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Community-based participatory research is an effective tool for improving health outcomes in minority communities. Few community-based participatory research studies have evaluated methods of optimizing smartphone apps for health technology-enabled interventions in African Americans.
This study aimed to utilize focus groups (FGs) for gathering qualitative data to inform the development of an app that promotes physical activity (PA) among African American women in Washington, DC.
We recruited a convenience sample of African American women (N=16, age range 51-74 years) from regions of Washington, DC metropolitan area with the highest burden of cardiovascular disease. Participants used an app created by the research team, which provided motivational messages through app push notifications and educational content to promote PA. Subsequently, participants engaged in semistructured FG interviews led by moderators who asked open-ended questions about participants’ experiences of using the app. FGs were audiorecorded and transcribed verbatim, with subsequent behavioral theory-driven thematic analysis. Key themes based on the Health Belief Model and emerging themes were identified from the transcripts. Three independent reviewers iteratively coded the transcripts until consensus was reached. Then, the final codebook was approved by a qualitative research expert.
In this study, 10 main themes emerged. Participants emphasized the need to improve the app by optimizing automation, increasing relatability (eg, photos that reflect target demographic), increasing educational material (eg, health information), and connecting with community resources (eg, cooking classes and exercise groups).
Involving target users in the development of a culturally sensitive PA app is an essential step for creating an app that has a higher likelihood of acceptance and use in a technology-enabled intervention. This may decrease health disparities in cardiovascular diseases by more effectively increasing PA in a minority population.
Cardiovascular disease remains the leading cause of death in the United States, and African Americans bear a disproportionate burden, leading to significant and excessive morbidity and mortality [
Mobile health technology (mHealth) is a potentially effective and widely accessible platform for community-based interventions seeking to improve health outcomes in areas of lower socioeconomic status. Approximately 72% of African Americans in the United States own a smartphone, and they are more likely to depend on smartphones for internet access than other racial groups. Thus, smartphone apps are a realistic target for interventions among African Americans [
In order to understand the potential impact of an app on health behavior, such as PA, it is helpful to rely on an existing theoretical framework. The Health Belief Model (HBM) consists of six relevant constructs related to behavioral change: perceived benefits, perceived barriers, perceived susceptibility, perceived severity, self-efficacy, and cues to action [
Typical CBPR methodology includes working alongside a community advisory board (CAB) to develop a relevant, tailored intervention that is appropriate for the community in question. CBPR, which is focused on the intentional engagement with minority populations, has been a validated approach for eliminating health disparities [
A convenience sample of African American women participated in 2 FGs assessing their views on the use of mHealth tools. Immediately following the preintervention FG session, the study app was downloaded onto participants’ mobile phones, and participants were given study-associated Fitbit accounts and a Fitbit Charge 2 device (Fitbit, Inc, San Francisco, CA, USA). Therefore, all participants began both study components—using the app and wearing the Fitbit—simultaneously. After completion of the 20-day study period, participants took part in the postintervention FG interviews to share their experiences with the study app and Fitbit device. The pilot study was conducted for 20 days to accommodate the 18-day push-notification message scheme, plus 1 extra day on each end. Findings of the postintervention FG are described in this manuscript. The study was approved by the National Heart, Lung, and Blood Institute (National Institutes of Health, NIH) institutional review board, and all participants provided written informed consent (NCT 01927783).
African American women aged 19-85 years and residing in low-income areas of Washington DC (wards 5, 7, and 8) and Prince George’s County, MD, were invited to participate. Participants were recruited from a convenience sample of communities in Washington, DC metropolitan area between August 2017 and October 2017. Participants learned about the study through local health education events, flyers at churches, and peer recommendations. Participants were required to own a smartphone device, be proficient in written and spoken English, be physically able to engage in study activities, and be either overweight or obese (body mass index, BMI, ≥25 kg/m2) by self-reported height and weight. The study criteria and convenience sampling resulted in the recruitment of 20 possible participants and, ultimately, enrollment of 16 participants.
The app was developed in partnership with Vibrent Health (Fairfax, VA, USA), a health technology company. The app was designed to deliver motivational messages via push notifications, educational content about PA, and a daily self-assessment of stress and participants’ opinions of the message content of that day. The app featured a welcome video of the Principal Investigator (TP-W) explaining the purpose of the study and encouraging participants to increase their PA. The app was tested by the study team and app development group prior to distribution to study participants.
