“The McSpoons”: Using puppetry's narrative impact to reduce family TV time

Abstract

Objective: To develop a theoretically based puppetry intervention, The McSpoon Family puppet show, and evaluate its narrative impact on families' intentions to reduce television (TV) time.

Methods: Development of The McSpoons was guided by the application of theory and empirical evidence using an Intervention Mapping framework. A single group post-test design (n = 19 family dyads) assessed narrative impact and feasibility.

Results: Parents (89.5%) and children (83.3%) reported intentions to reduce TV time over the next three months; and both parents (84%) and children (83%) perceived The McSpoons as a beneficial motivator for them to do so. The puppet show positively impacted knowledge, was highly rated on credibility and likability for story, props and characters, and compared favorably to other educational delivery channels.

Conclusions: The narrative impact of puppetry, enhanced with the application of educational and behavioral theory, makes it a potentially efficacious way of engaging families in health behavior change.

Keywords:

• television
• puppetry
• childhood obesity prevention
• educational entertainment
• narrative impact

Media Consumption as a Public Health Challenge

In the United States, media use among children is ubiquitous. According to studies conducted by the Kaiser Family Foundation, children 8–10 years of age had an average exposure of 7 h 21 min per day to media, including television (TV), computers and video games (Kaiser Family Foundation, 2005). In 2005, on a typical day, 90% of children between four and six years of age used screen media for an average of 2 h 28 min of total exposure per day (Rideout, Vandewater, & Wartella, 2003). The effects of media exposure have been associated with several health risk behaviors among children and adolescents (Escobar-Chaves & Anderson, 2008). Exposure to violent content, alcohol advertising and cigarette smoking in the media has been implicated as a determinant for violent and aggressive behavior (Bushman & Anderson, 2001), adolescent drinking (Collins, Ellickson, McCaffrey, & Habersoomians, 2007; Stacy, Zogg, Unger, & Dent, 2004) and increased risk of smoking initiation (Dalton et al., 2003; Pierce, Choi, Gilpin, Farkas, & Berry, 1998), respectively. Early media exposure to entertainment with violent content has been associated with poorer cognitive development and lower academic achievement (Zimmerman & Christakis, 2007). Media exposure has been also implicated in influencing children's food selection and dietary consumption and in contributing to childhood obesity due to the inactivity (Dietz, Jr. & Gortmaker, 1985; Robinson et al., 2003). Although the specific effects of the media on some health behaviors are still being investigated, concern about excessive media exposure for children has been sufficient for the American Academy of Pediatrics to recommend limiting “children's total media time (with entertainment media) to less than two hours of quality programming per day” (American Academy of Pediatrics, Committee on Public Education, 2001). The Academy has proposed that pediatricians be involved as practitioners, advocates, educators and policy makers, recognizing the importance of family- and community-level intervention. Intervention initiatives have been broadly focused, targeting the reduction of TV time, which includes television, computers and video games that encourage sedentary behavior. Interventions to reduce TV time have shown some promise to date. Results from an experimental reduction study conducted in two public elementary schools in California showed that the intervention group reduced TV viewing by four to six hours a week and had significantly smaller increases in BMI and three of four other measures of adiposity in comparison with the control group (Robinson, 1999). In project SMART, aimed at reducing screen media exposure among third- and fourth-grade children, researchers found that children significantly reduced their weekday TV viewing and weekday and Saturday video game playing post-intervention (Robinson & Borzekowski, 2006). While excessive media consumption has been identified as a culprit in compromising the health of adolescents, the converse has also been demonstrated where entertainment media has shown promise as an ally in health promotion efforts. This “positive paradox” with respect to the media–health association is exemplified by the emergence of interventions that use entertainment media to impact health behavior change.

Entertainment–Education: Using Narrative for Behavior Change

Entertainment–education (EE) (known as edutainment or infotainment) refers to the incorporation of educational messages into popular entertainment content to raise public awareness, deliver knowledge, change attitudes and stimulate behavior change (Singhal & Rogers, 1999). EE has been effectively employed in diverse media (television and radio serials and theatrical plays) and using diverse treatments (drama, comedy) to address varied health issues. While predominantly associated with adult public health awareness campaigns (Gray et al., 2000; Gray, Fitch, Labrecque, & Greenberg, 2003; Kontos & Naglie, 2006; Watts, 1998), research has also been applied to investigating the effectiveness of EE in impacting health behavior in children. Drama-based interventions have included DramAide that positively impacted knowledge and attitudes related to HIV/AIDS in high school students in KwaZulu Natal, South Africa (Harvey, Stuart, & Swan, 2000); Very Important Kids, a school-based multi-component intervention that impacted change in attitudes and behaviors regarding body weight in fourth through sixth graders (Haines, Neumark-Sztainer, & Morris, 2008); and Crossroads, a traveling drama that increased knowledge, attitudes and intended behavior about tobacco use and its effects in fifth through eighth grade students on the island of Oahu (Hawaii) (Mitschke, Loebl, Tatafu, Matsunaga, & Cassel, 2008).

