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Rural residents face numerous challenges in accessing quality health care for management of chronic diseases (eg, obesity, diabetes), including scarcity of health care services and insufficient public transport. Digital health interventions, which include modalities such as internet, smartphones, and monitoring sensors, may help increase rural residents’ access to health care. While digital health interventions have become an increasingly popular intervention strategy to address obesity, research examining the use of technological tools for obesity management among rural Latino populations is limited. In this paper, we share our experience developing a culturally tailored, interactive health intervention using digital technologies for a family-oriented, weight management program in a rural, primarily Latino community. We describe the formative research that guided the development of the intervention, discuss the process of developing the intervention technologies including issues of privacy and data security, examine the results of a pilot study, and share lessons learned. Our experience can help others design user-centered digital health interventions to engage underserved populations in the uptake of healthy lifestyle and disease management skills.
The ownership of cellular phones, smartphones, and tablet computers has reached historic heights across all US population groups in recent years [
In the realm of digital health, Internet- and mobile-based IT platforms (eg, SMS text messages, websites, social media, wearable technology) have been used to store, manage, and transmit data using hardware, software, and networks for delivering health care services and health promotion programs [
Healthy Frio is a translation study of the Y-Living Program (Y-Living), an evidence-based, family-focused intervention designed for urban Latino families (Trial Registration: ClinicalTrials.gov NCT03186885) [
In this paper, we describe the process undertaken by a multidisciplinary research team to develop the RT intervention for the Healthy Frio study. Key elements of the process include the formative research that guided the development of the RT intervention, the selection and integration of digital technologies [
The development of the RT intervention took place over 16 months, from the formation of the research team to the deployment of the RT intervention for the full RCT. The process included several steps: (1) formulating the research team, (2) engaging community partners and residents to adapt the Y-Living for rural Latino families, (3) reviewing the evidence on use of digital technologies for behavior change, (4) developing a prototype of the RT intervention in parallel with IP intervention, and (5) conducting a pilot test of the prototype.
Healthy Frio remote technology (RT) intervention development process.
A multidisciplinary team including researchers with expertise in computer engineering, database and instructional design, and public and behavioral health, and primary care practitioners (community/family medicine and nursing) developed the RT intervention. The instructional design specialist was designated as the coordinator. The technology modules and components integrated as a part of the RT intervention required development of necessary links, incorporation of application program interfaces (APIs), service interfaces, dashboards, and testing of interoperability, compatibility, and robustness. Thus, digital health RT interventions demand the expertise of a professional team of computer engineers to develop and manage seamless functioning and efficient intervention delivery in collaboration with behavioral health researchers who understand behavior change processes. A team science approach was critical in the communication and collaboration between computer engineers and behavioral health researchers and the development and management of the multidisciplinary team [
Y-Living is a 12-week behavioral modification program grounded in the Social Cognitive Theory of behavior change to engage the whole family in lifestyle changes [
Description of and alignment between in-person and remote technology intervention.
Mediators | Strategies | In-person intervention | Remote technology intervention |
Self-regulation |
Initial wellness report |
Provided at first wellness consultation. Includes height, weight, BMI, average PAa minutes, and caloric intake recorded at baseline assessments. A YMCAb wellness coach discusses with each participant and helps him/her set goals to increase PA and lower calorie intake, and set a target weight loss goal (5%) for 3-month assessment. |
Provided at first wellness consultation. Includes height, weight, BMI, average PA minutes, and caloric intake recorded at baseline assessments Health educator discusses with each participant and helps him/her set goals to increase PA and lower calorie intake, and set a target weight loss goal (5%) for 3-month assessment. |
Self-efficacy Perceived barriers Social support |
Orientation session |
Participants receive program materials (eg, program binder, self-monitoring logs) and information about the program schedule and goals. |
Participant is provided, and given instructions on how to use, all equipment (eg, tablet, Fitbit), apps, timeline, program goals, and expectations. |
Home environment Self-efficacy Self-regulation |
Healthy living lessons |
12 weeks of lessons at community center: 2 lessons per week. |
12 weeks of online lessons delivered via tablet computers: 2 lessons per week. |
Self-efficacy Perceived barriers |
Cooking demonstrations |
Brief cooking demonstration by YMCA staff following health education lessons. |
