The use of video to communicate water, sanitation and hygiene in Haiti A comparison between SAWBO, GHMP and UNESCO’s cholera prevention initiatives

Pau Abad Tent

Communication for Development One-year master 15 Credits Autumn, 2018 Supervisor: Tobias Denskus

ABSTRACT

Health communication campaigns in developing countries can take many different forms and make use of a wide range of communication tools. One of these tools are multimedia resources such as videos. Initiatives like the Scientific Animations Without Borders (SAWBO) or the Global Health Media Project (GHMP) have been created for the only purpose of developing videos adapted to different cultures and languages in order to tackle a variety of health issues relevant to developing countries. The present study pretends to focus on the use of such videos for water, sanitation, and hygiene (WASH) behavior in the context of cholera epidemic which hit Haiti in late 2010. By using comparative research procedures, three videos have been selected for content analysis from three different institutions: SAWBO, GHMP, and UNESCO Haiti. The results from this analysis served as guidelines for further survey analysis carried out through field questionnaires to a sample of the video’s target audience, that is, Haitian children aged from about 10 to 13 years old. The purpose of the study was to understand and compare the impact and effectiveness of these resources in transmitting disease prevention practices to the target audience. The results indicate that the videos usually coincided in the issues to inform about cholera, but differed in most of the features portrayed within the issues. Moreover, responses to the questionnaires reflected that the messages portrayed were only retained by an average half of the participants, with more or less success depending on the topic.

Keywords: Health communication, WASH, cholera, Haiti, Communication for Development, video, cartoon, multimedia

1

TABLE OF CONTENTS

1. INTRODUCTION ...... 4 1.1 HAITI AND CHOLERA ...... 4 1.2 WATER, SANITATION AND HYGIENE IN HAITI ...... 5 1.3 HEALTH COMMUNICATION AFTER THE CHOLERA OUTBREAK ...... 7 1.4 RESEARCH DESIGN ...... 8 1.4.1 RESEARCH QUESTION ...... 9 1.4.2 UNITS OF STUDY ...... 10 1.4.3 COLLABORATION WITH GAIN AND COGOP ORPHANAGE & SCHOOL ...... 12 2. LITERATURE REVIEW ...... 15 2.1 THEORETICAL FRAMEWORK ...... 15 2.2 HEALTH COMMUNICATION IN DEVELOPING COUNTRIES ...... 19 2.3 CONTEXTUALIZED VIDEO IN HEALTH COMMUNICATION CAMPAIGNS FOR DEVELOPMENT ...... 22 3. METHODOLOGY ...... 26 3.1 COMPARATIVE RESEARCH ...... 26 3.2 CONTENT ANALYSIS OF CHOLERA PREVENTION VIDEOS ...... 27 3.3 SURVEY ANALYSIS THROUGH QUESTIONNAIRES ...... 34 3.4 DISCUSSION ON THE METHODOLOGY ...... 39 4. FINDINGS ...... 41 4.1 CONTENT PORTRAYED ...... 41 4.2 CONTENT PERCEIVED ...... 43 5. LIMITATIONS...... 47 6. CONCLUSION ...... 50 BIBLIOGRAPHY ...... 52 APPENDICES ...... 58

2

FIGURES AND TABLES

FIGURES 1. Informational poster for a cholera prevention campaign by MSPP ...... 7 2. Knowledge rate before and after the OCV campaign (Haiti) by communication channels and type of information ...... 21 3. SAWBO’s strategy to develop educational videos to low-literate contexts ...... 23

TABLES 1. Summary of the impact of Cholera in Haiti, 2010-2018 ...... 4 2. Variables and values for GHMP cholera prevention video ...... 30 3. Variables and values for UNESCO cholera prevention video...... 32 4. Variables and values for SAWBO cholera prevention video ...... 33 5. Common variables and values for GHMP, UNESCO and SAWBO videos ...... 41 6. Questionnaire correct answers for Group 1 (GHMP video) ...... 44 7. Questionnaire correct answers for Group 2 (UNESCO video) ...... 44

3 1. INTRODUCTION

1.1 HAITI AND CHOLERA

Cholera “could not have emerged at a worse moment” in Haiti (Frerichs, 2016, p.2). The October 2010 cholera outbreak was neither caused by the earthquake nor by the devastating human conditions it brought about, despite the popular saying. In fact, it was proved to be brought by UN Nepali troops who were in the country since 2004 according to findings made by Renaud Piarroux, a French epidemiologist called by the Haitian government to track the origins of the epidemic.

In the first 3 months only, cholera had already caused 4.100 deaths1 and 185.000 suspects of being infected. The annual evolution of cholera in Haiti can be seen below:

Table 1. Summary of the impact of Cholera in Haiti, 2010-20182 Year Population Suspect Institutional Communitary Total Incidence rate cases deaths deaths deaths per 100 2010 10085214 185351 2521 1580 4101 18.38 2011 10248306 352033 1950 977 2927 34.35 2012 10413211 101503 597 311 908 9.75 2013 10579230 58574 403 184 587 5.54 2014 10745665 27392 209 88 297 2.55 2015 10911819 36045 224 98 322 3.30 2016 11078033 41421 307 140 447 3.74 2017 12201437 13681 110 49 159 1.12 20183 12542135 4437 18 21 39 0.27

Cholera has reduced drastically to only 39 deaths in the first 10 months of 2018, and 4.437 suspect cases. In 2017, most cases were detected in three main states4: Artibonite (854), Centre (774) and Ouest (561) where Port-au-Prince is, and also the

1 Data accessed from periodical cholera reports by the Haitian Public Health ministry, available at: http://mspp.gouv.ht/newsite/documentation.php 2 Idem 3 As of 27th, October 2018. It was the last data available when retrieved on 22nd November, 2018. 4 Pan American Health Organization / World Health Organization. Epidemiological Update: Cholera. 6 August 2018, Washington, D.C. PAHO/WHO, 2018, Retrieved from https://www.paho.org/hq/index.php?option=com_content&view=article&id=14544:6-august-2018- cholera-epidemiological-update&Itemid=42346&lang=es

4 area of concern for the present study: Ça-Ira (Leogane). However, the chances for a new outbreak seem to be always at stake. A first rupture with the decrease rate was in May 2014 when cholera reinvigorated after a rainy spring season, despite being at its lowest in the first months of 2014. The disease rebounded especially in areas “where little or nothing had been done to reduce local vulnerability” (Frerichs, 2016, p.4). Two years later, a third outbreak was influenced by Hurricane Matthew hitting Haiti in October 2016, which caused 546 deaths and affected 2.2 million people5. The cholera death toll raised again from 275 in the first 10 months to 447 at the end of 2016. These events showed once again that adverse weather conditions are favorable for the spread of cholera, but also proved the importance of water, sanitation and hygiene facilities “since both water and sanitation were insufficient” in Haiti at the time, and bacteria “became abundant in the aquatic environment” (Khan et al., 2017, p.902). In fact, 34 cholera treatment centers out of 212 were destroyed by the heavy winds and many cholera patients were treated alongside other patients, which increased the risk of infection6.

1.2 WATER, SANITATION AND HYGIENE IN HAITI

To “ensure availability and sustainable management of water and sanitation for all” is UN’s Sustainable Development Goal no.6. Access to water and sanitation are indeed a Human Right since 20107. Still, 29% of the global population lack access to safe drinking water and 61% are without safely managed sanitation services8.

But there is a third element to add to water and sanitation: hygiene. All three words make up what is known in development as WASH (water, sanitation and hygiene). The effects of a lack of all three elements can be perfectly identified in a cholera outbreak as was the case in Haiti. According to a WHO report, cholera and other diarrhea related diseases are linked to different transmission pathways which have to do with water, hygiene or sanitation, or a combination of them: ingestion of unclean water, lack of

5 According to UNDP: http://www.undp.org/content/undp/en/home/blog/2017/1/11/Three-months- after-Hurricane-Matthew-seven-years-after-the-earthquake.html 6 OCHA Situation Report no.12 (17 October, 2016). Available at: https://reliefweb.int/report/haiti/haiti- hurricane-matthew-situation-report-no-12-17-october-2016 7UN Resolution 64/292 (28th, July, 2010): http://www.un.org/en/ga/64/resolutions.shtml 8 For more on SDG no.6, see: https://sustainabledevelopment.un.org/sdg6

5 water linked to inadequate personal hygiene, poor personal, domestic or agricultural hygiene, contaminated water systems, etc. (WHO, 2014). But as well as a combination of water, hygiene and sanitation deficit is able to trigger diarrheal diseases as cholera, it has been proven that an integral intervention may reduce the risks in developing countries up to a 12% reduction rate. This means that up to 1.000 lives may have been saved from the Haitian Cholera outbreak with proper WASH facilities and knowledge.

WASH conditions in Haiti were already a growing problematic even before the 2010 earthquake. Before the disaster, only 69% of Haiti’s population had access to safe water and 17% to improved sanitation facilities9. Sanitation coverage decreased from 26% in 1990 to 17% in 2008 (Tappero & Tauxe, 2011). Disparities between urban and rural areas were evident: 85% against 51% of access to safe water, and 24% against 10% of access to improved sanitation, respectively10. A reform of the water and sanitation sector was voted in the Haitian parliament in March 2009, only 10 months before the earthquake. This propitiated the creation of the National Directorate for Portable Water and Sanitation (DINEPA by its French acronym). But DINEPA’s focus shifted from long term development to emergency response right after the earthquake. At the same time, foreign governments, multi-lateral lending institutions, NGO’s and other organizations were also committed to improve WASH conditions then. More than 100 NGO’s were identified to develop projects intended to improve WASH conditions in addition to a multitude of small-scale projects from small faith- based groups (Gelting et al., 2013).

The efforts had some good results and “residents of IDP camps had been largely spared from the outbreak because of safe water supplies and improved sanitation” (Tappero & Tauxe, 2011, p.2091). Some of the developments included increased chlorination of water supplies, rehabilitation of distribution networks and water treatment stations, distributions of household water treatment products and soap, and cholera prevention and hygiene promotion campaigns (Gelting et al., 2013). However, these efforts were mostly emergency response. In the following years, many activities ceased, while DINEPA retook some of the reforms planned in 2009. A

9 WHO/UNICEF Joint Monitoring Programme (JMP) for Water Supply and Sanitation, 2012. Progress on Drinking Water and Sanitation: 2012. Available at: https://reliefweb.int/report/world/progress-drinking- water-and-sanitation-2012 10 Idem

6 ‘National Plan of Action for the Elimination of Cholera in Haiti’ was approved by the Ministry of Public Health and Population (MSPP by its French acronym) which provided 2.2 billion U.S. dollars for the eradication of cholera, of which 70% were designated to developments in the WASH sector11 through DINEPA. Nowadays, Haiti’s score of the SDG no.6 went from 54% in 2017 to 61% in 201812, confirming the good progress of WASH improvements in the country.

