Abstract
The development, content and potential health promoting effect of the Dutch documentary series, Voor dik & dun (“For thick and thin”) were investigated. This series was based on the entertainment–education (EE) strategy and designed to prevent overweight. Qualitative data were collected from three perspectives: those involved in the program development (in-depth interviews), health communication scientists (in-depth interviews), and viewers (focus groups). In addition, viewing figures and website statistics were collected. Results show that finding a proper balance between entertainment and education is difficult for those involved. Voor dik & dun was not very successful in creating this balance and did not reach its priority audience. Findings suggest that, to achieve the desired health-promoting effects, EE programs should focus first extensively on narrative engagement by means of entertainment and later on, when the viewer is engaged, try to educate by means of positive identification with transitional role models.
The main focus of preventive health education is often on issues that do not embody a direct health risk, such as unhealthy eating and lack of physical activity. Therefore, initial interest in the health messages advocated is limited among many receivers because of which elaboration of the messages is limited. In addition, a substantial, potentially high-risk, group (i.e., people of lower socioeconomic status) often lacks the capacities to easily process the cognitively oriented, preventive health message (Bouman, Maas, & Kok, 1998; Wimbush, MacGregor, & Fraser, 1998).
The entertainment–education (EE) strategy is the process of purposively designing and implementing a mediating communication form with the potential of entertaining and educating people to implicitly enhance and facilitate different stages of prosocial behavior change (Bandura, 1986, 2004). The EE strategy posits an unconventional learning method: Its main focus is not on the cognitive processing of information, but rather on an incidental form of learning through narratives and role models (Sood, Menard, & Witte, 2003).
A popular television genre (such as a soap, comedy, or quiz) is employed to draw viewers’ attention. Recognizable, believable, and appealing role models and plots are then used to trigger parasocial interaction: a process in which viewers develop a friendship-like relationship with leading characters. Usually a combination of positive, negative, and so-called transition personages is chosen to visualize to viewers how they can change their own behavior in their own social circumstances. Transition personages (progressing from unhealthy to healthy behavior) can serve to reflect the dilemmas with which viewers themselves are confronted. When viewers see someone similar to themselves, in similar social circumstances, executing a specific behavior and being rewarded for that behavior, feelings of response efficacy and self-efficacy will result; this makes imitation of the behavior more probable (Koelen & Van den Ban, 2004).
By means of parasocial interaction, the EE strategy aims to bring about “real” social interaction: conversations with friends and family about the leading characters and their experiences (Bouman, 2003; Sood et al., 2003). In this indirect way, EE programs can realize several effects on awareness, knowledge, attitudes, and even behavior (Moyer-Gusé, 2008). By integrating an abstract health theme in everyday, recognizable, and personal situations, learning is no longer prescribed, but an added value of a pleasurable experience selected by viewers themselves. Therefore, EE programs can appeal to viewers who have no initial interest in the health message or who lack the capacities to process it (Bouman et al., 1998; Slater & Rouner, 2002).
The present study examined qualitatively the potential effects of the EE-based intervention, and the insecurities that attend the development of an EE program, by evaluating a specific elaboration of the format: the Dutch documentary series Voor dik & dun (For thick and thin). This six-episode series was broadcast by a Dutch national television station between November 24 and December 19, 2005. Voor dik & dun was characterized as a light program concerning a heavy subject. From a preventive angle, Voor dik & dun aimed to appeal viewers who, unknown to themselves, run the risk of being overweight. Emphasis was placed on lower socioeconomic status groups. The messages to be communicated were developed to inform viewers about the risks of gaining an extra kilogram each year, the different factors that contribute to the development of overweight, and the possible alternatives. Three everyday families with unhealthy eating and exercise habits were portrayed. In six separate episodes, viewers could see how they became aware of their bad habits and, with the help of two health professionals (a dietitian and an exercise professional), slowly but surely changed their lifestyle. The series was backed up by a website with additional information supplied by the professionals, the opportunity to watch the diverse episodes, discuss with other viewers the issues raised, and ask questions.
The present study had three aims: (a) to investigate the problems faced by both television and health professionals in the development of the series (with emphasis on balancing entertainment and education); (b) to explore how both viewers and health communication scientists evaluated the series on both entertainment and education aspects and to examine the role of the various EE criteria (i.e., narrative involvement, identification with characters, and parasocial interaction); and (c) to examine the series’ health-promoting potential.
Method
In-depth interviews were used to adduce the perspective of both program developers (television professionals and health professionals) and health communication scientists. First, a selection was made of nine persons who were closely involved in the development of Voor dik & dun (among which the executive producer, two researchers, the program coordinator, the director, the dietitian, the exercise professional, and two nutrition professionals). Each of them was interviewed separately. Next, six health communication scientists (all specialized in relevant areas of research such as EE, health promotion, and mass media communication) were selected. After viewing the first and last episode of Voor dik & dun, they were interviewed in pairs.
