An innovative approach to the assessment of nutrient intake in adults with type 2 diabetes : the development, trial and evaluation of a mobile phone photo/voice dietary record

Nutrition interventions in the form of both self-management education and individualised diet therapy are considered essential for the long-term management of type 2 diabetes mellitus (T2DM). The measurement of diet is essential to inform, support and evaluate nutrition interventions in the management of T2DM. Barriers inherent within health care settings and systems limit ongoing access to personnel and resources, while traditional prospective methods of assessing diet are burdensome for the individual and often result in changes in typical intake to facilitate recording. This thesis investigated the inclusion of information and communication technologies (ICT) to overcome limitations to current approaches in the nutritional management of T2DM, in particular the development, trial and evaluation of the Nutricam dietary assessment method (NuDAM) consisting of a mobile phone photo/voice application to assess nutrient intake in a free-living environment with older adults with T2DM. Study 1: Effectiveness of an automated telephone system in promoting change in dietary intake among adults with T2DM The effectiveness of an automated telephone system, Telephone-Linked Care (TLC) Diabetes, designed to deliver self-management education was evaluated in terms of promoting dietary change in adults with T2DM and sub-optimal glycaemic control. In this secondary data analysis independent of the larger randomised controlled trial, complete data was available for 95 adults (59 male; mean age(±SD)=56.8±8.1 years; mean(±SD)BMI=34.2±7.0kg/m2). The treatment effect showed a reduction in total fat of 1.4% and saturated fat of 0.9% energy intake, body weight of 0.7 kg and waist circumference of 2.0 cm. In addition, a significant increase in the nutrition self-efficacy score of 1.3 (p<0.05) was observed in the TLC group compared to the control group. The modest trends observed in this study indicate that the TLC Diabetes system does support the adoption of positive nutrition behaviours as a result of diabetes self-management education, however caution must be applied in the interpretation of results due to the inherent limitations of the dietary assessment method used. The decision to use a close-list FFQ with known bias may have influenced the accuracy of reporting dietary intake in this instance. This study provided an example of the methodological challenges experienced with measuring changes in absolute diet using a FFQ, and reaffirmed the need for novel prospective assessment methods capable of capturing natural variance in usual intakes. Study 2: The development and trial of NuDAM recording protocol The feasibility of the Nutricam mobile phone photo/voice dietary record was evaluated in 10 adults with T2DM (6 Male; age=64.7±3.8 years; BMI=33.9±7.0 kg/m2). Intake was recorded over a 3-day period using both Nutricam and a written estimated food record (EFR). Compared to the EFR, the Nutricam device was found to be acceptable among subjects, however, energy intake was under-recorded using Nutricam (-0.6±0.8 MJ/day; p<0.05). Beverages and snacks were the items most frequently not recorded using Nutricam; however forgotten meals contributed to the greatest difference in energy intake between records. In addition, the quality of dietary data recorded using Nutricam was unacceptable for just under one-third of entries. It was concluded that an additional mechanism was necessary to complement dietary information collected via Nutricam. Modifications to the method were made to allow for clarification of Nutricam entries and probing forgotten foods during a brief phone call to the subject the following morning. The revised recording protocol was evaluated in Study 4. Study 3: The development and trial of the NuDAM analysis protocol Part A explored the effect of the type of portion size estimation aid (PSEA) on