Food allergies (FAs) are a public health problem [1] with a prevalence of 7.6% in 1-year-olds, 6.7% in 2-year-olds, and 4.9% in 3-year-olds in Japan [2]. FA is defined as “an adverse health effect arising from a specific immune response that occurs reproducibly on exposure to a given food” [3].

FA is a serious and life-threatening disease associated with anxiety, worry, and decreased quality of life for children and their families. The difficulty in avoiding causative foods and the unpredictable nature of FA-induced symptoms are factors affecting children with FA and their families. FA requires daily management and constant monitoring, and the chronic and unpredictable nature of FA may affect the psychosocial functioning and quality of life of the child and family [4].

Oral immunotherapy (OIT) is a promising treatment for FA [5]. Studies have shown that the completion of OIT or reaching its maintenance phase significantly improves the quality of life of both the child and parents [6,7]. However, OIT is a challenging process for patients and parents. Induction can generate stress and anxiety. This, in turn, may affect their motivation and ability to cope with OIT challenges [8]. OIT is administered over an extended period, ranging from several months to several years, and requires daily consumption of food that patients were taught to avoid and fear. Also, patients commonly have oral aversion to the allergenic food, making regular consumption more difficult [9]. Moreover, adverse reactions are often experienced during treatment, ranging from mild symptoms to anaphylaxis [5].

The occurrence of frequent adverse reactions poses a challenge, necessitating close monitoring during treatment. OITcontrol (University of Navarra, Pamplona, Spain) appears to be a valuable tool for monitoring treatment in children with FAs. It is a suitable method for recording daily intake and reactions, promoting adherence to treatment instructions following adverse events, as well as compliance with dose adjustments for home reactions [10].

eHealth monitoring technologies offer opportunities to objectively assess symptoms when they appear in daily life [11]. The convenience and accessibility offered by digital health technologies in health care have the potential to transform the health care landscape by enhancing communication, improving efficiency, and empowering patients [12]. In addition, the use of patient-centered digital health records in nonhospitalized individuals with chronic health conditions is potentially associated with considerable benefits for health care use, treatment adherence, and self-management or self-efficacy [13]. However, limited research has been conducted on the use of electronic diaries (E-diaries) for FA.

Retrospective questionnaires have been used for decades to assess the severity and control of allergic diseases. Smartphone apps have recently facilitated the use of prospective clinical diaries based on daily patient-completed questionnaires [14].

FA diaries record the types and amounts of food and drink consumed, as well as the types and severity of induced symptoms. E-diaries may make it easier for parents to inform doctors of FA-induced symptoms by using the camera function on their smartphones, particularly when maintaining records of cutaneous symptoms. Most food diaries for FA in Japan are paper-based, and no confirmed experience exists with the use of electronic food diaries by parents.

A mobile health (mHealth) app (provided by Mylan EPD), released in Japan in September 2020, aimed to provide accurate medical information on FA and anaphylaxis, as well as to encourage the proper use of an adjuvant anaphylaxis drug (adrenaline self-injection).

This study aimed to assess the experiences of parents of preschool children diagnosed with FA as they transitioned from a paper diary (P-diary) to an E-diary, and to evaluate their perceptions of the technology.

This pilot study used a quasi-experimental one-group pretest-posttest design to evaluate the E-diary technology. To investigate the parents’ views on transitioning from regular P-diaries to E-diaries, the authors used data obtained from semistructured interviews conducted 6 months postusage of E-diaries to evaluate their usefulness compared to that of P-diaries.

Study participants who met the following criteria were recruited: (1) a parent of a preschool child receiving OIT and (2) someone with adequate information technology knowledge to use the app and transition from a P-dairy to an E-dairy using a smartphone. In addition, participants could send a PDF file summarizing the data of the E-diary to the researcher before the outpatient visit.

The E-diary used in this study was designed for recording content, including allergy symptoms, and saving photographs. It was part of the MyEpi mHealth app (provided by Mylan EPD), released in Japan in September 2020, which provides accurate medical information on FA and anaphylaxis and encourages the proper use of adjuvant drugs for anaphylaxis (adrenaline self-injection). Written approval for the use of the MyEpi mHealth app in this study was obtained from Mylan EPD.

The MyEpi mHealth App includes the following 4 features:

These 3 actions are given below:

The investigators were responsible for forwarding the E-diary PDF data, emailed by the study participants, to the doctors.

To evaluate the E-diary after its introduction, the authors used data obtained from semistructured interviews conducted 6 months postusage of the E-diary to evaluate its usefulness compared with that of the P-diary. An interview guide was prepared in accordance with the study objectives. The investigators provided the participants with the content of the interviews. All the interviews were conducted by the lead author, who had received training in conducting regular interviews. During each interview, the interviewer encouraged participants to speak freely about their experiences using the P-diary and E-diary. The interviewer did not assist participants with any information regarding FA. Demographic data on the child’s age, sex, age at onset of FA, and offending food were collected during the interview. The interview also covered participants’ experiences with (1) using the P-diary and (2) using the E-diary. With the participants’ consent, the interviews were recorded with a digital voice recorder.

We used Berelson “Content Analysis” method for data analysis [15]. “Content Analysis” is a method used for the objective, systematic identification of characteristics in text to draw inferences, ultimately enabling quantitative analysis [16]. All recorded data were transcribed verbatim in Japanese. Content related to (1) the experience of using a P-diary and (2) the experience of using an E-diary was coded as a unit. Subcategories and categories were generated based on the semantic similarity of the codes. The study team included 2 pediatric nurses (KY and KM). After the initial coding of each transcript, the investigators discussed the data together and identified a series of main codes, subcategories, and categories. Reliability was assessed during the coding stage, and a calculated concordance rate of ≥90% between the 2 investigators was confirmed. Validity was assured through the supervision of a pediatric nurse who served as a joint investigator.