Narrative impact is the degree to which stories shape our memories, knowledge and beliefs (Green & Brock, 2002). The success of EE interventions appears to reside, at least in part, in their ability to formally address educational objectives as well as to provide narrative impact through an “immersive” entertainment experience. EE dramas have used theories of learning and behavior change to attend to critical determinants of the targeted health behavior. Behavioral and communication theories provide guidance in explaining this impact through content salience (Attitude Accessibility Theory), vicarious learning through modeling (Social Cognitive Theory) and participant immersion to optimize narrative impact (Transport-Imagery) (Bandura, 1986; Fazio, Powell, & Williams, 1989; Green & Brock, 2000). Attitudes are more likely to predict behavior when they are accessible in an appropriate context (Fazio et al., 1989). Modeling theory suggests that viewing the behavior of socially similar others can provide a source of beliefs about social norms; that viewing outcomes of characters' behavior, if perceived as credible, might influence perceptions of the costs and benefits associated with the behavior (e.g. the expectancy–value equation); and that viewing socially similar models who successfully model necessary skills in realistic social situations can provide increased confidence and skills (Bandura, 1986). Very Important Kids and Crossroads were founded on social cognitive theory and theory of reasoned action, respectively. Theory assisted the developers of this EE media to effectively define the nature of a health problem, define intervention objectives, derive methods and strategies to address the problem and provide a guide for evaluation. Unique to EE applications, is the immersive experience that is unique to well-crafted drama (Green & Brock, 2000). Narrative impact is associated with viewers identifying with and liking the characters portrayed who provide a source of beliefs about social norms; narrative interest in the plot; artistic craftsmanship and style; credibility; and perceptions of the benefit of the drama (Slater, 2002).

Puppetry for Narrative Impact on Families

Puppetry is an immersive medium suited for the application of EE. This ancient theatrical art form has been in use for communication and recreation for over 30,000 years (Baird, 1973). While a puppet's nature (i.e. shapes, sizes, materials) and function (i.e. marionettes, hand puppets, rod puppets, shadow puppets) may vary dramatically across and within cultures, they are universally familiar to, and enjoyed by, children and families. Punch and Judy has been described as the first family-based puppet show (Baird, 1973). Ironically, puppet shows as an intervention medium are novel in the field of health education or at least the field of health education research. One empirical study reported on the successful use of life-size multi-cultural puppets in reducing negative stereotypes about large body shapes in fifth-grade school children (Irving, 2000). This study empirically highlighted the potential of puppet shows as a health education medium in that they offer a group-based interactive experience that is, at the same time, immersive for each participant. In this study, the puppet show rated positively on parameters of student enthusiasm, attention, engagement and receptivity and demonstrated broad appeal, reaching each strata of the children at a developmentally appropriate level of cognitive complexity. While intuitively appealing as an intervention channel for families, puppet shows have been subject to little empirical testing to determine feasibility, acceptance, or impact. Nor has there been any discussion of the application of systematic approaches to apply behavioral theory within the narrative context of puppet shows.

Research Approach and Methodology

The purpose of this paper is threefold: (1) to describe the development of a puppet show informed by behavioral theory and principles of narrative persuasion with the objective of reducing TV time among families; (2) to describe the systematic intervention development protocol used; and (3) to describe pilot test results assessing feasibility and narrative impact.

Study Design and Sample

A single group, post-test usability study was conducted among a randomly selected sub-sample of the “Fun Families” study. Participants were recruited from a large primary care clinic system providing pediatric services and from communities in the Houston, Texas, metropolitan area. The convenience sample of 19 families consisted of a parent–child dyad with one parent and one child (6–9 years of age). This study received ethics approval by the University of Texas Health Science Center at Houston Committee for the Protection for Human Subjects (HSC-SPH-05-0479).

The Intervention

The McSpoon Family is a 20-minute puppet show depicting the adventures of a dysfunctional family in their discovery of how to successfully reduce the amount of TV viewing. It is a component of a family-based intervention entitled “Fun Families” that is founded on social cognitive theory (SCT) (Bandura, 1986), and consists of a two-hour workshop and six bimonthly newsletters. The workshop component includes the puppet show and subsequent simultaneous activities for children and parents. Following the puppet show, parents learn skills to reduce their child's TV time, while children brainstorm alternatives to TV time, learn how to make a healthy snack, and create their own hand puppet as a cue to action once they return home. The workshop culminates in children and parents sharing their ideas regarding alternatives to TV time and creating a shared family action plan.

The McSpoon Family puppet show was developed from a script informed through the use of intervention mapping (IM), a stepped systematic process to incorporate theory and empirical evidence into intervention development, and by the transportation-imagery model (Bartholomew, Parcel, Kok, & Gottlieb, 2001; Green & Brock, 2002). The transportation-imagery model postulates that the propensity of immersion is affected by attributes of the recipient (e.g. imaginary skill); text/dialogue/plot (e.g. artistic craftsmanship, style and structure); and context (e.g. medium providing enough opportunity for imaginative investment and participatory responses) (Green & Brock, 2002).

