Health Education Research Advance Access originally published online on September 30, 2005
Health Education Research 2006 21(2):206-218; doi:10.1093/her/cyh057
Process evaluation of an innovative healthy eating website promoting the Mediterranean diet
Human Nutrition Section, Division of Developmental Medicine, Faculty of Medicine, University of Glasgow, Glasgow Royal Infirmary, Glasgow G31 2ER, UK
*Correspondence to: J. A. Scott. E-mail: j.a.scott{at}clinmed.gla.ac.uk
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Abstract |
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The Internet offers a promising medium for delivering nutrition education. This study aimed to evaluate user perceptions and usage patterns of an innovative healthy eating website promoting the Mediterranean diet. The website was evaluated over a 6-month period by female employees of University of Glasgow, aged 25–55 years. User satisfaction with the website was evaluated using a triangulation approach, including website visit counts, questionnaires (31 participants) and focus group interviews (18 participants). Although login frequency decreased over the 6-month study, questionnaires revealed that most sections of the website were viewed as being very helpful and the majority of participants perceived the overall website to be extremely interesting, informative, novel, trustworthy, easy to understand, useful, user-friendly, attractive and encouraging. The recipes section was the most visited and lack of time was the main barrier to using the website on a weekly basis, as recommended. The results of the questionnaires were confirmed by measures of website usage and the feedback provided by the focus group interviews. Several features that would improve the website, such as increased interactivity, nutritional analysis and fruit and vegetable serving content of recipes and more regular updates, were identified from the interviews and will inform future refinements of the website.
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Introduction |
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The Internet is now widely accessible to the general public and is a primary source of health information [1–3]. The National Statistics Survey revealed that in the first quarter of 2004, 49% of households in the United Kingdom (12.1 million) could access the Internet from home, with just over a quarter of adults in Great Britain (26%) accessing the Internet everyday or almost everyday and 56% of adults having used the Internet at least once in the 3 months prior to the survey [4]. Between February 2002 and February 2004, Scotland, in particular, displayed the highest increase in Internet access in the United Kingdom (16%) [5]. These statistics provide evidence of the increasing opportunities provided by the Internet to reach large numbers of people in a cost-effective manner.
The World Wide Web offers numerous resources providing healthy eating advice, recipes and interactive tools for dietary assessment. In a recent study investigating preferences for sources of nutrition information, Dutch adults ranked the Internet highly for its accessibility and clarity of information. However, it was rated less favourably in terms of reliability and expertise [6]. This is not surprising, as the vast majority of nutrition information on the Internet is posted by individuals or groups with vested interests and/or dubious expertise. Therefore, while the Internet appears to offer a promising medium for delivering nutrition education, the need to provide credible information via this channel must be addressed [7].
To date, several web-based applications have been designed, which provide nutrition education and aim to promote dietary behaviour and/or influence psychosocial determinants of dietary behaviour change [8–15]. Development of these web-based applications has been informed by a number of well-established health behaviour theories including the Health Belief Model [16], the Social Cognitive Theory [17] and the Theory of Planned Behaviour [18]. While several of these interventions have assessed user perceptions of their website or application [8, 10, 12, 15], relatively few have validated their findings against measures of actual programme usage [13, 15].
The authors have developed and conducted a preliminary evaluation of a healthy eating website, which promotes the traditional Mediterranean diet, in order to assess user perceptions and usage patterns. This work contributes to previous research assessing consumers' information needs regarding nutrition and is the first to our knowledge to evaluate users' attitudes towards a specific nutrition website in a real-life setting using a triangulation approach, including website visit counts, questionnaires and feedback from focus group interviews.
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Methods |
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Participants
Female employees of the University of Glasgow were recruited into the Internet arm of a 6-month controlled study investigating the effect on dietary behaviour of an Internet-based, tailored nutrition intervention, promoting key aspects of the traditional Mediterranean diet. Eligibility criteria included females aged 25–55 years, with Internet and email access at work and who were born or had lived in Scotland for >15 years. Participants were ineligible if they had a self-reported history of cardiovascular disease, cancer, diabetes or hypertension. We did not include participants with diet-related health problems as it was thought that pre-existing treatments and medications might obscure the impact evaluation of the intervention. Recruitment strategies included advertisements in newsletters, flyers, postings on the University intranet and email advertisements. A description of the intervention methodology and results of the impact evaluation have been published in detail elsewhere [19]. The study was conducted from May 2003 to December 2004 and was approved by the Ethics Committee of the University of Glasgow.
