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close this bookReporting with Pictures. A Concept Paper for Researchers and Health Policy Decision-makers (UNDP - WB - WHO, 2000, 85 p.)
View the document(introduction...)
View the documentList of abbreviations
View the documentAcknowledgements
View the documentOverview of some main questions
View the documentForeword
View the documentBackground: The multi-country study
View the documentThe purpose and layout of the manual
View the documentIntroduction: The challenge of COMDT
View the document1. Developing and testing the pictorial form in Nigeria. An overview of the Process
Open this folder and view contents2. Planning the research
Open this folder and view contents3. Implementing the research
View the document4. Selecting trainers and planning the training programme
Open this folder and view contents5. Analysing results of the testing
Open this folder and view contents6. Visual perception: Principles and examples
Open this folder and view contents7. Potential conflicts during implementation
View the document8. Researchers’ attitude change
View the document9. Questions and ideas for further research
View the documentAppendix 1: The revised (original Nigerian) pictorial form for distribution of ivermectin
View the documentAppendix 2: The original written form for distribution of ivermectin
View the documentAppendix 3: Draft form for reporting. Side-effects of ivermectin
View the documentAppendix 4: Structure of the testing of the “Oncho form”
View the documentAppendix 5: Sample analysis form: “constructed” answers
View the documentAppendix 6: Sample reporting Level III: Operational Use of the Oncho Form
View the documentAppendix 7: The “Oncho form”: Samples of “correct” interpretations of the pictures.
View the documentAppendix 8: Literature list

Introduction: The challenge of COMDT

This concept paper demonstrates the development and testing of a community reporting tool: the pictorial form for Community Directed Treatment (COMDT) to control river blindness (onchocerciasis), in this paper called “the Oncho form”. The form was developed in cooperation with mainly illiterate community members in a village in Iwo state, Nigeria. It is meant for use by literate and illiterate Community Distributors who are selected by their villages to distribute ivermectin. Ivermectin has to be taken regularly once or twice a year for 10-15 years to eliminate the disease.

Does the form work?

The pictorial form was tested in four communities in Nigeria by researchers and found to be an accurate reporting tool which was appreciated by the communities. It was then used in the multi-country study (see “Background”) in only two (of eight) sites: Mali and Yola (Nigeria). The form at that time was mainly thought of as “for illiterates only”, and researchers said communities almost exclusively chose literate distributors. The idea that illiterates can report on drug distribution is new - to researchers and communities alike.

Reporting turned out to be a major problem; Mali and Enugu (Nigeria) were the only sites showing little difference between reported and estimated coverage, with Mali showing the best results. (Yola was dropped from the analysis because of problems unrelated to the pictorial form). This indicates that the pictorial form could indeed be a valuable and reliable reporting tool for the communities, and needs to be tested out further, especially in its Simplified form (wich was essentially only page 1 of the revised form).

The high degree of reliability in the reporting enables the health authorities to use the forms to prepare their statistics as well as in their further planning of the project. Correct use requires adequate training and support of the distributors.

Will health planners buy the concept?

Many health planners have been (and still are) sceptical to community implemented health projects, especially if they involve drug distribution. A main reason has been the need for control, or for knowing exactly how the projects were implemented and the drugs distributed.

The low level of literacy skills in rural communities is often quoted as a reason for these communities not to take charge of their own information gathering - whether for project planning, implementation or evaluation.

The pictorial form was tested out in four communities in Nigeria, and found to be an accurate recording tool.

The development of the pictorial form described in this paper demonstrates that communities are fully capable of reporting on drug distribution, given an appropriate tool which is worked out in cooperation with them. This view is also supported by numerous studies using tools such as PRA, RRA, etc, to involve and encourage community members to take charge of their own definition of problems and needs, to define the solution to the problems, and to organize the implementation of the solutions.

Secrecy and mystique about drug distribution

Drug distribution has always been associated with the formal health sector, where trained health personnel have been in charge of dispensing the right amount of drugs to people after proper diagnosis. The knowledge about the drugs has remained relatively secret, and this has contributed to keeping up the aura of mystique often associated with the use of drugs.

