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Entertainment programming provides a unique opportunity for cancer education, particularly for higher risk racial and ethnic minority groups. Cultural relevancy is key to quality narrative cancer communication, and minorities often prefer media content produced by and featuring members of their own cultural in-group. However, little is known about whether cancer depictions or the television programs they appear in are culturally diverse. Using media content analysis, this study aims to assess the cultural diversity of cancer depictions on primetime scripted television to reveal opportunities to improve cancer education through entertainment. Indicators used to assess cultural diversity at the program level and depiction levels were collected. Out of 111 television programs, 10 (9.01%) programs mentioned cancer, from which 37 cancer depictions were identified. However, the majority of cancer depictions involved White patients and White health providers. Depictions of coping and treatment also dominated with less than 10% of depictions discussing cancer prevention. These patterns reveal a missed opportunity in existing cancer narratives on primetime scripted television and a lack of representation of cultural, social, and environmental factors that affect the health of minority communities, who need to hear these messages the most. Keywords Health communication · Entertainment education · Cancer · Health disparities Introduction cancer education through entertainment media can be opti- mized to address cancer disparities becomes salient. Racial and ethnic minorities experience persistent dispari- Entertainment education (EE) incorporates health and ties in cancer mortality, survival, and incidence ; thus, other educational messages into popular entertainment innovative ways to address these disparities are needed. media with the goal of positively influencing awareness, Researchers have turned to engaging, transporting stories knowledge, attitudes, and/or behaviors . From its incep- and narratives to help influence individuals’ cancer-related tion, EE has been closely associated with Bandura’s (1986) beliefs and behaviors [2, 3]. Entertainment programming, in Social Cognitive Theory (SCT) [9, 10], which describes particular, has the capacity to reach populations experienc- the effects of role modeling and vicarious learning on ing health disparities, such as racial and ethnic minorities, self-efficacy and the likelihood of enacting new behaviors for several reasons . First, some research suggests that . With this focus on role modeling, EE typically uses racial and ethnic minorities are heavy consumers of televi- actors who are ethnically and culturally homogeneous sion [4, 5]. Second, racial and ethnic minority viewers often with targeted audiences , also referred to as homoph- regard entertainment television as a source of health infor- ily. Although similar external characteristics, such as race, mation  and are also more likely to act on information may not be the sole factor contributing to audience identi- they learned through television [5, 7]. Thus, identifying how fication, SCT suggests audiences that view role models or characters similar to oneself, who model desired behaviors, are more likely to increase self-efficacy and willingness * Grace Kim to attempt the behavior than when less similar models are email@example.com viewed . Thus, characters in EE are developed to be similar to the intended audience to promote greater identi- Department of Community Health Sciences, Fielding School of Public Health, University of California, Los Angeles fication with those characters, with the goal of enhancing (UCLA), 650 Charles Young Drive South, Los Angeles, narrative persuasion [13, 14]. CA 90095, USA 1 3 Journal of Cancer Education (2022) 37:1842–1848 1843 In this context, cultural relevancy is key to quality nar- primetime television . Program level data included title, rative cancer communication, and minorities may prefer season, genre, network, number of episodes in the season, media content produced by and featuring members of their and length of show (i.e., half hour, hour). These data were own cultural in-group . However, research on cancer extracted from IMDb (imdb.com), a popular online database depictions on television has often focused on the impact of for films and television shows that includes information on individual cancer storylines focusing on cancer prevention, cast, production crew, plot summaries, ratings, and reviews, screening, diagnosis, treatment, coping, and using cancer and triangulated with the show’s official webpage on the patient navigators [16–19]. Little is actually known about broadcast network. Depiction level data included the type of whether cancer depictions or the television programs they cancer mentioned, name and demographics (i.e., age group, appear in are culturally diverse, which is an important first gender) of the patient, and provider characters, and whether step to understanding audience identification with cancer resources were mentioned (i.e., websites, phone numbers). narratives, a construct that is central to narrative persua- The coder also noted whether the cancer was depicted as a sion theories. Assessing the cultural diversity of cancer brief mention, dialogue, and minor or major storyline. A depictions found on popular television shows may disclose brief mention was defined as a passing mention with no fur - unintended programming biases and distortions that affect ther information or comments. Dialogue entailed at least minorities’ access to cancer information in the entertain- three lines of text, but did not