The interviews with both program developers and health communication scientists were set up around two central questions: what are the possible effects of Voor dik & dun, and how would these effects be accomplished? With regard to both questions, topic lists were generated from EE literature containing a series of sensitizing concepts (Wester, Smaling, & Mulder, 2000). Regarding the first question, the sensitizing concepts were differentiated into short-term (entertainment) effects and long-term (education) effects. The perceived short-term effects were making a connection with the priority group, attracting and holding the attention of the priority group, creating a sense of involvement among the priority group, bringing about identification with the leading characters, summoning feelings of recognition, and bringing about processes of (para)social interaction. The perceived long-term effects were increasing health knowledge, increasing health awareness, changing attitudes, changing behavior, and maintaining behavior change. With regard to the second question, the following concepts were identified: the use of recognizable, identifiable role models; the use of transitional role models; the use of realistic, appealing, and stirring plots; the use of medial style characteristics (such as style of presentation, camera positions); making use of the “look” of the program (dynamics, humor, tension, and relief, dramatization); the use of practical instructions.
The viewers’ perspective was adduced by means of 12 separate focus group discussions (with every focus group containing different respondents) in 6 different locations in the Netherlands (2 per episode). Each focus group was preceded by the first time viewing of a single episode of Voor dik & dun. The focus group sessions were conducted by a trained moderator.
The expertise of GfK Panel Services Benelux, which has several person and household panels that form a representative reflection of the Dutch population living in private households, was used for the selection of respondents. Respondents were selected mainly on the basis of social class; only respondents from lower social classes were approached (since this was the priority group of the series). Participants were offered an incentive of € 25 and a travel allowance. The mean number of participants in each group was six.
During the focus groups, a semistructured moderator’s guide was used, consisting of five central themes: (a) The meaning of the episode: What did the group members believe to be the meaning of the episode they just saw?; (b) The appreciation of the episode: What did the group members like and not like about the episode they just saw?; (c) The informative value of the episode: Did the group members learn anything from the episode? Did they find the episode believable? Did they find the information provided useful and applicable in their own lives? Were they motivated by the given information?; (d) The form of the episode: Did the group members find the episode realistic? Did they find the leading characters likeable, appealing, and/or recognizable? Did they find the dilemmas faced by the leading characters recognizable? and (e) The viewing behavior: Would the group members watch this program at home? Would they like to see a following episode? Would they talk about the episode they just saw with family, friends, or colleagues? How did the group members evaluate the program in comparison with other, similar programs?
Both the in-depth interviews and the focus groups were taped (audio and video) and transcribed. The empirical cycle as derived from Wester et al. (2000) was used for analysis.
Results
A total of 807,000 viewers watched the first episode of Voor dik & dun. This number decreased over the following episodes to 508,000 viewers for Episode 6. The audience actually reached consisted mainly of a group of dedicated Dutch Evangelical Broadcast Organization (EO) viewers: older, less educated, steadfastly religious. The number of website visitors varied across the episodes, but this number also decreased from 2,747 visitors the week following Episode 2 to 1,346 visitors the week following Episode 6. The opportunity to respond to the different episodes was hardly ever used: The total number of reactions varied from 4 to 19.
The Development of the Series
The television and health professionals involved indicated that the development of Voor dik & dun was not without difficulties. Both stated that their objective was to produce an engaging preventive television program in which everyday families who were not overweight, or only slightly so, were simply portrayed in their daily routines. In practice, this goal was hard to reach. For the television professionals, finding such characters was a first difficulty, for why would anyone participate in a television program concerning overweight when they did not even have a problem? Contrary to the initial goal, therefore, they included a less representative obese family. The unpleasant discovery that leading characters who are not obese are truly not dramatic and narratively interesting was a second problem for the television professionals. Such characters do not (yet) live with the physical, social, and emotional consequences of obesity and do not lose a lot of weight. This, according to the television professionals, resulted in a dry message that lacked important entertainment qualities of visualization, excitement, and drama.
The most important thing for me was: you can’t make a purely preventive television series. Television is just not the right medium. (Television professional)
The television professionals acknowledged the importance of a strong health message, but also emphasized the need for entertainment to reach the priority group. In addition, it was argued that the broadcasting television channel endorsed this need; they depend heavily on viewing figures and have to compete with other, more exciting, television programs.
