s health throughout their lives.11
The Raising of America emphasizes the importance of opportunity. If people have the opportunities and resources they need and still make unhealthy choices, their health truly is determined by personal behavior. But if people lack sufficient opportunities, children’s health and well-being cannot be attributed entirely to parental decisions or behaviors.
The film is designed to spark a rethinking of American values about balancing work and family. The goal is to help people move beyond feelings of economic insecurity and self-blame and to promote system-wide solutions that provide families with greater opportunity and choice. Middle-class people may not see themselves in messages advocating improvements in social and economic conditions for low-income people. Yet all families are getting squeezed for time, money and resources. Policies to make child care more affordable and to expand public transpor-
11 Poulain later said that the best parenting programs have nothing to do with parenting. Living wage jobs, affordable housing, safe neighborhoods, and good schools all influence parents’ ability to provide for their children.
tation would benefit all children and improve the quality of life for all working families.
The film’s opening episode, called DNA Is Not Destiny, begins by explaining the science of early childhood development.12 It shows how financial and time pressures create stress for parents, and it describes public policies that can change the social and economic environment for all families. Americans work more hours and have less vacation time than their counterparts in other developed nations, Poulain noted. Mothers are expected to work extra hours, commute, provide support for their spouses, be patient with their children, and volunteer in their schools. Americans have internalized societal expectations for mothers, but, in fact, parents’ abilities are affected by their social and economic environments.
The episode called Wounded Places shows that children raised in low-income neighborhoods develop symptoms similar to posttraumatic stress disorder. Racism, Poulain said, clearly has an impact on the featured neighborhoods, but the episode does not address racism directly. Most people, said Poulain, who viewed unfinished footage of the episode at pre-screenings said that they could relate to the story because they had grown up in similar neighborhoods.13
Another episode called Once Upon a Time describes the political ideology associated with President Nixon’s veto of legislation to provide universal child care. Nixon speechwriter Patrick Buchanan, who is featured in the episode, describes the veto as an opportunity to limit the role of government in family and community life. The action led to a major shift in the direction of public policy for working families. Audiences who have watched the story have expressed concern about its potential to upset people, said Poulain.14
The episode called Are We Crazy About Our Kids? makes the argument that investing in high-quality child care and early childhood education pays a 7:1 return on investment later in life. Invest now and society will benefit later.15
12 This film’s opening episode is now called The Raising of America. DNA Is Not Destiny is still under development and will be the fifth in the series. http://www.raisingofamerica.org/documentary (accessed January 26, 2015).
15 For more on this episode see http://www.raisingofamerica.org/crazy-about-our-kids (accessed January 26, 2015).
Activating Receptive Audiences
The Raising of America is meant to be a tool that engages the “choir”—meaning those audiences receptive to the message—to take a closer look at how people can work together across sectors to make societal changes that will encourage the consideration of child health and development as essential components in providing all infants in America the chance to live strong, healthy lives. Americans work more hours than people in most developed nations. How does that affect the ability to have time with family, be an advocate, and civilly engaged? People may identify as part of the choir, but that does not mean they are not affected or that they do not feel the squeeze themselves. The question is how people in positions of influence and power can create change while recognizing their own needs to balance work, child-rearing, and other parts of their lives. Poulain said that California Newsreel hopes the film will also be used to engage dormant allies who may be working in other fields. For example, in much of the work to increase the minimum wage, there has not been much emphasis on how an increase will benefit children. By explaining how the wage increase would help improve children’s health—and thus ultimately reduce violence and create safer communities—minimum wage advocates could activate a broader coalition.
Addressing Fundamental American Values
The production of The Raising of America has become a much larger research project than originally anticipated, Poulain said. Even before its release, the film has reached many more people than expected. In the process of creating the film, producers are addressing fundamental American values about wealth and happiness. While money is necessary to live, Poulain noted, it does not produce happiness. Instead, people will be happy when they feel safe in their neighborhoods, when their commuting times are reduced, and when they can spend more time with their children. Happiness comes from having choices, feeling a sense of empowerment at work, and being able to balance work and family obligations, she said. The Raising of America is intended to help audiences imagine a better place for themselves, for friends in their communities, and for future generations of Americans at all income levels.
During the brief discussion period, Folb reviewed effective strategies for working with the entertainment industry to disseminate public health information.
In response to a participant’s question, Folb stressed the importance
of providing television and film producers with objective information to ensure the accuracy and credibility of their stories. HH&S is not an advocacy group; it advocates only for truthful presentation of scientific research and data. Staff members do not promote specific storylines. Instead, they answer questions from television and film producers, connect producers with researchers conducting studies relevant to their projects, and help television storytellers interpret scientific information. HH&S has partnerships with the Writer’s Guild, the Television Academy, and similar organizations.
The organization’s goal is to inform television and screen writers about important health topics and inspire them to address those topics on their shows, Folb said. Because television writers like to read about real people, HH&S provides them with case studies about people facing a variety of health-related challenges. The organization sends Real to Reel, a quarterly newsletter highlighting news stories about people’s health experiences and challenges, to more than 900 entertainment industry professionals. In some cases, the organization provides information about high-priority health topics identified by CDC. By serving as a resource for accurate information, HH&S has built a solid reputation and gained the industry’s trust. Producers frequently contact HH&S for information and advice.
Gold asked how to encourage the entertainment industry to tell stories that explore the social determinants of health in a way that resonates with the public and transforms public opinion. Reiterating the effectiveness of an informational approach, Folb said that avoiding advocacy is a key factor in HH&S’s success. At the time when the program was being created, nearly 200 disease-specific advocacy organizations had formed in Hollywood to pitch their messages to the television industry. Writers stopped taking their calls. HH&S was established to provide writers with a one-stop shop to gather the information they needed without feeling pressure from advocacy groups. The organization shares information with writers about new developments and studies without criticizing or blaming them for inaccuracies in stories. Although sometimes the health information on television shows is not entirely accurate, Folb said, public health professionals may in some cases need to accept minor errors as the price to pay for disseminating important information that was not previously available to the general public. Folb encouraged public health professionals to share their most updated information with HH&S, and she offered to make it available to the television industry. She also urged organizations conducting their own industry outreach to take a supportive approach, provide useful information, and avoid blame.
In conclusion, March emphasized several summary points: First, a multi-faceted communication strategy—with public service announce-
ments, websites, and education campaigns that complement storylines on television and film—can maximize the impact of population health messages. Health-related stories on television and film can have powerful effects on audiences; therefore, it is crucial to do as much as possible to ensure the accuracy of the content. The goal of communication initiatives should be to prompt not only reaction, but also action to advance population health. When evaluating communication initiatives, researchers should track multiple outcomes. Evaluations limited to measuring a single outcome overlook important effects. Personal narratives can increase the impact of stories about social determinants. Television, film, and complementary communication strategies can help create a new common language for population health messages. Connecting with audiences is critical. Innovative approaches to production can actively engage key audiences in population health issues. Media projects to advance population health should be well-organized, and public health professionals should take a strategic approach to coordinating engagement efforts. Success may depend on the selective use of advocacy strategies.