This study was conducted with the approval of the Research Ethics Committee of the Faculty of Nursing and Social Work, Health Sciences University of Hokkaido (approval number 20N024030) and the Ethics Committee of the General Hospital.

The study participants who met the selection criteria were informed of the objective, importance, and methods of the study orally and in writing. The participants were informed by the investigators that they had the right to participate in the study of their own free will, including their right to withdraw at any time; that their data would be anonymized and confidentiality protected; how their data would be handled and disposed of; and the possibility of publication. Written informed consent was obtained. The study adhered to the COREQ (Consolidated Criteria for Reporting Qualitative Studies) guidelines [17]. Participants received a gift card worth 5000 Japanese yen as a research incentive.

All 5 parents who were contacted by telephone agreed to take part in the study. All were mothers in their 30s (Table 1). After using the mHealth app for 6 months, each participant underwent a single interview lasting between 26 minutes 40 seconds and 60 minutes 30 seconds (M_time=40 min 29 s). These interviews were conducted between September and December 2021. Due to the COVID-19 pandemic, a single investigator specializing in childhood allergies conducted all the interviews via a videoconferencing system. The difficulties with P-diaries and the effects and outcomes of E-diaries were analyzed. The results of the analysis showed 52 codes were extracted, grouped into 19 subcategories and 6 categories. Categories are indicated in italic text, subcategories in italic text, code numbers in {curly brackets}, and percentages in (ordinary parentheses). The parents of preschool children with FA reported: I. difficulties with using a P-diary, II. stress related to information-sharing with doctors, and III. difficulties in making disease management habitual, as problems associated with the P-diary, while IV. ease of using the E-diary as a positive effect of the E-diary, V. more efficient information sharing with doctors, and VI. improved adherence, as favorable outcomes of the E-diary (Figure 2).

Problems associated with the P-diary were categorized into 19 codes, which were grouped into 9 subcategories and 3 categories (Table 2).

Aspects of the effects of the introduction of the E-diary were categorized 11 codes, which were grouped into 4 subcategories and 1 category (Table 3).

Aspects of the outcomes of the E-diary were categorized into 22 codes, which were grouped into 6 subcategories and 2 categories (Table 4).

Parents of preschool children with FA reported the following: I. difficulties with using a P-diary, II. stress related to sharing of information with doctors, and III. difficulties with making disease management habitual as problems with the P-diary; IV. ease of using the E-diary as an effect; V. more efficient sharing of information with doctors; and VI. improved adherence as outcomes of E-diary use.

We explored the experiences of parents of preschool children with FA during the transition from a P-diary to an E-diary.

During the transition, parents reported categories I, II, and III as issues with the P-diary, category IV as an effect of E-diary use, and categories V and VI as outcomes of E-diary use.

This study had some limitations. After using the E-diary for 6 months, 5 parents were asked about their experience transitioning from the P-diary. Since only 5 parents were interviewed at a single medical institution, some of the aspects evaluated may have been underestimated or overestimated. In addition, the allergens of children with FA were milk, wheat, and eggs—the 3 major allergens in Japan—representing a potential selection bias. However, factors such as the number of years from diagnosis to interview, severity of FA, and number of allergens—which may affect how parents use the E-diary—were not considered in the selection of participants.

This study was the first in Japan to confirm the use of an E-diary specifically designed for parents of children diagnosed with FA. The results improve our understanding of the use of E-diaries by parents of preschool children with FA and have important practical implications for patient education.

Future studies should include a larger sample size and a longer follow-up period (eg, 1 year). Notably, all participants in this study were mothers. In Japan, despite the increasing participation of fathers in childcare, mothers typically record information in the E-diary and accompany their children to outpatient appointments. However, future surveys should include both fathers and mothers.

In Japan, few reports exist on the use of E-diaries. In this study, to facilitate sharing the contents of E-diaries between parents and physicians, the researchers received data in PDF format from the parents and then forwarded it to the physicians. The presence of the researcher as an intermediary was a positive factor in the use of the E-diary. The role of the researcher has not been fully evaluated. Further research is needed on the role of intermediaries who support medical treatment using E-diaries.

During the first 6 months after the introduction of the E-diary, the researcher was responsible for converting the data recorded in the E-diary into PDF files and sending them to the physician before the outpatient visit. van der Kamp et al [31] reported that communication, as demonstrated by self-monitoring data, builds trust between parents, children, and health care providers and enhances understanding and self-management of illness. The environment in which parents and physicians could share the contents of the E-diary prior to the visit may have facilitated effective communication. Sezgin et al [29] pointed out that a systematic approach using communication technology is needed to enable parents to share information with their health care providers. Furthermore, it has been reported [32] that when promoting eHealth interventions, it is important to have specific opinion leaders in the hospital who can encourage the adoption of digital care. These pilot study findings are important for the promotion of E-diary–based medical care. To facilitate a systematic approach in the future, it is necessary to secure supporters of E-diary implementation.

The authors found that parents of preschool children with FA were aware of the following problems with P-diaries: I. difficulties with using a P-diary; II. stress related to information-sharing with doctors; and III. difficulties with making disease management habitual. They reported IV. ease of using the E-diary as an effect of its use. They further reported V. more efficient information-sharing with doctors and VI. improved adherence as outcomes of using the E-diary. E-diaries will contribute to solving the problems of P-diaries and may be a useful tool for communication between parents and physicians, as well as for disease management.