Lessons Learned from the Development and Implementation of Two Internet-enhanced Culturally Relevant Physical Activity Interventions for Young Overweight African-American Women

Abstract

This research team has designed and implemented 2 culturally relevant, Internet-enhanced physical activity (PA) interventions for overweight/obese African-American female college students. Presumably, these are the only prospectively designed, culturally relevant interventions using the Internet to promote PA among African-American women. Due to the limited research on this topic, the experiences associated the design and implementation of these studies were syntesized and 5 key lessons learned from this research were formulated. Findings provide insight for researchers to consider when developing Internet-based PA promotion interventions for African-American women. Lessons learned included: 1) Elicit and incorporate feedback from the target population throughout development of an Internet-based PA promotion tool; 2) Incorporate new and emerging technologies into Internet-enhanced PA programs; 3) Maintain frequent participant contact and provide frequent incentives to promote participant engagement; 4) Supplement Internet-based efforts with face-to-face interactions; 5) Include diverse images of African-American women and culturally relevant PA-related information in Internet-based PA promotion materials.

Introduction

The benefits of physical activity (PA) are well established for the prevention of weight gain and the promotion of weight loss (U.S. Department of Health and Human Services, 2008; Stephens & Allen, 2012). However, despite these benefits, PA levels among minorities and women, particularly African-American women, remain at insufficient levels (Carter-Parker, Edwards, & McCleary-Jones, 2012). National statistics show that only 36% of African-American women achieve the national recommendations (U.S. Department of Health and Human Services, 2008) of performing 150 minutes of moderate-intensity PA each week (in comparison to 46% of White women) (Centers for Disease Control and Prevention, 2010). The low levels of PA among African-American women are disturbing given the current obesity epidemic in this population (Ogden et al., 2006) as well as the disproportionate burden of chronic diseases associated with insufficient PA (i.e., cardiovascular disease, colon cancer, type II diabetes) (U.S. Cancer Statistics Working Group, 2010).

Background and Significance

Interventions for Overweight and Obesity

Over the past five years, this research team has designed and implemented two culturally-relevant, Social Cognitive Theory-based, Internet-enhanced PA interventions for overweight and obese African-American female college students (Joseph et al., 2014; Joseph et al., 2013). To date, it is believed that these are the only two prospectively designed, culturally relevant PA interventions using the Internet to promote PA among African-American women. The development and implementation of these interventions provided this research team with an abundance of knowledge about the acceptability and feasibility of using the Internet to increase PA among African-American women. Further, feedback from participants provided valuable information regarding future directions for technology-supported approaches to promoting PA in this underserved population.

Purpose of the Study

Due to the limited research on the use of the Internet to promote PA among African-American women, the experiences associated with developing and implementing these two interventions were synthesized and five key lessons learned from this track of research were formulated. Lessons learned are based on questionnaire and focus group feedback from participants and qualitative observations from researchers and study staff. Findings were aimed at providing important insight for researchers who are considering the development of technology-based approaches to promote PA in African-American women.

Methodology

Design, Sample and Setting

Study 1 (Joseph et al., 2013), a descriptive study consisting of 34 participants (N = 34), was conducted in the Fall 2011/Spring 2012 and Study 2 (Joseph et al., 2014), a descriptive study consisting of 31 participants (N = 31), was conducted in the Spring 2013. Both studies used single group pre- post-test designs and were specifically designed to promote PA among African-American women. Participants were recruited from the University of Alabama at Birmingham campus during the fall semesters of 2011 and 2012, respectively. Inclusion criteria for the studies included: a) 19 to 30 years of age at time of study enrollment, b) body mass index (BMI) greater than 25, c) self-identified as African-American, d) enrolled as a student at The University of Alabama at Birmingham, and e) absence of any self-reported medical conditions that would inhibit or limit performance of physical activity. Exclusion criteria for the study included: a) concurrent participation in another physical activity, nutrition, or weight loss program (commercial or research), and b) uncontrolled high blood pressure (defined as greater than 140/90). Table 1 illustrates baseline demographic characteristics of participants enrolled in each study (See Table 1).