We actually had two different objectives, exciting television versus the honest, reasonable message. We had to bring those two together. (Television professional)
Half way through the first montage, the television professionals therefore changed their strategy: The initial observational approach (the leading characters were viewed from a distance) was partly replaced by a more interactive approach (the leading characters participated more actively), the presence of the dietitian became more central (she had to provide information that the characters did not have), the montage got faster and more dynamic, and more emphasis was placed (contrary to the initial goal) on the weight loss element. Moreover, the television professionals stated that the forced choice of an obese family was in fact inspired: They were the only ones with the necessary drama and were therefore drawn more to the foreground. In general, the television professionals assessed Voor dik & dun as a sound and deferential television series, lacking, however, excitement and drama.
The health professionals were not unequivocal about the results either. During the development of Voor dik & dun, they felt that they were in unknown territory. Consequently, they let themselves be led by the expertise of the television professionals. According to them, this did not always yield the desired result. The health professionals stated that most format changes had been made at the expense of the content: The information messages integrated in the series were shallow, already known by viewers, and provided too few concrete alternatives.
Everything was dealt with superficially rather than worked out. It was a mess, not specific enough. (Health professional)
The Entertainment and Education Content of the Series
Voor dik & dun aimed to distinguish itself from other weight loss programs with its implicit, feasible, preventive approach. Not only did the series aim to make viewers aware of the ease with which everyday routines (habits) can lead to health-threatening body weights, but it also wanted to offer a range of easily applicable alternatives.
The health communication scientists interviewed recognized the preventive starting point of Voor dik & dun but emphasized that the choice of an obese family and two slightly overweight families, as also the strong emphasis on direct effects, turned it into a weight loss program. Moreover, they believed that the episodes contained a great amount of information with limited practical value. According to the scientists, the information provided had a menacing and abstract medical undertone, emphasizing merely the risks of overweight, without offering any concrete alternatives.
It was real old-school education, like: Naughty, naughty! You may not do that, you have to do it this way. (Health communication scientist)
The viewers’ focus groups that saw a single episode of Voor dik & dun did not judge the informative value very positively and despite its preventive approach characterized Voor dik & dun as a curative weight loss program.
It’s another one of those diet shows of which there are so many already. (Viewer)
The information provided was considered familiar, superficial, and clichéd. Within these focus groups, women with a slight weight problem, and/or an initial involvement in the overweight theme, felt most strongly addressed by the information provided and considered it most useful. In that respect the series specifically attracted the attention of those who were already involved in the topic. These same women, however, most often characterized this information as too superficial.
It had a lot of repetition and information that is already known to me. (Viewer)
The focus groups also indicated that the separate episodes of Voor dik & dun aroused uncomfortable feelings among respondents (mostly female) who were slightly obese. The episodes confronted them once again with the risks of their situation, without providing clear insight into possible ways to reduce these risks.
It’s like, you’re not allowed to do this or that, but they don’t say what we can do instead. [ . . . ] Show us how we can continue when we have reached our target weight; give more advice about the yoyo effect; I don’t want to eat like a rabbit the whole week! (Viewer)
By using several recognizable role models, Voor dik & dun tried to bring about a learning effect: Viewing the leading characters was meant to trigger viewers to think about their own lifestyle and possible ways to change it. The health communication scientists interviewed believed that Voor dik & dun would only arouse feelings of identification amongst a very limited audience. They claimed that the choice of mainly overweight, female leading characters (the mothers, daughters, and aunts of the families) resulted in a lack of identification among male and low–body mass index viewers. Moreover, the health communication scientists deemed the leading characters to be merely passive role models clinging to their unhealthy behavior patterns and hardly making any progress. The passivity was judged to interfere with feelings of positive identification among viewers. They therefore pleaded for more empowerment of the leading characters.
People that are overweight would rather look like a positive role model than like somebody that fails finally, wouldn’t they? (Health communication scientist).
The focus groups suggested that the separate episodes of Voor dik & dun did instill some feelings of recognition.
I liked the set-up with three families and showing their lifestyle habits. I did recognize some situations. (Viewer)
However, participants who saw a single episode did not seem to instantly develop strong feelings of involvement with the leading characters: The character development was considered too limited for that.
I couldn’t quite understand it, it skipped from one family to another; I don’t know anything about that family. (Viewer)
Within the focus groups, slightly overweight women, and/or those interested in the overweight theme, were most curious about the progressions of the leading characters and identified most with them.
In line with the critique of the health communication scientists, viewers also judged the leading characters’ lack of progression negatively. They were characterized as unmotivated, as they kept relapsing into their old habits. This not only discouraged viewers, but even resulted in some having feelings of malicious pleasure (Schadenfreude).
