Prelingual bilingual deaf: Multimedia content perception of a Brazilian health campaign
First Monday

Prelingual bilingual deaf: Multimedia content perception of a Brazilian health campaign by Ney Wagner Freitas Cavalcante, Simone Bacellar Leal Ferreira, Elaine Tavares, Eliane Pinheiro Capra, and Aline da Silva Alves

Prelingual bilingual deaf individuals have, most of the time, difficulties comprehending textual information available on the Internet due to their linguistic specificities. Although this public has their right to access health information guaranteed by law, the majority of health campaigns available on the Web are inadequate for the hearing impaired.

The objective of this study was to verify the main barriers pointed out by prelingual deaf users during their interaction with multimedia content of a public health campaign, aspects that may hinder the comprehension, with the intent of providing a series of recommendations that may guide developers when designing online health campaigns. In order to achieve so, a case study with two units of analysis was conducted: one consisted of tests with five deaf people and the other was comprised of five normal hearing listeners with an educational profile and computer skills similar to the deaf group.

The research was conducted in eight steps: (i) ethnographic study; (ii) participants profiling and selection; (iii) selection of health campaigns to be examined; (iv) tasks definition; (v) pre and post-testing interviews; (vi) testing; (vii) data analysis; and, (viii) recommendation list development.

As a result of this study subject area, it became possible to notice that several campaigns presented informational polysemy in their verbal and visual content, i.e., the images presented in the folders may carry multiple and diverse meanings for users (Freitas, et al., 2014).


Accessibility and deafness
Research method
Case study
Data analysis




The Internet makes information accessible to users, such as images, video, and audio (CRF, 2014). Health campaigns offered via the Internet intend to help individuals in search of health guidance when noticing symptoms concerning diverse topics, aside from providing information regarding health risk factors and prevention (CRF, 2014; Love and Mackert, 2014; Ellis and Kent, 2015).

Despite its importance, multiple social strata of Brazilians still face difficulties when accessing information, both through the Web and conventional media. Among the groups facing these barriers are the individuals with some sort of disability. These campaigns should reach large numbers of individuals, but unfortunately these campaigns fail to understand different difficulties faced by many. It is important that these campaigns recognize that some users have difficulty in finding, reading, and comprehending digital information.

Overall, prelingual deaf individuals have difficulty comprehending Portuguese. Aside from language differences, not all the Portuguese words exist in sign language (Alves, 2012). This may hinder their understanding of the entire content of a health campaign, leading to the fact that deaf individuals do not have proper access to information. Therefore, efforts in making health campaigns available on the Web may fail if the interface is not easy to use and accessible to everyone.

The objective of this study was to verify the main barriers identified by prelingual deaf users during their interaction with multimedia content of a public health campaign, with the intent of providing a series of recommendations that may guide developers when designing future online health campaigns.

The research analyzed the Web Content Accessibility Guidelines (WCAG) (World Wide Web Consortium, 2008) recommendations related to principles of perceptible and comprehensible content of health campaigns, made available through text, video, and images, aside from content robustness.

A case study with two units of analysis was conducted: one consisted of tests with five deaf people and the other was comprised of five normal-hearing listeners with an educational profile and computer skills similar to the deaf group. The tests for the two units were the same and were divided in two parts: reading internal and external parts of campaign folders and viewing a campaign video.



Accessibility and deafness


Accessibility is simply the access of every person to the benefits and activities of society, independent of limitations in physical, motor, mental, or cognitive capacities. This includes the use of products, services, as well as information, reducing restrictions to the minimum (Ellcessor, 2015; Ferreira and Nunes, 2008).

Digital accessibility implies the ability to access information technology resources (Ellcessor, 2015). It is largely used to define the universal access to the various available services, such as chats, e-mail message, and other features (Ferreira and Nunes, 2008), precisely with the objective of including, not excluding, people with limitations and disabilities (Barbosa and Silva, 2010).

