Effect of ‘Healthy Eating with Food Record’ Web-based App on Maternal Eating Behaviour, Clinical Indicators and Pregnancy Outcome in Indonesia
: A Mixed Methods Study

  • Mira Trisyani Koeryaman

Student thesis: Doctoral Thesis


Background: Healthy diets in pregnancy are associated with beneficial effects for mothers and offspring, where they play an essential role in reducing the prevalence of maternal mortality rate (MMR). Effective nutrition monitoring is challenging. A mobile application technology that allows self-monitoring of dietary intake could improve healthy eating. Therefore, examining the effect of a web-based app as a logical alternative to enhance diet quality and positive pregnancy outcomes for Indonesian women is essential.
Objectives: The study aimed to examine the effects of 'healthy eating with food record' self- monitoring web-based app on maternal eating behaviour, clinical indicators and pregnancy outcomes among pregnant women in Bandung, West Java, Indonesia, and to explore the pregnant women's perspectives for their experiences in using the app to support dietary intake.
Design, Setting, and Participants: The thesis was based on mixed-method research designs sequentially used quantitative and qualitative studies. A randomised controlled trial (RCT) approach was conducted as an initial phase to compare the intervention and control groups to assess the MEB, clinical indicators, and pregnancy outcome. This RCT was conducted at multiple public health centres (PHC) in Bandung, Indonesia, and included 109 pregnant women who had been registered as PHC patients aged 19–30 years old, with first and singleton pregnancies at 22–26 weeks, and who had been educated at least at the primary level and had smartphone access. Participants were recruited between November 3rd, 2019, and mid-January 2020 and were randomly assigned (1:1; stratified by age and education level) to intervention (56 participants) or control (53 participants) groups and then, followed by four focus group discussions with 26 participants from the intervention group.
In four focus groups, participants answered six open-ended questions based on the qualitative analysis conducted by deductive and inductive thematic approaches to explore user experiences based on the Technology Acceptance Model (TAM) theory to capture their experience using the apps. Statistical analysis included descriptive statistics, a chi-square test, and an independent t-test. For non-normally distributed outcomes, the nonparametric Mann-Whitney test was used simultaneously.
Interventions: The participants received a face-to-face visit and standardised prenatal care and diet advice from healthcare professionals. The intervention group used a web-based app for 12 weeks to follow food choices and input their dietary intake on the dietary record that had synchronised total calorie estimation. At the same time, the control group received the usual care and a paper- based method only.
Primary Outcomes and Measures: The Adult Eating Behaviour Questionnaires (AEBQ) were used to assess appetitive traits behaviour, including food approach subscales (food responsiveness, emotional overeating, and enjoyment of food) and food avoidance subscales (satiety responsiveness, emotional undereating, food fussiness, and slowness in eating). Dietary diversity scores were measured using the Minimum Dietary Diversity for Women of Reproductive Age (MDD-W). Using dietary records to derive information on energy intake, the researcher used the Indonesian Recommend Dietary Allowance (RDA) to reference diet quality. Meanwhile, clinical equipment such as weight scales, a mercury sphygmomanometer, an electronic blood glucose metre, and the oxyhemoglobin method was used to measure the secondary outcomes.
Results: The primary objective (maternal eating behaviour) showed no differences between groups regarding sub-scales of appetitive traits behaviours. However, it was found that the intervention group showed significantly higher scores for those food approach traits and lower scores for the food avoidance traits, as seen in the follow-up mean scores. From all the appetite trait scores, only the Hunger (H) sub-scale showed a significantly higher score in the intervention group than the control group with a medium effect size (3.42±0.50 and 3.15±0.47; p=0.005; d=0.55). Furthermore, there were significant differences between the intervention and control groups in the minimum dietary diversity for reproductive women age (MDD-W) score (p=0.005). The mean MDD-W for the sample of both groups was 7.79 ± 1.20 and 7.02 ± 1.39, respectively. The percentage of pregnant women consuming the MDD-W's ten food groups was significantly more significant in the intervention versus the control group (adjusted mean difference: 0.77 [95% CI: 0.28 to 1.25]; d= 0.28). A small effect size was found. In daily macronutrients, there was a significant difference between the groups, noted for energy intake (156.88 kcal [95% CI:114.52 to 199.23]; d=-1.39 p=0.002), carbohydrate (102.43 g [95% CI: -125.2 to -79.60]; d=-1.68 p=0.017), protein (14.33 g
[95% CI:11.40 to 17.25]; d=1.86 p=0.000), fat (10.96 g [95% CI:-13.71 to -8.20]; d=-1.49 p=0.000),
and water 286.93 ml (95% CI:118.26 to 455.60; d=0.63 p=0.002). Also, there was a significantly higher intake of daily vitamins and minerals in the intervention group than in the control group, as noted for Fe (6.94 mg [95% CI: 4.96 to 8.91]; d=1.31 p=0.000), Zinc (1.97 mg [95% CI:1.34 to 2.59]; d=1.1; p=0.00), and vitamin C (22.47 mg [95% CI: 3.43 to 41.50]; d=1.38 p=0.029). A large
effect size was found.
In addition, the two groups had no significant difference in secondary objectives such as maternal weight gain, blood glucose, and blood pressure (p>0.005). However, the intervention group showed higher haemoglobin levels than the control group (adjusted difference = 0.36 [95% CI:0.03 to 0.68], p=0.023, d=0.41); also reported the safety amount in neonatal birth weight (adjusted difference = 185.79 g [95% CI:84.07 to 287.50]; p=0.000; d=0.68).
In the qualitative results, the app user group stated they had positive experiences regarding perceived usefulness, ease of use and actual use. Results identified the eight sub-themes revealed by users and things hindering their use, including the app's information, personal management, performance, responsiveness, personal failure, limitation, frequency of use, and type of mobile device used.
Conclusion: The 'healthy eating with food record' self-monitoring web-based app positively impacted some aspects of maternal eating behaviour and pregnancy outcomes among pregnant women in Bandung, Indonesia.
Date of Award27 Mar 2023
Original languageEnglish
SupervisorSasee Pallikadavath (Supervisor), Isobel Helen Ryder (Supervisor) & Ngianga Ii Kandala (Supervisor)

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