Visualizing participant experiences in maternal and child nutrition studies using timeline mapping

Introduction

India has the highest global burden of iron deficiency anemia in women and children, with the northern state of Uttar Pradesh (UP), India’s largest state, having persistently high rates of anemia in women of reproductive age (52%) and among pregnant women (51%)¹. The consequences of anemia during pregnancy are significant, and can lead to poor birth outcomes and postpartum complications^2,3. The National Iron+ Initiative of the Government of India recommends that all pregnant women with hemoglobin levels ≥ 11 g/dl take 180 iron and folic acid (IFA) tablets antenatally, starting at 12–14 weeks of pregnancy, and 180 IFA tablets postpartum⁴. For pregnant women with hemoglobin levels between 9–11 g/dl, the guidelines recommend taking 2 tablets/day. Distribution of IFA tablets to pregnant women is done through routine antenatal care (ANC) services provided by the Auxiliary Nurse Midwife, a community health practitioner, at designated village health and nutrition days (VHNDs)⁵. VHNDs are an inter-sectoral convergence platform at the village level, where the community can access a package of services, including registration of pregnant women, ANC services, immunization for all eligible children, growth monitoring, supplementary food provision, and health education. Other frontline workers (FLWs) such as the Accredited Social Health Activist (ASHA) and the Anganwadi worker (AWW) are responsible for follow-up and to ensure distribution of IFA to those women unable to attend VHNDs. Thus, distribution and receipt of IFA tablets are very closely linked to access, availability and quality of ANC services and timely follow-up.

In UP, intake of IFA among pregnant women remains low, with only 12% of pregnant women consuming 100 or more IFA tablets during pregnancy¹. Additionally, less than half (46%) of pregnant women have ANC check-ups in the first trimester and only 26% have at least four ANC visits during pregnancy. There are, however, inherent drawbacks to assessing IFA consumption using only quantitative data because of the potential for recall bias, as ANC and IFA data rely on mother’s recall of events up to 5 years before the survey. Several studies that have explored barriers and challenges to IFA compliance highlight different challenges such as poor knowledge of consequences of anemia, accessibility of ANC services, IFA stock-outs, low decision-making power and irregular follow-up by FLWs^6–9. Yet, there is a paucity of studies that have consolidated all of this critical information into a straight-forward, visual tool that can help program managers understand these factors comprehensively and identify potential areas of intervention.

The current study was conducted to explore the feasibility and field-friendliness of timeline mapping to visually document rich narrative data specific to IFA tablet distribution, consumption, counselling and follow-up. The map is intended to enable the implementation team to better understand critical events that occur during pregnancy, and to explore the nuances of health-seeking behaviour among pregnant women with respect to ANC services, including IFA consumption. The study sought to explore field experiences in using timeline maps to facilitate communication with pregnant women, including an understanding of the process of timeline mapping itself.

This feasibility study was part of an implementation study conducted in Behta block of Sitapur district, UP to explore factors associated with IFA consumption during pregnancy and gaps in knowledge of critical pregnancy events from a pregnant woman’s perspective. The implementation study, in turn, is part of larger on-going project based in UP that seeks to reduce morbidity and mortality due to malnutrition in children under five in 25 high priority districts in UP, by strengthening maternal, infant and young child nutrition service delivery through the Government of UP’s Integrated Child Development Services and National Health Mission programs¹⁰.

Developing a timeline map

Narrative interviews are a means of eliciting stories about people’s lived experiences via a conversation between the interviewer and interviewee that allow the interviewer to better understand participants’ experiences¹¹. Participatory visual methods help in shifting power imbalances between the researcher and the participants and provide more meaningful engagement with participants¹². Constructing timelines is one way of visually depicting rich narrative data. Timelines are usually constructed from a participant's life events, in some sort of chronological order, with visual notations of highlighted events^13–16. Timelines have been previously used to study several topics including substance use and treatment¹³, health equity and homelessness¹⁴ and resilience among marginalized groups¹⁵, but they are still underutilized in maternal and child health and nutrition research. Timelines are a useful tool to explore pregnant women’s antenatal experiences, since pregnancy naturally lends itself to thinking of antenatal experiences in a chronological manner. We used timeline mapping as a methodology, to explore not just the “what” around IFA consumption among pregnant women but also the “why”, within the context of their antenatal experiences.

The timeline map consists of a straight, horizontal line divided into several compartments (Figure 1). The circles on top and the squares on the bottom represent the month and date respectively. In our study, timeline maps were used to document (chronologically and in a single visual representation) critical events pertaining to ANC services, different contact points with the health system, and events specific to IFA distribution, consumption and counselling. In this instance, the compartments represented the nine months of pregnancy, and the woman’s last menstrual period and expected date of delivery were used as a frame of reference for the duration of pregnancy (Figure 1).

Figure 1. A template of the IFA timeline map.

Abbreviations used are: IFA- Iron and folic acid, VHND- Village health and nutrition day, Hb- Hemoglobin, LMP- Last menstrual period, EDD- Expected date of delivery.

