A methodological review of solicited diaries as a qualitative tool in health research in low- and middle-income countries

doi:10.21203/rs.3.rs-5234601/v1

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Systematic Review

A methodological review of solicited diaries as a qualitative tool in health research in low- and middle-income countries

https://doi.org/10.21203/rs.3.rs-5234601/v1

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Diaries have served as a vehicle to document personal narratives and as a research tool. However, diaries remain relatively underutilized in most research disciplines, particularly in the field of global health. This review aimed to explore the application, utility, and methodological potential of diaries as a qualitative data collection tool in the health sector within low- and middle-income countries. We applied a search string across several databases, which yielded 1,796 articles that were screened for eligibility. Eleven articles, covering topics including menstrual health, HIV, and mental illness, met our criteria and were included in this review. Across studies, authors highlighted a need to provide instructions in a diary’s early pages and make diaries appealing to the participants by incorporating color. Researchers and participants described diaries as an appropriate tool for conducting research especially among vulnerable populations (e.g. children) or on sensitive or stigmatized topics (e.g. HIV and menstrual health). Some participants said that diary entry clashed with existing obligations, leading to time conflicts and increased workload. Challenges related to diary comprehension suggests a need for researchers to engage more pointedly with participants to co-design diaries in a manner that facilitates understandability (e.g. language, use of audio/video recording among low literacy population) and age-appropriateness. An undercurrent across studies entailed a tension between what researchers desire from diaries (insights regarding a phenomenon of interest captured in a relatively timely manner) versus the original purpose of diaries (a space for individuals to note a variety of topics at a self-appointed pace). Studies generally under-report process insights from participants. Most studies stem from 2020 onward suggesting that this qualitative approach may continue to expand in the future. Our review organizes pertinent diary characteristics into a framework that may facilitate reporting of diary usage in global health research.

Design

Diarist

Diary

Journal

Low- and middle-income countries

Solicited diaries

Qualitative Method

Diaries, or personal journals, have a long and rich history that dates back to ancient times (Adler et al., 1998; Allport, 1949; Josselin, 1991). Diaries have served as a place to document personal records, capture reflections on a day’s events, and spark introspection for diarists (anyone who keeps diary) across time periods and cultures (Cucu-Oancea, 2013; Macfarlane, 1970). The use of diaries has been documented in many ancient civilizations including Ancient Egypt, Mesopotamia, and China where individuals recorded personal events, dreams, religious experiences, and other significant occurrences on various mediums such as papyrus, clay tablets, or bamboo slips (Castillo, 2012; Sreeramana Aithal & Padmanabha Shenoy, 2016). In the Renaissance period, the physical materials to create diaries became more readily available, enabling literate professionals such as merchants and bureaucrats to also chronicle day-to-day events and personal reflections (Alaszewski, 2006; Cucu-Oancea, 2013). Spiritual diaries, such as Catholic and Protestant religious diaries, can be traced back to the common practice of keeping a diary of thoughts in the 18th century (Lejeune, 2009; Macfarlane, 1970; Vickery, 2021). Diaries continued to evolve throughout the 19th and 20th centuries, including as a tool for personal and intellectual reflection (Woolf, 1980).

When considered as a qualitative research tool, diaries are distinct from other more common techniques such as in-depth interviews (IDIs) or focus group discussions (FGDs) (Alamri, 2019). A diary is a personal written record or log maintained by an individual to document their thoughts, experiences, emotions, and activities over a period of time (Thomas & Znaniecki, 1918). Notably, diaries are primarily under the control of the diarist in terms of their content, setting them apart from researcher-guided formats; diaries also typically capture a longer-term perspective over an extended period of time rather than the cross-sectional nature of IDIs or FGDs (Alamri, 2019; Bartlett, 2012). Hitherto, unlike blogs, documentaries, or memoirs, diaries were generally understood as intended for private use or for sharing with a limited audience, rather than geared toward wider public consumption (Alamri, 2019; Cao & Henderson, 2021; Harvey, 2011). However, the shape and form of diaries has changed markedly in recent years (Bartlett, 2012). With the expansion and access to digital tools, diaries have expanded beyond paper and pen formats to include audio, picture, video, and electronic diaries (Bartlett & Christine, 2015; Burton et al., 2007; Gibson et al., 2013; Kuo et al., 2022; Nurannisaa et al., 2022; Plowman, 2010; Spowart & Nairn, 2014).