Table 1.

Baseline Demographic Characteristics of Participants Enrolled in Both Internet-enhanced PA Promotion Programs.

Variable	Study 1 (N = 34)		Study 2 (N = 31)
	Mean	SD	Mean	SD
Age (years)	21.21	2.30	23.1	3.2
BMI	35.37	6.82	33.8	5.7
	N	%	N	%
Marital Status
Married	1	2.9	0	0
Divorced	1	2.9	2	6.5
Never married	31	91.2	29	93.5
No answer	1	2.9	0	0
Degree Currently Obtaining
Undergraduate	32	94.2	25	80.1
Masters	1	2.9	4	12.9
PhD	1	2.9	2	6.5
Highest Degree Father Obtained
Less than high school	2	5.9	0	0
High school or GED	17	50.0	11	34.4
Associates degree	3	8.8	5	16.1
Bachelors degree	4	11.8	6	19.4
Masters degree	0	0	5	16.1
Doctorate	1	2.9	0	0
Other	2	5.9	0	0
No answer	5	14.1	4	12.9
Highest Degree Mother Obtained
Less than high school	1	2.9	2	6.5
High school or GED	15	44.1	10	32.3
Associates degree	7	20.6	3	9.7
Bachelors degree	5	14.7	6	19.4
Masters degree	0	0	7	22.6
Doctorate	4	11.8	3	9.7
Other	1	2.2	0	0
No answer	1	2.9	0	0

Institutional Review Board Approval

The Institutional Review Board at the University of Alabama at Birmingham approved all study procedures.

Overview of Study Development and Brief Study Results

Website features and study activities for both studies were informed by formative research with the target population (i.e., overweight/obese African-American female college students). Detailed information on the formative research that informed website prototypes can be found elsewhere (Durant et al., 2014), but will be briefly discussed here. In the first phase of study development, qualitative discussion groups using the nominal group technique (n = 2) and traditional focus group methods (n = 2) were conducted to identify features that African-American women preferred in a PA promotion website. Information from this phase was used to build the basic website prototype used in both studies.

The second phases of intervention development for both studies were similar. Specifically, in both studies, 6-week demonstration trials were implemented to pre-pilot each respective study website and the exercise component protocol. In these demonstration trials, participants (n = 15 for Study 1 demonstration trial; n = 29 for Study 2 demonstration trial) accessed their respective study website while concurrently attending alternating weeks of supervised moderate-intensity walking sessions and “think aloud” (Ericsson & Simon, 1993) discussion groups. For the “think aloud” sessions, participants logged into the study website and provided feedback while navigating the site. Data gathered during these discussion groups were used to identify technical problems associated with the website and to provide further feedback for website refinement. Additional details for each study are provided below.

Study 1

Study 1, consisting of 34 participants, was a 6-month, single-arm pilot trial of an Internet-enhanced PA intervention (Joseph et al., 2013). Participants accessed the PA promotion website while attending four supervised exercise sessions (monitored by study staff) each week. For each supervised exercise session, participants were encouraged to either walk at a moderate-intensity pace on the indoor track at the university or to attend a group-based cardiovascular exercise class (i.e., Zumba, step aerobics, kickboxing, etc.).

While there was high attrition in this study (50%), results showed significant improvements in moderate-to-vigorous physical activity from baseline to 3 months (p = .02); however, PA gains attenuated by 6 months and were no longer greater than baseline (p = .31). Significant pre-post-intervention increases in social support (p = .02) and self-regulation (p = .02) for PA were reported. No changes in BMI (p = .64), exercise self-efficacy (p = .18), outcome expectations (p = .38) or PA enjoyment (p = .33) were observed.

