Improving Cardiovascular Health Among African-Americans Through Mobile Health: the FAITH! App Pilot Study

INTRODUCTION

African-Americans (AAs) have 82% lower odds than whites of meeting five or more ideal cardiovascular (CV) health components comprising the American Heart Association (AHA) Life’s Simple 7 (LS7), an evidence-based metric of seven health-promoting behaviors and biologic factors that, at ideal levels, improve CV outcomes (diet, physical activity [PA], cigarette smoking, body mass index [BMI], blood pressure [BP], total cholesterol, fasting glucose).¹ Mobile health (mHealth) interventions are promising for promoting CV health within this population.² Culturally relevant health interventions delivered through community-based participatory research (CBPR) approaches have proven successful in substantially impacting specific CV risk factors (e.g., hypertension) in AAs.³ However, to our knowledge, our study is the first mHealth intervention targeting multiple risk factors by promoting ideal CV health (LS7) for AAs. We hypothesized that an evidence-based, theory-informed, culturally relevant, community-based mHealth lifestyle intervention would improve CV health among AA adults.

METHODS

The study was approved by the Mayo Clinic Institutional Review Board and registered (clinicaltrials.gov [NCT03084822]); participants provided written informed consent. Details on study rationale, recruitment procedures, and participant inclusion/exclusion criteria have been described.⁴ Briefly, we collaborated with five predominately AA churches in Minnesota using a CBPR approach to co-design a CV health and wellness digital application–based program (Fostering African-American Improvement in Total Health [FAITH!] App) as a translation from a previous in-person intervention to promote CV health. We enrolled 50 AA adults from partnering churches with multiple CV risk factors into a single-group pilot study of a 10-week intervention through the FAITH! App. The FAITH! App included 10 core multimedia education modules with videos from health professionals on CV health, interactive diet/PA self-monitoring, and social networking through a discussion/sharing board. Baseline data were collected in July 2016 and follow-up data at 28 weeks postintervention (April 2017) by trained research nursing staff at in-person health assessments and by self-administered electronic surveys. The primary outcome was change in CV health biologic factors (BP, total cholesterol, fasting glucose) and behaviors (diet, PA, cigarette smoking, BMI) from baseline to postintervention (28 weeks). Our secondary outcome was change after 28 weeks in LS7 composite score (calculated by summing scores of LS7 components by AHA-defined criteria: 2 points, ideal; 1 point, intermediate; 0 points, poor [range, 0–14 points]; total score ≥ 9, ideal).⁵ Paired outcomes were compared with Wilcoxon signed rank tests (ordinal or continuous variables) or McNemar tests (categorical variables). All analyses were conducted in 2017 with SAS version 9.3 (SAS Institute Inc.).

RESULTS

Participants’ demographic characteristics are presented in Table 1 (70% women [35/50]; mean [SD] age, 49.6 [12.7] years; 58% < college-graduate education [29/50]). At baseline, 40% of participants had hypertension, 86% were overweight/obese, and over 70% had poor/intermediate diet or PA. Study retention at 28 weeks was 98% (49/50). At 28 weeks, substantial improvements occurred in some CV health biologic factors (systolic BP, 133.3 to 127.1 mmHg, P = .002; diastolic BP, 82.8 to 77.1 mmHg, P < .001) and behaviors (diet, 3.4 to 4.5 fruit/vegetable servings/day, P < .001; moderate-intensity PA, 35 to 75 min/week, P = .04). The LS7 composite score increased from 8.3 to 9.0 within the ideal CV health-score range (P = .05) (Table 2).

Table 1.

Sample Baseline Characteristics ( N = 50)

Characteristic	No. (%)*
Sex
Male	15 (30.0)
Female	35 (70.0)
Age (years)
Mean (SD)	49.6 (12.7)
Relationship status
Single	9 (18.0)
Divorced	7 (14.0)
Widowed	2 (4.0)
Married or committed relationship	32 (64.0)
Education level
High school graduate or less	6 (12.0)
Some college	12 (24.0)
Technical or Associate’s degree	11 (22.0)
College graduate or higher	21 (42.0)
Employment status
Employed, at least part-time	37 (74.0)
Unemployed	9 (18.0)
Retired	4 (8.0)
Annual household income
< $20,000	5 (11.1)
$20,000–$49,999	19 (42.2)
$50,000–$74,999	9 (20.0)
≥ $75,000	12 (26.7)
Chose not to disclose	5
Health insurance	48 (96)
Regular health care provider visits
Yes	44 (88)
No	6 (12)
Self-reported medical history
Overweight/obese	31 (62)
Hypertension	27 (54)
Type 2 diabetes mellitus	10 (20)
Hyperlipidemia	8 (16)

*Unless otherwise indicated

Table 2.

