Tailoring Mobile Health Technology to Reduce Obesity and ImproveCardiovascular Health in Resource-Limited Neighborhood Environments: A Multi-Level, Community-Based Physical Activity Intervention

华盛顿特区心血管(CV)健康和需求评估中的女性数据为未来体力活动(PA)干预队列的mHealth用户参与度提供了初步见解。在参与评估的女性(99%非裔美国人的平均年龄=59(12)岁)中，90%的人身体质量指数(BMI)被归类为超重或肥胖，其中30%为I级肥胖，19%为II级肥胖，17%为III级肥胖。在不同的体重等级中，PA降低(p0.05)，自我报告的久坐时间增加(p0.05)。尽管在不同体重类别的女性中，舒张压和空腹血糖显著增加，但血压、胆固醇和血糖相对得到很好的控制，平均值与美国心脏协会CV健康临界点的理想或中等水平一致。在参与研究的妇女中，在30天的研究期内，PA监测系统的遵从性保持在60%以上，肥胖症妇女在研究期内的遵从性类似。因此，将mHealth技术与CBPR战略一起部署可以帮助PA在资源有限的社区中改善非裔美国女性的心血管健康。 作为干预的第一步，我们收集了定性数据，为开发一款在华盛顿特区的非裔美国女性中推广PA的移动应用程序提供信息。我们从华盛顿特区心血管疾病负担最重的地区招募了一个方便的非裔美国女性样本(N=16，年龄范围51-74岁)。参与者使用了研究团队开发的一款应用程序，该应用程序通过应用程序推送通知和教育内容提供激励信息，以推广PA。随后，参与者在主持人的带领下进行了半结构化的焦点小组访谈，主持人就参与者使用该应用的经历提出了开放式问题。焦点小组被录音并逐字转录，随后进行以行为理论为导向的主题分析。从成绩单中确定了基于健康信念模式的关键主题和新出现的主题。三名独立的审查员反复对文字记录进行编码，直到达成共识。然后，最终的码本得到了一位定性研究专家的批准。在这项研究中，出现了10个主要主题。与会者强调，需要通过优化自动化、提高关联性(如反映目标人群的照片)、增加教育材料(如健康信息)以及与社区资源(如烹饪课程和锻炼小组)连接来改进这款应用程序。让目标用户参与开发具有文化敏感性的PA应用程序，是创建一个在技术支持的干预中更有可能被接受和使用的应用程序的关键一步。这可能会通过更有效地增加少数群体的PA来减少心血管疾病的健康差距。 为了更深入地了解针对PA的干预措施的效用，我们在杰克逊心脏研究中使用流行病学数据来检查PA作为邻里社会环境感知和抑郁症状之间关系的中介，这是一项对来自密西西比州杰克逊的非裔美国成年人(n=2209)进行的前瞻性、基于社区的队列研究。感知的社会环境由感知的邻里暴力(得分越高=暴力越多)、邻里问题(得分越高=问题越多)和社会凝聚力(得分越高=凝聚力越强)来定义。采用美国流行病学研究中心抑郁量表(CES-D)评定患者抑郁症状。多水平建模被用来估计每个社会环境因素和抑郁症状评分之间的关联，并调整协变量。以自述PA为中介变量，控制所有协变量，用Bootstrap生成的95%偏差校正可信区间进行多元线性回归估计，以检验邻里社会环境与抑郁之间的显著非标准化间接效应。更严重的邻里暴力和问题与更严重的抑郁症状有关。邻里暴力和问题也与抑郁症状间接相关。社会凝聚力与抑郁症状没有直接或间接的关系。PA似乎在知觉的社会环境和抑郁症状之间的关系中起中介作用。这些结果表明，对于非裔美国人来说，改善个人对邻居的看法可能有利于提高PA水平，这可能会影响心理健康和简历健康。 最后，鉴于冠状病毒病-2019年(新冠肺炎)大流行中的种族和民族差异，以及美国国内围绕健康差异的持续问题，我们提供了行为干预(包括PA干预)在此期间缓解心理社会压力源和促进健康行为的作用的视角。在大流行期间，包括PA在内的健康促进行为受到了更多的关注。然而，结构性种族主义和对邻里环境的社会经济影响的差异可能会限制健康行为在一些不同的社区中可能发挥的缓解作用。因此，在COIVD-19大流行期间，在环境和感知障碍的背景下，考虑使用多级别健康行为干预措施，例如多级别PA干预措施，可能很重要。

Data on women in the Washington, DC Cardiovascular (CV) Health and Needs Assessment provided initial insights into mHealth user engagement for the future physical activity (PA) intervention cohort. Among women in the assessment (99% African American mean age=59 (12) years), 90% had a body mass index (BMI) categorized as overweight or obese, with 30% having Class-I obesity, 19% having Class-II obesity, and 17% having Class-III obesity. Across weight classes, PA decreased (p0.05) and self-reported sedentary time increased (p0.05). Although diastolic blood pressure and fasting blood glucose significantly increased across weight categories among women, blood pressure, cholesterol, and glucose were relatively well-controlled with mean values consistent with ideal or intermediate levels of the American Heart Associations CV health cut-points. PA-monitoring system compliance remained above 60% for the 30-day study period among women participating in the study, with similar compliance among women with obesity over the study period. Therefore, deployment of mHealth technology with CBPR strategies can help target PA for improving cardiovascular health among African American women in resource-limited communities. As a first step for the intervention, we gathered qualitative data to inform the development of a mobile app that promotes PA among African American women in Washington, DC. We recruited a convenience sample of African American women (N=16, age range 51-74 years) from regions of Washington, DC metropolitan area with the highest burden of cardiovascular disease. Participants used an app created by the research team, which provided motivational messages through app push notifications and educational content to promote PA. Subsequently, participants engaged in semi-structured focus group interviews led by moderators who