Video recordings of cooking demonstrations conducted by YMCA staff.c |
Home environment Self-efficacy Self-regulation Perceived barriers Social support |
Physical activity sessions |
Immediately following Y Living lessons, a 1-hour PA session led by YMCA wellness coach. Examples of activities include circuit training, Zumba, and games from CATCHd curriculum. Children and adults are usually not separated. |
PA sessions (for both children and adults) are included in online lessons using videos curated from YouTube, as well as 5 videos produced by Healthy Frio and YMCA wellness coaches. Separate videos are provided that are oriented toward adults and children. |
Self-efficacy Self-regulation Perceived barriers |
Self-monitoring |
Paper and pencil log for PA and food intake. Weigh-ins during individual consultation. |
Use of Fitbit, scale, apps, etc. |
Self-efficacy Self-regulation |
SMS text messaging |
2 per week. Healthy Lifestyle tips for increasing PA and healthy eating. |
Lesson reminders, health challenges, same healthy lifestyle tips as in-person, polling question regarding health challenges. |
Social support Perceived barriers |
Grocery store tour |
Participants taken to a local grocery store where they are led on a tour and given tips for healthy shopping (eg, comparing labels, prices, and suggested routes through grocery store [perimeter first]). |
Virtual grocery store tour lesson using video segments for each section of grocery store. |
Home environment Social support |
Wellness consultations |
Small group discussions and coaching sessions. |
Group video calls via Google Hangoutse or Skype (weeks 2, 6, and 10). |
Home environment Self-efficacy Social support |
One-on-one meetings |
3 individual consultations between YMCA staff and participants to review progress report (weeks 2, 5, and 8). |
Biweekly phone calls with each family, and a midprogram progress report sent via email in week 7. |
aPA: physical activity.
bYMCA: Young Men’s Christian Association.
cCooking demos performed at Y-Living Program in San Antonio (not part of Healthy Frio Trial).
dCATCH: Coordinated Approach to Child Health.
eGoogle Hangouts used for Cohort 1. Skype will be used for remaining cohorts.
As the third step of the development process, the RT team conducted a review of the literature on the application of digital technologies in health promotion and disease management from the perspectives of health promotion practices and computer engineering. Furthermore, the team conducted a state-of-the-art review on modern health data collection and sharing approaches in the context of an emerging gig economy [
Application of digital health technologies has evolved from a single IT platform that focused on offering access to web-based intervention information to multiple platforms that extended exposure to the intervention in the context of the targeted behaviors. Research indicates that exposure is extended by (1) minimizing time-consuming data input and output activities, (2) automating delivery of task reminders and reinforced messages, (3) providing frequent and real-time feedback to intervention participants and staff, (4) offering the ability to tailor the intervention based on baseline information as well as ongoing changes of the behavior targets and the environment, and (5) leveraging the interactive capabilities of mHealth devices to incorporate BCTs [
The RT team identified key features of successful digital health interventions such as two-way communication between the participants and intervention, social support from intervention staff and others, and some forms of competition [
Finally, contemporary health behavior theories and models have been developed primarily based on face-to-face interactions for the management of behavior changes and do not address the time-intensive and interactive nature and asynchronous and dynamic process of digital health interventions [
Based on the results of the review, the RT team decided to adopt a user-centered system design [
The design of the Healthy Frio RT intervention was guided by a blended approach to create a program that is “both useful and easy to use, ie, at really serving the needs of the user,” following the principles of the persuasive design system (PDS) [
Implementation of features and techniques for designing the content and functionality of a persuasive design system.
PDSa features | Operationalization of PDS techniques in Healthy Frio digital health intervention |
Primary task support: Supporting and facilitating completion of the user’s main tasks | Guided goal-setting; self-monitoring of weight, physical activity, and diet; using simulation and rehearsal in online interactive health education; online health challenges to target specific behavior |
Dialogue support: Providing support, guidance, and feedback to users by verbal or other form | Suggestion and reminders via SMS text messaging; praise and reinforcement via health app (Fitbit app), and live online coaching |
System credibility support: Presenting program content as trustworthy and authoritative to users | Embedding spirituality in online health education; using respected and authoritative sources; connecting program content to local community; affiliating the program with trusted local entities |
Social support: Motivating and engaging users by leveraging social influence | Using parent–child dyad; providing physical activity trackers and weight tracking accounts to dyads; weekly calls by lifestyle coach |
aPDS: persuasive design system.
Healthy Frio remote technology intervention conceptual model. MVPA: moderate to vigorous physical activity; PA: physical activity.
The implementation of the RT intervention is accomplished by a multiple-system integrated platform that is designed to address 3 elements of behavior change for persuasive design in human–computer interactions: (1) motivating participants with goal setting, positive reinforcement, and social support; (2) increasing participant’s ability to adopt new behaviors by learning behavior change skills; and (3) providing cues to initiate and maintain new behavior via SMS text message reminders and feedback from digital technologies [
Healthy Frio remote technology intervention delivery platform.
Once Y-Living health education lessons were updated for the rural context, the RT team developed the interactive version of the lessons. The design and delivery of the lesson content were tailored to address the learning needs and the cultural and community characteristics of low-income Latino families [
E-learning authoring software Articulate Rise [
The RT team developed interactive activities within each lesson to increase participant’s knowledge and self-efficacy to change physical activity and diet behaviors. Examples of interactive skill-building activities include creation of SMART (ie, specific, measurable, adjustable, realistic, time-based) goals for physical activity and dietary intake, practice reading
To provide the RT intervention participants an experience similar to that of the IP participants, the RT team video recorded physical activity sessions and cooking demonstrations conducted by Y-Living program staff from the YMCA. These videotaped activities were similar to the ones used with participants in the Healthy Frio IP program. Videos included Zumba, salsa dancing, boot camp style-physical activity routines, 22 cardiovascular fitness routines, and demonstrations for healthy ways to cook proteins vegetables, fats, and grains. The RT version included additional curated videos that demonstrated various physical activity routines available on YouTube. The criteria for selecting the videos were that they were primarily suitable for beginners, did not require any equipment, included a variety of physical activities for both strength training and cardiorespiratory fitness (ie, yoga, stretching, body weight exercises), and were fun. Each lesson included 2 physical activity videos: 1 for adult participants, and 1 that was more suitable for children. Narrated instructions introduced each video.
The RT team underwent a tedious process of testing, developing, and integrating various hardware and software tools that would be supportive and cost-efficient for delivery of the RT intervention. Major considerations included (1) ease of use with user-friendly interface and minimum data entry burden, (2) product reliability (hardware durability and signal strength), and (3) ability to collect information from the tools via web-based API [
Technology components and functions used by remote technology intervention.
Technology component | Function | ||
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Verizon Ellipsis 10 tablet computer with mobile Wi-Fi hotspot and data plan | Intervention content delivery device to access the interactive health lessons; gathers and uploads information from monitoring devices |
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Fitbit Flex 2 activity tracker | Personal sensor to track physical activity and sleep |
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Nokia Body digital scale | Bluetooth scale to track weight |
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Smartphones (participants’ personal) | Device used to view SMS text messages from the study |
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MessageSpace | Automated SMS text messaging system to send motivational texts and reminders to participants |
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Moodle Learning Management System | Delivery of intervention content; tracks participant viewing of program lessons |
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Fitbit and Nokia Health Mate apps | Apps to help participants self-monitor physical activity, food intake, water consumption, sleep, and weight. Weight syncing through Nokia Health Mate app. |
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Google Hangouts/Skype | Video conferencing apps to conduct group counseling calls with health educator |
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MX Player | Video player to view physical activity videos |
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Electronic games | Games related to physical activity and nutrition for child participants |
Healthy Frio remote technology intervention system architecture. EC2, Elastic Cloud Compute; LMS, learning management system; REDCap, Research Electronic Data Capture.
To provide access to educational content during the intervention, we used Moodle as the learning management system to deliver program content, manage health education lessons, and track progress [
Summary of goals, design implications, and lessons learned in the design of remote technology intervention.
Design goal | Lesson learned | Design implication |
To investigate whether usage of the tablet by parent and child affects user engagement and frequency of regular synchronizing of hardware devices with respective apps on the tablet. |
Parents and children felt a burden with regard to synchronizing their activity, entering dietary data and weight, due to repeated log-in and logout from their respective accounts on the apps. This extra step led to very few, if any, syncs of their data. |
Parents and children should be able to synchronize their data without the hassle of logging in and out. We created clones of the apps that are used by both parents and children, and their devices are configured accordingly to their cloned version and accounts. This improved data synchronizing and we are able to get frequent updates on their syncs. |
To check the ease of access to educational content and health knowledge via Moodle, enhance access to information, get proper feedback for improving the content. |
Navigating the Moodle app is challenging as there are many steps to take before landing on the course page to access lessons. This dissuaded participants from accessing weekly lessons. Due to poor network connectivity, downloading of lessons from the app is inhibited or is slow, further dissuading participants from accessing the lessons. |
The app’s configuration settings on the Amazon EC2a server as well as on the tablet should be changed. With the configuration changes, participants are able to directly see the list of lessons upon opening the Moodle app. Providing offline access to content (ie, via SDb cards, download of complete 12 weeks of content from Moodle app onto the tablet) should resolve the network-related issue affecting access to lessons. This is essential when internet access is poor. |
To investigate whether regular one-on-one communication can fill the gaps due to missing data collected remotely. |
Due to diverse technical capabilities of participants in the intervention, they tend to forget some steps in constantly synchronizing the devices, accessing the content, and entering nutrition details. |
SMS text messages as reminders, polling questions, surveys, and one-on-one video calls with health educator help remind participants about various aspects of the intervention, which in turn helps collect a more robust set of data. |
To observe active logging of water consumption and tracking calories by entering dietary details and calories consumed. |
Logging food and consumed calories requires manually entering or scanning the food item. Participants mostly either skip entering it or do it less often than required. |
Regular SMS text messages as reminders and one-on-one video calls with Health Educator motivates and helps participants log food intake, keep track of their daily consumption, and stick to weight goals. |
To evaluate tools and methods to enhance tablet usage with ease of navigation for regular synchronizing of data as well as for constant motivation and participant engagement. |
Direct access to apps with little to no information to enter manually, easy methods of synchronizing their devices to the apps, automatic notifications from Fitbit (including device lights and vibrations), Health Mate, and Moodle apps seem to motivate participants to monitor their healthy living. |
Tools for the intervention should be as integrated as closely as possible with the participants’ daily schedule. User-centered design will support end-user engagement, improve user’s experience, and encourage attentiveness toward the intervention. |
aEC2: Elastic Cloud Compute.
bSD: secure digital.
The potential for digital tools such as mobile apps and wearable sensors to enhance behavioral health is substantial. However, the use of tablets, wearable trackers, and other technologies for digital health interventions introduces additional complexity for participant’s data security and privacy [
All the constituent apps in the Healthy Frio RT intervention have different security aspects. The current RT intervention delivery leverages Fitbit, Nokia Health Mate, and Moodle apps, which rely on remote servers for storing and processing the participant’s data, and adds to security challenges. Hence, the computer engineers and developers need to consistently secure servers, the transmission of data, and the involved software through their proper configuration. To address these issues, we performed a thorough evaluation of the complete RT intervention delivery infrastructure by observing the data and sensitive information flowing through multiple apps, modules that we developed leveraging corresponding software development kits, libraries, and APIs. This helps to anticipate potential security issues in order to take preventative measures. The third-party libraries and code have been assessed for any security vulnerabilities or other reported problems. Other safety practices include observing the differences between different APIs that enabled us to configure the apps properly for the security-related features and handle the permissions for data collection. This research helped us in adapting the code base accordingly to avoid compromising the security of participants’ information. We also generated participants’ credentials for the involved apps securely and ensured the passwords are not stored in the remote server in plaintext. We avoided storing their passwords and instead let them authorize our system to collect their activity, weight, and educational content access data prior to the start of the intervention. Finally, we used Amazon EC2 to deploy and maintain our remote server that communicates with the apps. While Amazon provides a secure environment including privacy protection, we took appropriate measures to configure the server for Fitbit, Nokia Health Mate, and Moodle course data-retrieval systems.
The prototype of the Healthy Frio RT intervention was tested with 5 parent–child dyads in a 3-week pilot, using content from the first 3 weeks of the intervention (ie, 6 lessons). The purposes were to (1) test the performance, management, and maintenance of digital equipment—especially with regard to connectivity and syncing of Fitbit trackers and weight scales; (2) obtain feedback about the design of the lessons; and (3) obtain feedback on the experience of engaging in a remotely delivered lifestyle modification program with digital technologies. Dyads were recruited from a convenience sample of eligible participants from the study population. The adult participants were all females aged 36 to 47. The ages of the children ranged from 7 to 14 years; 4 of the 5 families self-identified as Latino. Some of the participants had previously participated in an early IP intervention pilot. Therefore, they were able to provide feedback on the delivery of the RT intervention in comparison to the IP format.
