Feasibility, appropriateness, and acceptability of a mobile mindfulness meditation intervention to improve sleep quality among a racially/ethnically diverse population

Abstract

Objectives:

To evaluate the acceptability, appropriateness, and feasibility of using a mindfulness meditation mobile application to improve sleep quality among a diverse group of adults.

Methods:

This explanatory qualitative study used online focus group discussions (N=4 groups with 17 individuals) to collect information about user experiences with a mindfulness meditation mobile application (Headspace^™) among participants enrolled in the MINDS study. A rapid analyses approach was used to descriptively compare motivators of app use, barriers and facilitators to app use, and perceived tailoring needs across participants.

Results:

Participants on average were 30 years old, 88% female, and identified as Black/African American (52.9%), White (29.4%), Asian (11.8%), and Hispanic (17.6%). All participants felt the app was acceptable and appreciated the ability to personalize their app experience. Individuals with ≥50% intervention adherence (daily use for 30 days) reported being motivated to use the app because it helped them to fall asleep faster, while the remainder of participants used the app to relax throughout the day and faced external barriers to app use (e.g., lack of time) and difficulty with app navigation. Only those participants who used the app exclusively in the evenings reported falling asleep faster and staying asleep. Suggestions for tailoring the app differed by race and age. Only Black/African American participants preferred using an instructor based on their race and gender.

Conclusion:

Using a mobile meditation app to enhance sleep quality is acceptable and feasible, but additional tailoring for Black/African American individuals may improve uptake in this population.

Introduction

Sleep plays a vital role in physical, mental, and emotional well-being. According to the Centers for Disease Control and Prevention (CDC), about 70 million Americans suffer from chronic sleep issues [1]. Shorter sleep duration (<7 hours for adults) and poor sleep quality are associated with cardiovascular risk factors such as overweight/obesity, hypertension, and diabetes [2, 3]. There is a bidirectional relationship between sleep and overweight or obesity, which may be part of the mechanistic pathway linking insufficient sleep and cardiovascular disease (CVD) [2, 4-6]. For example, insufficient sleep can lead to overeating and an unhealthy diet, which leads to weight gain and obesity [7, 8]. Evidence also suggests that insufficient sleep has a negative impact on neuroendocrine function and hormonal balance, which can increase the risk of obesity and subsequently CVDs [9]. Therefore, sleep may be an important intervention target to improve cardiovascular and overall health.

Minoritized racial groups are disproportionately affected by both obesity and inadequate sleep [10-12]. Data from a population-based retrospective cohort study (1985 to 2011) found that overall obesity prevalence significantly increased over time, but was highest in Black and Hispanic adults [13]. The Chicago Area Sleep Study showed that 7-day actigraphy-measured sleep duration was significantly shorter in Black (mean = 399.5), Hispanic (mean = 411.7), and Asian (mean = 409.6) participants compared to White participants (mean = 447.4) [14]. Black and Hispanic individuals experience more stress, which is hypothesized to contribute to sleep disparities [15].

Stress and anxiety are important contributors to poor and reduced sleep [16, 17]. Anxiety affects about 40 million adults in the United States [18], and is associated with insufficient sleep [19]. Since 2020 the rates of moderate to severe anxiety have increased, particularly among Black, indigenous, and other communities of color [20]. Individuals with high stress have a longer sleep latency and experience increased night-time awakenings [21]. Not only can stress and anxiety lead to insufficient sleep, but insufficient sleep can affect mood and lead to stress and anxiety [21]. A 4-year cohort study found that the risk of developing anxiety was significantly higher in those with insomnia compared to those without [21]. Targeting stress and anxiety reduction may be advantageous in improving sleep.

Interventions focused on CVD risk factor reduction have mainly focused on diet or physical activity [22], however, there is a clear need to shift to intervening on sleep, and risk factors for insufficient sleep (i.e., stress and anxiety) as a novel approach. Meditation and breathing have been found to be effective techniques for stress reduction and anxiety management [23-25]. However, there is lack of evidence to support the uptake of utilizing these techniques at home to improve sleep health, particularly among high-risk populations. This paper qualitatively evaluates the acceptability, appropriateness, and potential feasibility of using a mindfulness meditation mobile application (app) to improve sleep among a racially and ethnically diverse population who are at risk for obesity (BMI >25) and had poor sleep quality.

