The Use of Videos in the Prevention of Chagas Disease in Ecuador
A thesis presented to
the faculty of
the Center for International Studies of Ohio University
In partial fulfillment
of the requirements for the degree
Master of Arts
Julia C. Nogueira
August 2008 2
This thesis titled
The Use of Videos in the Prevention of Chagas Disease in Ecuador
by
JULIA C. NOGUEIRA
has been approved for
the Center for International Studies by
Rafael Obregon
Associate Professor of Telecommunications
Betsy J. Partyka
Director, Latin American Studies
Daniel Weiner
Executive Director, Center for International Studies 3
ABSTRACT
NOGUEIRA, JULIA C., M.A., August 2008, Latin American Studies
The Use of Videos in the Prevention of Chagas Disease in Ecuador (148 pp.)
Director of Thesis: Rafael Obregon
More than 20 million people in the world are infected with Chagas disease in 18
Latin American countries, and 50,000 people die a year from the illness. Since there is no
vaccine for Chagas and the cure is only effective in rare cases, prevention is fundamental
to combat the disease. Different health communication theories present ways to achieve
behavior change, but little has been done regarding Chagas. And the existent educational
materials and videos were not produced following health communication theories. Due to the lack of awareness and proper educational materials dedicated to Chagas, this thesis created a series of preventative public service announcements and an educational video.
To guarantee they were adequate to the target audience’s needs and capability of action, the videos were pre-tested with 129 community members from Ecuador. The research concludes that presenting adequate information and using an appropriate language to the target audience’s comprehension is fundamental to the effectiveness of video materials.
Pre-testing video materials and making indicated changes before implementation is also fundamental. This research also created and suggests the implementation of a complete
Communication Strategy for Chagas disease prevention in Ecuador.
Approved: ______
Rafael Obregon
Associate Professor of Telecommunications 4
To my dearest godmother Heloisa Conrado (in memoriam)
5
ACKNOWLEDGMENTS
A special thank you to my parents Ralfe and Diva, my sister Paula, my beloved
Gustavo and my family for supporting me in this academic journey outside of Brazil.
To my advisors Dr. Rafael Obregón, Dr. Mario Grijalva, and Eric Williams for believing in me, supporting and helping me during this research.
To the Ohio University Tropical Disease Institute and the Centro de Investigación en
Enfermedades Infecciosas/Pontificia Universidad Católica del Ecuador (CIEI/PUCE) for financing my thesis research and believing in my capacity to produce the videos they will be using in their future activities.
To all the Ohio University students who kindly worked with me in the production of the videos done by this project, performing fantastic works of camera, sound, editing, animation and narration.
To Dr. Grijalva and the personnel from CIEI/PUCE for their help, support and friendship during this research and to the people in the communities in Loja and Manabí provinces in Ecuador that participated in the shooting and pre-testing of the videos.
To the many friends that patiently revised my scripts in Spanish and English.
To the Brazilian friends that are waiting for me in my home country and the new ones
I had the chance to meet during this research in Athens, and also to the new friends from the United States and other different parts of the world who gave me important advices and were there for me when I needed help and support. 6
TABLE OF CONTENTS
Page
Abstract...... 3
Dedication...... 4
Acknowledgments...... 5
List of Tables ...... 10
List of Figures...... 11
1. Introduction...... 12
2. Background and Theoretical Framework...... 16
2.1. Chagas Disease ...... 16
2.1.1. Chagas Around the World ...... 18
2.1.2. The Fight against Chagas Disease ...... 20
2.1.3. TDI and the Community Based Chagas Disease Research Project...... 21
2.2. The Role of Communication in Chagas Control ...... 22
2.2.1. Previously Produced Printed Materials ...... 22
2.2.1.1. Educational Booklet...... 22
2.2.1.2. Calendar ...... 24
2.2.1.3. Pamphlet ...... 25
2.2.1.4. Brochure...... 26
2.2.1.5. Chagas Disease CD Insert...... 26
2.2.2. Previously Produced Videos ...... 27
2.2.2.1. Chagas Disease Prevention Campaign in Manabí ...... 27 7
2.2.2.2. Chagas Disease Prevention Campaign in Loja ...... 29
2.2.2.3. Community Based Chagas Disease Research Project – Loja ...... 31
2.2.2.4. Chagas: A Hidden Affliction ...... 32
2.2.2.5. Video and Song about Chagas Disease...... 33
2.2.2.6. Kids without Chagas...... 34
2.2.3. The Gap in Chagas Related Communication Materials ...... 35
2.3. Health Communication Theoretical Framework ...... 36
3. Message Design and Pre-testing Methodology...... 55
3.1. Message Design ...... 55
3.1.1. Script Writing – Educational video...... 57
3.1.2. Script Writing – PSAs ...... 59
3.1.3. Video Editing ...... 62
3.2. Research / Pre-Testing Design...... 63
3.2.1. Pre-Testing of Pre-Scripts ...... 64
3.2.2. Participants in the Pre-Testing...... 66
3.2.3. Pre-testing Procedures ...... 67
3.3. Findings and Discussion of Pre-Testing ...... 70
3.3.1. Findings of Pre-Testing of Educational Video ...... 72
3.3.2. Findings of Pre-Testing of PSAs...... 76
4. Recommendations – A Communication Strategy...... 78
4.1. Goals and Objectives ...... 81
4.2. Materials of Communication Strategy...... 83 8
4.2.1. Educational Video...... 86
4.2.2. Public Service Announcements ...... 86
4.2.3. Radio Spots ...... 87
4.2.4. Promotional Video ...... 87
4.2.5. Educational Booklet...... 88
4.2.6. Calendar ...... 88
4.2.7. Pamphlet ...... 89
4.2.8. Brochure ...... 89
4.2.9. Website...... 90
4.3. Implementation of Communication Strategy...... 90
4.3.1. Launching of Program...... 91
4.3.2. Training of Personnel and Health Service Providers...... 94
4.3.3. Community Visits ...... 96
4.3.4. Recruitment Talks ...... 98
4.3.5. Meeting with Possible Sponsors ...... 98
4.3.6. Presentation in Conferences ...... 98
4.4. Evaluation ...... 99
4.4.1. Initial Evaluation ...... 99
4.4.2. Final Evaluation ...... 101
4.5. Dissemination of Results ...... 103
5. Conclusion ...... 105
References...... 108 9
Appendices...... 111
Appendix 01 – Educational Booklet...... 111
Appendix 02 – Calendar ...... 112
Appendix 03 – Pamphlet...... 113
Appendix 04 – Brochure...... 114
Appendix 05 – Chagas Disease CD Insert...... 116
Appendix 06 - Production Credits ...... 117
Appendix 07 – Simple Recording Consent...... 118
Appendix 08 – Complete Recording Consent ...... 119
Appendix 09 – List of Expert Reviewers...... 120
Appendix 10 – PSAs Pre-Testing Participation Consent...... 121
Appendix 11 – Educational Video Pre-Testing Participation Consent...... 122
Appendix 12 – PSAs Pre-Testing Questionnaire...... 123
Appendix 13 – Educational Video Pre-Testing Questionnaire...... 124
Appendix 14 – Changes on Educational Video after Pre-Testing...... 125
Appendix 15 – Educational Video’ Final Script...... 126
Appendix 16 – Changes on Psas After Pre-Testing...... 135
Appendix 17 – PSAs’ Final Scripts ...... 136
Appendix 18 – Stakeholders...... 138
Appendix 19 – Promotional Video’s Script...... 139
Appendix 20 – House Questionnaire...... 145
Appendix 21 – Materials’ Effectiveness and Behavior Change Questionnaire...... 147 10
LIST OF TABLES
Table 1: Communication Strategy Components...... 80
Table 2: Goals and Objectives ...... 83
Table 3: Educational Materials ...... 85
11
LIST OF FIGURES
Figure 1: P Process...... 40
Figure 2: Health Communication Program Cycle...... 45
Figure 3: Chagas Cultural and Educational Festivals held by CBCDRP in June 2007.. 93
12
INTRODUCTION
More than 20 million people in the world are infected with Chagas, a tropical disease that has few external symptoms; yet, it slowly destroys the internal organs of human beings. Approximately 16-18 million people are infected by Chagas disease in eighteen Latin American countries. Worldwide, the disease kills about 50,000 people per year. The disease is caused by a parasite called Trypanosoma cruzi; and the infection is usually transmitted via the feces of blood-sucking insects called triatomine or “kissing bugs”. (Carlier, 2003)
Chagas is practically unknown to the general public. One of the countries seriously affected by the disease is Ecuador, where around 300,000 people are infected. A survey conducted in the Loja province, in southern Ecuador, between 2002 and 2003, shows that only 2% of the individuals had heard of Chagas (Grijalva, Palomeque-
Rodriguez, Costales, Da Vila, & Arcos-Teran, 2005, p. 1). Despite the lack of medical care in poor regions, one of the main reasons for the low levels of awareness and diagnosis is that initial symptoms – such as fever, fatigue, headache, body ache, loss of appetite, diarrhea and vomiting – are easily confused with the ones of other illnesses and disappear after a while. Years or even decades later, 10%-30% of infected people develop
Chronic Chagas disease, frequently leading to sudden death. (Carlier, 2003)
Considering there is no vaccine for Chagas and the cure is only effective when the disease is diagnosed in the early stages after contraction, prevention is the most effective way to combat its spread. Therefore, it is fundamental that a larger population become aware of Chagas disease and of what can be done to prevent it, mainly by keeping kissing 13
bugs away from houses. Different health communication theories and models present
several ways to influence the audience and achieve behavior change. However, little
communication research has been done regarding the prevention of Chagas disease.
Despite the existence of printed educational materials and video products about the subject, they were not produced following health communication theories or models.
Due to the lack of awareness about Chagas, and the lack of educational materials and health communication literature dedicated to the disease, – in addition to the researcher’s previous experience and interest in video production – this thesis focused on the creation of a series of public service announcements (PSAs) and an educational video to help prevent Chagas. In order for these audiovisual products to reach their objective – increase the level of awareness about the disease and encourage behavior change towards prevention – it was necessary to identify the best way to reach the target audiences.
Previously produced videos about Chagas were analyzed to identify their effectiveness as
a prevention tool. Health communication theories and models were analyzed to identify if
they could successfully be applied to the disease.
The literature review indicated that media products need to use a particular format
and approach in order to catch the audience’s attention, transmit information properly,
and encourage people to act as needed – either by participating in prevention campaigns
or by dealing with the disease in their houses. The health communication literature indicated it was indispensable to pre-test the PSAs and the educational video with their target audience and make the indicated changes before their implementation. 14
The production and pre-testing of these videos had the support of the Ohio
University/Tropical Disease Institute (OU/TDI) and the Centro de Investigación en
Enfermedades Infecciosas/Pontificia Universidad Católica del Ecuador (CIEI/PUCE).
Along with the Ecuadorian Ministry of Health1 (MOH), these two institutions carry out
the Community Based Chagas Disease Research Project (CBCDRP), a Chagas control
program that operates in Loja and Manabí provinces in Ecuador. The videos will be implemented within the program’s pre-existing platform of prevention activities and educational materials.
Throughout the process, the following research questions were explored:
(1) What factors should be taken into account for the development of a series of
PSAs and an educational video to create awareness about Chagas?
(2) How does the pre-testing of audiovisual materials help develop more effective
materials for preventing Chagas disease?
However, as it can be found in most of the literature, video products might not be enough to encourage behavior change. Therefore, this research also makes
recommendations for the creation, implementation and evaluation of a complete communication strategy for Chagas prevention.
This study will benefit both the scientific community and the people that live in areas of Ecuador where there is risk of contracting Chagas disease. The research seeks to increase knowledge in an understudied field and proposes the use of videos to help increase awareness. As a consequence, the CBCDRP and the Ecuadorian MOH will be provided with effective videos to be used in the prevention of Chagas disease. The
1 Ministerio de la Salud Pública del Ecuador 15 researcher also hopes that the videos produced by this thesis will improve health conditions in Ecuador and provide a body of information that can be used to help prevent
Chagas in other countries.
16
2. BACKGROUND AND THEORETICAL FRAMEWORK
2.1. Chagas Disease
Chagas disease was discovered in Brazil in 1909 and named after its discoverer
Dr. Carlos Chagas (Dias & Schofield, 1999, p. 113). This Latin American tropical disease has few external symptoms, however it slowly destroys the internal organs of human beings. Chagas is caused by a parasite called Trypanosoma cruzi and is usually transmitted via the feces of blood-sucking insect vectors called triatomine, or the “kissing bug”. The infection is mostly found in small pets and livestock that serve as a food source
(blood) for the insects. Human disease results from the colonization of the human habitat by some vector species brought to the house by animals such as chickens, dogs, cats, pigs, guinea pigs, bats and birds. Another attractive feature for kissing bugs is the good living environment offered by dark houses made from materials like mud, adobe and straws, very frequent in poor areas of Latin America. Once in the houses, the kissing bugs can hide in the holes of walls and roofs, or under the beds. At night they leave their nests and bite the human occupants.
Although the kissing bug alone is not an infective agent, it can cause infection when it carries the parasite Trypanosoma cruzi. While sucking the person’s blood, the kissing bug defecates leaving the parasite in its feces. The bite causes itchiness and the person usually scratches the place where they were bitten. Because they are close to the bite, the feces easily enter the body. The parasite can also enter the body if the person scratches the bite and touches their mouth or eyes with the contaminated hand. In these two manners, the parasite that causes Chagas reaches the blood system (Carlier, 2003). 17
Vectorial transmission – via the feces of the kissing bug – is responsible for 80%
of human infections. However, the disease can also be transmitted through the transplant
of blood or organs infected with the parasite that causes Chagas (5-20% of infections).
This typically happens in urban centers where there is usually no transmission of the disease through kissing bugs. Transmission from mother to fetus during pregnancy happens in 2-10% of infected women. Transmission of infection via breast feeding is extremely rare. There are cases of oral transmission, but they are related to the ingestion of food contaminated by feces of infected triatomine (Carlier, 2003).
Chagas is practically unknown to the general public and many infected people are never diagnosed. Most of the at-risk population is not even aware of the existence of
Chagas or that the kissing bug transmits a disease. A survey conducted in Loja province, in southern Ecuador, in 2002-2003, shows that only 2% of the population had heard of
Chagas (Grijalva, Palomeque-Rodriguez, Costales, Da Vila, & Arcos-Teran, 2005, p. 1).
There are two main reasons for the low levels of diagnosis of Chagas. One of them is lack of access to medical care in poor rural regions where the kissing bug is more frequent. Initial symptoms – such as fever, fatigue, headache, body ache, loss of appetite, diarrhea, and vomiting – also make it difficult to diagnose the illness because they are easily confused with the symptoms of other illnesses. These symptoms disappear after a while and people think they are already cured of the health problem that produced the initial symptoms. However, five to ten years later, 10%-30% of infected people develop
Chronic Chagas disease. Sudden death, usually due to ventricular fibrillation, is the principal cause of death in 60% of cases. Congestive heart failure and cerebral or 18
pulmonary embolism are some of the other common causes of death (Carlier, 2003). To
decrease the risk of mortality, infected patients should be treated as early as possible in
the course of infection.
2.1.1. Chagas Around the World
Almost a hundred years after the discovery of the disease, more than 20 million
people in the world are infected with Chagas, and 50,000 people die from it each year.
The disease is more frequent in Latin America, where 16-18 million people are infected
in eighteen countries (Carlier, 2003). According to Carlier:
Approximately 20% of the Bolivian population is infected (i.e., approximately 1.2 million individuals), whereas Brazil, with a 1.3% global prevalence rate, has 5 million persons with Chagas disease. Prevalence is estimated to be 5-10% in Argentina, Honduras, Paraguay, and El Salvador; 1-5% in Chile, Columbia, Ecuador, Uruguay, and Venezuela; and less than 1% in Mexico and Nicaragua. (Carlier, 2003)
As can be seen though Carlier’s data, one of the countries affected by Chagas
disease is Ecuador, a small Andean country in northeast South America with a population
of approximately 13.3 million people (Jokisch, “Ecuador”, 45). It is estimated that around
300,000 of them are infected with Chagas disease (“La Enfermedad de Chagas”, n.d.).
Additionally, there are more than half a million Ecuadorians currently living in the
United States, more than half a million living in Spain, and 120,000 in Italy (Jokisch,
Ecuador, 48). Running away from poor living conditions and looking for a better life in
developed countries, many Ecuadorians take Chagas with them, increasing the risk of the spread of Chagas through blood transmission in the recipient countries. According to 19
estimates, 100,000-675,000 immigrants from Latin America are infected with T cruzi
(Carlier, 2003).
When Latin American immigrants establish lives in other countries, many of them become blood or organ donors not knowing they have Chagas. This would not be a
problem if blood or organ transmission were not one of the ways infected people transmit
Chagas disease (Chamberland, Epstein, Dodd, Persing, Will, DeMaria, Emmanuel, Pierce
& Khabbaz, 1998, p. 410). Since the United States and the European countries did not
use to have Chagas disease, they did not normally scan donated blood and organs for
Chagas. According to an article published in the Morbidity and Mortality Weekly Report
in 2006:
Although routine serologic testing of organ and blood donors is performed in areas of Latin America where Chagas disease is endemic, no T. cruzi screening test is licensed in the United States. However, seroprevalence studies using research tests have documented the presence of T. cruzi antibodies in U.S. blood and organ donor populations. (“Chagas disease after organ transplantation”, 2006, p. 800)
Because there is a lack of screening for Chagas when blood and organs are
donated by Latin Americans in the United States and Europe, Chagas is infecting
populations that previously had no contact with the disease. The result is that now there
are approximately 300,000 people with Chagas in the United States (“Faculty Expert”,
2005). According to Carlier, “people from Latin America who are infected also migrate
to Europe, Japan, and Australia, but quantitative information is lacking” (Carlier, 2003).
20
2.1.2. The Fight against Chagas Disease
Very early after the discovery of the disease in Brazil in 1909, Dr. Carlos Chagas
stated that prevention and control of transmission would be the most desirable goal and
the best strategy in the fight against the disease (Dias & Schofield, 1999, p. 104). In
Brazil, the control of Chagas disease has been ongoing since the 1950s. The country is
known for its success in fighting the disease, having had a reduction of 89% in infected
towns in the 1990s (Lotufo, 2007). On the other hand, countries like Ecuador have been
struggling to reduce the impact of the disease and trying to spread the word about
countermeasures.
In 2008, a vaccine for Chagas has yet to be discovered and treatments and a cure
are usually only effective in the early stages of infection, though the disease is rarely
discovered until much later. Unfortunately, there is no cure when the disease is diagnosed
during the acute stage of the disease (“Centro de Investigación”, n.d.). So, the prevention
and control of transmission continue to be the best ways to fight the disease. The necessary measures to prevent deaths caused by Chagas are not very complicated; they are related to eliminating the parasites and keeping kissing bugs away from where people live. Some of these measures involve: (a) keeping the house clean and ordered, (b) cleaning under the beds, behind pictures and in the holes of the walls, (c) avoiding the storage of tiles, stones, wood and other kinds of materials, inside and outside the house,
(d) avoiding the accumulation of agricultural products inside the house, because they attract mice and rats, (e) not allowing pets and other animals to sleep close to the house,
(f) sealing the holes and cracks in the walls inside and also outside the houses, (g) using 21
bed nets to sleep, (h) and putting screens on doors and windows to prevent the kissing
bug from entering the house.
2.1.3. TDI and the Community Based Chagas Disease Research Project
The Tropical Disease Institute (TDI) was founded in 1987 as part of Ohio
University’s College of Osteopathic Medicine and it works to improve the health status
of underserved populations through research, service and educational initiatives related to
prevent or minimize the effects of infectious diseases in endemic areas (“Tropical
Disease”, n.d.). Since the beginning, TDI provided training to students from the USA and
developing countries at undergraduate and graduate levels. The Institute's education
abroad programs were initiated in 1995. One of these programs is the Community Based
Chagas Disease Research Project (CBCDRP), which began in 2005 along with Chagas
disease control and Tripanosoma cruzi blood screening programs in Ecuador.
In 2005, 2006 and 2007 a Pilot Control Program was launched by OU/TDI and
Centro de Investigación en Enfermedades Infecciosas/Pontificia Universidad Católica del
Ecuador (CIEI/PUCE) in 66 communities in Loja province. The results after two years
showed an important reduction in triatomine (the kissing bug) infestations, so the
methodology was also implemented in Manabí province, the coastal area of the country.
The project also works towards identifying acute cases of Chagas in order to understand
the effects and the impact of the disease in the country (“Seventh Community”, n.d.).
TDI’s efforts to amplify the control program to a larger area of Loja have the objective of identifying the triatomine infestation in other areas and of verifying the effectiveness of 22 the interventions proposed. The expansion of the geographical area researched by the
CBCDRP will provide important data to the Ministry of Health and the National Chagas
Control Program for deployment of resources to these areas.
TDI considers how the coupling of the research with community education and development programs and basic health care (provided by the local health care system) can have a major impact on improving the health status of the people in the study areas.
Students and researchers that participate in the CBCDRP involve themselves in activities such as Geographical Information System (GIS), epidemiological and sociological study, entomological surveys, clinical studies, and community education.
2.2. The Role of Communication in Chagas Control
Not much had been done previously in terms of the use of communication to approach Chagas disease in Ecuador. A review of existing communication materials, revealed five educational printed materials as well as six educational and promotional videos. The following sections will describe and evaluate these materials. This sample does not cover all the existing videos produced on the subject; however, those are the accessible ones and they provide an overview of what has been produced.
2.2.1. Previously Produced Printed Materials
2.2.1.1. Educational Booklet
In 2005 the Centro de Investigación en Enfermedades Infecciosas/Pontificia
Universidad Católica del Ecuador (CIEI/PUCE) and the Ohio University/Tropical 23
Disease Institute (OU/TDI) produced an educational booklet (folleto in Spanish) about
Chagas disease to be distributed within the control and prevention activities of the
CBCDRP. According to Anita Villacís, Medical Entomologist of CIEI/PUCE, from 2005 until mid 2008, 4000 booklets were distributed in the schools and in the houses that were visited by the fieldwork team (A. Villacís, personal communication, May 8, 2008). The booklet has four games and entertaining activities about Chagas – which attract the attention of children – and didactic information: (1) what is Chagas disease, (2) how the disease is transmitted, (3) what are the symptoms, (4) how to identify the kissing bug, (5) where the insect hides in the household, (6) how to catch a kissing bug if one is found in the house, and (7) what has to be done to keep the kissing bug away from the house (*See
Appendix 01 for layout of educational booklet).
According to Villacís, the booklet’s target audience is composed of children,
teachers and other members of communities affected by Chagas. However, they were
also distributed in health centers, to doctors, to the SNEM (Servicio Nacional de
Erradicación de la Malaria) personnel, and other people interested in activities related to
Chagas disease. The objective of the booklet is for the target audience to acquire
knowledge about Chagas disease and the kissing bug as prevention and control measures.
According to Villacís, the production of the booklet was inspired by and adapted from another booklet, produced by Dr. Giovanni Onore about “El Escarabajo de Oro,” which was mainly composed of a short story. She states that the games were based on children’s game magazines, and the questionnaires were created by her, based on what she thought was adequate. 24
During the field trip to accomplish this thesis, the researcher observed that children have a lot of interest in the educational booklet. When families receive an educational talk from the CBCDRP personnel, many children immediately started playing the games of the booklet.
2.2.1.2. Calendar
A calendar was also produced by the CIEI/PUCE and the OU/TDI. According to
Anita Villacís, since 2005 about 3300 of them have been distributed by the fieldwork team when they visited the houses to search for the bug and gave the educational talk in some areas where there is risk of contracting Chagas disease (A. Villacís, personal communication, May 8, 2008). The content of the calendar was created by Dr. Mario
Grijalva, Director of OU/TDI, based on what he thought was pertinent.
The calendar has pictures of different species of the kissing bug and a list of ten ways to eliminate the kissing bug from the house: (1) keep the house clean and organized,
(2) avoid accumulating bricks, rocks and wood inside or near the house, (3) avoid accumulating agricultural products inside or near the house, (4) keep domestic animals from sleeping near the house, (5) change the chicken nests every 15 days and burn the old ones, (6) close cracks and holes in walls inside and outside the house, (7) put screens on doors and windows, (8) learn how to recognize the adults and the nymphs of the kissing bug, (9) if a kissing bug is found in the house, report to the community health volunteer, and (10) participate in activities that involve improvement of houses in the community
(*See Appendix 02 for layout of Calendar). 25
The calendar is well received by the rural population of Ecuador. When the
CBCDRP personnel visit the houses for the second time, usually the calendar they hung
during the first visit is still on the wall, and often families say they want to receive a new
calendar the following year. After pre-testing sessions performed by this research, adults
and many children were very eager to receive a calendar.