Accessibility on the Web may be defined as the right of access to information, eliminating various barriers, such as communication availability, physical access, hardware, software, content, or information presentation formats (Ellcessor, 2015; Ferreira and Nunes, 2008; Ferreira, et al., 2012).

Despite some advances on the legislative front, there is still much to be done, given that some developers are unfamiliar with recommendations for Web content accessibility. Moreover, there are soem organizations that believe that the costs to make their sites accessible are too high (Lima, 2003).


Deafness, that is complete or partial hearing loss, may be caused by different factors, such as a congenital problem, noise, aging, intoxication, and physical trauma (Ebo, 2014). Hearing loss may be defined as mild, moderate, severe, or profound. Taking into account the hearing loss onset period, two types of deafness can be distinguished — pre and post lingual.

Prelingual or prelinguistic deafness is congenital or acquired in the first years of life, before language development. One characteristic of individuals with this hearing impairment is their tendency to accept their situation (McKenna, 1995). The tests in this study were conducted only with these sorts of deaf individuals.

On the other hand, postlingual or post-linguistic deafness is acquired after language development. These individuals have, in general, more difficulties in accepting deafness (McKenna, 1995).

The partial or complete inability to detect sounds or even the human voice has a significant impact on the life of a deaf individual since it interferes with communication, and consequently, with social interaction and access to knowledge (Constantino and Bonati, 2014). Communication with the deaf is made through several ways that contribute to their education: oralism, total communication, sign language, and bilingualism.

Oralism is a method for teaching the deaf, where the main communication form is the spoken or oral language. Total communication is the practice of using signs, oral and facial readings, also called orofacial, amplification and manual alphabets, also known as fingerspelling or dactylology, as it uses the hands and fingers to represent letters, so that deaf students may express themselves in the way that they prefer through these linguistic elements (Moura, et al., 1993).

Sign language is the natural language of the deaf, that is, the one that a child acquires in a natural and spontaneous way, without specific training (Dizeu and Caporali, 2005). It has several characteristics. The majority of the verbs are expressed in the infinitive, without adjectives gender, or numerical agreement. Time adverbs are used for establishing a notion of time, indicating if the action happens in the present, past, or future. Aside from this, Libras (Brazilian Sign Language) does not have gender distinction. In this sense, the symbol “@” is used for textual representation when necessary (Alves, 2012).

Bilingualism is defined in a specific form, respecting the concepts relative to hearing impairment, language, and culture of the deaf (Kozlowski, 1995).

Prelinguistic Brazilian deaf, those born deaf or deaf before learning how to speak Portuguese, in general first learn Libras (that is, Língua Brasileira de Sinais or Brazilian sign language), while Portuguese becomes their second language. They face in regards to Portuguese all the inherent difficulties of a second language, and for this reason, frequently have little reading ability. There are educational strategies that introduce sign language through studies and strategies so that it is implemented, along with the use of visual images (Porto and Ponte, 2003).

The Libras linguistic system contains a complex structure involving phonetics, morphology, syntax, semantics, and pragmatics. It is not based on articles, prepositions, and conjunctions, and holds verbal conjugations distinct from Portuguese (Alves, 2012). For this reason, the prelinguistic deaf may have difficulties when reading text in Portuguese, such as it is the cases of information available through the Internet.

Overall, images play a substantial and important role in the educational processes of deaf students (Gesueli and Moura, 2006). Some researchers highlight the importance of using images to understand the context of a message. With objects, details can be discovered, aside from associating and combining other images, using words to recount what is seen (Sofiato, 2005).

The importance of visual and spatial aspects, as well as sign language, deserves emphasis, contributing to the building of knowledge through curricular contents, as well as language acquisition and an understanding of the world (Rosa and Luchi, 2010).

Previous work

Previous research show evidence of the difficulties of Web interaction by deaf users. Overall, images play a substantial and important role in the educational and knowledge building processes of deaf students (Gesueli and Moura, 2006).

