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Web-based time-use diaries for schoolchildren are limited, and existing studies focus mostly on capturing physical activities and sedentary behaviors but less comprehensively on dietary behaviors.
This study aims to describe the development of My E-Diary for Activities and Lifestyle (MEDAL)—a self-administered, web-based time-use application to assess diet and movement behavior—and to evaluate its usability in schoolchildren in Singapore.
MEDAL was developed through formative research and an iterative user-centric design approach involving small groups of schoolchildren (ranging from n=5 to n=15, aged 7-13 years). To test the usability, children aged 10-11 years were recruited from 2 primary schools in Singapore to complete MEDAL for 2 weekdays and 2 weekend days and complete a 10-item usability questionnaire.
The development process revealed that younger children (aged <9 years) were less able to complete MEDAL independently. Of the 204 participants (118/204, 57.8% boys, and 31/201, 15.4% overweight) in the usability study, 57.8% (118/204) completed 3 to 4 days of recording, whereas the rest recorded for 2 days or less. The median time taken to complete MEDAL was 14.2 minutes per day. The majority of participants agreed that instructions were clear (193/203, 95.1%), that MEDAL was easy to use (173/203, 85.2%), that they liked the application (172/202, 85.1%), and that they preferred recording their activities on the web than on paper (167/202, 82.7%). Among all the factors evaluated, recording for 4 days was the least satisfactory component reported. Compared with boys, girls reported better recall ability and agreed that the time spent on completing 1-day entry was appropriate.
MEDAL appears to be a feasible application to capture diet and movement behaviors in children aged 10-12 years, particularly in the Asian context. Some gender differences in usability performance were observed, but the majority of the participants had a positive experience using MEDAL. The validation of the data collected through the application is in progress.
The prevalence of obesity in children and adolescents has increased in recent decades, and this rising trend has surged in parts of Asia [
However, there is a lack of good quality and timely data on schoolchildren, particularly those aged 10-14 years [
Time-use diaries prompt users to provide an account of a series of activities in a 24-hour day through previous day recalls [
To bridge these gaps, we developed a self-administered, web-based time-use application to assess diet and movement behaviors in schoolchildren: My E-Diary for Activities and Lifestyle (MEDAL). This study aims to describe the development of MEDAL and evaluate its usability among schoolchildren in Singapore.
The development of MEDAL was a multistage, user-centric process (
Flowchart illustrating the development process of My E-Diary for Activities and Lifestyle (MEDAL).
Several data sources were reviewed to identify the elements and requirements for developing a self-administered, web-based application for assessing diet and movement behaviors in schoolchildren. Both electronic and hand-searched strategies were adopted to identify existing software-based diet and physical activity assessment tools for schoolchildren. MyDailyMoves in the Netherlands [
On the basis of the formative research in stage 1, we adopted an iterative stepwise refinement approach to design, develop, and test features of the application [
User-specific accounts are created by research administrators through the backend portal, and users can access MEDAL by logging on with a username and password given to them. Information on the date of birth and sex of the user is collected during the first log-in. MEDAL allows users to have the flexibility to record on any 4 days. Users can select if they are recording for the current day or the day before. The recall period is limited to the day before to minimize the retention interval and increase the likelihood of data validity [
Users are asked about the time they slept the night before and their wake-up time. Following this, users are asked to record their activities sequentially, with the end time of one activity leading to the start of the next, until the end of the day is reached (ie, bedtime). They can choose from 22 activities grouped into 6 broad categories: (1) shower or wash up, (2) eat and drink, (3) traveling, (4) sitting activities, (5) active activities, and (6) nap/sleep. For example, the traveling category included activities such as
