A critical qualitative content analysis of media representations of underrepresented groups in the context of health identity

Cultivation Theory

According to cultivation theory (Gerbner & Gross, 1976, we are more likely to perceive the information as the way it is represented in the media. This theory states that television functions as a homogenizing agent, cultivating a common culture known as mainstreaming (Morgan et al., 2014. We can view the world in a shared way through television, and heavy viewers tend to have faith in a reality as predicted in the medium despite the considerations of accuracy (Mosharafa, 2015. Therefore, how media portrays characters within what context is significant for the understanding of what message is delivered to the viewers.

A number of medical dramas, such as, ER, Chicago Hope, Grey’s Anatomy, Code Black and others have been very popular among overall viewers, and the popularity of medical television dramas is expected to remain stable for the anticipated future (Hoffman et al., 2017. Given heavy viewers may perceive and believe as reality what they find on television (Gerbner & Gross, 1976, research has been done to understand the accuracy of medical information, why viewers tend to watch medical dramas, how viewers perceive information and how they act in reality based on their perceptions and expectations (Burzyńska et al., 2015; Cambra-Badii et al., 2021; Hetsroni, 2009; Hoffman et al., 2017; Ismail & Salama, 2023 Sisson & Kimport, 2014). For instance, viewers get inspired to make organ donation through watching television dramas (Baumgardner, 2021; Khalil & Rintamaki, 2014; Morgan et al., 2009. Heavy viewers expect the same attitude and communication behaviors from their physicians based on how medical television dramas represent (Berger, 2010; Fadenrecht, 2015; Gerbner et al., 2002; Jain & Slater, 2013; Painter et al., 2020 Street, 2003; Tian & Yoo, 2020 Quick, 2009. Viewers tend to use health information in real-life even though their primary motive for watching medical television dramas was not to collect medical information (Lee & Taylor, 2014. Past studies emphasized on educational aspects of medical information through media representation, such as learning about emergency contraception, human papilloma virus (HPV), breast cancer, reproductive health, among others (Bodoh-Creed, 2017; Brodie et al., 2001; Hether et al., 2008; Kinsler et al., 2019). Medical television dramas can be used as a dynamic resource for featuring health literacy with entertainment (Brusse et al., 2015; Kato et al., 2017).

Health literacy refers to “the capacity to obtain, process, understand, and communicate about health-related information needed to make informed health decisions” (Berkman et al., 2010, p. 16). Given the significance of health literacy improvement through entertainment contents, past studies have reported that viewers demonstrate a higher level of knowledge and awareness about health topics (e.g., breast cancer screening, human papilloma virus (HPV), the lethal effects of binge drinking, etc.) compared to nonviewers (Bavin, & Owens, 2016 Brodie et al., 2001; Hether et al., 2008 Kato et al., 2017; Murphy et al., 2011. Research can provide rich insights into how certain health messages are conveyed through television dramas. For instance, an episode of Grey’s Anatomy created by the association between researchers and writers, featured information about the likelihood of delivering healthy babies by HIV-positive mothers (Rideout, 2008). After airing this episode, the study later reported an increased percentage of viewers’ awareness (from 15% to 61%) about this condition (Rideout, 2008). From viewing to seeking medical information through medical television dramas, viewers also get involved in real-life discussions about various health topics with their friends and family members (Brodie et al., 2001, which encompasses medical terminology knowledge, perceptions about healthcare professionals, as well as key concepts of health issues (Brusse et al., 2015; McClaran & Rhodes, 2021; Painter et al., 2020). Past research thus has highlighted the importance of media representation of medical information versus viewers’ perceptions and reactions to that information in their lives.

