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Recommendations for a Culturally Salient Web-Based Physical Activity Program for African Americans

Kariuki, Jacob K.1; Gibbs, Bethany B.1; Davis, Kelliann K.1; Mecca, Laurel P.1; Hayman, Laura L.2; Burke, Lora E.1

Translational Journal of the American College of Sports Medicine: January 15, 2019 - Volume 4 - Issue 2 - p 8–15
doi: 10.1249/TJX.0000000000000077
Original Investigation
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ABSTRACT Barriers to physical activity (PA) among African Americans (AA) have been extensively studied, yet there is limited research on innovative PA interventions designed to address them. In recent years, many studies have used the Internet to promote PA, but very few have included AA. In this study, we sought the input of AA focus groups to inform the development of a web-based Physical Activity for the Heart program for inactive AA. A qualitative design involving four focus groups stratified by sex and age was used to explore the needs and preferences for resources of AA to be included in the Physical Activity for the Heart program. We used an inductive approach to content analysis to analyze data using ATLAS.ti 7.5. Sixteen women and 10 men (age 30–65 yr) participated in the focus groups. Participants were obese (mean body mass index, 32.2 ± 5.4 kg·m−2) with below average confidence rating (mean 46.4% ± 19.1%) on the Barriers Self-Efficacy Scale. Three main themes emerged from the data: 1) need to see similar others engaging in PA (workout videos featuring models with relatable body size, age, and ethnicity), 2) flexible PA regimen (doable at any time/setting), and 3) age and sex differences in preferences for PA resources (religion, music, and intensity). These data suggest that specific intervention components, i.e., PA models who match participants’ profiles, flexibility, and tailoring to age/gender groups, could improve uptake of web-based PA programs designed for inactive AA. Therefore, a precision health approach needs to be used when designing interventions to promote PA among inactive AA.

1University of Pittsburgh, Pittsburgh, PA; and

2University of Massachusetts, College of Nursing and Health Sciences, Boston, MA

Address for correspondence: Jacob K. Kariuki, Ph.D., School of Nursing, University of Pittsburgh, 3500 Victoria Street, 415 Victoria Building, Pittsburgh, PA 15213 (E-mail: kigok@pitt.edu).

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INTRODUCTION

Physical inactivity (PA) has been described as the “biggest public health problem of the 21st century” (1). Despite the dose–response relationship between physical inactivity and a host of chronic illnesses including cardiovascular disease (CVD), (2) very few Americans (21%) adhere to the recommended 150 min·wk−1 of moderate-to-vigorous PA (3,4). African Americans (AA) in particular report very low levels of PA (18%) and the highest burden of CVD in the United States (50%) (4,5). Common barriers to PA such as lack of time, low exercise self-efficacy, and lack of motivation are pervasive in all racial/ethnic groups (4,6). In addition to these barriers, there is a growing body of research pointing to the role socioenvironmental factors in perpetuating the extremely low levels of PA observed in AA (7,8).

Although the sociocultural and environmental correlates of PA adherence among AA have not been extensively studied, the available evidence suggests that barriers related to the conditions in which people live, work, and play are particularly challenging to AA (8,9). In a systematic review that explored the impediments and facilitators of PA among AA, Siddiqi et al. (10) identified lack of childcare, cost of joining fitness clubs, neighborhood safety, and lack of parks and open spaces as the leading socioenvironmental barriers to PA. Other studies have reported barriers related to lack of PA models and interventions with a cultural appeal to AA (7,11). Building on these data, multiple studies have suggested the need for designing culturally relevant interventions that take into account the individual and socioenvironmental barriers to PA that are particularly challenging to AA (9,10,12).

In recent years, programs using the Internet and technology have been developed to promote PA in various settings, including the home environment (13). The main benefits associated with the web-based PA programs include scalability, cost-effectiveness, convenience, and the capacity to deliver tailored intervention messages to participants in real time (14). Currently, many web-based PA interventions are designed to provide online access to print-based resources that encourage behavior change, goal setting, and self-monitoring (14). These strategies have been demonstrated to be effective in predominantly White samples where they have been tested (14,15). However, very few studies have included a significant number of AA or resources designed to mitigate their PA barriers (14). A 2013 review of literature identified only 2 out of 72 studies that enrolled at least 20% AA in their web-based PA interventions (14). Moreover, none of the 72 studies included in the review were designed or adapted for AA (14).

