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A Case Study of Sesame Workshop’s Cleaner, Happier, Healthier Intervention in Bangladesh, India, and Nigeria: Reporting on Exposure and Impact

Summary and Keywords

The Cleaner, Happier, Healthier hygiene intervention was developed and tested in 2013, featuring the Sesame Workshop characters. Through broadcast television, four public service announcements (PSAs) addressed washing hands with soap, using a latrine, wearing sandals, and drinking clean water. The main audiences were young preschool children and their parents or guardians.

Research occurred in Bangladesh, India, and Nigeria, exploring the reach and impact of these PSAs. Although low percentages, from well-drawn samples of extremely vulnerable populations in these countries, reported awareness and recall of these messages, such percentages can reflect large numbers of viewers. Considering data from the participating children, measures of knowledge and attitudes were associated with engaging in several of the behavioral outcomes. As well, awareness and recall of the PSA messages predicted “all the time” for several of the hygiene behaviors. In contrast, parents’ reports of PSA awareness and recall were not associated with reports of children’s hygiene behaviors.

Conducting reach studies is extremely difficult, especially in developing countries and communities. Despite the challenges, this study is encouraging. Participants reported seeing the messages, and in several models, this “reach” predicted reports of hygiene and health behaviors. Lessons learned from this case study and research can offer valuable insight into the production of future health PSAs, especially with harder-to-reach populations.

Keywords: children, media, Bangladesh, India, Nigeria, Sesame Street, public service announcements, hygiene, television

Introduction

In 2013 the Bill & Melinda Gates Foundation awarded funding to Sesame Workshop to develop a public health intervention in Bangladesh, India, and Nigeria. The purpose of the intervention was to promote hygiene and sanitation among some of the most vulnerable children and families of these three countries. A new Muppet® named Raya was developed and introduced; this character would advocate for healthier behaviors including using a latrine, handwashing, and wearing sandals and shoes. The project’s educational objectives were determined in close collaboration with teams and advisors in all three countries to ensure that they were contextually and culturally relevant. The program’s educational framework was in turn informed by in-country and advisory meetings and formative research.

Although available, affordable, and effective interventions exist, diarrhea remains a leading cause of childhood morbidity and mortality (Bhutta & Das, 2013; Huda, Unicomb, Johnston, Halder, Sharker, & Luby, 2012). Globally, one in ten deaths among children under the age of five years is caused by diarrheal disease, resulting in around 800,000 fatalities annually. Many populations throughout the world are vulnerable to this illness. In the countries selected for this study, there is high prevalence of diarrhea in children under age five. Current diarrheal rates are around 4.6% in Bangladesh (BDHS, 2011), 11% in India (Gupta, Arnold, & Lhungdim, 2009), and 10% in Nigeria (DHS, 2014).

Bangladesh is a developing country facing many health challenges, exacerbated by the fact that it is the most densely populated country in the world (BDHS, 2011). The 2011 Bangladesh Demographic and Health Survey (BDHS) asked mothers about their children’s experience with diarrhea. Overall, 5% of Bangladeshi children under the age of five years had an episode of diarrhea in the two weeks before the interview. These rates were higher in rural than urban settings and higher among the poor. Children face other health issues as well; 41% of children under five are stunted, 36% are underweight, and 51% are anemic. Additionally, 35% of urban household and 52% of rural households do not have an improved toilet/latrine facility (BDHS, 2011).

India is a country experiencing incredible population growth. It has the second largest population of all countries in the world, and it is expected that the urban population will increase by more than 550 million by 2030 (Gupta, Arnold, & Lhungdim, 2009). According to the National Family Health Survey, with a significant portion of the urban population living in slums and vulnerable communities, health issues are anticipated to rise without intervention. Health outcomes for those who live in slums are generally worse than non-slum dwellers, including having higher rates of diarrhea in children under five, higher rates of anemia in children, lower average education of mothers, and less time spent in school for children. Around half (46%) of urban poor children in the capital city of Delhi were underweight compared to a quarter (24%) of the city’s children who did not live in slums. About one-third to one-half of people living in slums currently practice open defecation (Gupta, Arnold, & Lhungdim, 2009), which leads to many health issues.

Nigeria is the eighth largest country, in terms of population (CIA, 2015), and the most populated country in Africa with population still on the rise (DHS, 2014). Nigeria has extremely high under-five child mortality rates, with one in every eight children not surviving to his or her fifth birthday (DHS, 2014). More than a third (37%) of under-five Nigerian children are stunted and 29% are underweight. Diarrhea is quite common and is caused by consumption of contaminated drinking water and poor hygiene related to disposal practices of human waste. In Nigeria, less than a quarter (23%) of urban households and 62% of rural households lack improved facilities/pit latrines and 29% of households overall are without a toilet facility.

Children in these three countries often suffer health problems associated with a lack of sufficient resources, which can lead to stunted physical and cognitive growth (Haque, Arafat, Roy, Khan, Uddin, & Pradhania, 2014). Interventions to improve hygiene, access to nutrient rich diets, and offer sufficient footwear can decrease the number of childhood cases of diarrheal disease, parasitic infections, and anemia (Huda et al., 2012). Less illness will result in better school attendance and learning opportunities (Engle et al., 2013).

While a change in infrastructure is necessary, other interventions are being considered and evaluated. The intervention project described in this chapter involves using public service announcements to reach and impact vulnerable children’s health behaviors.

The Media Intervention

Communication and media campaigns can successfully inform and teach about health behaviors. In the past ten years, new communication channels have emerged, allowing greater reach to large populations with campaigns in previously hard-to-reach and poor infrastructure areas (Sood, Shefner-Rogers, & Skinner, 2014). Television messaging is still the most effective method to communicate with low socioeconomic status groups, as even the poorest households have access to television. This group also tends to watch at the greatest rates (Karanesheva, 2015).

To change behaviors, media intervention planners must know the characteristics of the target population, and develop appropriate communication strategies (Snyder, 2007). Campaigns must carefully craft message content with information that is germane to the target population to persuade behavior change, and this information must be disseminated in a viable channel (Snyder, 2007).

The Cleaner, Healthier, Happier intervention was broadcast through public airways. Four PSAs were created, covering the importance of engaging in healthy hygiene behaviors including washing hands with soap, using a latrine, wearing sandals, and drinking clean water. These short videos (30 seconds each) promoted the adoption of a new or replacement healthy hygiene behavior, which has been shown to be more effective than encouraging participants to refrain from unhealthy behavior (Snyder et al., 2004). The PSAs used the Muppet® characters Raya and Elmo to explain the importance of good hygiene and to show children how to engage in these healthy behaviors. While messages that clearly explain “how to” and “when to” information about the desired behavior have been shown to aid in supporting behavior change (Snyder, 2007), fewer campaigns have targeted young and vulnerable children through broadcasted messages.

This chapter describes research examining the reach and recall of the Cleaner, Healthier, Happier PSAs among vulnerable populations in Bangladesh, India, and Nigeria. It also offers data on if and how PSA exposure was associated with children’s sanitation and hygiene behaviors. As greater exposure to communication campaigns has been shown to lead to greater behavior change, it was hypothesized that children who had viewed the PSAs (as assessed through awareness and recall) would be more likely to engage in healthy hygiene behaviors.

Methodology

This reach study of the Cleaner, Healthier, Happier PSA intervention occurred in Bangladesh, India, and Nigeria. Four different PSAs were produced, focusing on the topics of handwashing with soap, using a clean latrine, wearing sandals, and drinking clean water. Each was dubbed into the local language. These PSAs aired on local terrestrial and cable channels in each of the countries for several months. Two of these PSAs were aired in India (handwashing with soap and using a clean latrine). Three of the PSAs were shown in Bangladesh (handwashing, using a latrine, and wearing sandals), and all four PSAs were shown in Nigeria.