Study 2

In Study 2, consisting of 31 participants, the Study 1 website was refined (based on participant feedback from Study 1) and implemented a 3-month, single-arm trial of the improved Internet-enhanced PA program (Joseph et al., 2014). Website refinements included: a) the addition of an “Ask the Doctor” message board, b) inspirational/motivational quotes from African-American women, c) increased number of hair maintenance tips for African-American women engaging in PA, c) a photo gallery of African-American women engaging in PA, and d) healthy eating and PA tips from a physician.

The exercise protocol was also adapted in Study 2 to incorporate additional flexibility in the exercise component of the program. Participants were still asked to engage in a total of four moderate-intensity exercise sessions each week; however, the number of required supervised exercise sessions was reduced to two per week. For the remaining two exercise sessions per week, participants were allowed to exercise by themselves. This study modification was based on feedback from Study 1 participants indicating that attending four supervised exercise sessions each week was difficult due to their school/work schedules.

Results of this study included increased retention from Study 1 (81%), and a significant decrease in sedentary screen time (p < .0001); however, similar to Study 1, no pre- post-intervention changes for PA were reported (p = .150). Participants also reported a significant increase in self-regulation for PA (p < .0001) and marginally significant increases in social support (p = .052) and outcome expectations (p = .057) for PA. No changes in BMI (p = .162), enjoyment of PA (p = .151), or exercise self-efficacy (p = .086) were observed.

Results

Key Lessons Learned

The following lessons learned are based on questionnaires and focus group feedback from participants and qualitative observations from researchers and study staff (See Table 2).

Table 2.

Lessons Learned From Developing and Implementing 2 Internet-enhanced PA Interventions for Overweight and Obese African-American Women Enrolled in College.

Lessons Learned Elicit and incorporate feedback from the target population (i.e., African-American women) throughout development of an Internet-based PA promotion tool. Incorporate new and emerging technologies into Internet-enhanced PA programs (e.g., Smartphone apps, social media). Maintain frequent participant contact (e.g., text messages, email) and provide frequent incentives to promote participant engagement. Supplement Internet-based efforts with face-to-face interactions (e.g., group exercise sessions). Include diverse images of African-American women and culturally relevant PA-related information (e.g., hair maintenance tips) on the study website.

1) Elicit and incorporate feedback from the target population (i.e., African-American women) throughout development of an Internet-based PA promotion tool

An iterative, user-centered design (UCD) (Abras, Maloney-Krichmar, & Preece, 2004) process was used that incorporated participant feedback throughout conceptualization, development, and implementation of both of the Internet-enhanced PA promotion studies. UCD incorporates feedback from intended users of a product (i.e., African-American women for the purpose of these studies) to ensure the desired needs, wants, and preferences of the audience are incorporated into the final design of a product (i.e., PA promotion website). In these studies, the UCD process was used from the onset of website development and continued until the conclusion of each study’s demonstration trial.

We believe that believe that our commitment to formative research and engagement of the target population throughout the research process was key to development of these culturally relevant websites promoting PA. Given the limited research on culturally-relevant approaches to promote PA among young adult African-American women, and the fact that no studies, to our knowledge, have incorporated the Internet as a potential method to promote PA in this underserved population, the UCD process provided the basis of knowledge necessary to develop culturally relevant intervention materials for the target population of overweight and obese African-American female college students.

2) Incorporate new and emerging technologies into Internet-based PA programs (e.g., Smartphone apps, social media)

When the studies were initially funded approximately five years ago (2007–2009), computers were the most frequently used modality to access the Internet (Horrigan, 2009). Similarly, formative research with the study populations reflected this trend with participants identifying a website-based tool as the preferred modality with which to receive a PA intervention. However, over the period of time it took for the team to develop the study websites and perform the demonstration trials, mobile phone technology advanced at a rapid pace and slowly began to become the preferred method in which African-American women enrolled in these studies wanted to receive a PA intervention. In fact, by the close of the second study, 83% of the participants indicated in the follow up survey of the study that they would prefer to receive the study program via text message or a mobile phone application.

