JMIR MHEALTH AND UHEALTH Chandler et al

Original Paper

A Community-Engaged Approach to Creating a Mobile HIV

Prevention App for Black Women: Focus Group Study to
Determine Preferences via Prototype Demos

Rasheeta Chandler1, RN, PhD, FNP-BC, FAANP, FAAN; Natalie Hernandez2, MPH, PhD; Dominique Guillaume1,
MSN, APRN, AGPCNP-BC, ACRN; Shanaika Grandoit3, MPH, CHES; Desiré Branch-Ellis3, BSc; Marguerita
Lightfoot4, PhD
1
Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, United States
2
Department of Community Health and Preventive Medicine, Morehouse School of Medicine, Atlanta, GA, United States
3
Rollins School of Public Health, Emory University, Atlanta, GA, United States
4
Center for AIDS Prevention Studies, Division of Prevention Science, Department of Medicine, University of California San Franciso, San Francisco,
CA, United States

Corresponding Author:
Rasheeta Chandler, RN, PhD, FNP-BC, FAANP, FAAN
Nell Hodgson Woodruff School of Nursing
Emory University
1520 Clifton Rd
Atlanta, GA, 30322
United States
Phone: 1 404 727 8164
Fax: 1 678 668 8050
Email: [email protected]

Abstract
Background: Black women are an important but relatively overlooked at-risk group in HIV prevention efforts. Although there
is an aggregate decline of HIV diagnoses among women in the United States, there are persistent disparate rates of new HIV
infections among Black women compared to any other cisgender female subgroup. Strategies to end the HIV epidemic—as
outlined in the Ending the HIV Epidemic initiative—for all communities must consider HIV prevention messaging and message
delivery mediums that are created with community input. Although mobile health (mHealth) is a popular platform for delivering
HIV interventions, there are currently no mobile apps that consider cisgender Black women with the goal of promoting a
comprehensive women’s reproductive health and HIV prevention lifestyle. Previous research recommends inclusion of the target
population from project inception and iteratively throughout development, to promote use of the intervention.
Objective: The purpose of this study is to understand cisgender Black women’s preferences for functionality, format, and design
of a mobile HIV prevention app and to examine their willingness to use an app for HIV prevention.
Methods: We conducted a series of four focus groups with 23 Black cisgender women. Focus groups included discussion and
demonstration elements to address cisgender women’s general preference for apps, HIV prevention content that would be useful
in an app, and preferred app features that would promote use of an HIV-centric app. During focus group discussions, participants
were shown narrated, custom wireframes of HIV prevention app prototypes to demonstrate potential app function.
Results: Findings indicated the presence of eight subthemes within the coding structure of three overall themes: (1) health
content within the mobile app, (2) mobile app functionality, format, and design, and (3) other suggested features. Specifically,
participants detailed preferred educational content, content distribution, app aesthetics, privacy considerations, and marketing of
the app.
Conclusions: Findings suggest that Black cisgender women preferred an app that integrated HIV prevention and optimal sexual
health promotion. Participants provided a range of preferences for content integration and facilitators of app engagement with an
HIV prevention app. Preferences centered on gender and cultural congruency of information and content, evidenced by visuals,
language, and resources. Black cisgender women are viable consumers for a mobile app–based HIV prevention intervention.

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(JMIR Mhealth Uhealth 2020;8(7):e18437) doi: 10.2196/18437

KEYWORDS
mHealth app; mobile technology; Black women; HIV prevention; reproductive health; women’s health

