This study was conducted at the University of Massachusetts Memorial Health Care system, which provides access to the large and diverse patient population in central and western Massachusetts. The city of Worcester, Massachusetts, itself allows access to a diverse local population, with >13% of the city’s residents being Black or African American, 7% being Asian, and 21% being Hispanic or Latino, with 21% of the population living below the poverty line [25].

This feasibility trial enrolled participants with a current diagnosis of HTN to test OWL-H. Totally, 2 cohorts of patients (N=24) participated in an 8-week clinical trial testing of hybrid live cooking classes or medical group visits, combined with a web-based self-management platform (OWL-H). Participants’ qualitative comments and feedback were used to revise the OWL-H platform for the next iteration.

Inclusion criteria were as follows: people with a current diagnosis of HTN who were aged >18 years, could provide informed consent, and can understand educational materials written in English and whose physical and mental health status were sufficient to comprehend instructions and participate in the interventions. Participants also had to have access to computer technology (mobile phone, desktop, or laptop) and the internet to use the web-based OWL-H platform. Exclusion criteria were as follows: people with serious underlying comorbid physical, cognitive, or psychiatric disease, including psychotic or manic symptoms, which precluded full participation in the intervention; those involved in active substance abuse; pregnant women or those who were actively trying to become pregnant; and those not willing to participate in the intervention or attend medical group visits. In addition, those planning to begin new HTN treatments within 2 weeks from the beginning of the protocol or who were planning a major medical treatment within 4 months from being screened were not eligible to participate.

Participants were recruited from the Worcester area with a focus on adult primary care clinics and were either self-referred (via flyers and brochures distributed around the clinics) or referred by their primary care providers. They spoke in person or over the phone with the study research coordinator (RC) to complete the self-report portion of the screening process and review the study objectives and eligibility criteria. If eligibility was confirmed, the study RC read a study consent fact sheet to the participant and obtained verbal consent.

OWL-H is a password-protected website hosted on a Health Insurance Portability and Accountability Act–compliant server that can be accessed via a computer, tablet, or mobile device. It contains an orientation session (for training purposes) and 8 unique educational sessions (Figure 1; Table 1). One session is released each week, across 8 weeks, and participants can access these unlocked sessions at any time [26-31]. The study team (licensed dietician or nutritionist [BO], a culinary-trained family medicine physician [LJM], and a mindfulness-trained family physician [PG]) adapted the content from OWL (version 2) to create OWL-H. Most of the original content of OWL (version 2) created for patients with chronic pain was used (Table 1 outlines the new content that was added to strategies to reduce HTN) [24]. The third version added evidence-based self-management strategies for reducing HTN and cardiac risk factors such as cooking videos and recipes using the Dietary Approaches to Stop Hypertension (DASH) [32,33] and Mediterranean diets. The new content developed specifically for OWL-H was completed with the input of patients in the clinic, who were attending a medical group visit at University of Massachusetts Memorial Health Care, to ensure appropriate literacy levels and diverse patient engagement. In addition, curriculum changes were made based on participant feedback between cohort 1 and cohort 2.

Upon logging in to OWL-H, participants were greeted with a 4-item check-in box asking them to rate their mood (ranging from 0-10, with high numbers indicating positive mood) and physical comfort (ranging from 0-10, with high numbers indicating high levels of comfort); record their current blood pressure and pulse; and answer whether they had taken their high blood pressure medication today, if applicable. Within OWL-H, the measurement record charted these daily readings throughout the duration of the program so that participants and staff can track their progress. All the participants received an Omron 7 Series upper-arm blood pressure monitor with an appropriately sized cuff.

After completing the check-in process, participants had the option to navigate through OWL-H session modules, tools, or resource pages. Each session included 1-2 videos on health topics, with duration ranging from 2-20 minutes, covering the week’s topic (Figure 1). Next, the participants completed a home practice (eg, meditation, body scan, and mindful movement) and posted it on the community board or journal. When any media item was played and completed, a comment box appeared to facilitate collection of real-time qualitative feedback from the participants (“What are your thoughts and feelings after completing this video?”).

