Entertainment-Education and Health and Risk Messaging
Summary and Keywords
Entertainment-education (EE) began as a communication approach that uses both entertainment and education to engender individual and social change, but is emerging as a distinct theoretical, practice, and evidence-based communication subdiscipline. EE has roots in oral and performing arts traditions spanning thousands of years, such as morality tales, religious storytelling, and the spoken word. Modern-day EE, meanwhile, is produced in both fiction and nonfiction designs that include many formats: local street theater, music, puppetry, games, radio, television, and social media. A classic successful example of EE is the children’s television program Sesame Street, which is broadcast in over 120 countries. EE, however, is a strategy that has been successfully planned, implemented, and evaluated in countries around the world for children and adults alike. EE scholarship has traditionally focused on asking, “Does it work?” but more recent theorizing and research is moving toward understanding how EE works, drawing from multidisciplinary theories. From a research standpoint, such scholarship has increasingly showcased a wide range of methodologies. The result of these transformations is that EE is becoming an area of study, or subdiscipline, backed by an entire body of theory, practice, and evidence. The theoretical underpinnings, practice components, and evidence base from EE may be surveyed via the peer-reviewed literature published over the past 10 years. However, extensive work in social change from EE projects around the world has not all made it into the published literature. EE historically began as a communication approach, one tool in the communication toolbox. Over time, the nascent approach became its own full-fledged strategy focused on individual change. Backed by emerging technologies, innovative examples from around the globe, and new variations in implementation, it becomes clear that the field of EE is emerging into a discrete theoretical, practice, and evidence-based subdiscipline within communication that increasingly recognizes the inherent role of individuals, families, communities, organizations, and policies on improving the conditions needed for lasting social change.
Entertainment-Education (EE) as a Theoretical, Practice, and Evidence-Based Communication Subdiscipline
Entertainment-education (abbreviated as EE throughout this article) began as a communication approach that uses both entertainment and education to engender individual and social change, but now it is emerging as a distinct theoretical, practice, and evidence-based communication subdiscipline (Singhal & Rogers, 1999, 2002, 2004). EE has roots in oral and performing arts traditions spanning thousands of years, such as morality tales, religious storytelling, and the spoken word (Storey & Sood, 2013). Modern-day EE, meanwhile, is produced in many formats, including local street theater, music, puppetry, games, radio, television, and social media (de Fossard & Lande, 2008). The development and use of mass media in the 20th century particularly helped to disseminate the strategy to larger audiences than ever before. Today, as part of an overarching strategic communication framework, EE has put multiple forms of communication together, combining, for example, mass media and interpersonal communication.
EE combines both fiction and nonfiction in its design. At the heart of EE is a delicate balance between entertainment and education (Singhal & Rogers, 2004), although considerable debate exists on what may be considered “educational” and a wide spectrum of EE programs exists to change individual practices and/or enact social change, such as shifting norms or policies. A classic successful example of EE is the children’s television program Sesame Street, broadcast in over 120 countries (Cole, Labin, & del Rocio Galarza, 2008). EE, however, is a strategy that has been successfully planned, implemented, and evaluated in countries around the world for both children and adults. There are nine Ps that explain EE: pervasive, popular, passionate, personal, participatory, persuasive, practical, profitable, and proven effective (Piotrow & de Fossard, 2004). What these explanations mean is that, by design, EE is everywhere, enjoyable, tied to our emotions, identifiable to audiences, hands-on, influential, works within existing communication infrastructures, generates a profit, and is shown to be successful.
The History of EE
The idea of storytelling for change goes back thousands of years. Morality tales, storytelling, spoken-word, and performing arts traditions across oral cultures have commonly combined entertainment with educational components to explain the meaning of life, impart wisdom, and convey important lessons. Consider, for example, Aesop’s fables, persuasive stories that have been passed down for generations and translated into many languages. The conscious use of EE as a methodology for specifically addressing individual and social development, however, is relatively new.
The beginnings of modern-day EE are often cited to an Australian radio program called The Lawsons in the 1940s (Singhal & Rogers, 2004), which was designed to promote farming messages as part of the war effort; a British radio soap opera called The Archers in the 1950s, which also contained agricultural information; and a series of television programs developed in Latin America by Miguel Sabido in the 1960s and 1970s, designed to promote family planning (Poindexter, 2004). In the United States, the development of EE efforts were spearheaded by PCI Media Impact and the Johns Hopkins Center for Communication Programs (Rimon & Sood, 2012). PCI Media Impact built upon the work of Sabido in Mexico and transferred the soap opera strategy to India, Tanzania, and other countries, and the Johns Hopkins Center for Communication Programs not only expanded the strategy into long-running narratives, but also applied EE as a core strategy into their social and behavior change communication programs.
Conscious use of EE has since spread around the world. One of the best-known projects is the Soul City program in South Africa (Tufte, 2001). Soul City is an example of long-running EE, or EE designed from the beginning with the purpose of social change (Usdin, Singhal, Shongwe, Goldstein, & Shabalala, 2004). This television program has aired since 1994 and is now accompanied by a website, print materials, and other resources (Soul City Institute for Health & Development Communication, 2016).
EE can also take the role of embedded messages within an existing program. This is the format most likely to be familiar to those living in the West. Beck (2004) cites such examples (from American soap operas) as an HIV storyline on The Bold and the Beautiful and a breast cancer message on The Young and the Restless. Like specifically designed health communication efforts, including educational content within an existing communication program can have measurable effects. The HIV storyline, for instance, led to a significant increase in calls to a CDC hotline listed at the end of the program (Kennedy, O’Leary, Beck, Pollard, & Simpson, 2004). While in the United States, the trajectory has typically focused on incorporating education into ongoing programs with a few exceptions (Wang & Singhal, 2016), global initiatives led by organizations such as Soul City, BBC Media Action, MTV, and UNICEF have continued to test long-running narratives alongside newer models using multichannel approaches and new digital media technologies. Meanwhile, there are plenty of projects that fit the definition of EE without being characterized as such, including plays, films, and television shows. Educational games are one such example that fit the EE definition, but may not have been developed using specific EE-related theories. Developments in EE scholarship are increasingly investigating results from these projects as well.
