Table 4.

Lessons Learned from the Strong Hearts, Healthy Communities Program: Focus Group (n=46) and Interview (n=15) Responses

Theme 1: Positive Aspects of Overall Program
Subtheme	Respondent	Selected Quotes
Thorough and organized content	Leaders/coordinators and participants	“I just thought it was a fantastic program…as far as how it was organized and the content material…you know, it covered a wide range of topics...and it was all very well put together and very well done.” (Participant_MT_01)
Group camaraderie	Participants	“…in the beginning, I thought there was no way I could do this twice a week for six months. And then, it was just so much fun! I hated it if I had to miss one! Just the support…it really provided the motivation I needed to make changes.” (Participant_MT_01)
Dedication of leaders and coordinators	Leaders/coordinators and participants	[Leaders were] very supportive! If anyone seemed like…they were having trouble with anything, they’d always stop and check with you to make sure that everything was okay. (Participant_NY_08) “Having a…co-leader was...amazing, and I would not have been able to do it without her.” (Leader_MT_05)
Theme 2: Negative Aspects of Overall Program
Subtheme	Respondent	Selected Quotes
Insufficient class time	Leaders/coordinators and participants	“So often there wasn’t time to go through the curriculum...and even when we could go through the curriculum...there just wasn’t enough time...to make it really meaningful or powerful to them.” (Leader_MT_03)
Limited social influence and support	Leaders/coordinators and participants	“I think the friends and family part of it would have been much bigger in our community if we stressed to them how much they needed to be doing this at home. It wasn’t just come to the class and do it, but try to bring it home with you…this is not a two day a week lifestyle change, it’s a seven day a week lifestyle change.” (Coordinator_MT_06) “I don’t know how effective it [social support content] was for the women...a lot of them have stress in their lives that I can’t even relate to…A big problem for our participants was that their husbands, or their families, refused to eat healthy… so they ended up having to make two dinners. And so it’s always this constant difficulty for them.” (Coordinator_MT_03)
Theme 3: Recommendations for Overall Program
Subtheme	Respondent	Selected Quotes
Extending class time	Leaders/coordinators and participants	“…the class was not long enough, [laugh]...it was supposed to be an hour...but, it was just not enough time. Most of the time it averaged I would say an hour and a half...and it didn’t seem to bother them. So, I think if you’re going to have the education piece and the exercise bit...you definitely need to have more than just an hour.” (Leader_MT_04) “One of the things I would see as a change in the program would be to have more time for the discussion groups…When we got into having a half-hour of aerobic exercise and then fifteen minutes of strength training, it didn’t really leave any time to discuss all the stuff that was in the book.” (Participant_NY_07)
Reorganizing content	Leaders/coordinators and participants	“The food portion…such as meal planning and…dealing with family, that was more towards the end of the curriculum...that would be a great thing just to start out with. That way they’re trying to make those changes from the beginning.” (Coordinator_MT_04)
Emphasizing goal setting	Leaders/coordinators	“…I think that the goals are very important. But we didn’t follow through with the goals! To me if I was changing the curriculum, every week we would have had a goal. You set your goals, and you...look at your neighbor and say, “Here’s my goals.” Then you follow back up on them.” (Leader_MT_02)
Theme 4: Positive Aspects of Physical Activity Components
Subtheme	Respondent	Selected Quotes
Exercise enjoyment	Leaders/coordinators and participants	“I’m just glad you introduced us to the walking videos…in the winter, to go outside and walk … I guess you could do it, but if it’s icy or something you’re not going to. And those videos they really give you what you need, and by the time you’re done that thirty minutes doesn’t seem like thirty minutes!” (Participant_MT_03)
Peer support and accountability	Participants	“And I know it’s a lot easier to do lunges and squats with that group than it is when I’m [laugh] by myself, I’m like, „Oh yep, seven, I’m done.‟” (Participant_MT_02)
Fitbit usage	Participants	“My motivation was the Fitbit...because I have been dealing with my illness for two years, and it pulled me out of a... slump, because it gave me a reason to move...and I did not, honest to God, quit until I hit that ten thousand steps, every day, and...it was the greatest thing.” (Participant_MT_01)
Theme 5: Negative Aspects of Physical Activity Components
Subtheme	Respondent	Selected Quotes
Complex aerobic routines	Leaders/coordinators and participants	“In the aerobic dance, they’re moving across the floor in different directions…and people would get a little discombobulated... you’re not really working out, you’re just trying to stay where you’re supposed to be...people weren’t able to follow that quite as easily, so it got a little off-track.” (Leader_MT_02)
Inconsistent and difficult strength training	Leaders/coordinators	“So, for weights... when we were following the curriculum it was sporadic, so you might do... bicep curls, squats, and lunges today, but then we didn‟t do those three things again over the next month. And so, those women unless they were doing them at home, didn’t gain any benefit from just doing their reps that one day.” (Coordinator_MT_02)
Theme 6: Recommendations for Physical Activity Components
Subtheme	Respondent	Selected Quotes
Improving variety and consistency	Leaders/coordinators and participants	“It would be nice to get into a pattern…if we’re meeting on Tuesdays and Thursdays, we’re going to go through and we’re going to do all of these exercises...maybe we have to whittle it down a little but we’re going to do all of them twice a week, so that way they get a consistent benefit.” (Coordinator_MT_02) “I guess there could have been a little more variety... We bought some videos ourselves, and a lot of us had different ones... Maybe that could have been something... a few time have members bring in the videos they like...Just to mix it up a little.” (Participant_MT_06)
Modifying strength exercises	Leaders/coordinators	“And some of them weren’t willing...to get, or able to get down on the ground, so having alternatives for those folks, I mean even though the goal is to give them the confidence that if they...did fall or anything, they could get back up and to try to build some of that...balance and coordination.” (Leader_NY_07)
Theme 7: Positive Aspects of Nutrition Education
Subtheme	Respondent	Selected Quotes
Awareness of healthy strategies	Participants	“It just makes you more aware, and you’re...reading labels more...thinking more about...portion size…and what you’re eating...those kinds of things...so, yes, it was worthwhile!” (Participant_NY_07)
Exposure to new foods	Participants	“You know, they made a lot of snacks that I enjoyed, that I wouldn’t have thought about eating...that were really quite good, and I probably wouldn’t have tried them if I would have just read the recipe...but after trying them I definitely would have made some of them.” (Participant_MT_06)
Theme 8: Negative Aspects of Nutrition Education
Subtheme	Respondent	Selected Quotes
Extensive preparation time	Leaders/coordinators	“…they took so much of our time to prepare... we were having to use what would have regularly been office time and after hours‟ time... so that we could get them to the class every night.” (Leader_MT_04)
Limited applicability	Leaders/coordinators	“I think we gave out a lot of information, and I think we needed to be a little more proactive…we just gave out information, but there wasn‟t a whole lot of accountability, so it was like “Here‟s this, do what you will with it” …So a lot of people they close their binders, they go home, that‟s the end of it.” (Leader_MT_02)
Inadequate food access	Leaders/coordinators and participants	“In a rural area…we don’t quite have access to all the healthier type foods…When you go into the big cities the produce department is humungous…in my community, it‟s probably about a twenty-foot section [laugh] that’s about four-foot deep...And it’s expensive, a lot of fresh produce around here is expensive.” (Participant_MT_03)
Theme 9: Recommendations for Nutrition Education
Subtheme	Respondent	Selected Quotes
Sharing food preparation	Leaders/coordinators and participants	“...we’re going to continue in September, start up again, just cause summer’s busy, and they were willing to <bring snacks>... Especially now that the funds aren’t there...that’ll be excellent for our group.” (Coordinator_MT_04)
Increasing discussion time	Participants	“...we all knew a lot of the information but when somebody would say, „Oh! This has really worked for me!‟… there was a lot of ideas on getting your water intake...some people were really struggling with that… and I don’t know, we got a lot from each other” (Participant_MT_06)