Skliar (2001) noted that the deaf visual experience encompasses several matters, beyond linguistic ones, such as the use of nicknames or visual names, visual metaphors, visual images, among others. This visual experience of the deaf, also called visual literacy, results from social and cultural practices, both from reading and from images, once symbols are used to retain events and ideas in memory (Lebedeff, 2010; Lester, 2006). In this respect, it is worth highlighting that Web 2.0 increased the use of social networks and mobile devices providing increased access to images and videos (Jaeger, 2011).

Although the Internet has increasingly been used to promote health behavior change, little empirical evidence exists on the impact on individual health behavior due to digital resources (Cowdery, et al., 2011).

Due to linguistic difficulties of the prelinguistic deaf, some digital features may play an important role, such as icons, figures, colors, and symbols. Augmentative and alternative communication (AAC) involves multimodal approaches incorporating gestures, vocalizations, signs, orofacial expressions, as well as picture symbols and voice output devices. These features may contribute to knowledge building, as facilitators or, if poorly used, deterrents for the construction of mediated dialogues (Constantino and Bonati, 2014; Alves, 2012).

For those who do not use sound to express themselves, visual expressions may become increasingly significant (Rosa and Luchi, 2010). For example, drawings and videos may be perceived quickly during activities. Unfortunately, not all words can be represented by images (Reitsma, 2008). The use of images and textual information without proper contextualization may not be sufficient, leading to frequent difficulties in understanding the context of messages.

Celikkale, et al. (2015) explored the role of visual attention in the comprehension of an image. Human intuition is perhaps more prone to remember an image, depending on the parts of the image receiving attention.



Research method

The qualitative and exploratory research was based on a case study, with 10 users, five deaf and five normal-hearing listeners. The number of participants was defined using Nielsen’s (2000) recommendations involving users, with the number of participants limited to five users. According to Nielsen, the first user provides one-third of the information required. As the number of users increases, the information that is collected tends to repeat itself, providing a smaller amount of new information, similar to saturation criteria used in qualitative research. After the fifth user, little is learned. Five users can detect 85 percent of usability problems with Web sites (Nielsen, 2000).

In this study, by observing prelinguistic deaf users, we identified the main barriers with the multimedia content of a public health campaign. The research was conducted in eight steps: (i) ethnographic study; (ii) profile definition and participants selection; (iii) health campaigns selection; (iv) tasks definition; (v) pre- and post-test interviews; (vi) tests; (vii) data analysis; and, (viii) recommendation list development.



Case study

The case study had two units of analysis: one consisted of tests with five deaf individuals and another was composed of five normal-hearing listeners with educational profile and computer skills similar to the deaf. The profiles of the participants is illustrated in Table 1. The tests with the two groups were split in two parts: one comprised the reading of the campaign’s internal and external parts, and the other, viewing the same campaign video.


Table 1: Profile of participating deaf (S) and normal-hearing listeners (O).
UserGenderOccupationComputer skills
Deaf users
1D1MaleGraphic technicianModerate
2D2MaleLibrary assistantModerate
3D3MaleOffice boyHigh
4D4FemaleLibrary assistantModerate
5D5MaleGraphic technicianModerate
2L2MaleDoorman assistantLow
4L4FemaleService assistantModerate


The interviewer established the maximum reading time of each folder as 10 minutes for the internal part and two minutes for the external one; these limits were not provided to the users. After reading, all participants answered a questionnaire about the campaign. The same procedure was followed after the volunteers watched a video. All interactions were recorded with Debut Video Capture software ( This recorded information along with notes taken during the tests provided data for analysis. There were four stages in the study: (a) participants recruitment; (b) questionnaire completion; (c) first unit of analysis; and, (d) second unit of analysis.



Data analysis

The analysis of observations, videos, and user accounts was performed in stages: external folder, internal folder, video, and images. Difficulties faced by users during the health campaign reading were identified, as well as suggestions for improvement. As a result, recommendations were developed in order to promote the comprehension of the health campaign by the hearing impaired.