rise to the level of a minor ment media further perpetuating disparities in cancer out- storyline. A minor storyline was identified as a secondary comes. In other words, this study seeks to address whether plotline, often carried throughout the entire episode, but not cancer-related health messages found on popular television as central to the episode as the major storyline, while a major are actually reaching the individuals who need to hear these storyline was defined as a primary focus of the episode messages the most. Research questions for this study are . Type of health information conveyed (i.e., prevention, threefold: detection, diagnosis, treatment, prognosis, coping) was also coded, allowing for more than one choice since a depiction RQ1. How frequently is cancer portrayed on primetime could involve both diagnosis and treatment. scripted television? Indicators used to assess cultural diversity at the program RQ2. To what extent are cancer depictions found on level included demographic characteristics of the main cast primetime scripted television culturally diverse? and producers, which were defined by those whose names RQ3. What kinds of health messages are promoted in can- were mentioned in the show credits. Awards or nomina- cer depictions present on primetime scripted television? tions from minority award shows were extracted from the show’s IMDb webpage. To assess cultural diversity at the depiction level, demographics of patient and provider char- Methods acters involved in the cancer depiction functioned as proxy measures for the more complex concept of homophily: the A media content analysis was conducted to examine cancer degree to which audience members perceive themselves as depictions on primetime television shows that aired in the similar to characters in entertainment programs, which has 2016–2017 network television schedule. The 2016–2017 been defined similarly in other studies [ 20]. Cultural sensi- network television schedule includes the 5 major US broad- tivity issues that appeared in the cancer depiction were also cast networks (ABC, CBS, NBC, FOX, and CW) covering recorded, such as alternative medicine or religion and spir- primetime hours. The sample was further limited to scripted ituality. Collectively, program-level data can answer ques- series, thus excluding variety, reality, newsmagazines, news, tions regarding the characteristics of the shows that depict and sports, leaving a final sample of 111 programs. To iden - cancer, and whether they varied by genre or race/ethnic- tify television programs with plots involving cancer, the ity of its producers, while depiction level data describe the search function was used to review episode summaries on characters, content, and the types of cancer that are most TV Guide (tvguide.com) and Wikipedia (Wikipedia.org) for frequently portrayed. key words: cancer, tumor, melanoma, lymphoma, leukemia. Programs that mention cancer based on episode summaries were subsequently watched in full, with a particular focus Results on episodes with cancer mentioned in the online episode summaries. Television Programs One coder collected data at both the program and depic- tion level, requiring two separate, but related codebooks. Out of 111 broadcast primetime programs, 10 (9.01%) Codebook development and coding categories were guided programs mentioned cancer: Chicago Justice, Chicago by a previous media content analysis of health issues on Med, Doubt, Dr. Ken, Grey’s Anatomy, Jane the Virgin, 1 3 1844 Journal of Cancer Education (2022) 37:1842–1848 Marvel’s Agents of S.H.I.E.L.D, Pure Genius, Scream Queens, and This is Us (Table 1). All but one of them were hour-long programs. The majority of programs with cancer depictions were also classified as dramas, but only a third were medical shows. Almost half of the programs were in their first season, with the outlier of Grey’s Anatomy, which was in its thirteenth season. Programs ranged from having 1 to 8 cancer depictions, with two medical dramas, Pure Genius and Chicago Med, exhibiting the most cancer depictions. With regard to cultural diversity, 30% of programs with cancer depictions featured minority-dominant casts with more than half of the main cast being of a racial and ethnic minority: Jane the Virgin, Dr. Ken, and Chi- cago Justice. Of note, Jane the Virgin and Dr. Ken are shows targeting specific ethnic groups. Jane the Virgin is a romantic dramedy on the CW that parodies com- mon tropes of telenovelas, featuring the story of Jane Villanueva, a devout 23-year-old Latina virgin, who becomes pregnant after an accidental artificial insemi- nation. Dr. Ken is an ABC sitcom, created, written, and co-produced by its lead actor, Ken Jeong, that follows the story of a Korean American doctor and his family. Two programs involved an executive producer that was of a racial and ethnic minority: Ken Jeong (Dr. Ken) and Shonda Rhimes (Grey’s Anatomy). Lastly, 40% of programs with cancer depictions were recognized by minority award shows, such as the Black Reel Awards and the National Association for the Advancement of Colored People (NAACP) Image Awards, demonstrat- ing a degree of approval and acknowledgement of how minority groups were represented on the show. Cancer Depictions Across the 10 primetime programs, 181 episodes were reviewed, among which 37 cancer depictions were identi- fied in total (Table 2). Most depictions appeared as minor single-episode storylines, but about a quarter of these depic- tions only entailed brief mentions of cancer. For example, in a brief mention on Scream Queens, the patient (a were- wolf) loses all of her hair and compares herself to a cancer patient, prompting the Chanels to