Importance of Collecting Information About Infant Daily Experience
The perception-action perspective suggests that to understand an organism's behavior, one must consider the environment or context in which the behavior is produced.1 For example, placing an infant in different postures (eg supine, sitting, or prone positions) affects the movement patterns of their spontaneous kicking.2 In addition, infants move their legs differently when positioned in a car seat compared with a supine position with no device.2 While infant positioning and/or device use such as tummy time, swaddling, and car-seat use vary across cultures and parenting styles, the effect of these varying practices on infant motor development has received little attention in the research.2,3
Information regarding the amount of time an infant spends in various positions, activities, and devices has been collected through parent reports, usually through retrospective questionnaires or prospective paper activity logs.4,5 However, parent-reported data using these methods are subject to recall bias and can be cumbersome to collect. Therefore, development of a method for collecting prospective, longitudinal data about an infant's environment and experiences is needed to inform the literature about infant development. Additionally, collecting these data in a way that is translatable (ie, accessible, understandable, and easy to use) in a variety of cultures would provide foundational information about infant development from a global perspective.
Researchers who study children older than 3 years and adults have collected experiential and environmental data in everyday life through the use of ecological momentary assessment (EMA), smartphones, and smartphone applications.6 In this brief report, we discuss how developmental researchers and clinicians can collect these data in the first year of life, in a way that is translatable to a variety of cultures by using an EMA framework and smartphone technology. In addition, we present examples and suggest next steps for collecting these data globally.
Methods of Collecting Information About Infant Daily Experience
Paper activity logs have been used to provide contextual information about an infant's everyday life.4 However, these data are subject to recall bias5 and valuable data may be lost to human error (eg, loss of activity logs or forgetting to record an activity). One approach that can aid in the collection of contextual information about an infant's daily life is EMA. EMA is a framework that focuses on minimizing recall bias in self-reported data by deploying multiple assessments that ask about the participant's current state, occur in real life, and are scheduled strategically.5 With these ideas in mind, a prudent course of action for assessing infant physical activity while collecting experiential and environmental data would be to combine smartphone technology and methods based on an EMA framework.
Collecting Information About Infant Daily Experience for Global Practice and Research
There is growing interest in the use of smartphone technology in settings where research on infant development is particularly challenging, including low- and middle-income countries.6 Our understanding of infant development is biased toward studies performed in western, educated, industrialized, rich, and democratic (WEIRD) populations.7 As an example, a study with Cameroonian and German children (9-40 months old) supported an interaction effect of cultural background on the fine and gross motor scores. Cameroonian infants' experiences led to early balancing abilities, whereas German children advanced faster in certain motor skills such as stair walking and jumping. Stairs are absent in Cameroonian natural surroundings and are a part of the everyday life of German children, suggesting an interplay between culture, environment, and infant motor development.8 Furthermore, although some studies examined infant development in indigenous people,3 we have limited insights into the relative amount of time infants and caregivers in other populations engage in specific activities of interest. Use of a simple smartphone approach may help researchers begin to collect these data from populations of interest in a way that is respectful, noninvasive, and efficient.
Guatemala is one example of a non-WEIRD population where there is an opportunity to study infant development. A Central American country of approximately 16 million inhabitants, Guatemala is a low-/middle-income country and has one of the largest indigenous populations in Latin America. In Guatemala, indigenous Maya are more than 40% of the population, and experience some of the highest rates of chronic malnutrition, poverty, and lack of access to early childhood services, making them one of the largest populations of at-risk children in the Americas.9 Infant care practices and activity profiles in rural Guatemala are different than in many WEIRD contexts; for example, infants reportedly spend a very large proportion of their time swaddled or in slings across the caregiver's back. Guatemala is just one example of global variability in caregiving practices. Further study into different caregiving practices could contribute to a deeper understanding of infant development, the relationship between daily experiences and developmental rates and outcomes and, in the future, could support educational programs or improve intervention outcomes for children at risk.
Although it might be optimistic to propose using smartphone technology to study infant development in poor, rural communities around the world, our ongoing research in Guatemala shows that virtually all young adults are literate and have low-cost smartphones.10 Guatemala is emblematic of this worldwide explosion of smartphone availability and usage. Cellular telephone coverage in Guatemala has grown explosively in the last decade. For a population of 16 million, there now exist more than 19 million cellular phone lines.10,11 Access to education has improved over the last several decades, and nearly all young adults (prospective parents) are now literate, making their use of smartphones feasible in developing countries. The time is right to use smartphone technology to conduct assessment of infant activity and caregiving behaviors with young parents of different cultural background and socioeconomic resources.
Example of Using Smartphone Surveys to Measure Infant Position and Use of Devices
We used a free, open-source smartphone application, PACO (pacoapp.com), to create a custom pilot survey. We developed a survey that asked caregivers about the amount of time their infants spent in various positions and devices (Table). Institutional Review Board approval was obtained from the University of Southern California and Virginia Commonwealth University, and informed consent was obtained from each parent who participated. The survey was designed to take a minute or less to complete each time. Participants used a de-identified email address provided by the laboratory in order to separate personal identifying information from survey responses. We asked caregivers (n = 18) from the Southern California and Richmond, Virginia, areas to answer our survey for 7 days according to the following schedule: 6 times a day every 2 hours, and again on the 12th hour for a full-day recall (total of 7 prompts a day). Infants were younger than 1 year.
Comparison of Aggregated 2-Hour Recall and Full Day Recalla
||Aggregated 2-h Recall Duration (Range), min
||Full-Day Recall Duration (Range), min
aMedian (range) time is reported in minutes as data were not normally distributed. The Wilcoxon signed ranked test was calculated to compare differences between aggregated 2-recall data and the full-day recall data.
bSignificant difference P < .05.
Our pilot results support that smartphone-based surveys are feasible according to the median response rate for both survey structures, inclusively (median = 97.62%; range = 0%-100%). Caregivers reported that the surveys were easy to download and complete, and that the surveys were not an inconvenience. Caregivers took between 25 and 380 seconds to complete the survey with the average time of 76 seconds. A preliminary analysis of our data supported that caregivers reported differently for duration of time their infants spent sitting and being carried, when asked every 2 hours compared with at the end of the day (Table). Based on this result, we speculate that recall of some variables is accurate when asked once a day, while others might need more frequent prompts to achieve accurate reporting. While asking caregivers once a day would be more feasible for our survey structure, more work is needed on a larger scale to test and validate our survey questions. Global collaboration would be optimal to collect data from a large sample across a variety of cultures and aid in this endeavor. Additionally, the use of wearable sensors and video-recorded data could be used to validate survey responses.2
The potential exists to use smartphone surveys to advance our understanding of the relationship between the environmental and experiential data on infant development. Smartphones are particularly exciting because they offer the ability to respond, in real time, to the information provided by the caregiver. Thus, the possibility for intervention to support infant development around the world also exists. Additionally, as shown in our pilot work, caregivers are willing to answer surveys about their child's daily activities and the general response is that smartphone surveys are not inconvenient for the caregiver.
While the use of smartphone surveys has promise, some limitations may need to be overcome in certain cultures. For example, in cultures in which both parents work, the childcare provider would need to receive the prompts during daycare time.
One of the most exciting aspects of this approach is the use of a flexible open-source smartphone application, combined with the ubiquity of smartphone use in many populations of interest around the globe. Therefore, we feel that this technology has the potential to rapidly advance the study of infant activity and development from a global health perspective, and to include the ability to comonitor the environmental and device use data—something that has previously not been easy to do.
Thank you to the families who participated! Thank you to Joaquin Anguera for his comments on an early draft of this manuscript.
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