Implementing an Evidence-Based mHealth Diet and Activity Intervention: Make Better Choices 2 for Rural Appalachians

Rural residents maintain extremely high rates of suboptimal diet and sedentary behaviors, placing them at elevated risk for obesity, cancer, diabetes, cardiovascular disease, and other chronic conditions. Within the vulnerable low socioeconomic status population of rural residents, Appalachian Kentuckians experience even worse health outcomes, including among the highest rates of chronic disease morbidity and mortality in the nation. Such adversity is exacerbated by and associated with inadequate community resources. Increasingly, however, Appalachian residents and other traditionally vulnerable populations are gaining access to modalities that may be useful in addressing these health challenges, including internet connectivity and nearly ubiquitous cell phone use. Despite accelerating technology use, the evidence base on personal technology-associated interventions (mHealth) in a rural, high need population remains sparse. To rectify this knowledge gap, we propose a hybrid effectiveness trial of an adapted evidence-based multicomponent mHealth intervention, the Make Better Choices 2 (MBC2), a behavioral program consisting of an app, personalized coaching, accelerometer, and financial incentives. In a recent randomized controlled trial among urban adults, MBC2 produced large, sustained diet and physical activity improvements by leveraging effective behavior change techniques, including goal-setting, self-monitoring, accountability, feedback, and overall support. To prepare for the adaptation and implementation of this successful intervention to a distinct population marked by extreme health inequities and sparse resources, our team has engaged in extensive foundational efforts. These include: (1) conducting focus groups, key informant interviews, to assess the feasibility, acceptability, and readiness for rural Appalachian residents to use the MBC2 program; (2) undertaking a comprehensive community inventory to reveal existing and needed resources; (3) conducting community and academic team meetings, including forums and CAB meetings; (4) identifying MBC2 programmatic and structural elements in need of adaptation. With this extensive preliminary activity, we now propose a hybrid type 1 effectiveness trial in which we: (1) engage in wireframing the adapted MBC2 with local Appalachian residents to ensure fit and function of the adapted MBC2 protocol and program; (2) administer and evaluate for effectiveness the adapted MBC2 during a randomized community-based trial with a relevant, active control arm; and (3) using theoretical constructs and instruments from implementation science, determine optimal sustainment approaches. The long term goal of this project is to effectively, appropriately, and sustainably improve dietary intake and physical activity in the nation’s most vulnerable populations, including rural Appalachians. This project aspires to demonstrate that systematic adaptation and rigorous implementation of an evidence-based intervention can lead to meaningful and sustained behavioral changes and prevent excess morbidity and mortality.