Home practices, assigned at each session, included mindful movement (a video with duration of 24 minutes or audio with duration of 32 minutes), meditation with a focus on the breath (3 audio options with duration of approximately 20 minutes each), and body scans with a focus on noticing sensations in different areas of the body (3 audios with duration of 23 minutes or 12 minutes). Each mind–body practice was recorded by a certified yoga or meditation teacher. As participants progressed through the sessions, they were slowly introduced to new techniques or longer meditations to enhance their experience, and after completion of each, they were asked to provide feedback on the session. The mind–body progress log, which can be accessed from within the session or the upper taskbar, added a gamification element to OWL-H by tracking the completion of these practices. The participants received 1 checkmark and puzzle piece to fill in their week’s progress on the log. By practicing for 6 out of 7 days, the participants can earn enough puzzle pieces to complete the week’s reward image.

The journal is a private feature that allows participants to write about their daily events, thoughts, and reactions at their own time. In addition, the home practices periodically asked the participants to follow up on a lesson learned that week through a written journal assignment, such as writing about common stresses or creating a healthy shopping list. Participants were asked to participate in the monitored web-based discussions hosted on the community board of the website. OWL-H’s extensive resource library contains 12 unique content areas, all derived through participant feedback and requests (focus on health, mind and body, poems, quotes, nutrition resources, nutrition tips, healthy eating, recipes, integrative medicine, support services, videos, and audios). Each area contains information and tools that support what is learned in the main session content, either directly linked from within a session’s written materials or as stand-alone supplemental material. It also contains information on local resources (eg, affordable gyms, food pantries, free meals, and community resources), spotlights on foods of interest (eg, salt, whole grains, fruit, and vegetables), information on mindfulness and mental health, and motivational content (eg, poems; Figure 2) [33-37].

As a feasibility study, the primary outcomes were centered around confirming whether OWL-H is a feasible tool to deliver and facilitate self-management of HTN and other cardiac risk factors. The second primary outcome was to characterize participants’ use of and feedback on OWL-H to further adapt and revise the content and platform for use in a large study. These data were collected through surveys administered at baseline and 8 weeks (or web-based through REDCap [Research Electronic Data Capture; version 9.3.0; Vanderbilt University] [38] if a participant was not able to attend in person). Questions regarding participants’ preintervention and postintervention blood pressure monitoring habits were asked, and a blood pressure entry log was collected using the OWL-H system to provide quantifiable self-management data. Using these outcomes, we evaluated preintervention and postintervention effects.

Demographic information included the following: age, sex, race, ethnicity, country of birth, marital status, health insurance status, education level, employment status, and yearly household income. Other questions assessed the status of social and cardiac determinants of health such as food security (“In the last 12 months, the food that I bought just didn’t last, and I didn’t have the money to get more” and “In the last 12 months, I couldn’t afford to eat balanced meals”), access to healthy food (“In the last 12 months, I couldn’t afford to buy fresh fruit and vegetables”), prescribed blood pressure medication (“Do you currently take a prescribed blood pressure medication?”), whether they smoke cigarettes or drink alcohol (“How often do you practice non-smoking [tobacco]?” and “How often do you practice moderation in drinking alcohol daily [2 glasses or less for men; 1 glass or less for women]?”), and their recent level of stress (“Stress means a situation in which a person feels tense, restless, nervous, or anxious, or is unable to sleep at night because of his or her mind is troubled all the time. Within the last 30 days, how often have you felt this kind of stress?”).

The Blood Pressure Knowledge Questionnaire (BPKQ) [39,40] was used to assess the participants’ level of knowledge regarding risk factors of HTN. It consists of eight items covering topics such as common symptoms, white coat syndrome, and the amount of salt consumed by the average American individual, with a mix of multiple-choice (6 items) and true or false questions (2 items). The total number of correct items determines the score, which ranges from 1 to 8, with high scores indicating high level of knowledge. The information needed to answer each item correctly was covered in the OWL-H’s curriculum.