Development of the Mediterranean Eating website
A Mediterranean Eating website was developed and was available to participants in the Internet arm of the trial via the web page of the Department of Human Nutrition during the 6-month study. The concept behind the Mediterranean Eating website was that Scottish people regularly holiday in Mediterranean countries and are familiar with, and allegedly enjoy, the Mediterranean cuisine. Therefore, the website incorporated pictures of Mediterranean settings featuring sunny scenery, as well as many pictures of colourful, Mediterranean cuisine dishes. The focus on colours aimed to refresh memories of Mediterranean holidays and create a relaxed mood that could attract participants to incorporating the Mediterranean diet into their everyday lives in Scotland.
The content of the website was written in non-technical terms and in a friendly and encouraging tone. Although scientific evidence on the benefits of the Mediterranean diet and nutrition information (e.g. food labels, nutrients) was provided, effort was made to deliver this using easily understood terminology. Despite the provision of scientific information, the website mainly focused on practical tips for dietary change. In this respect, the website provided healthy eating, shopping and cooking tips, adjusted to reflect and promote the Mediterranean diet. The ‘Recipes’ section was a major feature of the website and 20 new recipes were added every 2 weeks, in order to introduce participants to a Mediterranean way of eating. The recipes incorporated were inspired mainly by Greek and Mediterranean dishes. However, recipes for popular Scottish dishes, prepared in a Mediterranean style (e.g. with more and a greater variety of vegetables), were also included.
The format and layout of the website were simple and easy to use. There were 11 main sections presented as navigation links, leading to a total of 682 online pages that were developed and introduced during the course of the study (including pages that were updated over the 6-month trial). For ease of navigation, pages were linked to each other, where appropriate, and the size of each page was relatively small, in order to avoid having to scroll to access information. For this purpose, links to some pages also opened in a new window. The website sections and their contents are described in Table I.
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Several theoretical models informed the development of the Mediterranean Eating website. For instance, the Health Belief Model [16] guided behavioural strategies for addressing several barriers towards healthy eating. In addition, many of the behavioural strategies to increase self-efficacy skills regarding healthy eating can be inferred from the Social Cognitive Theory [17], while advice was also provided in order to improve attitudes and social influences, as well as increase perceived behavioural control, in keeping with the concepts of the Theory of Planned Behaviour [18].
The website addressed a number of the barriers to healthy eating identified in a Food Standards Agency Scotland [20] report. In order to overcome the barrier of cost, the website included a ‘Fruit and Vegetable of the Month’ section, providing information on low-cost, seasonal produce. Cost-effective food shopping and preparation tips and low-cost recipes, focusing on the use of seasonal produce were also provided. To tackle the perception that preparing healthy foods is time consuming, the website provided simple, quick-to-prepare recipes. In addition, timesaving eating tips were provided on how to adjust everyday diet to the Mediterranean diet (e.g. frozen vegetables, portable fruit, canned legumes and advice when eating out).
To overcome the perception that healthy foods are boring and tasteless, the website encouraged participants to experiment with different flavours. Information was provided on the use of different herbs/spices, as well as on ways to add variety to meals (e.g. use vegetables of different colours in food, add legumes and different vegetables in soups). The Fruit and Vegetable of the Month section also included advice on how to prepare different seasonal products that participants might not have been familiar with. Lack of cooking skills was addressed by providing easy-to-prepare recipes, requiring relatively few, easy-to-obtain ingredients. For participants with minimal cooking skills, the ‘Better Eating Tips’ section also provided advice on ways to eat more Mediterranean in everyday life (fruit as a snack, ready-made salad and frozen/canned vegetables and vegetable/legume-based dishes when eating out).