The scholarship on EE followed its development and traditionally focused on asking, “Does it work?” given the high levels of donor investment in large media projects. This resulted in critiques of EE programs as promoting Western elitism and bias (Dutta, 2009). Early on, overestimating effectiveness and attribution was also a criticism of EE, as outlined by Yoder, Hornik, and Chirwa (1996). The main research questions then shifted focused to both attribution and contribution of EE to promoting individual behavior and social change. More recent scholarship is moving toward understanding how EE works, drawing from theories across social sciences and humanities disciplines. From a research standpoint, such scholarship has increasingly showcased a wide range of methodologies, including quasi-experimental designs, time series, and current trends, including randomized controlled trials to examine engagement and effectiveness experimentally. The result of these programmatic and methodological transformations is that EE is developing into its own area of study, or subdiscipline, backed by an entire body of theory, practice, and evidence.
Several published works have summarized these developments along the way. The preface to the May 2002 issue of the journal Communication Theory proposed a theoretical agenda for EE. Two books, Entertainment-Education: A Communication Strategy, and an updated edition, Entertainment-Education and Social Change: History, Research and Practice, examined the history of the field, including Sood, Menard, and Witte’s (2004) review of the literature on EE theory and methodological characteristics, and Greenberg, Salmon, Patel, Beck, and Cole’s (2004) research agenda.
In addition, since 1989, five international EE conferences have brought scholars and practitioners together on the subject. Storey and Sood (2013) summarized the lessons learned from these conferences, indicating that the field is diverse and maturing rapidly, even though it is relatively new and likely to be on the cutting edge for some time. A robust review of the literature focused on recent theorizing and research, however, has not been published in over a decade. This article examines the theoretical underpinnings, practice components, and evidence base of EE using a literature review of the peer-reviewed literature over the past 10 years, while acknowledging work in social change from EE projects around the world that have not made it into the published literature. The text concludes by discussing the current status of EE theorizing, practice, and evidence and providing recommendations for the future. Backed by emerging technologies, innovative examples from around the globe, and new variations on implementation, it becomes clear that the field of EE is emerging as a discrete theoretical, practice, and evidence-based subdiscipline within communication that increasingly recognizes the inherent role of individuals, families, communities, organizations, and policies on improving the conditions needed for lasting individual and social change.
EE Research in the 21st Century
A literature review using a process of three distinct stages (identification, abstract review, and full text review1; see Figure 1) revealed the published EE literature from 2005 through early 2016, with an emphasis on English-language, peer-reviewed articles that evaluated or researched EE programs and interventions. The literature review focused on a list of variables (Table 1) corresponding to information on theory, practice, and evidence. Published EE studies from 2005 through early 2016 indicate that three general areas of theories guide much of the research associated with EE. A broad array of topics associated with health and risk appear in these studies, and a range of implementation and program goals, channels, audience, and location for the work appears. Anecdotally, it appears that EE is widely used. However, the translation of EE theorizing and research into peer-reviewed publications remains low compared to the overall number of EE programs being implemented (see Figure 1). For example, evaluations, project reports, and other nonscholarly sources may have been published or reported locally but not made in the academic literature. Thus, the universe of knowledge about EE is not fully represented in peer-reviewed publications. The review of the manuscripts, however, revealed a wealth of information that supports the idea that the field is no longer a nascent strategy, but is emerging as a theoretical and evidence-based communication subdiscipline.
Table 1. Summary of Variables Considered in 2005–2016 Published EE Research (N = 126) Reviewed
Theory and Model Variables
Explicit theories and models
Theories that were specifically mentioned in the text in the development and implementation of the program
Implicit theories and models
Theories that were not specifically mentioned in the text, but the authors inferred were used in the program
The overarching intentions of the program, whether it was to change knowledge, attitudes, etc.
Whether the program was aimed toward influencing community, individual, family, or policy
The setting where the program was implemented (i.e., region, country, community)
The health topic that the program focused on (i.e., HIV/AIDS, etc.)
The number of platforms that the program was implemented on (i.e., single-channel or multiple-channel)
The specific style or mode of delivery that the program used for implementation (i.e., games, reality shows, narratives, etc.)
Whether the program evaluation was designed to collect quantitative data, qualitative data, or both
The strategy used to collect data and evaluate the program
The number of participants
How effective the program was; whether it was able to accomplish its goals
Theory Utilized in EE Research
The 126 published EE manuscripts yielded 56 (44.4%) separate explicit theories (Table 2). This long list includes theories from a wide range of social science and humanities disciplines, including communication, psychology, public health, theater, and information technology. One category of theories included audience-centered theories that focus on how audiences engage with and react to EE (i.e., psychological and internal processes). Examples include audience involvement, character identification, parasocial interaction, narrative engagement, and transportation. Three different types of outcome-centered (or result-centered) theories were identified in the published research: individual outcomes, social outcomes, and individual and social outcomes. An example of an individual outcome theory is the Health Belief Model; an example of a social outcome theory is the social ecological model; and an individual and social outcome theory is diffusion of innovation. A final grouping included stages of change theories that identify where audiences are and move them along a continuum toward either individual or social change. An example of an individually focused stage of change theory is the Transtheoretical Model, and a socially focused stage of change theory is the Community Readiness Model.
Some of the most frequently used theories were ones that have been used in explanations of EE for years, such as social cognitive theory (Bandura, 1977; 19.8%, N = 37), the theory of reasoned action and planned behavior (8.6%, N = 16) and elaboration likelihood (4.3%, N = 8). A good example of the use of social cognitive theory was given by Love, Mouttapa, and Tanjasiri (2009). In this study, role modeling was used in videos in a soap opera format to promote discussions about cervical cancer testing among Thai women. Social cognitive theory was also the most commonly implied theory among the sample, accounting for 42.7% (N = 89) of all the implied theories.
EE programs using interactive communication technologies meanwhile, tended to use updated theories to reflect the use of new digital media. For example, Waters, Amarkhil, Bruun, and Mathisen (2012) cited the PodCred Framework in their content analysis of environmental podcasts. In addition, topic-specific theories were found to tailor particular interventions, such as by Schmied et al. (2015), who joined a community health worker model with an EE intervention, and Jones (2008), who used sex script theory to develop a soap opera intervention to promote HIV risk reduction. In consideration of a social ecological model applied to the theories utilized in published EE research, 44.4% (N = 83) of the theories were considered individual-level, 23.0% (N = 43) were interpersonal-level, and 10.7% (N = 20) were community-level (Figure 2).