1.3 HEALTH COMMUNICATION AFTER THE CHOLERA OUTBREAK

One of the 9 specific objectives set by MSPP for the eradication of cholera was “that by 2022, 75% of the general population in Haiti will have knowledge of prevention measures for cholera and other diarrheal illnesses”13. Right after the cholera outbreak, NGO’s and public institutions immediately lead health communication campaigns tackling the risk of cholera infection and encouraging the population to pay attention to WASH recommendations. These campaigns were targeted both to health

Figure 1. Informational poster for a cholera prevention campaign by MSPP

11 “National Plan for the Elimination of Cholera in Haiti, 2013–2022, Short Term Plan 2013–2015”: http://new.paho.org/hq/index.php?option=com_docman&task=doc_view&gid=20578&Itemid=270 12 Data available at: http://opendata.investhaiti.ht/ttdsgad/haiti-mapping-tool-english 13 “National Plan for the Elimination of Cholera in Haiti, 2013–2022, Short Term Plan 2013–2015”: http://new.paho.org/hq/index.php?option=com_docman&task=doc_view&gid=20578&Itemid=270

7 professionals and general population with the aid of the Center for Disease Control (CDC) (Tappero & Tauxe, 2011). Moreover, MSPP broadcasted messages, displayed banners, and sent text messages encouraging people to take specific measures to prevent cholera. Even Haitian President René Préval led a 4-hour televised public conference to promote cholera prevention.

In May 2011, an investigation and joint statement by US researchers informed that in the first two months after the outbreak, IDP camp managements implemented 670 cholera risk-reduction activities in camps and their surrounding communities. “UN education cluster partners distributed cholera prevention and water treatment protocols in schools across the country; phone companies, along with the International Federation of the Red Cross and Red Crescent Societies, the International Organization for Migration, and others, sent public health warnings via SMS; and radio stations dedicated broadcasts to education programs, provided updates from the MSPP, and answered caller questions” (Farmer et al., 2011).

1.4 RESEARCH DESIGN

The present thesis covers the impact of Health/WASH communication campaigns in Haiti with a particular focus on one specific communication tool: video. Its specific goal is to compare health communication video initiatives working towards cholera prevention and the promotion of water, sanitation and hygiene practices in Haiti.

The methodology for the study is based on comparative research using two different methods: first, the comparison of video initiatives and their content by way of content analysis; secondly, by analyzing the coherence -or not- of such content with the video’s target audience perception by a survey analysis exercise. It is a sequential process, which means that the survey analysis depends on the content analysis findings to determine the content used for the questionnaires. In other words, the survey analysis uses questionnaires which questions are derived from the issues highlighted by the content analysis. This is an important feature of the research as it increases the reliability and validity for the survey exercise in a significative way.

8 1.4.1 RESEARCH QUESTION

From the description above, the research question can be easily stablished:

What are the similarities and differences between different health communication videos tackling WASH/cholera regarding content portrayed and content perceived by the target audience?

First, the question reveals that it is a double-sided research question: on one side, the content shown or portrayed by the videos regardless of the public to which it is directed; on the other side, the content understood or perceived by the identified target audience to which the videos are directed. It does not mean there are two questions or even more in the research question, though. The “content portrayed” and “content perceived” part of the question might be summarized as “impact”, but then, the two phases of the transmission of content would not be as evident in the questions. The same is applied to “similarities and differences”, which are the two objectives from comparative research. In fact, a first draft only included “differences”, but “similarities” was included afterwards.

What is the purpose of asking this research question? What do I pretend to achieve with it which may be relevant to Communication for Development? Why should the answer to this question matter? The approach to Communication for Development in this thesis, as it will be explained in more detail in the concluding chapter, is linked to the notion of “seeking change”14 and more specifically to the field of Social and Behavior Change Communication (SBCC). By comparing the “impact” (content portrayed vs. content perceived) of these video initiatives we will be able to identify which of them has had more success and effectiveness, or which health messages were retained by the target audience, which have not been retained. Therefore, the question is leading us to understand what is the impact (change) in the target audience’s mindset, and also what changes need to be made in order to be more effective in transmitting content: Are the videos effective in order to transmit at least the basic ideas of cholera prevention practices? To what extent (percentage)? Is one video more successful than the other in the general perspective? What issues are highlighted in these videos both in terms of the message and the retention of it by the

14 See Chapter 6.1

9 target audience? Were the messages in the videos captured by the viewers’ mind? All these are subsequent questions that derive naturally from the primary research question.

Almost every health communication program in developing countries seeks some kind of change (Bertrand, Babalola & Skinner, 2012). This case is not an exception. Our study, however, does not deepen into the visible behavior change processes, but rather focus on the cognitive side of behavior change among children, that is the initial phase of behavior change. It humbly tries to set the ground for further SBCC interventions and communication campaigns which might profit from the findings.

1.4.2 UNITS OF STUDY

Ti-Joel “Campaign Against Cholera” by UNESCO Haiti and MSPP

The UNESCO Campaign Against Cholera implemented after the 2010 cholera outbreak consisted of several resources integrating a famous Haitian cartoon character, Ti-Joel, “to show young people how to protect themselves from cholera at school and outdoors, how to purify water and how to prepare oral serum”15. A total of six short animated films were produced and spread through national public TV as well as private TV channels and made available in internet and social media16. Apart from these, a 44- page comic book was also created with the same stories. It was distributed by the Haitian Ministry of National Education and Vocational Training, UNICEF, PAHO/WHO and other organizations in schools, recreations centers for children, IDP camps, libraries, community centers, scout organizations, health centers and cholera treatment centers17.

For the sake of time and focus, only one of the six videos has been selected for study. The selection criteria was mainly based on similarities to other videos used in the study, length -the more length, the more content-, and number of shots and

15 For more on the campaign, see: http://www.unesco.org/archives/multimedia/document-2134 16 According to news article: https://www.20minutos.es/noticia/1077560/0/dibujo/animado/colera/ 17 OCHA Humanitarian Bulletin: 19th, November, 2011. Available at: https://reliefweb.int/report/haiti/humanitarian-bulletin-19-november-19-december-2011-enfr

10 sequences -the more shots and sequences, the more content too-. The selected video can still be found in the UNESCO official Youtube channel18.

“The story of cholera” by Global Health Media Project

The Global Health Media Project (GHMP) is a non-profit organization that designs and produces video and animation video to teach healthcare practices for frontline health workers and families in low-resource settings (Monoto & Alwi, 2018). Both “The story of cholera” and “The story of ebola” videos are of important success for the purpose of developing short films to use during epidemic crisis to teach citizens on how to deal with the disease and how to prevent it. However, there are a high number of videos available at its website for different healthcare issues19.

“The story of cholera” was produced in response to the Haitian cholera epidemic outbreak in 2010 in order to help “affected populations around the world better understand cholera and how to prevent it”20. It was dubbed into 35 different languages and it “has become a favorite educational tool among communication for development specialists, aid workers, animators, and public health experts”21. According to the GHMP website, “several experts made sure that the technical information on cholera was accurate and up-to-date”, among them UNICEF’s Deputy Coordinator of the WASH cluster in Haiti in 2011. The video may be watched and downloaded at the GHMP platform22.

“Cholera Prevention” by Scientific Animations Without Borders

Scientific Animations Without Borders (SAWBO) is an initiative from the University of Illinois seeking to provide animation materials on different development topics in local languages in order “to improve the livelihoods of low-literate learners” (Bello-Bravo, Olana & Pittendrigh, 2015, p.27). Topics covered by the SAWBO videos include: agriculture, health, women empowerment and economic development. Most of the

18 See: https://www.youtube.com/watch?v=ruh0pashlJ8 19 GHMP video platform: https://globalhealthmedia.org/videos/ 20 According to GHMP’s website: https://globalhealthmedia.org/what-we-do/projects/about-cholera/ 21 Idem 22 See: https://globalhealthmedia.org/videos/cholera-portfolio/

11 videos are short 3-D animation. These are produced through partnerships and collaborations, and made available through the website, but also via the University of Illinois online library system as well as provided by SAWBO for communication for development projects through a recent Deployer app developed for field workers23.

The cholera prevention video was also created for the specific context of the Haitian outbreak in 2010, months before the SAWBO project was officially launched (Miresmailli, Bello-Bravo & Pittendrigh, 2015). “A script was given to the animation team, and the animation was then created and reviewed. Upon approval, language overlays were created in Creole, French, Spanish, and English, and the animations were given out to a diversity of organizations for free distribution” (Bello-Bravo, Seufferheld, Steel, Agunbiade, Guilot & Pittendrigh, 2011, p.55). The cholera prevention video is available for watching and downloading at the SAWBO platform24.

1.4.3 COLLABORATION WITH GAIN AND COGOP ORPHANAGE & SCHOOL

One of the main reasons for choosing the theme for the thesis is the previous relationship with Global Aid Network (GAIN)25, an international NGO with development and humanitarian relief projects distributed in more than 50 developing countries. One of them is a school and orphanage rebuilt after the 2010 Haitian earthquake in the Ça-Ira village (Leogane, West Department) run by GAIN and by its local partner COGOP, a faith-based community and network of churches within the country. I was myself a volunteer in 2015 during 5 months in the project where, among other things, I worked as school teacher, an experience which has facilitated the contact with field workers for the purpose of the study.

The GAIN Spain office, to whom I have close contact, is the responsible for the evaluation and improvement of water, sanitation and hygiene not only for the school and orphanage, but also for the Ça-Ira community. Early talks with GAIN Spain office on the opportunity to elaborate this thesis around the Ça-Ira project developed in several ideas which went from creating the basis for a WASH communication campaign

23 See: https://www.youtube.com/watch?v=1DrbWxL8dRQ 24 See: https://sawbo-animations.org/video.php?video=//www.youtube.com/embed/4kgriJ7A-IA 25 For more on GAIN’s work and structure, see: http://www.gainworldwide.org/

12 to integrating the study in one of the biggest necessities there at the moment: latrines and the appropriate use of them. However, two major reasons forced us to reject these ideas: 1) time constraints; 2) they required a longer and more sophisticated field research work, the success of which could not be guaranteed. After an evaluation of previous studies and availability of resources, it was decided to evaluate the impact of WASH video resources for the opposite reasons: it was very plausible in terms of time, and more simple field research work could still be carried out with much higher success possibilities.