The Hypertension Self-Care Profile (HTN-SCP) consists of three separate instruments designed to assess self-care behavior, motivation for self-care, and self-efficacy in people with HTN. It was developed and validated in 2014 [41]. The self-efficacy instrument (HTN-SCP–Self-Efficacy [HTN-SCP–SE]) used in this study consisted of 20 items assessing the respondent’s confidence, on a scale of 1 (not confident) to 4 (very confident), to regularly engage in lifestyle habits that are recommended for patients with high blood pressure. This resulted in a total confidence or self-efficacy score ranging from 20 to 80, with high scores indicating high levels of confidence in engaging in heart-healthy lifestyle habits.

The Mediterranean Diet Questionnaire consists of 14 yes or no items that assess the participant’s consumption of heart-protecting or heart-harming foods, such as various healthy proteins (eg, legumes, nuts, and fish) and commercial sweets or pastries, respectively. It was originally developed in Spain in 2004 to briefly assess adherence to a Mediterranean diet [42] for patients at risk for cardiac complications and has been validated in multiple studies [43]. Items assess not only the type of food consumed but also whether the appropriate serving size is consumed, on a weekly basis. The number of “yes” responses are totaled, resulting in a score ranging from 0 to 14, with high scores indicating high adherence to the Mediterranean diet.

To assess the blood pressure self-monitoring before and after the intervention, we asked the following question at baseline, “Are you regularly (at least once per week) able to measure your blood pressure outside of your doctor appointments?” Those who said “yes” were asked, “How often, in a regular week, do you measure your blood pressure outside of your doctor appointments?” In their postintervention surveys, they were again asked to estimate their average weekly number of entries. Along with the self-reported numbers, the OWL-H platform also maintains a log of every blood pressure reading entered by each participant across the 8 weeks. Surveys were administered either in person, over the phone, or via an email invitation through REDCap—a password-protected research tool.

Self-reported blood pressure and pulse data were collected each time the participants logged in. Collected data included participant’s use of the OWL-H website, such as the number of minutes spent on the site, use of home practices, or number of health videos completed; any text that was inputted in the website through the comment boxes, journals, and community board; and any resource content that was accessed.

Qualitative data were gathered in real time through written comments in media comment boxes. Qualitative feedback was also collected from the participant entries into the journal and through surveys on both the specific sessions and the overall OWL-H content and platform. The video comments and journal entries were collected to gain an understanding of reflections, reactions, and opinions about the OWL-H project and to ascertain their impact on the overall satisfaction of the patients.

Descriptive statistics were used to analyze the survey information. Means, SDs, frequencies, and percentages were calculated for demographic characteristics. To compare the results between baseline and follow-up, we used paired sample t tests (1-tailed) and descriptive statistics. We carried the missing values forward from the pretest measurements to account for missed survey items. Means and SDs were calculated for the BPKQ, Mediterranean Diet Questionnaire, HTN-SCP–SE, and blood pressure self-monitoring at baseline and 8 weeks. All quantitative analyses were conducted using SPSS (version 26, IBM Corp).

For OWL use data, we tracked and summed the average and total number of accessed mind–body practices, number of times the participants used the journal, and total duration of time spent on OWL-H.

Qualitative data analysis methods were used to identify themes that were related to participants’ OWL-H platform use. The media comments and journal entries were reviewed and independently coded by 2 research assistants (LCK and AC). Using modified grounded theory, the coders inductively generated new codes. After the media comments and journal entries were coded, the 2 research assistants (LCK and AC) reconciled the codes with the RC and resolved any differences through consensus and review. The coders identified high-density codes and combined similar codes into categories and themes, which were shared with the research team.

This study was approved by the University of Massachusetts Medical School institutional review board (H00015619).

The study flow, screening, and study enrollment are illustrated in Figure 4.