The origin of diary use as a research tool is a subject of debate among historians and researchers, and there is no clear consensus on its exact beginnings. Some historians and authors argue that diary use as a scientific tool began as early as the 16th century within the fields of astronomy and archaeology (Galileo, 1610; Josselin, 1991; Mickel, 2015; Symmons-Symonolewicz, 1968). Other researchers contend that the systematic use of diaries for scientific purposes gained prominence in the 20th century within the field of sociology (Thomas & Znaniecki, 1918). Regardless of the specific time when diaries were first employed as scientific tools, the importance in scientific research and inquiry remains undisputed in the present day (Boter et al., 2022; Buchwald et al., 2009; Engin, 2011). A vast majority of diary-based research stems from high-income countries (HICs) in studies that generally draw from the field of social science (such as education, agriculture ethnography), and engineering (Bernays et al., 2014; Burton et al., 2007; Gebhard & Wimmer, 2022; Jacelon & Imperio, 2005; Plowman, 2010). More recently, studies have incorporated diaries as a method in health research (Chan et al., 2022; Coombes, 1998; Duclos et al., 2019). Examples of solicited diary use in health-related contexts include food behavior among people with Type 2 diabetes in the United Kingdom (McClinchy et al., 2023), water consumption and quantifying household demand in China and the United Kingdom (Fan et al., 2014; Parker & Wilby, 2013), intensive care unit patients in Sweden (Strandberg et al., 2018), and psychiatric mental health nurses in South Korea (Hwang et al., 2018). Diaries have also been used to capture events according to the calendar or to assess events according to time of day or activity duration (Córdova-Cazar & Belli, 2019). Table 1 presents the range of diary types across the core characteristics of impetus for use, medium, level of guidance and content produced.

Table 1

Characteristics of diaries
Characteristic	Types of diaries
Impetus for use	• Unsolicited: Diaries initiated and used based on the diarist’s initiative (Jones, 2000). • Solicited: Diaries specifically created for a particular purpose or project. These diaries are often used as a research tool or a means of gathering specific information from participants, also known as diarists (Adler et al., 1998).
Medium	• Paper: Paper diaries are the most common method of diary keeping. The use of paper diaries in research began in the early 1940s (Allport, 1949). They are usually designed into little booklets that can fit in a pocket. • Electronic: Beginning in the early 1990s, advancements in mobile computer technology provided a chance to utilize electronic diaries (Burton, Weller, and Sharpe, 2007). • Audio: The audio diary has also been used in different capacities in several (primarily recent) studies (Gibson et al., 2013; Hislop et al., 2005; O’Reilly et al., 2022). This approach allows participants to record themselves verbally, which is particularly useful for people with low literacy (Worth, 2009), and people with visual impairment (Wiseman et al., 2005). • Video: Computerized audio-visual recordings have been used to record personal memories and daily struggles (Coombes, 1998; van dijck, 2004). In the context of research, video diaries typically entail audio and visual filming sessions wherein participants convey their thoughts, experiences, and emotions about a particular issue or subject of interest (Buchwald et al., 2009).
Level of guidance / prompts	Diaries exist on a spectrum from fully unstructured to highly structured: • Unstructured: A completely open space that can be used as often or infrequently as the user sees fit; participants can generate content on whatever they feel compelled to reflect on, using prose, poetry, drawings, scrapbooked items, without any standard fields at all (Jones, 2000). • Structured: The diary includes instructions for use and specific prompts, such as asking the participants to record the date, location, activities completed, places visited, emotional states, etc. The act of using the diary comes with an expected frequency (e.g., daily, weekly, etc.) and duration (e.g., for one week, one year, etc.) (Adler et al., 1998).
Content produced	Many diaries generate qualitative and quantitative data • Qualitative data on personal experiences, thoughts, and reflections (Day & Thatcher, 2009; Harvey, 2011). • Quantitative data on activities (e.g., water use, time-motion documentation, daily mood tracking, exercise, and diet tracking) (O’Toole et al., 2009; Punna et al., 2023).

To date, little is known about the use of diaries as a tool in health research within low- and middle-income countries (LMICs) (Chen et al., 2022; Gebhard & Wimmer, 2022; Pinheiro et al., 2022). Insufficient attention has been given to the practicality of diaries as well as recommendations regarding their design, development, utilization, and enhancements proposed by participants and researchers. The purpose of this scoping review is to understand how diaries have been used, and to identify the benefits and challenges of adopting diaries in health research in LMICs. By analyzing the merits and drawbacks of previous studies, we intend to provide guidance to future researchers contemplating the use of diaries in forthcoming health-related studies.

This scoping review was based on the methodological framework developed by Arksey and O’Malley, (2005), which entails: 1) identifying the research questions, 2) identifying relevant studies, 3) selecting studies, 4) charting the data, and 5) collating, summarizing, and reporting results (Arksey & O’Malley, 2005).

Identifying research questions

Our process commenced with an initial meeting to establish the overarching aim and research objective that directed our review. Via an iterative process, we finalized our scoping objective, which was to determine how diaries have been used and assess the strengths and challenges of using solicited diaries as a qualitative tool in global health research in LMICs.

Following the finalization of the research question, we identified the core concepts and refined the set of keywords. In collaboration with a university librarian, we utilized a combination of Medical Subject Headings (MeSH) and non-MeSH terms to locate and include articles pertaining to the topic of “diary” (including diary, journal, memoir*), and LMICs (including the names of all LMIC countries, as well as terms such as “low-and middle-income”, “developing country”, “global south”). We employed Boolean operators, specifically ‘AND’ and ‘OR’, to encompass all possible permutations in titles, abstracts, and keywords. Additionally, we utilized nesting techniques, such as employing the use of an asterisk to truncate the keywords. The final search strings and research databases searched is attached in appendix 1 and 2.