In Bangladesh, three PSAs (handwashing, latrine use, and wearing sandals) were collectively shown 157 times from January 16 through March 31, 2015. These PSAs were shown on several stations and at a variety of times. Efforts were made to broadcast these PSAs on popular stations featuring films (four stations), dramas (one station), news (one station), and cartoons (one station). In India, the two PSAs (handwashing with soap and using a clean latrine) aired on the cable POGO channel 357 times from August 10 through October 31, 2015. All four PSAs aired in Nigeria on NTA Abuja, AIT Lagos, and AIT Kano before and after children’s programming on Monday and Wednesday evenings. PSAs were shown a total of 138 times between August and December 2015.

The Principal Investigator, in consultation with Sesame Workshop, developed the research protocols and instruments. The research approach was created to suit the age of the target population and materials were translated and reviewed with researchers in each country for cultural appropriateness. The School of Public Health, University of Maryland’s Institutional Review Board reviewed and approved the protocols and instruments.

Selection of Geographic Areas

In all three countries, data were collected from parent/child pairs in peri-urban/rural and urban settings, however, the selection methods differed somewhat by region. Because the PSAs aired on TV and were targeted at children and adults, selection criteria involved having a member of the target audience in the household (children ages three to seven years old) and having the potential to see the PSAs (regular television and reliable electricity). Systematic sampling was conducted from both urban (n=250 pairs) and rural (n=250 pairs) settings. In India, there was an additional requirement that participants have access to the POGO channel, which is delivered through cable services. Efforts were made to have a sample from lower socioeconomic communities, so slum and low-income geographic areas were selected.

Interview Sessions and Exposure

Interviews were conducted in all countries with both the parent and the child to examine the reach, impact, and perceptions of the PSAs. Figures 1 to 3 show photographs of data collection. One-on-one, in-person interviews were done, all in the participant’s native household language. Parents were surveyed separately from their children; however, when researchers interviewed the children, they were often within sight of the parents. On average, the interviews with the parents took around 35 minutes, and the interviews with the children took 45 minutes.

Researchers began by asking parents about the child’s demographics and household resources. Then, parents/guardians described their children’s hygiene behaviors and health. Next, parents were questioned about TV health messages through a series of open- and close-ended questions. Parents were shown images from current PSAs and commercials, including images from Cleaner, Healthier, Happier PSAs, and asked if they has seen them. A foil PSA/commercial was included in each country, so that respondents could be asked about a message that they probably would not have seen. Researchers also specifically asked parents if they had seen a message with Elmo and Raya. If they said they had, they were asked to describe the PSA message involving these characters.

Children were asked about their own hygiene behaviors and media use. Researchers asked three open-ended questions to measure the children’s hygiene knowledge. Seven close-ended statements assessed children’s attitudes about hygiene behaviors. Like the parents, children viewed images from PSAs/commercials and were asked which ones they remembered.

A Case Study of Sesame Workshop’s Cleaner, Happier, Healthier Intervention in Bangladesh, India, and Nigeria: Reporting on Exposure and ImpactClick to view larger

Figure 1. Researchers collecting data from children in Bangladesh, India, and Nigeria

(Photo credit, D.L.G. Borzekowski).

A Case Study of Sesame Workshop’s Cleaner, Happier, Healthier Intervention in Bangladesh, India, and Nigeria: Reporting on Exposure and ImpactClick to view larger

Figure 2. Researchers collecting data from children in Bangladesh, India, and Nigeria

(Photo credit, D.L.G. Borzekowski).

A Case Study of Sesame Workshop’s Cleaner, Happier, Healthier Intervention in Bangladesh, India, and Nigeria: Reporting on Exposure and ImpactClick to view larger

Figure 3. Researchers collecting data from children in Bangladesh, India, and Nigeria

(Photo credit, D.L.G. Borzekowski).

Measures and Analyses

The objective of this research was to determine the reach of the Cleaner, Healthier, Happier PSAs with vulnerable populations in Bangladesh, India, and Nigeria, examining if PSA exposure was associated with children’s sanitation and hygiene behaviors.

Demographics

The main demographic variables included the analyses were child’s sex, age, home location, highest level of education achieved by any adult member of the household, and access to an improved latrine. For subsequent analyses, each of these variables was transformed into dichotomous categories. Additional information was collected on whether the child attended school, number of people living in the household, household resources, and main language spoken in the home.

Awareness and Recall

Using several approaches, parents and children were asked about their awareness and recall of the Cleaner, Healthier, Happier PSAs. It is important to note that the study for Bangladesh was conducted first; the research team learned a great deal from the study and refined subsequent methodologies for India and Nigeria.

To begin, parents and children were asked whether they had seen any television messages in the last few weeks that “try to teach boys and girls about being healthy.” If the parent or child responded “yes,” they were then asked the unprompted question of what was the message about. Close-ended questions were asked about whether the participant had seen a message about eight different behaviors, including the featured hygiene behaviors.

In the next section of the survey, parents and children were shown several images from TV and asked to point to the images they remembered seeing. In Bangladesh, five images were shown, including one image featuring Elmo and Raya. In India and Nigeria, eight images including one of Elmo and Raya were shown. One image in each country did not air and served as a foil.

In Bangladesh, participants were then shown another picture card with four images, each from the Cleaner, Healthier, Happier PSAs (Figure 2). Three images were from the broadcasted PSAs, and one was a foil and never aired in Bangladesh (the clean water PSA). As obvious in this figure, each image offered a visual prompt of the PSA’s specific message. The researcher asked participants about each image: “Do you remember seeing this one?” The researcher then followed with, “Tell me a little about what was going on in the message?” Responses were coded on a scale from (0) cannot tell anything about the PSA; (1) gives a very simple response; (2) mentions the [theme of the PSA]; (3) mentions something beyond the [basic theme of the PSA]. Therefore, the foil differed in the three countries: in Bangladesh, the foil was an unaired Cleaner, Healthier, Happier PSA (whose image looks similar to the aired PSAs), and in India and Nigeria, the foils were commercials that did not air in those countries.

In refining the methodology and measures for India and Nigeria, after showing the participant the eight images, a single image of Raya and Elmo was shown (see Figure 3). This image featured the characters but did not give any obvious visual prompts of the PSA messages. Participants were asked, “Do you remember seeing them in any messages?” followed by the open-ended question, “What was that message about?” Responses were coded (0) if the participant was unable to say anything about the PSA. In India (where only two PSAs were broadcast), the participants who mentioned either handwashing or using a latrine were scored as having recall of the message. In Nigeria, a participant was scored as having recall if he or she talked about one of the four PSA themes (handwashing, using a latrine, wearing sandals, or clean water).

Knowledge

In every country, children were asked three questions to assess their hygiene knowledge: Why is it good to wash hands with soap after going to the latrine? Why is it good to use a latrine (instead of going in the field). Why is it good to wear sandals to the latrine? Children’s answers were recorded verbatim and then coded as (0) cannot provide any response (1) gives a simple correct response, and (2) provides more than a simple response. Answers to the three questions were summed for a knowledge score, with a possible range from 0 to 6. The Cronbach’s alpha was 0.59 in Bangladesh, 0.72 in India, and 0.64 in Nigeria.

Attitudes

Children were asked their attitudes regarding seven hygiene behaviors, including washing hands, washing hands with soap, using the latrine for urination and defecation, wearing sandals outside and to the latrine, and drinking clean water. Responses were on a scale from unimportant (1) to important (3). Answers to the three questions were summed for an attitude score, with a possible range from 7 to 21. The Cronbach’s alpha was 0.79 in Bangladesh, 0.80 in India, and 0.71 in Nigeria.