With growing technology, people tend to believe and expect things based on what the media represent. While the media portrayal of facts is a primary factor of consideration, how characters are framed in a context is also a significant aspect to consider when analyzing how viewers perceive them. Studies have explored how individuals from both dominant and underrepresented groups are depicted as characters within particular contexts. For instance, Latinos have been portrayed at the lowest in social attraction as characters, identified as less attractive and less appropriately dressed as well as involved in negative roles in terms of the nature of characterizations compared to their white counterparts (Gonzalez,2018; Haynes, 2018; Harwood & Anderson, 2002; Mastro & Behm-Morawitz, 2005 Stamps, 2019). Lauzen et al. (2008) examined gender stereotypes in media representation and indicated how male characters are demonstrated as in work-related roles, whereas female characters are demonstrated as in interpersonal roles such as being engaged in romance, friendships, and family. This study additionally pointed out that an increased number of female writers/creators in prime-time television programs tend to assign interpersonal roles for both male and female characters, while programs with exclusively male writers/creators tend to assign work-related roles for both male and female characters (Lauzen et al., 2008. Like Sowa (2021) has highlighted the perpetuation of Latina stereotypes, shedding light on casting breakdowns as a crucial factor in promoting and sustaining stereotypical portrayals and discriminatory casting practices in television like the way roles crafted for Latinas often uphold outdated racial and gender stereotypes. Hence, these types of television programs may intensify the stereotyped gendered social roles among viewers as well as reinforce the male-dominant culture in television (media) careers (Smith et al., 2012 Sink & Mastro, 2017 Ward & Grower, 2020). Lauzen (2006a) explained this by noting a large percentage gap between male and female individuals in ‘powerful behind-the-scenes roles’ employment on prime-time television programming. How television portrays characters in the context of gendered stereotypes or sexism in work-life does impact viewers’ perceptions and assessments about individuals’ social identities and lives.

Emphasizing the importance of media representation of underserved groups in relation to viewers’ perceptions or assessments, Garretson (2015) documented the change in television portrayals from 1970 to 2000 and the finding pointed out negative attitudes among frequent television viewers when they find low recurring portrayals of underserved groups. This study also indicated the likelihood of increased levels of social tolerance among viewers when they find recurring portrayals of such groups on television (e.g., women and minorities), however, this might vary depending on the substance and quality of such portrayals (Garretson, 2015. Understanding the connection between homonegativity and exposure of gay-male characters featured television programs, Sink and Mastro (2018) reported decreased homonegative attitudes among viewers towards gay men in society. Existing literature highlights how the framing of characters can convey multifaceted messages to viewers, influencing how they perceive those individuals in reality as well as what ways they connect them to their lives. There is a study gap of media representation of underrepresented groups within the health context. Examining how individuals from underrepresented groups are portrayed within the context of health can shed light on their social positioning of health identities because media portrayals have a significant impact on viewers from diverse perspectives.

RQ: How are underrepresented groups portrayed in a fictional medical television drama in the context of health identity?

Condescension and Cultural Appropriation

In this ‘New Amsterdam’ television drama, most of the Latinos are portrayed working as janitors. Even more concerning is how this drama has depicted a condescending positioning of Latino janitors when Dr. Goodwin (white male) engaged in conversations with them in Spanish. In scenarios where Latino janitors were blithely discussing in Spanish among themselves in Dr. Goodwin’s presence, he (Dr. Goodwin) pretended not to understand them. He (Dr. Goodwin) then suddenly surprised the Latino janitors by speaking in Spanish while giving them bonus money and expressed his approval of their conversations with a playful remark like ‘And, I take those odds.’ In other instances, Dr. Goodwin was speaking in Spanish with janitorial staffs about inspirational montages to indicate how every individual matters. This was a contrast to his earlier attempt at feigning ignorance, and the negative portrayal of Latino janitors was evident. Representation of multiple languages in television dramas does not fulfill the purpose when it takes a condescending form because this resembles more like cultural appropriation than appreciation. The ethical foundation of cultural appropriation can be found in power imbalance. Although it is possible to interpret a specific instance of cultural appropriation as a form of offense or exploitation, the main reason for its wrongfulness is the contribution of this phenomenon to the marginalization and inequalities in society (Matthes, 2019. When the growing viewership and popularity of Spanish-language television networks is recognized, makes it particularly meaningful (Arellano, 2017; Barnes & Jordan, 2005; Castañeda, 2020. Therefore, the purpose cannot be meaningful if portrayals are patronizing. Not only Latinos are positioned in low-ranking career, but also the context of Spanish-language is demonstrated in a defaming way in this drama. This aligns with past research, which reported a notable underrepresentation of Latino characters on television in the positioning of holding high-status jobs, rather they were often portrayed as domestic workers compared to any other racial or ethnic groups (Children Now, 2004 Ramos & Gonzalez-De-Garay, 2021; Sowa, 2021.

Stereotyping and Negativity

Various critical and paradoxical circumstances are exhibited predominantly among people of color in this drama. For instance, the doctors quickly diagnosed a sick kid having Ebola without proper diagnosis because he was Liberian. Later, a crime division official came and asked the doctors to leave the case to them given they suspected the kid having an involvement with the Islamic State of Iraq and Syria (ISIS). Subsequently, it turned out that the kid was not infected with Ebola, rather he was just infected with a different virus that is curable. The incident in that scene was further exacerbated by the fact that the virus was injected by a terrorist identified as a black man. These types of portrayals can generate the ‘Mainstream’ effect of cultivation theory, which implies a convergence of viewers’ perceptions of reality with what is portrayed on television.