Identifying relevant studies

We performed all searches from January 4, 2023 – November 17, 2023. We pilot tested the final search strings to one research database to identify potential problems. TA and AZP independently ran for validation purposes. There we no discrepancies noted. We selected three electronic data databases; PubMed, ScienceDirect, and EMBASE to identify peer-reviewed articles across multiple journals. Inclusion criteria included: studies conducted in English between 1980 and Nov 2023, that focused on generating qualitative insights (thoughts, reflections, and subjective experiences). We excluded quantitative diaries on exercise habits, diet consumption patterns, water usage tracking, etc. A full list of inclusion and exclusion criteria is outlined in Table 2.

Table 2

Inclusion and exclusion criteria of solicited diaries in LMICs
Criterion	Inclusion	Exclusion
Literature focus	• Original research articles that used solicited diaries as a qualitative data source	• Articles that did not use solicited diaries as a data source (i.e., uses unsolicited diaries or other qualitative or quantitative methods) or used quantitative diaries • Articles that are editorials, commentaries, observations, reviews, summaries, and opinions
	• Research topic falls within the domain of health	• Articles that does not focus on health (i.e., focuses on agriculture, education, social work)
	• Published in a peer-reviewed journal	• Articles that are abstract only and/or lack retrievable full text
	• Research conducted in an low or middle income country	• Research conducted in a high income country
Time period	January 1980 – November 2023*
Language	English

* Articles published before the 1980s are not available through online databases and thus impractical to include.

Selecting the studies

Following the retrieval of studies across the three databases, we performed a de-duplication process (Kwon et al., 2015) with support from Zotero’s reference manager and Rayyan’s de-duplication tools. After duplicate removal, we uploaded all articles to the Rayyan website. The lead author (TA) and co-author (AZP) conducted a review of paper titles and abstracts. Articles that did not meet the previously defined inclusion criteria were subsequently excluded. Full texts of articles that passed through the title and abstract screening were retrieved and again screened against the inclusion criteria.

Charting the data

Once all relevant literature was gathered via full-text screening, we used an Excel spreadsheet to compile and tabulate the information culled from the final selected studies. A spreadsheet of charting tables was developed to extract relevant information from the chosen studies or publications. The data extraction sheet contained the following information: first author’s name, research title, publication year, study aims, study design, study setting (countries), methodology (including design of the diary, instruction of use), strengths and challenges faced by the participants and the researchers using the diary, and all relevant information related to the research questions.

Collating, summarizing, and reporting the data

We used descriptive and content analysis methods to summarize and report information from all included studies (Finfgeld-Connett, 2014). Each of the included studies underwent a comprehensive review, involving multiple readings, to extract information about how data generated by diaries was used, as well as the diary's design and usage instructions, and the strengths and challenges of using diaries for research as reported by participants and researchers. Key findings from these studies were emphasized and documented in a pre-structured Excel spreadsheet to illuminate prominent themes (see Supplementary Table 1). Furthermore, notable quotes that align with the research scope were extracted, contributing to a deeper understanding of the depth and significance of diary usage and its content. These quotes also provided guidance on the meanings conveyed through diary entries, including insights into the methodologies used and potential flaws. These data extracts were reviewed for consistency in a collaborative effort by the lead author and last author in routine data debriefings conducted via Zoom. Routine debriefings further facilitated a refinement of findings across the seven major themes.

A total of 1,796 titles were extracted from PubMed, Science Direct, and EMBASE databases after utilizing the final search strings. Figure 1 outlines the process of screening and assessment of literature for study eligibility. We identified 32 papers that were deemed eligible for full-text screening: of which, only 11 of these articles met the inclusion criteria. Articles were excluded on several grounds including that they were out-of-scope (n = 13), stemmed from research in high-income countries (n = 4), not constituting primary data/research (n = 3), or were not available as full-text despite thorough searches and after reaching out to the corresponding author (n = 1).

Six of the 11 studies employed an exploratory qualitative design (Agampodi et al., 2019; Cudjoe, 2022; Munyewende & Rispel, 2014; Porter et al., 2022; Thomas, 2006; Tripathy S et al., 2020), four used single and multiple case studies (MacLean et al., 2020; Mendoza et al., 2021; Mkandawire et al., 2022; O’Reilly et al., 2022), and the remaining study used a qualitative phenomenological approach (Rahiem, 2021a). Table 4a and 4b below provides an overview of the included studies while Table 5a and b highlights comparative and methodological insights across included studies. The tables provide an overview of several research studies across countries and health topics that incorporated diary methods into their methodologies. The data collection methods often involved a combination of IDIs, FGDs, and diaries. The diary designs varied, including paper diaries, digital diaries via mobile phones, and audio diaries. Common challenges identified in these studies included issues with diary compliance, varying diary entry lengths over time, and challenges related to participant literacy and confidentiality when using audio diaries. However, the use of diaries also yielded valuable insights, such as providing a means for participants to clarify questions and record experiences over time. In one case, the diary served as both data elicitation and an intervention to improve communication between research participants and doctors: doctors and the relatives of patients in the hospital ICU would pass a diary back and forth, each of them adding entries. The doctors’ entries explained the admission status of the patients while avoiding medical jargon (Tripathy et al., 2020).

