title: Effect of emailed messages on return use of a nutrition education website and subsequent changes in dietary behavior.
abstract: BACKGROUND
  At-risk populations can be reached with Web-based disease prevention and behavior change programs. However, such eHealth applications on the Internet need to generate return usage to be effective. Limited evidence is available on how continued usage can be encouraged.
  
  
  OBJECTIVE
  This analysis tested whether routine email notification about a nutrition education website promoted more use of the website.
  
  
  METHODS
  Adults from six rural counties in Colorado and New Mexico, United States (n = 755) participating in a randomized trial and assigned to the intervention group (n = 380) received, over a period of 4 months, email messages alerting them to updates on the website, along with hyperlinks to new content. Update alerts were sent approximately every 5 weeks (each participant received up to 4 messages). Log-ons to the website were the primary outcome for this analysis.
  
  
  RESULTS
  A total of 23.5% (86/366) of the participants responded to at least one email, and 51.2% (44/86) of these participants responded to half of the email messages by logging on to the website. Significantly more log-ons occurred on email notification days compared to all other days (OR = 3.71, 95% CI = 2.72-5.06). More log-ons also occurred just after the notification but declined each day thereafter (OR = 0.97, 95% CI = 0.96-0.98 one day further from mass email). Non-Hispanics (OR = 0.46, 95% CI = 0.26-0.84), older participants (OR = 1.04, 95% CI = 1.04-1.06), and those using the Internet most recently (OR = 0.62, 95% CI = 0.51-0.77) were more likely to log on. Responders to the messages had a more positive change in fruit and vegetable intake (mean change = +1.69) than nonresponders (+0.05), as measured with a food frequency assessment (adjusted Spearman partial correlation coefficient = 0.14, P = .049). Compared to nonresponders, responders were more likely to be non-Hispanic (P = .01), older (P < .001), and had used the Internet more recently (P < .001).
  
  
  CONCLUSIONS
  Messages sent by email appeared to promote a modest short-lived increase in use of a disease prevention website by some adults. Those who responded to the messages by logging on to the website may have been influenced to improve their diet.
authors.affiliation: University of New Mexico, Albuquerque, NM, USA.
authors.forename: W Gill
authors.initials: WG
authors.lastname: Woodall
authors.forename: David B
authors.initials: DB
authors.lastname: Buller
authors.forename: Laura
authors.initials: L
authors.lastname: Saba
authors.forename: Donald
authors.initials: D
authors.lastname: Zimmerman
authors.forename: Emily
authors.initials: E
authors.lastname: Waters
authors.forename: Joan M
authors.initials: JM
authors.lastname: Hines
authors.forename: Gary R
authors.initials: GR
authors.lastname: Cutter
authors.forename: Randall
authors.initials: R
authors.lastname: Starling
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004032:Diet; D034742:Electronic Mail; D005260:Female; D015438:Health Behavior; D006266:Health Education; D006801:Humans; D020407:Internet; D008297:Male; D008875:Middle Aged; D009747:Nutritional Physiological Phenomena; D015397:Program Evaluation; D017010:Reminder Systems