The show is designed to reduce family TV time behavior by impacting selected constructs from SCT (knowledge, skills, self-efficacy, outcome expectations and social support) through methods of consciousness raising, modeling and interactive learning and audience interaction with the puppets. Table 1 outlines the performance objectives, theoretical constructs and excerpts from the script, showing how each was operationalized. The hand puppets, props and portable hand puppet stage were designed and constructed by a local puppetry company and simply manufactured from readily available and mostly recycled items. For example, the puppets were made using plastic spoons, the stage frame from PVC pipe, and the curtains and puppet costumes from fabric off-cuts (Figure 2a).

Table 1 Matrix of Behavioral Objectives, Example Behavioral Determinants, and Example Script Operationalization of The McSpoon Family Puppet Show.

Behavioral objective	Behavioral determinant	Script operationalization
Choose less than 2 hours a day of quality TV time	Knowledge	Step number one: “Less Television!” There are so many other important things to do besides watching television and playing video games. I'm thinking about getting your homework done and helping Mom and Dad with some chores around the house. Who can give me some examples of something important to do?… That would be an excellent choice. I would like to give that a try … Does anyone else have any ideas?… Those are all wonderful suggestions. Experts suggest that you select the television shows you watch carefully and never spend more than two hours a day in front of a screen. Okay everyone please tell me what is the first step?… That's right, step number one is “Less TV”.
Turn TV off when nobody is watching	Knowledge	Professor McPuppy: Step number two: “Turn TV off!” When you are not watching television, turn it off. There is no need to waste electricity and then you won't be tempted to pay attention to the television when you can be enjoying more important things. Does everybody agree that turning off the TV when you are not watching it is a good idea? Alright everyone what is step number two?… That's right step number two is “Turn TV off”.
Consume snacks and meals away from TV/TV off	Self-efficacy	Mom: Okay family, what are going to do without the TV?… I have an idea. We can start by doing something really different and sitting down at the dining room table and eating dinner.
		Pops: It was our family tradition to share our thoughts while eating. We told each other about our day and about all the important things that were going on around us and in our minds. Let's give it try. Sissy, how was your day?
Create a fun bedroom	Outcome expectations	Professor McPuppy: Step number four: No TV in the bedroom. How many of you have televisions in your bedrooms? Well I did, but not anymore. I used to fall asleep with the TV on and then I would have terrible nightmares and have a hard time waking up in the morning. Without the television I have a much more restful night. Who can tell me what step number four is? That's it, “No TV in the bedroom”.
Do other activities besides TV/video games/computer use	Social support Skills	Mom: I went to the library today and checked out some interesting books. The best one is called “How to make puppets out of trash and other stuff”.
		Pops: That's it!!!! … Perhaps we can entertain ourselves by putting on our own show … we can each search for things around the house that we could turn into puppets.
		Bro: Now that's a twist that might actually make cleaning our room's kind-a fun. What do you say Sissy?
		Sissy: If Mom and Dad do it, I'll try it.
		Mom: Well, I do have to clean up the mess in the kitchen.
		Pops: My work room is out of control. I bet there are a lot of things in there just waiting to become puppet parts. What are we waiting for?
		Mom: Okay, everyone cleans a room, finds some puppet stuff and the last one to make a character of themselves is a rotten egg!
Family activities they can do	Knowledge Skills	Mom: When I was at the library today, I saw a notice about a Fun Family workshop being sponsored by the University of Texas. It's being held tomorrow evening.
		Bro: That's sounds great.
	Outcome expectations	Sissy: Can we try it?
	Social support	Dad: Why not? Another night away from the old Telly might not be such a bad idea.

To optimize narrative impact, The McSpoon Family plot structure was developed in accordance with theatrical convention (Figure 1) (Field, 1982).

Figure 1 The Theatrical Plot Structure. Adapted from: Field (1982).

The 20-minute theatrical storyline presents a dysfunctional family, The McSpoons, who are forced to confront life without their television when it is accidently broken (plot point 1) and discover life in each other, after resolving to produce a family puppet show (plot point 2). The overweight workaholic father (“Pops”) is a perennial TV watcher with no time for the family. The mother (“Mom”) escapes her “overwhelming” house chores by surfing the web and watching soap operas. The sister (“Sissy”) and brother (“Bro”) constantly play video games, spend no time being physically active, and make low grades in school. The final member of the family is their dog (“Puppy,” the main protagonist) who is playful, yet neglected (Figure 2a). Along the way, the audience learns the five steps to reducing their TV time. In an interactive dialogue with the audience, “Professor McPuppy” reiterates the five steps to reduce TV viewing: watch less than two hours of TV; no TV in the bedroom; turn the TV off when nobody is watching; no TV with food; fun activities (Figure 2b). The script was developed by the investigators and a professional puppeteer with 18 years' experience.

Figure 2a The McSpoon Family Puppets on Stage.

Figure 2b Professor McPuppy and the Five Steps to Reduce TV Time.