Table 3

Overview of included studies
Author, Country, health topic	Research objective	Methodology	Data collection method	Main findings related to the use of diaries
Agampodi et al., (2019), Sri Lanka, maternal mental health	To identify social capital constructs that leads to poor maternal mental wellbeing among pregnant women	Pregnant women (n = 41) from four communities were asked to document their social lives in a diary for two weeks; they were phoned by the researchers three times as a reminder and to answer questions. The same women were also interviewed once at the end of the study period, using tailored interview guides developed based on each woman’s diary entries.	IDI and Diary	No data was reported on the number or length of dairy entries. Data were analyzed using the framework approach and bubble plots were generated for the communities based on themes identified in the diaries and interviews to represent social capital constructs (marital cohesion, family cohesion, etc.).
(Cudjoe, 2022), Ghana, Mental Illness	To assess the psychological experiences of children whose parents have mental illness	Children (n = 19) whose parents suffered from mental illness completed the diary for 3 weeks. The children were asked to concentrate on any life event related to living with parents who had mental illness.	IDI and Diary	A pre-designed A4 paper diary was used in the study. Each diary had 22 pages. The front page contained guidelines/instructions
(MacLean et al., 2020), Kenya, Menstrual Health	To determine the social and cultural geographies of young women's everyday experiences of menstruation	Young women (n = 40) between 18–21 years attending six schools in Oyugis were included in FGDs section, followed by distribution of diary over two months. Everyday experiences and menses challenges were captured in FGD and diary.	IDI, FGD and Diary	No data on design of diary Many of the participants were excited about keeping diaries because it also offered them a chance to write down their experiences, especially on taboo-related topics like menstruation health, which may be difficult for them to discuss during interviews and FGD.
(Mendoza et al., 2021), The Philippines, Hypertension	To explore the opportunities and challenges in employing “digital diaries” via mobile phones to track the lived experiences of people with hypertension	Hypertensive adults (n = 40) were invited to submit digital diaries over 12 months. A web-based application was used to collate content in the form of video, photo, audio, and text	IDI and Diary	A total of 760 messages, were analyzed predominantly using an inductive approach guided by grounded theory. Entries were exported from the platform to identify emerging themes about participants’ motivations and understanding on the use of the platform
(Mkandawire et al., 2022), Malawi, HIV-infected pregnant women	To explore the experiences of newly diagnosed HIV‑infected antenatal women in disclosing their HIV status to their male sexual partners	Participants (n = 7) were given a diary (or a tape recorder for those who did not know how to read and write) to take home where they recorded their experiences of the disclosure. The paper diary was in the form of a health passport book to preserve confidentiality. The diary was returned after 4 weeks.	IDI and Diary	No information on how diary was analyzed. Participants would forget their diaries at home when coming for their appointments. Challenge: Non-compliance to guide by participants

Table 3: Overview of included studies

Author, Country, health topic	Research objective	Methodology	Data collection method	Main findings related to the use of diaries
(Munyewende & Rispel, 2014), South Africa, Working Experiences	To explore the work experiences of PHC clinic nursing managers through the use of reflective diaries	Participants (n = 22) were requested to keep individual diaries for a period of 6 weeks, using a clear set of diary entry guidelines. Event-contingent diary method was used, as participants were asked to record an event that answers a specific research question.	Diary	An attractive diary, with guidelines pasted in the front of the diary. Diary entries were analyzed using thematic content analysis Challenge: Diary entries were longer and more detailed in the first week and shorter in subsequent weeks.
(O’Reilly et al., 2022), India, WASH-related Maternal Stress	To explore the feasibility of making audio diary recordings from prompts in a rural, Indian context where many women are illiterate to assess their stress experience.	Pregnant women (n = 3) living in rural Karnataka (India) were trained on the prompts and audio recorders and were asked to make audio entries over two weeks.	Diary	The pictorial prompts were reported as being more effective than written prompts. Barriers to using audio diary entries include confidentiality; interruptions; and ability to concentrate.
(Porter et al., 2022), Nigeria, South Africa, and Tunisia, Mobility Practice	To explore how COVID-19 has impacted the lives of young women residents in peripheral, low-income areas of three African cities – Abuja, Tunis and Cape Town.	Young women (15–35 years old) (n = 22): 12 diarists for Abuja; 4 diarists for Cape Town, and 6 diarists for Tunis were given diaries to report personal reflections of mobility.	IDI, FGD and Diary	Diary entries were analyzed using content analysis No information on the experience of diary as a method
(Rahiem, 2021a), Indonesia, Motivation to learn during COVID-19	To assess how students remained motivated to learn during the COVID-19 crisis.	An online learning platform was used as a diary system involving university students (n = 80) in Jakarta, Indonesia in two weeks.	FGD and Diary	Diary entries were analyzed in two stages producing phenomenological themes No information on experience of diary as a method
(Thomas, 2006), Namibia, HIV/AIDS	To explore how illness and the daily and long-term duties of caring impacts upon the physical and psychological well-being of ill people and their carers.	Diaries were kept by ill people (n = 7) and by their main carer for periods of 1–6 months. Diaries were given to participants to take home and return. Dairies were recorded in the preferred language of each recorder, and translated in English	IDI and Diary	Diaries appeared to be an appropriate and non-intrusive method of collecting sensitive information from otherwise hard-to-reach households.
(Tripathy S et al., 2020), Experience of patients’ families in ICU	To explore how families of ICU patients experienced ICU diaries	Relatives of patients (n = 13) admitted to the ICU were given diaries. A ‘Get to know me’ sheet was used to allow HCWs and families to individualize their entries. A three-step coding process- open, axial, and selective coding, followed by the formulation of a theory embedded was used.	IDI and Diary	The diary brought novelty and acted as a communication enabler for diarists. The diary acted as a confessional for hopes, fears, guilt, and faith for many members