It is no wonder that many health professionals react with scepticism and often outright negativity to plans for changing such well established traditions. Allowing villagers with low literacy skills to be in charge of the distribution of prescription drugs must seem like negating the very basis of what the medical profession sees as one of its sacred rights.

Furthermore, the fact that ivermectin is being given to people who are not complaining of any symptoms of the disease, have not taken any initiative to obtain treatment and are otherwise in good health, has contributed to the understandable scepticism shown by professionals.

Many medical researchers seem to share these attitudes and opinions, and research on community based medical solutions to health problems has so far not received much attention from mainstream researchers. This may change over the next few years, as governments as well as donors demand more operational research to find practical solutions to health problems.

Community-directed distribution of drugs is relatively untrod territory so far - there is limited experience that has demonstrated that the idea will work, and thus be able to convince the medical professionals to support it.

The multi-country study is building up this experience, and the evidence is very positive:

The research on COMDT in Nigeria, Mali, Cameroon, Ghana and Uganda shows that COMDT is a very viable alternative to programme (or health system) implemented drug distribution of ivermectin: It works better, and it is cheaper.

COMDT is characterized by the following

· Efficient: Community distributors react more quickly to information about drugs being available from the local government, and they also distribute the drugs quicker than the programme designed (PD) system.

· High coverage: COMDT has consistently higher coverage than PD.

· Reliable: Dosage determination of ivermectin is close enough to correct to conclude that it is safe to use COMDT, provided the distributors are given adequate training and support.

· Flexible: In COMDT communities, the distribution system was often changed to suit the local situation. The freedom to determine what is most appropriate for the community contributed to higher coverage.

· Trusted members as distributors: Communities selected people they found trustworthy, respectable, competent and literate to be their distributors. All distributors were indigenes to the communities, and thus perceived the benefits of the programme in terms of success for the village.

· Community distributors are better motivated: Distributors selected by the community have a higher motivation to do a good job than their PD counterparts.

· Pride: Community leaders and members are enthusiastic about the system, which demonstrates that the health authorities trust them to distribute drugs.

Is COMDT sustainable?

A number of factors point towards sustainability of this approach:

The “Ownership factor”: Research in a number of areas has shown that where the community has REAL influence on the planning process and implementation of projects, the chances for long-term sustainability are good. COMDT provides for this, with the outsiders being primarily facilitators of the initial process.

The “In-built self-evaluation factor”: Communities can change the distribution system to fit their local situation.

The “Community Confidence factor”: Communities build confidence by being able to manage the distribution, and see their family and neighbours improve their health. Presumably, they would also get positive feedback from the health system. The COMDT experience could lead to initiatives to take on other projects to improve community health.

Relatively independent of the administrative system in the country: as long as the system supports the establishment of a community distribution system.

The Pictorial Form can be used for other purposes

The use of a reliable reporting tool opens up exciting new possibilities for communities to take charge over projects that involve describing their situation or keeping records of distribution of a commodity, e.g. a drug. The purpose of the records will often be to allow the Government or NGO to see that the project has been run satisfactorily.

However, the method can also be used e.g. in project planning, to gather information to make feasibility studies, etc.

Some potential areas where the method could be used are:

To develop pictorial forms for mass distribution of other drugs (other than ivermectin);

Forms can be used by illiterate or low literate

Community Health Workers (CHWs) and/or Traditional Birth Attendants (TBAs) to record their activities;

Communities can describe and quantify their problems (e.g. on malaria cases, diarrhoea, schistosomiasis, etc.);

To carry out a census - etc. etc. etc.

Experiences with PRA, RRA and other participatory methods show that when community members choose their own visuals (be it drawings on paper or on the ground, stones, seeds, leaves, etc. to represent numbers and trends), they are perfectly able to use these in complex discussions about further analysis of and solutions to problems. Consequently, a pictorial form developed in cooperation with (or adapted by) community members is likely to be well understood, accepted and used. While PRA requires the presence of a trained facilitator through - out the activity, the use of a pictorial form would need only initial training, and then be in the control of the community alone.