implications for the use of mobile technology to facilitate the

Introduction delivery of health care rely on general mobile phone usage by
Nearly 40,000 Americans were newly diagnosed with HIV in the target population.
2017 [1]. Although there has been an 8% decline in new HIV Among Black youth and residents of low-income households,
diagnoses, individuals of color—particularly Black smartphone ownership exceeds 80% and plays a critical role in
women—continue to be disproportionally affected by the current providing internet access, compared to laptops or desktop
HIV epidemic, trailing only men who have sex with men (MSM) computers [9,14-16]. As a result, Black youth and adults are
[2,3]. Black individuals are the most affected racial or ethnic more likely than White people to rely on their smartphones for
group, with Black men having a lifetime HIV risk of 1 in 20 certain activities, including seeking health care information
and Black women having a risk of 1 in 48, compared to 1 in [14]. The increasing popularity of smartphones along with
132 and 1 in 880 for White men and White women, respectively smartphone apps have made the possibility of employing mobile
[4]. In 2017, Black women accounted for almost 60% of newly phones and apps as a platform to provide HIV prevention
diagnosed HIV infections among women and comprised 26% information for Black women highly feasible [17].
of HIV incidences among the Black population in the United
States [3,5]. HIV prevention interventions delivered through mobile apps
have been largely aimed at MSM [18,19]; yet, they have failed
Black heterosexual women have a higher rate of HIV and to attract the attention of, and positive responses from, other
sexually transmitted infections (STIs) compared to any other ideal audiences, particularly Black women [18]. Studies that
female group in the United States [1]. There are several social have focused on mHealth for HIV prevention among Black
determinants of health that contribute to this increased HIV risk women have primarily utilized telephone calling and text-based
among this population [6]. These include poverty, lack of access counseling interventions, which have demonstrated marked
to quality health care, unstable housing, sex-based power efficacy in reducing risk behaviors and incident STIs among
differentials in couple relationships that limit women's ability women compared to face-to-face counseling sessions [10,12].
to negotiate HIV protective actions with their regular male sex Although interventions that have assessed texting and calling
partners, limited HIV prevention education, the increased as HIV prevention interventions have been effective, there is a
prevalence of other STIs, and alcohol and drug use [6,7]. In need for the development of mHealth interventions that
addition to these factors, it is also important to consider that specifically target Black women and use innovative and
many Black women are at an increased risk for HIV acquisition resourceful approaches that promote user engagement and
due the mere concentration of people living with HIV within sustainability. The few research studies that have taken on this
their geographical area or communities, coupled with their approach have shown promising results. Jones and Lacroix [9]
sexual networks [8]. Black women themselves may have few employed an mHealth intervention for Black women that used
sexual partners; however, they are more likely to have sexual smartphones to deliver culturally tailored, soap opera videos
contact with individuals who have multiple sexual partners that focused on HIV prevention for young Black women to
[8,9]. Thus, Black women may remain at high risk for encourage a reduction of high-risk behaviors. The video
contracting HIV even when they do not exhibit risky behaviors intervention was compared to weekly text-based HIV
[8].These factors are important to recognize when addressing risk–reduction messages, which tend to be more commonplace
HIV prevention interventions for Black women in high-risk in mHealth HIV prevention efforts. The intervention arm showed
areas, such as the southern United States. a dramatic reduction in unprotected sexual encounters
Evidence-based, face-to-face behavioral interventions (eg, postintervention when compared to baseline [9]. Gonzalez
SiHLE [Sisters, Informing, Healing, Living, Empowering] and Gladstein [20] conducted a pilot randomized controlled trial
Horizons) [10] that involve educational sessions led primarily that evaluated the feasibility and efficacy of a web-based app
by Black women have been effective in reducing disparities in to increase HIV and STI knowledge and use among Black and
HIV transmission [7,11]. Although effective, such interventions Latina young adult women. Study participants in the intervention
have been greatly limited by factors related to cost, scalability, arm found the app to be trustworthy and useful, and results
sustainability, and reproducibility [7,12]. For example, barriers revealed that participants in the intervention arm had high levels
commonly associated with traditional interventions are of engagement and retention [20]. Currently, Browne et al [21]
limitations related to ease of access (eg, location of study is conducting a randomized controlled trial that involves trialing
activities), cost (eg, childcare), transportation difficulties, and a mobile app to provide HIV prevention and risk-reduction
time constraints, which can prevent study enrollment and education to young African American women living in North
engagement and/or lead to high study attrition [13]. Carolina who are sexually active and use drugs. If efficacious,
Technologically delivered behavioral interventions driven by this mHealth app can be useful in expanding the reach of HIV
mobile health (mHealth) have the ability to overcome such risk–reduction interventions for Black women and increasing
barriers while offering several advantages compared to accessibility for Black women who use mobile devices [21].
traditional face-to-face interventions [13]. Promising

