Collectivistic health promotion tools: Accounting for the relationshipbetween culture, food and nutrition$

Andrea G. Parker a,n, Rebecca E. Grinter b

a College of Computer & Information Science, College of Health Sciences, Northeastern University, 202 West Village H, 360 Huntington Ave., Boston,MA 02115, USAb School of Interactive Computing, College of Computing, Georgia Institute of Technology, Atlanta, GA, USA

a r t i c l e i n f o

Article history:Received 27 July 2012Received in revised form1 June 2013Accepted 28 August 2013Available online 7 September 2013

Keywords:Community computingCollectivismCultureHealthNutrition

a b s t r a c t

Human–Computer Interaction (HCI) researchers are increasingly examining how Information andCommunication Technologies (ICTs) can help people eat more healthfully. However, within HCI, therehas been little examination of the way that cultural values influence how people think about food andwellness, and how sociocultural context supports or impedes attempts to eat healthfully. Our workfocuses on the diet-related health challenges of African Americans within low-income neighborhoods.This population disproportionately experiences diet-related disease, and as such, researchers haveconsistently advocated research that examines the way in which food practices are culturally situated.

Through formative focus groups with 46 participants we identified several design implications fortools that promote healthy eating while accounting for collectivism, a cultural value often ascribed to theAfrican American population. Based on our design implications we developed, deployed and evaluatedtwo systems that supported the sharing of community-held knowledge about making healthy eatingdecisions. In our discussion, we present implications for the design of collectivistic systems that addressfood practices. We conclude with recommendations for HCI research that investigates the relationshipbetween culture and food more broadly.

& 2013 Elsevier Ltd. All rights reserved.

1. Introduction

How can technology help a community come together aroundthe topic of food? This is a question that we have explored overseveral years of research. Our work contributes to a growing bodyof Human–Computer Interaction (HCI) scholarship focusing onhow Information and Communication Technologies (ICTs) can helppeople eat more nutritiously (Chang et al., 2006; Chi et al., 2007;Chiu et al., 2009; Comber et al., 2012; Glasemann et al., 2010;Mankoff et al., 2002; Noronha et al., 2011). For example, research-ers have leveraged crowdsourcing, mobile computing, and sensortechnology to help people monitor, assess, and receive feedback onthe foods that they eat (Chang et al., 2006; Chi et al., 2007; Chiu et al.,2009; Mankoff et al., 2002; Noronha et al., 2011; Siek et al., 2006).While important work has been done in this area, few projects haveexamined how culture (which we define in Section 2.1) influenceseating habits and the implications that this has for the design of ICTs.Yet, healthcare research has consistently shown that it is criticalto account for individuals' cultural backgrounds when designing

interventions that encourage healthy eating (Airhihenbuwa andKumanyika, 1996; James, 2004; U.S. Department of Health andHuman Services, 2011). Indeed, researchers find that accounting forculture can enhance the effectiveness of interventions (Campbellet al., 1999; Karanja et al., 2002; Kreuter et al., 2003). As such, thereexists an exciting opportunity for HCI research to explore how ICTscan encourage healthy eating in a way that reflects this richintertwining of cultural values and food practices.

In our research we begin to address this opportunity (Grimes,2010; Grimes et al., 2008; Grimes et al., 2010a; Grimes et al.,2010b; Parker et al., 2012). We focus on health concerns within aparticular population—African Americans in low-income, SouthernUnited States (U.S.) neighborhoods—because this group dispropor-tionately experiences diet-related health problems (such as dia-betes and obesity) and barriers to healthy eating (e.g., limitedhealthy food options) (American Heart Association and RobertWood Johnson Foundation, 2005; Flegal et al., 2010; Morland et al.,2002; Palmer et al., 2008; U.S. Department of Health and HumanServices, 2011). Specifically, we investigated the value of culturalfoods, and the cultural construct of collectivism. Collectivismprioritizes communal responsibility, interdependence, cooperationand collective survival (Black et al., 2005; Chesla et al., 2004;Kreuter et al., 2003). Researchers have characterized the AfricanAmerican culture as collectivist and argue that it is critical to

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Int. J. Human-Computer Studies

1071-5819/$ - see front matter & 2013 Elsevier Ltd. All rights reserved.http://dx.doi.org/10.1016/j.ijhcs.2013.08.008

$This paper has been recommended for acceptance by E. Mottan Corresponding author. Tel.: þ1 617 373 7228; fax: þ1 617 373 5121.E-mail address: a.parker@neu.edu (A.G. Parker).

Int. J. Human-Computer Studies 72 (2014) 185–206

understand how this cultural construct shapes health attitudesand behaviors (Black et al., 2005; Chesla et al., 2004; Kreuter et al.,2003). Describing the African American culture as collectivistic is abroad generalization (and we critically reflect on this throughoutthe paper), but it provides a starting point from which to explorerelevant values for design.

We begin by reviewing related work and describing the resultsof formative studies that helped us identify design implications forcollectivistic health promotion tools that help users work togetherfor the common good. Next, we discuss our subsequent design oftwo systems: EatWell and Community Mosaic. These applicationsare collectivistic because their primary functionality helps userstake an active role in sharing and promoting healthy eating habitsin their local communities. We then discuss how participants usedour tools in their daily lives. We build upon our prior work (Grimeset al., 2008; Grimes et al., 2010b; Parker et al., 2012) by detailingfour overarching themes that characterize participants’ prefer-ences for, interactions with, and use of collectivistic tools. First,we describe their strong desire for a positive portrayal of, andinteraction amongst, the collective. Second, we detail the sense ofempowerment that our tools supported as individuals engaged infood advocacy. Third, we discuss the distinctive ways in whichpeople with individualistic and collectivistic perspectives inter-acted our systems. Finally, we focus on the dichotomous way inwhich participants desired but did not discuss cultural foods in thetools we designed. Together, these findings shed light on thecomplex set of considerations that can arise when designing forcultural values. We conclude our discussion by making broaderrecommendations about the design of systems that promotehealthy eating while accounting for users' values and makerecommendation for future research.