Participants were sent a letter with detailed website login instructions and were encouraged to contact the researcher (A.P.) if they encountered difficulties with the login procedure. A personal login identification password was assigned to each participant in order to monitor their entry into the website and to provide a measure of website login frequency and use. For this purpose, participants were specifically asked not to share their password or bookmark any pages of the website and to always enter the website through the login page. In order to personalize the procedure, passwords were recognized by the Web Server and participants were greeted with their first name and a welcome message once they entered the website's home page. Participants were emailed weekly and encouraged to visit the website and the updated sections.
Measurements
During the 6-month trial, overall website login frequency for the 53 participants originally recruited in the Internet arm of the study and usage patterns (total visit counts for each website section) were measured via statistical summaries generated from the University of Glasgow Web Server.
At the end of the 6-month trial, participants were asked to complete a self-administered website evaluation questionnaire. This was used to rate the helpfulness of the overall website and its specific sections, as well as the overall satisfaction with the website. Participants were also asked whether they had used any of the recipes presented on the website and, if applicable, to rate the ease of preparing recipes and whether they perceived ingredients to be easy to find or expensive. These variables were measured on a three-point scale (‘very’, ‘moderately’ and ‘not at all’) [21]. In addition, participants were asked to rate the frequency of use of the overall website and its sections (‘a few times the first few weeks’, ‘once a month’, ‘once a fortnight’ and ‘more than once a fortnight’). They were also asked whether they perceived the website to be interesting, informative, trustworthy, easy to understand, useful, attractive, encouraging, timesaving and limited (three-point scale, ‘extremely’, ‘somewhat’ and ‘not at all’). A question about perceived barriers to using the website was also included.
Following the return of the post-test process evaluation questionnaires, participants who completed the 6-month trial and those who withdrew before the end of the intervention were invited to attend semi-structured focus group interviews in order to provide additional feedback on appreciation, perceptions and attitudes towards the website. An interview guide/schedule was developed, outlining questions about previous interest in obtaining nutrition information and previous sources accessed for information, as well as determinants of information credibility. Participants were asked their opinion about how the website compared with other nutrition information sources and to identify and comment on website features that they liked and did not like and whether they expected the website to contain features that were lacking or if there were any existing features that they would prefer changed. Barriers to using the website, effects of the information provided on everyday food choices and which website sections were perceived as most/least interesting were also discussed.
The sequence and wording of the questions were modified, when appropriate, in order to explore emerging issues in more detail and allow participants to provide additional information. Interviews were audiotaped with the permission of participants and audiotapes from each focus group were transcribed verbatim. The focus group interviews were carried out anonymously and participants could not have been identified from the audiotapes.
Four interviews lasting 
1 hour were conducted during participants' lunch-time. A light lunch was provided to facilitate and encourage attendance at the interviews.
Data analysis
The questionnaires were analysed using the Statistical Package for the Social Sciences (SPSS for Windows, release 11.5, 2002, SPSS, Chicago, IL, USA) and descriptive statistics were used to report attitudes towards the website and website usage patterns. Transcripts from the focus group interviews were read in order to identify emerging themes, based on the interview guide, and were hand coded using appropriate keywords. All transcripts were then analysed, in order to examine similarities and differences within and between the focus groups, according to each theme, and to create a summary of the key findings. Findings from the focus group interviews are reported descriptively and issues that emerged are illustrated by quotations from participants.
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Results |
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Website login frequency and usage patterns
Participants visited the website an average of 15.5 times over the 6-month trial. On average, there were 150 hits to the website each month, with Recipes and ‘Food Safety’ being the most- and least-visited sections, respectively (Table II). For both the overall website and its different sections, the number of visits decreased over the course of the study (data not shown).
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Mediterranean Eating website evaluation questionnaire
Post-test evaluation questionnaires were completed by 31 participants (58.5% of those who started the study; 73.8% of those who completed the 6-month trial). All participants were Caucasian (mean age, 40.6 years) and the majority [22 (70.9%)] had a university or higher degree.
The overall website was viewed as being ‘very helpful’ [18 (58.1%)] or ‘moderately helpful’ [13 (41.9%)]. The majority of participants found most of the individual sections of the website to be very helpful (Fig. 1). The least-helpful section was the Food Safety section, which the majority of participants found to be only moderately helpful [19 (61.3%)] and a substantial proportion found to be ‘not helpful at all’ [6 (19.4%)].