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The etiology of HIV transmission among Black women largely SurveyMonkey, which assessed participant eligibility. Inclusion
differs from that of other high-risk populations, further criteria for this research study required participants to be (1)
emphasizing the need for more tailored interventions to be English speaking, (2) cisgender female (ie, assigned female sex
developed for Black women [7,11]. While HIV prevention at birth and identified as female), (3) 18 years of age or older,
efforts targeting MSM are necessary, it is crucial that we engage (4) self-identified as Black, African American, and/or Hispanic
other vulnerable populations in prevention efforts in order to or Latina, and (5) sexually active within the previous 3 months
successfully meet both national and global HIV elimination during study enrollment. Additionally, it was required that
goals. Black women are not likely to engage with mHealth apps participants owned a smartphone and had never tested positive
developed for MSM, due to lack of relatability and contextual for HIV per self-report. Eligible women were contacted by
relevance as it relates to their intersecting HIV prevention and phone to participate in a prescheduled FGD.
women’s health needs. More specifically, health promotion
interventions for Black women focusing on HIV prevention
Study Procedures
should promote self-empowerment, gender and ethnic pride, In total, there were 23 participants who were divided among
self-efficacy, and skills building [7]. Mobile apps developed the four in-person FGDs held. We concluded that our sample
for Black women have the potential to deliver HIV prevention size was adequate based on data saturation and empirical
information and skills in interactive, useful, nonstigmatizing, evidence of sufficiency [30]. Each FGD lasted approximately
and discrete ways [7]. Furthermore, Black women are willing 90 minutes and took place at a partnering community-based
to participate in mHealth research that promotes the prevention organization or academic institution. FGDs were conducted by
and management of chronic illnesses, especially when such two trained moderators who were knowledgeable about the
research is culturally tailored and comprehensively considers objectives of the HIV prevention mobile app. We employed an
their reproductive and sexual health concerns. mHealth purports FGD guide (see Multimedia Appendix 1) during each session,
care continuity and constant accessibility, thus offering users and both moderators were present during all sessions to ensure
flexibility and convenience with no limitation of time nor space the specific aims of the study were met and to ensure that there
[17,22-26]. In addition, mHealth provides the ability to deliver was consistency across the data collection procedures. The
highly engaging HIV prevention information to populations FGDs covered four main topics: (1) HIV prevention app
that have been typically hard to reach, while offering user usability, (2) features of an HIV prevention app, (3) app content
privacy and anonymity [17]. Considering Black women’s use to include barriers and facilitators to HIV testing and
of mobile apps for the prevention of other chronic diseases, we pre-exposure prophylaxis (PrEP) initiation, and (4) mobile app
are optimistic that our proposed HIV prevention mobile app commodity ordering (eg, condoms and at-home HIV testing
will have similar outcomes [13,27]. kits). During the FGD, we demonstrated four HIV
prevention–focused mobile app wireframes—digital depictions
This study was guided by the social cognitive theory of mass of app content and functionality—that were developed by and
communication, which postulates four constructs from the for Black women. Specific mobile app functions included the
original theory—self-efficacy, use of incentive motivation, following: (1) information about HIV and women’s reproductive
social environment, and reciprocal determinism—that impact health (eg, via videos), (2) location-based HIV testing and PrEP
behavior, but adds that messaging to influence these behaviors clinics, (3) use of an in-app calendar for reproductive health
can be effectively delivered through media and technological (eg, ovulation and sexual acts diary) and HIV-specific
sources [28]. In order to understand vulnerable, cisgender, Black notifications (eg, testing reminders), (4) commodity ordering
women’s preferences for functionality, format, and design of a for HIV prevention efforts (eg, condoms), (5) sexual behavior
mobile HIV prevention app, and to examine their willingness tracking, (6) frequently asked questions repository, (7)
to use an app for HIV prevention, we conducted formative prevention navigator and/or provider communication, and (8)
qualitative research with Black cisgender women who live in community connectivity (eg, peer chat group). Participants were
communities that are geographically affirmed to have the highest also encouraged to provide suggestions for how to improve app
HIV rates in Atlanta, Georgia [11]. function and recommend additional app features that should be
integrated. All interviews were digitally recorded with the
Methods consent of each participant. Field notes were drafted in real time
by the research assistant and later transcribed and appended to
Study Population and Recruitment
the FGD transcripts. Participants were given US $30 in
This study was approved by the Emory University Institutional compensation for their time.
Review Board. This qualitative study was implemented from
February to March 2019 with cisgender Black women residing Data Analysis
in metro Atlanta, specifically Fulton County, one of the targeted All FGD audio files were transcribed verbatim using a
counties from the Ending the HIV Epidemic initiative [29]. professional transcription service. Thematic analysis, combining
Participants were recruited for focus group discussions (FGDs) inductive and deductive approaches, was completed using
via flyer distribution and community-based organization MAXQDA software, version 18 (VERBI GmbH). A codebook
outreach. Flyers were distributed in venues that Black women was compiled in close coordination between researchers (RC,
frequent, such as beauty salons, churches, community-based NH, SG, and DBE) using existing literature, the research
organizations, and community events like health fairs. The flyers objective and aims, along with themes that emerged during the
provided a link to a survey via the online survey tool FGDs. The researchers then evaluated the FGD transcripts to