Another aspect demonstrated in this drama was about patients from prison, with a noteworthy emphasis on the fact that all patients were from underrepresented groups. For instance, a pregnant female patient of color was brought to the hospital from prison who was accused of robbing. She was afraid and refused to give birth as she did not want her baby to suffer the way she did in the foster care system even though she was going to die. So, she requested the doctors to postpone the delivery for a few more days as she will be released soon. Later, Dr. Goodwin found a way to keep the baby with her by taking help from a powerful individual of authority (white female). Similarly, another black male patient who was brought to a hospital from prison exhibited signs of drug use, but he denied using illicit substances when asked by the doctor. Later, the doctor learned that he had been the victim of police brutality committed by a white female officer. However, the patient did not report the incident due to how he believes nobody cares for victims like him. The doctors reported the incident to the authorities but were met with doubt and disbelief. Being victims of racial discrimination is not a new phenomenon in our society. The portrayals of racial issues by the media are often contradictory and negative. For example, Petermon and Spencer (2019) noted how ‘a gender-and sexuality-neutral backstory’ can be created for ‘Black Lives Matter’ in popular television dramas, even when it has predominantly white audiences. This type of representation can obscure the innate and authentic values and intentions of such movements.

There was an incident portrayed where two boys of color were admitted to the hospital after being mistakenly shot by the police, and unfortunately, one of them did not survive. The victim's brother was desperate to find out his condition and the strict protocol made matters incredibly messy that the brother accidentally beats the doctor (Dr. Goodwin). Then the protocol responded to the incident by forcefully restraining and silencing the brother. This incident as a result has portrayed the brother rather as a very annoyed individual than just a very sad brother. Individuals from underserved groups are often demonstrated as aggressive or contradictory characters, which negatively impacts viewers’ perceptions about such groups in reality (Bussell & Crandall, 2002 Cosby, 1994; Dates, 1980; Punyanunt-Carter, 2008). Like there was a situation where a female patient of color needed heart surgery and her family wanted a perform a religious ritual named ‘Protection Ritual’ before the surgery. However, the doctors refused to let the family perform the ritual and tried to proceed with the surgery. The scenario showed that the patient would die even though the doctors repeatedly tried to carry out the surgery. After the religious ritual was performed, the doctors successfully conducted the procedure. This portrayal of religious belief demonstrates stereotyped and wrong information. CIID (Centre For Interreligious and Intercultural Dialogue) made a powerful assertion in this instance:

When we open a newspaper or turn on the television, we are unlikely to hear any reference to religion unless it is in reference to a crisis, a scandal, or a misguided fanatic promoting conflict or violence in the name of religion (February 6, 2015, n. d.).

Religious communities tend to encounter issues with representation in the media. Mass media entertainment utilizes stereotyping as a basis and a shortcut to character development (Wilson & Gutierrez, 1995).

This drama has also highlighted a complicated romantic relationship between doctors of color and doctors from the dominant ethnic groups. For instance, a white female doctor and a black male doctor started dating, but he eventually rejected her because she wasn't black. Then, he started dating a black woman. This is incredibly flawed, relying on stereotyped media representations of individuals from those groups. However, research pointed out “racial stereotypes are still present because they are entrenched within the cultural fabric of the United States” (Tyree, 2011, p. 395). Television, in this case, is considered as the key in the perpetuation of negative stereotypes when it comes to African Americans, influencing the majority of societal assessments of them (Martin, 2008. This leads to the second process ‘Resonance’ of cultivation theory, which suggests that “viewers are more likely to believe and become invested in a television show that relates to their own life” (Colston, 2013. What if the depiction is totally opposite of the reality? In another context, patients were criticizing a black female doctor’s credentials given the representation of her as a self-centric and commercial individual. People of color are demonstrated mostly in a negative situation or a position of criticism that can have negative impacts on viewers’ perceptions about them in reality.

