One out of nine Dutch people is functionally illiterate. It is difficult to transmit medical information to this group, and if they are able to read the information, it is often too complex and ends up being disregarded. By using soaps, internet series and serious games, Martine Bouman, a professor occupying an endowed chair in Entertainment Media and Social Change at Erasmus University Rotterdam, wants to turn the tide.

There are women in the Netherlands who repeatedly become pregnant in spite of the fact that they’re on the pill. You’d think this was a medical miracle, but after a bit of probing, an explanation emerged: these women were using the pill vaginally or they only took the pill orally before engaging in sexual intercourse. Reading and understanding the medication leaflet was simply too difficult a task. “That’s something we would never imagine happening to us”, says Martine Bouman, founder of the daily television programme Nederland in Beweging (Netherlands on the Move), and a story consultant for Medisch Centrum West. “But these things really happen. If you consider the cost involved and how much personal suffering this causes then it’s vitally important to make reaching this target group a priority.”

Getting the message across

Bouman emphasises that without a doubt there are competent, committed people working at medical institutions who do their best to communicate with this target group. “But somehow the message doesn’t come across. Due to their education and background, they are accustomed to thinking and speaking in a very rational and cognitive manner. As healthcare professionals you have to be able to provide service to an entire range of people, from the highly educated to the illiterate. This requires quite a bit of insight into various communication styles and how people process information. In practice the message doesn’t get across as often as it should. This isn’t the result of unwillingness. It’s due to an overestimation of what people understand. This comes in part through people’s tendency to nod ‘yes’ even when they don’t understand. They’re too embarrassed to ask for the information to be repeated or they think ‘I won’t say anything now but I’ll figure it out when I get home’. And as a result they don’t get the information they need.”

Sense of right and wrong

Bouman’s personal motivation for focusing specifically on this target group goes back a long way. “I come from a hard-working family in the Westland region. I encountered many different types of people and this has enabled me to effectively build bridges. In the past I worked for the Netherlands Heart Foundation and our financial resources came from collection boxes. I saw that everyone contributed money to the collection boxes, regardless of their social status, age, background or income. My salary was literally paid by everyone.”

“I wanted to give something back. Then I read in epidemiological research that cardiovascular diseases were far more prevalent among people who were less educated. Their life expectancy was also seven years less than people who are well educated and they experienced health problems twelve years earlier than those who are highly educated. People who have never had the opportunity to educate themselves, or for whom a study was out of reach, have poorer chances of survival. That ran contrary to my sense of right and wrong. Of course it’s much more complex than that, but bringing health information in line with the target group’s daily experience and level of understanding is certainly an important part of the solution.”

Tips for Scripts

Taking in information and understanding it is one thing, but there’s an earlier step in this process: becoming aware that information is meant for you or interesting for you in the first place. Bouman: “If you’re not ill, if you’re not overweight or suffering from a hearing impairment, why would you want information on these matters? This all has to do with preventive healthcare and that operates differently for each target group. It is often said that poorly educated people are difficult to reach but that’s not true. They certainly can be reached; it’s just that our methods don’t work effectively. Television is one way they can be reached. With television you can get your message across to a huge number of people in one go. People who are functionally illiterate are not always able to take in information with complex content. But they do often become captivated by an interesting storyline or through developments affecting characters they identify with.”

Image credit: Ronald van den Heerik

At the Center for Media & Health in Gouda, where Bouman is the Scientific Director, an online platform called Tips voor Scripts (Tips for Scripts) has been developed by Bouman and her team. “If a television series is popular and successful, then it’s a great advantage if the writers raise certain social issues that are currently topical and presented realistically. As a writer you can search for information using Google, but there is so much information out there and much of the information lacks a scientific basis.” The Tips for Scripts platform gives writers valuable health tips and recommendations to inspire them and ensure they are provided with the correct information. “Naturally the writers decide for themselves how they will use the information. It has to be appropriate for the storyline and the characters have to remain credible. But within the framework of the new direction taken by the public service broadcasting system – moving away from only providing pure entertainment – a new win-win situation is being created.”

