Overcome the Fear (Vencer el Miedo): Using Entertainment Education to Impact Adolescent Sexual and Reproductive Health and Parent-Child Communication in Mexico

"...viewership of an EE telenovela of high production quality and informed by extensive formative research is related to adolescent health outcomes and parent-adolescent SRH [sexual and reproductive health] communication on a countrywide scale in Mexico."

Entertainment-education (EE), also referred to as edutainment, is a strategy that has been used to improve sexual and reproductive health (SRH) outcomes among adolescents and young adults, including knowledge, behaviours (e.g., condom use), and the testing and management of sexually transmitted infections (STIs). This study investigates the impact of an EE intervention called Overcome the Fear (Vencer el Miedo) on adolescent contraceptive practices and parent-adolescent communication about SRH topics in Mexico, where adolescents experience high pregnancy and birth rates.

The paper begins by laying out the theoretical background for EE telenovelas, covering Michael Sabido's methodology and its grounding in two key theoretical frameworks: social cognitive theory and the extended elaboration likelihood model. Using this theoretical framework, Population Media Center (PMC) and Grupo Televisa, a television network in Mexico, co-produced OTF, a 47-episode telenovela that incorporates transitional characters in tailored storylines. These characters were designed to model behaviours for parents and adolescents to address unplanned pregnancies among youth in Mexico. (For example, in one plotline, a teenaged Areli goes to a clinic to get information about contraceptives after a misunderstanding with her father, who ultimately realises his mistake in punishing her for seeking answers to her questions about sex online.) Promoted across multiple media channels (e.g., social media accounts) before and during broadcast, OTF aired for 1 hour on weeknights January 20 through March 22 2020 to a national audience.

The development of OTF began with secondary research in 2015 that included, among other components, a literature review indicating that parents can play an integral role in SRH education and related risk behaviours among their adolescent children in Mexico. For instance, adolescents who rate their communication with parents as good are more likely to report fewer sexual partners, and parent-adolescent discussions about sexual behaviours are more likely to lead to condom use at first sex. The secondary research was followed by qualitative research that included a series of key informant interviews and focus groups that participated, for instance, in WhatsApp and Facebook exercises. A technical advisory group was also established to check the accuracy of health information in the scripts. A key partnership was formed with MexFam, a Mexican non-governmental organisation that delivers SRH services and operates the OrientaSex call centre; at the conclusion of each OTF episode, a 20-second epilogue was delivered by cast members with a message about SRH followed by the OrientaSex hotline telephone number.

OTF reached 3.5 million viewers nightly, and it garnered over 20 million video views and reached over 40 million individuals on social media. In addition, 2,868 callers every week to OrientaSex reported finding the hotline because of OTF.

To assess OTF's impact, the researchers conducted cross-sectional survey interviews (street-intercept and telephone) with 12- to 19-year-olds (n = 1,640) and parents of adolescent children (n = 820) post-broadcast across Mexico's five most-populated metropolitan zones. Quotas were implemented for gender, zone, and OTF viewership (viewer vs. non-viewer).

Nearly half of adolescents (47.9%) and parents (47.7%) were viewers. Selected findings:

• Among parents, bivariate analyses suggest that non-viewers had more positive attitudes towards abstinence (p = .045) and more negative attitudes towards contraception and communication with adolescents about sex (p = .001). Multivariable logistic regression models show that viewers had significantly higher odds for talking with their adolescent child about sexual relations (odds ratio (OR) = 1.69; 95% confidence interval (CI) = 1.26, 2.25; p < .001), contraceptive methods (OR = 1.46; 95% CI = 1.10, 1.95; p = .01), condoms (OR = 1.57; 95% CI = 1.17, 2.09; p = .002), and abstinence (OR = 1.57; 95% CI = 1.18, 2.10; p = .002) in the last 3 months compared to non-viewers. Put another way, 62.4% of viewers talked to their adolescent children about sex, compared with 43.9% of non-viewers. However, the odds of viewers talking to their adolescent child about unhealthy romantic relationships were not significantly higher than that of non-viewers.
• Among adolescents, bivariate analyses suggest that viewers had less-negative attitudes towards contraception (p < .001). Logistic regression models suggest that adolescent viewers had significantly higher odds for seeking information about contraception (OR = 1.67; 95% CI = 1.32, 2.14; p < .001) and about unhealthy relationships (OR = 1.56; 95% CI = 1.09, 2.17; p = .019), using a contraceptive method other than condoms (OR = 1.75; 95% CI = 1.07, 2.87; p = .027), and using dual contraception (OR = 1.77; 95% CI = 1.02, 3.05; p = .042) in the last 3 months compared to non-viewers. However, the odds of viewers using a condom at last sex were not significantly higher than that of non-viewers (which may be due to a ceiling effect, as condom use was already fairly high among the sample). Co-viewing OTF with a parent was significantly related to contraceptive practices in the last 3 months, with differences present by parent and adolescent gender.

In conclusion: "This study suggests that viewership of a high-quality entertainment-education telenovela informed by extensive formative research is related to adolescent health outcomes and to parent-adolescent SRH communication on a country-wide scale in Mexico. Entertainment-education remains an underutilized public health strategy, despite its promise to engage viewers and motivate healthful behaviors."