Folder evaluation

Folders had two parts: the cover, called external folder, and an internal part, called the internal folder. Both contained images of three girls in different styles, for whom the campaign adopted the terms: nerd, rocker and hipster.

The external folder (Figure 1), with a single page, contained little textual information, such as the campaign slogan; campaign starting date (March 2014); ages of the girls to be vaccinated; address of a blog by the Health Ministry; and, the Public Health Care information hotline (Disque Saúde).


HPV vaccination campaign external folder
Figure 1: HPV (human papillomavirus) vaccination campaign external folder.


Basically, the folder contained the slogan of the campaign: “Every girl is different, but they all need protection.” This passage refers to the diversity of the target audience, their personalities, social classes, disabilities, and educational levels. In spite of this diversity, they all need access to vaccination. The second line of the campaign read: “Check to see if your daughter’s school will have the campaign for vaccination or look for a health clinic.”

The folder included three red circles with information from the campaign. The first stated that the campaign would start in March 2014. The second promoted #vacinaHPV with information available on a Brazilian government blog. The third emphasizes the girls’ age range for the campaign, from 11 to 13 years old. The internal folder (Figure 2), with four pages, presented the following information: age group of the target audience; virus transmission; types of vaccine; vaccine safety; warnings for those sensitive to active ingredients; a description of the human papillomavirus; information on the possibilities of developing cervical cancer; and, vaccine schedule.


HPV vaccination campaign external folder
Figure 2: HPV (human papillomavirus) vaccination campaign internal folder.


The deaf found 13 words to be unknown, while listeners identified only four unfamiliar words. Some examples of those words pointed out by the deaf were drastic, hypersensitivity, campaign, and HPV. Several deaf users did not understand the acronym “HPV” (as Human PapillomaVirus) or misunderstood it, such as did participant D1, who thought that the letter H meant disease or health, P meant protection, and V, vaccine.

Some normal listeners also had difficulties with certain words, such as participant L2 who, despite not declaring any difficulties, noted that “I could not enunciate, speak the correct word.” By this statement some users probably implied that had difficulty pronouncing some words, such as papilloma and hypersensitivity. Nevertheless, the participant did not investigate into their meaning or suggest alternatives.

Participant L3 pointed out “hypersensitivity” as an unknown word, but explained that she understood it as “a kind of allergy.” Actually, hypersensitivity means an excessive reaction to an immunization, such as an immune response to an antigen (Digimed, 2014).

Six participants, two deaf and four listeners, reported reading difficulties due to font size. When magnified, letters would become blurred. As participant D1 indicated that the “fonts too small, hard to read.” The campaign did not follow criteria of WCAG 1.4.3 on minimal contrast (, intended to provide sufficient contrast between text and background so that text can be read by those with moderate vision issues.

Participant L3 complained about the size of the font, what made reading difficult for her. She remarked that “the letters get blurry because the colors chosen are bad.” However, she was the only participant who pointed out issues related to color. In this situation, the health campaign could have been greatly assisted had it followed WCAG 1.4.1 on the use of color ( A solution to all of these issues would have been simply to adhere to WCAG 1.4.3 on minimal contrast, WCAG 1.4.1 on color, and WCAG 1.4.4 on text size (

Participant L5 said that he liked the images because they helped his understanding of the campaign, but suggested that “there could be an image to explain it more clearly, like a human body.” This participant also thought that the Health Ministry could divide this campaign ito “several stages, because it was too much to explain all at once.” The user believed that there was too much information to read and assimilate in the short testing period.

In regards to the folders’ images, eight participants — four deaf and four listeners — stated they liked the images. Out of the eight, four listeners and one deaf, said the images helped them understand the campaign. To cite one example, participant L2 said that he liked the images in the folder because “it shows to us what may occur if you have the disease”. This participant believed the images helped campaign comprehension since “it is for women, the cervix, it is more for women and consequently, the girls are the ones who will carry babies”. The user made a proper connection between information contained in the folder regarding cervical cancer and the images of the girls, since the HPV vaccine prevents cervical cancer.