From the outset, we recognize that our evaluations are explora-tory and focused on how participants used and reacted to oursystems. Larger, experimental studies are needed to determine theeffectiveness of our tools on sustained attitude and behaviorchange and to confirm the trends we have identified. However,we sought to close a gap, to examine user engagement withculturally-focused health ICTs, providing evidence to supportinvestment in clinical trials of such systems (Klasnja et al., 2011).

2. Related work

Research at the intersection of food, health, culture, andtechnology design requires grounding in literature from thediverse domains of HCI, the health sciences, and the socialsciences. In this section we overview diet-related health dispa-rities work and then transition into a discussion of how culturalvalues, norms, traditions, and histories impact eating and thepursuit of wellness. In so doing, we discuss the concept ofcollectivism, and how researchers have incorporated it into healthinterventions previously. We then provide an overview of relevantHCI research on social health applications, nutrition-focused tools,and online health communities.

2.1. Culture and health

Minority populations in the U.S. (such as Hispanic and AfricanAmericans1) disproportionately experience diet-related healthproblems. For example, as compared to Caucasians, African Amer-icans are 40% more likely to be hypertensive and obese, and almost

two times as likely to have diabetes.2,3 Low-income minorities faceeven greater challenges: poor neighborhoods are less likely tohave supermarkets than affluent communities (Morland et al.,2002) and when present the stores are less likely to stock healthyfoods (Horowitz et al., 2004a). In addition to these structuralinfluences on health, medical and public health researchers in theU.S. overwhelmingly argue that an agenda to eliminate healthdisparities must also account for the way that culture affectshealth behaviors and attitudes (Horowitz et al., 2004b; James,2004; Karanja et al., 2002; Kreuter and McClure, 2004; Plowdenand Thompson, 2002). Indeed, failing to do so can lead tointerventions that cause people to feel socially isolated, forexample, if the recommendations naively force them to shun theircultural traditions and values (Airhihenbuwa and Kumanyika,1996; Horowitz et al, 2004a).

This naturally raises the question of what, exactly, is culture?In this paper, we follow Kreuter and McClure's (2004) definition asthese researchers have conducted extensive research on healthdisparities in the African American community:

“Culture is learned, shared, transmitted inter-generationally,and reflected in a group's values, beliefs, norms of communica-tion, familial roles, and other social regularities.”

While other definitions exist, we use this one to guide ourresearch as it touches upon key features of culture that we focusupon (particularly values, beliefs, and practices). Kreuter andMcClure (2004) suggest that health communication interventionscan be made culturally sensitive by taking a socio-culturalapproach. These interventions are tailored such that “culturalvalues, beliefs, and behaviors are recognized, reinforced, and builtupon to provide context and meaning to information and messagesabout health” (Kreuter and McClure, 2004).

One significant influence on the culture of eating practices ishistory. Researchers have found that some African Americans feeltheir food practices have been shaped by the impact of slavery ontheir ancestors' diet (Airhihenbuwa and Kumanyika, 1996;Horowitz et al., 2004b). James (2004) describes it like this:

“Slaves who were brought to the USA combined their WestAfrican cooking methods with British, Spanish, and NativeAmerican (American Indian) techniques with whatever foodswere available to produce a distinctive African American cuisinecalled ‘soul food’… Soul food emphasizes fried, roasted, andboiled food dishes using primarily chicken, pork, pork fat, organmeats, sweet potatoes, corn, and green leafy vegetables.” (p. 351)

James (2004) notes that traditional African American dishes arereferred to as soul food because “the foods of the ancestors nourishthe body, nurture the spirit, and comfort the soul.” Examples of soulfood dishes include fried chicken, chitterlings, barbecued proteins,macaroni and cheese, collard greens, cornbread, cobblers, and fruitpies (Airhihenbuwa and Kumanyika, 1996; James, 2004). Thesedishes are enjoyable, and often, high in fat and calories.

Despite the nutritional challenges these traditional foods pre-sent, they have such an important history that it can be hard tomoderate one's consumption of them. James’ (2004) participantsfelt eating healthfully meant they had to conform to the dominantculture, thereby giving up some of their own cultural heritage.Further, they not only wanted to partake of these foods them-selves, but also wanted to pass them down to their children.Indeed, cultural foods are hard to let go of: they are one of the last

1 In this paper, we use the terms “Black”, “Black American” and “AfricanAmerican” interchangeably to refer to individuals living in the United States whoself-identify as being of African descent.

2 http://minorityhealth.hhs.gov/templates/content.aspx?lvl=3&lvlID=537&ID=6456.

3 http://minorityhealth.hhs.gov/templates/content.aspx?lvl=2&lvlID=51&ID=3017.

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traditions that people hold onto when assimilating into a newculture (Kittler and Sucher, 2001). As such, food can act as a meansof preserving traditions and maintaining group (e.g., cultural)identity (James, 2004). Thus, researchers must consider that whilesome cultural foods may be unhealthy, interventions that askpeople to give them up completely may face significant opposition.Accordingly, researchers have argued that it is important toincrease awareness of how certain cultural foods can be preparedmore nutritiously (Rankins et al., 2007).