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ensure congruency with the extracted themes using MAXQDA had a regular health care provider (15/17, 88%). Over half of
software. Following this process, the researchers discussed and the participants reported they had previously heard of PrEP
compared their findings. Transcribed text and field-note data (12/17, 71%) and less than half reported that they would not
were then reviewed for overall impressions; finally, a use PrEP (7/16, 44%). Broadly, participants reported their main
line-by-line review for extraction of significant statements health concerns as chronic diseases, sexual and reproductive
occurred [31]. health issues, along with inadequate acute and chronic mental
health services.
Results Results were categorized into three overarching themes and
Overview eight related subthemes. The first overarching theme, health
content and communication, included two subthemes:
A total of 23 cisgender Black women participated in the FGDs; comprehensive information and health provider profiles. The
they ranged in age from 18 to 45 years, with a mean age of 30 second theme, functionality, format, and design of the mobile
years (SD 8). Demographic content was recorded for 17 of the app, included three subthemes: customizability, layout, colors,
23 participants (74%), as 6 participants opted not to complete easy navigation, and simplistic design; safety and privacy
the demographic form (see Table 1). Most of the participants concerns; and visual content. The third theme, other suggested
in the study were not married (12/16, 75%), did complete high features, included two subthemes: peer chat room(ie, community
school (10/16, 63%), had health insurance (15/17, 88%), and building) and “tell me where, get me there” transportation.

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Table 1. Participant demographics.

Category and description Value, n (%)a,b

Race (n=17)
Black or African American 16 (94)
West Indian 1 (6)
Marital status (n=16)
Married 2 (13)
Never married or single 12 (75)
Not married but living with a sexual partner 2 (13)
Currently in school (n=17)
Yes: full time 6 (35)
Yes: part time 0 (0)
No 11 (65)
Highest level of schooling (n=16)
Elementary or middle school 1 (6)
High school 10 (63)
Trade or technical college 1 (6)
College or university 3 (19)
Not reported 1 (6)
Employment status (n=16)
Full time 3 (19)
Part time 7 (44)
Unemployed 6 (38)
Yearly household income (US $; n=16)
0-9999 7 (44)
10,000-19,999 2 (13)
20,000-29,999 2 (13)
30,000-39,999 3 (19)
40,000-49,999 2 (13)
Current health insurance (n=17)
Yes 15 (88)
No 1 (6)
Unsure 1 (6)
Access to a regular health care provider (n=17)
Yes 15 (88)
No 2 (12)
Have you heard of pre-exposure prophylaxis (PrEP; n=17)
Yes 12 (71)
No 5 (29)
If you have heard of PrEP, would you use it (n=16)
Yes 7 (44)
No 7 (44)
Maybe 2 (13)
Where do you obtain health information (n=17)

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Category and description Value, n (%)a,b

Family and/or friends 6 (35)
Google 10 (59)
Health apps 7 (41)
Health care provider 15 (88)
Social media 2 (12)

a
Out of 23 participants, 6 opted out of completing the demographic document.
b
Not all category percentages add up to 100 due to rounding.

among the participants on having a virtual communication

Health Content and Communication option to access their health care providers using either a
Overview face-to-face feature or a private chat room forum. Some
participants were interested in having a peer-support option and
The participants expressed the need for a comprehensive health
wanted a monitored peer chat room available. The risk
app that included various topics in connection to a woman’s
assessment questionnaire that was incorporated in three of four
overall health. Along with HIV, participants communicated that
of the mobile app prototypes garnered reactions from
the mobile app would be most beneficial and would foster
participants that should govern how to solicit sensitive
continued use if it included resources on additional health topics
information via electronic devices from Black women. Existing
that were of concern to them, such as mental health. A directory
app functions were desired; however, participants explicitly
of providers was a distinct feature desired by participants. More
expressed wanting all features to be included in one mobile app,
specifically, Black women requested having the app generate
thereby minimizing the need to download multiple apps or the
health care provider profiles based on geographic location (ie,
need to exit the app (eg, period or mood trackers). Table 2 lists
geofencing) that would locate Black female providers. In regard
and describes the codes for the themes and subthemes.
to communication facilitated by the app, there was a consensus

Table 2. Code definitions.

Code Definition
Health concerns Primary health concerns mentioned by participants, including those related to sexual and reproductive health;
nutrition, exercise, or weight management; mental health; chronic disease; cancer; and accessibility to care
HIV Discussions of HIV or HIV-related topics by participants, including HIV prevention methods and strategies
they are aware of; experience, utilization, discussion, or knowledge regarding pre-exposure prophylaxis (PrEP);
perceptions and preconceived notions regarding HIV; discussions related to HIV, HIV treatment and care, HIV-
related illness, and risk factors related to HIV
Information delivery preference Discussions regarding participants’ preferred methods of receiving health-related information, including those
related to the utilization of mobile apps or social media apps to receive health information, seeking health infor-
mation on the web, and seeking health information from television commercials
Health app features: reliable digital Discussions regarding participant preferences in app features and usability, including the following preferences:
dialogue receiving health information through the app, interacting with health care providers through the app, interacting
with other women in an app chat room, and personalized health information received by participants through
the risk assessment
Comprehensive app content Discussions of the app that include comprehensive information pertaining to all aspects of women’s health,
discussions about participant ability to search the app for information by typing in specific symptoms, and
ability to access provider profiles that include information regarding their services
Convenient consumerism Discussions regarding participant ability to order health kits, tests, etc, directly from the app
Customizability Discussions regarding customizing the app and the display of features, including, but not limited to, color, font,
layout, background, and music
Visual content Discussions regarding nontraditional delivery methods of health care information through videos, short clips,
and representative imagery
“Tell me where, get me there” Discussions of transportation and accessibility of services presented in the app, including health care providers
transportation within the participant’s geographic area, links and accessibility to Lyft and Uber, and information about com-
munity carpools to health care services
Other suggested features Discussions regarding additional suggestions voiced by participants to ensure efficiency and overall satisfaction
with the app (ie, iOS and Android compatibility, journal component, and panic button for emergencies)
Privacy and confidentiality Discussions regarding security measures to ensure participant confidentiality while using the app