Despite the initial possibility to join in a field trip, it was decided that the survey could be perfectly carried out remotely thanks to the close contact and communication with the Ça-Ira orphanage and school as well as with a WASH committee created by GAIN Spain. Anna Mueller, a GAIN worker from Germany living and working there for the past three years was thought to be the perfect contact in the field as I personally knew her from my time in Haiti. Also, she was now the link between GAIN Spain and the WASH committee. After explaining the purpose of the study and giving details to her of what was needed, she offered to carry out the screening of the videos and undertake the survey exercise. After her acceptance to help, more details were given to her and the videos for study were uploaded to a Dropbox folder from where she downloaded them. The videos were uploaded with different sizes in case the internet network speed did not allow to download the high-quality videos. A small retribution or donation was given to Anna in gratitude to her willingness to help, even though she refused at the first time because it was something she was “happy” to help with.

Since the videos were going to be shown in Haitian Creole -despite using English transcripts for the content analysis-, it was asked from Anna to check the translation, to what she responded it was well translated from English to Haitian Creole. Once the content analysis was finished, the questionnaire was created and sent for translation to two other field contacts which will be further detailed in the survey exercise explanation. The Creole version of the questionnaires was then sent to Anna with more specific details on the procedure and deadlines. More information on the sampling and on previous steps taken for ethical considerations are explained further in the survey chapter under ‘methodology’.

13 Potential benefits and outcomes for GAIN

The present research may have several interesting practicalities for GAIN in its holistic approach to water, sanitation and hygiene in the Ça-Ira community. First of all, the background information gathered about different topics such as the evolution of WASH and cholera in Haiti, and others -some of which have been excluded from the degree project for several reasons, i.e., an update on the estimate census of the Ça-Ira community- as well as most of the research analysis included in the literature review will add to the NGO’s documentation.

Apart from the already existing projects, GAIN has also been thinking of the possibility to work on SBCC campaigns to teach villagers on recommended WASH practices in order to prevent waterborne diseases. This is where this study comes in. From my experience in Haiti, I discovered how much cartoon films have an impact on these children. They would stop whatever they were doing to watch a movie, no matter whether it was more or less boring, or it was longer or shorter, and they would remember scenes and messages for several months. On the other side, schools are critical to the communication of WASH practices to children, and children are highly effective change agents to their families when it comes to WASH issues, as field research shows (Bresee et al., 2016). To analyze the impact of these animated cholera prevention videos will help to understand their strengths and shortcomings, the highlighted messages which have been understood, the ones which have not, etc. All of this within the context of children from the Ça-Ira school.

Moreover, GAIN Spain has links to university students and professors in Valencia and Barcelona, which has been an important part of its strategy for involving volunteers in development projects lately. It is not at all discarded that a project like an animated video to communicate water, sanitation and hygiene in Haiti would be done in collaboration with university students or even scholars, probably not on cholera prevention (as there are some already), but on related WASH issues. Therefore, the results from this research might give indications on what information needs to be strengthened, what is the most effective model to use, etc.

14 2. LITERATURE REVIEW

2.1 THEORETICAL FRAMEWORK

Communication for Development and Social Change The present study is clearly framed within the field of communication for development or ComDev. It focuses on the study of a specific communication format as multimedia and videos while analyzing its implementation on WASH and health communication campaigns for improving societal knowledge and behavior. Moreover, we have set the study in Haiti where health communication campaigns have been so important in the last years after the 2010 earthquake and the cholera outbreaks which followed. Therefore, more than asking if this study fits more or less within the ComDev field, the real question is: how is this thesis relevant for ComDev?

First, it must be clear that the notion of development used here does not concern neoliberal approaches to development where mismanagement is the principal reason for the existence of under-developed societies (Nederveen Pieterse, 2010). But it does not ignore, however, the role of economic progress in bringing better health infrastructures and resources at a national scale, and health conditions and access to resources on a personal scale, as it is the matter of concern in the present study. Nobody questions that the new cholera outbreak and the more than hundred deaths caused by Hurricane Matthew in Haiti in 2016 were highly favored by the widespread state of poverty in the country when comparing the post disaster situation in Cuba or Saint Vicent and the Grenadines where the hurricane hit even stronger. Post- development theorists may be right when stating that neoliberal development actions such as World Bank and IMF policies do not take into account cultural and historical variables (McEwan, 2009), as well as to consider the degradation of development as a business and cultural westernization (Nederveen Pieterse, 2010). But the importance of economic progress and poverty reduction in development should not simply be taken out of the equation. It is one more factor to development, an important one, but not the only one.

As Clammer (2012) states: “The answer cannot lie in the reduction of poverty alone, but must reside in accompanying resocialization, education and cultural rather than material development, the last being the most neglected element of all in

15 development studies” (p.20). Health communication campaigns attend the educational and cultural side of development, but as noticed by Farmer et al. (2011), any efforts towards behavioral change and knowledge acquisition were irrelevant in the Haitian case when not accompanied by resources.

The development world is facing more severe and complex communication challenges which development agents seem not to be adequately prepared to meet (Hemer & Tufte, 2012). Meanwhile, the field of communication for development has been facing a reformulation of its core values and conceptualizations in the era of globalization. This coping with the “transitional processes of the global present” as described by Hemer & Tufte (2012) might be demanding ComDev to “step back and reflect, to analyse and understand, rather than to impose development strategies” (p.234-235). This reflection points to every branch of the communication for development field, including health communication for development.

The first World Congress on Communications for Development (Rome, October, 2006) stated that ComDev was “about seeking change at different levels including listening, building trust, sharing knowledge and skills, building policies, debating and learning for sustained and meaningful change” (World Bank, 2007, p.23). This definition is based on a strong relationship between scholars and practitioners, between academic spheres and development agents. Field research is a very important link between them in order to understand communication as a powerful force for social change.

That is indeed the objective of health communication campaigns in developing countries: social change. Communication for development has different variants depending on its goal, and it might be interpreted with different nomenclatures such as communication for social change or even combine both as communication for development and social change (CDSC). It is appropriate to remark that even Wilkins (2009) recognizes the problematization of both the ‘development’ and the ‘social change’ concepts. On one hand, development presents clear historical limitations due to its traditional meaning which usually didn’t include individuals as powerful actors for social change. On the other hand, the term ‘for social change’ is ambiguous in many aspects. These conceptualization struggles are partly explained by the intersectional function of ComDev which pursues both individual behaviour and social changes as well as socio-economical changes (Enghel, 2013). The truth is that the field seems to be

16 moving beyond the concept of development towards a broader emphasis on communication for social change which recognizes that processes of change are a recurrent and permanent feature of societies, and that communication plays an intrinsic role in those processes (Obregon, 2014).

Entertainment-Education in Social and Behavior Change Communication (SBCC)

Besides its inclusion in the field of CDSC, this thesis also steps on the ground of a few theories related to ComDev. The most remarkable are Social and Behavior Change Communication (SBCC) and Information, Education and Communication (IEC) theories linked to Entertainment-Education programs.

First of all, let us differentiate Entertainment-Education from Edutainment in that, briefly said, the first seeks entertainment prior to education, while the latter works in the opposite way, that is, it tries to teach with an entertaining approach to the lessons, but it is not an entertainment product in itself (De Fossard, 2016). Our study moves in between them. For instance, the SAWBO video leans more to the Edutainment concept as the narrative is purely instructional, but the UNESCO video fits better as Entertainment-Education for its mostly storytelling narrative. On the other hand, the GHMP initiative combines both instructions and storytelling in a fairly balanced way, which is a very good feature, since it is usually a fact that health communication campaigns tend to focus too much on education while not enough on entertainment, and vice versa (Piotrow & De Fossard, 2003).

Behavior Change Communication (BCC) is an interactive process with communities to develop messages and approaches using a variety of communication channels to promote positive behavior in individuals (FHI, 2002). However, this individual approach shifted into Social and Behavior Change Communication, a process which focuses more on sustainable behavior change at a societal level (McKee, Becker-Benton & Bockh, 2014). In this sense, scholars started to “move beyond individual behavior change to focus on the structural determinants of development, and the assumption that empowering communities through effective communication processes makes individual and collective change possible” (Obregon & Tufte, 2014, p.191). Therefore, SBCC may be better defined as an approach seeking to address change not only at the

17 individual level, but also and specially at the community and social level through integrated communication strategies (Obregon & Waisbord, 2012).

Important to notice is that SBCC has much to do with health communication. In fact, BCC was born within the health sector (McKee, Benton & Bock, 2014) and it is generally understood as an approach used in health communication programs. Even though a larger scale study would be needed to shed more light on the impact of animated videos within health communication campaign in the Haitian society, the present study is not only about analyzing individual BCC in a small school in a village, but also serves as a pilot study for larger studies with the capacity to analyze the phenomenon of audiovisual Entertainment-Education campaigns and its effect in the Haitian society so to work on the social change processes. Moreover, narrowing down the study to a smaller and more specific audience has led the thesis to a quite interrelated approach with SBCC: Information, Education and Communication (IEC).

Entertainment-Education in Information, Education and Communication (IEC)

The differences between SBCC and IEC have never been clear enough to researchers (Clift, 1998). However, the key to differentiate them is the specificity of the latter. The IEC approach is understood as the development of planed communication interventions and strategies that combines informational, educational and motivational processes aiming at influencing behavior among specific audiences or groups (FHI, 2002; Clift, 1998) regarding a specific problem in a predefined period of time (WHO, 2001). IEC is a multidisciplinary approach drawing from the fields of previous theories as BCC and others such as diffusion theory, social marketing, behaviour analysis, anthropology, and instructive design (WHO, 2001). It is also very well integrated into the study of health communication strategies.

This framework is where this thesis settles as it is analyzing the impact of a specific communication strategy (Entertainment-Education) in a specific target audience within a specific community (school children in Ça-Ira) regarding a specific problem (WASH and cholera prevention behavior). Also, if a ComDev project would essentially come out of the findings, it would be the production and deployment of discrete communication materials. This is also an important differential characteristic of IEC

18 regarding SBCC, which rather seeks to establish communication as strategic and integrated interventions into entire programs (FHI, 2002).