In addition to focusing on the value of traditional dishes, wealso explored the cultural concept of collectivism. Numerousresearchers have studied the extent to which cultures are collecti-vist versus individualist. Individualistic cultures prioritize personalgoals and achievement and prefer independence and resistingpressure to conform to group norms (Nelson and Shavitt, 2002).In contrast, collectivist cultures believe that the basic unit of societyis the group (not the individual) and value communal responsi-bility, group-oriented achievement goals and seek to fulfill theneeds and expectations of family, friends and the larger commu-nity (Komarraju and Cokley, 2008; Nelson and Shavitt, 2002).Thus, one hallmark of collectivist cultures is the collective pursuitof group success, and in the context of health, the pursuit of groupwellbeing.

Moving beyond the binary classification of people as individu-alist or collectivist, researchers have added a horizontal versusvertical dimension to explain individuals' belief in the equalityversus inequality of cultural group members (Komarraju andCokley, 2008; Triandis and Gelfand, 1998). Individuals with ahorizontal perspective tend to believe that one person is generallyequal to another person (Triandis and Gelfand, 1998). That is, theytend to discourage competition and attempts to be better thanothers and value the ability to be unique without comparingoneself to others (Komarraju and Cokley, 2008). In contrast, peoplewith a vertical perspective value hierarchical social relationships,personal achievement, competition, and status (Komarraju andCokley, 2008; Triandis and Gelfand, 1998). This leads to fourpossible classifications: horizontal individualist (HI), vertical indi-vidualist (VI), horizontal collectivist (HC) and vertical collectivist(VC) (Triandis and Gelfand, 1998).

Overall, the United States is characterized as VI (valuingautonomy/independence and competition), though differencesarise when looking at subcultures (Komarraju and Cokley, 2008;Rabi S. Bhagat, 2002; Triandis and Gelfand, 1998). Yet, researchershave found that ethnic minorities within the U.S. such as Africanand Asian Americans are often more collectivistic than EuropeanAmericans (Coon and Kemmelmeier, 2001; Phinney, 1996). Forexample, amongst African Americans, extended family, co-work-ers, neighbors and friends have been shown to be importantsources of social support (Kim and McKenry, 1998). The differencebetween minority groups and European Americans is often attri-buted to the ethnic group's country of origin (Coon andKemmelmeier, 2001). For example, researchers have argued thatcollective unity and kinship characterized West African cultureand that these values not just brought to the United States butamplified by slavery (Komarraju and Cokley, 2008).

Researchers have found it important to consider collectivismwhen addressing health in the African American population, asevidenced by the many interventions focusing on the family andcommunity (Feathers et al., 2005; Karanja et al., 2002; Kreuter andMcClure, 2004). While researchers have translated the concept ofcollectivism into health communication materials and educationalprograms (Karanja et al., 2002; Kreuter and McClure, 2004), it hasnot yet explicitly focused on the design of collectivist ICTs. This is acontribution of our research: providing concrete examples andrecommendations for translating the concept of collectivism intotechnologies that encourage healthy eating habits. However, while

collectivism has been widely incorporated into non-technicalhealth interventions, researchers have also begun to examine thepresence of individualism in the African American culture (Jones,1997; Komarraju and Cokley, 2008). By critically reflecting on ourparticipants' collectivist and individualistic values, another con-tribution is examining how these values can impact the use ofhealth ICTs.

One approach that we drew inspiration from is the Lay HealthAdvisor (LHA) Model because it is guided by a collectivist philo-sophy. LHAs are community members who are trained to deliverunderstandable (no medical jargon), culturally meaningful inter-ventions such as sharing information about resources, services andself-care and encouraging others to learn new skills and knowl-edge (Auger and Verbiest, 2007; Hinton et al., 2005; Raczynskiet al., 2001). The LHA model also provides important benefits forthe LHAs themselves. First, their confidence in their ability toadvise others is often increased as they see that others found theinformation they shared to be valuable (Auger and Verbiest, 2007;Zuvekas et al., 1999). Second, they feel that they are effectivelyimproving the health of the community (Auger and Verbiest, 2007).The LHA model inspired us to see whether we could help moremembers of the community share advice and encouragement.

2.2. Health technology

The growing ubiquity of technology has made it easier tomonitor, store, aggregate and share health information (Enget al., 1998; Grimes et al., 2009; Intille, 2004). In this section weoverview three relevant classes of systems that HCI researchershave explored. First, we describe previous efforts to design toolsfor healthy eating. Second, we overview the growing body ofresearch on tools that help individuals manage their health insocial contexts. Third, we discuss online health communities.

Nutrition-related research in HCI has largely focused on dietarymonitoring. Medical research suggests that regular reflection ondietary behaviors can help people reach wellness goals such asweight loss because it increases awareness and prompts discrimi-nating behavioral decisions (Wing and Hill, 2001). However,challenges with self-monitoring include its labor intensiveness,individuals’ discomfort with recording data, and life stressors thatcan keep people from adherence (Patrick et al., 2009). To addressthese and other barriers, researchers have developed a number oftools that attempt to make monitoring easier, more convenientand engaging. For example, some researchers have used photo-graphy to help people document their choices (Brown et al., 2006;Smith et al., 2007). The MAHI system leveraged a networked cellphone and glucose meter to help diabetes patients photographmeals and analyze how their eating practices and glucose readingsrelated (Mamykina et al., 2008). Others, for example Siek et al.(2006), developed a PDA application that allows users to build afood journal by scanning the barcodes of foods eaten or byrecording voice entries. PmEB is a mobile phone system that helpspeople manually log their diet and exercise activities, examinecorresponding calories consumed and burned, and see a history ofactivities (Tsai et al., 2007). In addition to these academic projects,there are many commercial web and cell phone based applicationsthat similarly help individuals log their dietary behaviors.4

