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

Iron and folic acid (IFA) supplementation is one of the most cost-effective interventions to prevent and treat anemia during pregnancy. Despite having the highest global burden of anemia among pregnant women, rates of IFA uptake in pregnancy in India are still very low, particularly in the state of Uttar Pradesh. While there have been several studies that explored challenges around IFA consumption and adherence, there is a paucity of studies that have synthesized this information into a single visual tool that can help program implementers understand the challenges and identify potential areas of intervention.  Timeline maps were developed as a visual qualitative tool to explore the nuances of health behaviors among pregnant women with respect to antenatal care (ANC) services, including IFA consumption.  Timeline maps were used to visually document critical events pertaining to ANC services chronologically, including details on contact points with the health system and events specific to IFA distribution, consumption and counselling.  Six research assistants (RAs) were trained on how to use timeline maps and record participant narratives. The RAs later participated in a focus group discussion to gain insight about their experiences using the tool. RAs reported that the timeline maps were easy-to-use and facilitated in-depth conversations with participants. RAs shared that they were able to actively engage the participants in co-creating the maps. The visual nature of the tool prompted participants' recall of key pregnancy events and reflexivity. Challenges reported with the tool/process included recollection of past events and potential misrepresentation of information. These highlight a need to restructure training processes. Our findings indicate that timeline maps have the potential to be used in a variety of other program contexts, and merit further exploration.