2.2 HEALTH COMMUNICATION IN DEVELOPING COUNTRIES

The range of journals including articles on health communication campaigns, and the range of countries covered by such campaigns “is laudable” (Sood, Shefner-Rogers & Skinner, 2014, p.81). According to Ahmed (2012), adapting from different authors, health communication might be defined as “the study of the interactions among various participants in the health care process, the dissemination of health-related messages and messaging by individuals, groups, and/or mass media to other individuals, organizations, and/or the general public, and the interpretation of these messages” (Ahmed, 2012, p.148). Its main goal is “to increase awareness and knowledge about a particular issue; to modify or influence behavior; and to encourage healthier lifestyles” (Rozario & Arulchevan, 2015 citing Leiner, Handal & Williams, 2004, p.232).

There is general consensus among scholars that health communication campaigns are necessary to achieve behavioral and social change in health development. However, it is also believed that these campaigns in development contexts are usually of modest impact. These shortfalls may be explained by the common comparison with successful health communication campaigns in Western culture and by the complexity of any communication campaign in developing countries (Sood, Shefner-Rogers & Skinner, 2014).

Through their thorough research on publications about Health Communication in developing countries, Sood, Shefner-Rogers & Skinner (2014) detected several main topics: HIV/AIDS and sexually transmitted infections and contraception; maternal, newborn and child health; chronic and non-communicable diseases; communicable diseases (tuberculosis, malaria, etc.); and safe water. What is most interesting to notice from this research, though, is the importance of combining multiple approaches and channels. “The fact that most campaigns do not rely on one strategic approach, but instead combine mass media, community mobilization, interpersonal approaches and, increasingly, interactive and mobile technologies, is a testament” to the idea that

19 the more communication, the better the impact (Sood, Shefner-Rogers & Skinner, 2014, p.81). This has been proved in many health communication campaigns across the globe, from HIV/AIDS campaign in rural Uganda (Mitchell, Nakamanya, Kamali & Whitworth, 2001) to WASH campaigns in Rwanda (Chankova, Hatt & Musange, 2012), and even Haiti (Mathieu et al., 2004). Communication channels are demonstrated to be ineffective when used in isolation of other communication channels.

WASH communication in Haiti after the 2010 cholera outbreak

Fortunately, there is enough research to understand WASH communication campaigns in Haiti and their results after the 2010 cholera outbreak. Because of the renown explosive character of a cholera outbreak, an emergency public health campaign started immediately including health communication initiatives. At the same time, research and evaluations were also initiated even without institutional review due to the emergency character of the problem as approved by CDC (Beau de Rochars et al., 2011). Such evaluations were done through surveys to 405 households from 27 clusters in resource-limited areas surrounding Port-au-Prince before and after WASH communication campaigns were carried out by MSPP. Most of the households had access to mobile phones, radio and television, the latter being the preferred ITC to be informed about cholera, which confirms the appropriateness of focusing our research on audiovisuals. Regarding knowledge gained through the campaigns, awareness on cholera’s common signs among respondents was high as well as of transmission modes. The most common prevention method cited was handwashing (86%). Therefore, campaigns proved to be somewhat effective, but authors recommended to keep carrying out communication campaigns, especially focusing on cholera prevention.

A joint statement by health professionals and scholars in Haiti and the US strongly suggested the necessity to combine community education through communication campaigns with the provision of necessary supplies in order to “improve hygienic behavior and reduce social stigma” (Farmer et al., 2011, p.9). WASH communication campaigns proved to be effective, but they were worthless if the community did not have access to water treatment products, latrines, etc. Surveys carried out in schools

20 through Petit Goave and Miragaone (West Department) one month after the cholera outbreak also found that if facilites such as soap and proper latrines were not provided, pupils would not retain their gained knowledge on hygiene after communication campaigns (Prandini, Giardina & Sorlini, 2013).

Evaluations on the success of WASH communication campaigns in Haiti have continued through the years. One of them was Childs et al. (2016) done through household surveys after MSPP implemented its first oral cholera vaccine campaign in 2013 in Petit Anse (Gonave Island) focusing on oral messaging, posters and pamphlets. The study found that all respondents for the pre and post campaign surveys had heard of cholera and different aspects of the disease. “49% and 50.4% reported receiving educational information on cholera within the past 6 months” (Childs et al., 2016, p. 1310). The communication channels through which they received such information and the type of information gained are shown in Figure 2 below. The increase in response rate over health professionals and CHW shows that the campaign focused heavily on oral messages while dismissing the use of radio and TV.

Figure 2. Table included in Childs et al. (2016) showing knowledge rate before and after the OCV campaign by communication channels and type of information.

A different study in the Artibonite Department found that health messages related to WASH issues were retained by the community, especially regarding hand washing, use

21 of latrines and proper food handling (Gaines et al., 2015). All respondents could describe messages heard in the past year and some of their behavior changed because of these messages. Interestingly, different field research showed the same results for retention and behavior change on a larger, national scale. According to Beau De Rochars et al. (2011), household water treatment increased from 30% to 74% because of health communication campaigns. Also in the Artibonite Department, a more recent research about WASH communication campaigns concluded that messages through the different communication channels (CHW, radio, SMS, church, etc.) had been well retained, specially regarding hand washing which had been internalized in almost all participants after having heard of the consequences of not doing so (Williams et al., 2015).

2.3 CONTEXTUALIZED VIDEO IN HEALTH COMMUNICATION CAMPAIGNS FOR DEVELOPMENT

There are several communication approaches in health communication campaigns, within which there is a disparity of communication channels and mediums used. Video animations is only one of them, but one which is attracting more and more attention from scholars and practitioners in the last decade. Not only for health communication purposes. In 2010, already 78% of development organizations in Asia and Africa used live-action videos in their training programs with farmers according to a study (Van Mele et al., 2010). Whether cartoon, 3-D animations, live-action, or any other video formats, its growing use comes aside the development of new ICT’s in developing countries which have made of educational videos and similar forms of ‘Entertainment Education’ and ‘Edutainment’ a potential competing or complementary approach to development communication for traditional mediums, especially radio (Bello-Bravo, Olana & Pittendrigh, 2015; Ramirez & Quarry, 2004). Moreover, internet as a source of information is increasing in developing countries, making access to health communication resources more feasible. As an example, several African-based studies have proved that most people with internet access use it to inform themselves about health issues like cancer or HIV/AIDS (Okonofua and Olagbuji, 2014; Kivuti-Bitok et al., 2012). It is also known that cell phones as a tool to see health communication videos are already highly profitable in developing contexts, as it was the case with a cholera

22 and malaria prevention campaign in Benin using SAWBO’s materials (Bello-Bravo, Dannon, Agunbiado, Tamo & Pittendrigh, 2013).

An important notion to the development and deployment of videos as a tool to communicate on health is contextualization. Factors such as belief systems, religious and cultural values, life experiences, and group identity “act as powerful filters” through which health information is communicated (Thomas, Fine & Ibrahim, 2004, p. 2050). To adapt the content to the local reality is nothing new to development practices, but recent studies keep arguing the importance of also developing locally- based videos. Frett el al. (2016) analysis of the impact of health communication videos in Haiti to prevent cervical cancer and promote vaccination developed into videos written and featured by local film professionals within a typical family scenario in Haiti. Results showed that knowledge on cervical cancer and prevention methods increased significantly. Another example of good practice to avoid ‘westernized’ health communication videos are SAWBO procedures as despite being based in the US, they do not produce videos themselves, but work alongside local partners for creation and deployment (Bello-Bravo, Olana & Pittendrigh, 2015) as it can be seen below:

Figure 3. SAWBO’s strategy to develop educational videos to low-literate contexts.

The effectiveness of contextualized videos in health communication for development has been demonstrated by many field research studies. To mention some examples, Chartchalerm et al. (2010) examined the knowledge of villagers in a Klongmai

23 community in Thailand regarding diabetes in order to develop an “effective” video (p.59). The resulting video demonstrated that both diabetic and non-diabetic participants who watched the video gained knowledge on all dimensions of diabetes education despite the complexity of the content. As most research by SAWBO founders Bello-Bravo and Pittendrigh, their case study in Benin found agricultural as well as cholera and malaria prevention videos to be well-received by local population as training and learning tools (Bello-Bravo, Dannon, Agunbiado, Tamo & Pittendrigh, 2013). Yeager et al. (2002) research on a campaign for the promotion of hygienic feces disposal behavior in Lima, Peru, used video presentations, leaflets and counseling by health staff in consultations. All three types of communication were well-received by the community, but videos were “extremely well received” by health staff and audience (p.767).

However, probably the most related study to our subject of concern is that of Rozario & Arulchevan (2015) which analyzed the benefits and shortcomings of 10 animated cartoon videos to communicate health messages in developing countries by way of content analysis. Among the findings were: characters portrayed more adults than children; average length of videos was close to 5 minutes; there was a mix of 1st, 2nd and 3rd person narratives; the main protagonist acted in most cases as the change agent profile, being a male in 7/10 cases; the issue was not highlighted in detail in most cases; and 7/10 did not show heavy imagery such as wounds, blood, etc. From the content analysis results, the authors elaborated a list of 20 recommendations to animation videos for health communication in developing countries which can be read at the Appendix 1.

On the potentialities of video as a health communication tool, Bello-Bravo, Olana & Pittendrigh (2015) derived three different conclusions from three different studies: 1) information is accurately understood (Medhi, Prasad & Toyama, 2007); 2) viewers are more easily motivated (Ladeira & Cutrell, 2010); and 3) videos have the capacity to inform about complex issues in a simple manner (Lie & Mandler, 2009). Moreover, Rozario & Arulchevan (2015) identified up to 12 major benefits from using animations, also based on a thorough literature research. These are: 1) greater production flexibility; 2) it grabs the viewer’s attention; 3) it leads to increase in recall of information: 4) it overcomes barriers of age, culture, language or literacy levels; 5)

24 easily customized for regional use; 6) appealing to a wider audience; 7) animated characters are more relatable; 8) depiction of complex ideas; 9) depiction of sensitive information; 10) removal of unnecessary elements such as heavy imagery and sounds; 11) emotional connection; and 12) motivation to learn and put into practice the ideas included in the message by feeling identified with the characters (Rozario & Arulchevan, 2015, p.234-236).

Now for the limitations of videos as tools for communicating health, most of them have to do with ICT’s limitations in developing countries. A survey of 1.700 projects on mobile technology for health concluded that most services did not provide “essential, actionable, offline guidance for direct use by citizens addressing the range of acute healthcare situations commonly encountered in low-resource settings” (Royston et al., 2015, p.356). The reasons were mainly three: most mobile phones in low-resource settings are basic phones that can accommodate only voice and SMS text messaging with no internet connectivity or multimedia capability; there is a shortage of appropriate content with the exceptions of SAWBO, GHMP and Medical Aid Films, but there is little investment in such content; and how to place the content onto individual phones remains a challenge. Videos make it also harder to target messages at specific groups, since they are generally targeting all groups from a region, country or even transculturally (Mitchell, Nakamanya, Kamali & Whitworth, 2001).

