As shown in Table 1, the majority of participants in both cohorts were female (88.8%) aged 40 years (39.1%). Most identify Mexico as their country of origin (83.4%) and prefer to speak Spanish (95.7%). The majority had lived in the US for more than 10 years (83.4%). 48% of participants had a family income of <$20,000 per year.
The response rate for the pre-survey was 100%. Examination of pre- and post-study data for the CHARLAR virtual cohort showed significant improvements in exercise days per week (+1.52 days), daily fruit consumption (+1.35 servings), daily vegetable consumption (+0.56 servings) ) and self-reported general health (+ 0.38) (all p < 0.05). There was no significant change in daily exercise time and sweetened beverage consumption for the virtual cohort. In comparison, the historical cohort also showed increases in exercise days per week (+ 0.91 days), exercise time (+ 7.78 minutes per day), daily fruit consumption (+ 0.244 servings), and daily vegetable consumption ( + 0.282 servings) (all p < 0.05). There was no significant change in general health status and daily sweetened beverage consumption for the historical cohort (Table 2). Additionally, within the virtual cohort, there was a numerical decrease in scores for anxiety (-0.83, p = 0.568) and depression (-1.07, p = 0.067) (Fig. 1). In the historical cohort, there was a significant reduction in depression scores (-1.89). Changes in anxiety scores (-0.972) were not significant (p = 0.052).
Analysis of attendance data from CHARLAR virtual classes shows that, on average, participants attended four out of six (67%) of the CHARLAR virtual sessions, compared to five out of the last six classes (78%) of the historical in-person cohort. Of the 11 classes overall, average participant attendance was eight of 11 sessions (73%) in the virtual class cohort compared to nine of 11 sessions (82%) in the historical cohort (p = 0.613).
Interviews with participants revealed more detailed information about the impact of the virtually delivered CHARLAR program. A total of five participant themes were identified: (1) improving health habits, (2) mental health, (3) delivery challenges, (4) adaptability and flexibility, and (5) interpersonal connection. Citations supporting these themes are provided, with edits for clarification indicated in square brackets.
Improving healthy habits
When asked how the CHARLAR program affected their health, participants reported that through the program they learned new information about CVD and diabetes, their health status, and how diet and exercise can affect health. This information enabled many participants to implement lifestyle changes aimed at improving CVD risk factors. Participant 2 states:
“It helped motivate me to eat healthier and exercise.”
Participant 3 also shared how CHARLAR helped her change her habits in a manageable way. She stated:
“Yes. Um, I feel like the class actually helped me, like learning how to change my eating habits and stuff and what’s bad and what’s not bad and little by little I’m starting to get things in my head and stick to goals that are good, I’ll walk 20 minutes every day, for the whole week.”
When asked how the online program influenced mental health-related understanding and behavior, some participants noted that the program helped them learn more about anxiety and depression. Participant 6 shared:
“It was really good for [my] mental health because [I] started doing relaxation and breathing exercises and [I] also learn more about anxiety and depression. And that was helpful.”
Another participant shared that CHARLAR was beneficial for her mental health, as weekly goal setting helped her focus on gratitude and how positive thinking can affect her physical health. Still, others appreciated the extra support overall. Participant 2 shared how the issue of mental health allowed her to see how it might affect her home life:
“They asked me about my mental health, like if I have fears, if I have stress, if we’re OK and how we’re coping, and I don’t always associate those things with home life, and it opened my mind to that.”
Qualitative interviews captured some of the challenges of moving to a new mode of delivery. Although the online classes broadcast via Zoom and Facebook Live used the original curriculum, most of the educational content was condensed into a 30-minute recorded video, which was followed by 30-minute group discussions. Moving to a distance learning platform has created several technological challenges. Prior to this, participants and promoters had varied backgrounds in information technology and had challenges and concerns in downloading and working with online software. Promotora 3 states:
“So my apprehension was with me, me personally, I just wasn’t comfortable. I have been running courses and teaching for over 25-30 years and this was very different for me. I need that personal one-on-one contact. So it was hard for me to just accept it and go with the flow, but it was better for me to learn it and help explain it than for them not to get the class at all.”
Despite the difficulties, over time it became less daunting and even had the unexpected benefit of helping people feel more comfortable around technology. Promotora 3 explains how technology use becomes more manageable over time:
“As I said [using technology] it was practice, it got easier. It also made it easier to explain because if I didn’t know what part of the chat was and all this stuff… I was able to explain it the best way I knew how and as simply as I knew how to explain it so that people can have the best, you know, the best experience that way.”
Promotoras suggested that the CHARLAR program offer more training for promotoras to facilitate discussions through virtual formats. Additional information to improve the virtual delivery of the program may be included in future trainings.
Despite the inherent loss of face-to-face contact, all promoters and participants acknowledged that technological challenges should be expected and expressed a general acceptance of the platform given the inherent necessity. However, all promoters and participants expressed a preference for face-to-face classes. Across all nine interviews, there were a total of 13 testimonials from participants and promoters expressing a preference for in-person classes.
Adaptability and flexibility
The promoters were flexible and willing to learn to implement virtual CHARLAR and adapt to new situations. This greatly benefited the program as it allowed adaptation as promoters and program staff learned how to improve the online format. Participants initially watched the main video content on their own and then moved to the video chat platforms for discussion as a larger group. When the promoters realized that discussion was difficult with such a large group, they quickly turned to smaller discussion groups. Promotora 2 explains how the small groups affected the participants:
“Yes, it’s easy, and I think participants feel more comfortable talking to three or four people than more than 20.”
Furthermore, promoters and participants adapted to the new technology with practice. Some participants were able to get help from children or family members who were more familiar with technology. Participant 3 explained how her son was able to help her when she needed help managing Zoom. She shared:
“It was difficult at first. I couldn’t figure it out. I just didn’t know how to turn on the sound. I didn’t know Like I was messing with him. It was hard. I asked my teenager. I want you to help me with this. And I’m not that old. But I don’t use that. I don’t do that, so I’m like, ‘Help me. I don’t know how to do this. It was a bit difficult.”
Promotoras also expressed interest in making further adaptations to achieve better results. When asked about suggested improvements in virtual program delivery, promotoras suggested experimenting with longer hours.
The shift to a virtual platform had an effect on personal connectivity. Overall, participants and promoters expressed initial challenges in developing a “deep connection” with participants. Promotora 2 explains these challenges:
“A lot of times Hispanics will talk with their eyes or their faces, and it can be a little hard to connect with people when you’re having conversations with them online. So sometimes those conversations can seem a little colder, and there’s not as much of that humanity as you would have in person.”
While technology initially served as a barrier to connectivity, promoters adapted through additional follow-up calls. In addition to the videos and small group discussions, facilitators checked in with participants after each class. These weekly phone check-in sessions allowed the promoters to answer questions and ensure participants had access to the class. The calls had the added function of helping to keep the promoters and participants in touch. Additionally, small groups combined with video and follow-up conversations allowed CHALAR to reinforce information from each session through various modalities. Promotora 1 reads:
“We feel like between the videos, that way we have all the integrity of the program so we’re really delivering the message the way it’s designed and the small groups and the calls we’re, you know, having all the components that we needed for CHARLAR.” “