The play was performed by students enrolled in the theater class at their local public high school. These students were selected because they had extensive theater experience, liked to work with children, were responsible and were willing to commit their time to the project. Students received three two-hour trainings by an expert puppeteer and completed 10 hours of practice under staff supervision before pilot testing the play. After the pilot test, the puppet show was performed at 15 workshops with a total participation of 80 families. The workshops took place at the primary care clinic locations (n = 12) and public libraries (n = 3) conveniently located to the participants. To assure participation, the workshops were scheduled on Friday evenings, Saturdays, or Sundays. Puppeteers assembled one hour before each show to erect the portable stage, prepare the props and rehearse. The students received a small stipend for their involvement, and transportation to and from the workshop location was provided.

Measurement Constructs

The McSpoon Family puppet show was assessed on constructs relevant to narrative impact and feasibility adapted from existing usability surveys (Shegog et al., 2007). The 25-item self-report survey using Likert scale and open-ended response formats was provided to parents and children immediately following exposure to the puppet show. Survey completion was voluntary and written parental consent and child assent were obtained. Project staff assisted children with written their responses if required.

Narrative Impact

Narrative impact and artistic craftsmanship and style were assessed by ratings of how participants liked the entire play as a whole, the story, the characters and the physical devices of the play (stage and props). Ratings were based on a five-point Likert scale with responses “dislike at lot,” “dislike a little,” “not sure,” “like a little,” “like a lot.” Narrative impact was assessed also using three single items addressing whether the duration of the puppet show was “too short,” “just right,” “too long”; whether participants would see the puppet show again; and whether they would recommend it to others (using response formats of “yes,” “no,” or “don't know”); and four items comparing the puppet show to favorite TV shows and movies, computer programs, other puppet shows and teacher or doctor's advice regarding reducing TV time. Response options for these four items were, “less fun,” “as much fun,” “more fun.”

Credibility

Credible behaviors and outcomes can influence perceptions of the costs and benefits associated with the behavior (e.g. the expectancy–value equation). Credibility was assessed by asking whether the information was “right” and “could be trusted” using a three-point Likert scale with responses of “yes,” “no,” or “don't know.”

Perceived Benefit

Perception of the puppet show as beneficial to changing behavior entails an implicit effect on confidence and skills from viewing socially similar models who successfully model necessary skills in realistic social situations. Perceived benefit was assessed in terms of the usefulness of the puppet show in encouraging behavior to reduce TV, computer and video games usage and was measured using a three-point scale of “yes,” “no” and “don't know.”

Behavioral Intentions

Intentions to reduce TV viewing represent a correlate of subsequent behavioral change and were assessed by one item (child) or four items (parent) using a five-point Likert scale, and one open-ended response question. Children were asked whether they intend to watch the “same,” “more,” or “less” TV in the next three months compared to the amount of TV they watched in the last three months. Parents were asked this question for their own, and their children's, behavior. They were also asked the likelihood of their child watching less TV, and the likelihood that they would assist their child in achieving this goal.

Knowledge

The five steps to reduce TV time taught by Professor McPuppy provided the seminal behavioral prescription in the puppet show. Knowledge was assessed from recall of this content using an open-ended item.

Feedback from the Audience

An open-ended response format was also used to ask participants what they liked the best and the least about the program as well as recommendations for improvement and additions to the program.

Data Analysis

All three-point scales were reduced to two-point dichotomies. An exact binomial probability was calculated based on the assumption that each response choice was equally likely; that is, responses were random. The probability reflects the expected chance that at least as many positive responses as reported would be observed, given this assumption. Variables that had five or more responses were treated as continuous variables. A neutral point was selected, such as “not sure” or “the same amount,” which would be the expected response if the show had no impact. The observed mean was tested against the neutral point by centering on the neutral point and performing a one-sample t-test (two-tailed). Differences were calculated within the parents and within the children.

Open-ended questions were reviewed for content and categorized by topic areas.

Results

Demographics

A total of 19 families (19 parent–child dyads) participated in the study. Of parent participants, 90% were female with a mean age of 40.5 years (SD ± 6.03). Parents were white non-Hispanic (n = 8), African-American (n = 8) and Hispanic/Latino (n = 3). Over half of the parents were employed full-time and had a household income of $50,000 or more (Table 2). Child participants were comprised of 10 males (52.6%) and 9 females (47.4%) with a mean age of 8.2 years (Table 2).

Table 2 Demographics Characteristics of Parents and Children Participating in The McSpoon Family Puppet Show (n=19).