Methods

This study utilizes data from the Mindfulness Intervention to Improve Sleep and Reduce Diabetes Risk Among a Diverse Sample in Atlanta (MINDS). The MINDS study is a mixed methods study designed to determine the feasibility of delivering a mindfulness meditation mobile app plus sleep education intervention to improve sleep and subsequently improve diabetes risk among a community sample of racially diverse adults with a body mass index ≥ 25 and with poor sleep quality, as determined by a score greater than five on the Pittsburgh Sleep Quality Index (PSQI) [26]. This intervention was grounded in evidence indicating that mindfulness-based stress reduction interventions can improve sleep by reducing sleep disturbances and insomnia symptoms [27-30]. Participants were instructed to complete sessions on stress and anxiety reduction via the Headspace app, which utilizes mindfulness and meditation techniques (further details below). Following the intervention, the participants attended a focus group. Using an explanatory research design [31], whereby focus group discussions conducted post-intervention were used to explain differences in app usage, the aims of this qualitative analysis were to identify barriers to and facilitators of app acceptance and use, with a focus on assessing the appropriateness and feasibility of using the mindfulness meditation app. Understanding the barriers and facilitators to app use among study participants can inform adaptations to the intervention for a larger study among racially and ethnically diverse individuals with poor sleep hygiene.

Eligible participants were ≥ 18 years of age, English-speaking, owned a smartphone with the ability to download the mindfulness meditation app, and were living in the Atlanta Metropolitan area. Participants were excluded if they were pregnant, reported using drugs, were receiving treatment for alcohol or drug use, were prescribed medication to lower glucose, lipids, or blood pressure, or were previously diagnosed with HIV/AIDS, liver disease, or kidney disease. Recruitment of participants involved posted flyers in the Atlanta area and social media advertisements. The study was approved by the Emory Institutional Review Board (eIRB).

Study Procedures

Participants were enrolled in waves of 3-6 participants, yielding a total of 4 waves. Prior to starting the intervention, data on weight, blood pressure, and sleep were collected from all participants. Participants received and were instructed on the use of the study devices: an ActiWatch (sleep monitor), sleep diary, a scale to collect weight, and a blood pressure cuff and monitor. Participants underwent a minimum of three days of actigraphy measured sleep prior to the intervention to establish baseline sleep patterns. The ActiWatch was worn on the non-dominant wrist throughout the duration of the study (30 days). Participants were instructed to fill out the sleep diary every night and morning to track sleep and nap times, off-wrist time, beverage consumption and nicotine use within two hours of going to sleep, and whether they became sick. Questionnaires were completed at intervention baseline, midpoint, and completion to collect information on participant demographics, socioeconomic status, general health, sleep, psychosocial, and health behaviors.

All MINDS study participants (n=18) were invited and eligible to participate in the focus group discussion following completion of the 30-day pilot intervention. A total of 17 individuals participated and received a $50 gift card as compensation for their time. Focus group discussions (n=4) were conducted via Zoom, over a four-month period in 2021. Focus groups were held after each wave of intervention piloting was complete at a time that accommodated participants’ schedules, each discussion lasting 1-1.5 hours in length. Prior to each focus group, participants completed the informed consent process by reviewing the study consent form and providing an electronic signature. This form was reviewed at the start of each focus group discussion and participants were provided an opportunity to ask questions before choosing to participate.

All discussion groups were moderated by LJ, an experienced qualitative researcher (i.e., a postdoctoral researcher at the time of the FGDs) with previous experience tailoring and testing mindfulness-based interventions for Black and African American individuals in Atlanta. Guided by Proctor and colleagues framework for measuring implementation outcomes [32], a semi-structured discussion guide was designed to elicit information on the feasibility (i.e., extent to which the app could be used as intended), appropriateness (i.e., perceived fit of the app to be used to improve sleep quality), and acceptability (i.e., degree to which the app was perceived as satisfactory in improving sleep quality) of the app among a group of racially and ethnically diverse individuals.. Topics included: reflections on app use, ease of use, level of fit with lifestyle and routine, barriers and facilitators to use, perceived benefits, recommendations for tailoring, and attitudes and beliefs towards sleep. Open-ended questions on each topic were posed to the group and then probes were used to gain a contextualized understanding of how and why people interacted with the app the way they did. A notetaker was present for all focus groups and discussions were audio-recorded for use in the data analysis process.