Behaviors

Parents and children were asked about various sanitation and hygiene behaviors. Researchers asked about the last time (i.e., such as the last time the child defecated) and the frequency that a child typically engaged in a behavior. While the researchers asked about many behaviors, the analyses focused on handwashing in general, handwashing with soap, using a latrine for urination (“pee”), using a latrine for defecation (“poo”), wearing sandals outside of the house, and wearing sandals to the latrine. Parents were also asked questions about their child’s general health and the last time the child had diarrhea.

Researchers asked children to describe their morning activities, and researchers considered both unprompted and prompted discussions of behaviors. Children were then specifically asked about handwashing in general, handwashing with soap, using a latrine for urination (“pee”), using a latrine for defecation (“poo”), wearing sandals outside of the house, and wearing sandals to the latrine.

As we anticipated high levels of social desirability for these questions, we used the extreme of “knows for sure” or “all the time” as a positive and dichotomous reflection of a child engaging in a hygiene behavior.

A Case Study of Sesame Workshop’s Cleaner, Happier, Healthier Intervention in Bangladesh, India, and Nigeria: Reporting on Exposure and ImpactClick to view larger

Figure 4. Images from the four Cleaner, Healthier, Happier PSAs, picture card used in Bangladesh. The bottom right image did not air in Bangladesh and served as the foil.

“Awareness” represents self-reported exposure to the PSAs. Awareness involved a participant responding “yes” he or she remembered seeing at least one of three broadcasted messages in Bangladesh, and “yes” he or she remembered the general image of Raya and Elmo in India and Nigeria protocols. In this study, awareness was a generous measure of exposure to any of the PSAs.

“Recall” suggests that participants both saw and remembered at least some of the PSA’s content. Recall comprised not only having awareness of a PSA but also being able to provide an adequate description of the PSA’s theme. As the images in Bangladesh offered a visual prompt, it is not surprising that there was high recall among these participants. After data collection in Bangladesh, the research team decided to have a stricter measure in India and Nigeria, and participants saw a more nondescript image of Raya and Elmo.

A Case Study of Sesame Workshop’s Cleaner, Happier, Healthier Intervention in Bangladesh, India, and Nigeria: Reporting on Exposure and ImpactClick to view larger

Figure 5. Picture card prompting recall for the Cleaner, Healthier, Happier PSAs, used in India and Nigeria.

Analyses

The reach study occurred in peri-urban/rural and urban and areas within each of the three countries, with 500 parent-child pairs in Bangladesh, 504 parent-child pairs in India, and 595 parent-child pairs in Nigeria. First, researchers examined trends and patterns for every variable, within each country. Basic bivariate analyses were conducted with demographic data to discover whether differences existed between the peri-urban/rural and urban areas. Percentages as well as bivariate analyses were calculated for parent and child responses for media use, hygiene behaviors, knowledge and attitudes around hygiene, exposure to TV messages about health, and awareness and recall of the Cleaner, Healthier, Happier PSAs.

Multivariate logistic models were estimated with data from the children. The analyses considered if awareness as well as recall (inserted as dummy variables) of the Cleaner, Healthier, Happier PSAs predicted health behaviors, in comparison to those without any awareness. Additional analyses were done using exposure to TV messages other than the PSAs as well as reported exposure to foils.

All analyses were done separately by country, as the samples, instruments, and protocols were similar but not identical. Additionally, this approach allows a thorough examination of what occurred in each location, as well as the unique contributions of the presented variables.

Results

Sample Information

Table 1 presents demographic and Table 2 offers household resource information about the sample.

Bangladesh

In Bangladesh, 500 parent and child pairs participated in this study (see Table 1). Half of the sample was urban (Bauniabad slum [n=125], Muktijoddha slum [n=125]), and the other half was rural (Pathalia [n=125], Yearpur [n=125]). While there was no difference in the sex proportions, the urban sample was slightly older than the rural sample (urban mean = 5.8 (SD=1.0) vs rural mean 5.5 [SD= 1.3]). A higher proportion of the rural sample had a parent with post-secondary education compared to the urban sample (15.2% vs. 8.0%). Researchers mainly spoke with mothers (414, 82.8%), but some of the adult participants were fathers (29, 5.8%), grandmothers (10, 2%), or other guardians (40, 8%). The average age of the adult participant was 30.7 years (SD=8.6, range from 18 to 80 years). Three-fourths of the adult sample (77.6%) reported that their main occupation was “housewife.” Bangla was the main language spoken in all the households. Adult participants indicated that on average 4.9 people (SD=1.9, range from 1 to 14) lived in the household with the child.

In Bangladesh, slightly fewer of the rural participants had access to electricity compared to urban participants (97.1% vs. 99.6%). Interestingly, a higher percentage of the rural sample had a color TV (92.2% vs. 83.2%), and a refrigerator (65.0% vs. 23.6%). Around 90% of the participating adults said that they stored water at home, but this differed by location (88.1% of the rural sample vs. 94.4% of the urban sample). Access to drinking water differed by location; similar percentages had piped water into their households; however, 52.4% of the urban sample (compared to 0.4% of the rural sample had piped water into a community compound and 15.6% of the rural sample (compared to 1.6% of the urban sample) used a tubewell. Around 40.7% of the rural sample described “other water access” (such as “motor pump water”), while 0% of the urban sample offered “other water access.”

Table 1. Demographic Characteristics Across Countries.

Bangladesh

N=500

India

N=504

Nigeria

N=595

Child’s Sex, N (%)

    Girls

231 (46.2)

249 (49.4)

303 (50.9)

    Boys

269 (53.8)

255 (50.6)

292 (49.1)

Child’s Age (in years), Mean (SD)

5.7 (1.1)

5.5 (1.2)

5.6 (1.2)

Location, N (%)

 Urban

250 (50.0)

251 (49.8)

355 (59.7)

 Peri-urban/rural

250 (50.0)

253 (50.2)

240 (40.3)

Highest Education Level for any Adult in the Household, N (%)

    Non-Literate

5 (1.0)

94 (18.7)

10 (1.7)

    Literate, No Formal Schooling

30 (6.0)

85 (16.9)

8 (1.3)

    Completed Primary School (or less)

252 (50.4)

141 (28.0)

54 (9.1)

    Completed Secondary School

101 (20.2)

140 (27.8)

196 (32.9)

    Beyond High School

57 (11.4)

32 (6.4)

260 (43.7)

    Other

48 (9.6)

12 (2.4)

67 (11.3)

Table 2. Household Resources Across Countries.

Ownership of household items

Bangladesh N (%)

India N (%)

Nigeria N (%)

Electricity

485 (97.0)

500 (99.2)

582 (97.8)

Radio

17 (3.4)

42(8.3)

432 (72.6)

Color TV

432 (86.4)

479 (95.0)

554 (93.1)

DVD player

47 (9.4)

53 (10.5)

515 (86.6)

Mobile Phone

474 (94.8)

446 (85.5)

575 (96.6)

Access to Internet

11 (2.2)

75 (14.9)

329 (55.3)

Motorcycle

19 (3.8)

97 (19.2)

83 (13.9)

Car

5 (1.0)

4 (0.8)

245 (41.2)

Refrigerator

222 (44.4)

188 (37.3)

389 (65.4)

Water for Drinking

Piped into household

220 (44.0)

182 (36.1)

94 (15.8)

Piped into compound

132 (26.4)

161 (31.9)

57 (9.6)

Motor pump water

96 (19.2)

96 (19.2)

N/A

Tube well

42 (8.4)

28 (5.6)

203 (34.1)

Tanker

N/A

51 (10.1)

N/A

Covered well

N/A

N/A

18 (3.0)

Toilet facility used at home by child

Flush toilet

N/A

51 (10.1)

487 (81.8)

Potty

N/A

17 (3.4)

N/A

Ventilated improved pit latrine

373 (74.6)

278 (55.2)

85 (14.3)

Traditional pit toilet

114 (22.8)

41 (8.1)

21 (3.5)

No facility/bush/field

N/A

116 (23.0)

N/A

India

In India, 504 parent and child participated in this study (see Table 1). Researchers mainly spoke with mothers (368, 73.0%), but some of the adult participants were fathers (49, 9.7%), aunts (40, 7.9%), grandmothers (24, 4.8%), or other guardians (23, 4.6%). The average age of the adult participant was 30.0 years (SD=7.6, range from 18 to 70 years). Two-thirds of the adult sample (65.6%) reported that their main occupation was “housewife.” Hindi was the main language spoken in the households, as reported by 80% of the adult participants. On average, 5.7 people (SD=2.1) lived in the household with the child. According to parents, most children (86.35%) attended school; around 40.3% were at school 20 to 29 hours a week, and 39.7% were at school 30 hours or more per week.