2.2.1.3. Pamphlet
The Pamphlet (díptico in Spanish) was created and has been previously used by
the Ecuadorian Ministry of Health’s Programa Nacional de Control de la Enfermedad de
Chagas. The Pamphlet presents the following subjects about Chagas disease: (1) how to
recognize the kissing bug, (2) where the bug hides inside the house, (3) the transmission
process, (4) symptoms of early and acute phases of Chagas disease, and (5) how to
cooperate with the Ministry of Health (MOH) (*See Appendix 03 for layout of
Pamphlet).
The Pamphlet was sent to the researcher in 2007 by Anita Villacís, Medical
Entomologist of CIEI/PUCE, when communication materials about Chagas previously
produced in Ecuador were requested. In May 2008, Dr. Víctor González, Jefe Nacional
del Departamento de Educación para la Salud in Ecuador, was contacted. According to
him, he produced the pamphlet in 2006 within the activities of SNEM’s Department of
Health Education. Around 10,000 of them were distributed in the Ecuadorian provinces
of Manabí and Loja. The creation process was based on Dr. Gonzáles’s personal 26
experience and knowledge of the kissing bug infestation and Chagas transmission (V.
Gonzáles, personal communication, May 8, 2008).
2.2.1.4. Brochure
The Brochure was also created and has been previously used by the Ecuadorian
MOH’s Programa Nacional de Chagas. In seven pages it presents the following medical
information about Chagas disease: (1) physiopathology, (2) diagnosis, (3) symptoms, (4)
treatment possibilities, (5) medicines used in acute and chronic phases, (6) transmission
(including congenital transmission), and (7) specificities of pediatric treatment (new born
and children under 15). Its technical language and information indicate that its target
audience is composed of doctors, nurses and other health workers that are capable of
understanding such specific vocabulary (*See Appendix 04 for layout of Brochure).
The Brochure was also sent to the researcher in 2007, by Anita Villacís.
According to the Medical Entomologist of CIEI/PUCE, the brochure had been produced by the MOH. In May 2008, Dr. Víctor González said he did not know any information about the creation of this brochure (V. Gonzáles, personal communication, May 8, 2008).
2.2.1.5. Chagas Disease CD Insert
The Chagas Disease CD Insert (Libreto para grabación de CD sobre Enfermedad de Chagas in Spanish) is being created by Dr. Víctor González within the office of
National Control of Diseases Transmitted by Arthropod Vectors2. According to the Jefe
Nacional del Departamento de Educación para la Salud in Ecuador, this CD insert will
2 Servicio Nacional de Control de Enfermedades transmitidas por vectores artrópodos. 27
accompany a video which will be used to give talks about Chagas disease in health
centers, hospitals, schools and community meetings (V. Gonzáles, personal communication, May 13, 2008). The insert is the transcription of a narration that directly addresses the population, inviting them to talk about Chagas disease, what he considers a very important subject for the entire family’s health. It talks about transmission of the disease and its symptoms, about the kissing bug and where it hides inside and around the house. It emphasizes the importance of the family in eliminating the kissing bug from households, but does not give specific recommendations of how to do it. It ends by telling people that if they find kissing bugs they should capture them alive, put them in a receptacle and take them to the nearest heath center (*See Appendix 05 for text of
Chagas Disease CD Insert).
2.2.2. Previously Produced Videos
2.2.2.1. Chagas Disease Prevention Campaign in Manabí
The video Chagas Disease Prevention Campaign in Manabí (Campaña de
Prevención de la Enfermedad de Chagas en Manabí) is an educational video produced in
2004 by OU/TDI in co-production with the NGO PLAN International Ecuador and CIEI/
PUCE. It was written and directed by Dr. Mario Grijalva, and Paula Castellanos Cuervo – at the time a Latin American Studies graduate student at OU responsible for the camera and video editing. Neither of them had any previous experience in video production or communication. According to an e-mail received from Castellanos, “90% of what took place was instinct and the will to improve the project as a whole. (…)We had no real 28
script, just the message we wanted to transmit, so we recorded audio pieces according to
what was needed” (P. Castellanos, personal communication, May 15, 2008).
With a duration of 16:44 minutes, the video is narrated in Spanish and has six
interviews (two young local health volunteers and four SNEM personnel). According to
Grijalva, this video was produced to be exhibited to children in the areas of Manabí province in order to create awareness and teach how to identify the kissing bug and prevent the disease. The video approaches the following subjects: (1) what Chagas disease is, (2) where it happens in Ecuador and how it is transmitted, (3) what the kissing bugs look like, (4) where they like to hide inside and around the house, (5) what they feed on (emphasis on domestic animals), (6) how to catch it if you find one and what to do with it, (7) the need to avoid contact between people and the kissing bug, and (8) advice on how to do it. Participation of communities in the control and prevention activities is approached in the young health volunteers’ interviews, and the four interviews with
SNEM personnel highlight the importance of their work and how well they are received by the local population. The video also emphasizes Manabí as one of the pioneer provinces in Chagas prevention in Ecuador and gives details of the kissing bug species found in the region and the types of local houses that attract them.
The video is quite long (mainly the interviews), the language is overly technical to be understood by rural populations and the information is repetitive. The researcher observed the exhibition of the video Chagas Disease Prevention Campaign in Loja to children from 2 to 12 year old (mainly 6 to 10) and their mothers, while they waited to be seen by the doctors of the clinic organized by the Community Based Chagas Disease 29
Research Project (CBCDRP) in a school in a city in Manabí in June 2007. Children lost
interest in the video and were easily distracted. When refreshments were brought into the
room during the video, children no longer paid attention to the video.
2.2.2.2. Chagas Disease Prevention Campaign in Loja
The video Chagas Disease Prevention Campaign in Loja (Campaña de
Prevención de la enfermedad de Chagas en Loja) was produced in 2005 by OU/TDI to be
shown to children and distributed to schools, hospitals, health centers, and media
specifically in the province of Loja, in southern Ecuador. The video is 21:41 minutes long
and is very similar to the video described above in terms of content, structure and format.
It is also narrated in Spanish and has the same direction and production credits.
According to e-mail received from Castellanos,
“... for Loja, Mario [Dr. Mario Grijalva] thought about a strictly educational video, directed to the population living in risk areas. The project needed to have a strong educational campaign since it was getting bigger in Loja province. (…) We needed to explain the disease in simple terms but still give a clear and strong message; so we had community members talking about it and also some ‘authorities’ to give more ‘weight’ to the message”. (P. Castellanos, personal communication, May 15, 2008)
The main difference from the previous video is the use of specific scenes of the
region of Loja, instead of Manabí. According to Dr. Grijalva, this was done for people to
identify the region where they live. It also includes animals that are common in the area –
like squirrels (ardillas) – and uses vocabulary that is different in Loja. The word “fox,”
for example, is “huanchaca” instead of “zorro”. This video does not explain in as much
detail as the previous one the two kinds of kissing bugs that exist in the region, including 30
their physiology. Also different from the Manabí video, it does not give as many details about how to improve the conditions of the houses, depending on construction.
Like the video produced in Manabí, the one for Loja also includes interviews of
community members and SNEM fieldworkers (in this case eight interviews), but they are
longer. Criticisms are the same as the ones about the video produced for Manabí: the
video is excessively long, the interviews are too long, and the information is too technical
and repetitive. These considerations go along with the opinions of Dr. Martha Rodríguez
from the Communication Department of the OPS-OMS3 who also finds the video is too
long and does not have a clear structure, being repetitive in some points. She criticized
the narrator saying that in the production of a new video, a professional should be hired
to do the work. For her, in some moments, the narration is not directly connected to the
images. Rodríguez considered the interviews important, mainly to exemplify and
reinforce what is being said by the narration, but emphasized that in some cases they are
too long. She thinks it is important to include people’s personal experiences, but they
have to be direct and clear. She believes that it is important to emphasize the participation
of the Ministry of Health / SNEM, because they play an important role in the prevention
of Chagas disease. It is also necessary to emphasize the role of the population and the
families in the fight against the kissing bug and tell them clearly what they are supposed
to do. For Rodríguez, some of the strengths of the video are the parts related to the
transmission of Chagas and how the population should report the existence of kissing
bugs in their houses (M. Rodríguez, personal communication, March 3, 2008).
3 Organización Panamericana de la Salud / Oficina Regional para las Américas de la Organización Mundial de la Salud 31
2.2.2.3. Community Based Chagas Disease Research Project – Loja
The video Community Based Chagas Disease Research Project – Loja was created in 2005 by OU/TDI in order to promote the project of the same name and recruit college students to participate in its summer study abroad program. According to Paula
Castellanos, “the project also needed other ways to reach possible ‘sponsors,’ so shortly after [the production of the two educational videos analyzed above] came the idea of a promotional video in English and Spanish to give away whenever possible” (P.
Castellanos, personal communication, May 15, 2008). The promotional video was directed by Grijalva, shot and edited by Castellanos. The video is narrated in English and addresses the following subjects:
1. what Chagas disease is and how many people it affects in the American continent; 2. what the kissing bug is and how it transmits Chagas; 3. the symptoms of acute phase and details of symptoms during chronic phase; 4. institutions that collaborate and fund the project; 5. details of the activities of the CBCDRP in Ecuador, including explanation and details of fieldworks (research activities in houses, fumigation, visits to schools, use of communication technology, sociological, entomological research, selvatic and laboratory research, and follow up visits); 6. and preliminary results of research; 7. and contact information for the ones who want to learn how to get involved or how to provide support for the project.
The video addresses many important issues to promote the CBCDRP summer study abroad program. However, the video is too long (11:32 minutes), and gives excessive details about some subjects – such as the symptoms of Chagas in the chronic phase – that might not be of interest to some viewers. The researcher also considers the language to be excessively technical, making comprehension hard for viewers who are not familiar with such scientific vocabulary. 32
2.2.2.4. Chagas: A Hidden Affliction
Chagas – A Hidden Affliction is a feature length documentary (85 minutes) about
Chagas disease that was produced in 2005. It was directed by Ricardo Preve, in a co- production between the United States and Argentina. The Argentine director was aware that Chagas affects millions of people worldwide and kills nearly 50,000 per year and is practically unknown to the general public. The documentary’s website also indicates the concern about Latino immigrants that take Chagas to the United States and Europe
(“Chagas a Hidden,” n.d.).
Preve originally wrote a script for a fiction film, a love story between a U.S. or
European woman and an Argentine man. He decided with his co-writers that the male character should be a doctor and the female should work for the pharmaceutical industry, sort of a love-hate relationship. “Then we thought why not have him be a Chagas specialist (the disease is well known in Argentina). We then decided that I would go to
Salta in NW Argentina to research the reality of the disease, so that even if the work was fiction it would have a solid factual background,” explains the director. The crew interviewed people in Argentina to find out more about the Chagas situation in the
country, and went to Europe and the U.S. to find if there were sick people there. They found them, as is shown in the documentary (R. Preve, personal communication May 11,
2008).
Preve did basic research about the disease before starting the shooting. His idea was to present it to the viewer, but in the words of the characters, with little or no narration. When asked what target audience he was aiming for, he said: “I wanted to find 33 a cure for Chagas, so I was thinking about decision makers and people who could fund the research, but also about the general public because I did not want a boring institutional video.” Regarding the choices of where to shoot, he chose to film in locations that were near where he was living or working because he had no funds for extensive travel.
Preve said no communication or health institutions were involved in the production of the documentary, “the [Argentine] Government was openly hostile or indifferent to the project. However, Doctors without Borders provided some support to make it known. The support I got came solely from patients, doctors, nurses, a few foundations, and private individuals who fight against this disease.”
Since its release in 2006, Chagas: A Hidden Affliction has been broadcast on PBS television stations in Virginia and has been exhibited in conferences and many film festivals in the U.S., Spain, Italy and Latin America, mainly in Argentina and Brazil.
Ricardo Preve is on the Board of the Chagas Disease Foundation and donates 50% of the royalties on the sales of the DVD to the Chagas Disease Foundation.
2.2.2.5. Video and Song about Chagas Disease
The Video and Song about Chagas Disease (Video y Canción sobre la
Enfermedad de Chagas) was made by JICA Chagas disease control project in El
Salvador. The song was composed by Mr. Alquilo of Olopa, Chiquimula with collaboration with Doctors without Borders and added to the website youtube.com in
November 06, 2006 (http://www.youtube.com/watch?v=Xx8jiSs6OCw). The video clip
(04:48 minutes long) shows scenes of rural areas and local populations, many scenes of 34
the kissing bug (called chinche) and people with Chagas disease. The song talks about
what kind of kissing bugs exist, where it hides inside the house, how dangerous they are
and that they can be carried to the house by domestic animals and rodents. The song also
talks about the different phases and the symptoms of the disease. The song emphasizes that it is necessary to combat the presence of the kissing bug. The researcher was not able
to find information about the video clip’s production, exhibition or distribution.
2.2.2.6. Kids without Chagas
The animation called Kids without Chagas, Let’s Eliminate the Kissing Bug from
our community (Niños sin Chagas ¡Eliminemos las Chinches de Nuestra Comunidad!) tells the story of Pedrito, a boy who liked to go to school and play with his friends. The
video shows Pedrito sleeping in a disheveled house made of adobe. A dog sleeps inside
the house near him. Even though the video shows a typical type of construction where the
kissing bug likes to hide and the presence of animals inside the house that attract the
insect, it does not explain it clearly or indicate these conditions should be avoided.
Pedrito starts missing school because of fever and body ache. He discovers he has Chagas
and explains to his classmates it is a disease transmitted by the kissing bug (chinche
picuda). The narrator than explains how kissing bugs bite people and defecate while
feeding. Scratching can introduce the parasite into the body. He says this is how Chagas
Disease is produced. The version found youtube.com is missing the last 4:30 minutes of
the animation, so it was impossible to verify if the video also approaches important 35
aspects of Chagas such as what happens after the transmission of the disease and what people can do to prevent it.
The animation was produced by the Communication Department of the El
Salvador University (UES) and volunteers of the Japanese Agency of International
Cooperation (JICA). The animation was released in 2007 by the Chagas Disease Control
Project carried out by JICA which, since 2003, maintains educational programs for
Chagas prevention and elimination of the vector, as well as training of health personnel in
El Salvador, Honduras and Guatemala. Kids without Chagas was created to be disseminated on local television channels and in educational centers of rural areas in the three countries. According to Felipe Vargas, UES – Communication Secretary, more than
70 children and adults participated in its animation, which makes the animated video a participatory project (“Animación Digital,” n.d.).
2.2.3. The Gap in Chagas Related Communication Materials
The previous sections described five printed materials and six videos related to the prevention and education about Chagas disease. The evaluation of all these communication materials revealed at least one gap: despite the fact that they were created by institutions or people that have substantial knowledge about Chagas, no health communication theories or models were used in their creation and production processes.
The next section of this research will describe some of theories and models and explain the importance of their use. 36
2.3. Health Communication Theoretical Framework
The high and increasing number of infected people throughout the world and
deaths per year caused by Chagas disease indicate that something needs to be done
urgently to help the affected population. Since a vaccine is not available and a cure is
only effective in the early stages of infection, it is very important that the population that lives in the areas where there is risk of contracting Chagas be aware of the existence of the disease and of what can be done to prevent it from spreading. Health communication theories show that education and communication campaigns can be very effective in working towards achieving behavior change.
The development of health communication strategies can be based on different theories and models. The following section will describe some of the more commonly known approaches to health communication that were created to serve as guidelines for planning, designing, implementing and evaluating a communication strategy. All of these health communication guides and tools present theories and models used to achieve the same final objectives: encourage adoption and maintenance of new behaviors to improve health conditions. This is not meant to be exhaustive on the subject, but will give an overview of what will be critical to serve as a basis for the creation of materials related to
Chagas disease.
According to the Participatory Communication Strategy Design Handbook – produced by the Food and Agriculture Organization of the United Nations –, to be relevant to a community and achieve the intended objectives, a communication strategy needs to be shaped according to the community’s needs and mainly to its capability of 37
action (Mefalopulos, 2004). The idea that in order to achieve behavior change a
communication material needs to provide precise and useful information about the
subject is also found in many other health communication guides and tools. They all
emphasize that the presence or absence of an accurate content has a direct impact on the
way people receive a message. They also agree that, in order to achieve this objective, it is necessary to pre-test any communication/educational material with members of the target audience before implementing it.
An approach to health communication that is relevant to this research is Health
Communication: Lessons from Family Planning and Reproductive Health. Written by
Phyllis Tilson Piotrow, D. Lawrence Kincaid, Jose G. Rimon II, and Ward Rinehart, it emphasizes that, in the field of family planning, people want to know what family planning is, what the available methods are, where they are available, how to use them, and what results to expect. If the subject of family planning is substituted for Chagas disease, these questions can be taken as pertinent to issues studied by this research.
The guide presents a systematic process for developing strategic communication programs that can improve health behavior. The examples chosen to prove that a well planned communication strategy can change health behavior were the lessons learnt from family planning and reproductive health experiences over many years in more than 50 countries, all over the world. More specifically, they based their research “on the experience of the Population Communication Services program at the Johns Hopkins
University School of Public Health, one of the largest, oldest and most comprehensive programs in this field” (Piotrow, Kindai, Rimon II, & Rinehart, 1997, p. 3). The fact that 38
health communication can influence people’s behavior is evident and has been
undeniably proven over years of family planning communication. The concern is how to
use existent theories and rapid growth of communication’s power to sharpen strategies
and get better results.
Family planning programs began to be used in the mid-20th century. Since then,
family planning programs and related communication campaigns have evolved
considerably, causing several changes in the strategies used by health and communication professionals all over the world. By the early 1970s, new contraceptive technologies (the
intrauterine device – the IUD – and oral contraceptives – the pill) were used by many
women, and general knowledge about family planning had already reached levels as high
as 70 to 85 percent of married women of reproductive age (Piotrow, Kindai, Rimon II, &
Rinehart, 1997, p. 6). Although theories of family planning may not be directly related to the Chagas, disease, their communicative strategies are extremely relevant. In the 1980s,
the focus was on reducing high-risk fertility, stimulating people to consciously choose the
size of their families, and increasing the use of contraceptives. By the beginning of the
1990s, the concern about HIV/AIDS changed the center of attention on family planning strategies towards encouraging sexual responsibility, limiting the number of sexual partners and increasing the use of condoms. In the mid 1990s, international conferences added new concepts to the concerns, such as quality of health care, safe motherhood, and protection from sexually reproductive diseases. By this time, more than 168 countries had already adopted national population and development policies (United Nations 39
Population Fund [UNFPA], 1995) and most of them included family planning programs
(Piotrow, Kindai, Rimon II, & Rinehart, 1997).
Piotrow and his coauthors’ Health Communication guide describes the
development of family planning as an example of development of communication. The authors show that the wideness of range and the focus of family planning messages changed since the 1950s. The change in family planning that is most relevant to this research regarding Chagas disease is that communication processes went from a one-way transmission of message – with little concern over the content of the message or the different audiences that could receive it – to two-way communication programs in which the audience is included in the process to help create and pretest the message. The tactics and components of health programs in family planning also changed, going from simple brochures and flipcharts used in clinics to complex strategies that combine interpersonal communication, community actions, and mass media. Increasing participation of the media in health communication, the appearance of new technologies and the exponential growth of the number of radio and television receivers in the developing world had a direct impact on health behavior change. These last two factors were considered in this study to create the PSAs, the educational video and the communication campaign for
Chagas disease prevention.
Focus on the audience and individuals led the health communication field to turn to processes based on behavior change. Many models emerged in different fields, all of them explaining steps which individuals go through while they exchange information and react to a message until they adopt a new behavior. Based on this idea, the Population 40
Communication Services – the program on which Piotrow and his coauthors based their research – developed a theoretical framework called Steps to Behavior Change (SBC).
The model consists of five major stages of change: knowledge, approval, intention, practice and advocacy (Piotrow, Kindai, Rimon II, & Rinehart, 1997).
Studies show that progress from one stage to the next increases the probability of continuity of the new practice adopted in the previous step, leading to an effective
behavior change. That is the reason why the John Hopkins University School of Public
Health developed a Systematic Process for Developing Strategic Communication
Program based on behavior change through stages. What is called the P Process consists of six steps that are used to develop and implement national communication strategies, programs or activities: (1) analysis, (2) strategic design, (3) development, pre-testing and
revision, and production, (4) management, implementation, and monitoring, (5) impact
evaluation, and (6) planning for continuity (see Figure 1) (Piotrow, Kindai, Rimon II, &
Rinehart, 1997).
Figure 1. P Process (Piotrow, Kindai, Rimon II, & Rinehart, 1997, p.27)
41
Since the late 1990s, the P Process has been adopted and applied by many family
planning communication programs all over the world. To prove its efficacy, Piotrow and
his coauthors explain how to put this theoretical framework into practice. The initial step
– called Preliminary Analysis for Program Planning – is to identify what needs to be done so the communication process can help achieve the objectives of the program. The initial communication analysis has to focus on the people, on the information they already know, what they believe, hope for and practice. The analysis also needs to identify the existent government policies and other organizations related to the subject, and how they can impede or assist the communication program. The preliminary analysis also has to worry about finding the best communication channels to reach the different audiences.
The Health Communication guide emphasizes the second step – the Strategic
Design – as important to all kinds of projects, because it determines all the key elements during the entire communication program. The main tasks in this moment are related to setting objectives that are specific, measurable, appropriate, realistic and adequate to the timeframe. The Strategic Design step also points out the importance to determine how to achieve objectives, identify implementing organizations that will cooperate with the program and plan for documentation and evaluation.
In the third step – Development, Pretesting, Revision and Production –, professional quality and creativity in the communication field have to work along with
expertise in the health field. Audience participation and feedback is also indispensable
when producing communication materials. And after creating a material of high quality, 42
its production in large scale will also make it cost-effective and it will be used for many years.
The fourth step deals with details of Management, Implementation and
Monitoring that can turn a project into a success or a failure. Key concepts at this moment are to mobilize and engage the main organizations linked to the project, implement the action plan, and monitor the dissemination, transmission, and reception of program outputs. The last two steps – Impact Evaluation and Planning for Continuity – reinforce the need to dedicate time and resources to review the impact of the
communication strategy and plan future actions based on the strengths and the correction
of flaws.
From the 1970s to 1997 (year when the analyzed Health Communication guide
was released), numbers show that the total fertility rates in developing countries declined
from an average of six children per woman to 3.4. According to the authors, the use of
well-planned communication strategies had a direct impact on this positive results of
family planning programs. However, they recognize the P Process is liable to have
problems in cases such as budget, human resources, and timeframe limitations, or need
for fast results (Piotrow, Kindai, Rimon II, & Rinehart, 1997).
Despite the fact that the Health Communication guide focuses on family planning
communication, the ideas are not limited to family planning issues. They can be applied
to health communication in general. The authors explain that, “most of the lessons
learned from the Population Communication Services project apply to other fields of
public heath as well. They apply specially to activities that require informed individual 43
choice and changes in personal behavior” (Piotrow, Kindai, Rimon II, & Rinehart, 1997,
p. 3).
The possibility of being applied to other fields is the reason why this guide was
chosen to be analyzed and serve as one of the examples for the Chagas related communication materials produced by this thesis. The fact that the number of radio and television receivers in the developing world had a direct impact on health behavior change, helps support the choice of producing a series of public service announcements to be broadcast on television and an educational video to be exhibited in schools and also on television. The focus on the audience and on the individuals is also largely taken into consideration by the researcher, as an encouragement to behavior change.
Within the six steps suggested by Piotrow and his coauthors, the ones that are most relevant to this research are steps 1 (analysis) and 3 (development, pre-testing and revision, and production). For the videos to achieve the objectives of the program – encourage behavior change towards Chagas prevention –, research focused on the people who live in areas of Ecuador where there is risk of contracting the disease. The research analyzed the information the population already know about Chagas – which is minimal
– and identified the communication materials already used by the local Ministry of
Health and the Community Based Chagas Disease Research Project (CBCDRP).
Following recommendations of the preliminary analysis, this research also dealt with finding the best communication channels to reach different audiences: television and activities already organized by the CBCDRP. 44
As is recommended in step 3, this research combined professional quality and
creativity in the communication field – video production and editing personnel – with the
expertise in the health field – the personnel of Ohio University/Tropical Disease Institute
(OU/TDI) and Centro de Investigación en Enfermedades Infecciosas/Pontificia
Universidad Católica del Ecuador. The guide also states that audience participation and feedback is indispensable when producing communication materials. Based on that, this research pre-tested the videos in order to create effective materials of high quality, which can be used in large scale for many years. Pre-testing is also one of the main recommendations for the implementation of the Chagas prevention communication strategy. However, it was difficult to apply all the Health Communication guide’s suggestions to this research. The budget was limited to the resources of OU/TDI for travel to Ecuador for the shooting and pre-testing of the videos. A larger participation of the Ecuadorian community in the creation process of the videos was not possible, because during a large part of the script writing process the researcher was in the United States.
Human resources were limited to the OU students that agreed to collaborate with the project. And the timeframe was restricted to the fact that the OU/TDI wanted to start using the educational video created by this research in the summer of 2008.
