Humans having been using stories or narratives to transmit crucial information for thousands of years. Despite that, Western medicine largely ignores the use of narrative and instead continues to rely on lists of dos and don’t’s, facts and figures to compel behavior change.
So are these lists, facts and figures the best way to present health information to people? Or would we remember and act on health-related information better if it was presented in a narrative or story?
My team at the University of Southern California has been studying how narratives and stories about health can influences people’s knowledge, and ultimately their behavior. We’ve looked at the impact of a number of health storylines on popular TV shows, such as “Grey’s Anatomy,” “Desperate Housewives,” “ER” and “Law & Order,” as well several Spanish language telenovelas.
In fact, we received a grant from the National Institutes of Health to conduct controlled trials to test whether narratives might produce a stronger and more sustained impact on health knowledge, attitudes and prevention behavior.
Our research has suggested that the narratives and stories can be more effective in both communicating health information about cancer and even encouraging people to be screened.
How do you measure if a story is better?
In one study, we wanted to see if narratives could help reduce cancer health disparities.
We started by surveying 900 women between the ages of 24 and 45 who lived in Los Angeles. The women were randomly selected, and the sample was equally divided between African-American, Mexican-American and non-Hispanic white women. We wanted to find out what they already knew about cervical cancer and when they had last been screened, if at all, via Pap test for cervical cancer.
We focused on cervical cancer because it is the third most common cancer worldwide and is almost always treatable if caught early through Pap test screening. Moreover, in Los Angeles County the incidence for cervical cancer for Hispanic women was almost double that for non-Hispanic whites – 14.3 cases per 100,000 women for versus 7.5 per 100,000. The incidence for African-American women 7.6 per 100,000.
Then we randomly assigned these women to watch either a short narrative film or a nonnarrative film. Both films were 11 minutes long and contained the same 10 facts regarding cervical cancer prevention, detection and treatment. After the women had watched one of the films, we resurveyed them two weeks and then six months later.
The nonnarrative film, “It’s Time,” uses a more traditional approach to communicating health information. It features doctors, patients, and facts and figures.
“The Tamale Lesson,” on the other hand, revolves around a family’s preparation for their youngest daughter’s quinceañera, a coming-of-age ceremony when girls turn 15. It begins with Lupita, the family’s eldest daughter, finding out she, like half of all sexually active women in the U.S., has the human papilloma virus (HPV), which can cause cervical cancer. This leads to a discussion with her sister Connie, who is a virgin, about how you contract HPV, how Pap tests can detect it and how the HPV vaccine can protect you from contracting the virus.
The results revealed that “Tamale Lesson” was indeed more effective than the nonnarrative film. For instance, by the six-month follow-up, Mexican-American respondents who viewed “Tamale Lesson” went from having the lowest rate of screening (32 percent) of the sample to the highest (82 percent being screened).
The narrative film also led to more supportive attitudes toward Pap tests for all three ethnic groups and strengthened the intentions of Latina and African-American women to undergo screening.
The narrative film proved particularly useful for those with lower levels of education. It changed their perceptions of relevant social norms, such as what percentage of “women like them” had Pap tests. This, in turn, increased their own intention to be screened.
So why do stories work?
Two key psychological processes help explain why stories work so well at conveying information and even changing behavior. The first is identification with characters, and the second is being transported or absorbed into a story.
Identification has roots in social cognitive theory which suggests that one of the ways people learn is through observing others and modeling their behavior.
Studies have shown that people are more likely to adopt a behavior that they have seen others perform, especially if they perceive these individuals as being similar to themselves.
For example, a study by Michael Cody and his colleagues found that among four organ donation storylines on popular television shows, viewers of a storyline on “NUMB3RS,” which showed a main character signing up to become a donor at the DMV while renewing his license, were more likely to register to become organ donors. It is not because this was the most dramatic storyline about organ donation, but rather it was the one storyline that explicitly encouraged and demonstrated how to sign up. Viewers not only identified with the characters in the storyline but also learned that you can register as a donor at the DMV in most states.
As the prior example illustrates, physically demonstrating the desired behavior is important for health campaigns that promote behavior change. Often campaigns that attempt to change the public’s perception of how frequent or normative a particular behavior is fail because they lack the contextual detail that makes them applicable and believable to the audience.
In narrative persuasion, audiences identify with the characters in the story which, in turn, makes the message conveyed more relevant to their life. In a 2013 study comparing “Tamale Lesson” with its nonnarrative equivalent “It’s Time,” Mexican-American and African-American women identified more strongly with the character of Lupita than their European-American counterparts. This identification was significantly associated with more positive attitudes toward Pap tests.
But identification with characters can be complex and nuanced. Our research suggests that to achieve the desired outcome – encouraging people to be screened for cancer, for instance – narratives need to include positive role models of different ages, ethnicities and health histories so that different individuals can find a character they identify with.
Narratives featuring positive role models that underserved populations can identify with may be particularly helpful in reducing health disparities.
Engaging stories help
Transportation into the story or narrative is also key. It describes a state in which an audience member is highly engaged or absorbed in a story.
For instance, on the TV show “Desperate Housewives,” one of the main characters, Lynette, was diagnosed with lymphoma and underwent chemotherapy. We measured the impact of that storyline on 167 regular viewers of the show, and found that transportation into this story was most strongly associated with changes in knowledge, attitudes and behaviors surrounding cancer prevention. These changes included audience members seeking further information seeking about lymphoma and discussions with their doctor, family and friends.
Similarly, in our “Tamale Lesson” study described above, women who found the narrative to be relevant to their lives and reported being transported into the story were more likely to think that HPV infection was serious and that the vaccine was effective.
Writers and industry professionals need to be involved
Our research shows that narrative may be a valuable tool in health communication.
But there are some caveats. The first is that writing or creating narratives that immerse or transport viewers may require the help of professional screenwriters, filmmakers and other entertainment industry professionals.
In addition, producers of popular film and television need to depict disease accurately to enable viewers to recognize symptoms and seek treatment. This is something that the Hollywood, Health & Society program at the Norman Lear Center at the Annenberg School for Communication and Journalism does. HH&S provides expert advice and information for the entertainment industry on how to include health information in their narratives without decreasing audience engagement in the story.
This story was updated to correct information about cervical cancer incidence among African-American women in Los Angeles County.