Table 4

Comparative and methodological insights across included studies
		Location of Study (Date of Publication)
	India (Tripathy S et al., 2020)	Kenya (MacLean et al., 2020)	Ghana (Cudjoe, 2022)	Namibia (Thomas, 2006)		Sri Lanka (Agampodi et al., 2019)		Nigeria, South Africa and Tunisia (Porter et al., 2022)	South Africa (Munyewende & Rispel, 2014)		Malawi (Mkandawire et al., 2022)	India (O’Reilly et al., 2022)	Philippines (Mendoza et al., 2021)	Indonesia (Rahiem, 2021a)	Total
Type of Diary Used
Paper	✓	✓	✓	✓	✓		✓			✓	✓				7
Audio											✓	✓			2
Electronics													✓	✓	2
Design of Diary (as described by researcher/research team)
Diary decorated with colorful writing, pictorial cutouts	✓				✓								✓		3
Diary includes instructions on first page	✓		✓		✓							✓			4
Diary includes page numbers			✓		✓										2
Use of simple, familiar local language	✓		✓	✓						✓	✓	✓			6
Tailor-made pre-set form	✓										✓	✓			3
Visual word illustrations			✓									✓			2
Take-home diary	✓	✓	✓	✓						✓	✓	✓			7
Strengths of Diary (researcher perspective)
Provide protection for sensitive topics and vulnerable populations	✓	✓	✓	✓	✓		✓			✓	✓	✓			9
Provide a private space for participants			✓							✓	✓	✓			4
Validate participants’ importance			✓							✓		✓	✓		4
Enhance qualitative research outcomes	✓		✓		✓		✓					✓	✓		6

Table 4: Comparative and methodological insights across included studies

		Location of Study (Date of Publication)
	India (Tripathy S et al., 2020)	Kenya (MacLean et al., 2020)	Ghana (Cudjoe, 2022)	Namibia (Thomas, 2006)	Sri Lanka (Agampodi et al., 2019)	Nigeria, South Africa, and Tunisia (Porter et al., 2022)	South Africa (Munyewende & Rispel, 2014)		Malawi (Mkandawire et al., 2022)	India (O’Reilly et al., 2022)	Philippines (Mendoza et al., 2021)	Indonesia (Rahiem, 2021a)	Total
Strengths of Diary (participant perspective)
Creates a sense of continuity	✓												1
Appreciates the novelty of the concept	✓												1
Challenges of Diary (researcher perspective)
Low adherence to guidelines by participants									✓				1
Time conflict with personal obligations			✓	✓						✓			2
Prolonged follow-up and reminders			✓								✓		2
Liable to short responses		✓						✓					2
Challenges of Diary (participant perspective)
Fear of someone in the family reading personal information										✓			1
Additional workload			✓									✓	2
Lesson learned (researcher perspective)
Participants-centered contextual diary	✓							✓					2
Participant-driven co-creation of diaries								✓			✓		2
Supplement audio diary for low literacy population										✓			1

Type of diaries used

About two-thirds (seven of 11) of the articles included in the review used a paper and pencil form of diary for their studies while one used a combination of audio and paper diaries, one used audio diaries exclusively, and two studies used electronic (typed) diaries.

Stated design of diary (researcher perspective)

Five studies detailed design decisions made by researchers for diaries, including the use of color to make them appealing and the placement of guidelines, instructions, and other information on the first few pages (Agampodi et al., 2019; Cudjoe, 2022; Mendoza et al., 2021; Munyewende & Rispel, 2014; O’Reilly et al., 2022; Tripathy S et al., 2020). When designing their study’s diary to explore the experiences of primary health care (PHC) nurse managers in two South African provinces, the researchers described their approach as “an attractive diary, with the guidelines pasted in the front of the diary” (Munyewende & Rispel, 2014). Similarly, a study in India emphasized the importance of creating a diary that appeals to the participants, especially when dealing with sensitive and emotional topics like the families of intensive care unit patients: “We used colorful writing paper, multicolored pens, and decorated the diary with pictorial cutouts to make it attractive” (Tripathy S et al., 2020, page 2).