Another theory relevant to this research is present in Making Health
Communication Programs Work: Planner’s Guide – created by the National Cancer
Institute of the U.S. Department of Health & Human Services. Based on a social marketing framework, this theory applies the “commercial marketing technologies to the analysis, planning, execution, and evaluation of programs designed to influence the 45
voluntary behavior of target audiences in order to improve their personal welfare and that
of their society” (Andreasen, 1995, p. 7). The Planner’s Guide was created to help plan
communication programs for different health issues. The purpose is to teach planners how to identify their target audience, and how to prepare and implement a successful communication strategy based on their needs.
Social marketing is not a one-way, top-down strategy. It is a complex process of information transmission. The guide recommends following a Health Communication
Program Cycle, which is composed of four stages that constitute a circular process in which the last stage leads back to the first one. It is a continuous loop of planning, creating, implementing, and improving (National Cancer Institute, 2004, p. 11) (see
Figure 2). Despite its division into a different number of stages, the Making Health
Communication Programs Work: Planner’s Guide suggests a process very similar to
Health Communication guide written by Piotrow and his coauthors.
Figure 2.Health Communication Program Cycle 46
Stage 1, Planning and Strategy Development, creates the foundation for the entire communication program. The Planner’s Guide suggests evaluating the health issue that is being addressed and identifying all the components of a possible solution, to define the communication objectives, determine and learn details about the intended audience. The guide also emphasizes the need to identify the best channels and activities to reach the intended audiences. The planner should identify partnerships, and plan activities and surveys for outcome evaluation.
In Stage 2, Developing and Pre-testing Concepts, Messages, and Materials, the planner should review pre-existing materials, develop new messages and evaluate them with the intended audience. After that, it is necessary to decide what new materials will be developed, create them and pre-test them with intended-audience members. Stage 3,
Implementing the Program, is the moment to launch and implement the new program, make the first evaluations and necessary adjustments.
Stage 4, Assessing Effectiveness and Making Refinements, is the time to conduct an outcome evaluation of the communication program that was planned, created, and implemented in previous stages. The evaluation should be done by quantitative and qualitative research. The data must be carefully analyzed in order to identify weaknesses and strengths. The results should be disseminated and used to solve current problems, as well as to increase the effectiveness of future programs.
The guide Making Health Communication Programs Work emphasizes the four stages and each of their different steps as very important. Not all the suggested steps might be feasible or necessary for all programs. The planner is supposed to analyze the 47
specificities of his or her own project, along with the available resources, and only apply
the appropriate steps. According to the guide, by going through the complete process,
even the less experienced planner will be able to organize his or her ideas, create realistic
time table and budget, and justify such a long process to clients and financial supporters.
One of the most important Social Marketing concepts used in the Planner’s
Guide is Market Research. According to Melkote and Steeves, the Market Research is a detailed investigation of the market, looking for a specific audience, product, idea or
service (Melkote & Steeves, 2001, p. 128). For this Guide, Market Research is vital to identify and understand details about the intended audience and to develop adequate messages and strategies that will motivate action (National Cancer Institute, 2004, p. 8).
One of the uses of the information found through market research is to understand what tone and language communicators should use (National Cancer Institute, 2004, p. 48).
One strength of the Planner’s Guide is the emphasis on how to get feedback from intended audiences. This was applied to the creation of the Chagas disease prevention materials in the form of pre-testing before implementation. Despite the fact that the Guide does not present clear instructions on how to create an effective budget, it discusses the importance of not letting a small budget keep the project from achieving its objectives. For this reason, Ohio University students who wanted to collaborate on the project were welcomed and and the videos were finished on time for implementation by
the CBCDRP in summer 2008.
Another Social Marketing concept adopted by the Planner’s Guide is the use of
incentives. This concept implies the use of monetary or psychological incentives that are 48
given out to help the target audience adopt a new product or service (Melkote & Steeves,
2001, p. 128). The Guide goes further, saying that incentives can be not only economic or psychological, but also social (i.e. in a weight-loss campaign, people realized exercise is a fun group activity), family-driven (when family members benefit from individual behavior change), or ego-driven (when a behavior change improves the way an individual looks) (National Cancer Institute, 2004, p. 68-69). The introduction of a behavior change
is seen as an exchange and not only a persuasion (Melkote & Steeves, 2001, p. 128).
The use of incentives is one of the aspects of the Planner’s Guide that applied
to the creation of materials to help prevent Chagas disease. In this case, the incentives to
behavior change are not monetary, psychological, social or family-driven. The main
benefit the population receives for adopting the suggested Chagas prevention actions is
not contracting a killer disease. That is the reason why the message of the public service
announcements and the educational video created by this research emphasizes not only what the population should do, but also the benefits they will receive (*See Appendices
15 and 17 for video scripts).
As the Planner’s Guide emphasizes, not all suggested steps in health communication might be feasible or necessary for all programs. Following the Planner’s
Guide recommendations, the researcher analyzed the specificities of her project, the available timeframe and resources, and decided to focus on Stage 2, which consists of developing and pre-testing the messages and materials. This choice was made because the previous educational and communication materials used to address Chagas disease prevention did not follow these procedures. This research reviewed the pre-existing 49 materials used to address Chagas disease prevention, developed new and more adequate messages, pre-tested them with the target audience, and made necessary changes before implementation.
Planning Social Mobilization and Communication for Dengue Fever Prevention and Control: A Step-By-Step Guide (Dengue Guide) is another approach to health communication that has relevant parts that can be applied to the prevention of Chagas disease. The Dengue Guide was written by Will Parks and Linda Lloyd, and published by the World Health Organization, in 2004. It was designed for the prevention and control of a specific health problem, Dengue Fever. The justification for a guide dedicated to
Dengue is an average of 50 million infections and at least 21,000 deaths every year.
According to Parks and Lloyd, around 40% of the world’s population (2.5 billion people) lives in risk areas.
Despite its specificity, the Dengue Guide presents an innovative approach to social mobilization that can be used in the prevention of other diseases such as Chagas.
Known as Communication-for-Behavioural-Impact (COMBI), the model assembles marketing, education, communication, promotion, advocacy and mobilization approaches to encourage behavior change and promote partnerships between the program and the endangered community. The Dengue Guide proposes the adoption of 15 detailed steps to help plan, implement, and monitor a variety of communication actions. The final objective is to engage individuals in considering recommended healthy behaviors and to encourage their adoption and maintenance. Parks and Lloyd emphasize that a small 50
budget cannot keep the project from achieving its objectives and highlight how each step
needs to fit the campaign’s budget.
The Dengue Guide sums up communication theory models developed over the
past 50 years. Many of its lessons were taken into consideration in the creation of the
Chagas prevention videos and communication strategy. A health communication program
has to understand and adapt itself to the cultural differences of the receivers. The setting
in which the communication takes place must facilitate the process since the program
must choose the right communication channel for different target audiences, and the
source that will deliver the message must be credible. The educational video will be
exhibited in schools and community meetings in endemic areas to inform people that are
at risk of contracting Chagas. The PSAs were chosen to be broadcasted on Ecuadorian
national television, to reach the at-risk population, politicians, sponsors and health
promoters.
The message must be clear, so the technical vocabulary about Chagas disease used in the first videos created by the OU/TDI and CIEI/PUCE was changed to words that can be easily understood by the target audience. Also to attend to their needs, the
PSAs and the educational video are narrated in Spanish. Considering that the
communication must allow the receiver to give feedback, the PSAs and the educational
video were pre-tested with members of their target audience. The participants’ opinions
and reactions were taken into consideration and necessary changes were made to make
them more comprehensible and, consequently, more effective. The same pre-testing
process is suggested for other materials of the communication strategy. And behavioral 51 change should be the end-result of the communication effort (Parks & Lloyd, 2004, p.
45).
One of the main differentials of this model is the attention given to human resources, the people behind the development and implementation of the communication program. The COMBI tool not only explains how relevant it is to work with a multidisciplinary planning team (e.g. an anthropologist, sociologist, and communication specialist). It also gives a list of expertise and previous experiences that the professionals should have. The model also approaches the need to strengthen staff skills by providing
... opportunities for service personnel to learn how to develop and implement appropriate social mobilization and communication strategies, how to listen and work with community members, and how to link their plans and activities with local perceptions, conditions, and resources. Training may also need to be arranged (…) for volunteers and staff from other agencies supporting your programme. (Parks & Lloyd, 2004, p. 67)
To follow these recommendations, this research gathered a multidisciplinary team including health communication, video production, and Chagas disease specialists. In the case of the communication strategy, many activities are suggested to strengthen the communication skills not only of the staff directly linked to the strategy, but also of the
MOH’s personnel.
Although not many health communication theories have been applied specifically to Chagas disease, there does exist a Report on the Technical Consultation on
Information, Education and Communication (IEC) on Congenital Chagas Disease produced by the Pan American Health Organization, in 2007. The report is dedicated specifically to the transmission of Chagas from mother to fetus, which is presented as 52
“the only mode [of transmission] that is still active without any type of intervention in many endemic countries” (Pan American Health Organization, 2007, p. 1). The report was produced to set the base for IEC in order to create awareness towards diagnosis and treatment of newborns infected with Chagas. Among its recommendations, the report emphasizes the need to strengthen IEC with the purpose of adequately including congenital Chagas on national health agendas in the Americas, inform the general and at- risk populations, and train human resources.
The Technical Consultation recommends establishing five group goals for the messages and output on congenital Chagas that should receive different messages and actions: (1) women and their family environment, (2) health workers, (3) educators, (4) decision-makers, and (5) the general public. Regarding (1) women and their family environment, the report recommends the following groups should be taken into consideration: women at risk of Chagas infection, pregnant women, infected mothers and children, and the family of infected persons. They should be informed about the disease and that any woman with Chagas can transmit the infection to her fetus, however, that it does not happen in all cases. They should also be informed that diagnosis is relatively simple and any child with congenital Chagas disease should be diagnosed in a timely fashion, because the lower the child’s age, the more effective the treatment will be. The report also states the need to perform adequate actions against the vector in the household and surroundings, in order to prevent re-infection (Pan American Health Organization,
2007, p. 4). 53
Within the (2) health workers sector, the report points out the need to address physicians, laboratory technicians, obstetricians, midwives, social workers, nurses, and institutional and community health-care workers. (3) Educators are also part of this group because it is suggested that the congenital Chagas should be included in undergraduate and graduate curriculums, continuous education programs for professionals and technical courses to train health workers. The suggested IEC package dedicated to this target group includes knowledge about the disease regarding its natural history, infection, diagnosis, and treatment. The report states that this is “part of a strategy to strengthen the motivation, involvement, and obligation of health workers with regard to their basic skills, attitudes, and practices related to care for people with Chagas infection in general and congenital Chagas disease in particular” (Pan American Health Organization, 2007, p. 4).
Regarding the educators, the Technical Consultation on Congenital Chagas
Disease says that Chagas disease and its congenital transmission should be part of academic curriculums. Therefore, teachers, faculty and staff in primary, middle and secondary schools and higher education institutions are included as target audiences for
IEC activities. In terms of (4) decision-makers, the report says that IEC efforts should address not only the health sectors, but also other sectors that might be related to the subject at the national and local levels. For this target audience, the IEC package should focus on advocacy at the level of decision making, in order to get congenital Chagas included in the health political agenda. It is suggested that clear reference should be made 54
to the socioeconomic impact of the disease. Community “empowerment” is also cited as
part of the basic strategic lines that should be encouraged in the decision-making level.
Despite the fact that the (5) general public is one of the five group goals listed
initially by the Technical Consultation on IEC on Congenital Chagas Disease, the report
does not give further explanation on how it should be addressed. It focuses on the target
groups that should be addresses by an Information, Education and Communication (IEC) strategy and the general messages they should receive. However, it does not give
guidelines on to how this message should be presented to the target groups and it does not indicate a theoretical framework in which educational materials should be produced or activities should be organized. Despite this limited attention to health communication theories, this Report is already an advance from the other guides and models analyzed above, because it is a recent study, dedicated specifically to Chagas disease.
55
3. MESSAGE DESIGN AND PRE-TESTING METHODOLOGY
Previously existing printed materials and videos used for Chagas prevention
activities were not based on health communication theories (*section 2.2). However,
successful experiences discussed in the health communication literature achieve the
intended objectives by shaping the communication strategy according to the community’s
needs and mainly to the community’s capability of action (*section 2.3).
Based on these findings, the researcher’s interest and previous experience in video
production, and on the needs of the Community Based Chagas Disease Research Project
(CBCDRP), this research created a series of public service announcements (PSAs) to help prevent Chagas in Ecuador, and a new educational video to substitute the one that had been used in the past years by the CBCDRP. This section describes the methods and procedures of message design, production and pre-testing of the videos. It also makes recommendations for the final version of a series of public service announcements
(PSAs) and an educational video.
3.1. Message Design
The PSAs and the educational video were created to translate the existing technical information about Chagas into a language accessible to people outside the scientific world. The main intention was to reach adults and children that live where there is risk of
Chagas contraction and encourage their behavior change regarding prevention measures.
Another intention was to sensitize Chagas disease and communication researchers, in addition to private, academic, governmental and non-governmental institutions that can 56
perform or sponsor initiatives that can change the current situation. The final objective
was to increase awareness about Chagas, decrease the number of infected houses,
decrease the number of bugs in infected houses, and decrease the number of infected
people.
To answer the first research question about which factors should be taken into account for the development of a series of PSAs and an educational video that create awareness about Chagas, health communication theories were implemented. Since elements of a communication strategy have to be focused on the audience they intend to reach, the narration of both videos was written in Spanish to be accompanied by local
Ecuadorian music as soundtrack. In both cases, the first concern was to design the message for a particular target audience.
The shooting of the PSAs and the educational video was done during field work in Ecuador4 (*See Appendix 06 for production credits), with the help of Ohio University
Film graduate and Telecommunication undergraduate students. The purpose was to
accompany and collect images about the work of the Chagas control and prevention
groups, interview the local population affected by the disease and the participants of the
CBCDRP (*See Appendix 07 for simple recording consent). In the case of doctors,
students, researchers and people with a higher level of literacy, they were asked to sign a
more complex and complete recording consent (*See Appendix 08 for complete
recording consent).
Ideally, the process of message design of the PSAs and the educational video
produced by this thesis would have been more theory driven but time constraints
4Shooting trips: two weeks in March 2007 and four weeks in the summer of 2007 (June 12th – July 13th). 57
demanded a modified approach. According to successful initiatives found in health
communication theories, more orthodox research employs a detailed formative research.
As is emphasized by the Planning Social Mobilization and Communication for Dengue
Fever Prevention and Control: A Step-By-Step Guide, the formative research is relevant to:
a. identify social issues, gaps in knowledge and health education, and resource constraints that impede existing prevention or control programs; b. highlight community-felt needs; c. identify what local populations are doing, thinking, and saying about focal issues, behaviors, technologies, and service staff; d. discover key cultural analogies that can be used for health education messages; e. identify current behaviors that, after slight modification, could become more effective at removing or reducing health risks; f. examine what barriers might stand in the way of adopting new behaviors and how to resolve them; g. investigate motivations and opportunities for change; and h. provide information on how, who, when, and where best to implement the strategy (Parks & Lloyd, 2004, p. 27)
Piotrow and his coauthors also state that the initial step in health communication should be a preliminary analysis for program planning, which leads to the creation of educational materials such as the PSAs and the educational video created by this research. Ideal research allows for the message to be participatory from the beginning, using community members to help identify barriers to behavior change, discover solutions for it and design the communication materials.
3.1.1. Script Writing – Educational video
At first, the same target audience previously used by the CBCDRP was adopted and the educational video was made focusing on children living in areas where there is 58
risk of Chagas disease in Ecuador. According to CBCDPR, the children are eager to learn new information and they are capable of passing the information along to their family members. In this manner, the children would grow up already knowing about the risks of
Chagas.
The script suggested an educational video of approximately nine minutes duration, a length that would catch children’s attention without letting them get bored.
The script was designed to help children understand that they can collaborate to eliminate the kissing bug, help prevent Chagas disease and contribute to the well-being of their own community. To give some dynamic to the video, it included interviews with community members, the SNEM personnel and Dr. Grijalva, who talks directly to the children, explaining that they are the heart of the Chagas Prevention Program. Mixing animation and real images, using a language that can be easily understood by children and is not too childish for adults that might accompany them during the exhibition, the educational video approaches:
a. What Chagas disease is and how it is transmitted; b. What the symptoms of the acute phase (right after contraction) are and what to do if someone feels them; c. What the symptoms of the chronic phase are; d. How to recognize the kissing bug; e. Where to find the kissing bug inside and around the house; f. How to eliminate the kissing bug from the house; g. How to catch the kissing bug if one is found in the house; h. Instructions to contact the Ministry of Health; and i. Incentives to change behavior in order to prevent Chagas.
Also in terms of the target audience of the educational video, the initial idea was to follow what had been done in the past and produce separate educational videos for the 59 different regions of the country in which the CBCDRP operates: Loja and Manabí provinces. Grijalva considered this necessary because of the differences in landscape and type of houses in each region. Due to limited editing time and production restrictions, this research produced only one educational video, including scenes from Loja and Manabí.
To check the acceptance of this single video, it was pre-tested in Loja to see if the local population had any problems with seeing images from both areas.
To guarantee the educational video would reach the target audience properly, from August 2007 to March 2008 (when the pre-testing was done), small changes were made on the script based on feedback from expert reviewers and need of Spanish corrections.
3.1.2. Script Writing – PSAs
The first versions of the scripts for the PSAs were written during the second shooting trip to Ecuador under the request of Grijalva who said that PLAN Internacional
– international NGO that supports the CBCDRP – might start broadcasting the commercials immediately. Grijalva, as the director of the project, requested that the PSAs say that many people die of Chagas every year but not to use the specific number of victims in Ecuador so as not to create panic among the population, which could lead to an emergency situation in the country. He also suggested that the following subjects be addressed:
a. The kissing bug transmits the disease through its feces; b. Where the bug lives; 60
c. What to do when community members find bugs inside or around their houses; d. and How to prevent the bug from entering the house.
The length of the PSAs is 30 seconds, which is the international pattern for
television commercials. The scripts were created to reach the target audience: adults living where there is risk of Chagas contraction. The focus on adults is because they have the power to make decisions in their houses that may lead to behavior change towards
Chagas prevention.
Also related to the PSAs’ target audience, videos were created that represented the entire country and would be broadcast nationally, instead of making separate videos for different areas or choosing one area to represent the entire country. In the beginning
of each PSA, the screen splits in four, showing four different houses, from different
regions. In each of the two PSAs, one of the houses takes up the entire screen. This was
also a solution to show that Chagas is present in many different areas, in different kinds
of houses.
Due to the data that only 2% of the population in southern Ecuador is aware of the
existence of Chagas and that, even when they recognize the kissing bug, they are not
aware it can transmit a disease (Grijalva, Palomeque-Rodriguez, Costales, Da Vila, &
Arcos-Teran, 2005, p. 1), all the scripts started by showing images of the kissing bug
with the following questions: “Have you seen a kissing bug like this one in your house?”
and “Do you know it can transmit Chagas Disease?” To help people understand that their
participation is important in the prevention process, the following sentence was: “But
with your help it is possible to prevent this disease that kills many people every year.” 61
The other objective of the PSAs is to teach the at-risk population how to prevent
the disease. To be able to include all the information on how to prevent the bug from
entering the house it was decided to create eight PSAs. Each of these recommended a
specific action the audience can take to prevent Chagas disease and, to increase credibility, they also said what the benefit is to adopting the suggested behavior:
a. Always keep the house clean and organized, so the kissing bug won’t have a place to hide. b. Use bed nets with piretroid insecticide when you go to sleep, so the kissing bug won’t bite you. c. Avoid accumulating agricultural products close to the house, because they attract rodents. d. Avoid accumulating bricks, rocks and wood close to the house, so the kissing bug won’t have a place to hide. e. Make sure the domestic animals sleep away from the house, because the kissing bugs feed on them. f. So that kissing bugs do not have a place to hide, change chicken nests every 15 days and burn the old ones. g. If you find any bugs in the house report to a Health Promoter, so what is necessary can be done. All PSAs have the same beginning and ending. The common structure was
created to make it possible for the audience to identify the subject – Chagas disease
prevention – when they see any of the commercials on television. The common ending
was: “Eliminate the bug from the house and around it! You can prevent Chagas Disease!”
The PSAs’ 30 second duration also resulted in limits in terms of how much
information they could include. Part of the information initially suggested by Grijalva to
be included in the PSAs was not used: “the kissing bug transmits the disease through its
feces” and “where the bug lives”. This was done because the information was considered
too complex to be explained within 30 seconds. The time constraint also led to the
decision not to include in the PSAs some information that is in the educational video, 62
such as how Chagas is transmitted, the symptoms, and how to identify the kissing bug.
None of the PSAs tells specifically how to catch the kissing bug if one is found in the
house, but the PSA that instructs the viewer to contact the Ministry of Health, shows the process through scenes. This information will be given to the target audience through other educational materials.
3.1.3. Video Editing
The video editing and animation for all the videos produced by this thesis were done by Ohio University Telecommunication (OU/TCOM) undergraduate students who agreed to collaborate with the project (*See Appendix 06 for production credits). Editing was done in OU/TCOM facilities or on the editor’s home equipment. The PSAs and the educational video were edited on Media Composer 2.8 from September 2007 to June
2008. The promotional video, which is part of the recommendations of this thesis, was edited on Final Cut Studio 2 in May and June 2008. The animation was created on Adobe
Flash CS3, from January to June 2008. For the PSAs and the educational video, the narration was recorded by Spanish native speakers in a studio in Ecuador. For the promotional video, the narration was recorded in the OU/TCOM facilities.
Ideally, a professional musician would have been contracted to create a sound track specially for the videos. The music for the PSAs and the educational videos would be based on local music references, so the audience would recognize it as part of their culture. However, the project did not have funding to hire a professional musician. The 63 music of Andesmanta, an Ecuadorian group that plays mostly instrumental music, was used with their permission.
3.2. Research / Pre-Testing Design
To answer one of this thesis’s research question of what to consider in order to make sure the PSAs and an educational video would create awareness about Chagas, a suggestion of communication tools and guides was used: pre-test communication/educational materials with members of the target audience. Based on the responses, changes were made before the videos were considered ready for implementation so, when broadcast or distributed, the educational materials will have the expected effect.
The research design determined that the public service announcements (PSAs) were going to be pre-tested among adult Ecuadorians who live in Chagas endemic areas.
The educational video was to be pre-tested among Ecuadorian children who live in areas where there is risk of contracting Chagas disease. In both cases, the general objective was to verify if they understood the videos’ message, and if they were motivated by them to collaborate to eliminate the kissing bug from their communities and change their behavior towards Chagas prevention. Specifically, the objectives of the pre-testing were:
a. Identify the weaknesses and strengths of the videos; b. Identify the target audience’s reaction to the videos; c. Detect if the correct audiences were being addressed; d. Detect if the right message was being used; e. Identify any unplanned messages; f. Assess whether messages were clear and compelling; g. Detect if the correct language was being used; 64
h. Detect unpredictable audience responses and other aspects of materials that may require modification; and i. Provide some insight into whether the messages and materials were going to generate the desired behavioral impact.
Based on the findings of the pre-testing, the original scripts of the PSAs and the educational video were revised and necessary changes were made to the edited videos to improve and adapt them to the needs of the target audience. However, as the following will show, some of the suggestions of pre-testing were not followed for different reasons.
(*See Appendices 14 and 16 for changes on videos).
3.2.1. Pre-Testing of Pre-Scripts
After writing the first version of the scripts of the PSAs and the educational video, they were pre-tested with expert reviewers to make necessary changes before finishing the video’s version used for pre-testing (*see Appendix 09 for list of expert reviewers).
During this process, the Ohio University/Tropical Disease Institute (OU/TDI) and the
Centro de Investigación en Enfermedades Infecciosas/Pontificia Universidad Católica del
Ecuador (CIEI/PUCE) indicated they might only be able to negotiate the exhibition of one PSA by Ecuadorian television channels. This possible limitation raised the question if only one PSA should be produced, gathering the most important information. To not abandon the production effort of seven PSAs and to not damage the already initiated pre- testing process, the researcher decided to continue to work on eight PSAs. Negotiation with the television channels to broadcast one PSA each week or month was suggested. If only one PSA has to be chosen, it was agreed that it should be the one that tells the population to contact the Ecuadorian Ministry of Health if they find a kissing bug in their 65 house. It was also considered that even if there was no possibility to broadcast all the
PSAs, they could still be made available to researchers and educators through other channels of communication such as DVDs and the OU/TDI website.
Regarding the script of the educational video, expert reviewers were concerned if the phrase “It’s easy!” (Es fácil!) would be effective, because the population might not consider the suggested actions so easy. In order to encourage the population to believe that the prevention actions are easy, the researcher changed it to “Look how easy it is!
You only have to follow this advice” (¡Mira qué fácil es! ¡Sólo debes seguir estos consejos!).