Table 2. Explicit EE Theories and Models Identified in 2005-2016 Published EE Research (N = 126) Reviewed
Transportation (Green and Brock)
Audience involvement (Sood)
Character identification (Cohen)
Narrative engagement (Busselle and Bilandzic)
Uses and gratifications (Blumler and Katz)
Cultivation theory (Gerbner)
Drama theory (Kincaid)
Emotional involvement (Mamet)
Entertaining overcoming resistance model (Moyer-Gusé)
Experiential learning (Kolb)
Framing theory (Scheufele)
Involvement with characters (Moyer-Gusé)
Parasocial interaction (Horton and Wohl)
Perceived realism (Potter)
Psychological reactance theory (Brehm and Brehm)
Regulatory focus theory (Higgins)
Sleeper effect (Hovland, Lumsdaine, and Sheffield)
Theory of Entertainment Persuasion (Moyer-Gusé)
Outcomes-Centered Theories: Individual
Theory of reasoned action (Fishbein); theory of planned
behavior (Ajzen); theory of reasoned action and planned
behavior (Fishbein and Ajzen); integrated model of
behavioral prediction (Fishbein and Cappella)
Elaboration likelihood (Petty and Cacioppo); and extended
elaboration likelihood (Slater and Rouner)
Health belief model (Hochbaum, Rosenstock, and Kegels)
Information motivation behavior (Fisher and Fisher)
behavior change communication
Extended parallel processing model (Witte)
Heuristic-systematic model (Chaiken, Liberman, and
Hierarchy of coping mechanisms (Pearlin and
Motivational interviewing (Miller and Rollnick)
Protection motivation (Norman, Boer, and Seydel)
Self-concept discrepancy theory (Higgins)
Self determination theory (Deci & Flaste)
Model of illness cognition (Cameron and Leventhal)
Outcomes-Centered Theories: Social
MARCH (modeling and reinforcement) model (Pappas-DeLuca, Kraft, Galavotti)
Freirean theory of dialogic communication (Freire)
Intergroup contact theory (Pettigrew and Tropp)
Social capital (Scheufele and Shah)
Social movement theory (Melucci)
Theory of social integration (Durkheim)
Outcomes-Centered Theories: Individual and Social
Social cognitive theory (Bandura)
Power as knowing participation in change theory (Barrett)
Sex script theory (Simon and Gagnon)
Community health worker/promotora (Forster-Cox)
Diffusion of innovations (Rogers)
Soul City model
Theater of the oppressed (Boal)
Change, agency, discussion, and action (CASCADA) Behavior change model
Implementation of change in health care (Theunissen, Te Pas, and Friele)
Modified labeling of mental illness (Link)
Natural opinion leader model (Kelly)
Re-AIM framework (Glasgow, Vogt, and Boles)
Sexual socialization (Rodgers)
Social marketing (Kotler and Lee)
Youth engagement framework (Rose-Krasnor)
Stages of Change Theories: Individual
Transtheoretical model (Proschaska and DiClemente)
Theory of change (Lewin)
PodCred framework (Tsagkias, Larson, and de Rijke)
Technology acceptance model (Davis)
Note: * Total does not equal 100% due to rounding.
The Practice of EE
The review of the 126 published manuscripts revealed 257 goals, with many programs designed with more than one purpose (Table 3). The most common goal was behavior change, reported by 30.7% (N = 79) of the manuscripts. Knowledge was a close second, included in 28.8% (N = 74) of the manuscripts. Attitudes, beliefs, and perceptions were included as goals in 23.3% (N = 60) of the articles. Intention was a goal in 7.4% (N = 19) of the articles, and the rest of the categories, such as information retention and recall, risk reduction, efficacy/empowerment, involvement, and understanding of EE processes were reported as goals in less than 5% of the manuscripts.
Table 3. EE Practice in 2005–2016 Published EE Research (N = 126) Reviewed
Understanding the EE process
Information retention and recall
Diet, nutrition, and physical activity
Hypertension, diabetes, heart disease, and stroke
Note: * Some totals do not equal 100% due to rounding.
The social ecological model (Sallis, Owen, & Fisher, 2008) determined program focus (Table 3; Figure 3). The overwhelming majority of programs focused on individuals (68.5%, N = 111), an expected and traditional focus of EE; 16.7% (N = 27) focused on communities; and 11.7% (N = 19) focused on interpersonal or family dynamics. Just 1.9% (N = 3) focused on policy, and only one manuscript focused on national and organizational issues r Comparison of a single level or multiple levels of influence indicated that 23.6% (N = 29) of the manuscripts focused on two or more levels of the social ecological model.
Geographical location included six categories: small scale, subnational/local, national, regional, global, and not specified (Table 3). An example of a small-scale location is a single setting, such as testing a program at one university (Hobart, 2012); a mere 4.8% (N = 6) of programs were implemented on this scale. Almost half of the programs (46.8%, N = 59) were considered subnational or local. This indicates that most published research on EE is based on programs only reaching small, local audiences. An example of a subnational or local program is a program designed for a handful of areas, such as in the Midwest in the United States (Castelli, Goss, Scherer, & Chapman-Novakofski, 2011). A national program is one that is designed for the majority of a country’s population, for instance a national multimedia campaign to address cross-generational sex in Tanzania (Kaufman et al., 2013). About a third of programs (33.3%, N = 42) were directed at the national scale. A regional program is one aimed at more than one country in the same geographic region, such as in Cameron et al. (2014), which investigated the effects of an EE program across Botswana, Namibia, and Swaziland; 2.4% (N = 3) of the EE programs were implemented across geographic regions. Only 1.6% were implemented globally, or across continents, such as in van Weert, Hermanns, Linn, and Schouten (2011), which evaluated a dance program in 14 countries across Africa and Europe; and 11.1% (N = 14) did not specify their location. One example includes Huebner et al. (2013), a study of an online film intervention for parents of lesbian, gay, and bisexual children, but where the geographic response demographics were not reported.