Advances in sensing technologies have allowed for increasedautomatic tracking and monitoring of behavioral and physiologicalhealth information. Systems that leverage this technology attempt tolower the burden of recording information manually. For example,

4 For example, http://www.fitday.com, http://www.myfooddiary.com, andhttp://www.loseit.com.

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the BodyBugg5 is a commercially available armband that usessensors to estimate an individual's caloric expenditure. While muchresearch on monitoring health behaviors has focused on physicalactivity, some systems have been developed to monitor and analyzefood consumption as well (Comber et al., 2012). For example, Changet al., (2006) developed a dining room table that tracks a person'smeal consumption by sensing food moving from a serving containerto their plate. Other researchers have created sensor-augmentedcutting boards and kitchen knives (Kranz et al., 2007) as well as on-body sensors (Amft and Tröster, 2008) for inferring the foods peopleare cooking and eating. However, some researchers suggest that adrawback to automatically recording is that it may remove theprocess of critical self-assessment and regulation that happens whenindividuals have to document behaviors themselves (Connelly et al.,2006).

Researchers have also explored ways of providing individualswith feedback on their current eating behaviors (Chi et al., 2007 ;Mankoff et al., 2002). The PNA (personal nutrition assistant) is aweb-based tool that allows individuals to receive a nutritionalanalysis of what they eat on a daily basis (Beidler et al., 2001).Users create a food journal within the application and the PNAsystem displays a nutritional breakdown of each meal. In addition,the results of these analyses are made available to health careproviders so that further support can be provided to the user. Kimet al. (2010) took yet another approach by designing a system thatuses image recognition software to provide a caloric assessment ofusers’ photographic food journals.

In addition to those more individually focused projects,researchers have developed applications that focus on health ina social context. For example, this work has examined theimplications of allowing people to collaboratively analyze thenutritional value of food in photographs (Mamykina et al., 2011;Noronha et al., 2011). But despite an increased interest in nutrition,most of the social health research within HCI-related fields hasfocused on helping people share information about their physicalactivity, particularly with friends and coworkers (Consolvo et al.,2006; Lin et al., 2006 ; Maitland et al., 2006; Toscos et al., 2008).The goal is that, by facilitating such transparency, systems can helppeople encourage one another to be more active. This encourage-ment can be provided through social support (e.g., friends cheeringone another on as they reach their goals) or social pressure (e.g.,pursuing one's goals so as not to look bad in front of peers).

Competition is frequently facilitated in these systems both asan articulated design goal and through the way users appropriatethe system. For example, TripleBeat is a mobile phone system thathelps runners achieve their goals, in part by allowing them tocompete with other system users to effectively stay in their targetheart rate zone during a run (Oliveira and Oliver, 2008). Houston(Consolvo et al., 2006) is a cell phone application that allows usersto share the number of steps they take each day (step counts) withfriends. In a field trial of Houston, researchers found that partici-pants were motivated to increase their step counts so that theycould “beat” their friends. Users of the Fish‘n’Steps system (anapplication that allowed coworkers to share their step counts) alsoenjoyed the in-system competition because it gave them a bench-mark with which to compare their progress (Lin et al., 2006).However, some participants felt that competition was in conflictwith the spirit of the system. Toscos et al. (2008) developed amobile phone application that allows middle school girls to sharetheir step counts. They found that some participants liked thecompetitive nature of the system, while others found it to benegative (e.g., because it might be unhealthy for a friendship).

A third strand of related research focuses on online healthcommunities. While social health applications have often focusedon existing social networks, online health communities helppeople to communicate about health with a much broader groupof people (Kummervold et al., 2002; Leimeister and Krcmar, 2005;Maloney-Krichmar and Preece, 2005). Online communities havetaken the form of discussion boards and chat rooms (Frey, 2003).These support groups exist for a range of health topics, includingweight loss, injuries, addiction, and cancer management (Frey,2003; Maloney-Krichmar and Preece, 2002). They supplementtraditional healthcare services by helping people address theircognitive, spiritual and affective needs (Johnson and Ambrose,2006). These needs are met as community members shareexperiential knowledge and provide peer support (Kummervoldet al., 2002).

The information shared in online communities is quite diverse:members may provide information about health issues, referrals toexperts, interpretations of illness symptoms or guidance forcoping with a disease (Coulson, 2005; Frey, 2003). Frequentlythe information shared is personal. Salem et al. (1997) found thatin an online health community for individuals coping withdepression, people were four times more likely to share experi-ential knowledge than information gleaned from second-handsources. These results contrasted previous work that in face-to-face support groups, impersonal information is actually sharedmore than personal information (Salem et al., 1997).

One of the main benefits of these communities is that theyallows individuals living throughout the world to share theirexperiences with one another (Maloney-Krichmar and Preece,2005; Salem et al., 1997). However, in our research we exploredthe implications of constraining the user population to peopleliving in the same local geographic area. In addition, while onlinehealth communities typically support people in sharing theirexperiences through textual commentary on personal computers,the systems that we developed allow people to share theircommentary via cell phones and an interactive public display.

Our work is inspired by and builds on this related work.However, we offer two sources of differentiation. First, we takeculture into account explicitly. Second, we focus on the localgeographic community as opposed to social networks comprisedof friends, families and co-workers or distributed online groups.In so doing our goal is to identify new spaces for HCI research toexplore.