Another large concern was regarding the phrases “Chagas is a disease that kills many people all over the world. Among them, thousands are Ecuadorians. Do you want to be one of them?”(Chagas es una enfermedad que cada año mata a muchas personas en todo el mundo. Entre estas personas, miles son ecuatorianos. ¿Quieres ser tú uno de ellos?). Some of the expert reviewers were afraid the last sentence was too aggressive or that by talking about something as dramatic as death, people would not believe it could happen to them. The researcher decided not to change it and pre-test to see what the target audience would think of it.
The expert reviewers’ suggestions led to some vocabulary adjustments, like changing the use of the Word “poop” (caca) to “feces” (heces) as being a less aggressive word. The term “the animal” (el bicho) was also substituted for “kissing bug”
(chinchorro) as more adequate. The reviewers were also concerned about the video having too many interviews and asked that a balance be found in their use: to include 66
statements that represented the different regions where the video will be exhibited and
also the different institutions that support the project.
3.2.2. Participants in the Pre-Testing
After the pre-testing of the pre-scripts and adaptations were made following the
recommendations, the PSAs and the educational video were pre-tested with two different
groups of people: expert reviewers and members of the community where there is risk of
Chagas contraction (the target audience of the videos). The pre-testing with expert
reviewers was done with 21 adults: eleven members of PLAN Internacional, six health
workers from Hospital in Catacocha, two biologists of CIEI/PUCE, and two Ohio
University professors (*see Appendix 09 for list of expert reviewers).
For the pre-testing with community members, the recruitment was done based on
one criterion: for respondents to be residents of communities in which people are at risk
of contracting Chagas disease. Screening sessions were organized in schools or churches
of three communities in the province of Loja, in southern Ecuador: Naranjo Dulce, San
Antonio and Yamana. The three communities were chosen for convenience since they are
close to the city of Catacocha, used as a base for the pre-testing. The choice was also made because PLAN Internacional – the NGO who supported the research – had connections with the community leaders, which facilitated the gathering of people. The researcher also had the opportunity to gather people from rural communities in the city of
Catacocha. With the permission of the local priests, churchgoers were invited to
participate in the pre-testing of the videos after Sunday mass. The participants who 67
agreed to take part in the research were from the following cities and communities:
Catacocha, Guanchuro, La Supa, Limón, Loja, Macará, Playas, Promestillo, Puente
Playas, San Pedro Mártir, Sauce, Supira, Tundunda, Zapotepamba, Pasaje, the last in the
province of El Oro. In total, the pre-testing was done with 129 community members: 67
adults and 62 children, varying from five to 15 years old.
3.2.3. Pre-testing Procedures
The pre-testing of the PSAs and the educational video took place in March 2008,
in rural communities in the province of Loja where there is risk of Chagas contraction.
The Chagas prevention PSAs and educational video was exhibited to groups of the target audience that varied from five to 25 people.
In order to fulfill Ohio University Institutional Review Board (IRB) regulations, at the beginning of each pre-testing session, respondents were asked to sign a participation consent. A combination of oral and written consent forms was used because previous academic research has proven that the respondents – Ecuadorians that live in rural areas – have low levels of human capital (i.e. low education). Given that many respondents could have trouble reading, the use of just a written participation consent could be ineffective. Therefore, the participation consent process consisted of explaining the purpose of the study, how the research would be conducted, any potential risk and/or discomforts, and the benefits of such research to society, emphasizing that respondents were free to stop participation at any moment with no penalty. Subsequently, they were
asked to sign the written consent. In the case of participants under 18 years old, their 68 parents were asked to sign the consent giving permission for their participation in the research. *(see Appendices 10 and 11 PSAs and educational video’ participation consents).
In the research design, two different participation consents were prepared: one for the pre-testing of the PSAs and other for the educational video. However, in the course of the pre-testing, the researcher realized that the participation consents should have been different for adults and children, and not for the educational video and for the PSAs. This is because, different from what was planned, it was not possible to hold separate sessions with adults and children as some adults always came to the exhibition accompanying the children. However, the combined sections turned out to be very beneficial to the process, since the adults encouraged the children to talk. In general, younger children did not give substantial personal opinions. The children mostly responded to yes/no questions if they liked the video, the music and the animation. The adults were more participative with comments.
Due to the holding of session with respondents of all ages, the researcher changed the participation consents to one dedicated to children and one to adults, both of them regarding the pre-testing of the PSAs and the educational video. The researcher also noticed that some of the adolescents changed the word “children” (niño) to “adolescent”
(adolescente) in the consent. This is an indication that the consent for participants under
18 should have said “children and adolescents” (niños y jóvenes), so as not to insult the older children. 69
The pre-testing was done through the exhibition of the PSAs and the educational
video and application of follow-up questionnaires in the form of oral questions asked by
the researcher (*See Appendices 12 and 13 for pre-testing questionnaires). Individual
interviews were considered too time consuming and unnecessary since people would not
be talking about secret or uncomfortable subjects. Interaction and discussion among
participants was encouraged.
The questionnaires were created based on the suggestions made by some of the
heath communication guides and adapted to the subject of Chagas disease and the format
of the materials. Both pre-testing questionnaires were very similar, gathering basic
characteristics of the respondents (age, gender, and living location) and their opinion
about the videos. Both questionnaires had a table which the researcher filled in based on
observation of respondents while they watched the videos and also on the answers to the
questions. Through the table, the researcher was able to classify the level of the participants’ interest and comprehension of the video, their opinion about the precision and the amount of information, the quality of the images and of the sound, and the duration of the videos. In the case of the educational video, the table also included their
opinion about the animation.
The pre-testing questionnaires also had similar questions that inquired what the
respondents thought was the main message of the videos and who the message was
directed to – if it was for them or not. It also asked if the videos used adequate words and
language, if they were easy to understand and if they had a good rhythm. The
questionnaires also inquired if the respondents recognized the region where they live in 70
the images, what they thought were the weak and the strong points of the videos, if any of
the information was not comprehensible to them and if they would change something to
make it easier to understand. It also asked if they thought the information presented by
the video was important and if the videos would motivate people to adopt the suggested
actions.
3.3. Findings and Discussion of Pre-Testing
The pre-testing of PSAs and the educational video showed slightly different
results between expert reviewers and members of the video’s target audience. However,
some findings were similar. Expert reviewers and community members stated they were
interesting and not boring, and said the information was clear. However, the survey
indicated the need to include in the videos more information about the kissing bug:
different species, that the smaller ones also transmit the disease, where they can be found
in terms of climate and altitude, and how to combat it. It was also found that, besides the name “kissing bug” (chinchorro) the words “chinche” and “chinche caballo” should also be included, because those are other names the rural population use. The information mentioned above was included in the educational video, but it was not added to the PSAs, due to their limited duration. It was also recommended to add “community leader” (líder comunitario) or community agent (agente comunitario) to the already included health
promoter (promotor de salud), regarding who the rural population should contact when
they find the kissing bug. Following the suggestion of pre-testing respondents, the term 71
“community leader” was incorporated to the PSAs and the educational video. (*See
Appendices 14 and 16 for changes on videos).
The pre-testing showed that community members liked the music used in the PSAs
and the educational music and recognized it as Ecuadorian songs. Some expert reviewers
were concerned that the music was too typical from the Andean region, which could lead
some viewers to believe the videos were directed only to that area of the country. Within
the community members, only 4% showed dissatisfaction with the music being typical
from the Andes. Due to the low disapproval, the original sound track of the videos was
kept.
To guarantee the technical accuracy of the educational video, expert reviewers
also suggested the change of some specific scenes. In this case, a scene of a pig was
removed because of the inexistence of proof that kissing bugs feed from them, a scene of
a donkey was removed because such animals do not live close to houses, so they do not
create risk, and a scene of green coffee was replaced for corn because green coffee does
not attract rodents that attract the kissing bug.
During the presentation of this thesis project in the Conference on Latin American
Social and Public Policy at the University of Pittsburgh, in February 2008, one member
of the audience questioned the fact that the educational video and the PSAs suggest that people keep animals and livestock outside the house. She sees this as a problem because, according to her, guinea pigs, for example, would freeze if not kept inside the house. To evaluate the pertinence of this concern, the researcher included in the pre-testing questionnaire an inquiry asking if the prevention actions suggested in the educational 72
video could be adopted in the endemic areas. The survey showed community members
believe there is no problem in keeping animals away from the house. Only 2% of
respondents said they have always had these habits and it might be hard to make people
change them.
On the other hand, the survey indicated that the PSAs and the educational video
were considered a good motivation force for the population to collaborate in the
elimination of the kissing bug. Community members said it was very important to learn
about the kissing bug, mainly that it transmits such a dangerous disease. According to
respondents, if the population is aware of the risk and know what they can do in their
houses to prevent the presence of the insect, they will change their behavior and adopt the
suggested actions. Some respondents believed the PSAs would not be enough to motivate
them to adopt the suggested actions, and indicated the educational video would be more
efficient.
At the end of each pre-testing session, 100% of community members remembered
almost all of the information of the educational video and the PSAs, showing they are effective in transmitting information about Chagas. The children also demonstrated their
interest, stating they would like to see such videos in school to learn about Chagas
disease.
3.3.1. Findings of Pre-Testing of Educational Video
All respondents of pre-testing approved the duration and the amount of
information of the educational video. To the contrary of the positive evaluation of 73 community members, some expert reviewers thought the video was too technical and boring for children. When asked to whom the message was directed, adults and children of the target audience said they thought it was directed to people of all ages. On the other hand, some expert reviewers had the initial impression the video was made for adults; but in the last interview, when Grijalva talks directly to the children, they were not sure any more. Some experts suggested that different videos should be produced for adults and children, the last including music that is fun for children, with more animation and colorful drawings. The expert reviewers also suggested that children should participate in the script writing and in video production, so their impressions and doubts about Chagas would be addressed, therefore attracting the attention of other children. Time and production limitations made it impossible to produce a video specific for children or have them participate in the creative process of the video. But, not to give the impression the video is directed only to children, a new narration was included before the interview of
Grijalva saying: “Not just adults but also young people and kids can help prevent Chagas
Disease.”
Results of the survey with children also indicated that there was a distrust of some of the information children might bring home from school about the disease as, in general, parents often disregard what children say. The survey with adults confirmed the distrust with information brought home by children. As a solution, respondents suggested the educational video should be exhibited to community members of all ages, including elementary and high schools, so adults and children can work together on prevention. 74
Regarding the suggestion in the pre-testing of the scripts to have two different
videos, one for Manabí and another for Loja, the survey proved it was not necessary. All
participants stated that when people see scenes of regions different from theirs, they feel like they are not alone and that they are part of a larger, national process. Most
community members did not realize the video presented images of different regions of
Ecuador. The ones who recognized regional differences said it did not change their
confidence in the information presented by the video.
Regarding another concern of the script’s pre-testing, the survey proved that the
sentences: “Chagas is a disease that kills many people all over the world. Among them,
thousands are Ecuadorians. Do you want to be one of them?” (Chagas es una enfermedad
que cada año mata a muchas personas por todo el mundo. Entre estas personas, miles
son ecuatorianos. ¿Quieres ser tú uno de ellos?) are not too strong. Respondents agreed
that being too delicate in addressing such an important issue would not be effective,
because people need to understand Chagas is a serious subject. One expert reviewer
stated it is necessary to be dramatic to grab people’s attention, and that the educational
video should specifically show sick people. Five percent of community members
suggested the question “Do you want to be one of them?” should be substituted for “Let’s
not be part of this” (No seamos parte de esto). Due to the low percentage of disapproval,
the sentence was kept in its original form.
The survey showed respondents believed in the effectiveness of the sentences
“Look how easy it is! You only have to follow this advice” (¡Vea qué fácil es! ¡Sólo
debes seguir estos consejos!) and “Did you know how easy it is to eliminate the kissing 75
bug from your house?” (¿Viste qué fácil es eliminar el chinchorro de tu casa?) to
encourage behavior change, because it is important to tell people that it is easy to prevent
Chagas. The respondents also approved the sentence “Say no to Chagas disease!” (¡Dile no a la Enfermedad de Chagas!) as the slogan of the prevention campaign.
In order for people to better retain information of the educational video, the survey indicated the need to include the words “Chagas disease,” so it was included three more times. It was also suggested to include what other diseases the symptoms of Chagas can be confused with and how people can know if they have Chagas and not another disease. Reviewers also suggested including interviews of school teachers, because they have credibility among adults and parents. They also suggested including the name of the communities where the scenes were shot so people would identify with it. The last two suggestions were not taken, because they were not considered necessary for the effectiveness of the video.
The pre-testing found the animation was approved by all respondents. Despite the fact that some expert reviewers had raised the concern that adults might not be interested in the animation, the survey with adults showed the animation actually helps them understand the symptoms. However, a community member said that adults from the countryside would not understand the animation, and suggested that the animation should be replaced with real images of sick people. Since an insignificant percentage of less than
1% of respondents suggested the change, the suggestion was not taken. The pre-testing with expert reviewers indicated that the animation seemed to be separate from the rest of the video. In order to make the animation flow more naturally throughout the video, more 76
animated scenes were added to the final version. Some suggestions were also made
regarding the biological aspects of the kissing bug, and some changes were made related
to the way the insect bites a child, and the way the parasite enters the body.
Expert reviewers recommended that the interview with Mellida Mervallos – who
said she does not raise guinea pigs any more – should be removed. Their argument is that
guinea pigs are an important part of the local people’s diet, so they should not be told not
to have guinea pigs but just to keep them away from the house. (*see Appendix 14 for changes on the Educational Video and Appendix 15 for final script).
3.3.2. Findings of Pre-Testing of PSAs
Findings of the pre-testing of the PSAs reflected similar results as the pre-testing of the educational video. Regarding the clearness of the information, only 2% of community members stated they had comprehension difficulties because they did not know the information before. Regarding the fact that the PSAs have similar beginnings, some community members said that if they see all PSAs on television they could think
they had already seen it, leading to the loss of interest. But, at the same time, they said the repetition is good to help memorize the information. On the other hand, some of the expert reviewers said the similar openings were not a problem, because people will not
see all of them in a row, so it would not be repetitive. The divergent opinions resulted in
the following change: editing of different scenes for every other PSA.
The pre-testing showed the effectiveness of the sentence “You can prevent Chagas
Disease!” (¡Tú puedes prevenir la Enfermedad de Chagas!) because it motives 77 community members by saying they can help as part of the prevention process. One community member suggested changing the sentence to “Together we can prevent the disease!” (Todos juntos / Nosotros juntos podemos prevenir la enfermedad).
Similar to the results of the pre-testing of the educational video, most adults said they thought the PSAs were directed to everybody, adults and children. However, some adults said they thought the PSAs were made for children because there are many children in the beginning and ending. They also said the scenes in the beginning of the
PSAs of children looking at the camera were too cold. For the PSAs to be more appealing for adults, they suggested showing adults and children together and including more images of children playing and people in different activities. As a solution for divergence of opinions, new scenes of adults were intercalated with the ones of adults.
Specifically about PSA 3, community members suggested changing the word
“agricultural products” (productos agrícolas) to “grains” (granos) or at least include granos because it is the word people use more frequently to refer to agricultural products.
The word “grains” was included in the final script.
Some community members suggested adding more information about Chagas disease to the PSAs, such as: how it is transmitted, what the symptoms are, if there is treatment and vaccine. Expert reviewers suggested adding an image or a picture of the kissing bug at the end of the PSAs – when the narrator says “Eliminate the kissing bug” – to reinforce the image of the insect people are being taught to recognize and eliminate.
(*see Appendix 16 for changes on the PSAs and Appendix 17 for final scripts).
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4. RECOMMENDATIONS – A COMMUNICATION STRATEGY
Public service announcements (PSAs) and educational videos alone will not
completely solve the problems of Chagas disease prevention in Ecuador because they will
probably not reach the entire population in the areas where there is risk of Chagas. The
PSAs might not be shown on all local TV stations and some people do not have television at home, so they will never be able to watch them. Therefore, the prevention efforts in which the educational video is exhibited by the Community Based Chagas Disease
Research Project (CBCDRP) might reach all the at risk communities. Nonetheless, as
stated in some of the health communication guidelines and tools analyzed earlier, it is
always important to present information to audiences in different ways, through different
mediums, to increase the level of comprehension and to help audiences retain
information.
Due to the limitations of the dissemination of the video products produced by this
thesis, the researcher suggests the creation, pre-testing and implementation of other
educational materials, along with the execution of education and training activities that will constitute a larger communication strategy dedicated specifically to Chagas disease
prevention in Ecuador. The researcher recommends that the communication strategy
should become a branch of a larger effort such as the Chagas National Program
(Programa Nacional de Chagas) carried out by the Ecuadorian Ministry of Health
(MOH). To suggest and encourage the MOH to adopt the communication strategy as part of their policies goes along with the suggestion of the guide Making Health
Communication Programs Work of identifying partnerships to the project. 79
Piotrow and his coauthors, in the Health Communication Guide, emphasize the combination of interpersonal communication, community actions, and mass media as essential in the creation of a communication strategy. The Making Health
Communication Programs Work also suggests planning activities to engage individuals in
considering recommended prevention behaviors and to encourage their adoption and
maintenance. Based on these recommendations, the Chagas disease communication strategy should implement a range of community outreach activities and use a mix of
materials (see Table 1). To reduce creation and implementation costs and time, the
researcher decided to base the suggested communication strategy on the pre-existent
platform of activities and materials used by the Community Based Chagas Disease
Research Project (CBCDRP) and the Ecuadorian MOH. The previous efforts and
materials were analyzed and improvements are suggested before their re-utilization.
An executive director, a communication campaign manager, a visual designer and
a press agent should carry out the activities of researching, preparing, creating messages
and pre-testing the communication materials. A group of fieldworkers and an external
evaluator should join the above cited crew to launch, implement and evaluate the
complete communication strategy in 2009, using the celebration of the centenary of the
discovery of Chagas disease to call attention to the cause.
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Table 1
Communication Strategy Components Component Activities Materials Mobilizing - Launching of Program (Chagas Festivals) - Public service announcements Community - Community visits - Educational video - Youngsters making videos about Chagas - Radio spots - School visits - Educational booklet - Teacher training - Calendar - Exhibition of educational video - Pamphlet - Dissemination of results (Chagas Festivals) Advocacy - Launching of Program (Press conference - Promotional video and Chagas Festivals) - Website - Recruitment talks - Meeting with possible sponsors - Meeting with stake holders - Presentation in Conferences - Dissemination of results (Press conference, Chagas Festivals, presentation in conferences and publishing in journal articles) Health providers’ - Training of Personnel and Health Service - Brochure skills Providers Evaluation - Initial Evaluation - House questionnaires - Final Evaluation - Materials’ Effectiveness and Behavior Change Questionnaire
The CBCDRP should try to rise funding from: (a) the Ohio University - Tropical
Disease Institute (OU/TDI), (b) Chagas National Program/SNEM - Ecuadorian Ministry of Health (MOH), (c) the Centro de Investigación en Enfermedades Infecciosas/Pontificia 81
Universidad Católica del Ecuador (CIEI/PUCE), (d) non-profit organizations such as
Plan Internacional and (e) the United Nations.
Many stakeholders should be involved in the project. The Prevention
communication strategy should support the goals of the activities that have already been carried out by (a) the OU/TDI, (b) the CIEI/PUCE and (c) the Ecuadorian MOH. The main beneficiaries are the at-risk population, who are the target audience of the project.
The community leaders in Loja province – many already work in empowerment activities
organized by NGO Plan Internacional – should be used as a bridge between the project
and the local people. The doctors and nurses are the service providers in hospitals and
health centers, institutions with a large capacity for delivering of information. The
fieldwork team will be responsible for the interpersonal communication with the local
population and also with doctors, nurses and teachers. Other sponsors and supporters
such as NGOs and the United Nations might also become stakeholders in the project
(*see Appendix 18 for list of Stakeholders).
4.1. Goals and Objectives
The creation and implementation of the communication strategy intends to inform the ones who suffer from Chagas – the population that lives in endemic areas – and the ones who can do something to prevent it from spreading – health providers, researchers, students and possible sponsors. The Health Communication Guide written by Piotrow and his coauthors emphasizes that setting objectives is an important element of a strategic 82 design. For a communication effort to be effective, the goals have to be specific, measurable, appropriate, realistic and adequate to the timeframe.
The major goal of the communication strategy is to help prevent Chagas disease contraction. To help achieve the major goal, this communication strategy has seven specific and measurable objectives: (a) to increase the awareness about the existence of
Chagas, (b) to increase the awareness about the menace of the kissing bug as a transmitter of the disease, (c) to change at-risk population’s behavior towards Chagas Prevention, (d) to decrease the number of infected houses, (e) to decrease the number of bugs in the infected houses; (f) to decrease the number of infected people; and (g) to increase the number of reports to the MOH, concerning the existence of kissing bugs (see Table 2).
The success or failure to meet these objectives can be measured along the final evaluation process (see section 8.4.2) in order to detect the efficacy of the communication strategy. The (a) awareness about Chagas and (b) the menace of the kissing bug, and the
(c) behavior change towards Chagas prevention can be measured by conducting a questionnaire when fieldwork teams visit houses for control and prevention actions. The number of (d) infected houses, (e) bugs in infected houses, and (f) infected people can be measured by continuing to conduct the control program that is done by the Community
Based Chagas Disease Research Project, when fieldwork teams do house visits. The (g) change in number of reports of kissing bugs can be measured by comparing year-to-year statistics.
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Table 2
Goal and Objectives
Goal: Prevent Chagas disease contraction Objectives How to measure? a) Increase awareness about the existence of Chagas b) Increase awareness about the menace of kissing Application of questionnaire bugs as transmitter of Chagas c) Behavior change towards Chagas prevention d) Decrease number of infected houses Conduct control programs when e) Decrease number of bugs in the infected houses fieldwork teams visit houses to f) Decrease number of infected people look for bugs and fumigate g) Increase number of reports of kissing bugs to the Analyze change in the number of MOH reports to MOH
4.2. Materials of Communication Strategy
The communication strategy proposed in this thesis includes nine materials that should be used along with other educational and training activities performed by the
CBCDRP and the Ecuadorian Ministry of Health. The materials are three video products
(a series of PSAs, an educational video and a promotional video), a series of radio spots and four printed materials (an educational booklet, a calendar, a pamphlet, and a brochure). A visual designer should be hired to create a logo and a visual identity for the project, as well as re-design the pre-existing printed materials and create a website. The objective is that all the materials have the same visual identity, so the target audiences 84 will be able to recognize each of them individually as part of a larger communication strategy.
All these materials and activities translate the existing technical information about
Chagas into language accessible to people outside the scientific world. Some of them transmit the same contents, but in slightly different formats and/or to different target audiences. Some of them transmit different contents to a specific target audience (see
Table 3). The overlapping of information is used to reach all the different target audiences in more than one way. Repetition is a tool that can be used to reinforce messages. The objectives are to make stockholders aware of the disease, to make the fight against Chagas part of the at-risk population’s life, and to encourage them to act to change the current situation.
Due to the researcher’s previous experience and interest in video production, this thesis focused on the creation, pre-testing and finalization of the PSAs and the educational video and the production of the promotional video. The printed materials already exist and have been used by the MOH and by the CBCDRP. However, they have not been used together, as part of one concentrated effort. As exemplified earlier in this thesis, all the pre-existing printed materials should be revised by communication and
Chagas disease experts and pre-tested with community members, and necessary changes should be made before they are re-printed and implemented as part of the communication strategy. The following sections will explain the videos and printed materials in detail and will list the changes and adjustments suggested to enhance their effectiveness.
85
Table 3
Educational Material
Material Audience Message PSAs - 8 specific actions to prevent Chagas disease ; Adults Radio spots - the benefit from adopting the suggested behavior. Booklet - What is Chagas disease and how it is transmitted; - symptoms and what to do if someone feels them; Children Educational - how to identify and find the kissing bug in the house; Adults video - how to keep the kissing bug away from the house; - directions to contact the Ministry of Health. Students - CBCDRP’s history, achievements, and on-going Promotional Sponsors activities in Ecuador; video Stakeholders - Chagas disease transmission and prevention. Calendar Adults - 10 ways to eliminate the kissing bug from the house - What is Chagas disease and how it is transmitted; Patients in - how to identify the kissing bug; hospital and Pamphlet - where the insect hides in the household; health center - symptoms of early and acute phases of Chagas disease;
- how to cooperate with Ministry of Health workers. Doctors - transmission; diagnosis; and symptoms; Brochure Nurses - treatment possibilities (acute and chronic phases); - CBCDRP’s history, achievements, and on-going activities in Ecuador; - what is Chagas disease and how it is transmitted; - how to identify and catch a kissing bug; Stakeholders: - where it hides in the house and how to eliminate it Researchers - symptoms of early and acute phases of Chagas disease; Students Website - what to do if someone feels the symptoms; Sponsors - specific actions to prevent Chagas disease ; Doctors - the benefits from adopting the suggested behavior; Nurses - directions to contact the Ministry of Health; - Scientific information about Chagas - information about the communication strategy; - results of activities and evaluation.