When an
When the category
MEDAL requests users to indicate activities that were performed simultaneously (eg, watching TV while having their meals), which may not be achievable in existing assessment tools [
Several game design elements were implemented to motivate children to complete MEDAL. Users can personalize the background interface and select their choice of avatar. The chosen avatar provides instructions and prompts in the form of visual texts and auditory dialogs, which serve to alert the user to action (ie, more reactive) and enhance user immersion in the MEDAL task [
Each completed day of recording rewards users with a gardening tool to nurture their virtual plant. At the end of 4 complete days of recording, a randomly assigned mystery fruit will be revealed to the user. These visual representations of achievements directly communicate the success or completion of the task and serve to evoke feelings of competence and efficiency in children [
On completing 4 days of recording, users will instantly receive a personalized lifestyle report. The report provides information on 4 components of movement behaviors—physical activity duration, outdoor duration, screen viewing duration, and sleeping duration—and evaluates the intake of 5 food groups—fruits, vegetables, whole grains, sugar-sweetened beverages, and dairy and dairy products. The mean durations or servings per day (ie, daily estimates) were calculated based on standardized algorithms and compared with the recommended guidelines [
To test the usability of MEDAL, primary 5–level children (aged 10-11 years) from 2 coeducational government schools in Singapore were invited to participate in the usability study between April and August 2019. Children were eligible if they were able to understand and respond to the assessment in English. Of the 458 invited children from 13 classes (7 classes from school A and 6 classes from school B), 49.8% (228/458) were recruited. The main reasons for nonparticipation were
Practical sessions were conducted for each class in the schools’ computer laboratories by 2 trained researchers who demonstrated how to log in and navigate the MEDAL application. Participants started their first MEDAL entry using school computers and completed the rest of the day’s entry at home. Participants were instructed to record their diet and activities over 2 specified weekdays and 2 weekend days. They were encouraged to complete the day’s entry at the end of the day (ie, before bedtime) or the day after. The schools’ computer laboratories were opened during recess and after school to allow participants with no access to the internet or computer at home to complete MEDAL. School meal photography during the recess period was also conducted, and devices to capture objective data on movement behaviors (ie, accelerometers) and outdoor time (ie, FitSight watch, which measures light intensity [
At the end of the study, participants were instructed to complete a 10-item usability questionnaire based on a 4-point Likert scale (strongly disagree, disagree, agree, and strongly disagree). The questionnaire was adapted from existing usability questionnaires [
Information on participants’ sex and age was collected from MEDAL. The time taken for participants to complete MEDAL each day was calculated as the duration of the first and last entry input (ie, bedtime), summed and averaged over the number of recording days. Height and weight were measured biannually in schools, and the most recent records were obtained. Underweight (<5th percentile), normal weight (5th to 90th percentile), and overweight (>90th percentile) were classified according to the age- and sex-specific BMI reference of the local population [
Participants’ characteristics were summarized according to sex, and comparisons were assessed by the Fisher exact test (categorical) and Wilcoxon Mann-Whitney test (continuous). Differences in usability attributes between sexes were examined using the Fisher exact test. The usability questionnaire responses
Of the 228 participants, 204 logged on to MEDAL and completed the usability questionnaire and were included in the analysis (
Flowchart of participants. MEDAL: My E-Diary for Activities and Lifestyle.
Characteristics of participants summarized by sex (N=204).