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The majority of participants [25 (80.6%)] reported trying recipes presented on the website while 51.6% (n = 16) tried some recipes more than once, suggesting that they incorporated them into their menu repertoire. The recipes were generally perceived as ‘very easy’ [17 (54.8%)] or ‘moderately easy’ [8 (25.8%)] to prepare and the ingredients generally ‘very easy to find’ [19 (61.3%)]; 25.8% (n = 8) reported that ingredients were ‘moderately expensive’.
Most participants [27 (87.1%)] reported visiting the website once per month or more. The most popular sections appeared to be the Recipes and the Better Eating Tips, with 90.3% (n = 28) and 54.8% (n = 17), respectively, reporting visiting these pages once per month or more. The majority of participants visited the remaining sections only a few times during the first weeks after the website was launched. These were also the sections that were not updated with new information during the 6-month study. The self-reported usage patterns were confirmed by the monitoring summaries generated from the University of Glasgow Web Server (Table II). Sections of the website that were perceived as very helpful by the majority of participants were also visited more frequently.
The majority of participants reported that the website was extremely ‘interesting’ [24 (77.4%)], ‘informative’ [24 (77.4%)], ‘easy to understand’ [24 (77.4%)], ‘trustworthy’ [23 (74.2%)], ‘useful’ [21 (67.7%)], ‘attractive’ [21 (67.7%)] and ‘encouraging’ [20 (64.5%)]; 48.4% (n = 15) thought the website was ‘somewhat timesaving’, while 22.6% (n = 7) regarded the website as ‘not timesaving at all’. In addition, 48.4% (n = 15) disagreed with the statement ‘the website was limited’, whereas 45.2% (n = 14) reported that the website was ‘somewhat limited’ and 6.5% (n = 2) found it ‘limited’.
For the majority of participants [27 (87.1%)], ‘lack of time’ was the primary barrier to using the website weekly, as recommended. Of the respondents, 22.6% (n = 7) and 25.8% (n = 8), respectively, regarded ‘not enough new information/updates’ and ‘technical problems’ as being barriers to using the website. Only 3.2% (n = 1) noted the barriers ‘lack of interest in changing my diet’, ‘lack of interest in using the Internet’, ‘lack of Internet access at home’ and ‘not enough information to help me change my diet’.
Focus group interviews
Eighteen women participated in the focus group interviews (mean age, 39.6 years). None of the participants who withdrew before the end of the 6-month trial accepted the invitation to attend an interview.
Most participants had not actively sought nutrition information prior to the study. However, some mentioned that they had done so if they had a specific problem or when their children were young, in which case they would seek information on healthy eating or recipes from books and magazines. Some participants had used the Internet to find nutrition information, mainly for recipes, online diets and healthy eating advice. The most often mentioned criteria to assess information credibility were websites from official authorities and provision of scientific evidence to support information.
When asked to compare the information on the Mediterranean Eating website with other sources of nutrition information, most participants mentioned that it was clearly set-up, well-organized, reliable, attractive and easy to use. A summary of the major themes that emerged from the interviews, concerning the evaluation of the website, is presented in Table III.
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Features of the Mediterranean Eating website considered particularly helpful were the relatively regular, highlighted updates; easiness of finding specific information (layout and navigation); friendly and trustworthy writing; bright and happy appearance, theoretical background information; novelty and easiness of recipes and inclusion of self-test knowledge quizzes. The most often mentioned barriers to using the website were lack of time during working hours, inability to access the Internet at home and occasional lack of Internet access or technical problems at work. In particular, some participants mentioned they did not want their colleagues to see them visit a website during working hours.
Some participants thought that the information provided was not enough for people who have minimal cooking skills, while those with young children mentioned having difficulties incorporating recipes in their everyday lives. For others, however, family encouragement made incorporating new foods easier. In addition, although keeping to healthy eating when eating out was difficult for some participants, most found that the information on the website encouraged them to try to make healthier choices.
Website sections that were regularly updated were generally perceived as being the most interesting, whereas sections that contained mainly theoretical information were more likely to be considered less interesting. Although the website bulletin board was thought to be an interesting idea, most participants recommended that easier access to it would have increased its use.