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Comprehensive Information Additionally, participants recommended the inclusion of a period

Topics that participants voiced wanting to see included in the tracker feature within the app. Several participants already had
mobile app consisted of the following: location of health period tracker apps on their phones and stated that it would be
screening services for women (eg, mammograms), mental health most convenient for them if the app afforded period initiation,
coping strategies and local resources, information on chronic duration, and symptom monitoring so that they could refer to
health conditions that are most prevalent within the Black just one app for all of their reproductive health needs (see Figure
community (eg, diabetes and hypertension), holistic wellness, 1). Participants also liked the option of having a journal feature
and information on sexual and reproductive health that appends within the app to log journal entries and notes that are relevant
to HIV prevention, such as other STIs. to their health.

My three concerns are STDs [sexually transmitted I like the multipurpose features because if I'm not
diseases], mental health, and chronic illnesses like necessarily looking for HIV information, if it's a
high blood pressure, diabetes, and heart issues. well-rounded site and I'm able to get the period
[Focus group #3 participant] tracker, count my steps, and the other features like
the news section it's well-rounded for me. [Focus
My three [health concerns] are, well I’d say asthma, group #2 participant]
I haven’t got a sexually transmitted disease, but I’m
just saying it for other women. So, I would say I think if there's a way to search quick things like
sexually transmitted diseases and I’d say anxiety too. yeast infections. A quick way to search things you
[Focus group #2 participant] know about common female health issues. So, you
can just go ahead and see what you need to do.
Participants also expressed an interest in a search engine Instead of jumping through hoops for something basic
function. With this feature, women could receive quick, reliable, you can get out of the way quickly. [Focus group #3
and relevant information pertaining to common reproductive participant]
health trepidations, such as STIs and birth control methods.
Figure 1. Comprehensive health features included in the sample mobile app prototype.

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Health Providers’ Profiles participants stated that having the risk assessment appear
The participants reported an interest in having the mobile app immediately after signing in was a deterrent to using the app
accommodate a comprehensive directory of female health care because the questions being asked were perceived as intimate
providers of color within their communities. For the participants or invasive. One participant stated that the risk assessment
in this study, having access to health care providers they could included too many questions, which caused her to become
relate to—considering intersections like race and ethnicity as disengaged with the app. Multiple participants expressed that
well as gender—was influential when seeking reproductive and if the risk assessment were to be included in the app, then it
general health services. Participants also preferred having the should be placed in a different section entirely and serve a
option of directly communicating with a certified health care purpose (eg, usefulness to the health care provider for giving
provider or a trained health care surrogate (eg, patient navigator) feedback to the patient regarding a particular health concern)
via either in-app video conference or chat room in case they for collecting the type of information being queried. However,
have any immediate health concerns or questions (see Figure there were also some participants, specifically younger
2). participants, who did not have a problem with the placement of
the risk assessment nor the content of the questions asked in
...Or even something where you could literally get a the risk assessment.
directory of female doctors in your area. Female
Black doctors in your area. I think that would be very, It was for me [risk assessment], right off the bat, I
very helpful because I have no idea of any Black was like, ya know...I was over it. But now what I will
women doctors in Atlanta. That would be very say, I think that those questions can be asked, but you
helpful. [Focus group #2 participant] would probably do it when they get to certain levels
[within the app]. [Focus group #1 participant]
A risk assessment that would collect health information about
participants was a proposed component of most mobile app I feel like even the health tracker thing on your iPhone
prototypes that were presented to the focus group participants. tells you to put in your weight and your height. I know
Components of the risk assessment were as follows: sexual my BMI is 39, but I also know I'm active as heck. So,
encounters, use of contraception, and demographic information, yes, you can tell me this but my lifestyle says
such as age, race, and gender. The participants noted that the something different. I feel like I would expect a health
placement of the risk assessment was crucial for the overall app to ask me that. I feel like that would be part of
acceptability of the app. There were differences in opinions the sign-in process. But I guess I'd maybe give the
among FGD participants as to where the risk assessment should option to skip [the risk assessment]. [Focus group #3
be placed, along with the content of the risk assessment. Some participant]

Figure 2. Sample mobile app prototype features and pages. PrEP: pre-exposure prophylaxis.

