title: Nationwide implementation of Hello World: a Dutch email-based health promotion program for pregnant women.
abstract: BACKGROUND
  In November 2006, an email-based health promotion program for pregnant women was implemented nationally in the Netherlands. The program consisted of emails containing quizzes with pregnancy-related questions tailored to the number of weeks of pregnancy. Emails were sent out once every 4 weeks, up to a maximum of nine emails.
  
  
  OBJECTIVE
  The aims of the study were (1) to assess the recruitment of participants and their representativeness of the Dutch population and (2) to study differences in recruitment, program use, and program appreciation among women with different levels of education.
  
  
  METHODS
  Data from 13,946 pregnant women who enrolled during the first year of the program were included. Upon registration, participants were asked how they found out about the program and subsequently received an email questionnaire to assess demographic, lifestyle, and Internet characteristics. Program use was tracked, and participants were classified into five user groups (inactive to very active). Program appreciation (low, intermediate, and high) was assessed twice with an email questionnaire that was sent after the woman had received her third and sixth quiz email. Information about pregnant women and their characteristics was obtained from Dutch registries to assess representativeness of the study population.
  
  
  RESULTS
  About 8% of the pregnant women in the Netherlands enrolled in the program. Immigrants were underrepresented, and women with a low level of education seemed to be slightly underrepresented. Most women knew about the program from a promotional email sent by the organization (32%), followed by the Internet (22%) and midwives (16%). Women with little education were more often inactive users of the program than were highly educated women (15% vs 11%, P < .001), whereas highly educated women were more often very active users compared with women with little education (25% vs 20%, P< .001). However, women with less education were more likely than women with more education to have a high appreciation of the program after receiving three quiz emails (52% vs 44%, P = .001).
  
  
  CONCLUSIONS
  In this real-life setting, pregnant women can be reached through an email-based health promotion program. Selective engagement by education level remains a challenge.
authors.affiliation: National Institute for Public Health and the Environment, 3720 BA Bilthoven, the Netherlands.
authors.forename: Mariska
authors.initials: M
authors.lastname: Bot
authors.forename: Ivon E J
authors.initials: IE
authors.lastname: Milder
authors.forename: Wanda J E
authors.initials: WJ
authors.lastname: Bemelmans
mesh_terms: D000328:Adult; D001290:Attitude; D001835:Body Weight; D004522:Educational Status; D034742:Electronic Mail / Q000706:statistics & numerical data*; D005260:Female; D006293:Health Promotion; D006801:Humans; D008875:Middle Aged; D009426:Netherlands; D018579:Patient Selection; D011247:Pregnancy; D012984:Software; D011795:Surveys and Questionnaires; D055815:Young Adult
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