Furthermore, when designing a diary for data collection, studies described a perceived need to include a structure to help the participants provide accurate and timely data (Agampodi et al., 2019; Cudjoe, 2022; Mendoza et al., 2021; Munyewende & Rispel, 2014; O’Reilly et al., 2022; Tripathy S et al., 2020). A study conducted to identify social capital constructs that leads to poor maternal mental well-being among pregnant women in Sri Lanka emphasized the need to provide enough space on the diary’s opening and closing pages to convey guidance and to capture challenges (Agampodi et al., 2019). In their study, the initial pages of each diary contained instructions on how to write entries, guiding participants on how to effectively document their experiences. Additionally, the last two pages of the diary were left blank specifically for participants to document any challenges, problems, or difficulties they encountered during the diary writing period. Studying children in Ghana with mentally ill parents via the use of an illustrated diary, Cudjoe (2022) highlighted the need to provide proper instructions and dates on each page of the diary. In structuring and designing the diary, Cudjoe stated, “The booklet was a simple paper diary made with A4 sheets, each page was dedicated to a day’s writing activity. There were about 22 pages for each diary. The front page of the diary included guidelines on how to complete the diary. Pages of the diary were dated to ensure that the children were recording recent information about their daily activities as well as impact of parental mental illness on their views about life (Cudjoe, 2022, page 4)”.

Despite a lack of consensus on general instructions for diary use, in some of the studies, participants were encouraged to write in their local language to capture culturally relevant topics and information (O’Reilly et al., 2022; Thomas, 2006). Similarly, one study utilized a pre-set form, which allowed participants to fill their diaries at a specific data collection time and location (Tripathy 2020) while others gave participants diaries to fill out at home (Thomas, 2006).

Strengths of Diary (researcher perspective)

Ten out of 11 articles in this scoping review described diaries as a useful qualitative research tool. MacLean, Hearle, and Ruwanpura, (2020) used diaries in their study on the cultural and social context of young girls’ attitudes toward menstruation in Oyugis – a rural town in Kenya, where girls are often stigmatized and treated differently during their menstrual cycle. According to the research team, the diaries were intended to provide participants with a written medium for sharing their experiences. This approach was chosen according to MacLean and colleagues, to enable young women to overcome social barriers that might hinder them from openly discussing taboo topics during interviews or FGDs. Furthermore, a study in Ghana among children reported that, in contrast to interviews, diaries allowed children to have ample time and space for reflection (Cudjoe, 2022).

Mkandawire AK et al., (2022) likewise concluded in their study among HIV-positive pregnant women in Malawi, that diaries were incorporated into the study to ensure participant privacy and provide a space where they could freely express themselves. According to Mkandawire and colleagues, by using this method, participants were able to share information without the burden of recall, enabling them to share what they wanted, when they wanted, and in the manner they preferred. Researchers in South Africa and Namibia who also employed diaries came to conclusions on the benefits of this method for gathering information with little intrusion (Munyewende & Rispel, 2014; Thomas, 2006). Similarly, O’Reilly and colleagues (2022), in their study in India, reiterated that diaries offer great potential towards improving qualitative research outcomes as it was used among vulnerable populations like children, which may prove problematic with other qualitative methodologies, particularly when it comes to issues of concentration and attention.

Strengths of Diary (participant perspective)

Only one study from our scoping review highlighted the strengths of diaries from participants’ perspective. Tripathy S. et al., (2020), explored how ICU patients in India feel about the experience of documenting their daily routines in a diary. The participants stated that the diary gave them a ‘sense of continuity’ even if they missed visits to the ICU. Additionally, almost all of the participants stated they used diaries as a platform to express their hopes, concerns, guilt, and faith. Similarly, the participants also described appreciating the novelty of the diary, many of them stated they were not familiar with using this daily method, however, they have reported that through the act of writing in a diary, they discovered an ability to express emotions and sentiments they had previously kept hidden. By putting their thoughts and feelings into words, they described feeling a sense of relief and release of their innermost burden.

Challenges of Diary (researcher perspective)

Several studies highlighted challenges associated with diaries from the perspective of the researchers. Diary studies were hindered by factors like a conflict of interest and prolonged follow-up and reminders, as well as low adherence to guidelines (Mendoza et al., 2021; Mkandawire AK et al., 2022; O’Reilly et al., 2022). Mendoza and colleagues concluded in their study among hypertensive patients in the Philippines, that diaries as a means of data collection required a longer time and follow-up than the traditional methods which, for them, was a major challenge that resulted in some data being lost or missing during the follow-up process, contributing to a loss of valuable information.

Low adherence of the participants to the guidelines of the diary activities was another major constraint described by researchers. Studies highlighted that some participants could not follow guidelines and instructions for the use of the diary. For instance, in Malawi, Mkandawire, Jumbe, and Nyondo-Mipando, (2022) revealed that their participants deviated from using the diaries as they had instructed thereby impeding their ability to collect real-time information through the diary. The researcher stated, “The participants did not use the diaries as required. Some of them only used them once, after disclosure” (Mkandawire, Jumbe, and Nyondo-Mipando, 2022, page 13). As a result, Mkandawire and colleagues stated that they were not able to capture all the information while others forgot their diaries at home.