MINDS Study Intervention Components

Participants attended the intervention visit via Zoom. The intervention visit included a presentation on downloading and using the Headspace^™ app [33] and a sleep hygiene presentation. Participants were instructed to follow a 30-day schedule of app-based sessions that included basic mindfulness meditations, and meditations focused on managing anxiety and letting go of stress. Participants were advised to complete the app sessions at night before going to sleep. At the 15-day midpoint, participants attended an in-person visit to measure weight and blood pressure, download ActiWatch sleep data, and complete the midpoint questionnaires, which included psychosocial questionnaires. At the end of the intervention, anthropometric measurements were taken by participants, app usage data were compiled, and participants were emailed a link to complete the endpoint questionnaires that collected information related to sleep, psychosocial wellbeing, health behaviors, and COVID-19.

Analysis

Focus group data were analyzed using a rapid analytic approach [34-36]. A summary template consisting of nine domains (i.e., groupings of discussion guide questions that summarize the main topics, including those related to the feasibility, appropriateness, and acceptability of the app) was developed and revised using data from the first focus group discussion (see supplemental file 1). Four team members [LJ, JA, AJ, KM] used the initial template to summarize discussion points raised by individuals in the first focus group to ensure that the domains were identifiable and represented all dimensions of the group discussion. After one round of revisions that involved expanding the definition of one domain and relabeling two others for clarity, the team was able to consistently enter the summary content while listening to audio recordings of each group discussion. For the remaining three focus group discussions, the notetaker and one additional team member independently listened to the audio-recorded discussion and completed the template. Both team members then met and compared templates, aggregating all data into one form with any discrepancies resolved through discussion with the moderator. After this process was completed for all four focus group discussions, summary data were entered into an EXCEL matrix organized by domains (columns) for each participant (rows) with a tab for each group discussion [37]. Data from the matrix were analyzed for shared themes and app tailoring suggestions within and across groups, as well as within participant sub-groups (e.g., age, race-ethnicity, level of app use). Specifically, information about user experiences with the app over the intervention period were analyzed in conjunction with app usage data (i.e., sessions completed, and time spent using the app for each participant) to understand similarities and differences in perceptions of app acceptability, appropriateness, and feasibility based on intervention adherence.

Results

Of the 18 MINDS intervention participants, 17 participated in four focus groups (2-6 participants in each). As detailed in Table 1, participants were predominantly female (88%), 30 years of age on average (SD: 10.3; range 23-63 years) and racially-ethnically diverse (77% racial-ethnic minorities). Three of the four focus groups had a mix of race-ethnic groups (i.e., 50%, 67%, and 80% racial-ethnic minority representation across the groups), while one group only had participants who identified as Black/African American.

Table 1.

Participant Characteristics

Characteristic	N (%) or Mean (SD)
Sex
Female	15 (88.2)
Age	30.4 (10.3)
Race *
Black/African American	9 (52.9)
White	5 (29.4)
Asian	2 (11.8)
Ethnicity
Hispanic	3 (17.6)
Marital Status
Married	3 (17.6)
Divorced	1 (5.9)
Member of an unmarried couple	4 (23.5)
Single	9 (52.9)
BMI	30.12 (4.42)
Education
Bachelor’s Degree	8 (47.1)
Graduate Degree	7 (41.2)
Professional Degree	1 (5.9)
Some college but no degree	1 (5.9)
Income
≤ $14,999	6 (35.3)
$15,000 - $49,000	3 (17.6)
$50,000 - $74,999	3 (17.6)
$75,000 +	3 (17.6)
Not indicated	2 (11.8)
PSQI	9.2 (2.7)

Abbreviations: BMI, body mass index. PSQI, Pittsburgh Sleep Quality Index.

^*Note: 1 participant identified as Hispanic only

All participants reported that they joined the study with an interest in improving their sleep health, but participants had varied behavior change goals that they felt were necessary to see changes in their sleep quality. For example, participants expressed a desire to create an environment conducive to sleeping (e.g., turning off lights and/or TV), initiate a period before going to sleep where they would only engage in relaxing activities, and reduce time spent on their phone before going to sleep, in order to fall asleep faster and stay asleep. Changes to their evening routine were perceived as the most challenging to make given that their schedules were often dictated by school, work, or family demands.

App experiences based on intervention adherence

To contextualize findings on the perceived acceptability, appropriateness, and feasibility of the app, Table 2 provides a summary of key themes according to app-based data on intervention adherence (i.e., the percentage of days over the intervention period that participants completed meditation sessions). Participants with ≥50% adherence, daily use for 30 days, (n=10) completed an average of 51 sessions (SD: 12) with an average of 396 minutes of meditation (SD: 203.5) over the intervention period, whereas participants with <50% adherence (n=7) completed an average of 8 sessions (SD: 12) with an average of 60 minutes of meditation (SD: 111.4). One participant with <50% intervention adherence completed 34 sessions over 12 days, or approximately 300 minutes of meditation, which was comparable to the average amount of time participants with ≥50% intervention adherence interacted with the app.