3. Case study overview

To gain implications for the design of collectivistic tools, weconducted formative studies in which we examined (1) ourparticipants' knowledge of and experiences with nutrition andeating, and (2) how residents could most effectively come togetherto encourage each other. Ahye et al. (2006) make the case thatregional subsets of the African American population must bestudied to find a shared food culture. Accordingly, we focused onthe eating practices of individuals in Southwest Atlanta, GA, anarea where the annual household income level is well below thestate average.6 This focus on the concerns and values of AfricanAmericans in a specific geographic context helped us to operatio-nalize the concept of collectivism. After describing our formativework and the resulting systems that we designed, we discuss ourevaluations of these tools. In the remainder of the paper, where we

5 http://www.bodybugg.com/.

6 In 2009, the poverty level for the zip code in which the YMCA branch islocated was 23.5% (compared to 16.5% for the state of Georgia) and the estimatedmedian income level was 35% lower than the state average. For more information,see: http://www.city-data.com/zips/30311.html.

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share findings related to designing for local community contextswe do so with the goal of illuminating how the cultural constructof collectivism can be concretely translated into design and theimplications of doing so. Table 1 provides a summary of thestudies we discuss.

4. Designing EatWell

4.1. Method

We conducted focus groups with 15 participants to explore thefood-related attitudes and practices of individuals in our targetarea. We asked participants questions regarding the eating prac-tices of themselves and their family members, to what extent theyfeel there is a distinctive set of African American cultural foods,and their experience with trying to maintain a healthy diet.Participants received a $10 gift card for taking part in the study.While we cannot generalize about the perspectives held by allresidents in this area, our fieldwork helped inspire design ideaswhich we examined the feasibility and impact of in subsequentdeployments. We conducted a thematic analysis of the focus grouptranscripts in which we first inductively coded the data to denoteemergent phenomena and iteratively clustered related codes intogroups, and eventually, higher-level categories (Thomas, 2006).

We recruited participants by making announcements at eventsorganized by a community health organization that provideshealth services to low-income, predominantly African Americanindividuals. We also advertised the study verbally to maintenanceworkers at our University. We advertised the study to adult malesand females, however we had much greater interest from women.Our study included 14 female participants and one male partici-pant and we obtained demographic surveys for 14 participants.Participants came from a range of age groups: five were aged25–45, three 46–59, and six participants were 60 or older. Eightparticipants were either unemployed or retired. The remainingparticipants held a variety of positions including janitor, foodservice worker, administrative assistant, entrepreneur, and com-munity health worker. Just over half of participants owned a cellphone (n¼8) and six had a computer in their home.

4.2. Results: design implications

We identified two design implications: acknowledge commu-nity expertise and sensitively account for cultural uniqueness.We came to recognize the importance of acknowledging commu-nity expertise as we listened to our participants share stories abouthow they had overcame challenges associated with their socio-economic context, in particular, the challenges of finding healthy,affordable food. For example, while soymilk is an expensiveproduct, they found ways to obtain it for free from local commu-nity organizations. Other participants described trying to improvethe foods sold at local markets, for example one participant said:

“They don't have vegetables in our stores. A lot of times I wantsome lettuce to make a salad but they don't have it… I was

telling the man the other day about getting collard greens andgetting some … turnip greens or something like that… I toldhim that he would do good [sales if he sold those items].” (P6)

In other words, the community members were already tryingto improve the health of their own communities by sharing advicewith others and lobbying for change in their access to healthieroptions. So while our participants brought health disparity statis-tics to life because their stories were real-world examples of thestatistical picture painted by health researchers, at the same timethey also represented a defiance of those statistics trying tocounter these challenges. This led us to reflect on how low-income communities may seem information-poor; their knowl-edge of how (and where) the healthiest foods might be makesthem, in some ways, information-rich. Specifically, they knew howto navigate the constraints and affordances of eating in thisparticular socio-cultural environment.

This type of contextual knowledge translated into otherdomains. For example, they discussed experiences with traditionalsoul food dishes and the benefits of cooking with olive oil. Thus,they illustrated how to modify historically meaningful foods tomake health improvements. What was particularly striking to uswas the amount of information they had to share and the easewith which they offered it in these sessions. This suggested anopportunity for design to leverage this community embeddedexperiential knowledge (as opposed to, for example, designing asystem that facilitates outsiders imparting nutrition advice).

Our participants also cued us into the importance of sensitivelyaccounting for cultural uniqueness. Specifically, some of our parti-cipants were frustrated with what they saw as an unfair portrayalof the state of health within the African American community.By emphasizing significant health disparities, our participants feltthat others were creating a negative image of African Americans.Some were frustrated because they felt that African Americanswere being unfairly singled out as being worse off than others.P11 put it this way,

“We are not carryin' all this [disease] by ourself. God did notcreate for us to have all this by ourself.”

P10 also expressed her frustration to us by saying,

“I even get frustrated on television when I see something,where they say Blacks [have problems]. Why is it always got tobe Blacks? What make them think Black dominate just the low,the lowest of all?”

Our participants' concerns suggest that, when designing tech-nology, a balance has to be struck between accounting for culturaluniqueness and doing so in a way that does not alienate that groupfurther. It also suggests using a participatory approach in design toensure that what is being built engages rather than distancesusers. This is true when designing any kind of interactive system,but we suggest it has particular importance when focusing onculture and race.

Table 1Study overview. A summary of the studies described in this paper.

