9. Questions and ideas for further research

The project on community-directed treatment with ivermectin had some unique features that augured well for its successful implementation. Not all projects for which a pictorial reporting format is ideal will however have the same unique features as the COMDTI project. It is therefore an important and useful exercise to think through carefully, and document in the planning stage, all the components of the proposed intervention from the perspective of what needs to be recorded. Such an approach would be of considerable help in the appraisal and further development of the “reporting with pictures” concept.

Some of the questions researchers could consider are:

· How is the disease perceived?

If the disease is seen as a serious problem, there is more chance that they will participate in a project to deal with it.

(For COMDTI, people in the most affected areas are very aware of onchocerciasis, and motivated to cure it.)

· Mass distribution.

Can the drug be distributed to (almost) everybody?

(For COMDTI, there was no need for individual diagnosis to assess whether or not the person is affected by onchocerciasis)

· Dosage.

Is the dosage complicated?

(For COMDTI, ivermectin is given once, and the people receiving it swallow the drug in the presence of the distributor. This makes it unlikely that misuse (i.e. that some people do not take the prescribed dose) takes place

· How often does it need to be taken?

If the drug has to be taken often, there may be a problem.

(For COMDTI, the drug has to be taken at regular but infrequent intervals (annual or biannual depending on the rate of infection in the community.)

· Are exclusion criteria manageable?

Are the people to be excluded easy to detect?

(For COMDTI, those not to be given the drug were: Children under 90 cm, pregnant women, those too sick to stand up by themselves, and those who have recently (less than three months previously) taken the drug.

These criteria are few enough and simple enough to manage, and also lend themselves well to pictorial representation.)

· Are there serious side-effects?

If side-effects are common and/or severe, there may be a problem.

(For COMDTI, the common side-effects, like itching, swelling of the eyes, etc, can be treated with simple drugs, or just left to clear on their own within three days. The severe side-effects that require referral to health facility are rare, and are relatively easily identifiable by an untrained person - i.e. difficulty to breathe, and severe dizziness.)

· Does the drug have other beneficial effects?

If the drug is perceived as useful for more than one problem, it could be even better received.

(Ivermectin works as an expeller of intestinal worms, and as the majority of the people have some kinds of worms, they perceive this function as a very welcome “side-effect”.)

· The cost of the drug.

If the drug is free, or cheap, the acceptance rate will presumably be higher (although people are often sceptical about drugs given for free, doubting the motivation of the donor)

(In COMDTI, the drug is given out free. This is a real bonus to most people in rural Africa, who are not used to receiving free medicines. It seems as if this aspect does not have the negative effect of raising suspicion that the Government want to achieve something (which they don't tell people) by giving them this drug free. Only time can tell how this aspect will develop. When asked, most people say they would be willing to pay something for the drug, if necessary.)

Why did ivermectin distribution lend itself so well to development of the pictorial form?

With the above as a “rule of thumb”, one could draw up a list of possible topics for research with a pictorial form:

a) COMDT on other diseases, e.g. schistosomiasis (bilharzia) and/or worms in school children;

b) Health status in the community: Epidemiological data on distribution of diseases among different age groups, e.g. malaria among children, onchocerciasis (presence of nodules and leopard skin), etc.

c) Longitudinal data requiring continuos information gathering over a long period of time. This is especially useful in the collation of demographic data such as birth rates, mortality rates, census by age and sex, occupational groups, agricultural produce in an area, village activities by season, etc.

d) Social data e.g. on marriage, emigration, immigration, etc.

e) Prevalence of blindness and other handicaps by age, sex and occupation.

f) Information related to personal hygiene e.g. latrines, ectoparasites, sources of water supply, etc.

g) Community needs assessment.

h) Media survey, e.g. number of households which have access to radio, TV, newspapers.

i) TBAs, who are often illiterate and therefore not thought to be capable of collecting and recording data, could be trained to collect data on maternal mortality and morbidity, as well as various aspects of child health.

j) Health education. The form has potential as a health education tool when left in the village, with the distributor, village headman, or other important person. It would be an interesting research question to investigate the effect of an investment in educating the headman (and his wife), and other selected “change agents” or informal leaders, in the use of the form for education (one would assume they must have a role in the data collection as well).

The pictorial form can be a very useful tool for collection of data e.g. on tropical diseases in remote villages, at little cost to the health sector.

Are exclusion criteria manageable? Drawing by Yola artist.