Characteristics of participants | All (N=204) | Girls (n=86) | Boys (n=118) | ||||||
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.07 | ||||||||
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School A | 141 (69.1) | 53 (61.6) | 88 (74.6) |
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School B | 63 (30.9) | 33 (38.4) | 30 (25.4) |
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Age (years), median (25th-75th percentile) | 10.9 (10.6-11.2) | 11.0 (10.8-11.2) | 10.9 (10.6-11.1) | .03 | |||||
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.41 | ||||||||
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Underweight | 25 (12.4) | 12 (14) | 13 (11.3) |
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Normal weight | 145 (72.1) | 64 (74.4) | 81 (70.4) |
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Overweight | 31 (15.4) | 10 (11.6) | 21 (18.3) |
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.99 | ||||||||
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Yes | 170 (89.5) | 73 (90.1) | 97 (89) |
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No | 20 (10.5) | 8 (9.9) | 12 (11) |
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.01 | ||||||||
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<1 day | 45 (22.1) | 12 (14) | 33 (28) |
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1-2 days | 41 (20.1) | 13 (15.1) | 28 (23.7) |
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3-4 days | 118 (57.8) | 61 (70.9) | 57 (48.3) |
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Average time taken to complete in minutes per day, median (25th-75th percentile) | 14.2 (10.4-19.0) | 15.0 (11.1-20.3) | 13.1 (10.1-17.6) | .03 |
a
When assessing the usability of MEDAL, the majority (193/203, 95.1%) of participants agreed that instructions were clear, that MEDAL was easy to use (173/203, 85.2%), that they (172/202, 85.1%) liked the application, and that they preferred recording their activities on the web than on paper (167/202, 82.7%;
My E-Diary for Activities and Lifestyle (MEDAL) usability responses according to boys and girls.
Survey questions | Agree, n (%)a | ||||
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All (n=204) | Girls (n=86) | Boys (n=118) |
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1. I understood the instructions for MEDALc clearly | 193 (95.1) | 83 (96.5) | 110 (94) | .52 | |
2. It was easy to use and I do not require further instructions | 173 (85.2) | 76 (89.4) | 97 (82.2) | .17 | |
3. Earning tools to grow my plant makes me want to continue the game | 159 (78.7) | 75 (88.2) | 84 (71.8) | .005 | |
4. I was able to remember all the activities I did | 154 (75.9) | 70 (82.3) | 84 (71.2) | .07 | |
5. I was able to remember all the food and drinks I had | 165 (81.2) | 75 (87.2) | 90 (76.9) | .07 | |
6. The time I took to complete one day’s entry was just right | 149 (75.6) | 71 (83.5) | 78 (69.6) | .03 | |
7. Recording for 4 days was just right | 146 (71.9) | 66 (77.7) | 80 (67.8) | .15 | |
8. I prefer recording my activities online than using paper | 167 (82.7) | 73 (85.9) | 94 (80.3) | .35 | |
9. I would play the game again | 162 (79.8) | 73 (85.9) | 89 (75.4) | .08 | |
10. Overall, I liked the game | 172 (85.1) | 76 (89.4) | 96 (82.1) | .17 |
aValues shown are the sums of “Strongly agree” and “Agree.”
b
cMEDAL: My E-Diary for Activities and Lifestyle.
Compared with boys, girls were more motivated by the gamification to complete recording on MEDAL (75/85, 88.2% vs 84/117, 71.8%;
A total of 23 participants provided open-ended suggestions. Participants (n=8) who recorded MEDAL for ≤2 days preferred recording on paper rather than on the web (
Prefer recording on paper rather than on the web
“We could use paper to do rather than online” [Girl]
“I do not want the activity online but in paper” [Boy]
“To use paper than online is easy. I don’t know” [Boy]
Insufficient time to complete MEDAL
“This program is very interesting but a bit troublesome as I don’t have much time to finish the online diary” [Girl]
Include more options
“More options. Like more activities.” [Boy]
“Study in school” [Boy]
Include more options
“Include more options for us to choose” [Girl]
“Have more food options” [Boy]
“Sometimes we just do nothing, so please add a button saying ‘nothing’” [Boy]
Ability to edit timing of activity
“Delete stuff [cause (sic) I accidentally write what time I sleep wrongly but could not change]” [Girl]
“During the game, when putting in the timing slots, when I put some numbers in wrong it is impossible to change” [Girl]
“For example, if you forgot what you did but you suddenly remembered you can change what you wrote” [Girl]
Allow recording on MEDAL for more than 4 days
“I would ask them if they wanted to do more” [Boy]
“Make the days longer” [Boy]
“The ability to do the entries for the days even further behind” [Boy]
Modifying the game design
“Put more characters!” [Girl]
“I would change the reward given.” [Girl]
“...to do more and they could get another plant” [Boy]
“More games” [Boy]
Allow recording of sleep past midnight
“Make time for 12 am when I sleep” [Boy]
In this study, we described the development and evaluated the usability of MEDAL—a 4-day web-based time-use application to assess diet and movement behavior in schoolchildren in Singapore. Approximately 60% (118/204) of the participants completed more than 3 days of recording, whereas the rest recorded for 2 days or less. The majority of the participants reported having a positive experience using MEDAL. Compared with boys, girls were reported to be more motivated by gamification, had better reported recall ability, and agreed that the time spent on completing 1-day entry was appropriate.