asked open-ended questions about participants experiences of using the app. Focus groups were audio-recorded and transcribed verbatim, with subsequent behavioral theory-driven thematic analysis. Key themes based on the Health Belief Model and emerging themes were identified from the transcripts. Three independent reviewers iteratively coded the transcripts until consensus was reached. Then, the final codebook was approved by a qualitative research expert. In this study, 10 main themes emerged. Participants emphasized the need to improve the app by optimizing automation, increasing relatability (eg, photos that reflect the target demographic), increasing educational material (eg, health information), and connecting with community resources (eg, cooking classes and exercise groups). Involving target users in the development of a culturally sensitive PA app is an essential step for creating an app that has a higher likelihood of acceptance and use in a technology-enabled intervention. This may decrease health disparities in CVD by more effectively increasing PA in a minority population. To gain more insights into the utility of interventions targeting PA, we used epidemiologic data to examine PA as a mediator of the relationship between neighborhood social environment perceptions and depressive symptoms in the Jackson Heart Study, a prospective, community-based cohort study of African-American adults from Jackson, Mississippi (n=2209). Perceived social environment was defined by perceived neighborhood violence (higher score=more violence), neighborhood problems (higher score=more problems), and social cohesion (higher score=more cohesion). Depressive symptoms were measured by the Center for Epidemiologic Studies Depression Scale (CES-D) score. Multilevel modeling was used to estimate associations between each social environment factor and depressive symptom scores, adjusting for covariates. Multivariable linear regressions with bootstrap-generated 95% bias-corrected confidence intervals were estimated to test for significant unstandardized indirect effects between neighborhood social environment and depression with self-reported PA as a mediator, controlling for all covariates. Greater perceived neighborhood violence and problems were related to greater depressive symptoms. Neighborhood violence and problems were also indirectly related to depressive symptoms. Social cohesion was not directly or indirectly related to depressive symptoms. PA appears to mediate the relationship between perceived social environment and depressive symptoms. These results suggest that for African Americans, improving individuals neighborhood perceptions may be beneficial for increasing PA levels, which can influence psychological well-being and CV health. Finally, given the racial and ethnic disparities within the coronavirus disease-2019 (COVID-19) pandemic and the ongoing issues surrounding health disparities within the United States, we provided a perspective on the role for behavioral interventions, including PA interventions, to mitigate psychosocial stressors and promote health behaviors during this time. Within the pandemic, there has been more attention on health-promoting behaviors, including PA. However, disparities from structural racism and socioeconomic effects on neighborhood environments may limit the possible mitigating role of health behaviors within some disparate communities. Therefore, it may be important to consider the use of multilevel health behavior interventions, such as multilevel PA interventions, designed in the context of environmental and perceptual barriers during the COIVD-19 pandemic.