Using the Communication, Awareness, Relationships, and Empowerment Model [
A questionnaire was emailed to the CAB to identify local and culturally relevant barriers to PA and to solicit suggested motivational push notification messages that promote PA. Follow-up telephonic interviews were then conducted based on a prewritten script to further ascertain and clarify their suggestions (see
The app was designed to deliver 3 motivational messages daily via push notifications, which included photos of African American women of all body sizes and ages participating in PA. The app also allowed participants to review past messages by storing all received messages on a “wall” within the app. Motivational messages were disseminated via the app according to a programmed order (see
Information about PA was distributed via 2 educational modules, adapted from the Diabetes Prevention Program (
Participants were asked to complete a 6-item self-assessment every evening that evaluated their stress and cognitive affect (
Participants wore Fitbit Charge 2 devices 24 hours per day for the 20-day study period, with the exception of water-based activities. The wrist-worn activity monitor recorded minute-by-minute amount and intensity of PA achieved by each participant as well as sleep duration and quality. As the study app did not sync with the PA tracker, participants were able to view their activity via the commercially available Fitbit app.
Screenshots of the study app which show Educational Module 1 and the Daily self-assessment.
Immediately following the 20-day study period, all participants met at a local partnering church to discuss their experiences with the PA–promoting app, fitness tracker and associated app, and resulting changes in PA. Then, 2 simultaneous FGs, which included 8 participants each, were conducted to allow all 16 participants greater opportunity to speak. The FGs were conducted using a semistructured interview process. Each FG was led by 2 study team members, a moderator and a facilitator, with additional note takers present to document nonverbal responses. Both moderators followed a Moderator’s Guide, which included preselected questions and probes but allowed for open discussion based on the comments raised (see
Descriptive statistics were assessed from demographics and Fitbit data using SAS 9.4 (SAS Institute, Cary, NC, USA). A behavioral theory-driven thematic analysis based on the HBM was used to analyze FG data. The transcripts were reviewed, and a preliminary codebook of themes was developed based on theoretical constructs of the HBM. Each theme was accompanied by an operational definition that allowed 3 coders to systematically and independently identify quotes from the FGs that represented each theme. The coding process was iterative, with a total of 6 codebooks developed until consensus was achieved. An intramural NIH qualitative research expert (GW) validated the final coding and corresponding themes.
The study sample consisted of 16 African American women with a mean age of 62.1 (SD 6.6) years (
Sample characteristics (N=16).
Characteristic | Values | |
Age (years), mean (SD) | 62.1 (6.6) | |
Female | 16 (100) | |
African American | 16 (100) | |
Employed | 6 (37) | |
Retired or unemployed | 10 (63) | |
<60,000 | 6 (37) | |
≥60,000 | 5 (63) | |
Some college or below | 4 (25) | |
Technical degree | 2 (12) | |
College degree | 7 (44) | |
Graduate or professional degree | 3 (19) | |
Single, divorced, or widowed | 12 (75) | |
Married | 4 (25) | |
Maryland | 7 (44) | |
Washington, DC | 9 (56) | |
Body mass index (kg/m2), mean (SD) | 35.5 (8.29) | |
Overweightb, n (%) | 4 (25) | |
Obesec, n (%) | 12 (75) | |
Steps per dayd | 7359 (2201) | |
Sedentary minutes per day | 1174 (54) | |
Light intensity minutes per day | 236 (50) | |
Moderate intensity minutes per day | 12 (8) | |
Vigorous intensity minutes per day | 18 (10) |
aIncome information was only available for 8 participants.
bBody mass index≥25 kg/m2.
cBody mass index≥30 kg/m2.
dValid day defined as ≥10 hours of wear time (step data averaged over valid days during the 20-day study period).
The HBM includes 6 constructs, of which the following 5 were germane to the data: perceived benefits, perceived barriers, perceived susceptibility, cues to action, and self-efficacy. Perceived severity was not identified in the transcripts. Additional, emergent themes were identified, including technical difficulties, generational differences, and relationship with the community (
I didn’t lose weight, but it showed in my blood tests; the results of my blood tests. So, I did show some improvement with the increasing of the exercise.
This participant is highlighting the benefit she perceived from using the app to increase her PA (improved laboratory tests), in the absence of achieving her personal goal (weight loss).
During the FGs, participants shared their opinions of the app and provided suggestions for further improvement (
Perceived benefits
Impact on nonphysical activity health behaviors (mood, sleep, healthy eating, etc)
Goal setting
Education or new information
Safety of global positioning systems tracking
Perceived Barriers
Difficulty of use (ie, lack of automation)
Ambiguity over goals of daily self-assessment
Accuracy of physical activity tracking or ambiguity over physical activity goals
Technology literacy
Community or historical distrust of research
Safety as a barrier to physical activity
Insufficient data plan or memory
Perceived Susceptibility
Cues to action
Push notification messaging
Expanding the definition of “exercise”
Self-efficacy
Technical difficulties
Check-ins or IT support
Generational differences
Relationship with community
Connection to fellow participants
Connection to the research team
Social support
Preferred features
Participants’ suggestions for the app improvement.