the error associated with quantifying four portions of 15 single foods items contained in photographs. Seventeen dietetic students (1 male; age=24.7±9.1 years; BMI=21.1±1.9 kg/m2) estimated all food portions on two occasions: without aids and with aids (food models or reference food photographs). Overall, the use of a PSEA significantly reduced mean (±SD) group error between estimates compared to no aid (-2.5±11.5% vs. 19.0±28.8%; p<0.05). The type of PSEA (i.e. food models vs. reference food photograph) did not have a notable effect on the group estimation error (-6.7±14.9% vs. 1.4±5.9%, respectively; p=0.321). This exploratory study provided evidence that the use of aids in general, rather than the type, was more effective in reducing estimation error. Findings guided the development of the Dietary Estimation and Assessment Tool (DEAT) for use in the analysis of the Nutricam dietary record. Part B evaluated the effect of the DEAT on the error associated with the quantification of two 3-day Nutricam dietary records in a sample of 29 dietetic students (2 males; age=23.3±5.1 years; BMI=20.6±1.9 kg/m2). Subjects were randomised into two groups: Group A and Group B. For Record 1, the use of the DEAT (Group A) resulted in a smaller error compared to estimations made without the tool (Group B) (17.7±15.8%/day vs. 34.0±22.6%/day, p=0.331; respectively). In comparison, all subjects used the DEAT to estimate Record 2, with resultant error similar between Group A and B (21.2±19.2%/day vs. 25.8±13.6%/day; p=0.377 respectively). In general, the moderate estimation error associated with quantifying food items did not translate into clinically significant differences in the nutrient profile of the Nutricam dietary records, only amorphous foods were notably over-estimated in energy content without the use of the DEAT (57kJ/day vs. 274kJ/day; p<0.001). A large proportion (89.6%) of the group found the DEAT helpful when quantifying food items contained in the Nutricam dietary records. The use of the DEAT reduced quantification error, minimising any potential effect on the estimation of energy and macronutrient intake. Study 4: Evaluation of the NuDAM The accuracy and inter-rater reliability of the NuDAM to assess energy and macronutrient intake was evaluated in a sample of 10 adults (6 males; age=61.2±6.9 years; BMI=31.0±4.5 kg/m2). Intake recorded using both the NuDAM and a weighed food record (WFR) was coded by three dietitians and compared with an objective measure of total energy expenditure (TEE) obtained using the doubly labelled water technique. At the group level, energy intake (EI) was under-reported to a similar extent using both methods, with the ratio of EI:TEE was 0.76±0.20 for the NuDAM and 0.76±0.17 for the WFR. At the individual level, four subjects reported implausible levels of energy intake using the WFR method, compared to three using the NuDAM. Overall, moderate to high correlation coefficients (r=0.57-0.85) were found across energy and macronutrients except fat (r=0.24) between the two dietary measures. High agreement was observed between dietitians for estimates of energy and macronutrient derived for both the NuDAM (ICC=0.77-0.99; p<0.001) and WFR (ICC=0.82-0.99; p<0.001). All subjects preferred using the NuDAM over the WFR to record intake and were willing to use the novel method again over longer recording periods. This research program explored two novel approaches which utilised distinct technologies to aid in the nutritional management of adults with T2DM. In particular, this thesis makes a significant contribution to the evidence base surrounding the use of PhRs through the development, trial and evaluation of a novel mobile phone photo/voice dietary record. The NuDAM is an extremely promising advancement in the nutritional management of individuals with diabetes and other chronic conditions. Future applications lie in integrating the NuDAM with other technologies to facilitate practice across the remaining stages of the nutrition care process.