Condom jar

In this context the series Costa was a golden opportunity to put safe sex higher on the agenda. The film of the same name about youth vacationing in Salou was so popular at the time that a television series was made based on the film. The main characters are a close group of friends living together in the same house. “A lot happens in that house”, explains Bouman. “Sex was a prominent theme in the film.”

Together with Soa Aids Nederland, Bouman was a consultant for dramatic plot development related to safe sex in the series. It was treated as a natural part of everyday life and the objective was to prevent STDs and unwanted pregnancies. “This resulted in some amazing storylines. The condom jar became a running gag. Just like a candy jar, it was placed in the kitchen and everyone could use it. At one point the condom jar was empty. In a single day seven condoms had disappeared from the jar. This surprised everyone and it became part of the plot. It’s a great example of a sensitive approach and a suspenseful story line that at the same time focuses attention on something like condoms in a completely natural way.”

Cocakop and haperhoofd

Partly on behalf of her new Rotterdam-based endowed chair, Bouman wants to conduct a more in-depth exploration of the field of Entertainment Education. “It’s a challenging field with a great deal of theoretical supporting information. Fortunately we’ve now gained a great deal of experience in collaborating with the creative media sector. You also have to look at how you can research the educative effects within entertainment formats, separate from the viewing figures.”

An innovative step was made with a research project called ‘Mark My Words’, financed by ZonMw (The Netherlands Organisation for Health Research and Development). “In collaboration with the creators of the television soap Goede Tijden Slechte Tijden, we introduced what are referred to as ‘markers’ – unique new words – that are related to specific health issues. One of the characters in the series was a heroin addict and was said to have a ‘cocakop‘. This character was threatened by his dealer. When his brother intervenes he is struck in the head and suffers brain damage, which he refers to as ‘haperhoofd’.”

“We entered these two unique markers as keywords in a social monitoring tool. We subsequently searched for online exchanges between young people where these words were used. And we found them. What’s more, if you now enter cocakop and haperhoofd, you’ll get more hits from a search engine, such as a conversation on a blog between students who are planning a night out. One says: “I can’t go because I have a lot of studying to do and that’s not going well because of my ‘haperhoofd’. This is a unique effect that can be attributed to that particular Goede Tijden Slechte Tijden episode. We can say with much greater certainty whether any impact was caused by this particular storyline in the series.” Mark My Words has been nominated for the Best Practice Award during the General Online Research (GOR) Conference in Dresden to be held in early 2016.

More than just health

The new Rotterdam-based chair in Entertainment Media and Social Change is affiliated with the Erasmus Research Centre for Media, Communication and Culture within the Erasmus School of History, Culture and Communication. Martine Bouman was officially appointed on 1 July 2015. She gave her inaugural address on 22 January 2016 and her lectures will start in April of this year. Bouman’s chair will explore more than just health-related subjects. “Social tolerance, for example, is also an important subject”, says Bouman. “Especially now with the refugee issue it’s important to look at how people can live together with an open mind in closer quarters than they’re used to among different cultures.”

Martine Bouman (PhD) is Scientific Director and founder of the Center for Media & Health in Gouda and a professor occupying an endowed chair in Entertainment Media and Social Change at Erasmus University (at the Erasmus Research Centre for Media, Communication and Culture, ERMeCC). She obtained her doctorate at Wageningen University in 1999 and published her ground-breaking dissertation ‘The Turtle and the Peacock: the entertainment-education strategy on television’. Her current research focuses on media use, popular culture, storytelling, health-related communication, functional illiteracy, and socioeconomic disparities in health. She is an international award winner and an expert in the field of Entertainment Education for Social Change (EE). She has many years of experience in designing, implementing and researching healthy lifestyle projects and campaigns. She works with and has worked with creative professionals on various media projects such as Medisch Centrum West, Costa, Je Echte Leeftijd and Nederland in Beweging.