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Functionality, Format, and Design of the Mobile App web-based and smartphone apps allowing multiple ways to sign
up and sign in, participants were concerned with their personal
Overview information being shared. The majority of participants
Participants were adamant about helping to create a mobile app emphasized not wanting to sign in to the app using social media
that would not only be functional but also highly competitive platforms, such as Facebook or Instagram, due to the fear of
with, and more culturally centric than, all other pre-existing their information potentially becoming compromised. If personal
mobile apps concerning reproductive health. These suggestions health information was required in order to sign up for the app,
ranged from design features, layout, navigation within the many participants expressed that they would be less inclined to
mobile app, and concerns regarding safety and privacy to visual complete the form due to privacy concerns. Participants also
content and representation. suggested that they would prefer a name for the app that was
discrete and did not imply that the app pertained to HIV.
Customizability, Layout, Colors, Easy Navigation, and
Simplistic Design With so much stuff that’s going on with these different
Across all focus groups, the participants discussed the various social [media] sites, that’s why a lot of people don’t
customization elements they wanted to see incorporated into [share information online using these platforms]
the mobile app; for example, compatibility with both iOS and because they fear that this stuff can get linked back.
Android systems, limited ads within the app, volume options, [Focus group #2 participant]
and notification alerts. They also stressed that the app should I would rather not do it with anything social media.
be user friendly. This included a color layout with simplistic Especially anything owned by the company Facebook,
designs. One participant did note that she would like to see a which includes Instagram. Just because they track
reproductive app for women that was not “pink and flowery.” and keep everything. [Focus group #3 participant]
Participants also expressed how they liked that the pictures,
Visual Content
which were of Black women, within the app felt relatable to
them. There was not a clear consensus regarding the use of Participants were especially interested in receiving their health
emojis in the app; as some mentioned, it would be appealing to care information in new, innovative ways. Some participants
younger women, while others noted that it would come off as described including health education resources in the form of
less mature. short video clips of real-life scenarios (see Figure 3). Others
discussed the incorporation of animations throughout the app
I feel like just stay away from the color pink. I feel as a way of providing relevant information. These alternatives
like I'm very tired of seeing that color associated with to traditional methods of health information delivery were
women. [Focus group #3 participant] presented as a means of reaching all potential users. Participants
I think a lot of the ads come from funding. I want to suggested that given that literacy levels may vary among users,
talk about my health! If the ads pop up, make it along with young adults primarily obtaining news and
relevant to what you’re looking for. Just no random information through videos and clips, health education in the
ads... [Focus group #4 participant] form of videos may be easier for some to understand.
Safety and Privacy Concerns I think in this day and age, people are visual people
When using technology, privacy is oftentimes one of the major because of social media. A visual, I was thinking
concerns for an individual, and the same could be said of our something more like real-life scenarios, whether that
participants. Many were concerned that their private medical be a 60-second video, but something that’s real,
records and HIV status could be inadvertently disclosed. With something that’s honest, a real story. [Focus group
#1 participant]

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Figure 3. Interactive videos on the mobile app featuring Black women.

It [the peer chat room] just depends on how

Other Suggested Features compelling it would be. Also, if it's regarding health,
Overview I would like a doctor in the chat room. [Focus group
#3 participant]
In addition to the themes and subthemes related to the app health
content, functionality, format, and design, participants also ...The fact that they’re having these chat rooms and
provided additional suggested features they would like to see avatars is too...childish. That would push me away
present in the app. This included a peer chat room and because if we’re talking about something serious, I
information regarding transportation and location of services. don’t want to make an avatar of myself and I don’t
Regular news updates on important health topics were also want to be in a chat room talking to a whole bunch
suggested, along with the incorporation of a panic button for of people that may potentially have something that
emergency situations. I’m concerned about. Because to me it tends to turn
into something more fun than something more serious.
Peer Chat Room [Focus group #2 participant]
There was no clear consensus among the participants regarding
“Tell Me Where, Get Me There” Transportation
a peer chat room. On one hand, some participants were intrigued
by this feature, as it would allow an opportunity for community Participants stated that a GPS locator for HIV testing and PrEP
building and an opportunity to learn from others who may be clinics was a feature they would be interested in seeing
experiencing similar circumstances. Much of the opposition incorporated within the app. For some of the participants,
regarding the chat room was related to the potential for sharing although they had heard of PrEP, they did not know where to
of misinformation relating to HIV and STI risks. In addition, obtain it. Thus, they stated that having this information
participants were concerned with potential misuse of the chat accessible would make the process of utilizing such services
room. They suggested security and privacy measures should be much easier. Some participants even mentioned partnering with
considered, as individuals may be sharing personal information transportation services, such as Uber and Lyft, in order to
relating to their reproductive health. Some participants preferred provide transportation to promote accessibility of health care
having chat rooms solely with health care providers as opposed facilities.
to the peer chat rooms.

