Cat Rock talks to Katie Greenland, Assistant Professor at the London School of Hygiene & Tropical Medicine, from the Stronger – SAFE project about how they are trying to eliminate the Trachoma endemic in Ethiopia with the help of Puppetry.
Have you ever had an eye infection? A lot of us know the joys of eye problems, from a sty to keratitis, a rouge eyelash to the torment of a ripped contact lens. Many of us will know just how horrible contracting conjunctivitis is, I know I do! For most people, especially here in the United Kingdom, it is a simple trip to the pharmacy that will sort this problem, a few days of drops and you’re done.
But pretend for a moment that you live in a community where you do not have the resources or knowledge to treat your infection, where water is so precious and limited that you have to make a choice about who gets to wash their face. Picture seeing eye infections spread through your family and friends, causing them immense discomfort and pain, as you eventually watch them succumb to blindness. Now imagine watching all this unfold though your own infected eyes, knowing that this could have been prevented.
Tragically this is the case in many places as the trachoma-endemic rages on.
The situation is dire and things desperately need to change. Trachoma is a mild eye infection mainly affecting children, the serious consequences come from repeat infections that over time cause scarring and eyelashes to turn inwards and scratch the eye which is very painful and can eventually lead to blindness. luckily the team behind the ‘Stronger – SAFE’ project are on the ground fighting this endemic. Using new and exciting ways to engage communities they hope to save the eyesight of millions… with the help of some puppets!
Meet Caltu, a young girl from the Oromia Ethiopia. She will be traveling around communities performing in a drama demonstrating face washing and other measures that can help prevent the spread and contraction Trachoma.
So what is ‘Stronger – SAFE’?
The ‘Stronger – SAFE’ project will include a series of community interventions that will target the caregivers of preschool children. The pre-schoolers are the most likely age group to catch and transmit this disease. The team hopes that by highlighting the importance of prioritising this age group, creating a campaign that is relatable and memorable, focusing on the importance of face washing, that they will help reduce the overwhelming presence of Trachoma. This will take place near Shashemene, which is about 200km south of Addis Ababa, in the West Arsi Zone in Oromia, Ethiopia.
How did you come to the idea of using puppets as part of ‘Stronger – SAFE’ and what do you hope puppets will bring to the program?
Katie Greenland (KG): We are working in low literacy, quiet rural communities, which means we don’t have people who can read pamphlets or even posters, or things like that. They don’t have a lot of television, radio, and other media access. Things like roadshows and dramas are very popular; I was already planning a drama which is a standard approach for behaviour change communication.
Because of the Covid pandemic, I was part of a team reviewing proposals for some FCDO (Foreign Commonwealth and Development Office) and Unilever Covid related funding. I saw a proposal form the Sesame Workshop, which received funding; it just made me start thinking, that if we were using puppets it might make the drama more memorable and maybe more attractive. I was thinking about what we could do to engage the children. It would be more fun with the puppets and they would then be able to interact with the children making it memorable. We could then use them in other elements like house-to-house meetings and small group events.
It would also help the mothers to remember that they need to prioritise these young children. This is one of the problems that is happening at the moment. People are washing their own faces and older children are washing their faces with soap before they go to school, babies are well taken care of, but there is a gap when it comes to this age group. We wanted to emphasize that person within the family. We have messages about prioritising preschool children, if you don’t have enough water for face washing it is these children that need to be prioritised. This goes against the norms at the moment (in Ethiopia) of who gets prioritised, which would usually be the head of the household and the man. Also With a puppet, you’re not saying your child’s face is dirty and needs washing, you have that degree of removal by saying it to the puppet. It’s easier to have the puppet say, “My face is dirty and needs washing…” rather than trying to make people feel that it’s directly talking about their family.
We all know how powerful puppetry can be, by adding this element into these already well received dramas you not only bring a new and exciting twist to the performance, but by making the child the puppet, the unique factor, you highlight the importance of that child in the story. You bring attention to them, make them the focus, and this will really engage the audience with the different face washing behaviours associated with that character.
What was the puppet design process like, what factors did you take into consideration when developing Caltu?
KG: Before we even engaged Izzy Bristow (the puppet designer and maker) we wanted to understand how puppets might be received, which is quite tricky with remote working because usually I would do that kind of work on the ground. I would have bought a puppet here that I could have taken with me to do some field research. Instead we had to do all that remotely, via our field team. We sent them images (of puppets) that they could then show in the communities and to a wide range of people, we could then understand what they thought of puppets.