Parent variables	n (%)	Child variables	n (%)
Age (Mean 40.47 ± 6.03)		Age (Mean 8.16 ± 1.12)
31–35	4 (21.1)	6	2 (10.5)
36–40	5 (26.3)	7	3 (15.8)
41–45	6 (31.6)	8	5 (26.3)
46–50+	4 (21.1)	9	8 (42.1)
Gender		10	1 (5.3)
Male	2 (10.5)	Gender
Female	17 (89.5)	Male	10 (52.6)
Race/ethnicity		Female	9 (47.4)
White – non-Hispanic	8 (42.1)	Race/ethnicity
Black/African American	8 (42.1)	White – non-Hispanic	5 (26.3)
Hispanic/Latino	3 (15.8)	Black/African American	8 (42.1)
Marital status		Hispanic/Latino	4 (21.1)
Single, never married	1 (5.3)	Other Grade  Home-school  Kindergarten  1st grade  2nd grade  3rd grade  4th grade	2 (10.5) 1 (5.3) 2 (10.5) 3 (15.8) 5 (26.3) 7 (36.8) 1 (5.3)
Living with significant other, but not married	1 (5.3)
Married	15 (78.9)
Divorced	2 (10.5)
Household income
Less than $15,000	1 (5.3)
Between $15,000 and $50,000	7 (36.8)
Between $50,000 and $100,000	6 (31.5)
$100,000 or more	4 (21.1)
Don't know	1 (5.3)
Education
High school or less	3 (15.8)
Some college	6 (31.6)
College graduate	7 (36.8)
Post-graduate training	3 (15.8)
Employment status
Employed full-time	11 (57.9)
Employed part-time	5 (26.3)
Homemaker	3 (15.8)

Narrative Impact

Ratings of narrative impact in the puppet show were high (Table 3). Parents (88.9%) and children (100%) liked the show as a whole, and almost all participants enjoyed the story (both 94.5%), the physical devices of the stage (parents 88.9%; children 94.5%), and the props (parents 88.9% and children 100%). Participants rated the puppet characters as highly likable (both parents and children 100%). Individual characters were rated highly (parents 88.9–100%, children 83.4–100%) and the character of Puppy was universally appealing. Children rated the puppet show as understandable (83.3%) and most (88.9%) did not think they required assistance from parents to understand it. All outcomes were significant at p < 0.01.

Table 3 Ratings of Narrative Impact Factors for The McSpoon Family Puppet Show.

	Parents (N = 18)^a					Children (N = 18)^a
	Dislike a lot	Dislike a little	Not sure	Like a little	Like a lot	Dislike a lot	Dislike a little	Not sure	Like a little	Like a lot
	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)
The entire puppet show*	–	2 (11.1)	–	–	16 (88.9)	–	–	–	2 (11.1)	16 (88.9)
The story*	–	–	1 (5.6)	1 (5.6)	16 (88.9)	–	–	1 (5.6)	1 (5.6)	16 (88.9)
The stage*	–	–	2 (11.1)	4 (22.2)	12 (66.7)	–	–	1 (5.6)	3 (16.7)	14 (77.8)
The props (e.g. TV set, stage for the McSpoons' own puppet show, special effects, signs)*	–	–	2 (11.1)	3 (16.7)	13 (72.2)	–	–	–	4 (22.2)	14 (77.8)
The puppets used in the show*	–	–	–	1 (5.6)	17 (94.4)	–	–	–	5 (27.8)	13 (72.2)
Puppy*	–	–	1 (5.6)	–	17 (94.4)	–	–	–	–	18 (100.0)
Mom*	–	–	2 (11.1)	3 (16.7)	13 (72.2)	–	2 (11.1)	–	7 (38.9)	9 (50.0)
Pops*	–	–	2 (11.1)	5 (27.8)	11 (61.1)	–	2 (11.1)	–	6 (33.3)	10 (55.6)
Bro*	–	–	2 (11.1)	2 (11.1)	14 (77.8)	–	–	–	5 (27.8)	13 (72.2)
Sis*	–	–	2 (11.1)	4 (22.2)	12 (66.7)	3 (16.7)	–	–	3 (16.7)	12 (66.7)
Little puppets* (i.e. the puppets that the McSpoons' made for their puppet show)	–	–	6 (33.3)	1 (5.6)	11 (61.1)	–	–	1 (5.6)	–	17 (94.4)
^a1 parent, 1 child did not answer these questions *p-value < 0.01 differences within parents and within children.

Participants indicated the show was of appropriate length or too short (parents 94.7%, children 94.4%) (Tables 4 and 5). Both parents and children indicated that they would see the show again (parents 84.2%; children 77.8%) and tell a friend about it (parents 88.9%, children 89.5%). They also rated the puppet show highly on comparative items, indicating it was as much or more fun than favorite TV show and movie (parents 79%, children 88.9%; p < 0.05), video and computer games (parents 63.1% non-significant, children 66.7% non-significant), other puppet shows (both 84.2%) and teachers or doctors instructions (both 84.2%). All outcomes were significant at p < 0.01 unless otherwise stated.