In India, the peri-urban and urban samples were similar with regard to most household resources, except slightly more peri-urban compared to urban participants had a mobile phone (92.5% vs. 84.5%). Fewer peri-urban compared to urban participants got their drinking water piped into the household (31.5% vs. 41.0%) or piped into their compound (22.3% vs. 41.8%). Also, fewer peri-urban compared to urban parents said their child used a flush toilet (13.5% vs. 6.8%).

Nigeria

Table 1 also presents data about the Nigerian sample (N= 595 parent and child pairs). About 60% of the sample was urban (N=355) and 40% peri-urban (N=240). All children were enrolled in school; 41% attended private primary school, and 36% attended public primary school. Most of them (80%) stayed in school 30 hours or more. While no differences were observed in child’s age and sex by location, a higher percentage of the urban (60.6%) compared to peri-urban (39.4%) children attended private school (chi-square =19.6, p< 0.001). Pertaining to the adult sample, researchers spoke mostly to mothers (458, 77%), followed by fathers (67, 11%), aunts (26, 4.4%), grandmothers (23, 3.9), or other guardians (21, 3.5%). Forty four percent of the adult sample had completed college or at least some college. No statistically significant differences were found in parent education by location. Participants’ occupation was diverse and included “sales and services” (37%), “professional/technical/managerial” (23%), “skilled manual” (16%), and “unskilled manual” (11%). Yoruba (317, N=53%) followed by and English (208, 35%) were they main languages spoke at home. On average, 5.13 people (SD=1.48, range from 2 to 12) lived in the household with the child.

When comparing participants by location in Nigeria, fewer of the peri-urban participants had access to electricity (96.3% vs. 98.9%) and refrigerator (60.4% vs. 68.7%) compared to urban participants. No statistically significantly differences were found in color TV ownership between peri-urban and urban participants (92.9% vs. 93.2%, respectively). Type of access to drinking water differed by location; 43.3% of the peri-urban participants used tubewell/borehole as a main source of drinking water, compared to 27.9% of urban participants. Similarly, a greater proportion of peri-urban participants had access to cleaning water from tubewell/borehole (60.4%), compared to urban participants (49.3%).

Exposure to Television Messages about Health and Awareness of the Cleaner, Healthier, Happier PSAs

Table 3 offers the percentages by country among parents and children who say they remembered seeing different messages and images, including general messages, foils, awareness and recall of the Cleaner, Healthier, Happier PSA.

Knowledge of, Attitudes about, and Engagement in Hygiene Behaviors

Data were collected from the children, assessing their knowledge of, attitudes about, and engagement hygiene behaviors (see Table 4). Parents also reported about their children’s hygiene behaviors (Table 5).

Table 3. Exposure with Awareness and Recall, by Adults and Children.

Bangladesh

India

Nigeria

%

%

%

Parent remembers seeing a health message in recent weeks

74.2

55.4

41.0

Parent says they “remember” FOIL image

22.3

68.5

44.2

Parent remembers Cleaner, Healthier, Happier image among others

76.5

58.5

42.7

Awareness of Cleaner, Healthier, Happier PSA by parent

83.8

55.0

38.0

Recall of Cleaner, Healthier, Happier PSA content by parent

78.2

24.2

6.2

Child remembers seeing a health message in recent weeks

72.2

60.1

39.8

Child says they “remember” FOIL image

42

84.7

51.6

Child remembers Cleaner, Healthier, Happier image among others

83.2

72.2

61.3

Awareness of Cleaner, Healthier, Happier PSA by child

86.4

63.7

49.6

Recall of Cleaner, Healthier, Happier PSA content by child

33.8

17.9

11.6

Table 4. Knowledge of, Attitudes About, and Children’s Hygiene Behaviors. Across Countries.

Bangladesh

India

Nigeria

Knowledge (mean (SD)

1.9 (1.2)

1.6 (1.4)

(0.9)

Attitudes (mean (SD)

19.4 (2.1)

19.2 (2.7)

19.9 (1.9)

Behaviors (% “all the time”)

Wash hands

69.2

37.5

42.3

Wash hands with soap

37.8

37.9

34.1

Go to latrine for urination

55.8

55.4

45.9

Go to latrine for defecation

97.0

70.7

69.9

Wear sandals outside of house

62.4

71.8

63.9

Wear sandals to the latrine

89.2

83.2

57.5

Table 5. Parents’ reports of the child engaging in the behavior “all the time.”

Bangladesh

India

Nigeria

Wash hands after defecating

63.4

85.3

42.2

Wash hands with soap after defecatinga

67.0

70.3

63.7

Wear sandals outside of house

68.4

70.0

59.5

Wear sandals to the latrine

66.4

76.8

44.5

Awareness and Recall of the Cleaner, Healthier, Happier PSAs Associated with Reported Behaviors

Multivariate logistic regressions examining the effect of awareness and recall on predicting health behaviors for each country were done for children (Tables 6, 8, and 10) and parents (Tables 7, 9, and 11). In Bangladesh, “awareness” represents a participant responding “yes” he or she remembered seeing at least one of three broadcasted messages in Bangladesh, and in India and Nigeria “awareness” indicates “yes” the participant remembered the image of Raya and Elmo. For “recall” participants both saw and remembered at least some of the PSA’s content.

Controls included the child’s sex, age, location, parent education, and access to an improved latrine. In the child models, two addition controls were included: hygiene knowledge, and hygiene attitudes. For both, parents and children, an interaction term considering location by awareness and recall was also included in the models.

Bangladesh

Among children, awareness of the Cleaner, Healthier, Happier PSAs was predictive of reportedly washing one’s hands and going to the latrine for urination all the time (see Table 6). A child with awareness was 4.7 times more likely to say he or she washed his or her hands all the time and 5.4 times to say he or she goes to the latrine for urination all the time, compared to a child with no awareness. Recall was only significant in the model predicting going to the latrine for urination all the time. Here, a child would be 7.5 times more likely to report this behavior compared to the child with no awareness and no recall.

In the parent model, awareness and recall of the Cleaner, Healthier, Happier PSAs were not statistically associated with parent report of child hygiene behavior, when controlling for demographic characteristics (Table 7).

Table 6. In Bangladesh, Predicting “All the Time” Hygiene Behaviors, as Reported by Child Participants (N=500).