In contrast to the representation of underrepresented groups, this drama did not really put the individuals from the majority group in a context of criticism, negativity, or stereotyping rather the context was always about power. For instance, Dr. Goodwin (white man) was portrayed as a full of authority, always having a solution to every single problem that occurred in that hospital, and a very dedicated doctor to all patients regardless of any differences. Another patient, a white woman, was depicted as a very powerful individual. She wanted to get admitted to the hospital by exerting power, even though she did not have any severe health issues. So, her assigned male doctor who is Indian, did not want to admit her just for dizziness. He further questioned to figure out about what types of dizziness she was feeling. In responding the patient mimicked, ‘Dizz...y..! Are you even a real doctor?’. In terms of examining the relationship between media exposure and subsequent perceptions about the characteristics of different groups, research supports the statement that “television viewing has a measurable influence on consumers’ cognitions” (Mastro & Ortiz, 2008, p. 113). This demands a consistent necessity to examine how individuals from different groups are portrayed as characters. Individuals from dominant groups are predominantly demonstrated as characters in superior level contexts, whereas individuals from underserved groups are depicted as characters in low level contexts (Henderson & Baldasty, 2003. Hence, it specifies the presence of power and privileges among particular groups even in media portrayals (Coover, 2001).

Television rather functions more as a force for stability and uniformity than as a force for change (Gerbner & Gross, 1976. This can draw people closer to a ‘Mainstream’ reality as portrayed in the medium regardless of accurate information. For example, over 80% of Americans watch TV on a given day and over half of all time they prefer watching TV as the leisure activity (Krantz-Kent, 2018). Civilian noninstitutional population composed of individuals aged 15 and above in the United States spent about 2 hours and 46 minutes a day watching TV for the period 2013 to 2017, which is more than half of the average daily time spent engaging in leisure activities (Krantz-Kent, 2018). The way we perceive ourselves, society, and the world can be influenced by how we spend our time, how we consume images, and how we assume certain roles. As Novak (1986) pointed out, the practice of writing substantially alters one's perception and thinking, jogging for twenty minutes daily can alter one's mental image, working in an executive office can make one think more like an executive, then what can happen if we watch six hours of TV a day? What and how media represent to us are crucial to investigate to understand the impact of media exposure on viewers. Viewers tend to watch those shows where they can connect to their own life, experience, or race or look for certain characters in shows where they can connect to their own life, experience, or race (Beck, 2012 Colston, 2013; Cohen & Weimann, 2000; Eichner, 2020; Hammermeister et al., 2005; Shachar & Emerson, 2000). Therefore, underrepresented groups can encounter diverse consequences in their real lives when media portrays them through the lens of condescension, cultural appropriation, stereotyping, and negativity, as illustrated in this drama. Accurate and appropriate media representation is in demand regardless of any differences of individuals.

Implication and Limitation

This study indicates how media portrayal can affect people's beliefs and perceptions, especially when it comes to shaping health identity. Media practitioners, organizations, and individuals in the healthcare, media, education, and related sectors should take the necessary steps to recognize and address the impacts of media portrayal on the health identity of underrepresented groups. These could include establishing literacy initiatives to inform people about the messages they receive, facilitating collaboration between health professionals and media creators to create more inclusive communication strategies, promoting authentic and diverse representation of underrepresented groups, creating and disseminating uplifting health stories that highlight individuals’ diversity and resilience, among others. These practical insights can foster a media setting that enhances social comparison and identity formation, particularly for those belonging to underrepresented groups. It is essential to comprehend these dynamics to address potential health disparities, promoting a healthier, more inclusive, and informed society.

While this study provides insights into the representation of underrepresented groups in the fictional medical television drama, the findings may not capture the comprehensive understanding of the various dynamics of representation due to the limited scope of the study. The analysis is based on season one episodes of the show ‘New Amsterdam’ and the evolving nature of television series may introduce changes in representation narratives and themes over time. The study focuses on content analysis without incorporating viewers’ perspectives, therefore, understanding how viewers from underrepresented groups interpret and respond to these portrayals would provide a more comprehensive understanding of the impact. The limitations of this study are important to acknowledge in order to contextualize its findings and guide future research efforts to improve our comprehension of the complex dynamics of representations in fictional medical television dramas.

Conclusion

We tend to perceive and believe the things as reality the way media represent them to us (Gerbner & Gross, 1976. Individuals within a context and the context itself are crucial for media exposure to impact viewers’ lives in reality. Underrepresented groups are mostly portrayed in a contradictory situation in this drama compared to the counterparts from the majority group, which is prone to threaten their social positioning in terms of health identities. Media portrayal can result in consequences in the processes of identity formation and social comparison (Harwood & Roy, 2005). The identity of people is influenced by their associations with various groups, contributing to norms of thinking and behaving (Mastro & Ortiz, 2008. Individuals from underrepresented groups thus can encounter varied consequences in communicating their health identities based on how media portrays them.