Table 4 Parent's Ratings and Intentions to Reduce their Child's TV Time after Viewing The McSpoon Family Puppet Show (N=19).^b

				n (%)	n (%)	n (%)
Duration				Too short	Just right	Too long
I think that the puppet show was:*				–	18 (94.7)	1 (5.3)
Motivation				Yes	No	Don't know
Would you like to see the puppet show again?*				16 (84.2)	3 (15.8)	–
Would you tell your friends about the puppet show?*				17 (89.5)	2 (10.5)	–
How does this puppet show compare to:				Less fun	As much fun	More fun
Your child's favorite TV program or movie?				4 (21.1)	12 (63.2)	3 (15.8)
Your child's favorite video or computer game?				7 (36.8)	7 (36.8)	5 (26.3)
Other puppet shows you've had seen?				–	13 (68.4)	3 (15.8)
Having a teacher or doctor telling your child about watching less TV, playing less video or computer games?*				–	1 (5.3)	18 (94.7)
^bAll numbers indicate n(%) *p-value < 0.0001 differences with in parents.
Credibility				Yes	No	Don't know
I think the information I got from the puppet show was right.*				19 (100.0)	–	–
I think the information I got from the puppet show can be trusted.*				19 (100.0)	–	–
Usefulness
I think the information I got from the puppet show will help me cut down TV, video games, & computer use.*				16 (84.2)	3 (15.8)	–
I think the information I got from the puppet show will help my child cut down TV, video games and computer use.*				14 (73.7)	1 (5.3)	4 (21.1)
^bAll numbers indicate n (%) * p-value < 0.01 differences within parents.
Intentions	No TV	Much less TV	A little less TV	Same amount of TV	Little more TV	Much more TV
Compared to the amount of TV YOU watched in the last 3 months, will YOU watch the same, more, or less TV in the next 3 months?*	–	7 (36.8)	7 (36.8)	4 (21.1)	1 (5.3)	–
Compared to the amount of TV your CHILD watched in the last 3 months, will your CHILD watch the same, more, or less TV in the next 3 months?*	–	8 (42.1)	9 (47.4)	2 (10.5)	–	–
		Very unlikely	Unlikely	Neutral	Likely	Very likely
How likely is that your child will watch less TV in the next 3 months? *		–	–	1 (5.3)	6 (31.6)	12 (63.2)
How likely is that you will help your child to watch less TV in the next 3 months?*		–	–	1 (5.3)	4 (21.1)	14 (73.7)
^bAll numbers indicate n (%). *p-value < 0.01 differences within parents.

Table 5 Children's Ratings and Intentions to Reduce TV Time after Viewing The McSpoon Family Puppet Show (N=18).

				n (%)	n (%)	n (%)
Duration				Too short	Just right	Too long
I think that the puppet show was: *				4 (22.2)	13 (72.2)	1 (5.6)
Motivation				Yes	No	Don't know
Would you like to see the puppet show again?*				14 (77.8)	1 (5.6)	3 (16.7)
Would you tell your friends about the puppet show?*				16 (88.9)	2 (11.1)	–
How does this puppet show compare to:				Less fun	As much fun	More fun
Your favorite TV program or movie?**				2 (11.1)	8 (44.4)	8 (44.4)
Your favorite video or computer game?				6 (33.3)	1 (5.6)	11 (61.1)
Other puppet shows you've had seen?**				–	2 (11.1)	13 (72.2)
Having a teacher or doctor tell you about watching less TV, playing less video or computer games?*				1 (5.6)	–	16 (88.9)
Credibility				Yes	No	Don't know
I think the information I got from the puppet show was right*				17 (94.4)	–	1 (5.6)
I think the information I got from the puppet show can be trusted*				17 (94.4)	–	1 (5.6)
*p-value < 0.0001; **p-value < 0.05 differences within children.
Usefulness				Yes	No	Don't know
I think the information I got from the puppet show will help me cut down TV, video games and computer use.*				15 (83.3)	1 (5.6)	2 (11.1)
Understandability
Did you know or understand most of the words in the puppet show?*				15 (83.3)	2 (11.1)	1 (5.6)
Did you need any help from an adult to understand the puppet show?*				2 (11.1)	16 (88.9)	–
*p-value < 0.0001 differences within children.
Intentions	No TV	Much less TV	Little less TV	Same amount of TV	Little more TV	Much more TV
	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)
Compared to the amount of TV YOU watched in the last 3 months, will YOU watch the same, more, or less TV in the next 3 months?*	–	6 (33.3)	9 (50.0)	3 (16.7)	–	–
*p-value < 0.0001 differences within children.

Credibility

Parents (100%, p < 0.01) and children (94%, p < 0.01) perceived the content of the information delivered by the puppet show as correct and credible (Tables 4 and 5).

Perceived Benefit

Parents (84.4%, p < 0.01) and children (83.3%) perceived the puppet show as beneficial to reducing their own TV time behavior. Parents (73.7%, p < 0.01) also indicated it would be beneficial in motivating their child's intentions to reduce their TV time (Tables 4 and 5).

Behavioral Intentions

Parents and children reported high willingness to reduce their TV viewing over the next three months (89.5% and 83.3%, respectively). Parents also were motivated to reduce their own TV watching (73.6%). When asked about the likelihood of their child reducing his/her TV time in the next three months, 32% of parents said it was likely and 63% said it was very likely. In addition, 94.8% of parents said they were very likely to help their child watch less TV in the next three months (Tables 4 and 5). All outcomes were significant at p < 0.01.

Knowledge

At post-test, parents and children exhibited moderate retention of the five steps to reduce media consumption. Responses for both parents and children were positively skewed with 68.4% of parents and 72% of children recalling at least three or more steps (ranges were 0–5; means were 3.11 and 3.28, respectively).