Despite the paucity of data, preliminary studies exploring the therapeutic potential of web-based PA interventions designed for minorities suggest they can be efficacious and cost-effective in promoting adherence to PA goals (16,17). In addition, qualitative studies suggest that AA have a favorable view of using the Internet to address their barriers to PA via resources that relate to their lives and experiences (10,12). With 78% of AA connected to the Internet (18), the technology provides a promising and scalable avenue for designing and disseminating interventions that could address some of their most challenging PA barriers (9).

This article describes our study that used qualitative methods as part of our efforts to leverage the Internet in developing an intervention designed to promote PA among inactive AA. We conducted focus group discussions with AA men and women to identify their preferred and culturally salient web-based resources that could help mitigate their barriers to PA.

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METHODS

Design and Setting

The University of Pittsburgh Institutional Review Board approved the study protocol, and all participants provided a written informed consent before participating in the study. Eligibility was based on self-reported metrics: 30 to 65 yr old, AA, inactive lifestyle (<75 min PA per week), no history of CVD, no serious mobility restrictions, not pregnant, and residing in Allegheny County. Recruitment strategies included the following: University of Pittsburgh’s online research registry, e-mail announcements to the university community, and face-to-face/flyer recruitment in areas frequented by AA (e.g., barbershops and churches). Participants were compensated with $40 to cover transportation and participation in the sessions.

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Focus Group Structure

We convened four separate focus groups stratified by sex and age (30–45 and 46–65 yr) to explore AA needs and preferences for resources to be included in the Physical Activity for the Heart (PATH) program. Focus groups 1–2 (FG1–FG2) were attended by women only and FG3–FG4 by men only. An experienced focus group facilitator (LPM) used a semistructured interview guide to moderate the sessions between May and June 2017. Each session lasted about 90 min, and the data were captured using audio recording and field notes.

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Measurements and Procedures

Before commencing the focus groups, we collected demographics and health history data and requested each participant to respond to the Barriers Self-Efficacy Scale that measures perceived ability to engage in PA when faced with typical barriers to PA on a scale ranging from 0% (not confident) to 100% (highly confident) (19). Assessments included weight (Tanita digital scale [Arlington Heights, Illinois], wearing lightweight clothing), height (wall-mounted tape measure, bare feet), and blood pressure (mercury sphygmomanometer, seated). Participants with initial blood pressure > 140/90 mm Hg had the measurement repeated after 5 min rest following established protocols (20). We used these data to calculate heart age and total CVD risk for the participants using the non-laboratory-based Framingham algorithm, whose covariates include age, systolic blood pressure (SBP), antihypertensive medication use, body mass index (BMI), smoking, and diabetes status (21). The algorithm has been validated in an AA cohort (22).

After the assessments, each focus group commenced with initial questions that elicited participants’ motivations to exercise as well as their barriers to PA. The talking points then moved on to the PA preferences of the participants. Subsequently, the moderator informed the participants of our intention to develop a web-based program to promote PA among AA. Discussants were then asked to describe what they thought of the idea and the kinds of resources they would like to be included in such a program. After the ideas reached saturation, the moderator introduced a sampling of workout videos selected by the research team as potentially culturally relevant to AA based on previous literature. For each focus group, we played clips from four different workout videos and asked the participants to critique their appeal and relevance for promoting PA. The discussions were audio-recorded and professionally transcribed verbatim.

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Data Analysis

We analyzed the data using an inductive approach to content analysis (23,24), identifying the themes that emerged from the data. First, two coders in the University of Pittsburgh’s Qualitative Data Analysis Program independently reviewed the transcripts to draft an initial codebook based on recurring themes. Each coder used this set of codes to annotate two of the transcripts using ATLAS.ti 7.5 (25). The coding team adjudicated disagreements in code applications, reaching consensus on a revised codebook. The coders used the updated codebook to annotate the other two transcripts. The Qualitative Data Analysis Program project manager created files for each code that listed all the participants’ respective quotes. JKK and LPM then reviewed the individual code files to identify the key conceptual categories. Upon reflection and discussion, we saw relationships between multiple codes emerge to constitute the overarching themes.