Finally, accessibility to multimedia resources for individuals is no doubt harder in developing countries than in the West. However, digital and internet access in developing countries is also rapidly raising around health and disease prevention issues (Bello-Bravo, Lutomia, Madela & Pittendrigh, 2017). Some initiatives as distribution of micro-SD cards or the HealthPhone project to provide Medical Aid Films and GHMP resources are intended to overcome the digital gap.

25 3. METHODOLOGY

3.1 COMPARATIVE RESEARCH

Comparative research has been common to communication studies for decades. Since Blumler, McLeod and Rosengren (1992) considered it communication’s “extended and extendable frontier” (p.3), the number of communication scholars working comparatively has increased rapidly and constantly until today, facilitated mostly by ICT’s which have helped to establish, maintain, and manage even large international networks of research and researchers (Esser & Hanitzsch, 2012). It is stranger nowadays to study a phenomenon without asking whether it is or it is not distinctive to its specific context (Livingstone, 2012). However, when narrowing it to health communication literature, there is scarce comparative investigation and those existing only comprise a few countries or regions despite the disparity of nations and regions studied within the field of health communication (Pollock & Storey, 2012).

It is important not to misunderstand comparative research with comparative analysis. The present study uses comparative techniques as a methodology for research, not as a method itself. In this sense, whatever the method used, we may define the comparative approach as a systematic evaluation of cross-societal similarities, differences, and associations between social entities or units (Mills, 2008; Ragin 2014; Sasaki, 2004). As any other methodology, the distinctive note about comparative research is that it builds tehory by uncovering differences and similarities between social entities as well as revealing unique aspects of these entities which would be impossible to detect otherwise (Mills, 2008; Sasaki, 2004).

What these entities look like depends on the author. It may go from societies, cultures, nations, and institutions (Sasaki, 2004) to interviews, individuals, symbols, case studies, social groups, geographical or political configurations, and cross-national comparisons (Mills, 2008). They might be divided between macro levels -societal/global, industry/organizational, and community/neighborhood-, and micro levels - network/primary group and individual- (McLeod & Lee, 2012). Most important is that entities for study must be comparable in some way, they should be “functional equivalents” (Esser & Hanitzsch, 2012, p.10), that is, “similar in a few respects but not all” (Olsen, 2012, p.186).

26 Being our study defined as comparative, it is also of importance to stablish whether it will have a qualitative or quantitative approach. It is fair to anticipate that findings and conclusions will include interpretative decoding of data. It is also true that the number of units analyzed and surveys conducted are not to be considered as representative of the real scale reality in Haiti. However, the goal of this comparative research is to spot differences and similarities whether it is about content of the videos or survey responses, as the research question states. That makes of the present study a quantitative oriented research which will indeed use quantitative approach for its selected methods: content analysis and survey analysis. This is not as common in comparative social science as it is in most other fields, but the focus of comparison here falls more onto variables than onto the whole units for study as qualitative comparative research usually does (Ragin, 2014). Also, as Ragin notices too, qualitative comparative strategies tend to look for answers to historically and empirically defined questions in terms of origins, which do not concern in our case.

3.2 CONTENT ANALYSIS OF CHOLERA PREVENTION VIDEOS

Krippendorff defines conent analysis as a “research technique for making replicable and valid inferences from texts (or other meaningful matter) to the contexts of their use” (Krippendorff, 1980, p.18). This definition applies to its variety of approaches. The keyword here is ‘texts’ and the ‘other meaningful matter’ clarification in the parenthesis is also worth noticing. By “texts”, Krippendorf does not refer only to written text, but also to other forms of meaning such as “images, maps, sounds, signs, symbols, and even numerical records” (p.19) which may be included as data, that is, they can be recorded in the form of texts. This is crucial to our study as we are analyzing different sources of non-written meaning.

Content analysis may either be quantitative or qualitative, as well as inductive or deductively oriented. To be clear, the type of content analysis selected for the thesis has an inductive and quantitative approach. Qualitative or quantitative methods are defined by the research question, put simple, whether we need to answer “what” or “why” questions (Julien, 2012, p.120). In the first case -our case- quantitative content analysis is implemented. Additionally, even though trying to preserve the step by step

27 categorization procedure of quantitative content analysis, qualitative content analysis requires a dose of subjective text interpretation (Mayring, 2000). In our particular case, we intend to avoid interpretation as much as possible as such an approach would call for higher rates of reliability and validity which we cannot provide as it will be discussed with the rest of thesis limitations. Also, our research question is clearly a “what” question looking for answers in the denotative level of meaning rather than in the connotative level. We are interested in manifest content that can be recognized, categorized and ultimately quantified in order to be compared between the three selected videos.

Having in mind that the analysis is done mostly upon audiovisual content, Bell’s (2004) ‘Content Analysis of Visual Images’ has been of much help to orientate the analysis, beginning with his definition of visual quantitative content analysis as an “empirical (observational) and objective procedure for quantifying recorded ‘audiovisual’ (including verbal) representation using reliable, explicitly defined categories” (Bell, 2004, p.13). Here, two concepts are especially useful to our study:

• Empirical (observational), that is, a step by step categorization procedure will be taken letting the ‘texts’ decide on the conceptualization of categories throughout the research analysis. This is the reason why the present study is not deductive-approach driven, but rather inductive. To be deductive, content analysis should begin with a precise hypothesis (Bell, 2004). This is not the case.

• Quantifying recorded… representation in the present analysis may bring confusion if a relevant puntualization is not made. Let us remember that this is a comparative study which seeks to stablish the differences and similarities of three selected units of study rather than comparing how many times are values or variables repeated in the units of study. Numbers are important to the study and they will be noticed in the results and analysis, but let us not forget, though, that one is also a number.

Video transcription

The textual transcription of the videos was carried out using examples and guidelines provided by Heath, Hindmarsh and Luff (2010) and Rose (2011). It was decided to

28 transcribe all ‘texts’ separating verbal data and non-verbal data. Verbal data was transcribed first so that non-verbal data may overlay verbal data. The textual transcription was then organized and integrated within one same timeline where every dash represented 1/5 second, and a comma represented 1 second. In the timeline, verbal data was represented with a linear rectangle around the text, while nonverbal data was represented by a dashed rectangle. As it is somewhat utopic to describe everything shown in the screen (Rose, 2011), some visual aspects of the videos have been left without analysis, for example: settings, signs or different distance or scene angles.

When it comes to unitizing verbal and non-verbal data within the timeline, different criteria was followed. For verbal data, units -rectangles- were composed by the text shown in subtitles. For visual representation, data was collected from shot to shot. Within the shots, dots separated actions from different people or other elements. As the meaning of many of the non-verbal representations -and some verbal too- was distorted when alienated from its previous and following shots, we always took those into account following Heath, Hindmarsh & Luff (2010) suggestion of interrogating the ways in which it might attend to prior conduct and how it might be treated in subsequent action.

The whole video was identified as the unit of study. Therefore, three units have been transcribed separately. The full transcription can be seen in Appendix 2.

Categorization

Variables and values were placed within three different tables, one for each of the videos. Verbal data was first analyzed and most variables came from this first analysis. Non-verbal data was later analyzed and included in the same table. I chose to separate verbal and non-verbal content by way of text differentiation. Italic typography was used for non-verbal content. This allowed to mix verbal and visual content as part of the same ‘text’, but stablishing a clear differentiation among them. This practice has even lead to interesting findings which will be mentioned in the findings.

The majority of text is not represented in any of the categories, though. Through inductive -exhaustive- analysis, common patterns were detected among the three

29 videos representing different issues on cholera prevention. These have been set as variables, most of them common to more than one video. But they differ in their content, which is represented by the values and sub-values columns. It is important to note that the variables here are “nominal variables” (Krippendorff, 1980), absent of any ordering nor metric. They are unordered, but exclusive from each other as it is indispensable for the categorization process.

Close attention to the correct use of words has been paid when stablishing categories. Exact words from the transcription were used whenever possible, as avoiding synonyms is one important feature in content analysis procedure (Julien, 2012; Bell, 2004). This, however, is not always possible in order to maintain the text’s intelligibility. In such cases, some expressions were slightly adapted for the analysis.

Table 2. Variables and values for GHMP cholera prevention video VARIABLE VALUE SUB-VALUE Carriers / Causes of Infected water • By vomit and defecation near the river shore cholera • From the river • Water collected and carried home by women • Swallowed water from a glass of water • Cholera move from the glass to mouth together with the water Flies Flies impregnated with germs of cholera touching uncovered food Hands • Unwashed hands and fingers, hand shaking • Grabbing a ball touched by unwashed hands and fingers • Unwashed hands and fingers grabbing a glass of water • Unwashed hands and fingers taking food Food • Infected by a fly impregnated with germs of cholera • Vegetables • Fruits • Fish Non-sick people who swallowed germs of cholera Description of Tiny germs Too small to see cholera Dangerous Effects of cholera Fast spread • So fast • Overnight (… by morning) Acute disease Diarrhea • Like gray water • Containing germs of cholera that spread Vomiting Containing germs of cholera that spread Writhing • Kneeling • Bending • Crawling Paralyzed in • Trembling bed • Uncontrolled defecation • Impregnated with germs of cholera

30 Actions to help the Go for help • Fast infected person • Immediately • Red Cross • Clinic • Nurse • Medical kit Prepare Make 1 liter of water safe (inside a basin), filtered through a cloth special drink (most germs of cholera do not trespass the cloth), boiled (in a cooking pot) for 1 minute, pour water into a crystal jar and fill it to the top, add ½ teaspoon of salt, add 6 teaspoons of sugar Give special drink to the person affected by cholera Actions to prevent Safe water • Make the water safe by adding chlorine drops and waiting half cholera an hour • Filter and boil water • Take bottles or closed crystal jars to share Clean hands • Always wash hands with soap and safe water after going to the toilet • Eat with clean hands • Wash hands before preparing food • Always wash hands after using latrines Latrines • Dig latrines far from the river, 30 meters away • Always use latrines Clean food • Wash and peel the food • Cook the food • Always eat the food hot • Protect the food from flies by covering it with a cover • Boil the food • Wash hands before preparing food • Eat with clean hands Spread the word Effects of actions Recovery • Feeling stronger to help the person • Getting better affected by cholera • Stomach starts to fatten Effects of actions Healthy village to prevent cholera