Washes hands

Washes hands with soap

Goes to latrine for urination

Goes to latrine for defecation

Wears sandals outside of house

Wears sandals to the latrine

OR (95%CI)

OR (95%CI)

OR (95%CI)

OR (95%CI)

OR (95%CI)

OR (95%CI)

Sex

0.7 (0.4, 1.2)

0.8 (0.5, 1.1)

0.2 (0.1, 02)

0.3 (0.5, 1.5)

0.7 (0.4, 1.1)

0.9 (0.5, 1.8)

Age

1.6 (0.9, 2.8)

0.9 (0.6, 1.5)

1.1 (0.7, 1.9)

1.5 (0.3, 6.7)

0.5 (0.3, 0.8)

0.8 (0.4, 1.6)

Location

1.9 (0.5, 6.9)

0.3 (0.1, 1.2)

2.6 (0.6, 10.9)

1.9 (0.2, 20.9)

0.5 (0.1, 1.7)

1.8 (0.4, 7.3)

Parent education

1.2 (0.7, 2.0)

1.5 (0.9, 2.3)

1.1 (0.7, 1.9)

1.7 (0.4, 8.2)

1.2 (0.7, 1.9)

1.5 (0.7, 3.1)

Improved latrine

0.8 (0.5, 1.5)

1.2 (0.7, 2.1)

1.5 (0.9, 2.7)

1.5 (0.4, 5.9)

2.9 (1.7, 4.9)

1.3 (0.6, 2.6)

Knowledge

1.2 (0.9, 1.5)

1.2 (1.0, 1.5)

1.1 (0.8, 1.3)

2.0 (1.0, 3.9)

1.2 (0.9, 1.4)

1.3 (0.9, 1.8)

Attitudes

1.4 (1.2, 1.7)

1.4 (1.2, 1.6)

1.6 (1.4, 1.9)

1.4 (0.9, 1.9)

1.4 (1.2, 1.6)

1.3 (1.1, 1.5)

Awareness

4.7 (1.5, 14.1)

2.0 (0.6, 6.9)

5.4 (1.4, 19.7)

3.4 (0.2, 48.3)

1.4 (0.5, 4.1)

2.0 (0.5, 7.8)

Recall

2.1 (0.4, 9.0)

0.5 (0.1, 2.0)

7.5 (1.5, 38.1)

6.1 (0.1, 317.2)

2.0 (0.5, 8.1)

3.3 (0.5, 20.7)

Interaction term (PSA by location)

0.3 (0.1, 0.8)

0.9 (0.2, 2.7)

0.2 (0.1, 0.7)

0.3 (0.0, 3.3)

0.7 (0.2, 1.9)

0.5 (0.1, 1.7)

Note: Sex (female=0, male= 1), Age (3 to 5 yrs=0, 6 and 7 yrs=1), Location (rural=0, urban=1), Parent education (secondary or less=0, more than secondary=1), Improved latrine (does not use/have access =0, uses/has access=1). Knowledge and attitudes were continuous variables. Awareness and recall were entered into the model as dummy variables. The reference group consisted of those who had neither awareness nor recall of the Cleaner, Healthier, Happier PSAs. The interaction term is a three-way interaction of no awareness, awareness, and recall by location. Coefficients in bold are statistically significant at p< 0.05.

Table 7. In Bangladesh, Predicting “All the Time” Child Hygiene Behaviors, as Reported by Parents (N= 442).

Washes hands after defecating

Washes hands with soap after defecating

Wears sandals outside of house

Wears sandals to the latrine

OR (95%CI)

OR (95%CI)

OR (95%CI)

OR (95%CI)

Sex

0.9 (0.6, 1.4)

0.9 (0.6, 1.3)

0.6 (0.4, 1.0)

0.8 (0.5, 1.2)

Age

1.1 (0.7, 1.6)

1.0 (0.7, 1.5)

1.2 (0.8, 1.8)

1.2 (0.8, 1.8)

Location

0.6 (0.2, 1.7)

0.5 (0.2, 1.3)

0.7 (0.2, 1.9)

0.5 (0.2, 1.4)

Parent education

2.1 (1.3, 3.3)

1.6 (1.0, 2.6)

2.3 (1.4, 3.6)

1.5 (1.0, 2.4)

Improved latrine

1.5 (0.9, 2.4)

1.2 (0.8, 2.0)

1.9 (1.2, 3.1)

1.7 (1.0, 2.8)

Awareness

0.4 (0.2, 1.2)

0.5 (0.2, 1.4)

0.6 (0.2, 1.7)

0.5 (0.2, 1.3)

Recall

1.2 (0.5, 3.1)

1.0 (0.4, 2.7)

1.6 (0.6, 4.1)

1.5 (0.6, 3.8)

Interaction term (PSA by location)

1.2 (0.7, 2.2)

1.6 (0.9, 2.9)

1.1 (0.6, 2.0)

1.3 (0.7, 2.3)

Note: Sex (female=0, male= 1), Age (3 to 5 yrs=0, 6 and 7 yrs=1), Location (rural=0, urban=1), Parent education (secondary or less=0, more than secondary=1), Improved latrine (does not use/have access=0, uses/has access=1). Awareness and recall were entered into the model as dummy variables. The reference group consisted of those who had neither awareness nor recall of the Cleaner, Healthier, Happier PSAs. The interaction term is a three-way interaction of no awareness, awareness, and recall by location. Coefficients in bold are statistically significant at p< 0.05.

India

Among Indian children, awareness or recall of the Cleaner, Healthier, Happier PSAs was not predictive of any of the reported behaviors (see Table 8). As an aside, access to an improved latrine was predictive of the behaviors. Those with access were less likely to report handwashing behaviors than those without access, controlling for the other variables. In contrast, those with access were more likely to report going to the latrine (for urination and defecation) and wearing sandals (outside of the house and to the latrine) compared to those without access, controlling for the other variables. Higher scores on the hygiene attitude scale (indicating the child felt that hygiene was important) was a significant variable for handwashing (general and with soap) and going to the latrine (for urination and defecation), but not for wearing sandals outside of the house or to the latrine.

For parents, those with awareness of the Cleaner, Healthier, Happier PSAs were more likely to report their child wears sandals outside of house “all the time” (see Table 9). Recall of the Cleaner, Healthier, Happier PSAs was not associated with parents’ report of health behaviors. As an aside, those with improved latrine were more likely to report their child washes hands with soap after defecating and wears sandals outside of house “all the time.”

Table 8. In India, Predicting “All the Time” Hygiene Behaviors, as Reported by Child Participants (N=504).

Washes hands

Washes hands with soap

Goes to latrine for urination

Goes to latrine for defecation

Wears sandals outside of house

Wears sandals to the latrine

OR (95%CI)

OR (95%CI)

OR (95%CI)

OR (95%CI)

OR (95%CI)

OR (95%CI)

Sex

0.7 (0.4, 1.0)

1.0 (0.6, 1.5)

0.5 (0.3, 0.8)

0.8 (0.5, 1.7)

1.0 (0.7, 1.6)

0.8 (0.5, 1.4)

Age

0.5 (0.3, 0.9)

0.9 (0.6, 1.4)

0.9 (0.6, 1.4)

1.2 (0.7, 1.9)

1.0 (0.6, 1.5)

1.4 (0.8, 2.4)

Location

0.8 (0.4, 1.5)

1.4 (0.7, 2.6)

0.8 (0.4, 1.4)

0.5 (0.2, 1.0)

0.7 (0.3, 1.3)

1.2 (0.6, 2.6)

Parent education

0.7 (0.4, 1.1)

0.9 (0.6, 1.4)

1.5 (1.5, 2.4)

1.6 (1.0, 2.6)

1.2 (0.8, 2.0)

0.9 (0.5, 1.6)

Improved latrine

0.6 (0.4, 0.9)

0.6 (0.4, 0.9)

1.6 (1.0, 2.4)

2.1 (1.3, 3.2)

1.6 (1.1, 2.5)

1.7 (1.0, 2.9)

Knowledge

1.1 (0.9, 1.3)

1.1 (1.0, 1.3)

1.0 (0.9, 1.2)

1.0 (0.8, 1.2)

1.1 (0.8, 1.2)

1.3 (1.0, 1.6)

Attitudes

1.2 (1.1, 1.3)