Table 2.

Similarities and differences in perceptions of app acceptability, appropriateness, and feasibility based on intervention adherence

	Acceptability	Appropriateness	Feasibility	Requested app adjustments
Participants with ≥50% adherence	Difficulty maintaining stillness: “It was hard not to fall asleep during the exercises.” - M9780	Focus on user intentionality: “In the meditation sessions they said- ‘Remind yourself why you’re doing this, set an intention and keep that in mind while meditating’. I want my shoulders to hurt less, I want to feel less tense and less stressed after work too. So, setting that intention for me was very important” -M9767	Fit with evening routine: “For the most part I used it towards the end of the day when I was done with work. But it was kind of frustrating because if I had to stay up late to do something and I had to do the sessions I knew I was going to fall asleep because it made me very drowsy.” -M1494	Enhanced reminder settings (e.g., set frequency of reminder notifications)
	Usefulness in falling asleep: “Before I started doing [meditation] I would get into bed and lay there for like an hour, two hours, just like on my phone. but I’ve noticed when I was doing the meditation before bed I would get in bed and get settled and try to go into that routine, make it 10 minutes and then decide I am ready to go to bed.” -M1211	Flexibility within a daily schedule: “Initially I was trying to use it to wind down and go to bed, but then after doing that for probably about a week and a half I started realizing that I needed that little boost and calmness to start my day. So, I started to rotate. I would use some at night to settle down, and then I would use it in the morning as well.” - M9769	Perceived ease of app navigation: “In general, it was super easy to navigate, but there was just a lot to get through.” - M1211	Enhanced use of visuals to show data tracking metrics
Participants with <50% adherence	Ability to have small moments of calmness throughout the day: “I liked that the sessions weren’t too long, they were about 11-12 minutes so it’s something you can do literally at any time, take a break, and listen to at any time.” - M7322	Secondary meditation practice: “I did not use it as much as I should have but I did use it interchangeably with the breathing app because I’ve been using that for the last 2 years or so. I find them very similar.” - M2736	Difficulty with app navigation: “It’s very easy to click the wrong thing and you spend a minute or two down the wrong path.” - M2736	Improved walk-though of app navigation and features
	Seeking evidence-based approach to improve health: “I want to live a life less stressful because I have a family that has a history of heart disease and I don’t want to end up on that route…so I try to do things. I signed up for a meditation class, I want to continue using [the app] - M7322	Alignment with previous meditation exposure: “One of the things that really stuck with me from the [meditation] course is that mindfulness is not about having emotions that we often associate as positive or getting rid of sadness/anger. It is sort of like embracing those emotions, so going into the app I would pay attention to how they would address that.” - M9763	Incompatible with work schedule: "I have to make sure I have enough time to be at work and I get called to come in almost every day, even on my off days. Sometimes it's hard to wind down and find time for myself." - M9761	Integration of resources with scientific evidence on meditation and sleep
Shared across groups	Relieve symptoms of stress and anxiety: “The biggest appeal is that it really did put me to sleep, which is something I really needed. I tend to just lie awake at night and I can’t shut off my thoughts…So just the fact that it worked made me want to do it.” - M9766	Appreciation of session variety and options to personalize settings: “Just hearing a black woman walk me through stuff…that is just where I kind of gravitate. It was pretty cool and I was more was likely to do those that had a black instructor.” - M5551	Poor evening sleep routines: “I don’t have a consistent [bedtime routine]. That’s been a goal of mine for a couple months now. So, I think finding time to [meditate] or deep breathing in conjunction with a bedtime routine would be helpful for me to make sure I get the sleep quality I want.” - M5551	More options to personalize app experience (e.g., create playlist of sessions that play on loop)
	Reduced sleep awakenings: “When I do [the sessions], I don’t wake up as often throughout the night” - M7322	Appreciation for app aesthetics: “I liked the design of the app. It was very cute, colorful, and easy to look at.” - M9799	Competing priorities: “My life is already so scheduled, and I have a million alarms set for different things so to add something else won’t be realistic for me” - M9769	Options for longer meditation sessions

Racial-ethnic differences in app experiences

Across the group discussions, descriptions of participant’s app experiences varied by race and ethnicity. Only individuals who self-identified as Black/African American, Asian, or Hispanic reported that they liked the variety of instructors offered with each meditation session. Reasons provided for using different instructors included wanting variety in their app experience and wanting an instructor of the same race and gender. As one participant shared:

I like that they have some diversity. For me, just hearing a black woman walk me through stuff, or a black woman teach me yoga, that is just where I kind of gravitate. It was pretty cool, and I was more likely to do those that had a black instructor.