Challenges of Diary (participant perspective)

Participants described challenges such as perceived workload inherent to filling out diaries (Rahiem, 2021a). Another mentioned concerns about family members reading their personal information, which added to their apprehension (O’Reilly et al., 2022). In the study by O’Reilly et al., (2022) in India, married women faced challenges in creating audio diaries due to their primary commitments, such as agricultural work, which left them with limited time for diary activities. One participant mentioned feeling unable to speak freely due to her sister-in-law's presence, while another seized moments of privacy in the evenings when her husband took their child out of the house to record her diaries (O’Reilly et al., 2022).

Lesson learned (researcher perspective)

Four studies described lessons learned from diary usage in their studies including a need for a participant-centered contextual diary, and participant-driven co-creation while also suggesting that audio diaries may be most appropriate within low literacy populations (Mendoza et al., 2021; Munyewende & Rispel, 2014; O’Reilly et al., 2022; Tripathy S et al., 2020). Tripathy and colleagues noted in their study among ICU patients in India, that future studies embarking on diary usage should incorporate potential or actual participants in the design and development of diaries, to bolster cultural acceptability and delight, which aligns with lessons learned from Munyewende & Rispel, in their study among nursing managers in South Africa (Munyewende & Rispel, 2014; Tripathy S et al., 2020).

Our review consolidated insights on the use of diaries for health research in LMICs across various health issues such as HIV, mental health, maternal health and COVID-19. The findings encompassed diverse design features (structured, unstructured, decorated, etc.) and formats (written, audio and electronic/digital). The included studies also offered valuable insights into perspectives of both researchers and participants regarding the benefits and drawbacks of this research methodology. In general, diaries were a practical means of generating first-hand and participant-directed qualitative data. Diaries were primarily used in conjunction with in-depth interviews or focus group discussions, suggesting that researchers perceive diaries as having limitations when used as stand-alone data elicitation methods.

Our review covered a broad spectrum of health topics and examined diverse populations including pregnant women, children, adolescent girls, patient families, and undergraduate students. These studies highlighted the versatility of diary methods in exploring health-related issues in resource-constrained settings. The use of diaries for research in HICs similarly engages with a wide range of diseases and populations, such as analysis of time-use in Spain and food diaries in Australia (Gimenez-Nadal & Sevilla, 2014; Pendergast et al., 2017; Watanabe-Ito et al., 2020). Diaries appear to be flexible tools that transcend educational, geographical and economic boundaries.

Several studies also underpinned the importance of visual representations and user-centered features or interfaces in diaries. For instance, some studies aimed to create visually appealing diaries by incorporating color and lines pages, as well as ensuring easy navigation through the inclusion of simple instructions on the first page and page numbers. These design choices were made in accordance with the local research context (Agampodi et al., 2019; Cudjoe, 2022; Porter et al., 2022; Tripathy S et al., 2020). However, none of the studies conducted an assessment or evaluation of the different diary designs. We encourage future research focuses on assessing the characteristics of diaries, the ease with which their interfaces can be shared, and the benefits of involving participants in the design of diaries before their use, to enhance the collection of meaningful qualitative data.

Considering the challenges posed by low literacy rates in LMICs, the adoption of audio diaries emerges as a potentially superior and feasible approach compared to written diaries. Audio diaries enhance accessibility and engagement among populations who would otherwise be excluded (O’Reilly et al., 2022). This approach not only addresses the accessibility barriers faced by people with low literacy levels, but also has the potential to alleviate the burden associated with diary keeping, even for literate populations. By allowing participants to verbally share their experiences, audio diaries provide an inclusive and user-friendly alternative (Bolger et al., 2003; McGregor, 2006; Pinheiro et al., 2022; Worth, 2009). Alternatively, scholars in HICs have also utilized picture and video diaries as a means of gathering data from children (Iivari et al., 2014; Noyes, 2004; Seo & Ok, 2013), showcasing the adaptability of diary methods to suit the preferences and communication styles of different populations.

Several studies highlighted the unique benefits of using diaries for research (Cudjoe, 2022)(MacLean et al., 2020; Mkandawire AK et al., 2022)(Linn, 2021). Diaries provide a platform for uninhibited self-expression and unrestricted documentation of personal interests (Cudjoe, 2022). Additionally, diaries facilitate reflection on sensitive topics that may be challenging to address in direct interpersonal communication (MacLean et al., 2020; Mkandawire AK et al., 2022). Researchers in high income settings have also observed these advantages, for example, a study among urban refugee women in the United Kingdom found that the use of solicited diaries provided participants with a sense of independence and control, enabling them to confidently contemplate and express their feelings and emotions (Linn, 2021).

Several studies also identified challenges associated with using diaries in qualitative research. The issues encompassed the perception of diary tasks as overwhelming resulting in early discontinuation, the low adherence to guidelines by the participants, and the resurfacing of traumatic memories (Cudjoe, 2022). While some challenges may be unique to diaries, other issues (such as dredging up painful memories) apply to qualitative and even quantitative methods more generally (Ayers, 2007; Engelman et al., 2006; Gillies, 2000; Kensinger & Corkin, 2003). The issue of low adherence to guidelines identified in this review echoes findings from research in the USA, where participants also chose to complete the diaries based on their judgment, regardless of the given instructions (Palen & Salzman, 2002). This inclination may be due to participants' preference to personalize their diary entries and use the diaries in a manner that best suited their individual needs and experiences (Palen & Salzman, 2002). This observation underscores a crucial feature of diary keeping: it may not be suitable or feasible for everyone, and individuals' engagement levels can vary (Cudjoe, 2022).