1.2 (1.1, 1.3)

1.2 (1.1, 1.3)

1.1 (1.0, 1.2)

1.0 (0.9, 1.1)

1.1 (0.9, 1.2)

Awareness

0.7 (0.4, 1.3)

1.2 (0.7, 2.1)

1.0 (0.6, 1.7)

0.6 (0.3, 1.2)

1.1 (0.6, 1.8)

0.9 (0.5, 1.8)

Recall

0.7 (0.3, 1.6)

1.2 (0.5, 2.8)

1.3 (0.5, 3.0)

0.7 (0.2, 2.1)

0.7 (0.2, 1.7)

0.6 (0.2, 1.9)

Interaction term (PSA by location)

1.2 (0.7, 2.1)

0.8 (0.4, 1.3)

0.8 (0.5, 1.5)

1.2 (0.6, 2.2)

1.4 (0.8, 2.6)

1.2 (0.6, 2.5)

Note: Sex (female=0, male= 1), Age (3 to 5 yrs=0, 6 and 7 yrs=1), Location (rural=0, urban=1), Parent education (secondary or less=0, more than secondary=1), Improved latrine (does not use/have access =0, uses/has access=1). Knowledge and attitudes were continuous variables. Awareness and recall were entered into the model as dummy variables. The reference group consisted of those who had neither awareness nor recall of the Cleaner, Healthier, Happier PSAs. The interaction term is a three-way interaction of no awareness, awareness, and recall by location. Coefficients in bold are statistically significant at p< 0.05.

Table 9. In India, Predicting “All the Time” Child Hygiene Behaviors, as Reported by Parents (N=504).

Washes hands after defecating

Washes hands with soap after defecating

Wears sandals outside of house

Wears sandals to the latrine

OR (95%CI)

OR (95%CI)

OR (95%CI)

OR (95%CI)

Sex

1.0 (0.6, 1.7)

1.1 (0.8, 1.7)

0.9 (0.6, 1.3)

1.0 (0.6, 1.5)

Age

1.0 (0.6, 1.6)

1.0 (0.6, 1.4)

1.1 (0.7, 1.6)

0.8 (0.6, 1.3)

Location

1.2 (0.6, 2.4)

1.3 (0.7, 2.3)

1.2 (0.7, 2.1)

1.4 (0.8, 2.5)

Parent education

1.1 (0.6, 1.9)

1.0 (0.7, 1.5)

1.0 (0.6, 1.5)

1.0 (0.6, 1.6)

Improved latrine

1.5 (0.9, 2.6)

2.3 (1.5, 3.4)

1.7 (1.1, 2.6)

1.5 (1.0, 2.4)

Awareness

1.3 (0.7, 2.5)

0.9 (0.6, 1.6)

2.2 (1.3, 3.8)

1.4 (0.8, 2.4)

Recall

1.3 (0.5, 3.2)

1.0 (0.5, 2.0)

1.7 (0.9, 3.5)

1.5 (0.7, 3.2)

Interaction term (PSA by location)

0.9 (0.5, 1.7)

0.7 (0.5, 1.2)

0.7 (0.5, 1.2)

0.8 (0.5, 1.4)

Note: Sex (female=0, male= 1), Age (3 to 5 yrs=0, 6 & 7 yrs=1), Location (rural=0, urban=1), Parent educ. (secondary or less=0, more than second.=1), Improved latrine (does not use/have=0, uses/has= 1). Awareness and recall were entered into the model as dummy variables. The reference group consisted of those who had neither awareness nor recall of the Cleaner, Healthier, Happier PSAs. The interaction term is a three-way interaction of no awareness, awareness, and recall by location. Coefficients in bold are statistically significant at p< 0.05.

Nigeria

The multivariate models for Nigerian children show that awareness was not a significant predictor of any of the health behaviors and recall was only predictive in the model predicting wearing of sandals outside of the house (see Table 10). The interaction terms, however, need to be considered. The model for wearing sandals outside of the house shows that those children from urban areas who had recall were much more likely to report the behavior than those from rural areas without awareness or recall. Similarly, the interaction term was significant in the models predicting handwashing with soap and going to the latrine for urination. The significant coefficients suggest that urban children with recall are much more likely to report the behaviors than rural children without awareness or recall.

Parent awareness and recall of the Cleaner, Healthier, Happier PSAs were not statistically associated with any of the parent report of child health behaviors. The interaction term, however, was statistically significant. The interaction term suggests that urban parents with recall of the Cleaner, Healthier, Happier PSAs were more likely to report their child wears sandals outside house than rural parents without awareness or recall (Table 11).

Table 10. In Nigeria, Predicting “All the Time” Hygiene Behaviors, as Reported by Child Participants (N=595).

Washes hands

Washes hands with soap

Goes to latrine for urination

Goes to latrine for defecation

Wears sandals outside of house

Wears sandals to the latrine

OR (95%CI)

OR (95%CI)

OR (95%CI)

OR (95%CI)

OR (95%CI)

OR (95%CI)

Sex

0.6 (0.4, 0.9)

0.6 (0.4, 0.9)

0.7 (0.5, 0.9)

0.6 (0.4, 0.9)

0.7 (0.5, 0.9)

0.6 (0.4, 0.8)

Age

1.2 (0.8, 1.7)

1.0 (0.7, 1.5)

0.7 (0.5, 1.0)

1.5 (1.0, 2.3)

1.2 (0.8, 1.8)

1.1 (0.7, 1.5)

Location

0.9 (0.6, 1.6)

0.7 (0.4, 1.2)

0.8 (0.5, 1.3)

2.6 (1.5, 4.4)

0.4 (0.2, 0.7)

1.6 (0.9, 2.6)

Parent education

1.3 (0.9, 1.9)

1.4 (0.9, 2.0)

1.4 (0.9, 2.1)

1.3 (0.8, 2.1)

1.7 (1.1, 2.5)

0.9 (0.6, 1.3)

Flush toilet

1.9 (0.8, 1.7)

1.2 (0.8, 1.7)

2.2 (1.5, 3.2)

3.1 (1.9, 4.9)

1.5 (1.0, 2.3)

0.6 (0.4, 0.9)

Knowledge

0.9 (0.8, 1.1)

1.1 (0.9, 1.3)

1.1 (0.9, 1.3)

1.1 (0.9, 1.3)

0.9 (0.8, 1.2)

0.9 (0.8, 1.1)

Attitudes

1.1 (0.9, 1.2)

1.1 (1.0, 1.2)

1.1 (1.0, 1.2)

1.1 (0.9, 1.1)

1.1 (0.9, 1.2)

1.1 (1.0, 1.2)

Awareness

1.5 (0.9, 2.5)

1.2 (0.7, 2.0)

0.9 (0.6, 1.6)

0.9 (0.6, 1.7)

0.8 (0.4, 1.4)

1.1 (0.7, 1.8)

Recall

1.2 (0.5, 2.8)

1.1 (0.4, 2.7)

0.7 (0.3, 1.8)

1.0 (0.4, 2.6)

0.3 (0.1, 0.8)

1.4 (0.6, 3.4)

Interaction term (PSA by location)

1.4 (0.9, 2.5)

1.9 (1.1, 3.3)

2.9 (1.7, 5.1)

1.2 (0.6, 2.2)

3.1 (1.8, 5.4)

0.9 (0.5, 1.5)

Note: Sex (female=0, male= 1), Age (3 to 5 yrs=0, 6 and 7 yrs=1), Location (rural=0, urban=1), Parent education (secondary or less=0, more than secondary=1), Flush toilet (does not use/have access =0, uses/has access=1). Knowledge and attitudes were continuous variables.

Awareness and recall were entered into the model as dummy variables. The reference group consisted of those who had neither awareness nor recall of the Cleaner, Healthier, Happier PSAs. The interaction term is a three-way interaction of no awareness, awareness, and recall by location. Coefficients in bold are statistically significant at p< 0.05.