give her a makeover. Other examples of cancer depictions from each show are reported in Table 3. The type of cancer featured in these depictions varied widely, with the most common being general can- cer of which the type was never identified. The next most frequently mentioned were lung cancer, breast cancer, pan- creatic cancer, and leukemia, which were each found three times. Single depictions of cancer included stomach, cervi- cal, kidney, and prostate cancer. Health messages around coping and treatment domi- nated the cancer depictions found on primetime shows. An 1 3 Table 1 Description of television programs with cancer depictions (N = 10) Program Network Genre Season Episodes in Number of cancer Number of minority Number of Minority cast/ Number of season depictions producers minority cast total cast minority awards or nominations Chicago Justice NBC Crime, Drama 1 13 4 0 3 0.60 1 Chicago Med NBC Drama 2 23 8 0 4 0.44 0 Doubt CBS Drama 1 13 3 0 3 0.43 0 Dr. Ken ABC Comedy 2 22 3 1 6 0.75 0 Grey’s Anatomy ABC Drama, romance 13 24 4 1 6 0.43 2 Jane the Virgin CW Comedy 3 20 2 0 4 0.57 4 Marvel’s Agents of ABC Action, adventure, 4 22 1 0 2 0.29 0 S.H.I.E.L.D drama Pure Genius CBS Drama 1 13 8 0 3 0.43 0 Scream Queens FOX Comedy, horror, 2 13 1 0 3 0.25 0 mystery This is Us NBC Comedy, drama, 1 18 3 0 3 0.38 8 romance Journal of Cancer Education (2022) 37:1842–1848 1845 Table 2 Description of cancer depictions (N = 37) Scott Strauss can speak Mandarin fluently, she enlists his help to convince her mother to get examined and eventually Characteristic N (%) accept the innovative nanobot treatment. Role Brief mention 9 (24.3) Dialogue 7 (18.9) Discussion Minor storyline 16 (43.2) Major storyline 5 (13.5) The main objective of this study was to assess the cultural Type of health message conveyed diversity of cancer depictions found on primetime scripted Prevention 2 (5.4) television in order to disclose unintended programming Detection 7 (18.9) biases and distortions that may affect minorities’ access Diagnosis 9 (24.3) to cancer information in the entertainment media further Treatment 15 (40.5) perpetuating disparities in cancer outcomes. This study Prognosis 7 (18.9) found about 10% of broadcast primetime scripted shows in Coping 10 (27.0) the 2016–2017 network schedule depicted cancer to some Resources 1 (2.7) extent. This is consistent with previous studies demonstrat- Race of cancer patient* ing the lack of cancer depictions on primetime despite the White 23 (62.2) prevalence of cancer in real life, and how health content Black 9 (24.3) tends to lean towards more unusual illnesses and diseases, Latino 1 (2.7) which make for more dramatic storylines . Findings from Asian 3 (8.1) the current study thus reaffirm that most health content Biracial 0 (0.0) included in television shows are for entertainment rather Unknown 0 (0.0) than educational purposes . Race of health provider* Moreover, study findings reveal a missed opportunity in White 14 (37.8) existing cancer depictions on primetime scripted television Black 1 (2.7) to identify with and provide relevant cancer education to Latino 0 (0.0) minority viewers. Despite some programs having potential Asian 4 (8.1) to reach minority audiences based on recognition received Biracial 1 (2.7) by minority awards as well as the diversity of its cast and Unknown 16 (27.8) production, the cancer narratives themselves are not actu- Cultural sensitivities ally culturally diverse, mostly consisting of largely White Religion, spirituality 0 (0.0) providers and White patients. Based on Social Cognitive Alternative medicine 1 (2.7) Theory, individuals are more likely to pay attention to and be influenced by models who are perceived to be similar [ 10]; Percentages may not sum to 100 because not all cancer depictions thus, greater degrees of homophily should increase character involved a patient and provider identification. Through cognitive and emotional processes of character identification, viewers gain a better understanding example of a treatment storyline on Chicago Med featured of the character’s perspective and vicariously participates in Haley Cline, a child cancer patient, who experiences com- the character’s experiences . However, this study finds plications with infection and liver failure while being treated that the lack of cancer depictions with diverse characters may for non-Hodgkin’s lymphoma. Less than 10% of depictions impede minority viewers from experiencing character iden- discussed crucial messages on cancer prevention, such tification, thus reducing the impact of narrative persuasion. as risk factors or cancer screenings. Only one depiction Narrative messages also have the potential to achieve offered any resources, which was found in an episode of effects beyond those directly proposed in EE for role mod - Dr. Ken that concluded with a public service announcement eling and similarity of external characteristics, such as race. (PSA) promoting mammogram screening. With regard to In particular, experiencing identification from the closeness diversity, the majority of cancer depictions involved White of the story to one’s own situation or culture and subsequent patients (62.2%) and White health providers (37.8%), and transportation into the story world can reduce counterarguing, only one depiction addressed cultural sensitivity issues. or resistance to the message [11, 13, 22]. Thus, the lack of cul- Pure Genius addressed cultural barriers to healthcare when tural diversity found in cancer depictions also indicates a lack Angie Cheng’s mother is diagnosed with cervical cancer, of representation of cultural, social, and environmental factors but initially refuses to get examined and insists on taking that affect the health of minority communities. Given that Chinese herbal medicine. When Angie discovers that Dr. traditional health communication tactics have not adequately 1 3 1846 Journal of Cancer Education (2022) 37:1842–1848 Table 3 Examples of cancer depictions Program Cancer depiction Chicago Justice Officer Ted Cody, a victim of homicide, was struggling financially and battling pancreatic cancer with 6 weeks left. He wanted to ensure that his son would be taken care of after his death Chicago Med Nurse Maggie’s transgender sister experiences sudden blindness and is diagnosed with prostate cancer Doubt Sadie discovers that Billy had leukemia and received a blood marrow transplant from cousin Max, meaning that he does not have the same blood as he did when Amy was murdered and that his blood will not match what was found on the murder weapon. This leads Sadie to believe Billy is guilty of the murder Dr. Ken Allison finds a lump in her breast and receives the results from her mammogram Grey’s Anatomy Maggie’s adoptive mother is diagnosed with inflammatory breast cancer Jane the Virgin Rafael explains his motivation for exercising is his history with cancer Marvel Agents Dr. Radcliffe creates Aida (android version of ex-girlfriend Agnes) and “the Framework” because she was diagnosed with a of S.H.I.E.L.D brain tumor and he promised her a way for her to live Pure Genius Angie Cheng’s mother diagnosed with cervical cancer and struggles with cultural barriers, but eventually agrees to innovative nanobot treatment Scream Queens Patient (“werewolf”) loses all of her hair and compares herself to a cancer patient, prompting Chanels to give her a makeover This is Us William diagnosed with stage 4 stomach cancer and his family learns to cope addressed diverse populations or health disparities , health persisting cancer disparities that inhibit minority viewers’ promotion strategies that address persisting disparities expe- access to cancer information on entertainment programming. rienced by racial and ethnic minority groups by taking into Not only is there a lack of minority characters in cancer account complex interrelated psychological, sociocultural, depictions, but when these storylines are presented, they and structural factors are critical . Thus, cancer narra- rarely consider the complex, multifaceted cultural factors tives in entertainment can do much more to not only involve that are specic fi to racial and ethnic minority groups. Cancer more diverse characters, but better represent the experiences narratives that can adequately address the social, cultural, of minority groups for more effective cancer education. environmental, and historical factors affecting a minority Moreover, storylines on cancer prevention are essential group in addition to matching external characteristics of to cancer education efforts, but are largely neglected. Incor - characters may increase receptivity to the storyline . With porating more cancer prevention narratives is particularly recent demand for culturally diverse content and movements important given racial and ethnic minorities have been to diversify Hollywood, there is both monetary and educa- documented to be diagnosed later, when the cancer is more tional opportunity for television networks and producers to advanced [23, 24]. This could be partly explained by low include culturally diverse health content that can promote public awareness of cancer prevention strategies, particularly cancer education. Lastly, more spaces for collaboration are among racial and ethnic minorities . Given the increas- needed between public health professionals and entertain- ing emergence of shows that target minority audiences, such ment to communicate the needs of minority groups (i.e., as Fresh off the Boat , Blackish, Jane the Virgin, and Dr. prevention) for more effective cancer-related messages on Ken, there is a clear opportunity to educate minority viewers television. about cancer prevention. Implications for Practice Limitations Despite the prevalence of cancer in real life, few entertain- The current study only focuses on broadcast primetime ment programs depict cancer in a meaningful way. A previ- television, but the media landscape is constantly chang- ous study found that cancer is one of the most frequently ing, with more entertainment shifting to digital streaming portrayed illnesses and diseases on medical dramas ; platforms, such as Netflix and Hulu. Future studies should however, the current study found that cancer does not have examine how these newer platforms along with social media to be limited to medical shows and that cancer narratives can platforms, such as YouTube, depict and talk about cancer. be well integrated into non-medical shows, as exemplified This study also has some methodological limitations. First, by shows like This is Us. Study findings also reveal the dis - while ensuring inter-rater reliability is ideal, only one coder crepancy between current cancer depictions and the groups reviewed the episodes and collected data on cancer depic- that need to hear these messages the most. Current cancer tions. Another limitation is that race and ethnicity of char- depictions on television may unintentionally contribute to acters is a limited proxy measure of homophily and cultural 1 3 Journal of Cancer Education (2022) 37:1842–1848 1847 otherwise in a credit line to the material. 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Journal of Cancer Education – Springer Journals
Published: Dec 1, 2022
Keywords: Health communication; Entertainment education; Cancer; Health disparities
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