They know what’s bad for them, but they do it anyway [ . . . ] They look like a fool. And everybody’s watching. (Viewer)
The Health-Promoting Potential of the Series
The focus groups suggested that watching a single episode of Voor dik & dun could trigger viewers to reflect on their own lifestyle. However, no further effects seemed to materialize. Particularly viewers with no initial interest in the theme (among which mainly men, young respondents, and nonoverweight respondents) reported to have little need of more. They claimed that they would not think and/or talk about the episode and would not watch a following episode.
It’s just not appealing, it’s not something you would talk about. (Viewer)
Moreover, nearly all focus group attendees claimed that the separate episodes would not motivate them toward actual behavior change. A majority of focus group participants preferred the spectacular weight loss programs in which contestants battle to lose weight. These shows seem to outstrip Voor dik & dun on entertainment as well as education; even though they are often considered less realistic and recognizable, they were rated more fun to watch and, from the perspective of the viewers, contained more useful information.
Whenever Big Diet [Dutch TV overweight elimination programme] was on, we would move the table aside and participate in the exercises with the whole family! And it actually worked! (Viewer)
Discussion
Results suggest that Voor dik & dun did not succeed in creating the right balance between a realistic, preventive health message and entertainment characteristics such as excitement and drama. The program did not meet its main aim of attracting low socio-economic status viewers without an initial interest in overweight prevention.
The separate episodes of Voor dik & dun contained too much educational information and too few entertaining features, and therefore deterred rather than engaged the priority group that was mainly looking for an entertainment experience. One aspect of EE, setting it apart from traditional, overtly persuasive strategies, is its narrative entertaining format, allowing viewers to become engaged in the story as it unfolds. It is suggested that particularly this element of narrative engagement and transportation (being swept up in the narrative) reduces counterargument and psychological reactance to the health-promoting message (Moyer-Gusé, 2008; Slater & Rouner, 2002) and that this makes EE especially effective.
Another unique aspect of EE is the possibility for viewers to identify and develop a pseudo-relationship with leading, efficacious characters, and to learn through these characters how to deal with difficult situations (Moyer-Gusé, 2008). In Voor dik & dun, the leading characters did not appeal to the priority group and made too little progress, as a result of which feelings of negative identification and even malicious pleasure were aroused (especially among viewers without an initial involvement in the health theme). Furthermore, the practical value of the information provided was regarded as limited and hardly met the needs of viewers that were looking for more factual information that could increase their response efficacy.
On the basis of our findings, we would like to distinguish four important ingredients in regard to planning and conducting successful EE programs. First, properly balance entertainment and education, keeping in mind the key features of an EE strategy and what this means for the responding audience. It is this process, in which learning is not generated cognitively but indirectly by means of modeling, which distinguishes EE from other interventions, prevents it from becoming overly persuasive and pedantic, and contributes to its effects. By making the learning process an added value of a pleasurable experience, EE programs make it possible to speak to a wide audience of both viewers without an initial interest in the health theme and viewers that do feel a need for more information.
Second, in the first stage of the development of an EE-based intervention, the focus should be on entertainment rather than education. Only then, when narrative engagement with the viewers is established and their involvement with the leading characters is secured, will a solid basis be created in which to embed educational features in the program.
Third, use recognizable, positive, active, and appealing role models. To reach the priority group, this type of role model is most necessary. As suggested by many authors (e.g. Bandura, 2004; Brown & Fraser, 2004; Slater & Rouner, 2002), involvement with characters is a key component of a successful EE intervention. By portraying the experiences and dilemmas of individuals with whom the priority group can identify, EE is able to implicitly show and teach the risks and responsibilities that accompany all kinds of health-related behaviors in a way that books, pamphlets, and classroom instructions cannot (Collins, Elliott, Berry, Kanouse, & Hunter, 2003; Moyer-Gusé, 2008).
Fourth, use explicit transition processes. A clear transition from unhealthy to healthy behavior (and attention to the benefits of the latter over the former) is indispensable to maintain and motivate the priority group (and prevent feelings of Schadenfreude). An extensive outline of the transition process, with explicit attention to (and perhaps additional practical information about) every step undertaken, is of major importance for bringing about a process of reflection and social interaction amongst viewers and raising their levels of confidence (i.e., self- and response efficacy) in their abilities to change their own behavior.
In conclusion, the EE strategy is a promising intervention that in theory can achieve several unique effects. However, as our study has shown, the road to success is paved with many pitfalls. Differing interests and frames of reference on the part of both television professionals and health professionals contribute, as Bouman (2003) indeed has already argued, to a high-risk context in program development. Properly embedding education in entertainment is a prerequisite for success but is hard to accomplish in practice where the two concepts often seem to be at daggers drawn with each other.