Table 11. In Nigeria, Predicting “All the Time” Child Hygiene Behaviors, as Reported by Parents (N= 595).

Washes hands after defecating

Washes hands with soap after defecatinga

Wears sandals outside of house

Wears sandals to the latrine

OR (95%CI)

OR (95%CI)

OR (95%CI)

OR (95%CI)

Sex

0.7 (0.5, 1.0)

0.8 (0.6, 1.2)

0.9 (0.6, 1.2)

1.0 (0.7, 1.4)

Age

1.3 (0.9, 1.8)

0.9 (0.7, 1.3)

1.2 (0.9, 1.7)

1.6 (1.1, 2.2)

Location

1.0 (0.7, 1.5)

0.8 (0.5, 1.3)

0.9 (0.6, 1.4)

1.4 (0.9, 2.1)

Parent education

1.5 (1.0, 2.2)

1.6 (1.1, 2.4)

1.5 (1.0, 2.2)

0.8 (0.5, 1.2)

Improved latrine

0.7 (0.5, 1.0)

0.9 (0.6, 1.3)

1.2 (0.8, 1.8)

0.5 (0.3, 0.7)

Awareness

1.0 (0.6, 1.7)

1.0 (0.6, 1.7)

0.8 (0.5, 1.3)

1.4 (0.9, 2.4)

Recall

0.5 (0.2, 1.3)

1.1 (0.4, 2.9)

0.4 (0.2, 1.1)

1.0 (0.4, 2.6)

Interaction term (PSA by location)

1.5 (0.8, 2.6)

1.7 (0.9, 3.0)

2.1 (1.2, 3.6)

1.3 (0.7, 2.2)

Note: (a) “All the time” and “often” were combined into one category to adjust frequency distribution.

Sex (female=0, male= 1), Age (3 to 5 yrs=0, 6 and 7 yrs=1), Location (rural=0, urban=1), Parent education (secondary or less=0, more than secondary=1), Improved latrine (does not use/have access =0, uses/has access=1). Awareness and recall were entered into the model as dummy variables. The reference group consisted of those who had neither awareness nor recall of the Cleaner, Healthier, Happier PSAs. The interaction term is a three way interaction of no awareness, awareness, and recall by location. Coefficients in bold are statistically significant at p< 0.05.

Summary and Discussion

This research offers promising findings about the reach of the Cleaner, Healthier, Happier intervention. Substantial percentages, from well-drawn samples of extremely vulnerable populations, reported awareness and recall of these messages. Awareness among parents ranged from 38% in Nigeria to 83.8% in Bangladesh. Awareness for children ranged from 49.6% in Nigeria to 86.4% in Bangladesh. Recall of the main lessons presented messages varied tremendously, from 6.2% among Nigerian parents to 78.2% among Bangladeshi parents. While not as large a range, there were still diverse responses observed for the children, with 11.6% of the Nigerian children to 33.8% of the Bangladeshi children having recall. In such a reach study, small percentages can represent huge numbers of viewers. For example, in India we drew our sample from slum population in Delhi, which the Indian government has projected to have a population of 3.6 million people. Averaging the parent and child reported awareness from this study (55% for parents, 72% for children), in this limited geographic area it is possible that around 2.3 million people may have seen the broadcasted messages from the Cleaner, Healthier, Happier intervention.

Awareness and recall of the Cleaner, Healthier, Happier messages were associated with greater reporting of health behaviors, significantly so for many of the assessed variables in Bangladesh and Nigeria. People were more likely to indicate they engaged in the health behavior all the time if they remembered seeing the PSA and if they were able to talk about the main message of the PSA. Such associations do not imply causality, it is possible that self-reported awareness and health behaviors are likely to co-occur. Further validation of study variables or different research designs (such as a randomized controlled trial) might offer more information on the direction or connection between exposure and behaviors; however, such endeavors are challenging and go beyond this study’s objectives.

The intended goal of the funders, producers, and researchers of collecting data from large and vulnerable samples was met by this study. Around 500 parent and child pairs were interviewed, and a great deal of information is now known about these participants and populations. This report describes parents and children from low-resource households. For example, less than half of any of the samples had drinking water piped into their households. At least one-fifth of each country sample lacked access to either ventilated improved pit latrine or flush toilet. In our India sample, 23% of the parents reported that their child regularly lacked any toilet facility. In the last 30 days, the participating children suffered from illnesses that prevented them from engaging in activities, ranging from 10% to 53.8%. Around 5.4% (Nigeria) to 15.5% (India) of the child participants had experienced diarrhea in the past month.

The potential of reaching this population remains high though, as suggested by our earlier projections to the populations living in these slums and disadvantaged areas. Despite coming from poor households, practically all (97% to 99.2%) of the participants had electricity and most had a color TV in their household (86.4% to 95.0%) and a mobile phone (85.5% to 96.6%).

An important strength of this study was that research materials had been carefully developed for that target age group and pilot tested in similar communities in all three countries. Results of the pilot study as well as the study in Bangladesh aided in the refinement of materials used in the PSAs and research in India and Nigeria. Great efforts were made to get a sample that would resemble the target audience of the Cleaner, Healthier, Happier intervention. Local researchers from each country were trained to ensure consistency in data collection practices, which is especially important when collecting data from young children. One-on-one interviews allowed researchers to gather data on open-ended questions from children and parents. Images cards were used to aid in gathering data from children; our youngest participants could point to an image or give a head nod to note their response. Additionally, researchers used tablets or mobile phones that allowed children to view a PSA and give immediate feedback on the material. This was crucial in understanding child perceptions of the PSAs from children who may have not been exposed to the Cleaner, Healthier, Happier material on television.

Despite the challenges, this study is encouraging. In Bangladesh and Nigeria, specifically, we have observed that those who were aware and recalled the PSA were more likely to report health behaviors. The association between exposure to the PSA and the frequency of some health behaviors reported by child were statistically significant even when controlling for other factors likely to influence the health behaviors under investigation. While TV messages can reach a large audience, affect the senses, and have high impact, they are also expensive, exposure is fleeting, and it is sometimes difficult to control audience retention due to the availability of so many television channels (Karanesheva, 2015). In this case, we were forced to rely on broadcasters to place the PSAs, which may not have been done at optimal times or on TV stations where many children were watching. In Nigeria, PSAs were placed before and after children’s TV programming, but minimal frequency of broadcasts may have contributed to lack of exposure. TV messaging can be effective at increasing knowledge, and changing attitudes and behavior related to health, but it requires frequent or prolonged exposure to the messaging (Karanesheva, 2015). Using multiple channels for messaging may increase exposure (such as using print advertisements, billboards, radio spots, and even SMS phone messages) and should be considered in future studies to increase campaign effectiveness (Snyder, 2007).

There is published research showing that advertisements and simple media campaigns can reach even young children (Karanesheva, 2015). In studies conducted on the impact of educational television on preschoolers and their families found that at least short-term viewing of these programs increased knowledge and positively changed attitudes and behaviors of children (Karanesheva, 2015; Saunders & Goddard, 2002). This study of the Cleaner, Healthier, Happier intervention can add to the literature, offering important information on studying the reach and impact of PSAs on young and vulnerable children. The perception study contributes by showing that when children are shown hygiene PSAs they can understand and enjoy such messages.