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...if [you] could put something on PrEP, where to get level and preference for information delivery. We also confer
it free or at a low cost, because that’s the question I that the app will have to be malleable and inclusive as it relates
get most of the time, because PrEP is very expensive. to health issues that disproportionately impact Black women in
[Focus group #2 participant] order to remain relevant and be sustainable. Our participants
were enthusiastic about being partners in mobile app
Discussion development efforts and ensuring that the app was an authentic
reflection of their needs.
Overview
HIV prevention delivered through mHealth that is specifically
Aims of app development and definitions of success may differ
developed for Black women can offer a promising strategy to
between researchers and programmers, and each may be
curtail HIV incidence rates within this group.
responding to different perceived needs of end users. Teams
can address some of these differences through continuous The data obtained from focus groups will be used to adjust and
formative research with the target population during intervention modify the mobile app we developed to ensure that the app
development and creating very explicit deliverables, timelines, includes the needs and concerns of Black women and to ensure
and division of labor within the development team [32]. These that the app is culturally tailored to the population of interest.
first and second points emphasize the importance of designing Cultural tailoring is a crucial component of HIV prevention
technology-based interventions with the end user constantly in interventions, and research has demonstrated that Black youth
mind to create something that is intuitive, useful, engaging, and are more likely to reduce high-risk behaviors and increase
fun [32]. condom use when they are able to identify with, and find
meaning behind, the education that is provided [7,35,36]. Solely
Black Women and the Use of Mobile Technology for
possessing HIV or STI prevention information has shown to
Sexual and Reproductive Health not effectively reduce high-risk sexual behaviors [22]; however,
In this study, researchers solicited feedback from focus groups greater message frequency and individually tailored messages
consisting of Black women residing in a high-risk area for HIV have been effective in sustaining new health promotion
acquisition, in order to obtain qualitative data for the behaviors and reducing high attrition rates [10,37].
development of an HIV prevention mobile app that specifically
targets Black women. Black women remain disparate in HIV Aptitude When Considering Prior Work
acquisition and in other adverse sexual and reproductive health Black women continue to be disproportionately affected by
outcomes. Features of an HIV prevention and sexual and HIV, and there is a great need for strategic interventions that
reproductive mobile health app informed by Black women could are targeted, scalable, and sustainable in order to help reduce
help combat health outcome inequalities. The findings obtained HIV rates among this group [7]. Through mHealth, HIV
from this study indicate that, overall, participants strongly desire prevention efforts can be specifically targeted toward the needs
a mobile app that incorporates comprehensive health information of Black women, and they can also be scalable so that more
that discusses HIV prevention information. Participants also participants are reached compared to more traditional HIV
strongly desire a mobile app that incorporates information prevention interventions. Compared to traditional interventions,
pertaining to other aspects of women’s sexual and reproductive such as group counseling, mHealth reduces the amount of
health and information on other health conditions that have a resources needing to be expended, making the sustainability of
high prevalence within the Black community. One particular mHealth more feasible [7]. Although research has demonstrated
aspect of the app that was highly regarded by study participants that Black women are willing to utilize culturally tailored
was the ability for participants to be linked with health care mHealth interventions, there has been a dearth of research
providers within their geographical area who were Black assessing mHealth interventions—specifically the use of mobile
women. Representation oftentimes can play a major role in an apps—as a means of providing HIV prevention and
individual's health decision making. Research has demonstrated risk-reduction education for Black women [25]. Studies that
that when Black patients have a health care provider of the same have assessed mHealth as a means of HIV prevention among
racial background, there tends to be a more patient-positive Black women have focused primarily on web-based and
effect involving patient-centered communication, along with telephone-based (eg, calling or texting) interventions [10,22].
increased satisfaction [33,34]. Thus, by having access to Black In our review of the literature, we did not identify any articles
providers, Black women may become more engaged in their that speak to the use of mobile apps as a means of HIV
overall health care, which can facilitate access to more health prevention for Black women. Although calling and texting
promotion initiatives, including HIV prevention efforts. Other interventions have proven to be effective, with the increase in
desired app features may currently exist in some form smartphone ownership and mobile app use among Black women,
implicating feasibility, either in related apps (eg, HIV prevention a mobile app will offer a more expansive strategy that relies
apps for MSM) or unrelated apps (eg, period tracker), but minimally on human resources for the delivery of health
distinction will be demonstrated by culturally and contextually promotion content for this target population. Traditional HIV
relevant content that Black women will deem useful regarding risk-reduction interventions targeting Black women have
their sexual and reproductive health. Black women who are demonstrated marked challenges, including maintaining
skeptical about health resources or who cannot always decipher sustained intervention effects over time, along with the
health content will have a reliable source that will share feasibility of expanding such interventions to reach more
evidence-based content in a manner that considers their literacy participants [7]. Thus, there is ample potential for the utilization

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of mobile apps in order to overcome challenges in the delivery system. There are commercial apps, such as Maven [42], that
of HIV prevention content for Black women. are available but are not within the purview of our
population—the most susceptible to poor reproductive health
Mobile App Considerations outcomes—because they cannot afford the services. We,
We are not oblivious to the fact that mobile apps have to be however, plan to integrate the mobile app into an existing health
maintained and will require some resources for sustainability. care system that will afford our target population an opportunity
We propose integrating this app into an existing health care to engage with this mobile technology and with their health care
system, whose administrators can assume ownership of providers.
protecting and storing the data, mobile app updates, and tracking
patient usage. Our efforts would be to provide a general app Limitations
that can be assumed by health care agencies (eg, Healthy Start) We identified some limitations to this study. One of these
that deal primarily with female patients of color who oftentimes included the fact that our sample represented Black women
are not afforded digital services [38]. A recent systematic review residing in a large metropolitan community. Therefore, the
revealed the limited representation of Black people and African results of this study can only be generalized to women of a
Americans in health intervention research, even though they similar demographic. Additionally, of the four focus groups,
experience the greatest burden of health inequities [39]. only one targeted the ideal age group for the proposed mobile
Additionally, the review highlighted the increased willingness app, due to recruitment methods and interest in the research
by Black women to participate in mHealth studies [39-41]. It project.
is crucial for HIV prevention interventions delivered through
mHealth to expand beyond recurrent themes and groups, such
Conclusions
as MSM and medication adherence [40]. Other key populations This research project sought to understand the interest in an
such as Black women, along with themes such as HIV HIV prevention app by Black women of reproductive age. In
prevention and care initiation, need to be of focus in mHealth eliciting the opinions of Black women through focus groups,
interventions [40]. In developing an mHealth app for Black the information obtained can be used to ensure that the app that
women, it is important for the app to be revered as essential in is developed will be relevant to the concerns and needs of Black
order to incentivize Black women to keep it on their phones women. In doing so, we can ensure that the app we develop is
and permit the app to occupy valuable data space. We deduced both culturally and contextually relevant so that users can be
that the health concerns of Black women will motivate their use heavily engaged with the goal of promoting positive behavior
of the mobile app if they can receive some of the same health change and risk reduction. Moving forward, the researchers
benefits that are ordinarily afforded to them through traditional would like to work alongside an advisory committee of Black
engagement with a health care provider or the health care women, a research team, and a technology company in order
to develop the app prototype.

Acknowledgments
RC has received research support from the National Institute of Mental Health (grant No. R25MH067127).

Conflicts of Interest
None declared.

Multimedia Appendix 1
Focus group discussion guide.
[DOCX File , 174 KB-Multimedia Appendix 1]

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Abbreviations
FGD: focus group discussion
mHealth: mobile health
MSM: men who have sex with men
PrEP: pre-exposure prophylaxis
SiHLE: Sisters, Informing, Healing, Living, Empowering
STI: sexually transmitted infection

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Edited by G Eysenbach; submitted 28.02.20; peer-reviewed by J Jones, D Levine; comments to author 04.04.20; revised version
received 09.04.20; accepted 10.04.20; published 24.07.20
Please cite as:
Chandler R, Hernandez N, Guillaume D, Grandoit S, Branch-Ellis D, Lightfoot M
A Community-Engaged Approach to Creating a Mobile HIV Prevention App for Black Women: Focus Group Study to Determine
Preferences via Prototype Demos
JMIR Mhealth Uhealth 2020;8(7):e18437
URL: http://mhealth.jmir.org/2020/7/e18437/
doi: 10.2196/18437
PMID: 32706723

©Rasheeta Chandler, Natalie Hernandez, Dominique Guillaume, Shanaika Grandoit, Desiré Branch-Ellis, Marguerita Lightfoot.
Originally published in JMIR mHealth and uHealth (http://mhealth.jmir.org), 24.07.2020. This is an open-access article distributed
under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits
unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR mHealth and
uHealth, is properly cited. The complete bibliographic information, a link to the original publication on http://mhealth.jmir.org/,
as well as this copyright and license information must be included.

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