(M5551)

All but one individual who used more than one instructor was under the age of 30 years. Additionally, the majority of participants who reported using the app during high stress moments throughout their day identified as Black/African American or Asian. These individuals preferred to use the app in the morning and mid-day, whereas other Black/African American and Hispanic participants preferred to use the app at night because it helped them relax before going to sleep. Only one Hispanic participant preferred to use the app in Spanish, while other participants who self-identified as bi-lingual did not realize that feature was available.

Several modifications to the app were suggested based on participant’s experiences using the app to complete meditation sessions. All participants enjoyed the use of visualizations in the app, but only Black/African American and Hispanic participants agreed that additional visuals could be integrated into the sessions to make it more acceptable (e.g., visuals displayed during the sessions that align with the guided meditation script). Individuals across all racial and ethnic groups mentioned the desire for increased app notifications. A few participants also named additional features that they felt could improve the app experience, including being able to make a playlist of favorited sessions that could be played on loop when trying to fall asleep. Additionally, a subset of Black/African American participants under the age of 30 years emphasized the need for an in-app introductory guide to enhance navigation of the available sessions, settings, and features. These individuals also expressed a desire for in-app educational resources related to sleep hygiene and the health benefits of meditation.

Relationship between the timing of daily app use and perceived benefits

Only participants who regularly completed app-based sessions before bed expressed that the meditation induced feelings of sleepiness and resulted in noticeable improvements in the ease and time it took for them to fall asleep. In contrast, those individuals who reported using the app at different times of the day found the sessions helpful in relaxing during high stress times or when transitioning to their evening routine. These individuals varied when they used the app based on their mental status and to accommodate changes in their schedule. As stated by one participant:

I was trying to use it to wind down and go to bed, but then after doing that for probably about a week and a half I started realizing that I needed that little boost and calmness to start my day. So, I started to rotate.

(M9769)

Motivation to use the app varied between these groups. Only participants who used the app flexibly highlighted their practice as being beneficial to both themselves and others around them (e.g., setting a good example for their children), describing the app’s focus on intention setting as a feature they identified as important to cultivating their practice. One participant elaborated:

In the meditation sessions they said, ‘remind yourself why you’re doing this, set an intention and keep that in mind while meditating.’ That was it for me, I want my shoulders to hurt less, I want to feel less tense and less stressed after work too. So, setting that intention for me was very important.

(M9767)

These individuals also described how they used the app to help manage symptoms of anxiety. Individuals who flexibly used the app stated that they would consider a yearly subscription to try more sessions, despite the fact that more than half of these participants completed less than 50% of the app sessions required in the intervention. To improve continued app use, this group advocated for more frequent app notifications reminding them to complete their daily practice.

Impact of using multiple health tracking devices

Across the focus group discussions, approximately one third of the participants reported using other phone-based apps or activity trackers in conjunction with this app. Most of these individuals reported that they prioritize sleep and understand the benefits of good sleep quality, which motivated them to use the intervention app. This was reflected when examining app use data, which showed that a greater proportion of individuals who used other health-related phone apps completed over half of the designated intervention sessions compared to those who did not report using another app (67% vs 54%, respectively).

Discussion

Study participants identified several key challenges related to the feasibility of using a mindfulness meditation mobile app to improve sleep health but reached a general consensus that it was an appropriate and acceptable mode of intervention. Reasons why the app could not be used as intended included difficulty navigating the app, identifying a time to complete sessions before going to bed, and lack of a consistent schedule or evening routine. Participants agreed that the app was an appropriate mode of intervention to improve sleep health, particularly because the session exercises used techniques that were familiar to participants through other stress relief practices that they reported using and because the app offers flexibility in when and how participants could engage with it. Participants also reported how satisfied they were with how the app helped them fall asleep faster and stay asleep longer, while some described broader health benefits (e.g., reduced stress and anxiety) that they felt positively impacted their sleep.