Challenges and Methodological Considerations

Conducting the reach part of this study revealed great challenges. Many approaches were used to assess exposure, with their own weaknesses and strengths. Researchers asked not only open-ended questions about what health messages the participants had recently seen but also close-ended (yes/no) questions about the remembering of different images. Multiple approaches were used; however, it remains unknown as to the validity of the affirmative responses. Participants may be remembering actual health messages, or they may be wanting to seem positive and receptive of pro-health messages. Similarly, the researchers showed images from several actual messages currently being broadcast in the studied areas. Again, participants were likely to say they remembered the messages. Foils were presented to participants, and extremely high percentages of parents and children responded that they had seen these. For example, in Bangladesh the foil was a Cleaner, Healthier, Happier message that did not air in that country. Because of social desirability, a percentage of the respondents could have said “yes” they remembered the clean water message. On the other hand, participants may have been thinking of the similar looking Cleaner, Healthier, Happier messages and reporting without intended deceit that they remembered the message. While we used a foil message that had appeared on only the YouTube channel in India, we later learned that our image greatly resembled another advertisement currently being broadcast. It is possible that Indian participants were thinking of the other advertisement. Not only do foils need to be selected carefully, but it may also be useful to ask participants to provide descriptions of what they think the foils are communicating. It is not clear whether participants were misrepresenting the truth or if they were confusing the images with similar ones that they had seen. One aspect of this research work does offer support about the wide reach of the PSAs. When exposed to the PSA in the second half of the study, a high percentage of the children responded they had seen the respective PSA. Saying “yes” they saw the message during the comprehension study was associated with an affirmative awareness response in the first half of the study.

While our measure of awareness of the Cleaner, Healthier, Happier PSAs was liberal, our recall measure was more conservative. For awareness, a participant just had to report “yes” they had seen the characters featured in the messages. In contrast, the recall measure required the participant to offer correct messages communicated in the PSA. As expected, recall was lower than awareness in all three countries; the gap between the two was as high as over 30 percentage points for adults and about 50 percentage points for children.

Recall was difficult to measure; especially in Bangladesh, estimates for recall may be inflated from the choice of research materials. The first round of data collection occurred in Bangladesh and in our effort to offer stimulus materials that would allow us to discern between the different PSAs, we offered visual cues. Participants could have seen these cues and made educated guesses as to the messages being conveyed, thus inflating the figures for participants’ recall. Learning from this, we removed these cues from the Indian and Nigerian research materials. As a result, we are more confident in the recall measures for these countries. These methodological issues speak to the challenges of measuring exposure to fleeting media messages, such as PSAs, that are intended to influence knowledge, attitudes, or behaviors. The messages are brief, and exposure may be sporadic, which renders it challenging to measure exposure and attribute knowledge or behavioral changes to exposure.

Despite the challenges involved in conducting a reach study, this multicountry study conducted with some of the most vulnerable populations offers promising findings. Even with low percentages of awareness and recall, it is likely that the Cleaner, Healthier, Happier PSAs reached parents and children with extremely important health and hygiene messages. The study offers data that when shown these messages, participants were able to comprehend and enjoy the PSAs. This first step of delivering appealing and understandable PSAs to large and vulnerable audiences was achieved and so begins the process of successfully communicating positive health messages.

Further Reading

Borzekowski, D. L. G., & Henry, H. K. (2011). The impact of Jalan Sesama on the educational and healthy development of Indonesian preschool children: An experimental study. International Journal of Behavioral Development, 35, 169–179.Find this resource:

    Borzekowski, D. L. G., & Macha, J. (2010). The role of Kilimani Sesame on the healthy development of Tanzanian preschool children. Journal of Applied Developmental Psychology, 31, 298–305.Find this resource:

      Central Intelligence Agency (CIA). (2015). Nigeria in the World Factbook, 2015. Retrieved from https://www.cia.gov/library/publications/the-world-factbook/geos/ni.html.

      Fisch, S. M. (2014). Children’s learning from educational television. London: Routledge.Find this resource:

        Fisch, Shalom M., & Rosemarie T. Truglio (Eds.). (2014). G is for growing: Thirty years of research on children and Sesame Street. London: Routledge.Find this resource:

          Mares, M. L., & Pan, Z. (2013). Effects of Sesame Street: A meta-analysis of children’s learning in 15 countries. Journal of Applied Developmental Psychology, 34, 140–151.Find this resource:

            Whittington, D., Jeuland, M., Barker, K., & Yuen, Y. (2012). Setting priorities, targeting subsidies among water, sanitation, and preventive health interventions in developing countries. World Development, 40, 1546–1568.Find this resource:

              Additional Resources

              The following website will be useful to readers wanting to see materials produced by Sesame Workshop: http://www.sesameworkshop.org/our-blog/tag/international-co-productions-2/.

              References

              Bangladesh Demographic and Health Survey (BDHS). (2011). National Institute of Population Research and Training. Dhaka, Bangladesh and Calverton, MD.Find this resource:

                Bhutta, Z. A., & Das, J. K. (2013). Global burden of childhood diarrhea and pneumonia: What can and should be done. Pediatrics, 131, 634–636.Find this resource:

                  Demographic and Health Survey Program (DHS). (2014). National Population Commission Federal Republic of Nigeria, and ICF International. Nigeria Demographic and Health Survey Key Findings. Abuja, Nigeria, and Rockville, MD: DHS.Find this resource:

                    Engle, P. L., Fernald, L. C. H., Alderman, H., Behrman, J., O’Gara, C., & Yousafzai, A., et al. (2013). Strategies for reducing inequalities and improving developmental outcomes for young children in low-income and middle-income countries. The Lancet, 378, 1339–1353.Find this resource:

                      Evans, W. D., Uhrig, J., Davis, K., & McCormack, L. (2009). Efficacy methods to evaluate health communication and marketing campaigns. Journal of Health Communication, 14(4), 315–330.Find this resource:

                        Gupta, K., Arnold, F., & Lhungdim, H. (2009). Health and living conditions in eight Indian cities. National Family Health Survey (NFHS-3), India, 2005–06. Mumbai, India: International Institute for Population Sciences.Find this resource:

                          Haque, M. M., Arafat, Y., Roy, S. K., Khan, M. Z. H., Uddin, A. M., & Pradhania, M. S. (2014). Nutritional status and hygiene practices of primary school children. Journal of Nutritional Health & Food Engineering, 1, 00007.Find this resource:

                            Huda, T. M. N., Unicomb, L., Johnston, R. B., Halder, A. K., Sharker, M. A. Y., & Luby, S. P. (2012). Interim evaluation of a large scale sanitation, hygiene and water improvement programme on childhood diarrhea and respiratory disease in rural Bangladesh. Social Science & Medicine, 604–611.Find this resource:

                              Karanesheva, T. (2015). Choosing the communication channel—a factor for effective health communication. Bulgarian Journal of Public Health, 7(3), 35–47.Find this resource:

                                Saunders, B. J., & Goddard, C. (2002). The role of mass media in facilitating community education and child abuse prevention strategies. NCPC, 16, 1–22.Find this resource:

                                  Snyder, L. B., & Hamilton, M. A. (2002). Meta-analysis of U.S. health campaign effects on behavior: Emphasize enforcement, exposure, and new information, and beware the secular trend. In R. Hornik (Ed.), Public health communication: Evidence for behavior change (pp. 357–383). Hillsdale, NJ: Lawrence Erlbaum Associates.Find this resource:

                                    Snyder, L. B., Hamilton, M. A., Mitchell, E. W., Kiwanuka-Tondo, J., Fleming-Milici, F., & Proctor, D. (2004). A meta-analysis of the effect of mediated health communication campaigns on behavior change in the United States. Journal of Health Communication, 9(1), 71–96.Find this resource:

                                      Snyder, L. B. (2007). Health communication campaigns and their impact on behavior. Journal of Nutrition Education and Behavior, 39(2), S32–S40.Find this resource:

                                        Sood, S., Shefner-Rogers, C., & Skinner, J. (2014). Health communication campaigns in developing countries. Journal of Creative Communications, 9(1), 67–84.Find this resource: