Author: Morgan Foreman (2025)
Advisory: Amy Franklin, PhD
Committee members: Angela Ross, DNP, Sahiti Myneni, PhD, and Angela Haynes Burgess, MD, PhD
PhD thesis: McWilliams School of Biomedical Informatics at UTHealth Houston.
ABSTRACT
Digital health solutions, like mobile apps, are popular for managing health conditions such as pregnancy and hypertension. Although these tools have great potential, they struggle with sustaining long-term patient engagement, with 80% of users often only logging into a mobile application twice (Fleming et al., 2018; Meyerowitz-Katz et al., 2020; Pfammatter et al., 2017; Wang et al., 2017). App development often uses one-size-fits-all methods and can benefit from the inclusion of differences across user populations (Boucher & Raiker, 2024; Budak et al., 2024). Cultural-tailoring has improved adherence to healthcare interventions, with these tailored interventions proving to be more effective than unadapted versions. There is, however, no standard method for tailoring, and interventions often do not report on how it is tailored (Arora et al., 2024; Fernández et al., 2025; Griffith et al., 2024). Despite the popularity and increased production of digital health tools, few are designed with the cultural experiences of marginalized users in mind, limiting their effectiveness in promoting patient activation and self- management. In this work, I pursued developing a framework for integrating cultural-tailoring within digital health tools as a potential means of improving participant motivation and willingness to use a tool for self-management. Through the merging of socio-technical, socio-cultural, and socio-behavioral models, I generated a theory-driven framework to expand upon the process of the Behavioral Intervention Technology (BIT) Model (Mohr et al., 2014), and use evaluations from Technology Acceptance Models (Venkatesh et al., 2003).
Pregnancy was chosen as the clinical condition to study participant motivations for digital health use due to the duration, consistent engagement with healthcare, and the many commercial mobile apps on the market. Black women with hypertensive disorders of pregnancy were the specific population of focus, as these women are three to four times more likely to die or face adverse outcomes than white women and 60% more likely to experience hypertensive disorders of pregnancy, like preeclampsia. Combining cultural themes extracted from qualitative interviews (Foreman et al., 2025) and theories like Black Feminist Thought (Collins, 2022) with the proposed framework, culturally-tailored low-fidelity digital tool prototypes were created. 100 women (75 black) completed an online review of different mobile designs. For each display, participants were asked to rate their perception of the appropriateness, acceptability, intention to use, and cultural fit of the prototype. Prototype foils were prepared to allow the participant to review similar features in the market-available, culturally-tailored, and, as a contrast, age-tailored formats. In addition, each participant completed a standardized measure of Patient Activation, or readiness to act on behalf of their own health (PAM, Hibbard et al., 2004), as well as a history of health discrimination experiences (Healthcare Discrimination Experiences Scale) (Sanford & Pizzuto, 2022). Within participant comparisons between the market-available Likert score means and the tailored scores indicated that the culturally-tailored features are significantly preferred (p = 0.000) by Black mothers, and this effect is correlated with patient activation levels (r=0.21) and degree of historically experienced medical neglect or systemic bias (r=0.24,0.29). Non-Black women show a preference for age-based tailoring (p=0.003, 0.028), however, they do not show the same preferences as Black mothers for the culture-based tailoring (x2=0.002). These results identify that cultural-tailoring may improve perceptions of digital health tools towards sustained engagement and self-management behaviors.
This work proposed that culture is a necessary context for health engagement to reflect lived experiences toward sustaining self-management behaviors through increasing knowledge, confidence, and motivation. Culturally tailored features are not just preferred, they are essential for supporting those most affected by systemic health disparities. Developers and Informaticists can use these findings to develop tools that explicitly address patient activation and cultural relevance, especially for populations who have historically experienced medical neglect or systemic bias.