Several themes emerged concerning features that would improve the website. Some participants mentioned that more prompting to visit the website would have been desirable. Some participants also would have preferred some of the information on food choices to appear permanently on the website instead of as updates or for the updates to be more regular. In addition, discussions highlighted how additional features could enhance the usefulness of such a website. In particular, participants would have liked the website to include links to other trustworthy websites for more extensive information and recipes, as well as more links between the different sections, which would prompt visits to other sections of the site. Most participants also mentioned that a seasonal ingredient/recipe search index and inclusion of nutritional information and fruit and vegetable serving content of recipes, as well as a site map, would be helpful. In addition, suggestions for people who are dieting, more information and tips on physical activity/weight control and weekly tips before weekend shopping and suggestions of weekly meal planners would be additional useful features. More interactive features such as dietary assessment quizzes that would provide support during the study and raise awareness of dietary intake would be particularly welcomed, as would tips on places to find healthier food choices and more background information on Mediterranean traditions and foods eaten on special occasions.
A number of participants recommended that this Internet intervention should form part of a health promotion programme in the University of Glasgow, in association with food suppliers and canteens, where all employees would be prompted to visit the website on a weekly basis and encouraged to make healthier food choices.
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Discussion |
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The website overall and most of its sections were generally found to be very helpful and there was general agreement between reports of frequency of use and perceived helpfulness. Sections providing practical advice were most regularly visited and perceived to be the most helpful by the majority of participants. This finding indicates the need to include practical advice, based on established theories of behaviour change, when promoting dietary behaviour change (i.e. how to eat more healthy on different occasions) instead of only providing information on the benefits of healthy eating. The use of the Health Belief Model, Social Cognitive Theory and Theory of Planned Behaviour in developing the website provided useful frameworks to address determinants of dietary behaviour, such as barriers, self-efficacy skills, attitudes and social influences. Although we tried to provide simple, timesaving recipes and included popular Scottish dishes prepared in a Mediterranean style, a small proportion of participants did not find the Recipes section to be helpful. This stresses the need for future studies to identify ways to tackle the barrier of lack of cooking skills, perhaps by including recipe demonstrations.
The greatest barrier to using the website was lack of time, which is consistent with findings from earlier studies examining participants' perceptions of healthy eating promotion websites [13, 15]. The barrier of time might have resulted in the decrease in login frequency over the 6-month study, which was also somewhat expected due to the length of the intervention period. However, it is difficult to conclude that the website was not efficient due to the decreased login frequency during the study, since some participants might have used the website once and printed information to read at a time convenient for them or keep for future reference. This was possible even with website sections that were regularly updated, since the website provided archives for this information. It would be useful in the future to account for this by identifying the website pages, and the number of pages, printed off by users via appropriate statistical usage summaries.
It is also noteworthy that pages that were not updated over the 6-month study were more often rated as moderately helpful or not helpful and received fewer visits by many participants. This shows the importance of providing regularly updated information, which is likely to keep users interested in using such a site. This is also in agreement with insufficiency of updates being one of the regularly mentioned barriers to using the website more and the wish of many participants for the website to have more regular updates.
The majority of participants mentioned source credibility and provision of scientific evidence to support information as important criteria to assess a website's trustworthiness. This finding is consistent with previous research on users' expectations of Internet health resources [22–24]. Criteria for evaluating health-related websites that have been published to date include content, design and aesthetics, disclosure of authors, sponsors/developers, currency of information, authority of source, ease of use and confidentiality/privacy [25]. Although the interviews revealed that the Mediterranean Eating website was well accepted concerning these criteria, some issues were identified that will be considered for future refinement of the website. For example, the website was generally perceived as clearly set-up and user-friendly. However, approximately a quarter of participants did not find the website timesaving. Future refinement of this website will therefore provide easier access to some sections, possibly facilitated by a site map, an increase in links between the pages and making contents more noticeable on the website's home page.
