Thematic analysis relating to usability and acceptability of using myfood24 as a food record identified the following themes: (1) ease of use, (2) impact on food choices, (3) comparisons with clinic paper records, and (4) future developments. Due to the characteristics of the interview sample, these themes represent only the views of women who had completed myfood24.
(i) Getting Acquainted: Ease of Use
Many of the women had used similar technologies before to record their diet and reported finding myfood24 to be comparable once they had become acquainted with the technology. Most found myfood24 ‘straightforward’ and that inputting data became faster with practice, initially taking approximately 20 min.
‘I found it quite easy… I mean, you just typed in a word and it would bring what you wanted up and then you chose from the list’.
Several features were reported that helped or hindered the ease of use of myfood24. Features of the tool that were most commonly identified as being useful for input were the food photographs to help with portion estimation, and the use of reminder prompts. Some also used the recipe function and favourites list; most reported that they would use these functions on a longer-term basis. The food database received mixed feedback. Some found the food database too restrictive, whereas others found the choice overwhelming. Some reported finding food entry to be burdensome when cooking from raw ingredients, and the process was too time consuming to be feasible.
‘Obviously you don’t weigh your food… it was nice to see actually a portion size’
‘I didn’t have to go back and correct anything really because it reminded me’
‘For something that was quite simple, it would take actually a long time to find it’
‘It was quite time consuming having to kind of search for things and put everything in in its own, you know, like all the different components that made up a meal’.
One reported disadvantage was the need to record all food entries for the 24 h period in one go, rather than being able to add data after each meal, making myfood24 less easy to use than paper diaries. Interviews identified that accessibility was hindered by problematic initial access to the myfood24 website, offering insight into the completion rates observed. As shown in Figure 1
, myfood24 uses a web link accessed from the participant’s email account, with each recall requiring a separate email. Women reported that the process had been confusing and it was difficult to keep track of the multiple emails, all of which were sent on the day of entry to the study and without any indication as to which of the five days they referred to.
(ii) Feedback: Impact on Food Choices and Behaviours
On completion of a food record, myfood24 provides an instant summary of its nutritional composition, including energy, protein, fat, carbohydrate, fibre, salt, and micronutrients. This is compared to a dietary reference value.
All of the interviewees reported finding this feature useful to obtain feedback on their food intake and associated eating behaviours, although a minority questioned the accuracy. Women described how this feedback increased their knowledge of their dietary intake, how it could provide reassurance, and how it could enable women to consider what changes were required. Some women reported that the summaries were a motivating factor, influencing future choices about food types and portion sizes.
‘I did find it frustrating, to be honest, in terms of just trying to find what matched what I was eating, I don’t know how accurate it was for me’
‘a week’s worth of days in front of you it does make you think about what you’re eating and how much’
‘I was like ooh I shouldn’t have eaten that or oh, I’ve had a really good day today.’
Most women focused on the data relating to total carbohydrates and sugars—key to the management of GDM—but some also noted using the summaries to understand their fat and salt consumption. In addition, for some, the summary information highlighted that they had actually been too restrictive with their diet, in response to their diagnosis.
‘Once you can see it in numbers and can see the picture of it, it’s harder just to shrug off and think I’m fine...I couldn’t just go on with it’ (interview 11).
(iii) Comparing Online Self-Monitoring to Clinic Paper Diaries, and the Use of Real-Time Tracking
Comparing myfood24 with paper food diaries that women were required to complete as standard care, some felt myfood24 led to more accurate recording of food intake due to its use of reminders (for example prompting about snacks between meals, and the use of condiments) and recording of quantities, which had not been requested in as much detail in their paper food diaries.
‘I thought that [myfood24] made me remember things. It was more specific. I think it was easy to forget when you’re writing it down. You know because it reminded you—have you remembered to put a drink down here, have you remembered to put a snack down there.’
Women felt that whilst myfood24 was more accurate than paper-based diaries, in its current format it was also less convenient than paper-based diaries, particularly given the need to track blood glucose levels alongside the dietary intake in the paper-based diaries. Hence, although women valued the myfood24 summary information highly, the utility of myfood24 was limited by being produced at the end of a 24 h period and without any connection to blood glucose readings, limiting its use as a self-monitoring tool for improving blood glucose levels.
(iv) Future Developments: Suggestions based on Experience
Several suggestions were made by women, the most common being to improve accessibility via an app so that data could be conveniently logged throughout the day using a smart phone or tablet. Other suggestions for practical aspects relating to usability and improving its acceptability as an electronic food record were a larger food database, an option to scan bar codes, and easier retrieval of favourite foods. Women made several suggestions to adapt myfood24 to develop its accessibility, and also to develop its usefulness in promoting self-management and supporting behaviour change. Of greatest priority for this clinical population was the need to record blood glucose readings alongside dietary information, in order for the information to be meaningful and to develop knowledge of the impact of different types and quantities of food on blood glucose levels.
Some also identified the need for improved visual displays of the summary nutritional information, to support behaviour change. Suggestions included the ability to track information across time and individualised targets for nutritional intake, rather than reference values. Women also emphasised their perceived additional benefit from being able to use the tool in a diary format, rather than solely as a 24 h recall. This related both to aiding recall, but also to the way in which women used feedback to guide future food choices and behaviour.
‘I think a phone app would be a lot easier…you’d just keep updating it as the day went along… it’d make it more helpful like that’
‘I don’t know if there was an option where you could save that information, and maybe it was something that I missed, but I would have found that useful as an ongoing thing, if you could save it…’
‘I thought what might be quite useful would be more like a graph … that shows like you’re here and this is what you really should be getting, aiming for.’