App use varied across different participant sub-groups, with both shared and unique barriers to app use. Barriers to completing meditation sessions included having competing demands on their time and the lack of a consistent evening routine to embed their practice within throughout the intervention period. Participants with ≥50% intervention adherence and participants with <50% adherence differed in their motivation to use the app (e.g., falling asleep faster vs. having moments of calmness, respectively) and what barriers they experienced to using it on a daily basis (e.g., poor fit with their evening routine vs. incompatibility with work schedule, respectively), factors that shaped participants perception of app acceptability and feasibility. Participant experiences were also found to vary by race-ethnicity and the time of day they completed meditation sessions. Black/African American participants found the diversity of instructors appropriate and acceptable but advocated for a greater emphasis on app modifications that would further personalize settings and features (e.g., educational resources on the health benefits of meditation, app navigation guides).

Findings from this study echo recent evidence that racially and ethnically diverse adults experience multi-faceted barriers to achieving healthy sleep, including their current sleep habits, stress and anxiety, knowledge regarding sleep hygiene, and competing priorities, despite being motivated to improve their sleep health [38]. Sleep and mental health concerns are the primary reasons for people using smartphone-based meditation programs [39], particularly among those individuals experiencing sleep difficulties [40]. However, this prior data is limited in generalizability given the lack of racial and ethnic diversity represented in user databases. The findings from this study reflect the attitudes and experiences of a racially and ethnically diverse group of participants, thus offering insight into how individual’s motivations to use a meditation app may differ by racial/ethnic groups. Participants in the MINDS study all had poor sleep quality and reported being motivated by the desire to improve their sleep health while balancing work, school, and/or relational commitments (e.g., parent, partner, colleague) that make it challenging to establish or maintain good sleep hygiene habits.

There is a growing evidence base that shows mindfulness meditation is effective in improving sleep quality [41, 42]. Mindfulness meditation produces more significant improvements in sleep quality than sleep hygiene education intervention alone, although both are effective in reducing sleep disturbances [43]. The MINDS study utilized both components to improve sleep quality, with greater flexibility for completing mobile app-based meditation sessions. Recent studies have documented that mindfulness meditation app-based interventions result in reduced sleep-related symptoms, help participants fall and stay asleep, and increase sleep quality [44, 45], which aligns with what participants in this study reported. Though only participants with ≥50% intervention adherence reported falling asleep faster, previous research has shown that individuals who have longer duration and higher frequency app use are more likely to notice changes in sleep [39]. Because roughly 40% of the participants in this study completed less than half of the daily meditation sessions over one month it is possible that they did not have enough exposure to notice improvements in multiple dimensions of their sleep health. Further research is needed to determine whether different patterns of daily use over shorter or variable periods of time produce noticeable changes in sleep quality.

A subset of study participants noted that mindfulness meditation helped reduce their symptoms of stress and anxiety, which mirrors findings from previous studies showing that adults with sleep disturbance experience improvements in depression and anxiety symptoms after using a mindfulness meditation mobile app for eight weeks [45, 46]. Because recognition of different sleep and mental health-related outcomes were highlighted as motivators for continued app use, future research should seek to incorporate customizable sleep diaries so that individuals can track health indicators that most interest them.

Strengths and limitations

This study was strengthened by the use of app-based data to analyze and compare participant experiences. Because the majority of participants identified as a racial/ethnic minority, it was also possible to use the focus groups discussions to build consensus around the acceptability of app features, as well as modifications that could increase app appropriateness and continued use among racial and ethnic minority participants. The reporting of our study findings adhered to the consolidated criteria for reporting qualitative research checklist to provide transparency in the design, conduct, and analysis of the reported study [47]. Participants with low app usage may have acquiesced to the broader group’s experiences rather than state why they did not use the app as frequently. To minimize response bias, the moderator started each focus group reminding participants that each of their experiences was valid and there were no right or wrong answers. Participants' perceived improvements in sleep and anxiety due to app usage require further examination via quantitative measures, which will be explored in future analyses. Due to the COVID-19 pandemic, the focus group discussions were held virtually rather than in-person. Participants had the option of turning on their video camera during group discussions, but the majority of participants joined only via audio. While all participants contributed within their respective group discussions, the moderator was unable to use visible behavioral cues to engage less active participants. Additionally, individuals in groups with mixed racial and ethnic compositions may have reported their experiences and attitudes differently than if groups had been organized based on shared racial-ethnic identity.

Conclusion

This study found that a mobile mindfulness meditation intervention is feasible to implement in a community-based population and appropriate and acceptable among racially-ethnically diverse adults with poor sleep quality. Uptake and sustained use may still be improved for Black/African American participants by further tailoring of app visuals, navigation, and features. Efforts to expand the ability to tailor app experiences should be combined with tools to enhance users awareness of the availability of these features and how to navigate them.