31 Table 3. Variables and values for UNESCO cholera prevention video VARIABLE VALUE SUB-VALUE Wrong causes of cholera A curse Description of cholera Not a malefic disease Bacteria Can hit everyone if not applied rules of hygiene Effects of cholera Fast spread Death Vomit Paralyzed in bed Actions to help the infected Fast reaction person Oral serum • Measure 1 liter of water, pour water into the container, mix a sachet of oral serum with the water • 6 teaspoons of sugar and ½ teaspoon of salt in a gallon of treated water Take to health center Wrong actions to help the Do a healing ritual Shake maracas person affected by cholera Drugs Remain without effect Not take to health center Run after the person who brought the malefic curse Effects of wrong actions to Death help the person infected Actions to prevent cholera Wash hands • Purified water • Soap • After contact with an infected person Use chlorine water • Hands to wash • Sheet • Clothing • Dishes • Latrines • Cutlery • Objects affected by diarrhea of a person infected by cholera

32 Table 4. Variables and values for SAWBO cholera prevention video VARIABLE VALUE SUB-VALUE Carriers / Causes of Dirty water cholera Vegetables irrigated with contaminated water Glass of water Aples (fruits) Latrines near a river Description of Intestinal infection cholera Caused by bacteria inside water Found in dirty water or in vegetables… irrigated with contaminated water Effects of cholera Diarrhea Vomiting Actions to help the Go to nearest medical facility Consult with medical personnel infected person Actions to prevent Safe water Treat Filter Pour water to a bottle through a cholera turbid funnel, Use a clean cloth to strain water the water, let it stand Boil the • Use cooking pot, cover it for a filtered water minimum of 5 minutes, allow it to cool down before drinking, close the bottle • Airtight container If you cannot • Mix 6 drops of bleach or boil filtered chlorine per 4 liters of water, let water it stand 30 minutes, close the bottle, shake the bottle • Use a clean, airtight container Effervescent 1 tablet of 33 mg per one gallon of Aquatab pills water, let solution rest half an hour Storage Drums • Disinfect with a cleaning utensil of water • Keep them sealed Tanks • Disinfect with a cleaning utensil • Keep them sealed Containers • Disinfect with a cleaning utensil • Keep them sealed Bottles • Disinfect with a cleaning utensil • Keep them sealed Wash hands with soap • After using toilet • Before preparing food • Before eating

33 3.3 SURVEY ANALYSIS THROUGH QUESTIONNAIRES

Survey as a research method is a system used to collect information from or about people in order to describe, compare or explain their knowledge, attitudes, and behavior on a countless number of issues (Fink, 2002). Even though there are many types of survey format, survey data is mainly collected through questionnaires, whatever the channel used. So, what are questionnaires? They are tested, structured, systematic and clearly presented sets of questions to be answered by respondents in order to achieve the survey’s purpose (Payne & Payne, 2004). In fact, the research question must act as a guide and baseline for questionnaires (Smyth, 2016).

To design the questionnaire, we have made use of the following strategy:

• Content of the questionnaire has been linked exclusively to the content detected in the videos through content analysis in order to answer the research question: “What are the similarities and differences… regarding content portrayed and content perceived by the target audience?”. • Presentation format and wording have been carefully designed by following guidelines and best practices found in literature.

Sampling

First of all, it must be stated that the thesis scale is too limited as to be considered representative of the impact of video as a tool for WASH or health communication in the Haitian context. For that reason, there is a bit of a qualitative and interpretive tune in the background despite using a quantitative approach to theory. This survey’s sample must be understood as a non-probability sample within which a convenience sampling strategy has been used, meaning that units at hand have been selected for questionnaires (Vehovar, Toepoel & Steinmetz, 2016). As described in the research design, the relationship with GAIN’s orphanage and school was a major reason for choosing to conduct field research, even though remotely. But as almost every non- probability survey sample, it incorporates probability sampling design principles “whenever possible” (Vehovar, Toepoel & Steinmetz, 2016, p.333).

34 Our survey sample consisted of 30 school children from the COGOP school in the Ça-Ira village, 10 girls and 20 boys. The age ranged from 10 to 13 years old as this was about the age identified in the videos for the main character who also played the role of change agent, assuming this profile was the main target audience for the video campaigns. Despite it is not a meaningful number, they do represent part of the Ça-Ira community as they are most of the classmates in their own grade and there are only two schools in Ça-Ira, according to GAIN Spain. Therefore, it is possible to confirm they represent an estimate of between a fifth and a third of the total schooled boys and girls of their age in the village.

Content of the questionnaires

It is advisable to use as much previous information as possible to decide on the content and wording of questions. That involves literature, but especially previous similar studies and standard questionnaires already existing from where to adapt our own questions (Bourque & Fielder, 2003). In our case, the previous study was done right before developing the questionnaire as part of the research design process, therefore its content is directly linked to the content analysis exercise.

An important development was that the SAWBO cholera prevention video was not included in the survey exercise for three reasons:

1. The information on the video was considered too technical for children. 2. The video did not target children or teenagers, but rather adults, and it was not too viable to gather adults to participate in the research. 3. Time constraints made more feasible for field partners to conduct surveys to only two groups rather than three.

It is remarkable that the three videos manifested very similar variables as noticed in the findings. This developed into similar questions and response options for the two groups, and even helped to share ideas from one video to the other in order to fill the questionnaire with incorrect options which were portrayed in the other video.

35 Presentation format and wording

A variety of survey research literature has been the main source for determining issues like the number of questions, visual design, choice of questionnaire format, wording, and others. To begin with, it was decided that questionnaire should contain only close- ended questions as means to obtain easily standardized data which could be analyzed statistically (Fink, 2002). This decision had a few implications, to know, response options had to be mutually exclusive and exhaustive (Lavrakas, 2008; Peterson, 2000).

Also, choices had to be made regarding different types of close-ended questions. Because the comparative research approach drives the survey to search for similarities and differences among content portrayed and content retained, the questionnaire was conceived to be a multiple-choice test format. This means that response options include correct and incorrect options. To avoid a long and extensive set of questions, it was decided that: 1) for those variables found through content analysis which included more than one value and could not be unified in one sentence, the response options would be multiple-choice; and 2) for the variables which values could be summarized in one sentence would be a single-choice question. In this latter case, the total of response options would be three following Rodriguez (2007) suggestion, who also recommends asking questions as completion statements (“Complete the phrase”) rather than interrogative statements (“What is the…?”). Taking from Roulston (2008), explicit closed-questions were chosen over implicit questions, and specific facts and information were chosen over “yes/no” questions as the latter option would have been too easy to answer right after watching the videos.

Other suggestions found in the literature guided the formulation of questions and response options. Among them: clarity of word choice and writing style (Rodriguez, 2007); the stem of the question should contain the main idea or topic (Rodriguez, 2007; Byrne, 2017); keep the questions short (Byrne, 2017; SAGE Video, 2017; Peterson, 2000; Smyth, 2016; Payne & Payne, 2004); options should be independent, similar in content and grammatical structure, equal in length, and free of clues to the correct option (Rodriguez, 2007); questions should be purposeful, concrete, relevant and objective (Smyth, 2016; Fink, 2002; Peterson, 2000) as well as simple and understandable to everyone (Smyth, 2016; Payne & Payne, 2004).

36 The English version of the questionnaires for the two groups can be seen in Appendix 3, as well as a sample of an Haitian Creole version in Appendix 4.

Translation and adaptation to social-cultural context

The translation was done by Irene, a high-literate local with high level of English and Creole who knows well the context of the Ça-Ira orphanage and school as she lived herself in the orphanage and went to the same school. She is also now part of GAIN staff in Haiti as she is taking care for the guesthouse within the complex which is also part of GAIN’s project. A parallel translation was planned with a second person, Schaiden, a personal friend and medical student in the university of Port-au-Prince who offered to help with translations and could also review content as specialist within the health sector, but unfortunately a close friend of him died that same week and prevented him from participating.

Specific orders were made to Irene to pay attention to cultural differences and adaptability to the children. This resulted in small shifts in the expression of some sentences. The communication was done via Whatsapp as this was the fastest way for her to work with the texts. Irene was grateful for the chance to help: “that has helped me also to learn and see how my english is doing”, she said.

Procedure and ethical considerations

The screening and questionnaires took place the 7th December, 2018, at about 10 a.m, one group after the other. The activity was carried out in the conference room of the school building through a big TV screen. The children were split into two groups of 15, each of them watching either the GHMP or the UNESCO video and answering the related questionnaire. According to Anna Mueller, our primary field contact, one of the videos had to be shown twice as the noise from one classroom became too loud and children could not understand anymore. After screening the video, the questionnaires were filled by the children as planned. However, it was reported that some of the children struggled to understand how to fill the questionnaires: “We have many children in the 2nd and 3rd grade that are able to read and write, but they are not used

37 to fill out papers”, was Anna’s explanation. In general, the activity was well-received by the children. The school manager -and also a member of the WASH committee stablished by GAIN Spain- “really liked the idea” according to Anna.

Ethical issues have also been taken into consideration. Two major concerns raised regarding the screening of the videos and following questionnaires. First, the cholera spread has backed considerably in the past year and does not affect the Ça-Ira community despite being in the highly affected West Department. The videos were cholera prevention focused, even though most of its information is still useful for WASH communication purposes, and a new cholera outbreak could still be boosted by a new natural disaster or different reasons. Would the videos alarm the kids about a problematic which does not exist at the Ça-Ira community at the moment? This was not the first time that a similar research was carried out in a nearby location, though. Prandini, Giardina & Sorlini’s (2013) assessment of WASH in Haitian schools was carried out in Miragoane and Petit Goave schools, only a few kilometers away from Leogane and Ça-Ira. Secondly, the activity had to be done during teaching hours. Would the survey interrupt the syllabus daily progress? Would it create any tension among teachers and school managers?

To overcome these questions, our local contact first explained the activity and asked for approval from the school manager, who at the same time is member of the WASH committee established by GAIN for the care and periodical evaluation of its WASH projects in Ça-Ira. Once the approval was obtained, the local contact was asked to make the school manager and teachers involved watch the video and evaluate themselves whether it was appropriate or not to show them and undertake questionnaires. This new approval after watching the videos and questionnaires delayed the research, but it was considered necessary. Finally, our local contact reported back their agreement with the activity, which meant the activity could be scheduled and carried out.