Participant D1 identified several unknown words, such as drastic, hypersensitivity, and campaign, given that there were no Libras equivalents for them. An interpreter explained these words. For example, in the case of the word “campaign,” the closest Libras sign referred to advertising, so the participant understood it as advertising on television or the Internet. In this case, following WCAG 3.1 on comprehension ( would have been most useful.

It is worth highlighting the importance of the context of a message for content comprehension by the deaf. Participant D2 pointed out that, after reading, he understood a little about the disease and that he would need more information to understand the campaign. In his opinion, only individuals with normal hearing could understand everything since they could link words in the text. He could not understand everything, while those l familiar with the words understood “just from constantly listening them”. The same user explained that some words did not have Libras equivalent, “jeopardizing” his comprehension. In this case, repetition of main campaign information might improve comprehension. Verbosity and complex vocabulary needs to be avoided.

Participant L5 stated that the video was about HPV prevention. This user did not comprehend the content of the folder, and, therefore, could not explain disease transmission and prevention. He regarded the video as superior to the folders “because it is more clarified, it has speech, music, it is cooler.”

Participant L4 was the only tested individual that disliked the images in the folders. She explained that they were “complicated a bit, isn’t it? Because that one there is the rhythm of rock, of dance, you know?” She added “it may even pass, pay attention, but it will not stick in her mind, she is in a distraction moment.” She suggested that in order to facilitate comprehension, the image could be a video with girls “16 and older, more mature and that this more mature girl could talk to the younger ones about prevention, about care.” She said that there could be lectures at health care public units and schools. The user did not understand that the immunization schedule was just for girls between 11 and 13 and that the success of the campaign depended on comprehension by that age group.

Participant L3 liked the images with the girls and said that they contributed to her understanding because “if it is to vaccine girls, it is perfect.” However, she suggested that there should be images of older women, fathers, and mothers, warning them as well about the dangers of HPV and that it may “cause cervical cancer”.

The deaf participants did not make suggestions for alternative images that could contribute to additional comprehension. As noted earlier, listeners suggested different images. Two deaf users stated that they did not see anything related to the disease, since the images had only happy and healthy girls. Participant D3 asserted that the images were about “happy, lively, children taking pictures together and studying”. These observations may denote confusion over the images related to content. Following WCAG 1.4.9 on images ( would have been helpful.


Video evaluation

The video campaign (Figure 3) was a 60-second spot, with subtitles containing a transcription of a campaign jingle, “each girl is a certain way, but all need protection”. The video presented little information in relation to the folders, but mentioned the importance of the vaccine for protection against HPV. The video did not include information on the three-dose vaccination schedule or details on the disease.


An illustration from the video, part of the HPV vaccination campaign
Figure 3: An illustration from the video, part of the HPV vaccination campaign.


In the video, Images represented girls with different styles, such as rocker, romantic, nerd, and hipster, some who were practicing sports or not doing anything, as well as an artist, intellectual, and other variants. Given the diversity of images, it is reasonable to suppose that the intent was to use several different kinds of girls, including an individual in a wheelchair, to emphasize the importance of the HPV vaccine for the prevention of cervical cancer.

Three listeners understood the campaign and none of the deaf volunteers were capable of comprehending the video. Four listeners cited HPV, repeated five times in the 60-second video, while just one deaf participant mentioned it. Participant D3 stated that “the study was very important for health and the video was about music also.” This user presumed that there was music in the video because there are some scenes of girls dancing ballet as well as playing electric and acoustic guitar. The user could not understand the campaign theme and images in the video distracted his attention.

Participant D1 thought that the video was about happiness, fun, several girls, and friends, with no concerns and that this was good. He thought that it was like that because none were diseased and therefore, they were happy. The interpreter asked further about the girls’ happiness and he explained that it was because of the vaccine. When questioned about the purpose of the vaccine, he responded cervical cancer. The user did not understand that the vaccine was just for HPV, as he thought it could prevent several diseases altogether.