The study team contacted a total of 54 candidate participants of which 38 (70%) participants agreed to be screened (3/38, 8% participants were screened and found ineligible), 35 (65%) participants were eligible, and 25 (46%) participants consented. After enrollment and consent (25/54, 46%), 4% (1/25) of the participants voluntarily withdrew from the study and 8% (2/25) of the participants were lost to follow-up (1 before baseline data collection; N=24). Of the 24 participants, 22 (92%) participants completed follow-up data collection. Specifically, in cohort 1, there were 42% (10/24) of participants in the beginning and 41% (9/22) of participants at the end, whereas for cohort 2, there were 63% (15/24) of participants in the beginning and 59% (13/22) of participants in the end.

Table 2 lists all the demographic factors. In this study, the average age was 57 (SD 12.1) years, most participants were women (21/24, 88%), and 33% (8/24) of participants identified as belonging to a race other than White, and 17% (4/24) of participants identified as Hispanic. In all, 46% (11/24) of participants’ annual household incomes were <US $30,000, with 79% (19/24) of participants reporting they “have just enough money to make ends meet” or “do not have enough money to make ends meet or prefer not to answer” on a monthly basis. Participants responded “often true or sometimes true” that “the food that I bought just didn’t last, and I didn’t have the money to get more” (7/24, 29%); that they “couldn’t afford to eat balanced meals” (8/24, 33%); and that they “couldn’t afford to buy fresh fruits and vegetables” (9/24, 38%). Totally, 46% (11/24) of participants reported having used a food insecurity service (eg, Supplemental Nutrition Assistance Program; Women, Infants, and Children program; and food pantries).

Table 3 lists the baseline and follow-up mean values and comparisons for all the outcomes. Participants’ HTN knowledge, measured using the BPKQ, significantly increased from baseline (mean 5.58, SD 1.44) to follow-up (mean 6.13, SD 1.23; P=.03). Participants’ self-efficacy in applying heart-healthy habits, as measured by the HTN-SCP–SE, increased from baseline (mean 63.67, SD 9.06) to follow-up (mean 65.54, SD 7.56), but there was no significant change (P=.14). Participants showed a significant increase in their adherence to a Mediterranean diet from baseline (mean 7.65, SD 2.19) to follow-up (mean 9, SD 1.68; P=.004).

At baseline, of the 24 participants, 10 (42%) participants reported being able to measure their blood pressure at home. For those 10 participants, the mean of the self-reported baseline number of blood pressure measurements per week was 2.8 (SD 1.31; minimum=1, maximum=5). At the 8-week follow-up, 82% (18/22) of the participants had reported their blood pressure in OWL-H at least once during the 8 weeks. The self-reported average weekly blood pressure measurement of these participants was 4.78 (SD 1.90; minimum=1, maximum=7), with the OWL-H platform data reporting the mean weekly entries as 2.74 (SD 2.02). Across 8 weeks, the mean total number of measurements logged was 22.22 (SD 16.54; minimum=1, maximum=54). When considering only the participants who completed the entire 8-week protocol (22/24, 92%), the mean total log of blood pressure was 24.05 (SD 16.14; minimum=1, maximum=54). When dividing the total number of measurements logged for the same 92% (22/24) of the participants across the 8 weeks, the weekly logged blood pressure mean was 3 (SD 2.02). There was no difference in the change between baseline blood pressure 131/88 mm Hg (minimum=110/68 mm Hg, maximum=167/123 mm Hg; SD 17 systolic pressure and SD 11 diastolic pressure) and 8-week blood pressure 134/84 mm Hg (minimum=104/58 mm Hg, maximum=160/103 mm Hg; SD 16 systolic pressure and SD 11 diastolic pressure).

Participants’ average mood score across the 8 weeks was 7.23 (SD 1.70) and average physical comfort score was 6.63 (SD 2.11). After accounting for those who did not complete the study (2/24, 8%) and those not taking blood pressure medication (2/24, 8%), the average adherence to taking a prescribed blood pressure medication across the 8 weeks was 85% (17/20).