Additionally, other sensitive issues about the survey exercise were the involvement of both children and a responsible for the activity in the field, that is, Anna. For children, the approval from teachers and the school managers was the main indicator to assure that the activity was appropriate for them. Also, the questionnaires did not include personal questions and anonymity was guaranteed. To motivate them for the activity, it was asked

38 from Anna to give the kids any sort incentives such as candies after completing the questionnaire, but a misunderstanding prevented that from occurring26. In regard of involving Anna to carry out the activity, the idea came first from the GAIN Spain office as they thought it would be an incentive for her to have a task different from her routine work. It was also thought to be good for her and the rest of the WASH committee in Ça-Ira to be involved in an activity which was not about technicalities, but about to inform and communicate, even though a kind of test. Anna’s response to the proposal was positive from the first moment and she always expressed goodwill towards it. Even so, a small donation was sent to her after the activity was done in gratitude for her help.

3.4 DISCUSSION ON THE METHODOLOGY

The research design and methods used in this study have proven to be effective in its goal to collect and analyze meaningful data for the purpose of communication for development research and more specifically to the field of health communication. This was a sequential study where the answer to the question research depended on survey data, and survey data depended on content analysis. All steps during the process have flowed satisfactorily in that sense. Most studies analyzed in the literature review relied only on survey analysis, while others mixed surveys and focus groups. Only Rozario & Arulchelvan (2015) chose content analysis for their study on health communication cartoon videos. But, on the other hand, according to Bell (2004), “content analysis alone is seldom able to support statements about the significance, effects or interpreted meaning of a domain of a representation” (p.13). Our research fills this gap by adding the questionnaires in order to not only understand the message of specific health communication videos, but also their effectiveness in portraying those messages to their target audience.

Apart from this, Rozario & Arulchelvan (2015) also recognized “the limitation […] that only one video per health issue was identified” and suggested that “future research can focus on analyzing more videos for each health issue to get a more comprehensive picture” (p.242). This suggestion is accomplished here by covering different initiatives

26 This was Anna’s response after carrying out the activity: “We had many Christmas goodies but spontaneously we gave Nicolaus gifts to the children and because of a misunderstanding we used all the sweets we had. Sorry!”

39 tackling the same health issue: cholera. However, further analysis on the latent meaning of content by way of semiotics would increase knowledge in order to understand the relationships between specific content retained by the target audience and the factors which have favored its success.

40 4. FINDINGS

4.1 CONTENT PORTRAYED

Among the units of study, there are much more similarities than differences between variables. Those variables exclusive to only one of the three videos are: • GHMP video: Effects of actions to help the person infected by cholera • GHMP video: Effects of actions to prevent cholera • UNESCO video: Wrong causes of cholera • UNESCO video: Wrong actions to help the person affected by cholera • UNESCO video: Effects of wrong actions to help the person affected by cholera On the other side, these are the variables in common and its subsequent values. Synonyms and interrelated values have been unified into one so to reflect that the videos have included that same information (i.e., “vegetables” are considered “food”).

Table 5. Common variables and values for GHMP, UNESCO and SAWBO videos

Variable Value GHMP UNESCO SAWBO Carriers / Infected water Yes Yes Causes of Flies Yes No cholera Hands Yes No Food Yes Yes Non-sick people who swallowed germs of cholera Yes No Description of Bacteria Yes Yes Yes cholera Dangerous Yes No No Non-malefic disease No Yes No Can hit everyone if not applied rules of hygiene No Yes No Intestinal infection No No Yes inside water No No Yes Effects of Fast spread Yes Yes No cholera Acute disease Yes No No Diarrhea Yes No Yes Vomiting Yes Yes Yes Writhing Yes No No Paralyzed in bed Yes Yes No Death No Yes No Actions to help Go for help Yes No No the person Prepare special drink / oral serum Yes Yes No affected by Fast reaction Yes Yes No cholera Take to health center No Yes Yes Actions to Safe water Yes No Yes prevent Clean hands Yes Yes Yes cholera Latrines Yes No No Clean food Yes No No Spread the word Yes No No Use chlorine water to wash No Yes No

41 These evidences give a fair picture of what messages the producers wanted to tell the viewers. First, we see that unlike UNESCO and SAWBO, GHMP is interested in telling the effects of positive action to help people infected by cholera and to take prevention measures. On the other hand, only the UNESCO video reflects wrong perceptions and practices to help the sick, especially worried about not treating the disease as a spiritual malefic disease, probably due to a response to incidents provoked by this stigma which caused, for instance, lynching of individuals thought to have used witchcraft to spread cholera, according to Haitian media reported by OCHA (Farmer et al., 2001). Apart from these, all other variables detected were common to all videos except for the causes of cholera, which the UNESCO video did not explain. This agreement on such topics are not surprising to health communication videos, as it can be noticed in the type of information detected by Rozario & Arulchelvan (2015) in health communication cartoon videos: history (where and when it started), what causes the disease or problem, how it spreads, risk, diagnosis of the problem, treatment, and prognosis.

Moreover, many values coincide with those messages broadcasted by MSPP, banners, and text messages encouraging people to take 5 measures defined by early investigations in order to prevent cholera in the first emergency campaigns: 1) drink only treated water; 2) cook food thoroughly (especially seafood); 3) wash hands; 4) seek care immediately for diarrheal illness; 5) and give ORS to anyone with diarrhea (Farmer et al., 2011).

Out of the total 29 found values among the common variables, only three (10%) were common to all videos: bacteria as a description of cholera, vomiting as a symptom or effect of cholera, and washing hands as an action to prevent cholera. The GHMP video and the UNESCO video had 6 values in common (21%): bacteria as a description of cholera; fast spread, vomiting and being paralyzed in bed as effects of cholera; preparation of special drink / oral serum as actions to help the cholera infected person; and washing hands as action to prevent cholera. In relation to the SAWBO video, the GHMP video also had 6 values in common (21%): Infected /dirty water and food as possible causes of cholera; bacteria as a description for cholera; vomiting as effect of cholera; and safe water and washing hands as actions to prevent cholera. Lastly, the SAWBO and UNESCO videos only had 4 values (14%) in common, that is, only one more

42 apart from the three common values for all videos: Take the sick to a health center as an action to help the infected person.

These results show agreement on what the issues are to be covered, but they differ quite drastically on the elements within these issues. There are a few values that have been surprisingly equal, though, as the case for instructions on the preparation of oral serum explained in detail by the UNESCO video and the GHMP video, or on how to use chlorine to make water safe explained by the GHMP and SAWBO videos, thus manifesting a general consensus on these specific procedures recommended by the health sector.

It is also interesting to notice how non-verbal representations detected through the content analysis also play an important role. In the GHMP video, 4 out of 23 (17%) values were detected without having any verbal references to them, while 23 out 52 (44%) sub-values were identified only by visual representation, 9 (17%) had to mix both verbal and non-verbal data in order to be comprehensible, and 20 (39%) were found to be comprehensible by the audible narration. For the UNESCO video, 2 out of 18 (11%) values were non-verbal, and regarding sub-values, only 1 out of 14 (7%) was identified through non-verbal content analysis, the rest (93%) being fully explained by verbal narration. Lastly, in the SAWBO video 2 of 13 values (15%) were found to be non-verbal, and 1 (8%) had to be mixed with verbal language to be comprehensible, while no sub-values were detected to be only non-verbal, and 7 out of 18 (39%) combined verbal and non-verbal representations, the other 11 (61%) using verbal language. These results drive us to understand that GHMP, despite being the longest video, leaned on non-verbal language in a significant proportion regarding the other two videos, specially the UNESCO initiative which most of the message was transmitted verbally.

4.2 CONTENT PERCEIVED

Among the 30 filled questionnaires, 6 were considered invalid -4 from the UNESCO video, and 2 from the GHMP video- as they were either blank or answers were marked in more than one box for the single choice questions. The findings for the rest of respondents are showed below.

43 Table 6. Questionnaire correct answers for Group 1 (GHMP video)

Total Correct Failed Question Related variable Correct (%) (%) Cholera is a sickness produced 8/13 62 38 Q1 Description of cholera by… If a friend or familiar is infected Actions to help the person 9/13 69 31 Q2 by cholera, I have to… affected by cholera Q3 The cholera disease spreads… Effects of cholera 5/13 38 62 I can prepare a special drink for a Actions to help the person 6/13 46 54 Q4 person infected with cholera by… affected by cholera After receiving help from the kid Effects of actions to help the 8/13 62 38 Q5 and the nurse, the father… person affected by cholera 11/13 85 15 5/13 38 62 Q6* The effects of cholera are … Effects of cholera 2/13 15 85 6/13 46 54 12/13 92 8 9/13 69 31 What of these elements may 8/13 62 38 Q7* Carriers/Causes of cholera carry germs of cholera? 12/13 92 8 10/13 77 23 4/13 31 69 6/13 46 54 11/13 85 15 7/13 54 46 I can help to prevent Cholera Q8* Actions to prevent cholera 2/13 15 85 happening to me and others by… 7/13 54 46 7/13 54 46 3/13 23 77 * Results for all correct answers in the question. Specifications on some of the given correct answers are explained below.

Table 7. Questionnaire correct answers for Group 2 (UNESCO video)

Total Correct Failed Question Related variable Correct (%) (%) Q1 Cholera is… Description of cholera 4/11 36 64 If a friend or familiar is infected by Actions to help the person 6/11 55 45 Q2 cholera, I have to… affected by cholera I can help to prevent Cholera Actions to prevent 6/11 55 45 Q3 happening to me and others by… cholera Q4 The cholera disease spreads… Effects of cholera 5/11 45 55 If someone in your family gets Actions to help the person 4/11 36 64 Q5 cholera, he can also get better by… affected by cholera The effects of cholera are… Effects of cholera 7/11 64 36 Q6* 2/11 18 82 5/11 45 55 * Results for all correct answers in the question. Specifications on some of the given correct answers are explained below.

44 The results show several similarities and differences between the message given and the message retained by the target audience, as well as between the two separate groups. The correct answer was the most marked option for all 10 questions with a unique correct answer except for 1 in the UNESCO video questionnaire (Q5). However, only 5 questions had its correct answer chosen by more than 50% of the respondents: 3 of them in GHMPS’s group and 2 in UNESCO’s. On the other hand, correct options for questions with multiple correct answers were the most marked in 11 out of 17 correct possibilities: 1 of 3 in UNESCO’s, and 10 of 14 in GHMP’s. However, despite being correctly answered by a higher number of respondents than any other options, those correct answers did not show a generalized consensus.