The interpreter asked participant D2 if the video addressed the transmission or how a disease “is caught.” He answered that he thought it did so, explaining that transmission occurs via sex, just like AIDS. He asserted his preference for the video, saying it was cooler, even without understanding the content.

Several listeners presented difficulties in understanding the content of the video, even with subtitles and audio. Only participant L3 noted that the video was about HPV, remarking “ha, it’s the same campaign, the one on the paper, isn’t it?” This was the only participant that understood the connection between the video and documentation. She stated that she preferred the video because it was “more cheerful and laid-back, lighter.” However, she considered the folders more complete because they had more important information for understanding HPV.

Participant L2 explained that the video was about cervical cancer prevention, but did not remember the name of the disease. The participant could just remember cervical cancer, which was cited only once, while HPV appeared five times in the video. He was embarrassed and excused himself, because the music and the images distracted him and he did not even read the subtitles. He really wanted to answer and get all the answers correct so that the research “would be well done.” The researcher thanked him for his participation, highlighting that there were no right or wrong answers.

Participant L2 said that he liked the video for being more cheerful, although it could be distracting and then “the person doesn’t get all the information about the disease.” For this reason, he thought that the text were better for the campaign, in large part because the folders had more complete information than the video.

Participant L4 asserted that she understood the content of the video on HPV. She preferred the video because “it calls the attention, the rhythm, even singing it was possible to explain it well. I liked it better.” Nevertheless, she could not explain the transmission and prevention of HPV.

Subtitles were not perceived by the majority of all volunteers, deaf and normal hearing. Only deaf participant D5 stated that he liked the subtitles, “because it was easier, it had subtitles.” Nevertheless, when asked if he understood the context, he answered that it was about “playing, everybody together, friendship, bonding.” Another deaf user, D4, when questioned about the subtitles, declared that: ”I did not even notice that there were subtitles in the video because they were too fast.”

No normal hearing participant mentioned the subtitles. Just one of these participants stated that the video was superior, because it was unnecessary to dedicate so much time to understanding the basic message of the campaign. It is plausible to suppose that listeners did not comment on subtitles since they did not need to read the subtitles. Subtitles may be more important for the deaf and may contribute to their comprehension of the campaign.

The video did not include a feature with a Libras interpreter in a small window on the corner of the screen. None of the deaf users suggested this element or complained about its absence. However, if this criterion were met it could have contributed to a better comprehension of the campaign. Again, if the campaign has followed WCAG 1.2 on synchronized media (, it would have benefited deaf participants. However there should not be a priorities that defy bilingual communication (Flor, et al., 2013).

As a result of these findings, recommendations are proposed, presented in Table 2. They are divided into main and secondary items, based on WCAG recommendations. It is worth highlighting that the recommendations were developed based on the multimedia content of the health campaigns in order to promote understanding by the deaf. However, they could be extended to other types of content.