Suggestion | Illustrative quotes | |
Water intake | “So if I drank the water and it automatically like it does my sleeping. It counts the sleep. It needs to count the water.” | |
Food intake | “The food intake. I put in one thing and then I said, ‘Oh wow, this is just, I don’t know how much this is.’[…]But I looked at that and I said, ‘This is a little too much [work].’” | |
Redesign the daily self-assessment | “We not no children, get rid of them [smiley faces].” |
|
Including photos of heavier women | [Speaking about the photos that accompanied the messages] |
|
Saving or printing the recipes | “And then you’re on your phone and you don’t have a printer see you’re not putting it on your iPad or anything. If you had that you’d print it out. I couldn’t print it out and I wasn’t going to handwrite it.” | |
“Even add a few more modules.” | ||
Diet and nutrition | “About I guess they could talk about, because I know a lot of people don’t like calorie counting and different things but the health coach that I’m working with, or the program that I’m working with, we have measurements and they show you what your size is you know, protein your palm of your hand, the grain your first, or different things like that and they do a lot of visuals and so on like that so that we don’t have to worry about counting and how to prepare healthy nutritious meals you know with a protein, a carb I mean your grain, your vegetable. Things like that.” | |
Stretching, including an instructional video | “If there’s a video like there the pictures may show you someone exercising, how to exercise. Maybe if there is a video if the video shows you how to do that exercise or proper technique for that exercise or the benefit of that particular exercise. If the if video was to be included I think that would be helpful.” |
|
Sleep hygiene | “Maybe in the future since there are some of us that have sleeping issues. Maybe I didn’t see anything at any of the questions, like suggestions about either going to bed early, turning the T.V. off, you know those kinds of suggestions to help us.” | |
“I’m thinking maybe you know safe places to exercise in the community, places where we can get food, you know just whatever. Any kind of resources that I think would pair well with exercising and eating well and taking care of yourself.” |
||
Group exercise or dance classes at existing facilities | “Yeah, group exercise and stuff like that. And you’d get more people motivated and doing this cause so far that’s what we’re doing at the [Recreation Center]. We’re spreading the word and we’re getting a lot of people coming in now…The classes are free and they giving them four days a week. You could do stuff up there, and the most time they got line dance, hand dance, jazz you know all these classes.” | |
Community walking groups and ability to create them in the app | [Speaking about the benefit of having a group or competition component within the app] “Yeah, I know and that’s what made me think within the study maybe they could do something like that. Even if it’s to link up with some of those that is already in existence.” |
|
Safe places to walk or exercise outside | “Yes, and I think we just did a thing on, what they call it? Geographical information systems where they show you know they map out areas where you can go to get physical activity and different things like that. Because you know health information is being done through a lot of technology and that would be one because sometimes people in the community need to know where can I go, you know how can I get there? For children through adults. Different things like that.” |
This study demonstrates the effectiveness of community engagement techniques, such as CBPR and FGs, in developing and refining culturally tailored smartphone apps for use in a community-based, mHealth-enabled PA intervention. Introducing a user-centered mHealth intervention in a low-income, African American population at risk for cardiovascular disease increases the likelihood of adoption and, therefore, may be an effective method for addressing health disparities.