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4.2.1. Educational Video
The new educational video produced by this thesis should be used in substitution
for the two educational videos previously produced by the OU/TDI and CIEI/PUCE (the
two videos are described in details on sections 2.2.2.1 and 2.2.2.2) to promote awareness
about Chagas disease among children, adolescents and adults. To reach the younger
audience, the educational video should be exhibited in elementary and high schools in
Ecuador, and during the activities of the CBCDRP as it has been done in the past.
Activities should also be organized for the adult population to watch the educational
video. Copies should be provided for the video to be exhibited in meetings organized
independently by schools, community leaders, health promoters and health institutions. In
addition, the CBCDRP should try to negotiate the exhibition of the educational video on
local Ecuadorian television channels of Chagas endemic areas (*See Appendix 15 for
Educational Video’s script).
4.2.2. Public Service Announcements
The CBCDRP should try to negotiate the exhibition of the PSAs on local
Ecuadorian television channels that reach the areas where there is risk of Chagas.
Because television commercials do not require reading skills, the nine PSAs (described in
detail in section 7.5) are a medium capable of reaching a large portion of the least well-
served population, the poor and illiterate members of society, such as the ones that live in
Chagas endemic areas. The target audience of the PSAs is adults in at-risk areas, because
they are the ones that make decisions in the house that can lead to behavior change. The 87
objectives are to promote awareness about Chagas and teach the population some specific
actions they can perform in the house to help prevent the presence of the kissing bug and,
therefore, the risk of Chagas contamination (*See Appendix 17 for PSAs’ scripts).
4.2.3. Radio Spots
The series of radio spots should be composed of nine radio commercials, each 30
seconds long, an appropriate length to be broadcast on Ecuadorian radio stations. Similar to the case of the PSAs, radio broadcasting does not require reading skills and is capable
of reaching the illiterate or poorly educated people that live in areas where there is risk of
Chagas. The target audience of the radio spots is the Ecuadorian population that lives in
Chagas endemic areas. Specifically, the radio spots are aimed at adults, since they make
up the household. The radio spots should be narrated in Spanish (the local language) and should have local music as the soundtrack, for the people to recognize it as something
that comes from their own culture. The main objective of the radio spots is to promote
awareness about Chagas prevention within the rural population of Loja province, in
Ecuador. Similar to the PSAs, the radio spots should have different information from the
other, each dealing with one specific action the audience can take to prevent Chagas
disease and explain the benefit they will get from adopting the suggested behavior.
4.2.4. Promotional Video
The promotional video should be used in presentations about the CBCDRP to
inform people about the project’s history, the achievements, and the on-going activities in 88
communities in Ecuador affected by Chagas disease. The video also briefly explains what
Chagas disease is, how it is transmitted and how it can be prevented from spreading. The main objective of the promotional video is to recruit new people interested in being
involved with the CBCDRP, such as American and Ecuadorian college students and
faculty, and to attract the interest of possible funding agencies to invest in the project. A
10 minutes long promotional video was produced by the researcher as a parallel activity
to this thesis research and is already being used by the CBCDRP. (*See Appendix 19 for
promotional video’s script).
4.2.5. Educational Booklet
The educational booklet (described in section 2.2.1.1) should continue to be distributed by the CBCDRP and the Ministry of Health (MOH) to increase awareness
about Chagas among children and teach them important information about the disease,
the kissing bug, and how to prevent transmission. (*See Appendix 01 for already existent
educational booklet).
4.2.6. Calendar
The calendar (described in section 2.2.1.2) should continue to be distributed by by
the CBCDRP and MOH fieldwork teams when they visit the houses, in order to call people’s attention to Chagas disease and remind them every day of ten ways to eliminate the kissing bug from their houses (*See Appendix 02 for already existent calendar). 89
4.2.7. Pamphlet
The target audience of the pamphlet (described in section 2.2.1.3) is composed of
adults from endemic areas who go to hospitals and health centers looking for help
regarding Chagas disease and other health issues. It is suggested that the pamphlet should
be re-designed in order to follow the same visual identity as other materials of the
communication strategy. This will make it easier for people to identify it as part of the
larger strategy towards Chagas prevention. The pamphlet should be produced in large
quantities in order to be available for pick up at the information desk of all hospitals and
health centers in the risk areas. (*See Appendix 03 for layout of already existent
pamphlet).
4.2.8. Brochure
The content of the brochure (described in section 2.2.1.4) should be revised by
Chagas specialists and doctors to guarantee the information is correct and updated.
Besides re-designing it to follow the visual identity of the other materials of the
communication strategy, a reformatting of the already existing seven page brochure into
six pages is recommended to assure easy printing and distribution. The final format of the
brochure should be printed on high quality paper, so it will last in doctors’ offices as
reference material. The pre-testing of the brochure should be done with its target audience: doctors and nurses that work in hospitals and health centers in Chagas endemic areas. The brochure should be produced in enough quantity to be distributed to all service 90 providers in all hospitals and health centers in the risk areas. (*See Appendix 04 for layout of already existent Brochure).
4.2.9. Website
A website should be created to gather all information about the Chagas disease communication strategy and make it available to all kinds of people all over the world – researchers, sponsors, health service providers, the American and Ecuadorian students that participate or have interest in participating on the CBCDRP and any other people that might be interested in Chagas disease. The website should also make available for visitors all the videos that will be used by the communication strategy and facilitate a discussion forum about Chagas. The website could be part of the Ohio University /
Tropical Disease Institute website, emphasizing what has already been done and serving as a base to further improvements. Although TDI has already created a website, it is recommended that a professional web designer be hired to add the information regarding the communication strategy, besides updating and maintaining new information. To make sure that it will serve all the stakeholders, it is ideal that the website have English and
Spanish versions.
4.3. Implementation of Communication Strategy
According to Making Health Communication Programs Work: Planner’s Guide and also to Piotrow and his coauthors, implementation can turn a project into a success or a failure. For them, it is important to mobilize and engage the main stakeholders linked to 91
the project in the implementation of activities. The next sections will list the components of the communication strategy suggested by the researcher that are dedicated to its implementation.
4.3.1. Launching of Program
The first step to implementing the communication strategy towards Chagas disease prevention is the launching of the program. This is the moment in which all the indirect stockholders should acquire broad knowledge about the strategy and should be encouraged to participate in the prevention activities organized by the Community Based
Chagas Disease Research Project (CBCDRP). This thesis suggests that the official
launching of activities should be done in 2009, using the Centenary of the Discovery of
Chagas disease to attract the attention of stockholders and possible sponsors, besides
stimulating and encouraging local populations to adopt behaviors necessary to fight
Chagas.
The first activities suggested to launch the program are press conferences, done in
order to call media attention to the Chagas prevention activities done by the CBCDRP.
Contacting journalists, developing ideas and materials, creating events that interest journalists, distributing press releases, preparing useful background information, and setting up interviews are the main activities used to establish a strong relation with the media. To be more consistent and attractive to the reporters, the press conference should have the presence of the head of the project, local authorities (national authorities also, if possible) and the primary stakeholders. It is also important to have representatives of the 92
target audience to tell compelling personal stories. It would also be very attractive if the
Press Conference could present new information such as results of health research related
to Chagas disease or specifically accomplished by the CBCDRP.
As is emphasized in Making Health Communication Programs Work: Planner’s
Guide, plans for the press conferences should include compiling a detailed invitation list,
including the speakers, the date, the necessary logistics, and contents of the media kit.
The reporters should watch the PSAs, the educational and the promotional videos, and
receive a DVD copy of these, along with copies of all printed materials. The
Communication Manager of the strategy should also plan to maintain relations with the
reporters after the launch to try to keep the project in the media as follow-up news pieces.
Monitoring the outcome of news media coverage will help the program compare
accomplishments with objectives, revise strategy or its implementation, and measure
results.
To reach the population that live in areas where there is risk of Chagas
contraction, the mass media campaign – the PSAs and the radio spots – should be the
leading element of the communication strategy, calling the general public’s attention to
Chagas disease and teaching the target audience what they can do to prevent it from
spreading. To reduce costs to implement the project, the project should try to broadcast
the PSAs and the radio spots as educational pieces, getting discounts or total elimination of broadcasting payments. There should also be an effort to have local television stations exhibit the educational video, as a piece which brings more detailed information about the subject. 93
The third activity suggests to launch the communication strategy is the organization of what would be called Chagas Cultural and Educational Festivals.
Although similar events have already been organized in the past by the CBCDRP (see
Figure 3), and resulted in large community attendance and engagement in Chagas issues, it is recommended that the Festivals should be extended to more communities of endemic areas. The choice of the communities should be made considering the presence of Chagas disease, the location in relation to other satellite communities, and the capacity of attracting people from other villages. The Festivals should be held in the churches, schools’ patios or the main square.
Figure 3. Chagas Cultural and Educational Festivals held by CBCDRP in June 2007
The purpose of the Chagas Cultural and Educational Festivals is to engage the communities and let their members know that their effort is vital to the prevention of
Chagas disease and the consequent improvement of their health situation. The CBCDRP should encourage the community to participate in creating and performing plays, music 94
and/or cultural presentations related to Chagas. There can be a contest to create posters
and slogans for the campaign. This will not only get the community members involved
but will also make them talk about Chagas. Schools and teachers can be involved to help
students prepare presentations in the festival. The educational video and the PSAs should
be exhibited to call the target audience’s attention to other parts of the communication
campaign. As an incentive for community participation, this is an opportunity to
distribute Chagas related materials such as the brochure, T-shirts and caps. The Research
Project should provide stage, sound system, video projector, screen, chairs and any other
necessary supplies.
Together, all these actions will help the target audience recognize that all the initiatives are part of one larger prevention effort and that their participation is
fundamental for its success. As part of the advocacy component of the communication
strategy, local authorities should be invited to participate in the Chagas Cultural and
Educational Festivals.
4.3.2. Training of Personnel and Health Service Providers
The training of personnel and health providers is a very important element of the
communication strategy, because they are the ones who will have direct contact with the
local population/target audiences all year long, so they can distribute the educational
materials, and give support to all the activities that will be implemented.
The target audiences are workers from the Ecuadorian Ministry of Health / SNEM
and the fieldwork team hired specifically for the CBCDRP. The objective is to give 95 technical information about Chagas disease to the people that have direct contact with the at-risk population. Focusing mainly on prevention, the training may also approach the subjects of human relationships and cultural sensitivity. When visiting the houses to perform control and prevention actions, the fieldworkers and SNEM personnel need to know how to interact with the local population, how to build community partners and what is the adequate way to deal with people’s different cultures and habits.
Hospitals and health centers also have a large capacity of information delivery.
So, the training of health service providers also has a potential for being a powerful promotion tool of Chagas disease awareness and prevention. The objective is to teach doctors and nurses about the existence of Chagas and how they can contribute in terms of prevention and treatment. Besides giving the technical/medical information, the training should also focus on the importance of increasing awareness about the disease. The training should be done by the fieldwork team who participated previously in the training of personnel. Interpersonal communication with doctors and nurses should happen when the field teams visit the communities with the MOH to perform Chagas control and prevention activities.
This is also the moment to present the pamphlet and the brochure to health service providers and encourage them to distribute the pamphlet to patients that live in at-risk areas or have any symptoms of Chagas disease. Doctors should be encouraged to closely analyze the information in the brochure in order to be able to identify a patient with
Chagas and give the appropriate treatment. Acquainted with the content of the pamphlet and the brochure they will be able to use them as a communication tool of Chagas disease 96
awareness. The fieldwork team should leave in hospitals and health centers an amount of
printed materials sufficient to fulfill the institutions’ entire service capacity and reach all
service providers.
4.3.3. Community Visits
The activities suggested for the community visits are complementary to Chagas
Cultural and Educational Festivals. This is an opportunity to establish a connection with community members and an appropriate moment to pass on more information about
Chagas disease. This interpersonal contact is essential to the local populations’ engagement in behavior changes related to Chagas prevention. Based on the findings of the pre-testing – that all community members should receive information about Chagas and its prevention – this research suggests that the entire community should be invited to watch the educational video. This should happen in events organized by the CBCDRP
that can also involve other activities such as medical attendance, community empowerment or playful activities for the children. The researcher recommends that, at the end of the exhibition, someone from the CBCDRP personnel should perform message retaining activities, asking the people what they learned about Chagas and answer any questions about the disease.
To engage the youngsters into the Chagas issues, this thesis also recommends the continuation of an activity that started in the summer of 2007. Members of the CBCDRP
started a participatory action in which children and adolescents of communities Chagas
endemic areas used video technology to portray their communities. If well guided, the 97
youngsters can start approaching subjects related to Chagas in their communities and can
produce powerful participatory communication tool towards Chagas disease prevention.
This would respond to a demand presented in the pre-testing in which some expert
reviewers and community members said a prevention video about Chagas for children
should be created by children.
It is also recommended that the CBCDRP perform school visits. In order to reduce
the costs, the interpersonal communication with teachers and students – the target
audience of this activity – should happen when the fieldwork teams visit the
communities. The school visits should include training the teachers about Chagas and
encourage them to use the educational booklet in class with the students. The educational video should also be shown to all students. Besides learning about Chagas, the students
can pass the information along to their relatives, reinforcing the educational talk that is
given to families in their houses.
Since 2005, educational talks (charlas) have been a part of the activities of the
CBCDRP and SNEM personnel in the regions of Loja and Manabí provinces where there
is risk of Chagas contraction. This research highly recommends it should continue to be
performed and extended to other endemic areas of Ecuador. This interpersonal
communication provides the opportunity to hang a calendar in each of the houses and
distribute the educational booklets to the children. The objectives of this community
outreach effort are to teach the target audience about the kissing bug, about the existence
of Chagas, and what they can do in the household to eliminate the kissing bug and, 98 therefore, prevent the contraction of the disease. At this moment, the fieldworkers also apply the evaluation questionnaire.
4.3.4. Recruitment Talks
This is an activity that the Community Based Chagas Disease Research Project
(CBCDRP) has already been performing. This research suggests that the recruitment presentations to American and Ecuadorian undergraduate and graduate students continue to recruit them to participate on the CBCDRP. The promotional video is shown to inform them about Chagas and the project’s on-going activities in Ecuador. The more students decide to participate in the CBCDRP less people have to be hired to do the fieldwork, so less money will be spent.
4.3.5. Meeting with Possible Sponsors
The Project should organize meetings with possible sponsors. The promotional video should be exhibited in order to create awareness about Chagas disease, to inform potential sponsors and possible funding agencies about the on-going activities of the
CBCDRP in Ecuador, and foment their interest to invest in the project.
4.3.6. Presentation in Conferences
During the entire process of research, creation, implementation and evaluation of the communication strategy, its activities should be presented in scientific and communication conferences. The objective is to spread within the scientific and academic worlds information about Chagas and the use of a health communication strategy as a 99 powerful tool to prevent the Ecuadorian population from contracting the disease.
Ongoing versions of this thesis have already been presented in four conferences and the feedback received by the researcher was of fundamental importance for the accomplishment of the public service announcements, the educational and the promotional videos.
4.4. Evaluation
Valente, Piotrow and his coauthors, and the Making Health Communication
Programs Work Guide also emphasize the importance to dedicate time and resources to conduct an outcome evaluation in order review the impact of the communication strategy.
The resulting data must be carefully analyzed in order to identify weaknesses and strengths and provide information for improvements in future actions. Based on the recommendations of the health communication theories, it is suggested that the CBCDRP should conduct an initial evaluation, which will analyze data from before the implementation of the communication strategy, and a final evaluation at the end of the implementation.
4.4.1. Initial Evaluation
The Initial Evaluation should collect information from previous research done by the CBCDRP and of the Ecuadorian Ministry of Health (MOH) and their data basis, and should happen before the Strategy’s launching with the main goal of understanding the situation of the people that live in Chagas endemic areas before the implementation of the 100
communication strategy. To make a report about the initial levels of (a) awareness about the existence of Chagas and of (b) the menace of the kissing bug as a transmitter of the disease, it is necessary to analyze the results of the research “High Household Infestation
Rates by Synanthropic Vectors of Chagas Disease in Southern Ecuador,”5 which found
that only 2% of individuals had heard of Chagas; and although the presence of kissing
bugs was highly reported, the population did not consider them as vectors of the disease.
To make a report on the number of (c) infected houses, (d) bugs in infected
houses, and (e) infected people, it is necessary to analyze the results of the same research
cited above – which indicate a 35% house infestation rate – and other reports produced in
the past years by the CBCDRP and the MOH. To write a report on (f) house conditions and habits that affect the presence of kissing bugs, it is necessary analyze the information collected through the house questionnaires (Encuesta de Vivienda – Proyecto Salud
Comunitaria) that was implemented beginning in 2001 by OU/TDI and CIEI/PUCE. The focus should be on information that is addressed by the communication strategy, such as the type of house construction, storage of wood and agricultural products, and the presence of domestic animals, rodents and other animals inside or outside the houses
(*see Appendix 20 for House Questionnaire). It is also necessary to collect and analyze the historical registers of reports of the existence of the kissing bug to the MOH.
The final step of the initial evaluation should be to make necessary changes or adaptations in the house questionnaire and combine findings in order to serve as a basis for the final evaluation. The result should also be presented to the stakeholders at the launch of the communication strategy.
5 Study performed by Ohio University/Tropical Disease Institute 101
4.4.2. Final Evaluation
The final evaluation should be done at the end of the implementation of the
communication strategy to evaluate its effectiveness by comparing the initial evaluation
to the new information. It is important to understand that it is different to evaluate
knowledge and awareness about Chagas and behavior change, because people might
know about Chagas and what the prevention procedures are, but might not have adopted
new behaviors. Based on these ideas, the final evaluation should reapply the procedures
of the initial evaluation to (a) produce a new report on the number of infected houses and people and variation in number of reports of kissing bug presence to MOH. In order to
(b) evaluate the distribution of materials of the communication strategy and their (c) effectiveness it is necessary to analyze the effectiveness of the educational printed and visual materials. Although a previous questionnaire has been used, this should be done by conducting a new questionnaire in the areas where the communication strategy was implemented.
The suggested “Materials’ Effectiveness and Behavior Change Questionnaire”
should indicate if the respondent is elder, adult, teenager or child, male or female. This information is important to create future campaigns dedicated to specific target audiences. The ME-BC Questionnaire (*see Appendix 21 for complete questionnaire) consist of questions such as:
a. who makes decisions in the house: man, women or both; b. if respondent has any information about the kissing bug and Chagas disease; c. if yes, where and how he or she received the information; d. if the house has a calendar from the communication strategy. If not, why; e. if people have seen/heard the PSAs and the radio spots; which ones they have seen and how many times; 102
f. if respondent has seen the educational video and if yes, where; g. If respondent has received the educational booklet or the pamphlet; h. if in the past year (adapt to period which communication strategy has been used) that family made any changes in their household. If yes, which ones and if it was related to what the learned about Chagas prevention.
For question (e), the conductor of the ME-BC Questionnaire should take a portable mini-DV or DVD player and show the PSAs to respondents for them to better identify what the questions are about, also true for the radio spots. For questions (d) and
(g) the conductor of the questionnaire should take samples of the materials to show to the respondent in order to facilitate recognition.
The report with the findings of the final evaluation should be presented to the stakeholders as an indicator of the communication strategy’s materials distribution and of the levels of Chagas disease presence in the regions where the strategy was implemented, as well as the level of behavior change and awareness of the population. The final report should also provide recommendations to the stakeholders in order to plan future corrections and adjustments. If the proposed communication strategy it successful, it should be expanded. If the suggested evaluation shows the strategy was effective in helping preventing Chagas disease, the data will help the project to obtain more funding and political support to implement it in the rest of Ecuador and maybe in other countries as well.
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4.5. Dissemination of Results
According to Making Health Communication Programs Work: Planner’s Guide,
part of the final step of a communication strategy should be dedicated to disseminating
results, in order to ensure that the accomplishments of the project are documented and
appropriately spread. Results should be communicated to the most important audiences:
(1) the community, in order to improve the knowledge and awareness about the health
situation related to Chagas disease, (2) the political authorities, to understand what has
been done and its impact in the communities’ health care, (3) the stakeholders who are
going to plan future interventions, (4) and to those who conducted the campaign in order to improve the performance in future campaigns.
Many other dissemination activities should be held to facilitate continuation of the communication strategy in the following years. All stakeholders should be encouraged to participate in a meeting to analyze and discuss the final evaluation report to be able to better define future interventions. In order to demonstrate that positive results are possible, a new press conference should also be held to present the strategy’s results, such as the conclusions of awareness, attitudes, and behavior measurements. In addition, the stakeholders should announce the next steps to combat the problems demonstrated in the results. To increase the exposure of the project in the media, the press agent should encourage the local, national and international media to publish the key successful findings for the campaign, as well as the health situation of Chagas disease in Ecuador.
A second round of Chagas Cultural and Educational Festivals should be organized in the communities where the communication strategy was implemented, in 104
order to disseminate the results of the activities and encourage the community to continue
to participate in Chagas prevention campaigns. The Dissemination Festivals should be similar to the ones organized in the launching of the program. The events should cover as
much as possible the regions reached by the communication strategy and should happen
as soon as possible after the release of the final evaluation report.
The results of the communication strategy should also be disseminated through presentations in academic conferences, publishing in academic journal articles – in the fields of communication, biology and any other areas that might be interested in the
subject – and the communication strategy’s website. By spreading the information, the
strategy will gain respect within the academic areas, which will help raise funding for continuing the activities in following years.
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4. CONCLUSION
The public service announcements (PSAs) and the educational video created and pre-tested by this thesis, and the larger communication strategy which is recommended have the objective to minimize but not solve the problem of Chagas disease in Ecuador.
The researcher is aware of the limitations of the videos and the suggested communication strategy. After their implementation, many who live in the areas of Loja province where there is risk of Chagas contraction will still live in adobe houses where the kissing bug
can easily hide in the holes of the wall. A lot of people in Manabí province will still live
in bamboo houses, where it is not worthwhile to put screens on doors and windows
because the entire house has gaps in the bamboo. These are socio-political problems that
diminish the possibility of behavior change and which this research cannot solve.
Improving living conditions is a government responsibility that this project can only
encourage.
The literature review confirms that a communication strategy cannot do
everything on its own. But despite the fact that the PSAs and the educational video will
not solve all the problems or provide all the solutions towards Chagas Prevention in
Ecuador, the pre-testing process showed they can help. Answering the research question
of what factors should be taken into account for the development of a series of PSAs and
an educational video to create awareness about Chagas, the researcher concluded that the
videos have to present a large amount of information about the disease, and the
information has to be clear, using a language that is adequate to the target audience. This
conclusion was reached based on the amount of information responders retained from the 106
videos (what Chagas disease is, what causes Chagas, specific actions people can take to
prevent the disease and benefit they will get from adopting the suggested behaviors) and
the questions they asked during the pre-testing process regarding the information they were still curious about or thought was relevant to their health.
Regarding the second research question pursued by this research – how does the pre-testing of audiovisual materials help develop more effective materials for preventing
Chagas disease? – the researcher concluded that without the pre-testing process, the
series of PSAs would not have been effective in communicating all the information people need to know about Chagas disease. This is because, after watching the PSAs, the community member respondents still asked questions related to very important subjects
regarding the kissing bug and the transmission of Chagas disease. This was a clear
indication that the information in the eight PSAs used in the pre-testing was not
sufficient. Based on this finding, another PSA was added to the series to deal specifically
with these subjects. The same could have happened regarding the educational video.
Despite the pre-testing indications that the educational video and the PSAs have
the potential to encourage people towards behavior change, health communication
theories extensively indicated the need to approach health issued through different activities and using different materials. During the pre-testing process, after the exhibition of the videos, many participants suggested that the exhibition of the videos
should be accompanied with the distribution of printed educational materials about
Chagas. They also demonstrated large interest in receiving the educational booklet and
the calendar previously produced by the Community Based Chagas Disease Research 107
Project and usually distributed in their control and prevention activities. These are the reasons why the researcher created a communication strategy dedicated specifically to
Chagas disease and highly recommends it be implemented by the Ohio
University/Tropical Disease Institute and the Centro de Investigación en Enfermedades
Infecciosas/Pontificia Universidad Católica del Ecuador.
This research led to four main conclusions that are fundamental for the creation of effective video materials – such as the PSAs and the educational video created by this research – and a successful communication strategy:
1. Despite the limitations of message design and reach of the PSAs and the educational video, these materials can still be effective in informing at-risk populations about Chagas disease and the need to prevent it.
2. Presenting adequate information, and using a language that is appropriate to the target audience’s comprehension is fundamental to the effectiveness of video materials.
3. Pre-testing video materials and making the indicated changes before their implementation is fundamental for their effectiveness.
4. The use of video materials is not sufficient to create awareness and encourage behavior change towards Chagas disease prevention. It is necessary to implement a complete communication strategy, in which different activities are implemented and different materials are distributed, in order to achieve different target audiences.