Table 2: Multimedia content recommendations for the hearing impaired.
1. Allow the user to resize the text font, without blurring the font.
     1.1. Enable resizing, without assistive technology, up to 200 percent without losing content or functionality.
     1.2. Avoid the use of fonts that lose focus when maximized.
2. Separate properly the foreground from the background, by using adequate colors to make it easier the content reading.
     2.1. Avoid using some colors for the fonts, such as orange and red.
     2.2. Use a background that matches the font color, goes well and enables reading.
3. Emphasize repeatedly the group age target of the campaign.
     3.1. When there is a vaccine schedule, highlight the vaccination period and duration.
     3.2. Make it explicit and more emphatic about the choice of the target age group.
4. Use simpler words making the textual content more comprehensible.
     4.1. Make supplementary content or a simpler version available to enable the deaf to understand the content.
     4.2. Adopt a simple and concise layout.
     4.3. Avoid verbose text and with excessive information.
     4.4. Avoid some prepositions, such as: nevertheless, nonetheless, yet.
     4.5. Use simpler prepositions: but, however.
     4.6. Use a glossary with synonyms for more difficult words.
     4.7. Explain the meaning of acronyms for disease names each time they appear.
     4.8. Avoid words from other idioms, slang, and neologisms.
5. Present campaign content in parts to guarantee the text reading and comprehension.
     5.1. Make it explicit each part of the campaign and the sequence in which they should be read.
     5.2. Present a post-reading summary containing the main topics of the text.
6. Select images carefully in order to make it easy the content comprehension and the context understanding.
     6.1. Avoid the use of images that suggest too much joy or happiness because they confuse the perception of health campaigns by the deaf.
8. Use subtitles with simpler language and adapted for the deaf.
     7.1. Use subtitles for the entire content, laughter sound effects, songs, music, and not just for dialog.
8. Avoid excessive images in movement because this may be distracting for the deaf user.
     8.1. Use images that make it possible for the deaf to understand the context of the messages.
     8.2. Avoid long videos, giving preference for short and emphatic messages.
     8.3. Avoid images that suggest too much joy or happiness because they confuse the perception of health campaigns by the deaf.

9. Provide Libras interpretation for the pre-recorded textual content presented in the subtitles, in a small window on the corner of the screen with an interpreter (*).

(*) For health campaigns, the recording with an interpreter would be made just once, since all dissemination channels for these campaigns are non-dynamic sites, without constant change or content updates.

10. Select images carefully in order to make the content easier.
     10.1. Use images that enable the deaf to understand the context of a message. For example: the human body or a person with the disease symptoms.
     10.2. Use descriptors for images explaining their meaning within the context of a message.
     10.3. Avoid images that suggest too much joy or happiness because they confuse the perception of health campaigns by the deaf.
     10.4. Avoid excessive colorful images that may distract the user.





This research, qualitative and exploratory in nature, had as its objective evaluating the comprehension of the content of a multimedia health campaign. A case study was conducted with five deaf users and five normal-hearing users. Information from this study contributed to the development of recommendations in order to increase comprehension by the hearing impaired.

During the evaluations, the deaf pointed out a much higher number of unfamiliar words than listeners. The deaf las difficulty understanding and assimilating text, but also a generalized tendency for superficial processing which can result in reduced cognitive growth (Borgna, et al., 2010). One of the recommendations is to use the simplest language.

The deaf had difficulties in the use of more complex prepositions, such as “nevertheless (entretanto)” and “yet (todavia)”. Therefore, it was recommended the use of simpler ones, such as “but (mas)” and “however (porém)”. Moreover, it is important that medical acronyms are explained and repeated, as users had difficulties, mistaking, for example, HPV for HIV.

The deaf took much longer to read text than listeners, not perceiving important information, such as the vaccine schedule. For this reason, it is important to repeat the most important information. One of the deaf users, participant D3, when questioned about the disease discussed in video, answered that he couldn’t remember having seen anything regarding illness “in the video? No. I forgot. I didn’t see anything about diseases.”

The size and color of the fonts used in the campaign were mentioned several times as barriers. All volunteers reported difficulties in reading. Deaf access to information could have been facilitated by content visualization, using colors to highlight relevant information or ensuring minimum contrast.

Due to the study theme, images in this campaign acquired different meanings. One deaf user, when seeing an image of a person in a wheelchair in the campaign folder, understood that the vaccination campaign was to prevent polio. In reality, the campaign intended to transmit the idea that vaccination was for all girls between the ages of 9 and 13 years old, regardless of any kind of impairment.

Communication and information are part of all public health policies, related to the rights to well-being for all citizens. It is worth highlighting the importance of a clear message from sender to receiver, through preventive and informative health campaigns (Alves, 2012).