Despite the purported potential of technology to alleviate health disparities, little research has been done to evaluate the feasibility and effectiveness of mHealth in minority populations. Consistent with recent studies, we show that both wearable technology and smartphone apps are well received among urban, community-dwelling African American women [
Involving community members at the earliest stage of the study design upholds the essence of true CBPR methodology. We were able to incorporate the community perspective directly into the intervention through the process of developing tailored motivational messages with the CAB. The majority of CAB members share residence and demographic characteristics with the study participants. This allowed us to overcome a strong barrier to effective health disparities research, namely, the predominating influence of an “outsider” perspective. Previous research demonstrates the effectiveness of culturally relevant persuasive messages for PA promotion among African American women [
Using FGs to inform the development of our PA app was an effective method to facilitate end user tailoring and, potentially, satisfaction. Although prior studies have used FGs for mHealth interventions, most explored end user satisfaction and feasibility only after the final app development and immediately before commencing a randomized control trial. Very few studies have used FGs as a means of collaborating with the target population to obtain feedback for the enhancement of a PA app at its inception [
Grounding our qualitative data analysis within HBM allowed us to identify how the app acted as both a promoter and barrier to behavioral changes. Specifically, HBM elements showcase the app’s potential to facilitate a behavioral change by means of educating users on the benefits of PA, promoting self-efficacy, and providing cues to action. Although discussion on perceived severity did not arise during the interviews, that particular construct has been shown to be less influential in facilitating a sustained health behavioral change [
While the primary focus of the intervention, PA, was well received by participants, the qualitative data demonstrate a need for a significant secondary impact on nonPA health behaviors. Participants expressed a strong desire for additional information regarding other beneficial lifestyle modifications. For example, they spoke frequently about increased awareness of their sleep patterns and need for improved sleep hygiene. Discussion on diet and nutrition was also extensive, including a desire for increased information on portion size, healthy choices, and water intake. Participants also discussed their novel awareness of the connection between mood and activity. They expressed a realization that exercise can improve mood and discussed the benefits of engaging in relaxation and mindfulness techniques. Increased awareness of benefits of PA, including mood, may generate an additional, novel reinforcing mechanism that increases the probability of future PA.
Similarly, social support was a recurrent theme, and the participants’ comments suggest a relationship wherein social support is a vehicle for increased self-efficacy. Improved self-efficacy has been shown to substantially increase the probability of successful maintenance of health interventions, including smoking cessation [
Our findings affirm that using FGs to identify values, goals, experiences, and definitions of PA may result in more informed and, therefore, more effective strategies for PA promotion [
As this was a pilot study, the duration of the intervention was short, and the sample size was small. The study population was a convenience sample of middle-aged, African American women who were recruited from communities within Washington, DC metropolitan area. Although our findings may not be generalizable to other populations, they may be generalizable to other African American female residents of urban environments. The use of the Fitbit PA app may have influenced participants’ perceptions of the study app, but this was not assessed. Finally, due to technical difficulties, some participants were not able to access the entire app content, and we were unable to objectively evaluate the influence of the push notification message dissemination protocol on PA.
Previous work has explored smartphone usage and willingness to participate in mHealth weight management research via quantitative data collection [
Although culturally tailored push notification messages were the focus of this study, we plan to expand this approach to include geographically and personally tailored push notification messages as well. For example, the use of geographic information systems can provide suggested locations for safe sites for outdoor PA and increased awareness of existing community PA resources, such as recreation centers. Incorporating personally tailored step goals and push notification messages based on the real-time activity may further promote sustained PA as it has been shown that personalized, adaptive goal setting improves adherence to PA interventions [
This pilot study demonstrates that the development of mHealth-enabled interventions based on the qualitative CBPR methodology and community member engagement may improve future PA and cardiovascular health interventions. The resulting enhancements to the app may be useful in ameliorating health disparities and improving health outcomes of underserved, minority communities by increasing the likelihood of acceptability and utilization of mHealth by target users.
Community Advisory Board interview script for suggested push notification messages.
Diagram of the motivational push notification message development process.
Diagram of the pilot study push notification messaging strategy with educational modules.
The Moderator’s Guide.
Focus group themes, subthemes, and quotes.
body mass index
community advisory board
community-based participatory research
focus group
Health Belief Model
mobile health
National Institutes of Health
physical activity
The authors would like to acknowledge our study participants, members of DC Cardiovascular Health and Obesity Collaborative, and our DC faith-based community partners for helping to make this research a possibility. The authors thank our colleagues from NIH/Clinical Center Intramural Research who provided insight and expertise that greatly assisted with the data analysis. In addition, we would like to acknowledge GW as the initial author of the moderator guide for the study.
The Powell-Wiley research group is funded by the Division of Intramural Research of the National Heart, Lung, and Blood Institute and the Intramural Research Program of the National Institute on Minority Health and Health Disparities (NIH). SE-T is supported by the National Institute on Minority Health and Health Disparities (K99MD011755). SC is supported by the NIH Medical Research Scholars Program, a public-private partnership supported jointly by the NIH and generous contributions to the Foundation for the NIH from the Doris Duke Charitable Foundation, American Association for Dental Research, Colgate-Palmolive Company, Genentech, Elsevier, and other private donors. Finally, we would like to state that the opinions and assertions expressed herein are those of the author(s) and do not necessarily reflect the official policy or position of the National Heart, Lung, and Blood Institute, the National Institute on Minority Health and Health Disparities, the National Institutes of Health, and the Uniformed Services University or the Department of Defense.
None declared.