The key indicators are highlighted on the top right of the map and serve as a legend for the notations for each indicator. The timeline map is placed on an 11x17 (A3) sheet with sufficient room for the interviewer to annotate key details of participants’ pregnancy events. Having all these details in a single visual representation provides a quick contextual and comprehensive snapshot of all the relevant events from the participants’ perspective. Emphasis is placed on highlighting all the ANC services accessed by the pregnant woman during her pregnancy, including interactions with FLWs. Interviewers are encouraged to probe for details pertaining to each ANC visit such as location, tests performed, receipt of IFA and other supplements. However, the details (including the legend) can be customized to the specific thematic area of the researcher. The timeline map tool and methodology were developed with the assistance of project staff in Kannauj district of UP.

Methods

As part of the broader study, in August 2018, in-depth interviews were conducted with fifteen pregnant women in their ninth month of pregnancy in Behta block of Sitapur district in UP to understand the nuances around IFA consumption during pregnancy. Six interviewers (hereafter referred to as Research Assistants, RAs) were selected from among the existing project staff in Sitapur district, as they best understood the project context. The RAs were frontline staff of the nutrition project based at a sub-block level, trained in maternal, infant and young child nutrition as part of the larger project. Their primary responsibility was to mentor and provide on-the-job support to Government of India frontline workers (namely AWWs and ASHAs) to deliver high quality maternal, infant and young child nutrition services. All six RAs had graduate degrees, with more than 2 years of experience working at the community level. The RAs participated in a one-day training led by the project technical experts on the study objectives, how to use the timeline maps and the interview guides. RAs practiced using the tool on each other during the training sessions. Prior to actual data collection, the RAs practiced interviewing at least two pregnant women in their catchment areas using the timeline maps. A debrief was held after their practice sessions to respond to any queries or concerns. Signed informed consent was obtained from the pregnant women prior to the start of the interviews. A data collection team of two RAs conducted the interviews using a semi-structured interview guide and the timeline map. The interview guide comprised open-ended questions on different aspects of ANC, with a focus on IFA consumption. Questions included time of registration of pregnancy, ANC services received, IFA/anemia counselling received, number of IFA tablets received during each ANC visit, and patterns in IFA consumption. Of the two RAs, one acted as the moderator and constructed the timeline map, while the other team member was a note-taker and managed the logistics of the interview. While the data from the interviews with the pregnant women are not presented in this paper, a sample timeline map has been included (Figure 2).

Figure 2. A sample IFA timeline map in Hindi (de-identified).

No confidential information is included, and the participant provided written informed consent for sharing de-identified information.

Results

Focus Group Discussion with RAs to assess their experience with timeline maps

The findings from the focus group discussion with the RAs are presented under the following categories: 1) aspects of the tool that facilitated data organization; 2) how the tool facilitated a more in-depth understanding of a woman’s pregnancy experiences; and 3) challenges faced while using the tool.

Discussion

This study sought to describe and understand the use of the timeline map as a qualitative visual tool within an implementation research context. The findings suggest that the timeline map has great potential as a participatory, narrative interview tool to provide an in-depth understanding of women’s pregnancy experiences.

There are several reasons why the interviewers felt that the narrative interview process was made easier by using the timeline map. The structure of the tool helped organize their thinking around the interview process and helped them be consistent across interviews. The visual nature of the maps likely serves as a more effective guide, compared to a traditional discussion guide, to interviewers who may be less experienced as well. Nonetheless, RAs also reported using the semi-structured interview guide as a checklist during the interviews to ensure they did not inadvertently omit any key topics. Stewart-Tufescu and colleagues¹⁷ described how the “visibility” of a graphic interview tool helped participants or researchers return to a topic, as compared to a standard narrative interviewing technique. The RAs also observed that participants would, at times, point to a section that had already been discussed and add to the details. They also posited that the tool encouraged greater participation and reflexivity among the participants. Several studies have outlined how visual methods are more participatory and provide a more holistic view of the topics being researched^16–19. Additionally, participatory visual methods help in shifting power imbalances between the researcher and the participants and provide more meaningful engagement with participants¹².

In our study, the timeline map was intended as a means to organize complex narrative data. However, the RAs found that it also served as a means to reveal information that was previously not known and encouraged pregnant women to explore their pregnancy experiences and reflect on them. Visual methods, such as timelines, when combined with interviews, focus “attention beyond what is possible through talk alone, thus becoming not only a piece of data in its own right but a vehicle through which further data were produced”^16–20.

