In the over fifty years in which explicit efforts have been made to improve nutrition, there have been countless achievements in global understanding of the causes and consequences of malnutrition, and the actions required to change outcomes for women and children. In these same fifty years, technological advances have changed the modern world. We communicate with friends and family everywhere instantaneously on hand-held devices, and track our location, heart rate, and calories burned real-time. The confluence of smartphones with high resolution cameras and widespread access to social media outlets have made first-person photography ubiquitous.

Limitations of traditional methods. However, in this time, the methods to evaluate nutrition and key drivers of nutrition status, such as women’s time use patterns, have changed relatively little. The most widely used method for collecting data on diet quality and women’s time use is the 24-hour recall. Errors and biases introduced by the methodology are known to compromise data quality and pose a challenge to nutrition research. Direct observation, which is the gold standard, is resource intensive, imposes a serious burden on the participant, and likely influences their behavior. It is impractical for the purposes of programmatic evaluation.

Research aims and methods. The objective of the IMMANA-funded[1] ‘Using Information Communication Technologies (ICTs) to understand the relationships between labour- saving agricultural innovations, women’s time use and maternal and child nutrition outcomes’ study is to develop, validate and apply innovative methods to more accurately measure women’s time allocation and maternal and infant dietary diversity in rural Uganda. A multi-disciplinary team from the London School of Hygiene and Tropical Medicine, the Natural Resources Institute (NRI) of the University of Greenwich, and the Africa Innovations Institute (AfrII) set out in eastern Uganda to evaluate new tools and methods to capture maternal and child diet diversity and maternal time use data.

Can you collect nutrition and time use data as reliably (or more reliably) using a wearable camera, GPS logger, and automated interactive voice response (IVR) calls every 4 hours (asking about activities and diet) compared to other methods, and in a more cost-effective and less invasive manner? Over two hundred mothers are participating in a 5-day intensive study, including one 15-hour observation day, one 24-hour diet and time use recall, and two days of “innovative methods”. Dietary diversity scores for mothers and children, and calculations of women’s time allocation across key categories using the ICTs will be validated against results from direct observation, in comparison to the same validation for 24-hour recalls versus direct observation. The feasibility and acceptability of the method will also be assessed.

Early lessons learnt. The ICTs are easily available, inexpensive, and already being used for research in high income country contexts. However, devising a method for rural women with low education and literacy, limited access to electricity, limited exposure to TV or mobile phones, etc. to use photos on a tablet to recall their day posed some unexpected challenges, requiring many iterations of the protocol. It was difficult, for example, for some mothers to orient to a first-person perspective of the photos from their wearable camera – that is, to conceptualize where they were relative to the objects, people, and places in the photos. It was also challenging to devise a method that was both effective and rapid, that struck the right balance between enumerator-driven verses participant-driven interpretation of the photos, and to get enumerators and participants to see the photos as a series of activities rather than discrete snapshots.

Next steps. Conclusions from recent studies of the evidence for the role of maternal time allocation on maternal and child nutrition are limited and mixed, in part due to methodological limitations. A viable alternative to recall methods for diet and time use data collection in rural LICs has the potential to be a game-changer for the field of nutrition, and in particular the field of nutrition-sensitive agriculture. We need high quality impact evaluation data to know what works to improve nutrition. With better evidence provided by shrewd deployment of cost-efficient “innovative methods” – with a lower burden on participants and enumerators than traditional methods – we can design better and more cost-effective interventions to improve nutrition outcomes for women and children globally. The team is wrapping up data collection in early 2018; preliminary results are expected by the end of the year.

Supplementary materials:

• [INATU-pic1] Mother wearing the wearable camera and receiving her first automated IVR call while working in the sugarcane field. Key objectives of pilot testing were to rapidly assess the feasibility and acceptability of the suite of innovative tools.
• [INATU-pic2] IMMANA enumerators “code” wearable camera data before heading to the field the review the photos with mother participants.
• [INATU-pic3] This mother uses photos from her previous day (with the wearable camera) on a tablet to help her remember her activities and foods she and her child ate.

[1] Innovative Methods and Metrics for Agriculture and Nutrition Actions (IMMANA) (http://immana.lcirah.ac.uk/) is a research initiative funded by the UK Department for International Development (DFID) and coordinated by the Leverhulme Centre for Integrative Research on Agriculture and Health (LCIRAH). IMMANA aims to accelerate the development of a robust scientific evidence base needed to guide changes in global agriculture and food systems to feed the world’s population in a way that is both healthy and sustainable.

Written by Andrea L. Spray, World Bank Nutrition Consultant and PhD Candidate at LSHTM, with Gwen Varley[1], Jan Priebe¹, Joweria Nambooze[2], Elaine Ferguson[3], and Kate Wellard¹

[1] Natural Resources Institute (NRI), University of Greenwich (https://www.nri.org/news/2017/innovative-nri-projects-measure-up-tools-for-improved-nutrition)

[2] Africa Innovations Institute (AfrII) (https://www.afrii.org/)

[3] London School of Hygiene & Tropical Medicine (LSHTM) (https://www.lshtm.ac.uk/)