Rural Appalachians suffer among the worst health profiles in the US including elevated
rates of cardiovascular disease. Although a healthy diet and active lifestyle can reduce
mortality and morbidity, only 12% of rural Appalachian Kentuckians consume the
recommended daily intake for fruits and vegetables and nearly 35% indicate no physical
activity. Personal technology is increasingly common in rural Appalachia, presenting a
new opportunity to prevent and manage chronic disease. Most (68%) Appalachian Kentuckians
have smart phones and reliable internet access (78%). We propose the first (to our
knowledge) adapted evidence-based, multicomponent mHealth (mobile health) intervention
program among rural Appalachians. The Make Better Choices 2 (MBC2) intervention has
produced significant and sustained improvements in diet and physical activity, using
personalized health coaching, an app, accelerometer, and financial incentives. Because of
sparse local resources, rural Appalachian residents could greatly benefit from access to
appropriate virtual resources through health coaching and mHealth.
In this study, 350 participants will be randomized to receive either the adapted MBC2 or
a stress management program. The primary outcome, diet and activity improvement, is a
composite change score relative to baseline scores for fruit and vegetable (F/V) intake,
fat, physical activity, and sedentary leisure screen time.
Adapted MBC2 intervention content:
The program consists of four interconnected components: (1) app, (2) accelerometer, (3)
health coaching, and (4) behavioral incentives. These components encompass behavioral and
implementation principles-effectiveness, scalability, and synergy and correspond to the
Goal Systems Theory, enhanced by sociocultural and environmental considerations.
App: As demonstrated in recent research, increasing personal technology use among
rural populations provides a new opportunity for health equity. Apps and
accelerometers enable connectivity, accountability, and personalization between
participants and their coaches. This app includes a decision support system and
display that helps participants monitor fruit & vegetable (F/V) intake,
moderate-vigorous physical activity, and sedentary screen time relative to their
daily target. This daily diet and activity data entry is a core component of the
MBC2 intervention rather than an outcome or assessment. The app also transmits this
information to a web-based dashboard accessed by coaches, who use it to tailor
telephone counseling.
During the in-person training, participants will be given materials to help in
portion size estimation, plus reminders that entries are time and date-stamped to
encourage prompt entry. The app involves automatic wireless data uploading, which
enables detection of entry error or non-adherence to protocols. Additional
procedures to support adherence to personal goals include: a) visual thermometers to
provide feedback about intake and expenditure relative to targets; b) ability to
access smart phone diet and activity databases to support decision-making about diet
and activity choices; c) visual feedback about goal progress throughout the day to
guide self-regulation; and d) use of stepped goals to facilitate incremental
attainment of targets. Diet and activity data to assess intervention effectiveness
will additionally be collected at the assessment periods via REDCap (baseline and
months 3 and 9).
Accelerometer: Activity monitors also enhance accountability. Our prior work shows
that Appalachian residents have high levels of adherence and satisfaction with
accelerometers. For the proposed study, participants will be given a gold standard
accelerometer, the triaxial Actigraph GT9X. They will wear it on the non-dominant
wrist daily during the intervention. The accelerometer collects data on three axes
at a 100 Hz sampling rate, which will be sent via API (application program
interface) to display minutes of MVPA (moderate-to-vigorous physical activity) on
the study smart phone application as feedback to the participant.
Telephone coaching has demonstrated scalability (particularly in more isolated rural
locations), effectiveness, and greater reach than in-person counseling. In addition
to these benefits, during preparatory focus groups, Appalachians indicated that they
prefer telephone coaching over group meetings (due to lack of privacy,
time-consuming trips) or home visits (too intrusive). Despite these benefits,
telephone coaching is associated with more modest behavioral changes that can
undermine longer-term behavior change.
Behavioral incentives: An incentive is provided weekly to participants in both
conditions if their behavioral average meets goal criterion for the correct use of
the app (for data collection) and adherence to behavioral targets (F/V consumption,
physical activity and sedentary activity or stress management).