Changes in Cardiovascular Health

Variable*	Baseline	Postintervention	P value
Cardiovascular health factors
Systolic BP (mmHg)	133.3 (18.9)	127.1 (19.3)	.002
Diastolic BP (mmHg)	82.8 (10.3)	77.1 (12.0)	< .001
BP control
BP < 140/90, no. (%), mmHg	29 (59.2)†	40 (81.6)†	.005
BP < 130/80, no. (%), mmHg	13 (26.5)†	23 (46.9)†	.008
Total cholesterol (mg/dL)	182.8 (39.8)	185.1 (44.2)	.21
Fasting glucose (mg/dL)	89.1 (34.2)	86.4 (15.2)	.81
Cardiovascular health behaviors
Diet: fruit/vegetable intake, servings/day‡	3.4 (1.4)	4.5 (1.8)	< .001
Physical activity: moderate intensity, minutes/week, median, IQR	35 (0–110)	75 (25–188)	.04
Cigarette smoking status, current, no. (%)	1§ (2.2)	1§ (2.2)	1.0
BMI (kg/m2)	33.1 (7.3)	33.0 (7.1)	.48
Life’s Simple 7 composite score	8.3 (2.2)	9.0 (2.1)	.05

BMI, body mass index; BP, blood pressure; IQR, interquartile range

*Mean (SD) unless otherwise indicated

†Data missing for 1 patient

‡Adapted definition of diet from American Heart Association–defined healthy 5-component dietary pattern

^§Data missing for 5 patients

DISCUSSION

This small-scale, pre/post pilot study supports benefits of a culturally relevant, community-based mHealth lifestyle intervention for promoting CV health among AAs with high cardiometabolic risk. Recent analyses of National Health and Nutrition Examination Survey (NHANES) data show persistent CV health disparities by LS7 composite scores between whites and AAs and call for multifaceted, community-level interventions to curtail and eradicate these gaps.⁶ Our intervention, although a research prototype, offers an innovative medium to engage AA patients beyond office-based encounters through mobile technology with an overarching goal of diminishing CV disease risk and mortality.

Small sample size, no control group, relatively short study duration, and a convenience sample of predominantly women limit generalizability. Also, longitudinal data on health care utilization and medication adherence were not collected. However, our intervention had low attrition and several objectively measured positive outcomes for CV health, which are reflective of our formative work and prioritization of community engagement. A randomized controlled trial is planned to assess efficacy of the FAITH! App.

CONCLUSIONS

Culturally relevant, community-based mHealth interventions such as the FAITH! App may have potential to improve CV health among AAs.

Abbreviations

AA

African-American

AHA

American Heart Association

BMI

Body mass index

BP

Blood pressure

CBPR

Community-based participatory research

CV

Cardiovascular

FAITH!

Fostering African-American Improvement in Total Health

LS7

Life’s Simple 7

mHealth

Mobile health

NHANES

National Health and Nutrition Examination Survey

PA

Physical activity

Funders

Dr. Brewer is supported by the Building Interdisciplinary Research Careers in Women’s Health Scholars Program (award number K12 HD065987-07) from the National Institutes of Health (NIH) Office of Research on Women’s Health, Mayo Clinic Women’s Health Research Center, and the National Center for Advancing Translational Sciences (Clinical and Translational Science Awards Grant Number KL2 TR002379), a component of the NIH. This study was further supported by the Mayo Clinic Center for Innovation, Mayo Clinic Center for Translational Science Activities (UL1TR000135), Mayo Clinic Department of Cardiovascular Medicine, and Mayo Clinic Office of Health Disparities Research.

Compliance with Ethical Standards

The study was approved by the Mayo Clinic Institutional Review Board and registered (clinicaltrials.gov [NCT03084822]); participants provided written informed consent.

Conflict of Interest

The authors declare that they do not have a conflict of interest.

Disclaimer

The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. The funding source had no role in the design and conduct of the study; collection, management, analysis, or interpretation of data; preparation, review, or approval of the manuscript; and the decision to submit the manuscript for publication.