Year Study Overview

2006–2007 Formative study #1 Focus groups and background survey (n¼15)2007 Design and evaluation of EatWell 4-Week deployment: follow-up interviews and background survey (n¼12)2009 Formative study #2 Focus groups and background survey (n¼31)2009–2010 Design and evaluation of Community Mosaic 12-Week deployment: follow-up interviews, closing focus groups, and pre/post deployment surveys

(n¼43)

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4.3. EatWell

We used these design implications to create EatWell, a telephone-based system that helps people learn culturally relevant strategies forhealthy eating. EatWell allows users to create short audio “memories”(voice messages) describing how they have tried to eat healthfully intheir neighborhood (e.g., at fast food restaurants or cooking at home)and listen to the memories that others in their community havecreated (Grimes, 2010; Grimes et al., 2008; Grimes et al., 2010b). TheLHA model inspired our design, though we did not translate all of themodel's components into system features. EatWell's design reflectsone of the main goals of LHA interventions: lay users share informa-tion (in our case, their healthy eating experiences) to inspire commu-nity members to eat more healthfully.

We chose to leverage the cell phone platform because thepenetration rate of this device is high even in low-incomecommunities. During the time period in which we were designingEatWell, approximately 74% of people with a household incomesless than $25,000 per year owned cell phones (CEA, 2005). Oncewe identified a platform, we brainstormed ideas for an applicationthat reflects the construct of collectivism, specifically, helpingpeople to get involved in improving the health of others in theircommunity.

We acknowledged community expertise by designing EatWell tobe a repository of information and making community membersthe sole creators of content within the system. We did not seedEatWell with stories about eating healthfully or tips taken fromoutside sources. Such an approach may have been useful, but wewanted to privilege the experiences of community members in ourdesign. We supported individuals in learning from communityexperience by creating a mechanism whereby users' stories wereaccessible by other system users, all of whom lived in or frequentedthe same neighborhood. By having access to the stories of others inone's local area, EatWell supported individuals in gathering strate-gies for healthy eating from individuals who likely faced similarchallenges and who had a similar cultural frame of reference.

Finally, we attempted to sensitively account for (AfricanAmerican) cultural uniqueness. By constraining the user group toAfrican Americans who lived or spent a significant amount of timewithin the neighborhood, we acknowledged that there might be aunique set of issues and experiences that these individuals couldspeak to. At the same time, by making the categories of stories thatindividuals could create generic (e.g., “Cooking at Home” and “FastFood”), we did not force them to share stories relating to anyspecific health problem. Furthermore, the system did not in anyway emphasize the disproportionate health problems that existwithin ethnic minority U.S. populations. In other words, weattempted to make EatWell open-ended enough to allow usersto infuse it with stories that reflect their own cultural experience.

Users accessed the system by dialing a number that connectsthem to the EatWell service. They were greeted by the followingvoice message: “Welcome to EatWell. You can listen to or recordmemories about eating healthfully in your neighborhood. Pleasechoose what kind of memory you want to listen to or create.” Theuser then chose one from the five categories of memories:(1) fast food, (2) restaurants, (3) cooking at home, (4) grocerystores and markets, and (5) other. Examples of messages createdand shared during our deployment can be found in Table 2. Oncethe user chose a category (by selecting the correspondingbutton on their cell phone keypad, 1 to 5), they were given theoption to press (1) to listen to a memory or (2) to record theirown. If they chose to record a memory, they spoke their memoryinto the phone after a tone. Once finished they had the option tokeep, re-record, or delete it. As soon as memories wererecorded, they were immediately available to the other systemusers. When listening to memories, the newest was played firstand they could “scroll” through them by pressing the appro-priate keypad buttons.

Interactive Voice Response (IVR) systems can be frustrating andconfusing when users are forced to navigate deep menu hierar-chies (Asthana et al., 2013). As such, we played clips in reversechronological order, which allowed frequent users to quicklyaccess the newest content without having to bypass messagesthey had already heard. Furthermore, we sought to keep ourdesign simple by providing a small set of key features. This meantthat we did not provide opportunities for users to curate themessages (e.g., by developing their own categories or ratingmemories). Building on recent efforts to develop novel IVRsystems (Asthana et al., 2013), future work could explore how tosupport more complex system interactions while minimizing thetime it takes to navigate the system.

We implemented EatWell using the TellMe Studio suite of toolsfor creating voice-based applications, VoiceXML and PHP. Westored memory information (e.g., file locations) and user-interaction information (e.g., memories listened to and createdby each user) in an SQL database. All of this code was storedserver-side, so no software was installed on the user's phone.Users only needed to use their existing cell phone and service planand dial the EatWell number to reach the system.

5. Designing Community Mosaic

Our second formative study builds on the first, continuing todeepen our understanding of health and culture but also to inspirea more comprehensive second prototype system. For this study werecruited staff and members of a YMCA branch in a low-incomearea of Atlanta, GA. We picked the YMCA because it is non-profit

Table 2EatWell Memories.Shown below are transcribed examples of audio “memories” shared during our EatWell deployment.

Message category PID Memory exemplar

Cooking at home P3 I have a great memory for a lentil loaf. I actually got it off the food network. That Italian cook, the one they say is so sexy, did a lentil loaf. Soit’s like meatloaf only it’s made with lentils! And it is absolutely fabulous! It took me a long time to make it the first time. Um, and I actuallyas I was making it I said, ‘I am never doing this again ‘cause it’s just too much trouble.’ In reality it's not that much trouble but you just gottaremember to soak the lentils like a day ahead of time. It is so good that my daughter who is 4 and a half wanted to take it for lunch the nextday and asked if we had any extra to take to her teacher. Now you know it must be really tasty. Good and good for you! I also gave the recipeto a friend of mine who is vegetarian. She said she has made that lentil loaf 5 times since I gave it to her. So, give it a try.