In earlier studies, Oenema et al. [10, 12] used an interactive website to provide tailored dietary and psychosocial feedback and reported promising results in increasing awareness and intention towards dietary behaviour change. Their website, however, was evaluated under highly controlled conditions, with participants being required to complete the whole web-based programme on-site and in a predetermined sequence. An interactive website presented as part of school curriculum and providing tailored dietary and behavioural feedback also proved successful and acceptable in increasing vegetable and fruit intake among high school girls [8]. These studies have shown that the Internet is a practical and acceptable approach to deliver health information and encourage behaviour change and/or improvements in psychosocial determinants of dietary behaviour. Our results cannot be readily compared with earlier research, however, since ours is the first study, to our knowledge, to investigate users' attitudes and perceptions towards a healthy eating website, promoting the Mediterranean diet, in a real-life setting and using a triangulation approach to process evaluation, including questionnaires, statistical summaries of usage and focus group interviews. It has been suggested that it is insufficient to assess quality of a web-based programme by only counting website visits and that qualitative information should supplement quantitative measures of usage, in order to examine users' attitudes and the impact of these applications on users' lives and choices [26].
In order for a web-based application to be successful, it needs to incorporate interactive features, including record keeping, assessment and provision of tailored feedback on an ongoing basis, instead of primarily providing nutrition information [27–29]. Winett et al. [8] suggest that usage and effectiveness of nutrition-related websites would increase with more interactive features. This is consistent with findings from the interviews in the present study, where most participants suggested that more interactive features would be particularly welcomed. Interactive features are therefore also planned for the website's future refinement.
There are several limitations to this study, which limit the generalizability of our results. Despite attempting to conduct a focus group for participants who did not complete the study, only those who had completed the study accepted the invitation to attend a focus group. Therefore, they represent a self-selected group of relatively well-educated female employees who are likely to have favourable attitudes towards the website. Nevertheless, attrition from the study was relatively low with only 20% of individuals (n = 11) not completing the 6-month impact evaluation measurements, suggesting that the intervention was successful in engaging and maintaining the interest of participants. Nevertheless, obtaining these participants' perceptions towards the Mediterranean Eating website would have provided useful information as to whether these participants dropped out because the website failed to meet their expectations.
Furthermore, our results cannot be generalized to non-computer-literate populations. Despite the increasing number of people using computers and the Internet [4], a considerable part of the population, particularly low-literacy groups, has limited Internet access [30, 31] or difficulty in searching and finding relevant health information on the Internet [32]. Eysenbach and Jadad [33] comment that these are the groups that are also more likely to need such information. However, it has been suggested that even when participants are inexperienced in using the Internet, this can be a feasible method of promoting health and providing education if motivation, technical demonstrations and support are provided [34, 35]. Earlier web-based interventions have been successful in increasing awareness among participants with a low or medium education, as well as increasing intentions of dietary change among less motivated participants, with unfavourable baseline eating habits [12]. In addition, the level of participants' computer literacy does not seem to affect the increased appreciation of web-based applications [10], which shows promise for the applicability of such approaches in populations of different backgrounds.
Nevertheless, although it is difficult to generalize to the Scottish population, the present findings should apply to Scottish professional women with access to a website in their workplace. In the future, the use of a more interactive website will also make it possible to recruit a larger and more diverse sample, taking into consideration regional, socioeconomic, educational and other demographic characteristics. Female participants were recruited because research suggests that women are more responsible for meal planning, food shopping and preparation [36] and more likely than men to use the Internet to access health information [31]. It would however, be useful to examine the effect of such an intervention on male participants. In the past, men have also been receptive to Internet-based, tailored nutrition education [12, 15, 37] and have been found to influence family food decisions [38].
The present study aimed to evaluate user perceptions of an innovative website promoting healthy eating in the context of the Mediterranean diet. Before this intervention can be disseminated on the World Wide Web, the Mediterranean Eating website needs to be further refined, based on findings from the focus group interviews, and evaluated among a larger group of free-living adults in the general community and/or a primary care setting. If shown to be effective, the Mediterranean Eating website could then be promoted to general practitioners and other health professionals as a reputable, non-commercial tool for use by their patients and clients wishing to make simple improvements to their diet. Since 45% of general practitioners in Scotland would consider referring patients to the Internet for further trustworthy information [39], the proposed website could offer such an opportunity.
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Acknowledgements |
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The authors would like to thank the anonymous reviewers for their helpful comments, Joe Murray for his assistance with the website's development and all of the study participants for their cooperation. A.P. was supported by the Greek State Scholarship Foundation (IKY).
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References |
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Received on December 2, 2004; accepted on August 22, 2005
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