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RESULTS

Sample Characteristics

The sample comprised 26 individuals (16 women—six 30–45 yr old and ten 46–65 yr old; 10 men—two 30–45 yr old and eight 46–65 yr old) who self-identified as AA. The demographics and baseline characteristics are tabulated in Table 1. On average, the participants were inactive and obese (mean BMI, 32.2 ± 5.4 kg·m−2) with a high prevalence of hypertension (46.2%). Among those with hypertension, the use of antihypertensive therapy was higher among women compared with men (86% vs 40%, respectively). Women were also more likely to be married (56% vs 10%), have college education (86% vs 50%), and be employed (75% vs 20%) compared with men, respectively. Although more men reported participating in regular PA (50%) compared with women (43.8%), the latter reported more weekly PA minutes, albeit far below the recommended level of 150 min of weekly moderate-to-vigorous PA (Table 1).

TABLE 1

TABLE 1

The participants reported below average confidence rating (mean, 46.4 ± 19.1) on Barriers Self-Efficacy Scale. The barriers associated with the lowest self-efficacy included pain or discomfort when exercising (33.5% ± 25.9%), schedule conflicts with exercise session (35.8% ± 30%), difficulty getting to the exercise location (37.3% ± 27.1%), and dislike of the PA program (37.7% ± 28.3%).

When we assessed the baseline cardiovascular risk profile of all participants using the non-laboratory-based Framingham algorithm, men had a more adverse total cardiovascular risk profile compared with women; 60% of men were in the high-risk category (≥20% absolute risk score) compared with 19% of women, and 10% of men were in the low-risk category (<6% absolute risk score) compared with 44% of women (see Fig. 1). The key drivers of the higher risk in men were smoking (70%) and hypertension (50%). When we assessed the intention to modify behavior to attain more PA using the five stages of change in the Trans-theoretical model (26), women expressed more readiness to engage in PA, whereas men were more likely to be getting ready (Fig. 2).

Figure 1

Figure 1

Figure 2

Figure 2

Salient themes extracted from the focus groups are summarized in Table 2 and presented together below because the findings addressed similar themes. Participants between 30 and 45 yr old are identified as young men and women, whereas those between 46 and 65 yr old are referred to as middle-aged men and women.

TABLE 2

TABLE 2

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Motivation for PA

When our generally inactive sample was asked about what would motivate them to engage in PA, there was a convergence of ideas about improved health, longer life, and losing weight. Although the focus group facilitator was keen to steer the discussions in a way that emphasized the health benefits of PA, the participants frequently referenced PA as one of the things that people do to lose weight. Younger women and men viewed weight loss as an important motivator for engaging in PA, primarily for aesthetic purposes, although health benefits were also mentioned. For instance, a 42-yr-old woman expressed her motivation for engaging in PA as “… wanting my clothes to fit a certain way, while a young man stated “…smaller guys always get the better deals. Seriously!” On the other hand, middle-aged women and men appeared to reflect more on the health benefits of PA and tended to view any possible weight loss as an added benefit in their quest to improve health and longevity. A 52-yr-old woman summarized her peers’ motivation for engaging in PA, “… I think the biggest motivator would be our health. And especially if we have families we need to think about,… we don’t want … to die young.” Middle-aged men also reflected on their health-focused motivation for PA, “… for better health, and to build up my self-esteem.”

Notwithstanding the motivation and compelling reasons for engaging in PA, it was clear that these motivators were not enough for them to initiate exercise. Arguably, almost every inactive person wants to feel better, live longer, and lose weight. Yet despite these desires, there was a clear disconnect between intention and action. Most participants attributed their inactive lifestyle to barriers such as lack of time, laziness, stress, boring PA options, and being discouraged by a lack of progress after initial weight loss. At this juncture, the focus group facilitator introduced our concept of developing a web-based PATH program that would be designed to help inactive AA bypass their common barriers to PA with a goal of promoting cardiovascular health. The participants were invited to discuss what they thought of the concept and what they would like to see in such a program.

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Preferences for a Web-Based PATH Program

Overall, the participants in our focus groups expressed interest in a web-based PA program that (a) featured people they could relate to, (b) gave them the flexibility to engage in PA at any time and place that worked for them, (c) availed them of an option to engage in PA in settings where they did not feel vulnerable, and (d) included enjoyable activities.