Feedback from the Audience

Narrative Impact

The audiences were highly engaged with the puppet show, applauding loudly. Both parents and children commented on the “cute characters,” especially the Puppy, who was their favorite character. As one child stated, “the dog was the best; he was a cool dog; I liked his bark and how he sounded.” Both parents and children also commented on the interactive nature of the show – one child's favorite part was when “Puppy came and sat next to me.” Children responses included: “it was really good and awesome,” “it was funny,” “lot more fun than other things I would have been doing: cool to watch; puppets really creative.” Some parents even commented that “I wish it was longer.”

Artistic Craftsmanship and Style

Some parents were distracted by the structure of the stage, commenting that “The structure underneath was not that stable. Sometimes it was distracting,” and “the stage, performers sticking out, kind of distracting.”

Perceived Benefits

Both parents and children commented favorably on the mix of entertainment and educational aspects. Parents tended to focus more on the educational benefits of the show, while children focused more on the entertainment value. Parent responses included: “it really helped my child realize the importance of not watching so much TV,” “I would tell them [my friends] how my kids enjoyed it and what a learning, eye-opening experience it is,” “Excellent! Helped kids to focus in on other things to do besides TV,” “it was fun; an ingenious way of delivering the message; good message for kids and adults” Parents commented that the show was “fun and informative,” “very entertaining and useful”; they “liked the humor and the positive message,” and felt that “it was a more fun way to talk to them [children] about it [reducing media time].”

Knowledge and Behavioral Intentions

Both parent and child responses indicated that the show influenced their knowledge about the need to reduce media time. One parent commented, “it really helped my child realize the importance of not watching so much TV,” while child comments included, “They [‘The McSpoon Family’] realized how much TV they were watching and that they needed to watch less.” And “I liked when they made their own puppet show and [talked about] all the things you shouldn't do.” Both parents and children commented that they intended to “to spend more time with your family”; and “watch less TV.”

Discussion

Historically, puppetry has provided a channel to engage children and adults in dramatic stories, transfer information and provide vicarious experience. Like other theatrical strategies, it has been adopted to “edutain” families and community groups but has tended to evade the “stage light” of empirical evaluation. The findings of this study support this “old world” medium as a feasible strategy to engage families and potentially impact “modern day” health behavior. Theory-based methods can be applied to the puppet show genre. The systematic approach used in this study was informed through consideration of behavioral theory, narrative impact and theatrical conventions. The McSpoons provided an appealing entertainment–educational experience that positively impacted behavioral intentions to reduce TV time and to recall strategies to do so. The show rated highly on dimensions of narrative impact, credibility and perceived benefit from parents and children who were receptive to the show and enthusiastically participated with the puppets and puppeteers.

Despite its obviously contrived delivery, The McSpoon Family puppet show was perceived as credible and beneficial by parents and children. The issues displayed through narrative persuasion in the social context of family negotiation (such as those exhibited in the light family “drama” of The McSpoons) are more salient to making real-world change than through rhetoric persuasion (such as a lecture on the value of reducing TV time), thus providing for increased translation to real world application.

Using a narrative approach allows the complexity of the social world, and the range of beliefs and values of audience members, to be plausibly addressed. Some characters can model new values and norms and others can model skills while addressing the needs of a broader range of audience members. Greater immersion or absorption can occur in the context of narrative persuasion than traditional rhetoric persuasion. Within the narrative, the participant can leave their physical, social and psychological reality, at least momentarily, in favor of the world of the narrative and its inhabitants (Green & Brock, 2002; Green, Brock & Kaufman, 2004). In the current study, the narrative messaging presented by The McSpoon Family puppet show was rated more highly than the rhetoric message of the teacher or physician. This may be an expected result. Less expected were the favorable comparisons with TV, movies and computer games, which represent entertainment, rather than edutainment media. The high ratings of The McSpoon Family puppet show as a whole, and on elements of plot and artistic craftsmanship, as well as the enthusiastic and interactive engagement of participants during the performance, lend support to the immersive qualities of the production.

Psychological transportation is further enhanced when the participant adopts the character's goals, thoughts, emotions, behaviors and vicarious experiences resulting in greater liking of (or sympathy with) and greater identification (similarity to) with protagonists (Slater, 2002). A tribute to The McSpoon Family puppet show was that, although the characters were simply constructed puppets made from spoons, all were rated favorably by participants, including a 100% rating by all for the chief protagonist, puppy. This escape from self into an environment of alternate personalities, realities and actions of characters not only provides a high degree of enjoyment (Green & Brock, 2000), but also plays an important role in narrative-based belief change because a protagonist may serve as an internal source of information or beliefs. The relation between character likability and behavioral intentions was observed in this study and this reinforces the value of “assessing identification with key characters and their perceived importance to the story as part of the formative research efforts” (Slater, 2002).