Of the 9 modules, the average number of modules accessed was 4 (minimum=0, maximum=9). The average number of unique educational documents accessed from the resource library was 8.27 (minimum=0, maximum=51). Of the 24 participants, 11 (46%) participants attended all 3 cooking classes, whereas 3 (13%) participants attended only 1 class. Of the 24 participants, 2 (8%) participants did not spend time on OWL-H after the orientation class, and the remaining 22 (92%) participants used OWL-H on their own at least once. For those 22 participants, the average number of minutes spent in using the site was approximately 30 hours or 1773.64 minutes (minimum=101 minutes, maximum=4789 minutes). Participants’ average number of mindfulness home practices completed was 7 (minimum=0, maximum=40) and average number of completed videos on health topic was 7 (minimum=0, maximum=22). In terms of participation in mind–body practices at home, on average, participants completed 3 body scans (minimum=0, maximum=16), 2 meditations (minimum=0, maximum=18), and 1 yoga session (minimum=0, maximum=12). Further analysis of platform use is shown in Figure 5 (video use). These results show a trend of decreased use over time (Multimedia Appendix 1 reports mind–body activity schedule and Multimedia Appendix 2 reports mind–body activity use rates).

Overall, participant satisfaction and feedback about OWL-H was positive. From the survey feedback, we found that 73% (16/22) of the participants reported that they were “very satisfied” with using OWL-H to help manage their HTN. In all, 73% (16/22) of the participants reported that it was “very helpful” in “helping [you] to take and record [your] blood pressure at home.” Totally, 82% (18/22) of participants said that they “feel like OWL provided support and encouragement to reach [your] goals,” 73% (16/22) of them said that they would “like to use OWL again,” and 82% (18/22) of them said that they “would recommend OWL to someone they know.” Further participant feedback is presented in Textbox 1.

The main themes that emerged from the content feedback were centered on the health benefits of the mind–body practices, self-reflection on healthy behaviors, behavior change, and nutrition knowledge and skills (Textbox 1). Participants who practiced the body scans, meditations, or mindful movements overwhelmingly felt beneficial effects on their health. Of the 22 participants, 11 (50%) participants expressed that the practices had effects on their stress, pain levels, or blood pressure. Specifically, regarding blood pressure, a participant remarked, “Very effective. Dropped my systolic 15 pts.”

After watching the videos or participating in home practices, most participants (13/22, 59%) reflected on their own behaviors and beliefs. Videos on health topics such as Practical Eating and Stay Active had participants writing about their current or past health behaviors, and often ended with them deciding to reinforce a health habit, make a change, or discuss barriers to change. Participants said that they learned a variety of new nutrition skills to help them make healthy choices, such as “I will try ginger root tea. I will introduce turmeric into my cooking more as well. I could add a bit of flaxseed to my steel cut oats too.”

A mild adverse event was reported during the study; however, it was determined to be unrelated to the study.

The importance of using technology to encourage self-management and self-monitoring for patients with cardiac risk factors and HTN has become even more important during the COVID-19 pandemic, especially for those with health disparities in access to high blood pressure treatment [44]. We recruited participants with HTN to engage with the OWL-HTN platform combined with attending a TKMGV and found that 73% (16/22) of participants were highly satisfied with using OWL-H to manage their HTN. Participants’ blood pressure knowledge and adherence to a Mediterranean diet significantly increased. There was an increase in self-efficacy in applying heart-healthy habits. In all, 82% (18/22) of the participants reported their blood pressure in OWL-H at least once during the 8 weeks.

During the pandemic, the importance of internet access and health delivery technologies to assist with self-monitoring and social connection, such as mobile phones, computers, and tablets, has increased [17,45]. For example, in a recent study by Lustria et al [46], the prevalence of internet use was 72% among those with self-reported HTN or diabetes, which translates to 63 million US adults. Technologies present a way to create a community, educate, and sustain engagement in health practices. However, patients with low income and experiencing high blood pressure may not have access to the internet and spaces to exercise and have increased stress and food insecurity, further exacerbating disparities in HTN risk [47-49]. Furthermore, low diet quality is even more prevalent among adults with food insecurity, and diet quality is directly related to morbidity and mortality of cardiovascular diseases [47,49-51]. Therefore, it is important that this population have increased patient education and skills, such as healthy shopping and cooking, stress reduction, and regular monitoring of their blood pressure.