"Things I did not know”: Retrospectives on a Canadian rural male youth suicide using an instrumental photo voice case study

In Canada, it is young rural based men who are at the greatest risk for suicide. While there is no consensus on the reasons for this, evidence points to contextual social factors including isolation, lack of confidential services and pressure to uphold restrictive norms of rural masculinity. In this article we share findings drawn from an instrumental photo voice case study to distil factors contributing to the suicide of a young Canadian rural based man. Integrating photo voice methods and in-depth qualitative we conducted interviews with 7 family members and close friends of the deceased. The interviews and image data were analyzed using constant comparative methods to discern themes related to participants’ reflections on and perceptions about rural male suicide. Three inductively derived themes, “Missing the signs”, “Living up to his public image” and “Down in Rural Canada ” reflect the challenges that survivors and young rural men can experience in attempting to be comply with restrictive dominant ideals of masculinity. We conclude that community based suicide prevention efforts would benefit from gender-sensitive and place specific approaches to advancing men’s mental health by making tangibly available and affirming an array of masculinities to foster the well-being of young rural based men.

Picturing Probation: Exploring the utility of visual methods in comparative research

A previous review of research on the practice of offender supervision identified the predominant use of interview-based methodologies and limited use of other research approaches (Robinson and Svensson, 2013). It also found that most research has tended to be locally focussed (i.e. limited to one jurisdiction) with very few comparative studies. This article reports on the application of a visual method in a small-scale comparative study. Practitioners in five European countries participated and took photographs of the places and spaces where offender supervision occurs. The aims of the study were two-fold: firstly to explore the utility of a visual approach in a comparative context; and secondly to provide an initial visual account of the environment in which offender supervision takes place. In this article we address the first of these aims. We describe the application of the method in some depth before addressing its strengths and weaknesses. We conclude that visual methods provide a useful tool for capturing data about the environments in which offender supervision takes place and potentially provide a basis for more normative explorations about the practices of offender supervision in comparative contexts.

Student researchers in the middle : using visual images to make sense of inclusive education

Using ‘visual narrative’ theoretically and practically, this paper explores issues of inclusive education, during a period of curriculum reform and renewal in Australia. In Australia, the middle years of schooling, Years 5 to 9, are well researched and known as a period when students disengage with learning and participation in schooling. Research in the middle years affirms the importance of engaging with ‘student voice’. In this special edition, we are aiming to highlight how the use of visual imagery can be a rich source of understanding, illustrating students’ self-knowledge of schooling. Methodologically we refer to our research approach as ‘visual narrative’. Other writers in this edition use the term ‘photo voice’. For researchers it is important to highlight the differing orientations that ‘visual narrative’ and ‘photo voice’ signify. The terms are not mutually exclusive but highlight differing research possibilities and emphasis. Our argument, through the use of visual narrative produced by middle years’ students, is that visual texts open out some innovative possibilities for understanding inclusive education and supporting new relationships with our research community. Such approaches are not new; however, in a field such as special education that purports to support marginalised groups, liberatory research methods are under-represented. This paper aims to open out these discussions and provide a way forwards for teachers and researchers interested in breaking apart why it is that inclusive education remains a never-ending struggle.

Through the Lenses of Q’eqchi Maya: (Re)Framing the Story of Development in a Guatemalan Indigenous Community Through Participant-Created Photographs

The question of evaluations of development projects has been widely debated within the field of international development, with scholars and development practitioners calling for increased community-driven evaluations. However, there has been a paucity of research in community-led project evaluations, and a largely absent investigation utilizing visual anthropology/sociology methodologies. This paper seeks to shift this power by giving voice to the intended beneficiaries of an eco-tourism project in a rural indigenous Guatemala village. Through photographs taken by community members and corresponding interviews, this paper shows the way in which community members have and continue to reframe the idea of development in their village. Specifically, my analysis reveals how residents see changing forms of access, how they reframe ideas of beauty and modernization, and how they reframe their relationship to the land through Western conservation and private property ideals. This research thus provides an alternative narrative to the Western NGO’s evaluations and knowledge production, especially in respect to development and indigenous knowledge. By showing how community members are reframing the story of development, this paper demonstrates the usefulness of using participatory documentary photography in community-led evaluations, and helps balance the playing field by providing a much-needed alternative narrative of project evaluation.

Fallen Awake

Photo from process: David Megarrity, albury 2007 - example of convergence of writing/design/perfomance/video RESEARCH COMPONENT Fallen Awake was a practice-led research process that opened the development process to the influence of collaborative authorship across artforms. The project focused on of how multiple artforms and artists converge their vision into a singular text, in the context of collaborative authorship. The work also uncovered new questions relating to the dream-life of children. The stimulus for the work was a selection of verbal statements by three-year-olds, raising complex ethical questions as the project progressed about the child’s voice, mediated by the adult artist, for the eventual presentation to a child audience. With the text emergent and open to influence, this project raised other questions related to the lived experience of children, dreaming, creative play and the development of consciousness. It pushed the creative process to experiment with associative, rather then causal narratives, and to negotiate the challenges this raises for traditional story structures and the development processes that usually shape them. It led to the consideration of each artforms and artist as equal contributors in the development of story: traditionally the province of the sole author. The outcomes appeared in various artforms, none of which was live-performance based. An ‘artist’s book’ by the designer, a ‘video treatment’ - a DVD capturing the approach to the performance and a script for an innovative large-scale performance. Fallen Awake was developed with the assistance of Strut & Fret Production House, Arts Queensland, and HotHouse Theatre, Albury Wodonga, through their ‘Month in the Country’ initiative.