Only four studies discussed participant perspectives on utilizing diaries for research. One study highlighted how participants valued the novelty of diary keeping and its ability to provide a sense of continuity (Tripathy S et al., 2020). The other three studies identified challenges faced by the participants including increased workload (Cudjoe, 2022; Rahiem, 2021b) and concerns about the privacy of their dairy being compromised (O’Reilly et al., 2022). Research often prioritizes the examination of method outcomes rather than the views of participants on the research process (Herron et al., 2019). Nevertheless, as diaries are a relatively unique mechanism for data elicitation, further research is necessary to investigate the first-hand experiences and viewpoints actively engaged in the process.

The insights gained from this review underscore the importance of comparing diaries with other qualitative data methods in health research. In the realm of qualitative data collection for health studies, the choice of method can significantly influence the depth and richness of information obtained. In Table 5, we outlined the benefits and drawbacks that diaries bring to the research process.

Table 5

Unique benefits and drawbacks to using diaries for research
Potential benefit/strength of diaries	Potential challenges/drawbacks of diaries
• Allows the research participant to reflect on a topic privately • Allows the research participant to reflect on a topic repeatedly over time, as and when they choose • Enables participants to share sensitive or taboo thoughts with researchers but without being in the presence of researchers • Introduces research participants to a valuable tool for introspection and processing experiences, which may build participant clarity of perspective or confidence in self-expression	• Vulnerable to high attrition • Participants may not follow guidelines: may go off-topic, create diary entries irregularly, create extremely short entries • High burden on time for the participant • Researchers are often not able to probe/clarify what is recorded • Expose respondent to potential privacy breaches if the diary is read/listened to by a family or community member • Requires books or electronic recording equipment to be left with respondents, stored by respondents (and not stolen, broken, or lost), and retrieved by researchers • In the case of written diaries, the depth of entry may be limited by low respondent literacy

Strengths and limitations of the review

Our review, focusing on LMIC studies employing solicited diary methods in global health research, is the first of its kind to date. We provided a comprehensive analysis of diary design in the context of global health and presented recommendations for future LMIC research using this method. However, we acknowledge limitations. First, our review specifically examines research conducted in LMICs that used diaries as a data elicitation method. Consequently, we only identified 11 studies. We invite further research to expand the review to high-income settings. Second, our review yielded scarce information regarding the specific utilization of diaries in research, particularly in terms of design considerations, as well as the perspectives of researchers and participants toward this data elicitation method. The studies lacked consistent reporting of methodological details regarding diaries. Overcoming this limitation in a scoping review is challenging, indicating the necessity for primary research to involve researchers and research participants in reflecting on the method itself.

Our LMIC-focused scoping review provided valuable insights into diary design, benefits, and drawbacks in the context of global health. This review unveiled diverse approaches and considerations for diary implementation. The findings suggested that diaries can be used as a viable technique for collecting data, either as the main method or in complementary with other methods, with careful planning and consideration. Integrating color into the diary design may enhance user engagement. Additional research is required to examine the experiences and perspectives of participants using diaries in LMICs.

Acknowledgments

The first author would like to thank the Deutscher Akademischer Austauschdienst (DAAD) for the scholarship received to support the course of this research and lead author (TA). Also, we would like to thank the members of the Design and Implementation Research Group at the Heidelberg Institute of Global Health (HIGH) for their support towards the completion of this review.

Author contributions

TA and SM conceived the idea for the study. TA and AP performed the screening of the literature. TA and MDCR conducted the analysis and data interpretation. TA, MDCR, KS, and SM prepared the initial draft, contributed to the report writing, and critically reviewed the manuscript. All authors read and approved the final version of the manuscript.

Ethical clearance

Not applicable to this study

Declaration of conflict of interest

The authors declare no potential conflicts of interest concerning the research, authorship, and/or publication of this article.

ORCID iD

Temidayo Akinreni https://orcid.org/0000-0002-6621-8200

Mark Donald Reñosahttps://orcid.org/0000-0002-7414-7174

Agrin Zauyani Putri https://orcid.org/0000-0008-2095-5556

Kerry Scott: https://orcid.org/0000-0003-3597-9637

Shannon McMahon https://orcid.org/0000-0002-8634-9283

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The authors declare no competing interests.

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A methodological review of solicited diaries as a qualitative tool in health research in low- and middle-income countries

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Abstract

Figures

Background

Method

Identifying research questions

Identifying relevant studies

Selecting the studies

Charting the data

Collating, summarizing, and reporting the data

Results

Type of diaries used

Stated design of diary (researcher perspective)

Strengths of Diary (researcher perspective)

Strengths of Diary (participant perspective)

Challenges of Diary (researcher perspective)

Challenges of Diary (participant perspective)

Lesson learned (researcher perspective)

Discussion

Strengths and limitations of the review

Conclusion

Declarations

References

Additional Declarations

Supplementary Files

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