  • Someone that resembles our shape. In all focus groups, there was a strong preference for a PA program that featured trainers and participants who looked like them, especially in body size and age. A 45-yr-old woman captured the sentiment of her peers when she stated, “… sometimes I think we don’t see enough of us in the actual training setting, so we’re not the ones training. And I think seeing somebody that’s actually doing the exercises that might resemble us in our shape might be helpful.” Another young woman added in agreement, “I think it has to be realistic. It can’t be someone who is like a size 2 saying, ‘Oh, this is what I do,’ and the stomach is already fit. It has to be like a more realistic image.” In a different focus group, a young man dwelt on the same theme, “I’m sorry to keep reverting back to this, but also seeing that person that’s not in great shape and seeing that they’re doing the same 30-minute program, and struggling …, that would really help.”
  • Activities we can implement in our schedules. Many participants expressed the need to have their preferred activities conveniently accessible at any time and location that worked for them. Women stressed the importance of having PA options that they could move around to fit in their day-to-day schedules without inconveniencing their work and family commitments. A young woman stated, “I mean … some of us are stay-at-home parents, some of us are working moms, and you just have to, you know, implement it into our schedule and your daily routine and it’s really hard, especially if you have children and, you know, you may not have support, and you have to do the pick-up from school and the things of that sort and try to let them have their own activities and things of that sort; yours go on the back burner.” Even when fitness facilities offered free access to appealing programs, scheduling conflicts made it very difficult for them to participate. A 42-yr-old woman provided an example case, “Well, I know of Athletic Trauma Unit … that’s free … the guy’s encouraging, and … you go at your own pace or whatever, but you’re doing the same thing everyone else is doing, but for me, it’s just consistency, going there … they have it like early in the mornings or in the evening.” There was consensus that single parenthood posed a challenge to many AA.
  • Being seen. Some participants articulated the need for activities they could do with some level of privacy due to body image and peer stigma concerns. A young man shared his experiences trying to get back in shape, “… from my experiences, being an AA man, just AA men are much more harsh towards one another in regards to specific things, more centered in my experiences around physical activity. You can’t keep up, you know, you’re badgered on more, so.” On the same theme, some women expressed concern about how their bodies would look like while wearing workout outfits. A young woman stated, “I’m kind of happy when the winter comes ‘cause I now have to wear more clothes and I’m being less seen. And in the summertime when it’s warm out and I’m like … [laughter] ‘Oh, God. Everybody see me wearing these shorts … and it’s not a jealousy thing … I don’t want to reveal all the cottage cheese I got.’” Overall, the participants with body image concerns were aversive of PA programs that could expose them to vulnerable situations.
  • This ain’t fun. The participants also admitted to the challenge of engaging in activities that felt more like real work, leaving them sore. Many felt that after a long day at work, the last thing they needed was a PA program that was boring and strenuous. A young man stated, “If my son takes a nap, I’ll just try to bust out like 10 sets of pushups and sit-ups or whatever, but this is work, you know, this ain’t fun … I mean, I know it’s gonna benefit me, but after maybe the fourth set, and I get winded, my arms start shaking…, I’m like, you know what, let me go get a beer and turn on the TV…” To overcome this challenge, the participants expressed interest in well-paced programs that offer a variety of creative activities such as dance. They also preferred activities that they could do in chunks of time (e.g., 10 min sessions) instead of the typical longer sessions offered by many fitness facilities.

To conclude the focus groups, we played some workout videos that we were considering using in PATH because they included concepts often depicted as important to AA in the literature (e.g., background music and integration of faith and prayer in PA routines).

  • I look just like them. In all focus groups, there was consensus that participants preferred workout videos that included diverse participants who resembled them in body size and fitness status. In response to a clip featuring a diverse group (AA, Whites, and Hispanics) of women led by a male trainer in a cardio workout, a young man captured the prevailing sentiment in all focus groups when he stated, “You got these other people who aren’t as in shape, so they kinda struggle doing it …, and then I’m like, ‘I look just like them. [laughs] I have no rhythm. They don’t …, this is fantastic for me!’”

However, there were age and sex differences in the preferences, especially pertaining to the inclusion of religion in the workout videos and the intensity of the workouts.