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Andreasen, A. (1995). Marketing social change: changing behavior to promote health, social development, and the environment. San Francisco: Jossey Bass.
Animación digital educativa para prevenir la enfermedad del Chagas. (n.d.). Retrieved May 15, 2008, from http://www.rafaela.com/portal/modules.php?name=News&file=article&sid=7912
Carlier, Y. (2003). Chagas Disease (American Trypanosomiasis). EMedical Article Research. Retrieved on April 3, 2008, from http://www.emedicine.com/med/topic327.htm
Centro de Investigación de Enfermedades Infecciosas de la Pontificia Universidad Católica del Ecuador. (n.d.) Retrieved January 21, 2008, from http://www.puce.edu.ec/sitios/ciei/chagas_ecuador.htm
Chagas: A Hidden Affliction. (n.d.). Retrieved May 15, 2008 from http://www.chagasthemovie.com/
Chagas: A Hidden Affliction. A feature documentary about the Chagas disease. (n.d.). Retrieved May 15, 2008 from http://www.prevefilms.com/chagas2.html
Chagas disease after organ transplantation --- Los Angeles, California, 2006. (2006, July 27). Morbidity and Mortality Weekly Report, 55:29, 798-800.
Chamberland, M.E., Epstein, J., Dodd, R.Y., Persing, D., Will, R.G., DeMaria, A., Jr., Emmanuel, J.C., Pierce, B., & Khabbaz, R. (1998). Blood Safety. Emerging infectious diseases, 4:3, 410-411.
Dias, J.C.P., & Schofield, C.J. (1999). The evolution of Chagas disease (American Trypanossomiasis) control after 90 years since Carlos Chagas discovery. Mem Inst Oswaldo Cruz, 94, 103-121.
Faculty Expert: Mario Grijalva – Chagas Disease (2005). Retrieved March 12, 2008, from http://news.research.ohiou.edu/notebook/index.php?item=150
Grijalva, M. J., Palomeque-Rodriguez, F. S., Costales, J. A., Da Vila, S., & Arcos-Teran, L. (2005). High household infestation rates by synanthropic vectors of Chagas disease in southern Ecuador. Journal of Medical Entomology, 42, 68-74.
Jokisch, B. (2007). Ecuador: diversity in migration. Migration Information Source, Special Issue on Migration and Development, 45-53. 109
La Enfermedad de Chagas en Ecuador. (n.d.) Retrieved October 12, 2007 from http://www.puce.edu.ec/sitios/ciei/chagas_ecuador.htm
Lotufo, P., & Benseñor, I.. (2007). HowStuffWorks - Como funciona a doença de Chagas. Retrieved October 1, 2007, from http://saude.hsw.com.br/doenca-de- chagas.htm
Mefalopulos, P., & Kamlongera, C. (2004). Participatory communication strategy design: a handbook. Rome: SADC Center of Communication for Development, Harare and Food and Agriculture Organization of the United Nations.
Melkote, S., & Steeves, L. (2001). Communication for development in the world: theory and practice for empowerment (2nd ed.). New Delhi, India: Sage.
National Cancer Institute (2004). Making health communication programs work. Bethesda, MD: U.S. Department of Health and Human Services.
Pan American Health Organization. (2007). Report on the Technical Consultation on Information, Education and Communication (IEC) on Congenital Chagas Disease. Montevideo, Uruguay: OPS.
Parks, W. & Lloyd, L. (2004). Planning social mobilization and communication for dengue fever prevention and control: a step-by-step guide. Geneva: World Health Organization.
Piotrow, P., Kindai, D.L., Rimon II, J., & Rinehart, W. (1997). Health Communication: Lessons from Family Planning and Reproductive Health. Westport, CT: Praeger.
Seventh Community Based Tropical Disease Research in Ecuador. (n.d.). Retrieved May 21, 2008, from http://www.oucom.ohiou.edu/tdi/Tropical_Research/Tropical_Research %20Details.htm
Tropical Disease Institute. (n.d.). Retrieved May 21, 2008, from http://www.oucom.ohiou.edu/tdi/Mission.htm
Valente, T.W. (2001). Evaluating communication campaigns. In R.E. Rice & C.K. Atkin (Eds.), Public Communication Campaigns (pp. 105-124). Thousand Oaks, CA: Sage.
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BIBLIOGRAPHY
Aguilar, H.M.V., Abad-Franch, F., Racines, J.V., Paucar, A.C. (1999). Epidemiology of Chagas disease in Ecuador. Mem Inst Oswaldo Cruz, 94, 387-393.
Coffman, J. (2003). Lessons in evaluating communication campaigns: five case studies. Communications Consortium Media Center: Harvard Family Research Project, 1-42.
VIDEOS ABOUT CHAGAS DISEASE
Campaña de Prevención de la Enfermedad de Chagas en Loja, Ecuador. (2005). Dir. Mario Grijalva.
Campaña de Prevención de la Enfermedad de Chagas en Manabí, Ecuador. (2004) Dir. Mario Grijalva.
Chagas: A Hidden Affliction. (2005). Dir. Ricardo Preve. Ricardo Preve Films LLC. New York, NY: Distributed by the Cinema Guild.
Chagas Disease Research Project – Loja, Ecuador. (2005).Dir. Mario Grijalva. Retrieved November 20, 2007, from http://streaming.ohio.edu/imts/tdi/ref.mov
Niños sin Chagas. “Anime Chagas 02” posted: 11 julio a las 10:36:15. Retrieved May 16, 2008, from http://www.youtube.com/watch?v=DIU7pebIrgQ&feature=related
Video y Canción sobre la Enfermedad de Chagas. Produced by JICA Chagas disease control project in El Salvador. Song by Mr. Alquilo of Olopa. Retrieved May 16, 2008, from http://www.youtube.com/watch?v=Xx8jiSs6OCw
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APPENDICES
Appendix 01 – Educational Booklet
112
Appendix 02 – Calendar
113
Appendix 03 – Pamphlet
114
Appendix 04 – Brochure
115
116
Appendix 05 – Chagas Disease CD Insert
Libreto para grabación de CD sobre Enfermedad de Chagas
Buenos días a todas las personas presentes. Los invito a conversar sobre un tema muy importante para la salud de la familia. ¿Han oído ustedes hablar del Mal de Chagas? El Mal de Chagas es una enfermedad que causa graves daños en el corazón, en el esófago y en el intestino grueso. El Mal de Chagas lo transmiten insectos que la gente conoce con el nombre de chinchorros. ¿Han visto alguna vez a los chinchorros? Obsérvelos bien…, a lo mejor ustedes ya los conocen. Estos chinchorros viven y se esconden en las rendijas de caña de las paredes; en los huecos de las paredes de adobes; debajo de los colchones y de las tablas de las camas; debajo y detrás de los muebles y de los cuadros; en los techos de cade y de bijao… Estos chinchorros viven, se reproducen y se esconden en amontonamientos de cañas, palos, ladrillos, bloques y otros materiales que las familias acumulan en los patios; también en nidos de palomas y en gallineros. ¿Cómo los chinchorros transmiten a la gente la enfermedad de Chagas? Cuando las personas están dormidas o reposando, los chinchorros les pican y se repletan de sangre. Llenos de sangre, los chinchorros defecan un líquido de color obscuro, y se van. En ese líquido obscuro están los microbios que causan la Enfermedad de Chagas. Por la picazón, las personas se rascan y se hacen pequeñas lastimaduras alrededor de la picada. Por esas lastimaduras en la piel o al restregarse los ojos, se meten los microbios que enferman a la gente con el Mal de Chagas. ¿Qué hacer? Hay que eliminar a los chinchorros que transmiten esta enfermedad. La acción de cada familia es la más importante: • Si hay chinchorros dentro de su casa o en su patio, captúrelos vivos, métalos en recipientes, y llévelos al Centro de Salud más cercano. • Cuando el personal del Servicio de Malaria vaya a rociar su casa para eliminar chinchorros, acompáñelo y ayúdelo en su trabajo. Es por el bien de su propia familia y de toda la comunidad.
Autor: Dr. Víctor González. Jefe Nacional del Departamento de Educación para la Salud. Oficinas de Dirección Nacional de la ciudad de Guayaquil – Ecuador del Servicio Nacional de Control de Enfermedades transmitidas por vectores artrópodos.
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Appendix 06 - Production Credits
Production, Direction and script writing: Julia Nogueira (Ohio University (OU) Master of Arts – Latin American Studies and Film Studies)
Project Direction: Mario J. Grijalva C., Ph.D (Director of Ohio University/Tropical Disease Institute and coordinator of the Community Based Chagas Disease Research Project)
Shooting Crew: Camera: Jeremy Moss (OU Master of Fine Arts – School of Film)
Sound: Bruce Parsons (OU Master of Fine Arts – School of Film)
Camera assistant: Michael Kellogg (OU Telecommunications (TCOM) – Undergraduate
Program)
Editing crew: PSAs and educational video: Cory Monte (OU/TCOM – Undergraduate – Video production major)
Promotional video: Adam Caudill (OU/TCOM – Undergraduate – Video production major)
Animation: Ty Halley (OU/TCOM – Undergraduate –Digital Media major)
Aditional production credits: Music: Andesmanda
Narration of PSAs and educational video: Edwin Baus Acosta (Estudio EBA)
Narration of promotional video: Andrew Crabtree (OU/TCOM – Undergraduate – theater major)
Voice over of promotional video: Adam Fox and Lisa Marie Summerscales
Pictures for educational video: Leonardo Carrizo
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Appendix 07 – Simple Recording Consent
Instituto de Enfermedades Tropicales Irvine Hall, Athens, Ohio 45701 Tel.: 740-593-2530 Fax.: 740-597-2778
Autorización
Entiendo que las fotografía(s) o video o grabaciones de mi voz hechas por estudiantes de la Universidad de Ohio serán utilizados para el estudio y/o desarrollo de materiales educativos y de servicio público sobre la enfermedad de Chagas.
Le doy permiso a la Universidad de Ohio el uso de mi imagen y voz (fotografías, grabaciones, filmación) y copiar, exhibir, publicar o distribuir todas y cada una de dichas imágenes y grabaciones mías o en las que yo aparezca, inclusive composiciones o diseños artísticos, con el fin de difundir los programas de la Universidad o para cualquier otro propósito lícito.
Entiendo que abandono el derecho de ver examinar el producto final y abandono mi derecho a demandar a la Universidad de Ohio por el uso de mi imagen y voz a través de esta autorización.
______Nombre y Apellido Firma
______Localidad Fecha
Mayor de 18 años SI______NO______
______Nombre de Padre o Madre Firma 119
Appendix 08 – Complete Recording Consent
Instituto de Enfermedades Tropicales Irvine Hall, Athens, Ohio 45701 Tel.: 740-593-2530 Fax.: 740-597-2778
Autorización
Entiendo que las fotografía(s) o video o grabaciones de mi voz hechas por los agentes, empleados o representantes de la Universidad de Ohio serán utilizados para la diseminación de información en programas académicos y de servicio público destinados a la población en general.
Por medio de la presente autorizo irrevocablemente a la Universidad a copiar, exhibir, publicar o distribuir todas y cada una de dichas imágenes y grabaciones mías o en las que yo aparezca, inclusive composiciones o diseños artísticos, con el fin de difundir los programas de la Universidad o para cualquier otro propósito lícito.
Además, cedo mi derecho de examinar o aprobar el producto final, inclusive textos o transcripciones. Por lo tanto eximo y exonero para siempre a la Universidad de cualquier reclamo, exigencias o demandas que pueda tener yo o mis herederos, representantes, albaceas, administradores o cualquier otra persona que me represente o actúe en mi nombre o sucesión por motivo de esta autorización.
______Nombre Firma
______Fecha Localidad
(Si el/la firmante es menor de 18 años, debe obtenerse el consentimiento de su padre/madre o tutor, según se indica.)
Certifico por la presente que soy el padre/la madre o tutor de ______, la persona anteriormente mencionada, y doy amplio consentimiento respecto de lo anteriormente expresado en su nombre. ______Nombre Firma 120
Appendix 09 – List of Expert Reviewers
Esteban Baus - Biologist and Manager of the Laboratorio de Enfermedades Infecciosas / Universidad Católica del Ecuador (CIEI/PUCE)
Dr. Mario Grijalva Ph.D - Director of Ohio University - Tropical Disease Institute, coordinator of Community Based Chagas Disease Research Projec and Associate Professor at Department of Biomedical Sciences. Areas of expertise: Tropical diseases, Epidemiology, Immunoparasitology and International Health
Dr. Mario Mosquera-Vasquez Ph.D. - Associate Professor of Health Communication Research in the Academic Program of Social Communication - Journalism from Universidad del Norte, Barranquilla, Colombia.
Dr. Rafael Obregon Ph.D. – Director of Communication and Development Master of Arts at the Ohio University and Associate Professor at the School of Telecommunications. Areas of expertise: Communication for development and social change, Public health communication, Communication planning, monitoring and evaluation, Capacity strengthening and development.
Sofia Oscaña - Biologist of the CIEI/PUCE Dr. Martha Rodriguez - Communication Department of the Organización Panamericana de la Salud / Oficina Regional para las Américas de la Organización Mundial de la Salud
Eric Williams – Assistant Professor at Ohio University. Areas of expertise: screenwriting and International Media Projects.
PLAN Internacional Fredy Romero, Manager of PLAN Internacional in Catacocha Nicandro Sedamanos, Community Development Facilitator Pedro Barahona, Community Development Facilitator Erasmo Herrera, Community Development Facilitator Carlos Velez, Community Development Facilitator Nancy Aguilar, Community Development Facilitator Luis Moncayo, Community Development Facilitators Silvia Macias, Sponsorship Technician Luis Pillaga, Education Technician Carmen Salas, Health Technician Solanda Pardo, receptionist Ann Ku, Peace Corp Volunteer
Hospital in Catacocha Dra. Rita Saritama, Director of Health Area number 8 – Catacocha Dr. Leonardo Sivuak Patiño, dermatologist Dra. Tania Celi Barrazueta, general physician Bolney González, laboratory technician Viviane Guarreir, laboratory technician Ana Isabel Romero, nurse 121
Appendix 10 – PSAs Pre-Testing Participation Consent
Universidad de Ohio - Consentimiento para evaluación de Comerciales de Televisión Estrategia de Comunicación Para Prevenir la Enfermedad de Chagas en Ecuador Regulaciones federales y de la Universidad de Ohio requieren consentimiento para participar en investigaciones que incluyen a sujetos humanos. Después de que se le explique lo siguiente, por favor, indique su consentimiento para participar en este estudio firmando este formulario.
La información de esta investigación será utilizada para evaluar la calidad de ocho comerciales de televisión que son parte de una estrategia de comunicación para ayudar a prevenir el mal de Chagas, una enfermedad que mata cerca de 50 mil personas todos los años.
El objetivo principal de estos comerciales es enseñar a los ecuatorianos lo que pueden hacer para prevenir la enfermedad de Chagas. La investigación es muy importante porque evaluará los puntos fuertes y débiles de los comerciales e indicará los cambios que necesitan ser hechos antes de que sean mostrados a un número más grande de personas.
Para hacer esta evaluación, se mostrarán los comerciales para luego conocer su opinión a través de un cuestionario oral. Este proceso tomará entre 40 a 50 minutos.
Aunque no hay beneficios inmediatos para las personas que participan en este estudio, su colaboración es muy importante. Usted va a contribuir a encontrar la mejor forma de enseñar a las personas cómo prevenir la Enfermedad de Chagas.
No hay riesgos asociados con la participación en esta investigación. Ninguna pregunta representa un riesgo y usted puede negarse a que sus respuestas sean grabadas. En cualquier momento del proceso usted puede 1) negarse a contestar ciertas preguntas, 2) suspender su participación en cualquier momento o 3) pedir que respondan a cualquier inquietud que tenga.
La información colectada no será compartida con nadie afuera del proceso. Y las notas y grabaciones serán destruidas después de tener suficiente tiempo de terminar mi investigación.
Si usted tiene preguntas acerca de este estudio o de sus derechos como participante en esta investigación, puede comunicarse con: Centro de Investigación en Enfermedades Tropicales - Pontificia Universidad Católica del Ecuador (02 -299-1700/1856), Julia Nogueira - Investigadora (1-740-274-1574 / [email protected]), Dr. Rafael Obregon - Profesor Orientador de este estudio (1-740-593-4856 / [email protected]), o Jo Ellen Sherow – Directora de la Obediencia en la Investigación - Universidad de Ohio (1-740-593-0664)
Certifico que se me ha leído esta información, que yo entiendo esta información y que estoy de acuerdo en participar en este estudio. Se me ha explicado satisfactoriamente los riesgos de este estudio y entiendo que no hay ningún tipo de compensación de la Universidad de Ohio o de los empleados de esta universidad. Certifico que soy mayor de edad he decidido participar en este estudio por voluntad propia. Entiendo que yo puedo suspender mi participación en cualquier momento sin ninguna multa o consecuencia. Certifico que la investigadora me ha dado una copia personal de este formulario de consentimiento. Nombre Firma Fecha 122
Appendix 11 – Educational Video Pre-Testing Participation Consent
Universidad de Ohio - Consentimiento para evaluación de Video Educativo Estrategia de Comunicación Para Prevenir la Enfermedad de Chagas en Ecuador Regulaciones federales y de la Universidad de Ohio requieren consentimiento para participar en investigaciones que incluyen a sujetos humanos. Después de que se le explique lo siguiente, por favor, indique su consentimiento para participar en este estudio firmando este formulario.
Esta investigación será utilizada para evaluar la calidad de un video educativo que es parte de una estrategia de comunicación para ayudar a prevenir el mal de Chagas, una enfermedad que mata cerca de 50 mil personas todos los años en todo el mundo. El objetivo principal de este video educativo es enseñar a los niños ecuatorianos sobre de la enfermedad de Chagas y lo que pueden hacer para prevenirla. La investigación es muy importante porque evaluará los puntos fuertes y débiles del Video Educativo e indicará los cambios que necesitan ser hechos antes de que sean mostrados a un número más grande de personas.
Para hacer esta evaluación, se mostrará el video educativo al niño/a para luego conocer su opinión a través de un cuestionario oral. Este proceso tomará entre 40 a 50 minutos.
Aunque no hay beneficios inmediatos para las personas que participan en este estudio, la participación de su hijo/hija es muy importante. Ella/El contribuirá a encontrar la mejor forma de enseñar a los niños como prevenir la Enfermedad de Chagas. No hay riesgos asociados con la participación en esta investigación. Ninguna pregunta representa un riesgo y usted puede negarse a que las respuestas de su representado sean grabadas. En cualquier momento del proceso su ninõ/a puede 1) negarse a que conteste ciertas preguntas o 2) suspender su participación en cualquier momento o 3) pedir que respondan a cualquier inquietud que tenga.
La información colectada no será compartida con nadie afuera del proceso. Y las notas y grabaciones serán destruidas después de tener suficiente tiempo de terminar mi investigación.
Si usted tiene preguntas acerca de este estudio o de sus derechos como participante en esta investigación, puede comunicarse con: Centro de Investigación en Enfermedades Tropicales - Pontificia Universidad Católica del Ecuador (02 -299-1700/1856), Julia Nogueira - Investigadora (1-740-274-1574 / [email protected]), Dr. Rafael Obregon - Profesor Orientador de este estudio (1-740-593-4856 / [email protected]), o Jo Ellen Sherow – Directora de la Obediencia en la Investigación - Universidad de Ohio (1-740-593-0664)
Certifico que se me ha leído esta información, que yo entiendo esta información y que estoy de acuerdo en dejar mi hijo/hija participar en este estudio. Se me ha explicado satisfactoriamente las incomodidades y los riesgos de este estudio y entiendo que no hay ningún tipo de compensación de la Universidad de Ohio o de los empleados de esta universidad. Certifico que soy mayor de edad y que soy responsable por mi representado que es menor de edad. Mi representado ha decidido participar en este estudio por voluntad propia. Entiendo que él/ella puede suspender su participación en cualquier momento sin ninguna multa o consecuencia. Certifico que la investigadora me ha dado una copia personal de este formulario de consentimiento. Nombre del niño Edad Nombre del representante Firma del representante Fecha 123
Appendix 12 – PSAs Pre-Testing Questionnaire
Encuesta de Evaluación – Comerciales de Tele Fecha: ______/ Marzo / 2008 Comunidad: ______Cantidad de adulto: ______(_____ hombres / _____ mujeres) Cantidad de niños: ______(_____ chicos / _____ chicas) (edad: ______)
Chequear la opción que mejor describa la opinión de los respondientes: Muy Bueno Mediano Bajo Muy Bajo Bueno 1. Interese 2. Comprensión 3. Cantidad de Información 4. Retención de informaciones 5. Imágenes 7. Canción 1. ¿Son los comerciales interesantes o aburridos? 2. ¿Crees que las palabras y el lenguaje son fáciles de comprender? 3. ¿Has comprendido las informaciones rápidamente o hay muchos detalles/mucha información? 4. ¿De qué informaciones se acuerdan? 5. ¿Les gustaran las imágenes? ¿Creen que el comercial es bonito o feo? 6. ¿Reconocen las casas, los animales y los paisajes como de la región donde viven en Ecuador? ¿Si no, eso les impide de acreditar en el las informaciones del video? 7. ¿Les gusta la canción? ¿La reconocen como música Ecuatoriana? ¿Es muy andina? 8. ¿Les gusta la frase “¡Tú puedes prevenir la Enfermedad de Chagas!”? Porque, porque no? 9. ¿Qué piensas que son los puntos fuertes y débiles de los comerciales? 10. ¿Hay alguna información que no está clara para ti? ¿Cuál? 11. ¿Cambiarias algo en los comerciales para tornarlos más fáciles de comprender? 12. ¿Si ves comerciales en la televisión, les motivaría a adoptar las acciones sugeridas? 13. ¿Cuál comercial es más importante? Ten tu casa siempre limpia y ordenada Duerme con toldos impregnados con insecticida piretroide. Evita acumular productos agrícolas dentro de la vivienda. Evita acumular ladrillos, piedras y madera cerca de la casa. Asegúrate de que los animales duerman lejos de la casa. Cambia los nidos de gallinas cada 15 días y quema e los nidos viejos. Si encuentras algún chinchorro repórtalo a un Promotor de Salud. Coloca mallas finas en las puertas y ventanas de la casa. 14. ¿Cuál final les gusta más: ¿Chicos jugando al fútbol? ¿Chicas soplando burbujas? ¿Dibujo del chinche? 15. ¿Para quién piensas tu que el mensaje es direccionada? ¿Adulto o niños? 16. ¿Crees que estas informaciones presentadas en el video son importantes? 17. ¿Son estos cambios sugeridos por los comerciales posibles de ser hechos en la casa?
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Appendix 13 – Educational Video Pre-Testing Questionnaire
Encuesta de Evaluación – Video Educativo: Prevención de la Enfermedad de Chagas
Fecha: ______/ Marzo / 2008 Comunidad: ______Cantidad de niños: ______(_____ chicos / _____ chicas) (edad: ______) Cantidad de adulto: ______(_____ hombres / _____ mujeres)
Chequear la opción que mejor describa la opinión de los respondientes a cerca de los siguientes aspectos del Video Educativo: Muy Bueno Mediano Bajo Muy Bueno Bajo 1. Duración 2. Intereses 3. Comprensión 4. Cantidad de Información 5. Retención de informaciones 6. Calidad de las imágenes 8. Animación
1. ¿Es el video muy largo? 2. ¿Es el video interesante o es aburrido? 3. ¿Creen que las palabras y el lenguaje son fáciles de comprender? 4. ¿Han comprendido las informaciones rápidamente o hay muchos detalles/mucha información? 5. ¿De qué informaciones se acuerdan? 6. ¿Les gustaran las imágenes? ¿Creen que el video es bonito o feo? 7. ¿Reconocen las casas, los animales y los paisajes como de la región donde viven en Ecuador? ¿Si no, eso les impide de acreditar en el las informaciones del video? 8. ¿Les gustan los dibujos? ¿Les gustaría que el video tuviera más dibujos? 9. ¿Les gusta la frase “Diga no a la Enfermedad de Chagas”? Porque, porque no? 10. ¿Es la frase “¿Quieres ser tu uno de ellos?” muy fuerte? 11. ¿Qué piensas que son los puntos fuertes y débiles del Video? 12. ¿Hay alguna información que no está clara para ti? ¿Cuál? 13. ¿Cambiarias algo en el video para tornarlo más fácil de comprender? 14. ¿Crees que estas informaciones presentadas en el video son importantes? 15. ¿Crees que este video va a motivarte a adoptar las acciones sugeridas para prevenir la Enfermedad de Chagas? 16. ¿Son estos cambios sugeridos por el video posibles de ser hechos en la casa? 17. ¿Para quién piensas tu que el mensaje es direccionada? ¿Adulto o niños? 18. Si los niños llegan en la casa cuentan las informaciones a sus papas, van ellos a hacer los cambios necesarios en la casa?