The quality and types of communication are important factors for the success of public policies, including health campaigns. Information needs to be easy to assimilate by the entire society, breaking barriers, related to different factors such as illiteracy, regional singularities, or disabilities (Porto and Ponte, 2003).

It is essential that communication strategies respect the linguistic specificities of the prelinguistic deaf (Alves, 2012). Moreover, these users may stimulate new strategies (Rocha, et al., 2013), broadening the understanding and dissemination of health campaigns. This research fits into this context.

If the deaf are not recognized, they are forgotten. This invisibility should not be tolerated in society (Monteiro, 2006). This population has the right to access health services, including properly adapted educational and preventative health campaigns.

In addition, informational polysemy should be avoided. For some participants in this study, images had several distinct meanings (Freitas, et al., 2014). For example, a deaf user translated an image of a person in a wheelchair to mean that the campaign was aimed at polio, rather than HPV.

Some limitations of this study will be addressed in further research. Among the limitations is the fact that only one health campaign was analyzed. The analysis of other campaigns could enrich the knowledge on this field.

It is worth highlighting that this campaign of HPV prevention is a current one, aiming at national reach. In our small sample, HPV was in some cases unknown to the hearing impaired public as well as listeners. The replication of this research for other health campaigns could improve comprehension of multimedia content for more deaf users. End of article


About the authors

Ney Wagner Freitas Cavalcante is a doctoral student of the COPPEAD Institute of Administration — Federal University of Rio de Janeiro (UFRJ). He holds a Master’s in information technology from the Federal University of the State of Rio de Janeiro (UNIRIO) and has been a reviewer for the Brazilian Symposium on Information Technology (SBTI) and the Brazilian Symposium on Information Systems (SBSI).
E-mail: ney [dot] cavalcante [at] coppead [dot] ufrj [dot] br

Simone Bacellar Leal Ferreira is Associate Professor of Information Systems in the Department of Applied Informatics of the Federal University of Rio de Janeiro State (UNIRIO); He is the founder and coordinator of the Accessibility and Usability Center (NAU — UNIRIO). He holds a Ph.D. in computer science and a Master’s in computer science from the Pontifical Catholic University of Rio de Janeiro (PUC Rio) as well as Bachelor’s in oceanography, from the University of Rio de Janeiro State — UERJ. His areas of work and interest include human-computer interaction, information systems and use of colors.
E-mail: simone [at] uniriotec [dot] br

Elaine Maria Tavares Rodrigues is a ost-doc at CERGAM — Center d’Études et de Recherche en Gestion da Université Aix-Marseille III, France. She holds a Ph.D. in business administration from the Brazilian School of Public Administration and Business of Getulio Vargas Foundation (FGV/EBAPE) as well as a Master’s in business management from FGV/EBAPE. She is also Adjunct Professor in the COPPEAD Institute of Administration of the Federal University of Rio de Janeiro.
E-mail: elaine [dot] tavares [at] coppead [dot] ufrj [dot] br

Eliane Pinheiro Capra is a Ph.D. student in informatics at the Federal University of Rio de Janeiro State (UNIRIO).
E-mail: eliane [dot] capra [at] uniriotec [dot] br

Aline da Silva Alves is a Ph.D. student in informatics at the Federal University of Rio de Janeiro State (UNIRIO).
E-mail: aline [dot] alves [at] icict [dot] fiocruz [dot] br



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Editorial history

Received 11 May 2017; revised 11 June 2017; accepted 12 June 2017.

Copyright © 2017, Ney Wagner Freitas Cavalcante, Simone Bacellar Leal Ferreira, Elaine Tavares, Eliane Pinheiro Capra, and Aline da Silva Alves.

Prelingual bilingual deaf: Multimedia content perception of a Brazilian health campaign
by Ney Wagner Freitas Cavalcante, Simone Bacellar Leal Ferreira, Elaine Tavares, Eliane Pinheiro Capra, and Aline da Silva Alves.
First Monday, Volume 22, Number 7 - 3 July 2017

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