The week prior to the start of the pilot study, participants came to an orientation session in which they were given an overview of the RT intervention, received their equipment as well as an instructional manual. The orientation session included a description of the 3-week pilot intervention, demonstrations of the use of equipment (eg, syncing Fitbit trackers and weight scales to tablets), introduction to apps installed on the tablet that would be used for self-monitoring, and a tutorial on accessing health education content on the tablet. RT pilot participants engaged in 3 focus group discussions in a community center (1 per week). Each family received a US $60 gift card for each focus group they attended. A focus group guide was developed prior to the pilot study that included questions related to the orientation session, lesson content and format, weekly SMS text messages received, use of equipment, and participants’ overall experience. Participants’ responses were transcribed in field notes which were then analyzed using content analysis [
Participants stated that the orientation session needed more time and many wanted more one-on-one time with staff members to guide them to use the equipment. Participants wanted to spend more time going through the apps on the tablet and more demonstrations on how to log-in/log out of the apps for syncing the equipment—especially because 2 people were using the apps (parent–child dyad). Many participants suggested creating a hotline number that they could call for help troubleshooting any problems experienced.
A majority of the participants stated that the tablet was not very user-friendly. For instance, many found the tablet bulky and difficult to carry around. Participants indicated that they preferred a smaller tablet that they could carry around with them (in their purse). However, participants also stated that they really liked using the tablet to view the exercise videos that were provided during the second part of each online lesson. Most participants stated that they wore the Fitbit all the time (except when charging) and like using it to keep track of their steps and sleep.
Participants expressed that there were “too many applications or things to do.” In particular, participants did not like having to log-in/log out of the apps, for instance, to sync their child’s data in addition to their own in the Fitbit app. Participants also had a hard time navigating within the Moodle app to open and view the interactive lessons. Participants also had difficulty downloading the lessons to view. This issue was likely related to their cellular data connection speed.
Overall, the participants stated that they liked the lesson content, including the interface design, colors, and layout. Several participants requested SMS text message reminders to view the lessons because it was “easy to put off.”
Though participants were encouraged to view the lessons with their child, most participants viewed the lessons during the evening or on the weekends and did not include their child. However, they stated that they shared the relevant information with their child later.
Based on the findings from our pilot study, we learned that all of the equipment should be presynced and apps ready to be used prior to the orientation session. For the pilot study, when the participants were given the equipment during the orientation session, staff had to help them sync their Fitbit activity trackers and scales to the tablet for both the parent and child. Because the trackers and scales connect with the tablet using Bluetooth, this proved to be challenging due to multiple devices being in close proximity to one another. It was especially difficult for less technologically savvy participants. Additionally, both the parent and the child were using the same Fitbit app on each tablet, requiring them to login and logout each time they wanted to sync their equipment. This issue became a problem that caused their data to sometimes get mixed up, especially with the weight data from the scales. “Too many devices in one space using Bluetooth to sync Fitbits and scales to tablets” as one participant reported. We solved this issue by creating clones of the Fitbit app so that two copies of the app could be installed on the tablet: 1 for the parent and 1 for the child.
Many participants expressed that they had issues downloading the lessons to view. This issue was likely related to their cellular data connection speed. Because the participants lived in rural, south Texas, their cellular connectivity was less than optimal. Having a weaker cellular signal resulted in significantly long times for each lesson to download to the tablet, and caused the videos that were embedded into each of the lessons to often not be able to play. To solve these issues, we embedded all of the videos within the lessons rather than stream the lessons from their original source (primarily YouTube). This required having to download all of the videos from YouTube, and then importing them into the lessons. To address the issue of the lengthy time for downloading the lessons, which was exacerbated once videos were embedded due to larger file size, all of the lessons were predownloaded to the tablet prior to the equipment being given to the participants. It should be noted that making these changes resulted in the amount of data to be stored on the tablet hard drive exceeding the available space (16 GB). Therefore, we installed a micro SD (secure digital) data card (32 GB) into each tablet.
By addressing issues participants had syncing their equipment to the tablet and viewing online lessons, we were able to address many of the challenges that occurred during the pilot. For instance, we were able to provide more time during the orientation session so participants have more hands-on training in using the equipment and apps and we enhanced the user-friendliness of the tablet, Fitbits, and apps.
We designed a digital technology–based intervention to deliver a lifestyle modification program commonly delivered IP, by a lifestyle coach. The combination of digital technologies and live coaching affords the most efficient support to engage the study participants and close
application programming interface
behavior change techniques
Elastic Cloud Compute
in-person
information technology
mobile health technology
physical activity
persuasive design system
Research Electronic Data Capture
randomized controlled trial
remote technology
secure digital
structured query language
This work was supported by the National Institute of Nursing Research of the National Institutes of Health under Award Number R01NR016269. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
All authors wrote, reviewed, and approved the final manuscript.
None declared.