  • Um, I liked it, I liked it … he prayed before. Middle-aged women (46–65 yr old) found the inclusion of religion in workout videos to be very appealing and a source of motivation to engage in PA. In response to the clip featuring a lone clergyman doing a cardio workout that starts with a prayer, a 53-yr-old woman could not hide her excitement which was shared by her peers, “That’s my motivation right there. Come on, now. A praying brother? Come on, now.” The group was unanimous in its appreciation of the entire workout including its slow-paced nature and religious background music. Their overall critique of the workout was summarized by a 51-yr-old woman who stated, “Um, I liked it, I liked it. It was positive, and … he prayed before. You know, and then he … puts you in the right frame of mind.”
  • The Rev lost me five seconds in. In contrast to the middle-aged women, young women (30–45 yr old) and all men had a generally negative critique of the religious workout. They felt like it was religion taken too far. A 30-yr-old man asserted, “I’m somewhat of a religious person, so I’m not by any means diminishing religion, but it’s really disengaging.” A 42-yr-old woman expressed a similar sentiment, “The Rev lost me 5 seconds in. [laughter] … They’re mixing too much in.” Likewise, middle-aged men had reservations about mixing religion with PA. A 57-yr-old man stated, “Nah, I don’t—I wouldn’t want to mix it. I try to keep them separate, ‘cause if I’m going to exercise I’m trying to concentrate on that. I’m not trying to worry about religion.” It is noteworthy that middle-aged men appreciated the slow-paced nature of the religious workout. However, young women and men thought the pace was too slow for a workout.
  • I ain’t breaking nothing. I’m fifty. In response to a clip of a high-intensity workout video dubbed Urban Cardio Dance, young men and women found the burst of energy appealing. They liked the combination of pop music and movements to create a danceable PA routine, which they thought was fun to do. However, middle-aged men and women expressed lack of interest in the workout citing its intensity and fast-paced nature. A middle-aged man retorted, “If I was 35 and under … I would probably do that, but now I mean, I dance but I’m not going to do it—I ain’t breaking nothing. I’m fifty.” This sentiment was widely shared by his peers.
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DISCUSSION

Barriers to PA among AA have been studied extensively, yet there is limited research on innovative PA interventions specifically designed to address the barriers. This study was designed to address this gap in the literature by providing culturally salient insights into the considerations that ought to be made when developing PA programs targeting AA. Three main themes emerged from the data: 1) need to see similar others engaging in PA (workout videos featuring models with relatable body size, age, ethnicity), 2) flexible PA regimen (doable at any time/setting), and 3) age and sex differences in preferences for PA resources (religion, music, intensity). These themes are discussed in detail below.

One of the key findings of the study was that AA men and women strongly preferred having individuals who are similar to them, especially in body size, fitness status, and age, as their models for PA. Pekmezi et al. (7) reported a similar concern from their focus groups of AA women in the deep South. The women lamented the failure of existing PA materials to include images of AA and people with large body sizes exercising, which gave them an impression that the materials were not meant for people like them (7). These data reflect the theory of self-efficacy’s proposition that observing similar others succeed can increase self-efficacy and motivate action (27). The theory also posits that successful performance of an action by a model with perceived similarity to participants can help demonstrate the strategy needed for one to succeed (28). This was evident in the focus group discussions where the participants acknowledged the confidence they felt by simply observing individuals who were not “as in shape” finish a workout session. Although vicarious experiences are known to play an important role in the development of self-efficacy (27), many web-based PA interventions do not provide adequate opportunities for participants to observe similar others overcome PA barriers. The status quo as it pertains to web-based PA interventions focuses on providing online access to interactive learning modules and other initiatives that encourage behavior change, goal setting, and self-monitoring (14). Although these resources address various sources of self-efficacy, including persuasion, mastery of skills, and feedback, they are inherently limited by a lack of vicarious experiences that could help individuals with low exercise self-efficacy get the courage to start a PA regimen. Our concept of using workout videos in the PATH program is intended to make vicarious experiences more authentic and relatable. When we played the workout video clips to the focus groups, the participants were able to visualize themselves in the exercise sessions. They also identified with the struggles of the models who shared their attributes. Therefore, when designing web-based PA interventions for populations with low exercise self-efficacy, it is important to have models who initially struggle through exercise sessions before they demonstrate mastery.