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Appendix 14 – Changes on Educational Video after Pre-Testing
Suggestion or consideration Change made to script/video Repeat the words “Chagas disease” to help The word “Chagas” had already been used people retain the information better. more than 20 times. Three more were added along with other information and it was considered sufficient. Besides the name chinchorro (kissing bug) also The word chinche was included four times, the include the word chinche because it is the way first one explaining that it is another word for the rural population knows the insect. chinchorro. Include more information, scenes and details Information added: it can be found in many about the kissing bug, including in what areas regions of Ecuador, in tropical climate and of Ecuador it can be found. altitudes lower than 2000 meters. There are many species and sizes of kissing bugs. Scene 18 – animation – after biting, the bug Red spot added. leaves red spot near the poop which is not seen. Scene 20 – animation – boy scratches arm, but Bite added. bite cannot be seen Scene 27 – animation – Looks like he has back Change in animation indicates body pain and pain, which is not a Chagas symptom. not back pain. Scene 38 – The house with cement walls is too Scene changed to an adobe house. nice for a house with Chagas Scene 43 (shows a pig) – problem: there is no Scene of pig was removed. proof kissing bug feeds from pigs / narration leads to confusion between chinchorro and chancho (pig). Scene 43 (shows green coffee outside a house) Scene of green coffee changed for corn. – problem: green coffee does not attract rodents that attract the kissing bug. Scene 48 – add the expression líder Term Promotor de salud (health promoter) comunitario (community leader) to the already added. included Promotor de salud (health promoter). Scene 60 (shows a donkey) – problem: donkeys Donkey removed. do not live close to houses so are not a risk. Scene 68 – Interview with Esperanza Tinoco is Another part of the interview was added. too short. By the time people understands her accent, the interview is over. Scene 72 (shows a butterfly) – problem: video Scene with butterfly was removed. talks about eliminating an insect and people might get confused by seeing a butterfly. Video seemed to be made for adults but in the Scene was added before the interview saying: last interview, when Dr. Mario Grijalva talks “Not just adults but also young people and kids directly to the children, it was confusing. can help prevent Chagas Disease.” Tell with what other diseases Chagas can be Better explanation about the symptoms in confused. If someone has the symptoms, how scenes 27 to 37. do they know if it is Chagas or not? More children should participate on message Suggestion not followed because research design and production process. schedule did not include another shooting trip. 126
Appendix 15 – Educational Video’ Final Script
Images and Animations English Narration Narración en Español SOUND EFFECTS 1. BLACK FADES TO Sound effect of bug moving Estamos buscando este ANIM – Kissing bug crosses screen We are looking for this bichito, el chinchorro, el J CUT TO INTERVIEW animal, the kissing bug, chinche, 2. INTERVIEW because sometimes we can porque a veces se Cesar Yumiseva - CIEI find it in the houses encuentra en las casa (Manuel: yes, yes, there (Manuel: si, si, se hay) are) but we look for it pero le buscamos porque because it can transmit a puede transmitir una disease. It’s called Chagas enfermedad. Se llama la disease. enfermedad de Chagas. 3. GC – “Enfermedad de Chagas” ANIM – Bug walking on screen 4. INTERVIEW It looks like we found Parece que encontramos Santiago Montaño kissing bug eggs. And in a lo que son los huevos de Brigada de Chagas SNEM - MSP large quantity. chinchorros… Hay en bastante cantidad. 5. INTERVIEW They found a lot of kissing Encontraron chinchorros Doña Rosita bugs in the chicken nests. bastantísimo en los nidos Cruz Alta de Miguelillo – de gallina. Manabí 6. INTERVIEW I go to bed and feel it biting Me acuesto a dormir, Delia Maura Jaramillo me. I get up and see it on siento que me pica, me Tuburo - Loja the pillow. levanto y lo veo en la almohada. 7. Kissing bug walking on a wall Have you ever seen a ¿Has visto alguna vez un kissing bug like this in your chinchorro como este en house? tu casa? 8. ANIM – kid asks the question Do you know it can ¿Sabías que él puede that is in word bubble. transmit a disease called transmitir una Chagas? enfermedad llamada Chagas? 9. INTERVIEW I knew they bite, but didn’t Yo sabía que ellos Teresa Torres know they have a disease. pinchan, pero no sabía Jacapo - Loja que ellos tienen la enfermedad. 10. INTERVIEW They say it’s an animal that Es un animal que trae una Jose Arcesio Jiménez brings a bad disease, and is enfermedad mala dicen. Tuburo – Joja very dangerous. Y muy peligrosa. 11. Long shots of adults looking at Chagas is a disease that Chagas es una the camera kills many people all over enfermedad que cada año the world. mata a muchas personas en todo el mundo. 12. Medium-shots of kids looking at Among them, thousands are Entre estas personas, the camera (Scenes of people Ecuadorians. Do you want miles son ecuatorianos. 127
continue for a few seconds to be one of them? ¿Quieres ser tú uno de before next scene) ellos? 13. Close up fades away to black We can’t allow Chagas No podemos dejar que la Disease to keep making enfermedad de Chagas victims. siga generando víctimas. MUSIC FADE OUT DURING SCENE 14. ANIM – ‘NO symbol’ with the SOUND EFFECT OF word “Chagas” over kissing STAMP bug drawing 15. ANIM – ‘NO symbol’ stays on Together the health ¡Juntos, los profesionales the screen professionals and the de salud y la comunidad community can combat pueden combatir la Chagas Disease! enfermedad de Chagas! 16. Kissing bug walking on the This disease is brought to Esta enfermedad es wild us by the kissing bug, also transmitida por el called chinche. chinchorro, también llamado chinche o chinche caballo. 17. ANIM – map of Ecuador. Parts This insect can be found in Este insecto puede ser of country that have Chagas many parts of Ecuador, encontrado en varias turn red. In four regions a mainly in rural areas, in partes de Ecuador, miniature of a house appears. regions of tropical climate principalmente en áreas The map starts to fade away and in altitudes lower than rurales, en regiones de while the four houses get bigger 2.000 meters. clima tropical y en altitudes menores de 2 mil metros. 18. Screen splits in 4, each part This is an insect that, El chinchorro es un showing one different house / during the day, hides inside insecto que, durante el the houses appear one after the our house or around it. día, se esconde en nuestra other casa o en los alrededores. 19. Old man sleeping At night the kissing bug Por la noche, el espera a waits until you fall asleep que te duermas para to bite you and feed itself. picarte y alimentarse. 20. INTERVIEW They take a lot of blood Toman bastante sangre Gladys Amada where we find it and if we así donde se los encuentra Amarillos – Loja kill it, where someone y se los logra aplastar sleeps they leave a stain on donde uno se duerma the sheets. I’m scared. mancha bastante la Mainly because of my kids sabana. Por esto me that are growing up. preocupó. Y tengo miedo. Mas por mis pequeñitos que ellos están en desarrollo 21. ANIM – 10 year old boy. While it bites the people Mientras pica a las Kissing bug bites his right arm and feeds itself the insect personas y les chupa la and defecates. leaves its feces close to the sangre, el chinchorro deja bite. sus heces cerca de la picadura. 128
22. ANIM – parasites appear in the And it is exactly in the Y es exactamente en las feces feces that the parasites that heces donde están los cause Chagas are found. parásitos que producen la enfermedad de Chagas. 23. ANIM – kid scratches his arm When we scratch the skin, Cuando nos rascamos, we move the feces to the llevamos las heces hasta bug bite. el lugar de la picadura. 24. ANIM – kid with dirty hands Or sometimes, after O a veces, después de takes his hand to his mouth and scratching, we put the hand rascarnos, nos llevamos eyes. in our mouth or eyes. la mano a la boca o a los ojos. 25. ANIM – Arrow shows the This way the parasite that Así, los parásitos que parasite entering the body was in the kissing bug feces estaban en las heces del through a bug bite on right arm. gets to our blood and makes chinchorro entran en “Chagas” appears on kid’s T- us sick. nuestra sangre y nos shirt enferman. 26. ANIM – Kid walks slowly Some of the initial Algunos síntomas looking very sad and sick symptoms of Chagas iniciales de la Disease are fatigue, Enfermedad de Chagas son: malestar general, 27. ANIM – Kid pushes a plate of - loss of appetite, - falta de apetito, food away 28. ANIM – Kid with a hand in his - headache, - dolor de cabeza, head, indicating his head is throbbing 29. ANIM – Kid with a - fever, and - fiebre y thermometer 30. ANIM – Kid indicating body - body ache. - dolores musculares. pain 31. ANIM – 5 symptoms miniatures Usually, these first Normalmente estos appear in the same screen at the symptoms of Chagas primeros síntomas del same time. Disease get confused with Mal de Chagas se those of other diseases confunden con los de otras enfermedades 32. ANIM – The miniatures fade and disappear after a while. y desaparecen con el away That’s why some people tiempo. Por esto, muchas don’t even know they are personas no se dan cuenta infected by the kissing bug. que fueron infectadas 33. ANIM – 30 year old men (older But 5, 10 or 20 years later, Pero después de 5, 10 ó version of the kid) sitting on a when it gets to the chronic 20 años, cuando llega la chair, looks tired and sick. phase, Chagas Disease fase crónica, la reappears and can cause Enfermedad de Chagas serious health problems. reaparece y puede causar graves problemas de salud. 34. ANIM – A red heart appears in Your heart and other organs Tu corazón y otros the left side of the man’s chest. can start to grow more than órganos del cuerpo The heart gets bigger, taking up normal, and can even cause pueden crecer más de lo 129
whole screen. death. normal, pudiendo causar incluso la muerte. 35. ANIM – Heart shrinks again Don’t let the parasite that ¡No permitas que el and fits well in man’s chest. causes Chagas Disease hide parásito que causa la in your body! enfermedad de Chagas se esconda en tu cuerpo! 36. Kid being received by a nurse in If you have any of these Si presentas algunos de a Health Center symptoms, go immediately estos síntomas, acude People being seen by doctors / to the nearest Health Center rápidamente al Centro de Kids having the blood test / and tell the doctor, if you Salud más cercano y Stak Pak exam /kid in health have seen a kissing bug in cuéntale al Doctor si has center your house, to test you for visto al chinchorro en tu Chagas. This is the only casa para que te haga un way to know if you have examen. Esta es la única Chagas or not. forma de saber si tienes Chagas o no. 37. ANIM – Kissing bugs on the There is still no vaccine for Todavía no hay vacuna wall of a house. They move Chagas Disease. So, for no para la Enfermedad de away from the house. one to get sick, we have to Chagas. Por lo tanto, para eliminate the kissing bug que nadie se enferme, from our house. tenemos que eliminar los chinchorros de nuestra casa. 38. Bug walking on the bed or wall First it is important to Primero, es importante recognize the kissing bug. aprender a reconocer a los chinchorros. 39. ANIM – pictures of bug in There are many species and Hay varias especies y different stages. sizes of kissing bugs. The tamaños de chinchorros. big and the small ones can Tanto los grandes como transmit Chagas disease. los pequeños pueden transmitir la enfermedad de Chagas. 40. INTERVIEW The control of Chagas El control de la Mario J. Grijalva, Ph.D. disease is based on two enfermedad de Chagas Tropical Disease Institute - Ohio main principals. The first is está basado en dos University the improvement of the principios fundamentales. CIEI, Universidad Católica del houses and the El primero es el Ecuador improvement of the areas mejoramiento de las around where people live. viviendas, el There is also chemical mejoramiento del entorno control using insecticide. de donde viven las This is very effective if personas. Existen también J cut to scenes of fumigation applied properly and within las medidas de control a period in which the químico, de control insecticide is still active. utilizando insecticidas. Estos son muy efectivos si son aplicados adecuadamente y dentro 130
de un periodo en que el insecticida todavía está activo. 41. Scenes of fumigation Because there is no vaccine Como no hay vacuna y el and the treatment is only tratamiento solo es effective during the first efectivo en las primeras weeks after contamination, semanas después de la the solution for Chagas infección, ¡Por eso la Disease is prevention. solución para la Enfermedad de Chagas es la prevención! 42. ANIM – House with kissing And preventing Chagas Y prevenir el Mal de bugs in different places and means eliminating the Chagas significa eliminar around. “NO symbol” start kissing bugs from the house los chinchorros de la appearing over kissing bugs so they cannot bite you and vivienda para que ellos transmit disease to the no puedan picar y people. transmitir la enfermedad SOUND EFFECTS OF STAMP a la gente. 43. ANIM – Kid ask question in But where can we find the ¿Pero dónde podemos word bubble. kissing bugs? encontrar los chinchorros? 44. ANIM – two small kissing bugs Like other living beings, Como otros seres vivos, flying. There is a pile of wood the kissing bugs need los chinchorros, o leaning against outside wall of shelter and food to survive. chinches, necesitan de house and there is girl sleeping abrigo y alimento para inside. sobrevivir. 45. Façade of a house. ANIM - To protect themselves, Para protegerse, durante Arrows indicate different parts during the day they hide in el día ellos se esconden of house. many places inside the en varios lugares dentro house: de la casa: 46. Wall with holes and hanging - Hidden in the holes of the - En los agujeros de las pictures. walls, behind the pictures, paredes, detrás de los cuadros, debajo del empapelado, 47. Room with beds - under the beds, - debajo de las camas, 48. Pile of clothes in a room - and in any other place - y en cualquier otro lugar where we gather objects. donde se acumulan objetos. 49. ANIM –Kissing bugs fly around Because kissing bugs feed Como los chinchorros se the same house as end of scene on blood, they like to live alimentan de sangre, les 45. One finds a mouse sleeping in places where there are gusta vivir en lugares inside the pile of wood and animals they can feed from. donde hay animales o feeds from it. The other finds So, they also can be found seres humanos de quien the girl sleeping and bites her inside or around the house, se puedan nutrir. Por lo face. in places where there is tanto, también se los accumulation of materials puede encontrar dentro o that attract mice and rats, en los alrededores de la casa, en lugares donde se 131
acumulan materiales que atraen ratas y ratones, 50. Chicken nest made out of corn - and in chicken nests and - y en nidos de gallina y leaves nests of other animals. de otros animales. 51. The bug walking on the wall. So, if you find any kissing Si encuentras chinchorros bugs inside the house, be dentro o cerca de tu casa, careful catching them. ten mucho cuidado al atraparlos. 52. Someone catching a bug, using Cover your hand with a Cúbrete las manos con plastic bag as glove, puts it into plastic bag and put it inside una funda plástica y a plastic bottle a plastic container. ponlo dentro de un recipiente con tapa. 53. SNEM guy giving bottle to Don’t forget to put the No te olvides de poner la community person information about the información sobre el Someone writing on bottle kissing bug. Write where chichorro. Escribe dónde Bottles lined up – with you found it, the date and lo encontraste, la fecha y information of where they were the name of the head of the el nombre del jefe de tu found. family. You can write that familia. Puedes escribir Kissing bugs inside bottle information outside the esta información afuera bottle or on a piece of paper del recipiente o también and put it inside the bottle. en un papelito que luego This information is very pones dentro del important to the studies recipiente. Esta about Chagas Disease. información es muy importante para los estudios sobre la enfermedad de Chagas. 54. Snem personel looking for As soon as possible, give it Apenas sea posible, kissing bug to the community leader or entrégale este recipiente the health promoter of your al líder comunitario o al Men finds a bug community. This way they promotor de salud de tu Men fumigates house will report it to the comunidad. Así, éstos Programa Nacional de reportarán la presencia de Men guys find bug Chagas del Ministerio de los chinchorros al Bottles of bugs lined up Salud, so what is necessary Programa Nacional de can be done. Chagas del Ministerio de Salud, para que se tomen las medidas necesarias. 55. INTERVIEW We do very detailed work, Hacemos un trabajo muy Freddy Véliz looking in every centimeter minucioso, como le digo, Brigada de Chagas SNEM- MSP of the entire house and also demasiado minucioso, around it. And we see that revisamos como se puede besides the searching, what decir, centímetro por we do that is very important centímetro de toda la casa is the education, because it y lo que es perímetro is very important, because igual. E allí vemos, there are a lot of detectamos igual, mas communities that don’t que todo la búsqueda 132
know it, that don’t even nosotros más entramos know what Chagas Disease con educación porque es is. muy importante porque hay muchas comunidades que no conocen, en otras palabras, ni lo saben lo que es el Mal de Chagas. 56. INTERVIEW And I think this is a Y creo que es una forma Geovani Cumbicus contribution of a grain of de aportar con un granito Brigada de Chagas SNEM -MSP sand because we’re letting de arena pues les people know what is the haciendo conocer que danger of this vector, the peligro tiene este tipo de triatomines, the kissing vector, los triatominos, bug. los chinchorros. 57. Façade of Ministry of Health, But not only the authorities No sólo las autoridades people in different activities. can work towards pueden trabajar en la preventing Chagas Disease. prevención del Mal de The effort of all the Chagas. El esfuerzo de community is also very toda la comunidad important. también es muy importante. 58. Woman cleaning behind picture There are simple things that Hay cosas simples que on the wall you can do in the house not puedes hacer en la casa Woman making bed to attract the bug and this para no atraer al way avoid the disease. chinchorro y así prevenir la enfermedad. 59. ANIM – kid says sentence in It’s easy! You only have to ¡Mira qué fácil es! ¡Sólo word bubble. follow this advice. debes seguir estos consejos! 60. Ladies making up a bed For the bug not to have a Para que el chinche o place to hide, always keep chinchorro no tenga your house clean and dónde esconderse, organized. mantén tu casa siempre limpia y ordenada. 61. Lady sweeping the house Clean under the beds, Limpia debajo de las Lady arranging things on the behind the pictures and in camas, detrás de los wall the holes of the walls. cuadros y en los agujeros de las paredes. 62. People moving bricks/tiles away Avoid the storage of tiles, Evita las acumulaciones from a house stones, wood and other de ladrillos, piedras, kinds of material, inside madera, y otros and outside the house. This materiales, tanto dentro, way the kissing bug won’t como fuera de la have a place to hide. vivienda. Así, el chinchorro no tendrá dónde esconderse. 63. People moving corn from a Avoid accumulating Evita acumular productos house agricultural products inside agrícolas dentro y 133
and around the house, alrededor de tu vivienda, because that attracts mice porque esto atrae ratas y and rats that serve as food ratones que sirven de for the kissing bug. alimento para los chinchorros. 64. Cat being put away from the Don’t let animals sleep No dejes que los animales house inside the house because duerman dentro de tu they attract the kissing bug casa porque ellos atraen a close to your family. los chinchorros cerca de ti y tu familia. 65. Various scenes of animals: dog, The kissing bug that El chinchorro que Bird, Pig, guinea pigs, cats transmits Chagas Disease transmite la enfermedad (except for chickens) also feeds on the blood of de Chagas también se animals like dogs, cats, alimenta de la sangre de guinea pigs, pigs, pigeons, animales como perros, gatos, chanchos, cuyes, palomas, 66. Chickens walking around and mainly chickens. y principalmente gallinas. 67. Correct nests So, if you have poultry Por lo tanto, si tienes ANIM – show a house, the make sure there are at least gallineros, asegúrate de chicken nest and 10 meters of 10 meters between your que éstos estén lejos de tu distance between them house and the poultry. casa. Debe haber por lo Don’t build the chicken menos 10 metros de nests with banana or corn distancia entre tu casa y leaf. It is better to use los gallineros. No cardboard or “costal”. construyas los nidos con hojas de plátano o de maíz. Es mejor usar cartón o tela de costal. 68. Making a correct chicken nest Change the chicken nests Cambia los nidos de las every 15 days, gallinas cada 15 días, 69. Burning nest And remember to burn the y recuerda quemar los old nests. nidos viejos. 70. Correct houses with no holes on - It’s also important to seal También es importante walls. the holes and cracks in the que selles los agujeros y ANIM – brush paints the way walls inside and also grietas de las paredes, of the house of a color similar outside the houses, so the tanto dentro como fuera to the wall. kissing bug won’t be able de la casa, para que el to hide. chinche no pueda esconderse. 71. Baby in the bed with a bed net Use bed nets when you go No dejes de utilizar to sleep, toldos para dormir, 72. Someone putting screens on and also put screens on the y de colocar mallas finas windows doors and windows, so the en las puertas y ventanas, bug won’t be able to enter para que los chinchorros the house and bite you. no puedan entrar a tu casa ! 73. ANIM - Kid says sentence in Did you see how easy it is ¿Viste qué fácil es 134
word bubble. to eliminate the kissing bug eliminar el chinchorro de from our house? tu casa?
74. Scenes of kids Let’s unite against Chagas Unámonos todos contra el for the well being of your Mal de Chagas por el community. bien de nuestra comunidad. 75. INTERVIEW People need to be conscious La gente tiene que estar Esperanza Tinoco that these things have to be consciente que las cosas El Sauce – Loja done for the health, for the tienen que ir por la salud, well being. el bienestar. 76. Scenes of kids with educational Not just the adults but also No sólo los adultos booklet the young people and kids pueden ayudar. La actitud can help prevent Chagas de los niños y jóvenes Disease. también es importante para prevenir la Enfermedad de Chagas. 77. INTERVIEW You kids are the main tool Son ustedes los niños la Mario J. Grijalva, Ph.D. for Chagas control. You are herramienta principal para Tropical Disease Institute - Ohio the ones that can teach the el control de Chagas. Ustedes son los que pueden University message from one kid to the other. You are the ones enseñar el mensaje de CIEI, Universidad Católica del Chagas de un niño a otro. Ecuador that can teach your parents Son ustedes los que pueden where the kissing bug is enseñar a sus papás donde and what to do to prevent it están los chinchorros y qué J cut with scenes of kids with from living in the house hay que hacer para evitar Education Booklet over beginning and around it. You, the kid, que estén en la casa y sus of interview. are the heart of the Chagas alrededores. Ustedes los Prevention Program. niños son el corazón del programa de prevención de la enfermedad de Chagas. 78. People doing different With the help of the entire Con la ayuda de toda la activities. community it is possible to comunidad es posible eliminate the kissing bug eliminar el chinchorro de from our houses. nuestras viviendas. 79. ANIM – ‘NO symbol’ SOUND EFFECT OF STAMP 80. ANIM – ‘NO symbol’ Say no to Chagas Disease! ¡Dile no a la enfermedad FADE OUT TO BLACK de Chagas! 81. CG: Para mayores informaciones: 042284130 ext.131 / 042 392212 ext 131 Programa Nacional de Chagas, MSP 82. LOGOS: Plan Internacional, Pontificia Universidad Católica, Ohio University, Ministerio de la Salud 83. Credits MUSIC FADE OUT after credits
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Appendix 16 – Changes on Psas After Pre-Testing
Suggestion or consideration Change made to script/video Divergent opinions about common Editing of scene 5 will be different for every other beginnings of PSAs being repetitive. PSA. Include scenes of adults along with children, so PSAs would also be appealing for adults. Scenes of adults included. Include more images of children playing and Scenes of children playing were included. people in different activities. PSA 3 - Change agricultural products to Word granos included. “grains” (granos) or at least include granos because used more frequently to refer to agricultural products.
PSA 7 - Suggestion to add the expression Expression líder comunitário included. Líder was líder o agente comunitario (community chosen over agente for being a more powerful leader or agent) to the already included word. It was impossible to include both because Promotor de salud (health promoter). of time limitation. Words were cut in scenes 5 and 7 to include suggestions to PSAs 3 and 6 within 30 seconds. Add more information about Chagas disease. Add more information about the kissing bug. New PSA created with this information. Include chinche and chinche caballo.