The review revealed a total of 146 topics contained within the 126 manuscripts, with some programs covering multiple topics (Table 3). The most common topic across programs was HIV/AIDS/sexually transmitted infections (STIs)/sexual health (35.6%, N = 52). This was somewhat unsurprising, as HIV/AIDS remains a high-priority topic for international agencies and funders alike. One example of this is Zeelen, Wijbenga, Vintges, and de Jong (2010), who used storytelling for HIV/AIDS education in South Africa. The next most common topics were diet, nutrition, and physical activity (11.6%, N = 17) and miscellaneous topics (10.8%, N = 15). The miscellaneous topics included an interesting assortment that did not naturally belong together, including the death penalty, seat belts, and political propaganda. Cancer was the fourth most common topic (8.9%, N = 13), mental health fifth (6.8%, N = 10), and hypertension, diabetes, heart disease, and stroke sixth (5.5%, N = 8). The remainder of the key topics appeared in less than 5% of the manuscripts. Of all the programs, 83 (65.9%) focused on a single topic and 43 (34.1%) contained multiple topics. An example of a single-topic program is Aljafari, Rice, Gallagher, and Hosey (2015), which described the results of a randomized controlled trial of a video game for oral health in Scotland, whereas an example of a multiple-topic program is Ramafoko, Andersson, and Weiner (2012), a study of the impact of a reality television series in South Africa that covered prevention of HIV and AIDS, alcohol abuse, violence, and other topics.
The results of the channel analysis revealed 169 different media across 11 categories of channels (Table 3). The most commonly used channel was television (17.8%, N = 30). The second-most-common channel was computer or online media (17.2%, N = 29), which indicates an increase in EE programs using new digital media technologies corresponding to the increased proliferation of Internet access around the world in recent years. Radio (14.2%, N = 24%), print media (13.6%, N = 23), and live performance (10.7%, N = 18) rounded out the top five most commonly used media. Of the 126 manuscripts, 98 (77.8%) utilized single-channel approaches, whereas only 28 (22.2%) utilized multichannel approaches. Bae and Kang (2008), for example, examined viewers and nonviewers of an EE reality show in Korea (single-channel approach), while Rispel, Peltzer, Nkomo, and Molomo (2010) evaluated a television drama, radio drama, coloring booklets, and a school program for HIV/AIDS knowledge and behavior change in South Africa (multiple-channel approach).
The genre analysis disaggregated the data into 162 identified program-specific genres across 13 categories (Table 3). Overwhelmingly, the most common genre used was drama (28.4%, N = 46). This is not surprising considering EE’s rich history and development, starting with Sabido in Mexico, using a serial story or soap opera format. The next most common genre was fictional narratives (9.9%, N = 16). Nonfictional narratives and documentaries came in third (9.9%, N = 16). Games, including board games and video games, appeared 8.0% (N= 13) of the time, and photonovelas and comics appeared 6.8% (N = 11) of the time. Community efforts (6.2%, N = 10), and interactive genres (6.2%, N = 10) were the remaining items included in more than 5% of the sample. The other genres included reality television, promotional videos, posters/brochures, and miscellaneous.
A Note on Narrative
Throughout this review, anecdotal evidence was found that compared formats that highlighted the efficacy of narrative tools. For example, Murphy et al. (2015), from a comparison of narrative and nonnarrative formats on Pap smears for cervical cancer screening, concluded that narratives might prove to be a useful tool for reducing health disparities. Their data shows that the narrative was particularly effective for Mexican American women and eliminated cervical cancer screening disparities found at baseline. Oliver, Dillard, Bae, and Tamul (2012) similarly found that narrative-formatted stories produced more compassion toward the individuals in the story, more favorable attitudes toward the group, more beneficial behavioral intentions, and more information-seeking behavior. The authors, therefore, concluded that variations in news format have the potential to promote favorable social and behavioral change toward stigmatized groups. This subfinding will be elaborated further below.
The Evidence Surrounding EE
The review revealed that quantitative methods were by far the most common methods used to evaluate EE programs (61.9%, N = 78; see Table 4). Lemieux, Fisher, and Pratto (2008), for example, used questionnaires, which was an example of the use of quantitative methods. Mixed methods, meaning both quantitative and qualitative methods together, were utilized in 24.6% (N = 31) of the manuscripts; for example, Kawamura, Ivankova, Kohler, and Perumean-Chaney (2009) used both survey data and interviews. And qualitative methods alone were utilized in 13.5% (N = 17) of the sample. For example, McKee, Walsh, and Watson (2014) assessed data from focus groups.
Table 4. EE Evidence in 2005–2016 Published EE Research (N = 126) Reviewed
Pre and post
Randomized controlled trial
Pre and post with control group
Pre and post with control group and post-only program group
Pre and post control group with post-only control group
Evidence of Sustainability
Delayed posttest design
500 or more participants
Less than 49 participants
Level of reported effectiveness
Medium (changes in intermediate outcomes)
High (behavior and social change)
Low (effectiveness measures, reporting unclear, not applicable)
Information retention and recall
Measurement of involvement, engagement, transportation, etc.
Focus on implementation
Measurement of EE Practice (medium, genre, channel, etc.
Note: * Some totals do not equal 100% due to rounding.
The most common research strategy was a post-only design (40.5%, N = 51; Table 4). A pre and post design was used in 27.0% (N = 34) of the sample, followed closely by randomized controlled trials (23.0%, N = 29). A pre and post with a control group design was used by 5.6% (N = 7) of the sample. No studies in the review used either a pre and post control with post-only control design or the Solomon four-group design (Bamberger, Rugh, & Mabry, 2006). The review further indicated that 15 of the 126 articles (11.9%) used a delayed posttest design (i.e., evidence of sustainability). As one example of such a measure, Cherrington et al. (2015) returned to respondents six months after viewing a narrative smoking DVD to determine continued smoking cessation rates.
The results of the literature review indicated a wide range of sample sizes, which can be explained as resulting from varying research questions (Table 4). While most studies had between 100 and 249 participants (26.8%, N = 34), almost one-quarter had 500 or more participants (22.0%, N = 28), with a handful of studies including thousands of individuals. Some articles did not report sample sizes and were reported as unspecified (4.7%, N = 6). An example of an unspecified sample size is Morgan (2015). In this article, the author describes the process of collaboration between a rap artist and a nongovernmental organization to develop and evaluate an intervention on child rape in Liberia, but only anecdotal outcomes are reported due to suspending program research during the 2014 Ebola outbreak.