Only 5 of all correct options were chosen by more than 75% of the respondents, none of them in UNESCO’s group nor within questions with a unique correct answer in GHMP’s group. These 5 were: Diarrhea (85%) as an effect of cholera; infected water (92%), food (92%) and sick people (77%) as carriers/cause of cholera; and washing hands (85%) as an action to prevent cholera. Carriers/causes of cholera in the GHMP’s video was indeed the question with the highest percentage of correct answers among questions with multiple correct answers with an average of 71% of correct responses. Also in the GHMP’s, running for help before preparing a special drink as an action to help a person infected by cholera was the most agreed answer (69%) among questions with a unique correct option.

It is surprising to see so few answers (2/13) to writhing as an effect of cholera, same as cooking food and similar to “spreading the word” (3/13) as ways to prevent cholera, a variable which gathered many marks on wrong answers: 4 out of 7 wrong answers had more than 50% responses, from which “adding soap to the water”, “peeling the food before washing hands” and “using latrines near a river” stand out with 8, 8 and 9 responses out of 13, respectively. On the UNESCO’s video, the most chosen wrong answer was “medical drugs” within actions to prevent cholera, and the speed of the cholera symptoms was answered as “not slow, but not too fast” by 5/11 respondents.

In more specific comparative terms, GHMP’s video was found to be more effective in transmitting its message to respondents with a 55% average of correct answers, while the UNESCO video achieved 45% average of correct answers, even though it was shorter and had less content than GHMP’s. GHMP’s video achieved more success in

45 transmitting a brief description of cholera: 62% correct answer for only 36% in UNESCO’s video, this being the most significant difference between both. However, a slightly higher average than GHMP’s was found in UNESCO’s video group regarding important issues as the speed of the cholera symptoms (45% versus 38%) and the instructions to prepare oral serum (55% versus 46%). In general, results show similar difference margins between both groups on those common issues portrayed by the videos, excluding the exception of the cholera description question. Needless to say, the figures’ most significant outcome to be interpreted is that none of the groups show a significant agreement on the correct answers.

46 5. LIMITATIONS

Let me use the first-person narrative here for the personal and non-personal limitations encountered during the elaboration of this thesis. The first limitation to the project, which also explains most of the rest of limitations encountered, has been the personal inexperience on academic research. This has been my first experience with conducting academic research myself, which supposed more time investment on literature review about research methodology to assure that I was applying the correct approach and procedures. This left less time to invest in deeper investigation, while still leaving behind many features recommended by experts about comparative research, content analysis, and survey analysis. Validity and reliability checks or doing pre-questionnaire tests are only a few of them.

On the content analysis exercise, time constraints and inexperience also prevented me from taking into account other non-verbal elements in the content as symbols, written text or outstanding appreciations as it was the case with the switch from gray to colorful scenario at the end of the GHMP video. Some of these features were indeed written down at first, but not included in the final content analysis except for some of them which are reflected in the transcript timeline.

However, most limitations and obstacles came with the survey exercise, just as expected. First, the content analysis exercise and personal obligations delayed the deadlines I set to send the questionnaires to Anna Mueller in Haiti by two weeks. Once I finished developing the questionnaires, I had to send them for translation to two contacts in Haiti. A close friend of one of the contacts died that same week, which explained his delay in writing to say he was not able to help anymore. While the questionnaires were being translated by the other local contact, Anna was to show the videos to the school manager and teachers in order to receive approval from them before I would send instructions and resources for the activity. This also took more time than expected. However, the push of deadlines did not grow more than two weeks in the end.

Once I received the questionnaire responses on December 11th, 2018, the feedback and material received fulfilled the desired expectations. However, there was one important feature not taken into account when dividing the groups for the questionnaires and I think it is fair and important to mention it here as it might have

47 influenced the results for comparison between the two groups responses. The field contact, Anna, did not separate groups from the same age average. The UNESCO video group was mainly formed by 10-year-old children, while the GHMP video group mixed 12 and 13-year-old children. I did specify the required age range in the explanatory email with instructions, but I forgot to mention it should be balanced between the two groups. On another side, the previous knowledge of children on WASH or cholera prevention issues mentioned in the video was not taken into account since it would have needed a different survey analysis approach for it -specially the use of pre- questionnaires- and time constrains prevented this to happen. However, previous knowledge might, of course, have had an effect on responses. The findings do not offer much expectations on a remarkable number of children with an already previous knowledge on almost none of the issues addressed by the questionnaires, though.

Also, another important limitation found was that of children struggling to fill out the survey which has already been detailed in the survey analysis chapter. However, the comments contrast with the capture sent of the questionnaires. Apart from the six invalid questionnaires, the rest of children seem to have understood the process and filled only one response or multiple responses depending on whether it was multiple choice or single choice. The language used in the questionnaires was simple and had no technicisms, and it was written thinking it was going to be read by children from 10 to 13 years old. Instructions were also very simple. Also, as Anna said in the comments, children from that age at the school are able to read and write, a reality which was not unfamiliar to me as I worked for a few months with children in that same school in 2015. The struggle with filling out the questionnaires was more related to their lack of habit filling questionnaires, but their responses showed this was not a significative barrier.

Finally, another important limitation to be noted was the lack of videos on other WASH related issues different than cholera prevention, despite this would have been desirable as cholera incident rates have fortunately decreased drastically, specially in the last year. Waterborne diseases still remain at high risk in Haiti, though, with 26.3 - per 100,000- mortality rate due to unsafe WASH services27 and most of the teachings

27 By year 2016. Data from the Global Health Observatory (WHO), available at: http://apps.who.int/gho/data/node.main.INADEQUATEWSH

48 shown in the cholera prevention videos are thereof still applicable to the current reality. This points us to a first conclusion: more WASH related resources for communication such as videos are needed to transmit basic knowledge on such an important issue.

49 6. CONCLUSION

The main reason for the disparity of results between health communication campaigns in Western countries and developing countries is the complexity of the latter (Sood, Shefner-Rogers & Skinner, 2014). Thus, there is more need to analyze, understand, draw conclusions, apply them, and try again. This has been one of the goals from this research project. Similarities and differences between the units of study were identified, reaching the main conclusion that the video initiatives unconsciously agreed on most of the issues to be covered about the risk of cholera, but they tend to differ on the content and main elements to be transmitted within these topics. Also, non- verbal content proved to play a role in completing messages or communicating messages without the aid of verbal narration. On the other hand, survey analysis showed that highlighted elements in the videos were not retained as much as it could have been thought. They were usually the feature remembered the most, but it barely surpassed half of the participants response in most cases. This, despite any limitation, reflects the evidence that the content portrayed has not been perceived in a resounding way by the target audience. But let us remind, though, that communication channels -as videos- for health communication purposes lose effectiveness when used in isolation of other communication strategies. A multiple channel approach would have surely increased the correct response rate on the questionnaires, as it has been evidenced in the literature review chapter.

These thoughts bring us back to the research question as well as to the original pursue of changing knowledge and behavior for healthier practices regarding WASH and waterborne diseases like cholera. Now we know what the highlights and shortcomings of the videos are, what are the issues that need to be reinforced, how effective they have been, etc. One evidence is that there is room for improvement in the transference of almost all messages to the school children. There are many other issues which have not been transmitted that may apply better to Haiti’s current reality regarding water, sanitation and hygiene. This degree project must be considered as a kind of pilot study from which further research and campaign evaluations may be added in order to understand the evolution of the behavior change process as well as improving the internalization of disease prevention practices among school children in Haiti.

50 It is also suggested for future comparative studies in health communication campaigns a deeper focus on the relationships drawing the similarities and differences between content and impact, something which is barely grasped in this thesis. Such thorough analysis would help understand better the reasons why some features have been more successful than others in transmitting knowledge and behavior. For that purpose, semiotic analysis on videos would be very valuable in order to surpass the surface of content and deepen into connotation levels of meaning and Roland Barthe’s notions of signifier and signified through visual analysis. After all, the meaning of a representation is not so much about its material-superficial appreciation, but about its “symbolic function” (Hall, Evans & Nixon, 2013, p. 11). Additionally, the lack of comparative studies within health communication must be solved with more research not only on communication campaigns or initiatives from a same institution, but also comparing between different institutions as has been the case for this thesis, as well as comparing locations, cultures, health issues, etc.

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57 APPENDICES

APPENDIX 1

Recommendations for health communication animation videos in developing countries (Rozario & Arulchelvan, 2015) 1. Package the health message within a relevant story in order to attract viewer’s attention and to increase recall of information. 2. Use credible characters, plots and dialogues in order to be taken seriously by the viewer. 3. Animated video content can be used to target both adults and children. 4. The animated video should be simple and have a clear focus. 5. Balance both entertainment and education in the video. Too preachy videos put off people and too entertaining videos make them forget about the actual intended message. 6. The decision on whether the video should have a regional or universal focus should be made after considering the following criteria: target audience, health issue, budget, influence and role of local beliefs, customs and traditions. 7. Represent all genders in the video. 8. Use characters that the target audience can relate to. This offers scope for social modelling where the viewer learns by observing the experiences of the characters onscreen. 9. Identify one character in the animated video clearly as the change agent and use this character to motivate positive behavior change. 10. Highlight good health practices and the precautionary or preventive measures that are to be adopted. 11. The video should show how people will be benefitted or what they stand to gain by adopting a positive behavior change. 12. Include a message that targets the fears and apprehensions of the viewer in adopting a good health practice. 13. All videos should include the symptoms of a health issue and identify who is most likely to be affected. 14. The solutions provided in the video should be implementable in the lives of the target audience. 15. Give information on the various treatment options, possible complications and where extra information can be obtained. 16. Use background music to set the tone and mood of the video. Ambience sounds like the ringing of the bell, birds chirping and vehicles honking can be used to help set a scene. 17. Use animations of internal body processes only if it helps in greater understanding of the message that is to be conveyed. 18. Use fictional elements to make the story more appealing and engaging with the target audience. 19. Keep the duration of the video short. This helps retain attention easily. Longer videos may reduce the level of recall or result in boredom.If the video is comprehensive in nature i.e. it focuses on the different aspects of an issue in detail, consider splitting up the video into smaller videos or different episodes. Each episode can deal with one aspect in detail, thus the video remains appealing and audience attention is focused. 20. Summarize the main points at the end of the video.

58 APPENDIX 2

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APPENDIX 3

GROUP 1 – GHMP VIDEO

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