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Appendix 17 – PSAs’ Final Scripts
Images English Narration Narración en Español 1.Kissing bug walking on a wall or floor 2.Screen split in 4, each part Have you seen a kissing bug ¿Has visto alguna vez un showing different houses / the like this one in your house? chinchorro como éste? houses appear one after the other, not at the same time 3.One house in the previous scene Do you know it can transmit ¿Sabías que él puede takes up entire screen (Each 2 Chagas Disease? transmitir el Mal de PSAs will have the same house) Chagas? 4.House fades away to black 5.Different people (kids and But with your help it is Con tu ayuda es posible adults) look at the camera and possible to prevent this prevenir esta enfermedad smile. The last person fades away disease that kills many que mata a muchas to black. people. personas. Kids playing soccer in front of a house, playing with soap bubbles (different order of scenes for each 2 PSAs) 6.PSA 1 Always keep the house Ten tu casa siempre Lady arranging pictures on wall / clean and organized, so the limpia y ordenada, para Lady sweeping floor / Ladies kissing bug won’t have a que el chinchorro no making bed place to hide. tenga donde esconderse. 6.PSA 2 Use bed nets with piretroid Duerme con toldos Baby in the crib with a bed net insecticide when you go to impregnados con sleep, so the kissing bug insecticida piretroide, won’t be able to bite you. para que el chinchorro no pueda picarte. 6. PSA 3 Avoid accumulating Evita acumular Men moving coffee from inside agricultural products or productos agrícolas o house grains inside the house, granos dentro de tu Coffee on the floor outside the because they attract vivienda, porque éstos house rodents. atraen a los roedores. 6.PSA 4 Avoid accumulating Evita acumular ladrillos, Someone moving a brick away bricks, rocks and wood piedras y madera cerca from a house close to the house, so the de tu casa, para que el Bricks piled outside a house kissing bug won’t have a chinchorro no tenga place to hide. dónde esconderse. 6. PSA 5 Make sure the domestic Asegúrate de que los Cat being put outside the door of a animals sleep away from animales duerman lejos house / Dog walking / guinea pigs the house, because the de tu casa, porque el inside cage kissing bugs feed from chinchorro se alimenta them. de ellos. 6.PSA 6 For the kissing bug not to Para que el chinchorro Lady makes nest out of cardboard have a place to hide, no tenga donde and coastal?? / Chicken in correct change the chicken nests esconderse, cambia los 137 nest / Burning a nest every 15 days and burn the nidos de gallinas cada 15 old ones. días y quema e los nidos viejos. 6.PSA 7 - Snem looking for bug If you find any bugs in the Si encuentras algún Snem finds a bug house report to a Health chinchorro repórtalo a Person catches bug and puts in Promoter or a community un Promotor de Salud o bottle leader, so what is necessary líder comunitario para Snem fumigates house can be done. que se tomen las medidas necesarias. 6.PSA 8 Put screens on your doors Coloca mallas finas en Someone putting screen on a and windows, so the las puertas y ventanas de window kissing bug won’t get into tu casa para que el your house. chichorro no pueda entrar. 7.”NO sign” over kissing bug Eliminate the bug from your ¡Elimine al chinchorro de house! tu casa ! 8.CG: Para mayores You can prevent Chagas ¡Tú puedes prevenir la informaciones: Disease! Enfermedad de Chagas! 04 39 2212 ext 131 04 239 2217 ext 131 9.LOGOS: Plan Internacional, Pontificia Universidad Católica, Ohio University/TDI, Ministerio de la Salud.
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Appendix 18 – Stakeholders
Stakeholders Function Ohio University - Tropical Disease Institute Sponsor Centro de Investigación en Enfermedades Project creation Infecciosas - PUCE Project implementation Ecuadorian Ministry of Health Sponsor / Supporter Project implementation Plan Internacional Sponsor / Support Institution At-risk population Beneficiaries / target audience Community leaders Human relations Communication bridge Doctors Service providers Nurses Service providers Teachers Educators Fieldworkers Educators External Evaluator Evaluation United Nations and NGOs Possible future sponsors
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Appendix 19 – Promotional Video’s Script
Images, CG and Animations Narration 1. Black background CG (letters in red): Chagas Disease Triatomine, the kissing bug Trypanosoma cruzi, a parasite that causes death
CG (letters in green or white): Prevention Community effort Behavior change Title: Community Based Chagas Disease Research Project 2. Map of the Americas shows Approximately 10 million people in the American countries where there is Chagas continent are infected with Trypanosoma cruzi, the CG: 10 million people infected by parasite that causes Chagas Disease. Chagas Disease 3. Kissing bug Trypanosoma cruzi is transmitted mainly through the feces of blood feeding triatomine insects, also called in English the kissing bugs. 4. ANIMATION While eating, the insect leaves its feces infected with the parasite close to the bite site. When the person scratches the skin, the feces enter the blood, initiating the infection process. 5. ANIMATION Transmission can also happen through blood transfusion and from the mother to the fetus. 6. ANIMATION Some of the symptoms of Chagas Disease are fatigue, loss of appetite, headache, fever, and body ache. These initial symptoms are often mistaken for non-fatal ailments and the symptoms often disappear after a few weeks. 7. ANIMATION However, the disease itself has not disappeared and 5 to 20 years later, 10 to 30 percent of infected people develop Chronic Chagas disease, which usually produces heart damage often leading to sudden death. 8. PICTURES of affected organs The parasite can also cause damage to the nervous system and the digestive track. 9. Clinic – local population being Diagnosis of the disease is difficult due to lack of seen by doctors access to health care in the endemic regions. In addition, there is no vaccine for Chagas and treatment is only effective in early stages of infection. People moving bricks from house, Therefore, in order to prevent deaths we need to cleaning house, guy moving prevent people from contracting the disease. This can coffee from house, putting cat be done by eliminating the presence of the kissing bugs outside the house, putting screen from inside and around the houses. on window 10. MAP showing the countries Although great progress has been made in the southern cone of South America, little has been done to prevent or control the spread of Chagas disease in northern 140
South America, Central America and Mexico. 11. Field team –looking for bug In recent years, researchers from Ohio University and /leaving house Catholic University of Ecuador, in collaboration with MAP – locations turn red the Ecuadorian Ministry of Health, detected high rates of people infected by Chagas Disease and high levels of triatomine infestation in houses of communities located in Loja and Manabí provinces in Ecuador. 12. Field team and American The alarming findings led to the implementation of a students control strategy made possible with a strong collaboration between the National Chagas Disease Program, nongovernmental organizations, local authorities, community members and researchers from Ecuador, the United States and other countries. 13. INTERVIEW Dentro del diagnóstico que hizo la Universidad de Ohio Elizabeth Chacon se identificó las casas con mayor riesgo, con el mayor Gerente de Plan Internacional – peligro, la mayor presencia del insecto. Y gracias a Unidad de Programas Manabí Sur Plan y los patrocinadores se pudo mejorar la infraestructura de estas viviendas. Qué bueno que instituciones como estas cada vez se vayan uniendo y que vayan bajando a la población que realmente Voice over in English necesita y que está completamente olvidada. From the diagnosis done by Ohio University, the houses with the most danger, with the most insects were identified. And thanks to PLAN and the sponsors, it was possible to improve the houses’ infrastructure. It is good that institutions like these work together with the population that really needs it but is completely forgotten. 14. Landscapes with houses From 2005 to 2008, the Community Based Chagas Disease Research Project grew from 35 to 72 communities. 15. Base – people on computers The schools of visited communities are transformed Esteban on the radio into an operation center for the field teams who work Quito team under the supervision of trained biologists from Catholic University of Ecuador and Ohio University. 16. Fast forward - packing cars, This multidisciplinary research effort requires a loading cars, truck on the road, complex logistic that includes transportation, set up of working on microscope, the field laboratory and facilities for data processing, as computers, printers, cooking well as food preparation for all the personnel and community volunteers. 17. INTERVIEW Para nosotros es bastante fuerte en cuestión de trabajo, Anita Villacís porque nos toca estar pendiente de todos. Pero a Medical Entomologist nosotros también nos gusta mucho que otra gente de CIDR – PUCE países donde no ve tanta pobreza, y donde su desarrollo económico es bastante fuerte, llegan a conocer y quieren llegar a entablar con nosotros una relación. 141
Voice over in English For us it is very hard work, because we have to take care of everybody. But we also like it a lot when people from other countries, from where there is not as much poverty and the economic development is strong, want to learn and establish a relationship with us. 18. Snem personnel searching for In each house, well-trained field entomologists search kissing bug inside the house for the triatomine in the cracks on the walls, behind pictures, under the beds and any other places where the bugs can hide. 19. Snem personnel and students Also looking for places where the triatomines might be searching for kissing bug outside a feeding from other animals, they search throughout the house, looking in nest and looking peridomicile, in bushes, guinea pig pens, and chicken into pile of bricks nests, beside piles of firewood, bricks or construction materials, where rodents can hide. 20. INTERVIEW Hay muchas comunidades que no conocen, en otras Freddy Veliz palabras, ni lo saben lo que es el Mal de Chagas. Brigada de Chagas SNEM – MSP Entonces nosotros entramos con charlas educativas, llevamos folletos, calendarios, libros y les hacemos conocer lo peligroso que es esta enfermedad. Con mi ayuda se pueden salvar muchas vidas. Entonces para mí es algo que me llena de satisfacción. Voice over in English There are many communities that don't even know what Chagas Disease is. So we come with educational talks, booklets, and calendars to let people know how dangerous this disease is. With my help it's possible to save many lives. So, for me, this brings a lot of satisfaction. 21. Lab scenes As part of the entomological and parasitological surveys, collected bugs are taken to the field laboratory and then later to the Center for Infectious Disease Research at the Catholic University, in Quito, to identify cycles of transmission and other biological characteristics of the vectors and parasites in the region. 22. Fumigating If a house is found to be infested, a field entomologist, wearing adequate personal protection equipment, sprays all furniture, internal and external. 23. Applying questionnaire At the same time, epidemiological, sociological and housing questionnaires are administered to the head of the family. 24. Students writing number, taking The use of GIS technology enables the collection of pictures, measuring a house, GPS important geographical information. The combined data analysis provides a vital baseline for the control strategy, and for future social economic development programs. 25. Educational talks (charla) As another fundamental part of the control strategy, an educator gives the family members an educational talk about Chagas Disease and what they can do to keep the 142
triatomine insects away from the house. 26. INTERVIEW This program is really about people that have no real Stephany White resources, and we are here to really help them through Biological Sciences Student – that and also to help with something that is not only in Ohio University this country but in an entire continent. And I guess just the entire concept of being part of something that is so big is really important to me. 27. Educational talks (charla) The distribution of an educational booklet and a calendar reinforce the information and encourages behavior change towards Chagas prevention. 28. Someone catching a bug, using a To engage the community in the prevention strategy, plastic bag as a glove, puts it into the head of the family receives a container to deposit a plastic bottle any bugs found in the house and is asked to report any Ministerio de La Salud triatomine presence to the community health volunteers Sofia looks at bugs on bottle who will periodically inform the National Chagas Control Program for further action. 29. INTERVIEW Es una cosa maravillosa que nosotros tenemos aquí. Dilia Monserrote Porque si no haya sido por los gringuitos, que unos Cruz Alta de Miguelillo dicen, ni supiéramos que teníamos la enfermedad. It is wonderful what we have here. Because if it was not Voice over in English for the foreigners, as they are called here, we wouldn’t even know that we had this disease. 30. Clinic – show patients, nurses, When visiting communities, the control strategy also American students organizes a health clinic in which American students help local doctors in the clinical and epidemiological research activities. 31. Clinic – focus on kids The local population receives basic health care and children under 15 years of age are tested for Chagas. 32. Clinic – focus on American It is an opportunity for future doctors to have real students fieldwork experience with various health assessment indicators, blood sample collection, physical diagnosis and learn about infectious disease treatments. 33. INTERVIEW I’m studying microbiology and I’m really interested in Eric Carlsen disease prevention, and medicine, and the whole nine Microbiology Student yards. But you can really only sit in a classroom for so Ohio University long and then after that you need some real world experience. 34. INTERVIEW It’s just a very different experience being in a Ketzela Jacobowitz developing country, working in a clinic where in two Eastern Virginia Medical School – minutes we set up a clinic with very little supplies and Grad Student very little that you would be accustomed to in the States and create this exam room, you know, plastic and whatever you find, it’s just been really fun to just put it together, you know. 35. Kids and parents watching While waiting for children to be seen by the doctors, Educational video. community members watch an Educational video about Chagas prevention. 36. Starts with kids and parents This communication component of the Control Project 143
watching Educational video and is the result of a multidisciplinary effort, as many other go to American students in the students’ subprojects encouraged by Ohio University. clinic 37. Kids shooting – Cineastas de To engage the youngsters in the Chagas issues, in Cruz Alta 2007, the Research Project also started a participatory action using video technology to portray their communities. In the future, local children and teenagers can produce powerful communication tools towards Chagas Disease prevention. 38. INTERVIEW La comunidad siempre ha estado abierta, siempre ha Elizabeth Chacon estado dispuesta a colaborar. Yo creo que de allí viene Gerente de Plan Internacional – todo este entusiasmo y toda esta participación. La Unidade de Programas Manabí juventud está deseosa de participar en cosas que Sur signifiquen un cambio para su vida y que les quede un aprendizaje. Voice over in English The community has always been open, has always been ready to collaborate. I believe that that’s where all this enthusiasm and participation come from. The youth want to participate in things that mean a change for their lives and that make them learn. 39. SNEM guys working The Community Based Chagas Disease Research Project provides important training of local Ministry of Health personnel, community health volunteers, and local instructors, who are fundamental to the control of Chagas Disease. 40. Local population in community The project’s effort is also very well accepted by event community members and Ecuadorian authorities. However, Chagas Disease is still present in Ecuador. 41. Educational talks (charla) The long term effectiveness of the control strategy to eliminate infestations and prevent re-infestations needs to be tested. New communities also need to be included in the program. 42. People working with corn, lady With the biological and epidemiological knowledge flipping beans, kids playing with and the operational tools already acquired, a long bubbles, kids playing lasting control strategy may enable the elimination of Chagas disease from Ecuador. 43. Students, lab and SNEM Academic researchers and students, healthcare personnel in fieldwork. workers, community volunteers, and sponsoring institutions have put a lot of hard work and resources to help reach this goal. 44. INTERVIEW It was hands-on fieldwork, and that was very Meredith Maxey interesting to me. I guess it ties in with the public Biological Sciences/Pre-medical health aspect of it, and ties in with GIS and geography HTC Student - Ohio University which I’m getting interested in, and the biology of it too. 45. INTERVIEW - Tyler Verworn Just being oversees is a whole different culture, a SURF Program OUCOM whole different atmosphere; you get a lot to learn. Concordia College, Minnesota 144
46. INTERVIEW I’m really interested in infectious diseases and kind of Tamera Beam social community level, especially speaking to people. Medical Student Chagas is a serious concern in Ecuador and I don’t University of South Carolina think it is really recognized among the population, so hopefully I can help get the word out and spread exactly what the disease is and what a problem it is. 47. INTERVIEW Participating on a tropical Disease Research Project Mario Grijalva, Ph.D. allows students to learn about themselves, mostly. Director Tropical Disease Institute Because, yes, you are going to learn about the culture, Ohio University you are going to learn about different techniques to field research, to do GPS, the Geographic Informational System, you are going to be working in the lab, you might be doing biohazard research, or working with entomological samples, but also and most importantly, you are going to allow you, the student, to learn about your inner self. 48. OU Students + SNEM playing You can also help make this dream a reality. Participate soccer, students helping with in the Community Based Chagas Disease Research search, students in clinic Project or contribute funding to support these efforts. 49. CG: To learn how to get involved or how to provide support for this project send an email to [email protected] or visit www.ohio.edu/tdi 50. Logos: Plan Internacional, Pontificia Universidad Católica, Ohio University, Ministerio de la Salud 51. CG: Credits
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Appendix 20 – House Questionnaire
Proyecto Salud Comunitaria Universidad de Ohio – PLAN Ecuador Julio 2005
A1. ¿Tiene luz eléctrica? Materiales predominantes (Marcar D1. ¿Ha fumigado Ud mismo su casa? 1. Sí todos los que existan) 1. Sí 2. No 2. No B1. ¿Techo o cubierta? A2. ¿Cuántos dormitorios tiene la 1. Losa de hormigón D2. ¿Ha fumigado El Servicio de Malaria vivienda? 2. Asbestos o similares (Eternit) (SNEM) su casa? 1. 1 3. Zinc 1. Sí, ¿Hace cuánto tiempo? ____ (meses) 2. 2 4. Teja 2. No 3. 3 5. Paja, palma o similares 4. 4 o más 6. Otros materiales ______Animales Domésticcos dentro o cerca de A3. Número de personas que B2. ¿Paredes exteriores? la vivienda. duermen en la vivienda _____ 1. Hormigón, ladrillo o bloque 2. Adobe o tapia E1. ¿Gallinas o palomas u otras aves? A4. ¿Duermen 3 o más personas en 3. Madera 1. Sí, ¿Cuántas? _____ algún dormitorio? 4. Caña guadua revestida con papel 2. No 1. Sí 5. Caña guadua revestida o rellena de 2. No barro (Bahareque) E2. ¿Tiene un gallinero? 6. Caña guadua no revestida 1. Sí, ¿Dónde? A5. ¿Tiene servicio higiénico a. debajo de la casa disponible en la vivienda? B3. ¿Piso? b. junto a la pared de la casa 1. Escusado de uso exclusivo del 1. Entablado rústico c. menos de 5 m. alrededor de la casa hogar 2. Parquet d. entre 5 y 10 m. alrededor de la casa 2. Escusado de uso común de varios 3. Baldosa o vinyl e. más de 10m. alrededor de la casa hogares 4. Ladrillo o cemento 2. No 3. Letrina 5. Caña guadua 4. No tiene 6. Tierra E3. ¿Perros? 7. Otros materiales ______1. Sí, ¿Cuántos? _____ A6. ¿Cómo elimina las aguas 2. No servidas? B4. ¿Cuál es el principal combustible 1. Red Pública de alcantarillado que se utiliza para cocinar? E4. ¿Duerme el perro dentro de la casa? 2. Pozo ciego 1. Gas 1. Sí 3. Pozo séptico 2. Electricidad 2. No 4. Medio ambiente 3. Gasolina 4. Kerex o diesel E5. ¿Cuyes? A7. ¿Abastecimiento de agua para 5. Leña o carbón 1. Sí, ¿Cuántos? _____ cocinar y beber? 6. Otro ______2. No 1. Red pública 7. Ninguno 2. Pozo E6. ¿Tiene una cuyera? 3. Río, vertiente, acequia o canal Almacena los siguientes productos 1. Sí, ¿Dónde? 4. Carro Repartidor dentro de la vivienda (Completar a. debajo de la casa 5. Otro todas las opciones) b. junto a la pared de la casa 6. Agua de lluvia c. menos de 5 m. alrededor de la casa C1. ¿Leña? d. entre 5 y 10 m. alrededor de la casa A8. ¿Hierve o usa cloro en el agua 1. Sí, ¿Lugares? ______e. más de 10m. alrededor de la casa antes de beberla? 2. No f. dentro de la casa 1. Siempre 2. No 2. Aveces C2. ¿Productos agrícolas como maíz, 3. Nunca maní, arroz u otro? E7. ¿Chanchos o puercos? 1. Sí, ¿Lugares? ______1. Sí, ¿Cuántos? _____ A9. ¿Por qué trata el agua antes de 2. No 2. No beberla? ______Síga a la siguiente página >>>> ______
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Animales Domésticcos dentro o cerca G3. ¿Rocas, bloques o ladrillos? de la vivienda, continuación. 1. Sí, distancia de la casa _____ (metros) I3. ¿Árboles frutales? ¿Cuánta? a. poco b. mucho 1. Sí, distancia de la casa _____ (metros) E8. ¿Ovejas o chivos? 2. No ¿Cuánto? a. poco b. mucho 1. Sí, ¿Cuántos? _____ 2. No 2. No G4. ¿Basura de la vivienda? 1. Sí, distancia de la casa _____ (metros) I4. ¿Maleza o monte? E9. ¿Tiene un corral? ¿Cuánta? a. poca b. mucha 1. Sí, distancia de la casa _____ (metros) 1. Sí, ¿Dónde? 2. No ¿Cuánto? a. poca b. mucha a. debajo de la casa 2. No b. junto a la pared de la casa G5. ¿Otros? ______c. menos de 5 m. alrededor de la 1. Sí, distancia de la casa _____ (metros) casa ¿Cuánta? a. poca b. mucha J1. ¿Existen palmas o palmeras a una d. entre 5 y 10 m. alrededor de la 2. No distancia de 30 m de la vivienda? casa 1. Sí e. más de 10m. alrededor de la casa 2. No 2. No ¿Tiene el siguiente material vegetal acumulado alrededor de la casa? ¿Qué tipo de palmas se encuentran? E10. ¿Gatos? (Completar todas las opciones) 1. Sí, ¿Cuántos? _____ J2. ¿Palmas de coco? 2. No H1. ¿Hojas de palma de coco? 1. Sí, distancia de la casa _____ (metros) 1. Sí, distancia de la casa _____ ¿Cuántas? _____ (metros) 2. No ¿Con qué frecuencia ha visto los ¿Cuánta? a. poca b. mucha siguientes animales en su vivienda en 2. No J3. ¿Palmas de cade o tagua? los últimos 6 meses? 1. Sí, distancia de la casa _____ (metros) H2. ¿Hojas de palma de cade o tagua? ¿Cuántas? _____ F1. ¿Ratones? 1. Sí, distancia de la casa _____ (metros) 2. No 1. nunca ¿Cuánta? a. poca b. mucha 2. rara vez 2. No J4. ¿Palma africana? 3. frecuentemente 1. Sí, distancia de la casa _____ (metros) 4. todo el tiempo H3. ¿Hojas de palmera de otro tipo? ¿Cuántas? _____ ¿Qué tipo? ______2. No F2. ¿Ratas? 1. Sí, distancia de la casa _____ (metros) 1. nunca ¿Cuánta? a. poca b. mucha J5. ¿Otro tipo de palmera o palma? 2. rara vez 2. No ¿Cuál? ______3. frecuentemente 1. Sí, distancia de la casa _____ (metros) 4. todo el tiempo H4. ¿Desperdicios de la cosecha (hojas ¿Cuántas? _____ de maíz, cáscara de arroz o de maní)? 2. No F3. ¿Raposas, zorros, guanchacas o 1. Sí, distancia de la casa _____ (metros) zarigüeyas? ¿Cuánta? a. poco b. mucho 1. nunca 2. No 2. rara vez 3. frecuentemente H5. ¿Productos agrícolas de la cosecha 4. todo el tiempo (maíz, arroz, maní, etc.)? 1. Sí, distancia de la casa _____ (metros) ¿Cuánta? a. poco b. mucho ¿Tiene algunos de estos materiales 2. No acumulados alrededor de la casa? (Completar todas las opciones) ¿Tiene vegetación alrededor de la vivienda? ¿Cuál? G1. ¿Leña? 1. Sí, distancia de la casa _____ I1. ¿Piñuelas? (metros) 1. Sí, distancia de la casa _____ (metros) ¿Cuánta? a. poca b. mucha ¿Cuánta? a. poca b. mucha 2. No 2. No
G2. ¿Madera para construcción? I2. ¿Arbustos? 1. Sí, distancia de la casa _____ 1. Sí, distancia de la casa _____ (metros) (metros) ¿Cuánto? a. poco b. mucho ¿Cuánta? a. poca b. mucha 2. No 2. No
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Appendix 21 – Materials’ Effectiveness and Behavior Change Questionnaire
Age: _____ Gender: □ male □ Female Region/community: ______
Who makes decisions in the house? □ man □ women □ both Other: ______
Do you know about the kissing bug? □ Yes □ No Have you ever seen it in your house? □ Yes □ No Do you know it transmits a disease? □ Yes □ No Have you heard about Chagas Disease? □ Yes □ No
If yes, where did you receive the information? □ PSAs (television commercials) □ Radio Spots □ Educational booklet □ Educational bideo □ Calendar □ Pamphlet □ Your children (if applies) □ Your parents (if applies) □ Your teacher (if applies) □ Your neighbor □ Community leader □ Health promoter □ Ministry of Health/Malaria/SNEM personnel □ Other ______
Does the house have a Chagas prevention calendar? □ Yes □ No If not, has the family ever received one? □ Yes □ No If yes, why is it not up? ______
Have you ever seen any of the Chagas prevention PSAs? □ Yes □ No If yes, which ones: □ list of subjects of PSAs How many times have you heard them? □Never □Less than 5 times □More than 10 times
Have you ever heard any of the Chagas prevention radio spots? □ Yes □ No If yes, which ones: □ Keep the house clean and organized □ Use bed nets with piretroid insecticide □ Avoid accumulating agricultural products in the house □ Avoid accumulate bricks, rocks and wood close to the house □ Make sure the domestic animals sleep away from the house □ Change the chicken nests every 15 days and burn the old ones □ If find bugs in the house report to health promoter □ Put screens on your doors and windows □ Specific information about kissing bug and Chagas disease
How many times have you heard them? □Never □Less than 5 times □More than 10 times 148
Have you seen the Chagas prevention educational video? □ Yes □ No If yes, where: □ In a Community Based Chagas Disease Research Project activity □ In school (if applies) □ In a community meeting (if applies) □ On television □ Other ______
Have you received a Chagas prevention educational booklet? □ Yes □ No If yes, where: □ In a Community Based Chagas Disease Research Project activity □ In school (if applies) □ In a community meeting (if applies) □ Other ______
Have you received a Chagas prevention Pamphlet? □ Yes □ No If yes, where: □ In a Community Based Chagas Disease Research Project activity □ In school (if applies) □ In a community meeting (if applies) □ Other ______
In the past year (adapt to period which communication strategy has been used) have you made any of these changes in your house? □ Keep the house clean and organized □ Avoid accumulate bricks, rocks and wood inside or near the house □ Avoid accumulate agricultural products inside or near to the house □ Keep domestic animals sleeping away from the house □ Change the chicken nests every 15 days and burn the old ones □ Close the crack and holes of the walls inside and outside the house □ Put screens on doors and windows □ Learn how to recognize the adults and the nymphs of the kissing bug □ If a kissing bug is found in the house, report to the community health volunteer □ Participate in activities that involve improvement of houses in the community □Other ______
If yes, were any of the changes related to what you learned about Chagas prevention? □ Yes □ No Further Explanation:______