In an attempt to evolve with technology, an iPhone application for the study website was developed. However, due to cost and time constraints, the iPhone application was not as interactive as was hoped and lacked some of the features available on the PA promotion website. Moreover, many participants (in both studies) owned other types of Smartphones (i.e., Android or Windows phones); therefore, they were unable to use the iPhone application.

To further address the need for increased website accessibility via mobile phone, in Study 2 the website was reformatted to make it more easily accessible on any mobile phone with Internet capability. Feedback from the mobile website was well received from participants; however, they noted that they would still prefer to access the site through an application function, rather than using an Internet browser. Researchers conducting future technology-based PA interventions should further explore the use of Smartphone technology to promote PA among African-American women and should stay abreast of any other new and/or emerging technologies that have a high prevalence of use in this population.

3) Maintain frequent participant contact (e.g., text messages, email) and provide frequent incentives to promote participant engagement

During the implementation of Study 1, it was anticipated that the study website would be the primary mechanism with which the research team would communicate with participants and deliver PA promotion material. However, as the study progressed, participant website usage and attendance at the supervised exercise sessions slowly declined. Therefore, in an effort to increase participant engagement, participants were provided with reminders (approximately 2 per week via text, email, or telephone according to each participant’s preference) to access the study website and attend the supervised exercise sessions; which resulted in increased study website usage and exercise session attendance. In Study 2, this information learned from Study 1 was incorporated, and from the onset of the study participants were provided with frequent reminders to access the website and to attend the supervised exercise sessions.

Frequent incentives also appeared to be a useful strategy to maintain participant engagement. In Study 1, participants received a monetary incentive of $150 distributed incrementally at 3 time periods (baseline, 3 months, 6 months) over the 6-month study. However, participants informed study staff that they would like to receive monetary incentives on a more frequent basis and they felt that the $150 was not adequate for the participant burden associated with study protocol. Therefore, in Study 2, participants were provided with a higher monetary incentive (i.e., $250), received monetary incentives on a more frequent basis (i.e., bi-weekly), and were provided with additional tangible incentives (i.e., water bottles, sweat bands, bags of healthy snacks) for study participation.

We attribute the aforementioned modifications and refinements made to the Study 2 protocol for some of the improved retention and increased website usage observed (in comparison to Study 1). For example, attrition in Study 1 was 50%, which was much higher than the 19% attrition observed in Study 2. Furthermore, study website usage in Study 2 was almost twice as high as Study 1. It was noted that the duration of Study 2 was half the duration of Study 1 (3 months vs. 6 months); however, the 3-month attrition in Study 1 was 50% and remained stable for the last 3 months of the study. Researchers in future studies should continue to explore how to use incentives and frequency of contact with participants to improve retention and adherence to study protocol.

4) Supplement Internet-based efforts with face-to-face interactions (e.g., group exercise sessions)

At the beginning of each study, an orientation session was held to provide an overview of the study protocol and to demonstrate how to use the study website. These orientations allowed participants to interact face-to-face and were very well-received by participants. In fact, participants in both studies requested additional face-to-face sessions to facilitate group interaction. Since additional group meetings were not originally planned for either study, the research team carefully strategized on how to include these meetings without significantly altering the original study protocol or diluting the effects of the Internet-enhanced intervention. As a solution, two in-person group meetings were scheduled for both studies.

