1. Developing and testing the pictorial form in Nigeria. An overview of the Process

TDR: could illiterates record?

The idea of developing a pictorial form for use by illiterates to record information on community treatment was born in TDR's Task Force on onchocerciasis in 1994.

The Task Force was exploring ways to make communities be responsible for distribution of ivermectin to their members. The form could be developed for use in hard-to-reach villages where there is often no one who can read and write. Could community members in such places still be trusted to distribute the drugs according to the manufacturers' instructions, and record correctly what they did?

There was some scepticism in TDR to the practical outcome of such a challenge, but others with experience in working with communities and with illustrations for illiterates were positive it could be done. So - TDR decided to give it a try.

Multi-cultural team

Two experienced social scientists - one from the University of Ibadan, Nigeria and one TDR staff member - “attacked” the task together with one of the biomedical scientists involved in the TDR-assisted multi-country study on community-based treatment with ivermectin.

Brainstorm on concepts

The starting point was the written reporting form which had so far been used by the project-directed distribution system, where health workers had been in charge of distribution and recording of results, including side-effects.

The scientists brainstormed on how the form could be conceptualized and illustrated, and what we needed to know from the community to be able to make the first drawings.

Selection of high-prevalence community

We selected a community with high prevalence of river blindness, and met with the Local Government officials and the Primary Health Care workers responsible for the area. The PHC workers accompanied us to the village, where we met with the chief to explain our project. He called a village meeting, and introduced us. We had two artists with us, who were going to make drawings for the form.

Selection of illiterate community members

We explained our project, and asked for the community members to select six men and six women who could work with us to develop the pictorial form. Our wish was to work with illiterates only, and it turned out that the women were all illiterate, while among the men there were four literates and two illiterates. When we explained our wish to the chief, he arranged the selection of four more illiterates to be involved in the work. We involved the literates in some of the work to prevent any ill feelings on the part of the literates who had been first chosen, and also to see to what extent they saw and did things differently than the illiterates.

How do illiterates count and measure?

We met with the two groups separately, explaining our task and why we wanted to work with them. We asked how people in the village would count and mark the numbers of something, how they would measure height and weight, and if they had any symbols for visualizing any such aspects. We discussed their suggestions. The women especially were shy and kept a safe distance from us (by sitting on chairs 4-5 metres away). As we got to know them better and they saw that we really wanted and appreciated their opinions, the distance vanished, and we were soon all sitting around the same tiny table discussing the drawings.

Draft drawings developed

We went back to town and developed drawings based on the village observations and information.

The artists developed several versions (pencil sketches) of each of the topic areas that needed illustration.

We did a quick review of pretesting methods for the scientists and field workers who were going to test the drawings.

First pretest of drawings

The pictures were tested with individuals and in a group, with the women and the men separately (we explained what the pictures were for, and how they related to what we had already worked on with them). We tested for comprehension, and for preference of style, posture, dress, etc.

First pretest of form

The selected pictures were then revised, reduced in size, and arranged into a draft reporting form. Each concept was given a separate page (i.e. treatment, those not to be treated, those to be treated later, side-effects, and summary page).

The form was again tested, and new adjustments were needed.

Second pretest of form - Using it in practice

The adjustments were done and the draft form was ready to be tested out in practice: the two groups were asked to use it to do a mock trial and tell us how it worked.

Both the groups then “treated” the whole village, and gave us feedback on which pictures and columns were difficult to use, and how we should change them.

Community distributors were given the form to test out in a mock distribution in their village. This brought up several problems in the form, and suggestions for how they could be solved.

Abstract ideas like this one: “Total number of people not having been treated”- are not well understood, and need to be carefully explained during training of distributors.

Third pretest - in another village

The form was then tested in another village in the same area, to see if a “virgin” village where we had not involved the villagers in the development of the form, would give different responses.

The form was again revised, based on the suggestions from the two villages (the “new” village had only minor suggestions - basically, the form worked very well).

The large pretest in four communities

A “final draft” was then produced for a larger trial in four different sites in Nigeria (all representing different ethnic groups). The researchers were the Principal Investigators of the multi-country study sites, and they were collectively sceptical about the idea of the form. After three days they came back and reported that the form works - i.e. illiterates can easily use it - and they had suggestions for further improvements, none of which were major.

The form is introduced to the Multi-country study

With these improvements, the form was now revised and sent to the other countries participating in the study (Uganda, Cameroon, Ghana, Mali), with advice on how to adapt it to their cultures, and a common protocol for how to test the form with the intended users.

The results from the testing in the different cultures show that most of the images are usually well recognized, and that some require adaptations and revisions.

The ideas (or abstract interpretations) are not well understood, as expected. These have to be explained during the training programme, and the images will then function as reminders of the ideas.