We chose to train existing project staff as RAs, instead of using external researchers, since they best understood the project context. The tool’s easy-to-use interface is well-suited for program managers and staff to administer. The advantages to this approach were that the project staff were familiar with the implementation topic being studied; they were experts in rapport-building, since their responsibilities in the wider project entailed extensive nutrition counselling; and it provided them with a better understanding of all the events around a woman’s pregnancy. Moreover, an unintended consequence was that the RAs reported developing greater sensitivity and empathy towards women’s experiences during their pregnancies. For instance, they reported understanding why some women had misgivings about revealing their pregnancy to FLWs and family members, or why they did not attend ANC clinics. RAs revealed that the timeline exercise gave them greater insight into aspects of women’s pregnancies that could affect pregnancy-related health behaviors, particularly deeply personal ones such as family upheavals and unwanted pregnancies. Internal empathetic validity is the potential of research to transform the emotional dispositions of researchers and participants towards each other, in a manner that promotes interpersonal understanding and compassion²¹. The implications of this are enormous, particularly in relation to knowledge translation. Greater interpersonal understanding between researchers and knowledge users promotes enhanced engagement in producing and applying knowledge by both parties²². Indeed, the RAs noted that participating in the timeline mapping exercise changed how they approached interpersonal counselling when visiting the homes of pregnant women, and that they were now incorporating questions that they “previously did not ask”.

The RAs noted some challenges with the tool/process. They felt that some participants misrepresented or misremembered information pertaining to their pregnancies and suggested that having another family member present during the interview could alleviate this problem. However, this could lead to other biases in reporting, and could inhibit honest responses from participants. The RAs’ suggestion of having another family member to “fact-check” participants’ responses suggests a need for more interviewer training, focusing on the nuances of probing and follow-up questions. Recollection of events was identified as a challenge for a few participants, at least initially, since they were being asked about events that occurred some time ago. However, the RAs observed that it was less of an issue as the interview progressed. Prolonged participant engagement, using multiple methods of data collection and participant validation are some ways to enhance trustworthiness of findings using temporal visual methods such as life histories and timelines²³. RAs also recommended adding more “ANC boxes” to the tool to enable better notations, and to serve as a visual reminder to participants that accessing ANC services in the recommended time period was crucial.

This study has several limitations. The small number of interviewers provided a limited perspective on usability and accetability of the tool. Another limitation is that this paper only presents interviewers’ experiences and does not capture participants’ experiences with the tool. Power imbalances between the FGD moderators (co-authors PS and TS) and the RAs could be a potential limitation, since the moderators were the senior technical experts in the project. The RAs may have felt that they had to speak positively about the tool. However, the advantages of having the co-authors as the FGD moderators was the technical expertise that they possessed and the pre-existing rapport that they had with the RAs. Both FGD moderators (PS and TS) were aware of the power inequalities and tried to mitigate them in a number of ways. For instance, the Community Health Centre where the FGD was conducted was collectively decided upon by the RAs and the moderators, being mindful of the distances the RAs had to travel. The moderators opened the discussion by stating that the purpose of the FGD was to understand RAs’ experiences using the tool and by encouraging the RAs to provide inputs on how to improve it. By restating this often and by offering encouraging comments throughout the FGD, the moderators may have contributed to a safe atmosphere. Furthermore, the fact that the RAs shared challenges using the tool points to them feeling comfortable reflecting on their experiences using the map.

Despite the visual nature of the tool, participant literacy could pose a limitation. We did not systematically address the effect of literacy on the level of participation in the interviews. However, RAs interviewed an almost equal number of illiterate and literate women. According to the RAs, the level of participation was similar across participants because of the visual nature and structure of the timeline map. Due to the tool’s visual nature, the participants could understand the sequence of events being noted down which kept the conversation going. Visual methods, when combined with interviews, enhance participant engagement and facilitate a more in-depth exploration of experiences, possibly because they serve as a common visible frame of reference for the discussion between the interviewer and the interviewee^16,24. This is of particular significance in overcoming linguistic and literacy barriers.

In this study, we have outlined the feasibility and field-friendliness of using timeline maps, in an implementation research context, to understand in greater detail the key events during pregnancy and how these events influenced IFA consumption. Timeline mapping is an alternate method to understanding the complexities around IFA consumption in pregnancy, thus circumventing biases inherent in more traditional, self-reported methods of IFA assessment. It can be a valuable tool for understanding other events that change over time as well. Within the domain of maternal, neonatal and child nutrition, for instance, it can be used to explore complementary feeding practices among children 6–23 months of age, understanding events that influence early initiation of breastfeeding in a labor room, and exploring food behaviors of new immigrants. Timeline maps can also be used as a training tool and for nutrition counselling where frontline workers could use an ‘ideal’ timeline map depicting all the health services available to pregnant women during the course of their pregnancy to create greater awareness in the community. These alternate uses might be tested in future studies.

Conclusion

The timeline mapping tool is an easy-to-use and effective participatory tool that can be included in implementation research and program evaluation. It has immense potential to be used widely in studying other areas of program implementation. The visual representation of key pregnancy-related events, including service delivery at different time points, provides an opportunity address program gaps and to improve program delivery.

Data availability

For confidentiality reasons, the transcript of the focus group is not available; the focus group discussion was with six individuals who are still employed with the project. It should be noted that all relevant aspects of the focus group discussion have already been included in the article as quotes.