We learnt that basically people don’t really know much about puppets, that they really didn’t understand when they didn’t really look like a person. They’ve never seen them, which is another reason why I wanted to use them. Because they are ‘novel’ I thought that would be what would make them memorable. It probably was a bit hard for Izzy…
Izzy Bristow (IB): The Design Process for these puppets was a bit tricky. As a culture somewhat cut off from the visual shorthands and design sensibilities of the Anglo-European world that dictates most of what we think of when we think of “puppets for kids”, the Oromo (region in Ethiopia) focus group really didn’t like the simple and cartoonish look of muppets that they were approached with initially.
Even with forewarning, I went through three different initial design phases and then extensive tweaking of the final pattern to create a puppet realistic enough that the field team and focus group found appealing, but still achievable to make with the time and budget allotted. However, throughout the whole process I was supported incredibly well by the Stronger – SAFE team. Clair specifically, was there to answer questions and make sure my designs and suggestions were turned around quickly within their Ethiopia team.
KG: We had to be very careful that we made sure that she looked like a local person. We spent a long time thinking what colour she should be wearing; it couldn’t be linked to any political colours as there is a lot of political unrest in the area. We needed to be sure that her skin tone was correct and her features were correct; even her hair, because different hairstyles would have just meant that she wasn’t a girl from ‘here’. You have that balance of trying to get somebody who is from ‘here’ and also a slightly aspirational figure.
IB: It is an unfortunate truth that we live in a made world that is designed with white skin as a default, this made it difficult to find fabric that was the right colour to reflect the skin of the Oromo people. In the end I had to dye the fleece myself, which was time consuming but well worth it.
KG: There was a lot of back and forth about what she should wear and obviously making sure that her features were right and wouldn’t be offensive, this was really key. Each time there was an iteration we had to make sure, as best as we could in the current climate with all the movement restrictions, that we got as much community feedback as we could.
IB: This was the first time I’ve ever had to design anything that needed to be run by a focus group. It is definitely an interesting experience that wasn’t wholly good or bad. For some things like the costume, having feedback from so many people helped zero in on the ideal solution pretty quickly. It is very satisfying to know that everyone in a group responds well to a design. As for tricker things like the face, where the rendering medium is a shallow representation of the final, and where there are less common cultural touchstones to share ideas, having a lot of different uncertain reactions was a bit overwhelming at times.
A much harder challenge to overcome was my own design bias. It is one thing to understand that the client has different culturally defined ideas of what is cute and what is uncanny, and another entirely to act on it. Things like the super wide mouths of muppets that allow the exaggerated and enthusiastic movement we know and love were just as unacceptable and repelling as the ridged ventriloquist dummy style mouths. The solution to have a small almost immobile mouth was one I fought internally to the very end, but it was what the focus group liked best.
What stage is the Stronger – SAFE program at and what happens next?
KG: It’s a big trial, so that means we have 68 clusters (a cluster is a small community of about 90 households), half of them will receive the face washing interventions which include the puppetry elements and half won’t. We are at the stage where we have actually started collecting data for our baseline, which we need to do before we intervene. We need to understand what are people doing right now; are they washing their faces with soap? When in the day? Who’s washing? All those kinds of things. Then we do the intervention and then after that we will measure the outcomes.
Hopefully, we would see that there’s more face washing after they have been exposed to our intervention. Behaviour change is really hard so we will also be measuring other things throughout the intervention; did they enjoy it? Did they remember it? Which aspects were most memorable for them and why? So even if we don’t see any behaviour change as a result, we hopefully learn a bit more about why.
Stronger – SAFE are hoping to begin the interventions in the Spring. If all goes to plan, it will take about three and a half months to conduct with the 34 communities involved, then they will collect data again. They are hoping to have some initial results by the end of the year.
We all know the power of puppetry and what can be achieved through the exciting process of manipulation, design, and play. To see puppets being used for such an amazing project shows the breath of puppets and puppeteers potential. Puppets can entertain, they can inspire, and hopefully, alongside the hard work of everyone involved with Stronger – SAFE, they can help save the eye sight of so many people.
We look forward to talking with the Stronger – SAFE team in the future.
Find out more about the Stronger – SAFE project.
A big thank you to all the groups, charities, and people involved in the initiative:
London School of Hygiene & Tropical Medicine,
Wellcome Trust Sanger Institute,
The field Team,
Ms Claire Collin (LSHTM),
Oumer Shafi (Fred Hollows Foundation, Ethiopia),
And Izzy B (Puppets, Puppet Photos and Design Concepts).
Interviewed by Cat Rock