The vast majority of the studies reported medium-level effectiveness, i.e., some changes in intermediate outcomes but no behavior change noted (61.1%, N = 77; Table 4). Approximately 18.3% (N = 23) reported high levels of effectiveness (i.e., behavior and social change sustained over time). And 20.6% (N = 26) reported zero or low levels of effectiveness (i.e., minimal change noted, change not attributable to the intervention, or unclear or not applicable change). The results further indicated that outcomes were measured around goals that include behaviors (24.1%, N = 68), knowledge/raising awareness (22.0%, N = 62), attitudes/beliefs/perceptions (17.8%, N = 50), and intentions (12.8%, N = 36). Outcomes associated with efficacy/empowerment (8.9%, N = 25), dialogue (7.4%, N = 21), risk/stigma reduction (4.3%, N = 12), and information retention and recall (2.8%, N = 8) were reported less often in the reviewed literature. Finally, 29.4% (N = 37) of manuscripts included some measure of audience involvement, and some 21.4% (N = 27) of manuscripts measured EE practice in terms of specifically examining channels and genre.
Understanding Trends in the EE Literature
There are interesting trends regarding theory, practice, and evidence from the published EE literature over the last 10 years compared to earlier EE work, particularly as reported by Sood, Menard, and Witte (2004). In summary, changes in the published EE literature show that theory continues to be cited in EE publications, but a discussion on whether many theories are truly needed and exactly how theories are being applied (beyond being included in the “References” list) is missing. Practice trends include a number of programs that addressed multiple goals, topics, and focuses concurrently, and a shift from family-planning programs to programs reflecting changing global health priorities. And evidence trends included changes in methodology, a reliance on quantitative methods but some evidence of qualitative research, and a shift from large evaluations to smaller, more nuanced studies. Further discussion on theory, practice, and evidence findings, as well as some cross-cutting trends, is presented next.
This review examined the theoretical underpinnings of EE by examining different theories and models noted in the literature, different levels at which these theories operated within the social ecological framework, and the extent to which theorizing in EE reflected audience-centered perspectives and explained the processes through which EE works. The results reveal that the social cognitive theory was and continues to be one of the most common theories used in applications (Sood, Menard, & Witte, 2004), but a host of new theories and models are being developed to explain the process and impact of EE. Two particularly interesting models are worth noting. First is the Process and Collaboration for Empowerment and Discussion (PACED) approach used by Boneh and Jaganath (2011), which uses eight steps to generate empowerment and dialogue through theater. The second is the CASCADA framework, a behavior change model developed to address intermediate steps in change, including subjective norms and agency (Cameron et al., 2014).
While it is certainly necessary to continue to test such newer models, a discussion of whether so many theories are required and whether they translate into better practice is also greatly needed. When a field is nascent and developing, it is important to draw from different areas and sacrifice parsimony. However, the hallmark of a consolidated and well-accepted subdiscipline is overarching universal axioms. In short, the evidence from this review suggests the field of EE is ready for one overarching “theory of everything,” such as by Storey and Figueroa (2012), which developed a global health communication theory. Until that time, it is important for EE practitioners to explicitly name theories and models used in the design, implementation, and evaluation of EE interventions in order to continue to share and grow conceptual understanding around EE. Further, a discussion about how theory influences programs and evaluation is also needed. While this review did not formally review the use of theory, anecdotal results indicated that theory was used in vastly different ways. In some cases, theory influenced research design, but in others, theory was merely mentioned, and it was unclear how the use of theory influenced the project or research.
The results related to theorizing at different levels of the social ecological model indicate that individual level theories continue to be the standard. Sood, Menard, and Witte (2004) reported that the most predominant theory used in most EE interventions was social cognitive theory. Yet there is considerable theorizing about the processes of change related to social norms, suggesting that EE is a viable way to promote and sustain norm change (Fishbein & Yzer, 2003; Rimal, 2008; Sood et al., 2015). One such example from this review is Paluck and Green (2009), which evaluated a radio program in postgenocide Rwanda. This soap opera, broadcast a decade after the genocide, was designed to inform audiences about the causes of violence, promote independent thought, and encourage and increase collective action. While program evaluation revealed few significant individual effects, the drama was associated with a substantial impact on listeners’ willingness to express dissent and resolve communal problems by shifting perceived norms around open expression and promoting local responsibility for community problems. The published data from other manuscripts in this review show some similar promise, but such examples of norm change remain limited.
A final point from the review of theorizing aligns with past suggestions to move beyond theories of change designed to prove how much behavior and social change can be attributed to EE interventions to studying the role of emotions (i.e., the narrative elements of EE and its ability to spark dialogue). There is a substantial evidence of studies that are employing audience-centered perspectives and honing in on the processes of EE practice, as opposed to treating EE as a black box tool, is thus needed to reach objectives related to change.
This review of EE practice focused on the goals and focus, geographical location, key topics, channel, and genre associated with EE programs. Overall, the review revealed a noticeable number of programs that address multiple goals, topics, and foci concurrently. Such evidence suggests a marked shift to the various interconnected levels of the social ecological model outside of the individual level over the last decade (Sood, Menard, & Witte, 2004).
While vast room for improvement remains, there is some evidence of social ecological model use examining multiple levels of influence, including individual, group, and social levels, as well as the interaction between these levels engendered by EE practice. Several examples from the review show that EE programs affect various indicators within levels and across multiple levels of the social ecological model. The Dance 4 Life program in Russia, for instance, not only provided sexual and reproductive health information to young people through a series of individual empowerment activities, but also encouraged students to become agents of change in their communities (Alekseeva, Krasnopolskaya, & Skokova, 2015). Similarly, in South Africa, applied theater projects with young people by DramAidE (Drama for AIDS Education) were designed to bring about both individual knowledge and community-level action, and researchers found evidence in support of these goals (Dalrymple, 2006). The “One Love” multimedia campaign was a campaign in nine African countries designed to reduce HIV incidence (Jana, Letsela, Scheepers, & Weiner, 2015). Using qualitative methods, researchers evaluating this program found evidence of community-level communication alongside individual indicators. In the United States, Marcus, Huang, Beck, and Miller (2010) examined the impact of a prime-time cancer storyline in the popular show ER and found EE not only can result in changes ranging from individual knowledge and behavioral intentions, but also can contribute to policy-level decisions. Finally, Flora et al. (2014) reported that exposure to climate science in an engaging edutainment format changed youths’ knowledge, beliefs, involvement, and behavior positively. The authors concluded that such programs can inspire youth for deeper engagement in school programs, personal action, and political and consumer advocacy. These examples illustrate a move in the right direction and aligns with the theoretical agenda for EE by Singhal and Rogers (2002), which specifically called for EE research to explore the causal pathways between exposure to EE and social change.
At the same time, the review also revealed information related to the ability of EE to affect different levels of the social ecological model. In short, one of the assumptions of the social ecological model is that social change initiatives must be supplemented with supportive resources in order to be sustainable. Several articles pointed to the fact that there is much that EE cannot do; EE does not work alone, and in the short term, the effects of EE interventions are limited.
As noted previously, this review found this need is a given in many programs. For example, a brief, video-based sexual risk reduction intervention concluded that while risk reduction behaviors occurred as a result of the program, increasing and sustained behaviors would require more intensive, clinic-based interventions (Carey et al., 2015). Similarly, Cherrington et al. (2015, p. 567) concluded that “narrative communication via storytelling to promote smoking cessation among African-Americans, while being one method to communicate smoking cessation,” is insufficient in of itself without augmentation of routine clinical treatment for continuous smoking cessation. In some cases, audiences need additional information to augment information from an EE program, as was the case in the study on the effectiveness of a depression fotonovela for Latinos with limited English proficiency. The authors concluded that while appreciating the educational value of the fotonovela, participants reported that they wanted more information about the causes of depression and the process of recovery, and felt that the story did not shift their apprehensions related to antidepressants (Cabassa, Contreras, Aragón, Molina, & Baron, 2011). Finally, as noted in previous EE literature (Sood, SenGupta, Mishra, & Jacoby, 2004), the results of this review suggest that combining EE with other forms of health education and health promotion allows for message repetition and subsequent recall (Boneh & Jaganath, 2011; Kim, Bazant, & Storey, 2006; Ravenell et al., 2015).
Meanwhile, the results of the topical changes indicate a shift from family planning and HIV/AIDS in older EE applications (Sood, Menard, & Witte, 2004) to noncommunicable and chronic diseases, which importantly mirrors vastly changing global health priorities. With noncommunicable diseases (NCDs) poised to be the largest contributors to mortality and morbidity in the world at large, there is no longer the sharp divide in health issues pertinent to the developed and developing world. As the world grapples with chronic conditions, there is a parallel shift in priorities vis-à-vis EE programming.
The geographical location results found that most EE interventions are reaching a smaller, location-specific audience. It is possible to hypothesize that smaller interventions may lead to greater audience involvement and may be equipped to better reach hard-to-reach and marginalized populations than national programs, although analyzing these connections quantitatively was beyond the scope of this literature review. In addition, the smaller, nuanced programs may allow room for giving voice to audiences who would not be heard otherwise.
Several examples from the review highlight this fact. For example, Boekeloo et al. (2015) reported on an HIV prevention intervention for African American women. Dway et al. (2016) reported on the effectiveness of using edutainment to reach Lisu mothers about childhood immunization. Hennelly, Sly, Villagra, and Jandorf (2015) reported on the use of storytelling as a culturally acceptable method to educate the Latino community on colonoscopy. Jibaja-Weiss (2006) measured the effects of a values clarification exercise using an interactive jewelry box as a promising method for promoting informed treatment decision-making by low-literacy breast cancer patients. Leung, Tripicchio, Agaronov, and Hou (2014) reported on the efficacy of a Manga comic series that influenced snack selection in black and Hispanic youth in New York City. All these specific EE practices designed to reach niche audiences may have allowed these programs to practice what has been considered by critics of large-scale EE as a culture-centered approach (Dutta-Bergman, 2005; Dutta & Basnyat, 2008). In addition, these types of programs to some extent fulfill the theoretical agenda related to the study of reactance to EE programs in Singhal and Rogers (2004), forcing a greater attention to the competing forces in EE message production and reception, especially in media-saturated environments where audiences have access to a plethora of counterarguments. Overall, these findings clearly point to the sheer versatility of EE practice as being truly glocal (Hemer & Tufte, 2005).
The findings related to channel and genre indicate that interactive communication technologies (ICTs) have changed the communication landscape across the globe. These new technologies harness the vast reach of traditional mass media while allowing audiences to witness trust and confidentiality inherent to face-to-face interactions. The combination of assets with opportunities for interactivity afforded by ICTs makes them viable media. Considering the proliferation of online formats, global EE interventions using ICTs may increase in the future, but more evaluation is needed in this area to establish an evidence base, as argued by Gurman, Rubin, and Roess (2012).
In terms of channel, single-channel approaches have been employed in EE program implementation for decades. In fact, EE has historically been associated with the embedding of educational messages into soap operas through the work of Miguel Sabido in Mexico. Despite such a large body of evidence supporting EE today, it was surprising to find that so many continue to use single channel approaches. Of course, there are external factors, such as funding, that must be taken into account; nevertheless, multiple-channel examples, such as the Fataki campaign in Tanzania (researched by Kaufman et al., 2013), appear to remain the exception, not the rule. The use of multiple-channel approaches, as well as channel variety and genre, can be greatly improved.
This review examined research methods, research designs, sample size, and outcomes as measures of evidence. In terms of methodology, it revealed a substantial uptick in randomized controlled trials compared to previous reviews (Sood, Mendard, & Witte, 2004). While quasi-experimental designs continue to be the norm, the adoption of experimental designs is interesting. On the one hand, it supports elements of the five-point theoretical agenda proposed by Singhal and Rogers (2004), who noted the need for EE research to use innovative measurements and methodologies. On the other hand, this movement is somewhat contrary to the conventional wisdom proposed by transitional research, which posits that hypotheses and axioms that are proved through experimentation are diffused into broader practice over time. In the field of EE, the movement has appeared to have moved from evaluating large-scale programs to examining specific elements of EE programs (i.e., the variety of program design and implementation that falls within the EE umbrella and the desire to understand the role of narrative and emotional elements of EE). Essentially, this has translated into a study of ways in which to mitigate the divide between research and practice and balancing the science (education) with the art (entertainment) aspects of EE (Storey & Sood, 2013).
This review found that quantitative methods continue to be the most common methods to evaluate EE programs. In general, qualitative assessments appear to be on a small scale. This is not surprising, given that for qualitative research, the rule of thumb to consider is the level of saturation desired and achieved, as opposed to the sheer numbers of individuals included in the research. Another notable trend that emerged is the use of participatory techniques to understand audience engagement and program effectiveness. The EE literature appears to be using extreme case sampling and participatory methods more frequently; most notable in this regard is Singhal, Harter, Chitnis, and Sharma (2007), which examined an EE project in India through the use of participatory photography.
Historically, the EE literature has focused on examining the results of large-scale EE efforts (Rogers et al., 1999; Storey, Boulay, Karki, Heckert, & Karmacharya, 1999; Usdin, Scheepers, Goldstein, & Japhet, 2005). Some findings from this review of articles from the past decade included continued large-scale efforts designed to change individual and social behavior at the population level. For example, Do and Kincaid (2006) examined the impact of an EE television drama on health behaviors in Bangladesh and used a sample size of over 4,000 men and women. This review, however, indicates that the last decade has seen a shift in the literature from large-scale evaluations to smaller and more nuanced studies, with smaller sample sizes aimed at examining the extent to which EE programs can meet the needs of hard-to-reach and disadvantaged populations (Jackson, Mullis, & Hughes, 2010; Cabassa, Contreras, Aragón, Molina, & Baron, 2011), examining the effects of specific and novel types of channels and genres (Shrimpton & Hurworth, 2005; Peng, 2009; Jin, 2010; Ramafoko, Anderson, & Weiner, 2012; Knight, 2013; Prybutok, 2013; Leung, Tripicchio, Agaronov, & Hou, 2014; Mcginnis et al., 2014), and generating understanding on how audiences interact with EE and examining processes through which EE programs work through experimenting in controlled environments (Moyer-Gusé, 2010; Moyer-Gusé & Nabi, 2011; Moyer-Gusé, Chung, & Jain, 2011; Moyer-Gusé, Mahood, & Brookes, 2011; Sangalang, Quintero Johnson, & Ciancio, 2013; Schouten, Vlug-Mahabali, Hermanns, Spijker, & van Weert, 2014).
Three key points emerged from comparisons across theory, practice, and research domains. For example, a review of channels and genres revealed the importance of drama and narrative structure in EE. The goals, location, and research design elements in this review indicated the importance of engaging multiple stakeholders. Finally, a comparison of the topics, channels, and levels of influence indicated a reliance on singular topics, channels, and levels of influence.
The first key point that emerged from the cross-cutting comparisons of channels and genre was that drama and narrative structure matter. One notable exception was found in Zebregs, van den Putte, de Graaf, Lammers, and Neijens (2015), an examination of the effects of narrative versus nonnarrative information in school health education about alcohol drinking for low-educated adolescents. Their findings were that the effects on knowledge, attitudes, and intention to drink alcohol did not differ between conditions and school levels and the effects did not persist over time. The authors concluded that nonnarrative and narrative information are equally effective in the context of school health education. They further recommended that given that narrative texts are more expensive to develop, policymakers may not want to choose these types of texts over the traditionally used nonnarrative texts. Cirigliano (2012), on the other hand, explains that the success of using edutainment in a classroom environment is dependent on the psychographic characteristics displayed by different types of students, therefore raising questions about the results reported by Zebregs et al. (2015).
Additional manuscripts that compared narrative and nonnarrative formats highlight the efficacy of narrative tools. For example, Murphy et al. (2015), from a comparison of narrative and nonnarrative formats on Pap smears for cervical cancer screening, concluded that narratives might prove to be a useful tool for reducing health disparities. Their data show that the narrative was particularly effective for Mexican American women and eliminated cervical cancer screening disparities found at baseline. Oliver, Dillard, Bae, and Tamul (2012) similarly found that narrative-formatted stories produced more compassion toward the individuals in the story, more favorable attitudes toward the group, more beneficial behavioral intentions, and more information-seeking behavior. The authors, therefore, concluded that variations in news format have the potential to promote favorable social and behavioral change toward stigmatized groups. Overall, the manuscripts in this review provided support for the use of drama and narratives in their ability to help participants externalize their views (Francis, 2010), to feel authentic and real, to underscore the importance of engaging viewers to think about what could happen (Guttman, Gesser-Edelsburg, & Israelashvili, 2008), and to transport audiences into fictional worlds (Lapsansky et al., 2010). Once again, however, more evaluations on these approaches and examinations of the process of EE are needed to continue to build this body of evidence.
A second key finding that emerged from this review of practice and research design elements, which was apparent when comparing the findings across the program content and evidence categories, was the importance of engaging multiple stakeholders. EE was characterized as a transdisciplinary field involving theoreticians, program evaluation experts, content specialists, communications technologists, and donors, all of whom have specific roles to play and need to work together to ensure a balance of education and entertainment (Campbell, Bath, Bradbear, Cottle, & Parrett, 2009; Renes, Mutsaers, & van Woerkum, 2012; Storey & Sood, 2013). Successful EE appears to require partnerships at many levels. Examples from the review that mention different types of partnerships include Chen et al. (2009), who provided a successful example of a mutually beneficial relationship between public health professionals and television writers to increase accuracy of health content in television shows and concurrently strengthen the entertainment value of the shows. Jackson, Mullis, and Hughes (2010) reported on a successful community-academic partnership to develop a theater-based nutrition and physical activity intervention. Finally, Mitschke et al. (2010) reported on a unique collaborative partnership between a federal cancer agency and a community health center to use drama to prevent teen smoking in Hawaii.
A final key point that emerged from the comparison of topics, channels, and levels of influence indicated that slightly less than half of the examples (51 out of 126) focused on one topic, used one channel to get their message across, and addressed a single level of influence. The results showed that of the 126 studies, 44 (34.9%) focused on multiple topics, only 28 (22.2%) relied on multiple channels of communication, and 29 (23%) reported addressing more than one level of influence. Only 3 out of the 126 articles described interventions that worked across multiple topics, channels, and levels of influence. Campbell, Bath, Bradbear, Cottle, and Parrett (2009), evaluated performance arts–based HIV-prevention events in London with 13- to 16-year-olds and concluded that participants displayed improvements in knowledge, efficacy, and intentions to use condoms. While calling for a more systematic and robust evaluation, the authors demonstrated that outcomes could and should be measured.
Whittier, Gennedy, and St. Lawrence (2005) studied the effect of embedding health messages into entertainment television to improve gay men’s responses to a syphilis outbreak; they reported that exposure had positive outcomes vis-à-vis raising awareness and intentions, including the intent to advocate about the messages. The final example of a program addressing multiple topics and using multiple channels is from India. Singhal, Harter, Chitnis, and Sharma (2007) used participatory photography to examine the effects of an EE project and concluded that EE facilitates social change by stimulating the development of social capital in communities. Despite the commonalities in design—topics, channels, and levels of influence—these three examples have little else in common, highlighting that there is no one correct or optimal way of doing EE.
Limitations of the Present Research
As with any research, this review has several limitations. To begin with, it did not distinguish among models, theories, and frameworks. While, to some extent, these terms are used interchangeably, theories are meant to explain phenomena through generalizations, while models and frameworks help describe an application of a theory, provide a specific representation of reality, or both. This difference, though not critical, deserves mention because it is possible that some of the theories used in EE are actually models and frameworks. This may partially muddy the contention that there is much theorizing or generalizations to be made from the large number of models that exist.
In addition, this review was based on only English-language, peer-reviewed articles. Yet there is extensive EE work being conducted in non-English-speaking countries, most notably through the Center for Media and Health in the Netherlands. There is also a rich tradition of EE in Latin America and South America. In fact, as noted earlier, it is possible to argue that the study of EE as an academic endeavor, grounded in theory and research, is based on work that originated with Miguel Sabido in Mexico (Singhal, Obregon, & Rogers, 1995). There is also compelling recent evidence from Brazil that supports this argument by linking exposure to soap operas and fertility declines (La Ferrara, Chong, & Duryea, 2012). But insofar as this work is reported and cited in languages other than English, it was outside the scope of this review.
A third limitation is that this review relied on information given in peer-reviewed manuscripts. As noted earlier, there are numerous evaluations, reports from the field, case studies, and other sources that have been published and shared locally but are not part of the academic literature. In addition, the peer review process, while promoting rigor, has several constraints imposed by the publication process (most notably the demands of time and space, which often force authors to leave out components when trying to answer specific research questions from complex and complicated EE interventions). This is likely the reason for missing information regarding planning, implementation, and evaluation processes. A related limitation may be inherent weaknesses in the peer review process, which is biased toward academia as opposed to practice. As famously noted by Richard Horton, the editor-in-chief of The Lancet, “We portray peer review to the public as a quasi-sacred process that helps to make science our most objective truth teller. But we know that the system of peer review is biased, unjust, unaccountable, incomplete, easily fixed, often insulting, usually ignorant, occasionally foolish, and frequently wrong” (Horton, 2000).
A final key limitation of this review is related to the challenge noted by Storey and Sood (2013) of balancing research and practice in EE. EE practice has a long history in and continues to flourish as a practice in the Global South, but much of the peer-reviewed literature on EE is produced in the Global North. On the one hand, this is a function of the academic nature of this review and reflects the biases associated with searching in U.S.-based databases and peer-reviewed publications. On the other hand, this is not surprising, all in all; it reflects the so-called 10/90 gap that exists in health and other areas of research.
Recommendations Regarding the Future of EE Theory, Practice, and Evidence
Overall, it would be useful to document failures and successes with the development of a global repository on EE, where stellar and seminal projects can be housed with information on all aspects of program design, implementation, and evaluation. While such information is often available on organizational websites, project-specific websites, and social media sites, there is no global repository on or of EE materials. Beyond such a needed resource, EE practitioners and researchers should also consider the following in the movement of EE from an approach to a strategy to a full-fledged communication subdiscipline:
• Review the models and theories guiding EE and develop an overarching model that can be used to understand the past and plan for the future of EE as a subdiscipline within communication.
• Renew the focus on the different levels of the social ecological model, specifically on how EE can leverage the interactions between the individual, interpersonal, community, organizational, and policy levels.
• Continue to unpack the role of narrative engagement/transportation/emotional involvement to understand further how and why narratives matter.
• Harness the power of interactivity inherent in new digital media technologies.
• “Glocalize” EE by tailoring interventions for specific audiences, especially given the power of EE to reach specific marginalized populations while at the same time building on the successes of global EE efforts.
• Invest in formative and process research. There is evidence of formative research to help design EE programs and evaluation of the processes through which EE works. But a continued focus on formative and process evaluation for theorizing about EE and to ensure that successful practice is critical.
• Measure sustainability. The results herein around measuring sustainability are interesting. However, it is important to examine sustainability beyond “delayed-post tests” within experimental situations and study the sustainability of real-world EE interventions.
Conclusions Regarding EE
Traditionally, fields move from theory (i.e., testing in small-scale or lab studies) to practice. The process was partially reversed in EE theorizing and research. EE disseminated quickly as an effective and practice-based communication strategy. In many ways, the accompanying body of evidence (specifically, examinations of the processes through which EE works) came later than might have been expected. Recent programs from the past decade, including small-scale communication interventions using elements of EE, new digital media interventions, large-scale national programs purposefully designed as EE interventions, and popular media shows that incorporate EE storylines, illustrate a field ripe with innovation.
While there remains no “right” or “wrong” way to do EE, there is a cascade of knowledge about a strategy that can now be considered a distinct subdiscipline within communication. The results from this review (limitations notwithstanding) reveal a wealth of information that supports the idea that the field in its rightful place is no longer a nascent strategy; instead, it is emerging as a theoretical and evidence-based communication subdiscipline. Exactly how this subdiscipline will build on that knowledge and continue to propel the field forward, however, is a script that remains to be written.
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(1.) Articles were selected based on five exclusion criteria: “not available” (N= 103), “not after 2005” (N= 24), “not EE” (N = 40), “not evidence-based” (N = 87), and “not peer reviewed” (N = 9).