When the focus group participants reported lack of time as a major barrier to PA, they also expressed interest in PA programs that empowered them to choose when and where to engage in PA. Single parents and working mothers were particularly interested in a program that they could fit in their day-to-day schedules while also maintaining the flexibility to make changes depending on the demands of the day. The traditional PA programs do not offer a great deal of flexibility because they are based in structured fitness facilities with set operation times and availability of personal trainers. In recent years, PA programs designed to help people integrate PA into their day-to-day activities have been developed. However, many of these programs use a self-help approach with an assumption that the participants will have the motivation, self-efficacy, and skills required to initiate and maintain a PA regimen. For instance, the Be Active Your Way guide for adults was developed by the U.S. Department of Health and Human Services to help individuals integrate PA in their daily lives (29). Inactive individuals are encouraged to get started by engaging in do-it-yourself activities such as walking and biking. After several weeks, they are encouraged to increase their PA levels by doing the activities longer and more often (29). These strategies are intended to be pragmatic, but they assume that individuals will have conducive environment, self-motivation, and ability to maintain a successful PA regimen on their own without the help of a personal trainer.

Unsafe neighborhoods and limited access to fitness facilities and parks have been reported as major barriers to PA among AA (12,30). Therefore, innovative web-based PA interventions should take into account individual and socioenvironmental barriers to PA (9,10,12). We propose the use of workout videos as a strategy to provide convenient support for PA in almost any setting and around the clock, akin to having a personal trainer on demand. The results from this study suggest that AA are more likely to be receptive if the workout videos are carefully vetted to reflect their preferences. These results corroborate earlier studies that have reported a strong preference for audiovisual resources among AA (12,30). The use of videos to substitute personal trainers has been successfully tested in physical therapy, where prerecorded exercise videos have been shown to be as effective as personal training, and feasible in a wide range of settings including the home environment (31,32).

In all focus groups, the participants expressed interest in activities that were fun to do and relevant to their lives, but there was no consensus across the focus groups on the essential features for these activities. Middle-aged men and women expressed strong preference for slow-paced activities with calm background music, whereas younger men and women preferred fast-paced activities with pop music. Despite these differences, there was a general interest across focus groups for activities that included walking, aerobics, calisthenics, and dancing. These activities have been reported in other studies to be more acceptable to AA (7). The discussion on the inclusion of religious themes and prayer in a PA program elicited passionate conversations in all focus groups. Middle-aged women had a favorable view of the concept and were quite excited when we played them a clip of a religious workout video. On the other hand, younger women and all men, irrespective of their religious affiliation, were passionate in their view that PA and religion should be kept separate. Although previous studies have emphasized the need for addressing spiritual and religious beliefs in PA programs targeted to AA (7,30), our data suggest the need for more studies to explore the potential differences in preference by age and sex. The recommendation to integrate religion and faith in PA programs targeting AA has been informed by previous studies that predominantly focused on women (7,30). These studies did not report any analyses stratified by age, hence the need for more studies to explore these important themes.

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Limitations

The study had a small sample that we recruited through convenience sampling. Because our target population was very specific (i.e., inactive AA who report less than 75 min of PA in a week), we had estimated that we could attain data saturation with a proportional sample of 32 individuals (16 females and 16 males). The strategy worked well for women. However, six men did not attend the focus groups even after sending reminders and confirming the time of the meeting. We lost contact with these individuals either because they were not responding to our calls to reschedule or due to their phones being disconnected around the time we were conducting the focus groups. Although we were aware of the challenges of recruiting AA men in research, this experience gave us more insights into the need to time study activities around the beginning of the month (before participants exhaust their phone minutes) and the importance of having alternative contacts for each participant. Despite this limitation, the congruence of the themes across the different focus groups suggest we were able to elicit culturally salient considerations that should be taken in to account when developing web-based PA programs for AA. Lastly, some participants may have withheld their true opinions on the topics discussed in the focus groups.

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CONCLUSION

The input from the focus groups provided us with important insights into the needs and essential features of PA resources that are preferable and potentially helpful to AA in their efforts to increase PA. Our approach to stratify the focus groups by age and sex has provided us with important insights in the differential preferences that should be considered when designing and implementing PA programs targeting AA. In our next step, we plan to combine these data with the input of health promotion experts to inform the selection and vetting of the resources to be included in the PATH intervention designed for inactive AA.

This work was supported by University of Pittsburgh Central Research Development Fund and the National Institutes of Health through Grant Number UL1TR001857. Dr. Kariuki and Ms. Laurel Mecca had full access to all the data in the study and take responsibility for its integrity and the data analysis. Author contributions are as follows: study concept and design, Jacob Kariuki; interpretation of data, all authors; drafting of the manuscript, Jacob Kariuki; critical revision of the manuscript for important intellectual content, all authors. The authors declare no conflict of interest. The results/views of this study do not constitute endorsement by the American College of Sports Medicine.

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