Grocery stores andmarkets

P4 Greetings. This morning I am making a run to the Dekalb farmer’s market. And it’s unfortunate because I really enjoy the prices that I gatherthere, however it’s clearly on the other side of town (I live in Southwest Atlanta, 30 or so minutes away). So I have to kind of strategize anddo it in conjunction with trips to Walmart or other places to make it worthwhile to drive. But the produce is very fresh and the cost of theproduce is very affordable, so in instances it’s worth my while to make that drive all the way tot he Dekalb Farmers’ market. So if you don'tknow about that place definitely look it up—you can basically get produce from the entire world and under one roof. So the internationalmarket is a pretty good deal. Thanks, take care, bye.

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organization that provides services (childcare and health- related)to local neighborhoods and it attracts individuals who live, workor spend time in the same geographic area.

5.1. Method

This study was based in a predominantly African American,low-income community in Atlanta (the estimated median annualhousehold income in 2009 was 35% below the state average of$47,590). We conducted seven hour-long sessions at the YMCAconsisting of three to six participants (see Fig. 1), in which weasked participants to discuss health in their community, includingthe barriers to and resources for eating well. To facilitate discus-sion, we developed a set of 13 note cards and presented eachparticipant with one set (described and listed in Table 3). Eachcard contained an idea for how technology could help the com-munity encourage healthy eating amongst residents. By havingeach card focus on a community-oriented strategy, we were ableto obtain participants' reactions to a variety of approaches thatreflect the concept of collectivism (i.e., they indicate ways in whichthe community can work together to improve its wellbeing).

To brainstorm promising card topics, we began by looking atprior work. We considered barriers to healthy eating identified byprevious research (e.g., finding inexpensive, healthy foods), howsocial systems have encouraged wellness (e.g., facilitating thesharing of encouragement and peer advice), and ways in whichpublic health interventions have pursued health promotion (e.g.,community advocacy). We hoped that these cards would spark

Fig. 1. Focus Group. Participants discuss how the community can best worktogether to promote healthy eating during our second formative study.

Table 3Focus Group Card Topics and Results. The 13 ideas for community-based health promotion presented to our participants, including a description, the # of people who said itwould be an effective (E) and ineffective (I) idea, and the ratio of E:I (R). Ideas are color coded to show the most popular (dark green), marginally popular (light green), thosewith a more balanced reaction (white), those that were marginally unpopular (pink) and ideas that were most unpopular (red).

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discussion, not represent an exhaustive list of all potential strate-gies. Participants were asked to look at all of the ideas and choosethree cards with ideas that they felt would be most effective andthree that would be the least effective. (They could also take ablank note card and write their own idea.) Once their decisionswere made, each participant described the rationale behind theirchoices, and this activity served as the basis for further groupdiscussion.

We tallied the responses to determine how many people felteach card's approach was effective and ineffective. We thencomputed the ratio of the total number of people who felt theidea was effective to the number who felt it was ineffective (seeTable 3). This ratio provides a general sense of the overall responseto the card: a larger ratio indicates that participants felt morepositively towards the idea than negatively and a ratio under1 shows that people felt more negatively than positively towardsthe idea. (As there was at least one person who felt each approachwould be ineffective, we did not run the risk of having a ratio withzero in the denominator.) We also audio-recorded and transcribedthe focus group sessions and conducted an inductive analysis(Thomas, 2006) of participants' explanations for the cards thatthey chose. Through this analysis we derived insight into whatparticipants saw as positive and negative forms of communityinteraction around food and nutrition.

We recruited participants by placing flyers in the YMCA andmaking announcements during exercise classes. Thirty-one peopleparticipated in the study (23 female, 8 male) and they were between18 and 60 years old. All participants self-identified as Black/AfricanAmerican. Twelve were married and 21 had children. Twenty-sixparticipants reported their income levels and household size, and ofthem, 27% (n¼7) had a household income that was less than or equalto 235% of the 2009 federal poverty guidelines7 (metrics used todetermine individuals' eligibility for various federal aid programs).The remaining participants had annual household incomes thatranged from $40k to over $100k. Thus, while the community settingwe targeted was predominantly low-income, our participants didreflect a mix of socioeconomic statuses. Most had a post-high schooldegree (n¼26) and they had a range of occupations includinghairstylist, teacher, attorney, event coordinator, and tutor. Eightparticipants worked at the YMCA. Participants received a $15 giftcard for participating in the study.

5.2. Results

Participants' comments were not technology-specific; at thisstage we wanted to stimulate, without too many constraints,discussion about how the community could come together topromote healthy eating more broadly. In the following sections,we describe what participants felt were positive and negativeforms of community interaction. Understanding these sentimentswas a critical initial step towards designing collectivistic healthsystems for local communities. Several of our themes confirmprevious research on the healthy eating challenges faced by ethnicminority and low-income populations. The contribution of ourwork is identifying which of these issues our participants weremost concerned with, identifying what they feel the communitycan do to address these issues, and translating their ideas intodesign recommendations.

5.2.1. Positive forms of community interactionOur participants' perceptions about how their community can

effectively work together to encourage healthy eating can begrouped into three strategies, which we discuss below.