Studies have shown a link between knowledge about HTN and blood pressure outcomes [52]. Insufficient knowledge about HTN could lead to less optimal blood pressure control through lower rates of adherence to prescribed medications and engagement in lifestyle practices [53-57]. We found that the participants’ knowledge of common blood pressure and cardiac risk factors significantly increased after the intervention. High knowledge of HTN was associated with healthy lifestyle practices, including eating smaller portions to lose weight and reducing dietary sodium. Abu et al [58], in a study of adults with HTN who attended 2 primary care clinics in the city of Baltimore, Maryland, found that patients with low knowledge about HTN were less likely to be engaged in heart-healthy lifestyle practices than patients with high knowledge about HTN.

Both the Mediterranean dietary pattern and the DASH diet have been shown to improve blood pressure in adults and have been linked to reduced cardiac injury [59-62]. Our intervention presented engaging content, cooking demonstrations using a teaching kitchen, and recipes from the Mediterranean and DASH diets (high in fruits, vegetables, whole grains, and lean proteins, and low in red meats, sweets, saturated, and total fat) [63] and we showed an increase in adherence to a Mediterranean diet. There is very little research on the use of teaching kitchen or culinary skills as an intervention to reduce blood pressure [64-66]. In a study by Razavi et al [67], families living in New Orleans, Louisiana, were randomized to a hands-on teaching kitchen culinary education class or non–kitchen-based dietary counseling for 6 weeks. Compared with families receiving traditional dietary counseling, those participating in hands-on kitchen-based nutrition education were approximately 3 times as likely to follow a Mediterranean dietary pattern [67]. Qualitative findings from OWL emphasized themes that included healthy shopping on a budget, cooking one’s own food, and adapting the DASH and Mediterranean diets to appeal to diverse ethnic groups and income levels.

There is strong evidence that mind–body techniques such as meditation are linked to low blood pressure [68-70]. The main themes that emerged from the video content feedback were centered on the health benefits of the mind–body practices, self-reflection on healthy behaviors and beliefs, behavior change or reinforcement of healthy behaviors, and new health and nutrition knowledge and skills (Textbox 1). Participants who practiced the body scans, meditations, or mindful movements overwhelmingly felt beneficial effects on their health. In addition, the most widely viewed videos were on the topics of stress and inflammation, 2 videos assigned after the second in-person TKMGV; hence, more research is needed on how patients interact with live or web-based curriculum and which component leads to behavior change.

We found that participants increased their blood pressure monitoring. At the 8-week follow-up, 82% (18/22) participants had reported their blood pressure in OWL-H at least once during the 8 weeks. In the Framingham Health eHeart study, women were more likely than men to enroll in a digital intervention that tracked weekly blood pressure and activity with a Fitbit device, with high rates of device use through the 5-month intervention [71,72]. We showed that it is feasible to deliver the intervention at a teaching kitchen as part of a medical group visit and use web-based tracking, content, and experiences (eg, meditation) to reinforce self-management of HTN. Our future research direction includes a large fully powered randomized controlled trial that will allow us to test which parts of the intervention have the greatest impact or whether there is synergy in the different components that lead to behavior change.

As a feasibility pilot study, the sample size was not powered to detect reductions in blood pressure. External factors such as the variability in internet connectivity and type of device, such as smartphones, computers, or tablets, may have impacted the results. No valid methodology exists to measure and account for these external factors. In addition, the engagement of male participants was low (3/24, 13%), a limitation reported in other studies of similar nature [73-75]. The future upgrade of OWL-H will aim to include study materials in non-English languages with a goal to increase efficacy of the intervention for ethnically diverse participants.

As these technologies are associated with healthy behaviors, they present a way to create a community, educate, and sustain engagement in health. The flexible access to remote learning platforms creates a convenient and cost-efficient way to reach patients who are under geographic, pandemic, and economic burdens that prevent health care access.