During the development process of MEDAL, we observed that the completion rate of MEDAL was significantly lower in younger children (aged 8-9 years) than in older children (aged 11-12 years). Younger children aged <9 years may need more assistance to complete MEDAL independently; thus, MEDAL is more suitable for children aged ≥10 years.
Response rates for multiday diaries have generally been an issue among children [
We observed that participants who recorded for <2 days were less likely to have access to a computer and the internet at home (
Existing studies have shown that recall ability is a common difficulty reported by children [
Studies have shown that boys have lower attentional performance and poorer inhibitory control but perform faster than girls [
With regard to gamification, existing studies did not include this element [
MEDAL is a novel and engaging application for schoolchildren aged ≥10 years. It includes a range of Asian food options that cater to the key ethnic groups in Asia and captures data on food portions, which allow us to have a detailed assessment of energy and nutrient intakes. This is useful, as evidence suggests that portion sizes among children are increasingly poorly regulated [
However, there are some limitations to this study. First, we did not have information on children’s academic ability. However, our usability questionnaire showed that 95.1% (193/203) of the participants understood the instructions on MEDAL, which was not unexpected, considering that English is the main language of instruction in Singapore and primary education is compulsory. However, we recognize that the cognitive abilities to recall events, capability to concentrate, and comprehension of questions may have an impact on usability testing [
In conclusion, we developed MEDAL, which appears to be a feasible web-based time-use application for children aged 10-12 years and potentially useful for children above this age group. We observed some gender differences in usability performance, but the majority of the participants had a positive experience using MEDAL. The validity and reliability of MEDAL will be examined next, and the results of this study will be used to inform the next version of MEDAL to customize MEDAL for children in other parts of Asia, which includes translation to their native language and adaptation of application content to their local context.
Development process of My E-Diary for Activities and Lifestyle (MEDAL).
Functionality of My E-Diary for Activities and Lifestyle (MEDAL).
Food items under the eat and drink category.
My E-Diary for Activities and Lifestyle
The authors would like to thank the principals, teachers, and children from both primary schools for their participation and contribution to this study. The authors would also like to thank the Ministry of Education, Singapore, for their help in the recruitment of schools for this study. This study was supported by the National University Health System Summit Research Program Partnerships-Office of Deputy President Research and Technology; Saw Swee Hock School of Public Health; and Yong Loo Lin School of Medicine, National University of Singapore. Additional funding was provided by the corresponding authors’ National University of Singapore start-up grant. The funders had no role in the design of the study; collection, analysis, and interpretation of data; or writing the manuscript.
MFFC, FMR, SMS, and LPS conceived and designed the study. ARC and SYXT designed and developed MEDAL with inputs from PN, FMR (content related to movement behaviors), CL, SMS (content related to location), MJC, MTC, JYT, and MFFC (content related to diet). SYXT, MNJSC, and ARC collected the data with assistance from MJC, MTC, and JYT. MNJSC and ARC performed statistical analyses. ARC drafted the manuscript with inputs from MFFC, FMR, SMS, SYXT, JYT, PN, and CL. All authors read and approved the final manuscript.
None declared.