The extent to which a viewer identifies with characters and narrative interest of the plot has also been termed ‘involvement’ (Slater, 2002). Slater indicates that involvement is expected to impact viewer beliefs, attitudes, or behavior only to the extent that the portrayals and events bearing on those beliefs and behaviors are seamlessly integrated into plot and characterization (2002). If this is achieved then “it is likely that entertainment narratives, with their suspenseful story lines and viewer's identification with characters, will result in in-depth and quite personal discussion” (Rouner, 1984; Rubin & Perse, 1987). This is particularly relevant when using the puppetry as a prelude to group discussion among parents and children.

This study highlighted comparative advantages of puppetry as an edutainment channel. Puppet shows are not as constrained as linear media. They provide for a large degree of free-flowing audience participation and interaction in the puppetry/pantomime experience. The lively and upbeat script performed by high school students created an environment of open communication for children and parents. This shared involvement of family members offers an advantage over more recent technological applications that have not addressed shared involvement sufficiently well. An added benefit of The McSpoon Family puppet show is that family members can create their own puppets after the show, adding a tactile element to the learning experience. The often unstructured and impromptu elements of a puppetry performance mean that it can vary in pacing, more so than video or film, offsetting potential criticism that puppetry (like film) might constrain imaginative investment due to being typically concrete, complete and fast-flowing (Gerrig & Prentice, 1996). Despite this, puppetry is not as self-paced as text-based channels or interactive media.

The results presented here are preliminary and need to be interpreted within the constraints of study limitations. The single group, post-test design is open to internal validity threats so results obtained, while indicative, cannot be attributed conclusively to the puppet show. The limited sample size of relatively high socio-economic status parent–child family dyads limits the generalizability of the results to other populations. Although systematic protocols were followed in the development of the puppet show, it is not clear whether The McSpoons could be considered completely representative of the puppet show genre. This mono-operational bias is difficult to overcome as puppet shows vary dramatically in props, style and professionalism of the puppeteer. The modest “bare-bones” delivery platform of The McSpoon Family puppet show made it a “low-end” example of the medium. The high level of participant engagement and results are suggestive of a high level of immersion and that higher-end productions might do even better. The active ingredient appears to be the seamless integration of education and entertainment elements in a contextually relevant framework. This emphasizes the importance of providing plot and characterization that serves the educational, behavioral and entertainment objectives.

This study provides an initial focus on puppetry through the lens of narrative impact. Variables were assessed that relate to narrative impact in scales that were adapted from existing, previously validated usability instruments (Shegog et al., 2007). Major dimensions in measuring immersion from transportation theory include emotional involvement in the story, cognitive attention to the story, feelings of suspense, lack of awareness of surroundings and mental imagery. These were not assessed in the current study. Future work of this type could adopt more pertinent validated measures (Green & Brock, 2000).

Developing effective interventions that target children's and parents' behavior to reduce TV time is an important public health challenge given the high prevalence of media consumption among children and the detrimental consequences this consumption can have on their health. Puppets reach participants on affective and motivational domains (entertainment) but perhaps less on achievement domains (education). Knowledge is necessary but not sufficient to impact behavior. The moderate effect on rote learning seen in this study, however, may be secondary to the motivational and social effects of providing an immersive family experience.

Edutainment that is truly appealing to all family members has remained elusive. While results of this study are useful in establishing feasibility in engaging the audience and influencing intentions, more work is required on behavioral effects. Assessment of TV time behaviors is necessary for a more thorough understanding of the potential of the intervention. Further, assessments were conducted immediately following the intervention, offering no long-term outcomes. Such assessments should be on the agenda for future work, as should assessments of cost effectiveness. For The McSpoon Family puppet show, the start-up cost is minimal because the materials of the show are available in any department (plastic spoons for puppets), hardware (PVC pipe for stage frame) and craft store (material for stage cover and puppet costumes). This can make the show accessible and further invokes imagination from the participants, aiding in increased immersion. However, a cast of approximately five puppeteers is required to run the show successfully, which could be costly if a professional cast is considered. The potential of implementing the show with students in school contexts has advantages in this regard.

Persuasion research has mainly focused on persuasive messaging and on the impact of popular culture (i.e. TV and film) on beliefs, values and behavior. Understanding processes by which persuasive narratives influence behavior represents an emerging field of research (Slater, 2002), as does research on the relative advantages of the differing forms of theatrical channel, be it through radio, TV, or theater. Most research on transportation, for example, has been conducted only in textural contexts. This study provides a modest contribution towards this literature.

Conclusion

While puppetry has been adopted for entertainment and education in varied settings, its health-related entertainment education potential has rarely been formally assessed. Behavioral intentions to reduce TV time were influenced by the narrative impact of the puppet show providing contextual salience, vicarious modeling and participant immersion. Puppetry also provided added advantages of interaction and social engagement. By systematically attending to educational and behavioral theory and theatrical conventions the narrative impact of puppetry may make it an efficacious way of engaging families in health behavior change.

Acknowledgements

This research was supported by funding from the Centers for Disease Control and Prevention, Cooperative Agreement U48-DP000057-05.

 The authors acknowledge the help of Robert Addy and Ru-Jye Chuang with data entry and analysis.