To identify topics and activities for these face-to-face group meetings, participants were queried and asked to identify discussion topics for these group meetings. Participants in both studies reported that they would like to receive information on nutrition (e.g., healthy eating strategies while living in a dorm and how to eat healthy on a budget) and engage in group-based PA with other study participants. Accordingly, for one face-to-face session in each study, a certified dietician presented nutritional information to participants. For the second group session, a certified Zumba instructor led a Zumba class for study participants. Post-intervention consumer satisfaction data showed that these group sessions were well received among participants, with 90% of participants in Study 1 and 100% of participants in Study 2 rating these sessions as “somewhat” to “very” helpful for promoting PA. Moreover, 87% of participants in Study 1 and 84% of participants in Study 2 reported that they gained PA and health-related knowledge by attending the sessions. Observations from research staff (i.e., participant laughter, smiles, and lively conversation were all frequently observed) also indicated that participants enjoyed these sessions as well.

5) Include diverse images of African-American women and culturally relevant PA-related information (e.g., hair maintenance tips) on the study website

The Study 1 website included culturally relevant PA information for African-American women (i.e., links to African-American geared magazines, tips on hair maintenance, etc.) and stock photos of African-American women engaging in PA. However, post-intervention feedback from participants indicated that they would prefer to have more diverse images of African-American women and additional PA-related information specifically geared to African-American women on the website. Therefore, between the implementation of Study 1 and Study 2, a photo shoot was conducted with a diverse sample of young adult African-American women (recruited from the university campus) and these photos were included on the Study 2 website. For the photo shoot, African-American women with varying body shapes and skin colors were intentionally included in order depict the diversity of appearances prevalent among African-American women.

Several features were also added to increase the cultural relevance of the Study 2 website. An “Ask the Doctor” message board was added, where the study’s PI (NHD), an African-American female physician, would answer participants’ questions and provide motivational messages to participants. Inspirational and motivational quotes from well-known African-Americans (i.e., celebrities, political figures) were also featured throughout the study website. Additionally, the number of African-American hair maintenance tips was increased, including additional links to other websites that provide information on how African-American women can maintain hairstyles while being physically active, and message boards for participants to share their own experiences associated with PA were facilitated. It is believed that all of these refinements included in the Study 2 website increased the cultural relevance and led to the positive satisfaction outcomes reported by participants. For example, in Study 1 only 47% of participants indicated they were “satisfied” or “very satisfied” with the Internet-enhanced PA program, in comparison to 96% of participants in Study 2.

Discussion

The purpose of this paper was to help inform future technology-based approaches to promote PA among minority populations, especially overweight and obese young adult African-American women. The lessons learned presented in this paper illustrate both the challenges and successes of this research. Processes and experiences outlined in this article highlight the need for fluidity and flexibility when designing and implementing technology-based PA promotion programs for young adult African-American women.

It is believed that the commitment to formative research and the UCD process during intervention development were the key reasons for improved retention, increased website utilization, and improvements in various PA-related psychosocial variables in Study 2 when compared to the outcomes of Study 1. It is noted that while both studies lacked significant improvements in PA, enhancements in various PA-related SCT constructs (i.e., self-regulation, social support, etc.) were observed, which are often antecedents to behavior change.

The current paper adds to the limited research on technology-based approaches to promote PA among African-American women. While this is not the first research team to describe lessons learned from development and implementation of culturally relevant PA interventions for African-American women; this is the first team to describe lessons learned from the development of technology-based PA interventions for this underserved population. These findings should be viewed as complementary and placed in the context of lessons learned described by previous researchers (Cowart et al., 2010; Murphy & Williams, 2013; Wilder, Schuessler, Hendricks, & Grandjean, 2010; Wynn et al., 2011).

Limitations of the Study

Several limitations of this research must be noted. The samples of both studies were small, relatively homogeneous, and consisted of overweight and obese African-American women enrolled in college. Therefore, the findings cannot be generalized to women of normal weight, to women of other races, or to those not enrolled in college.

Conclusions

The lessons learned presented in this article highlight important issues and considerations that can be used by future researchers conducting technology-based PA research among minority women. As time and technology continues to advance at a rapid pace, researchers should strive to stay abreast of the prevalent modes of technology used by their target population and harness those efforts in order to promote PA.