Presentations in English : find your voice as a presenter

With estimates of more than thirty million given each day, presentations have become an integral part of modern society. They can signify the difference between gaining or losing a job, or being successful or unsuccessful at university and a future career. Presentations in English, combining a 128-page book and DVD, is an innovative and complete course aimed specifically at non-native speakers of English.

Open content creation : the issues of voice and the challenges of listening

This paper examines the proposition that increased ability to have a voice and be listened to, through ‘open ICT4D’ and ‘open content creation’ can be an effective mechanism for development. The paper discusses empirical work that strongly indicates that this only happens when voice is appropriately valued in the development process. Having a voice in development processes are less effective when participation is limited. Open ICT allows for more and more voices to be heard, but it is open ICT4D that has the obligation to ensure voices are listened to. In the paper I first explore participatory development and the idea of open ICT4D before elaborating on issues of voice and thinking about voice as process, and voice as value. Research findings are presented from research that experimented with participatory (or open) content creation, discussed in relation to notions of openness and voice. I then consider the challenges of listening, before drawing some conclusions about opening up ICT4D research.

Two voices : the marginalised body as a voice & Imperfect Offerings a novel

This thesis investigates the phenomenon of self-harm as a form of political protest using two different, but complementary, methods of inquiry: a theoretical research project and a novel. Through these two approaches, to the same research problem, I examine how we can re-position the body that self-harms in political protest from weapon to voice; and in doing so find a path towards ethical and equitable dialogue between marginalised and mainstream communities. The theoretical, or academic, portion of the thesis examines self-harm as protest, positing these acts as a form of tactical selfharm, and acknowledge its emergence as a voice for the otherwise silenced in the public sphere. Through the use of phenomenology and feminist theory I examine the body as site for political agency, the circumstances which surround the use of the body for protest, and the reaction to tactical self-harm by the individual and the state. Using Bakhtin’s concept of dialogism, and the dialogic space I propose that by ‘hearing’ the body engaged in tactical selfharm we come closer to entering into an ethical dialogue with the otherwise silenced in our communities (locally, nationally and globally). The novel, Imperfect Offerings, explores these ideas in a fictional world, and allows me to put faces, names and lives to those who are compelled to harm their bodies to be heard. Also using Bakhtin’s framework I encourage a dialogue between the critical and creative parts of the thesis, challenging the traditional paradigm of creative PhD projects as creative work and exegesis.

Rephrasing voice : art, practice-led research and the limits and sites of articulacy

While my PhD is practice-led research, it is my contention that such an inquiry cannot develop as long as it tries to emulate other models of research. I assert that practice-led research needs to account for an epistemological unknown or uncertainty central to the practice of art. By focusing on what I call the artist's 'voice,' I will show how this 'voice' is comprised of a dual motivation—'articulate' representation and 'inarticulate' affect—which do not even necessarily derive from the artist. Through an analysis of art-historical precedents, critical literature (the work of Jean-François Lyotard and Andrew Benjamin, the critical methods of philosophy, phenomenology and psychoanalysis) as well as of my own painting and digital arts practice, I aim to demonstrate how this unknown or uncertain aspect of artistic inquiry can be mapped. It is my contention that practice-led research needs to address and account for this dualistic 'voice' in order to more comprehensively articulate its unique contribution to research culture.

Cascading appearance-based features for visual voice activity detection

The detection of voice activity is a challenging problem, especially when the level of acoustic noise is high. Most current approaches only utilise the audio signal, making them susceptible to acoustic noise. An obvious approach to overcome this is to use the visual modality. The current state-of-the-art visual feature extraction technique is one that uses a cascade of visual features (i.e. 2D-DCT, feature mean normalisation, interstep LDA). In this paper, we investigate the effectiveness of this technique for the task of visual voice activity detection (VAD), and analyse each stage of the cascade and quantify the relative improvement in performance gained by each successive stage. The experiments were conducted on the CUAVE database and our results highlight that the dynamics of the visual modality can be used to good effect to improve visual voice activity detection performance.