Modifying cultural recipes: We presented participants withthe “Cultural Cooking Tips” card to examine how important theyfelt it was to adapt cultural dishes, as they are often preparedunhealthily (e.g., with high levels of fat and cholesterol) (James,2004). By far, this is the topic that participants were most excitedabout: 15 said it would be one of the most effective strategies andonly one person felt it would not be useful. Many participants feltthat soul food (traditional African American cuisine that includesdishes such as cornbread, chitterlings and candied yams) is verymuch valued amongst African Americans, as previous research hasshown as well (James, 2004). Some felt that soul food is a staplecuisine for numerous African Americans as many were raisedeating those dishes. Furthermore, participants felt that it can behard to stop eating those foods completely because they are ofteningrained in one's cultural heritage. Yet, given that these foods arefrequently prepared unhealthily, participants voiced the need for achange by reinventing recipes in healthy ways. They felt thatshowing people how to prepare soul food more healthfully wouldhelp them see that they do not have to lose the foods that theylove to be healthy. For example, P2 said,

“They are not gonna get your grandma away from eating turnipgreens [a soul food dish often prepared with pork fat]. But ifyou can get her to eat healthier then you know, [she might be]here for another five years.”

Locally and temporally relevant resource identification:Participants also wanted to identify locally-available healthy eat-ing resources that make sense given the time constraints thatpeople often face: overall, both the “Showcase CommunityResources” and “Alternatives for Cheaper, Healthier Groceries” cardswere viewed as positive ideas. Exposing these local resources wasseen as critical because participants felt that many are not awarethat they exist. Furthermore, participants discussed the economicchallenges that many residents face and how eating well is moredifficult in their community than in other parts of the city (e.g.,because there tend to be fewer high quality grocery stores). As P16told us,

“You gotta [show options for cheaper, healthier groceries]because eating healthy is not expensive when, you know,there's SUPERMARKET-X down the street or SUPERMARKET-Yor [a] farmer's market, somewhere! We don't have that! So likeI said, we have to travel to get fresh fruit. I'll take kids on tripsthat have been shocked at the thunderstorm in the fruit aisle[automatic water showers that hydrate produce], they love it!!”

P22 further described the necessity of identifying inexpensiveways to eat healthy:

“Typically the food that's least healthy is least expensive. So ifthere was a way to get inexpensive, quality vegetables so thatthey could compete with the inexpensive [local fast foodrestaurant] burgers, that would be helpful for the community,particularly in this area.”

Participants also spoke about the importance of identifying andcreating healthy local options when discussing the “CommunityAdvocacy” card. This card presented the idea of helping peopleadvocate for healthier food options in the community (e.g., byrequesting they be available at local grocery stores and restau-rants). Participants were somewhat divided in their reactions tothe card, with eight people saying it would be an effectiveapproach and six feeling that it would not. Some participants feltthat people would not be interested in actually making the effortto engage in such advocacy, for example because they have otherproblems to worry about. However, others argued that advocatingfor healthier foods in the community (e.g., by making their desires7 http://aspe.hhs.gov/poverty/09poverty.shtml.

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known to the “powers that be” [P11] such as local business owners)would effectively make more nutritious options readily available.These participants felt that the availability of more healthy optionswould make it easier for people to make good dietary choices.Thus, like those that were in favor of the “Showcase CommunityResources”, these individuals were vocal about the importance ofmaking healthy options more readily available in the community.

In addition to focusing on locally available resources, partici-pants who were in favor of the “Healthy Fast Food” card said that itis critical to encourage healthy eating by taking into accountpeople's temporal constraints. They described how buying fastfood was simply their reality when it came to providing meals fortheir children in the context of their busy, fast-paced lives. P31described the challenge she faces as a busy single mother trying toprovide healthy options for her son in the midst of her hecticschedule. P23, also a mother, described how she tries to help herdaughter make healthier choices:

“Sharing healthy fast food [ideas] is to me something you have todo because we are all busy and we are all taking our kids to thefast food restaurant… I started teaching my daughter to pull thecalorie guides out of all the stores ‘cause they have them, theyhave to have them. So I pull them from all the fast food stores wego to and I show her where the lower-calorie foods were and Ishowed her how to take calories off of her food.”

Our findings echo previous work that has pointed to thechallenge low-income caregivers face when trying to makehealthy decisions (Siek et al., 2009).

Making success visible: In addition to supporting resourceidentification, with the “Community Praise” card we examinedhow participants felt about receiving technological support for(1) seeing the success stories of people who are now eating morehealthfully and (2) giving those individuals praise. Participantswere practically divided in their reaction to this card, with fivepeople feeling that it would be effective and six feeling that itwould not. Participants who felt it would be ineffective wereskeptical and unsure of why they should care to see that otherswere doing well. At the same time, participants who felt it wouldbe an effective approach argued that through the sharing ofsuccess stories, people help others to see that it is possible tomake positive changes. Thus, participants who reacted positivelyto the card did so largely because of their excitement at the idea ofsharing success stories, not providing praise to the story sharers,which was something that few participants discussed as beingvaluable. They were excited about this idea not because theprocess of providing praise would be beneficial to the person withthe success—instead they felt that seeing the success stories wouldbe encouraging for the viewers. For example, P17 said,

“You know how a lot times people make excuses and they'lljust say, “Oh well I would do it but you know, you know I can'tbecause x, y, z”? I think when you see people that have done itand you know they are in the same situation as you are, theylive in the same community as you, they've got the sameresources as you. [It's] like okay, now I do have to acceptpersonal responsibility for the fact that I'm not you know doingthese things because it can be done and here's a real liveexample of it, so I think those kinds of things will be helpful.”

5.2.2. Negative forms of community interactionParticipants were not enthusiastic about all of the cards that we

presented themwith: there were some strategies that they felt wouldbe ineffective at helping the community to eat more nutritiously.

Providing generalized nutrition awareness: First, while par-ticipants were excited about showcasing the successes of those inthe community and pinpointing culturally, locally and temporally

relevant resources, they were strongly opposed to the idea ofsharing generalized health information about the community. Forexample, the “Showing How Healthy the Community Is” card wasmostly rated as negative. Participants did not want an overallpicture of the community's health because they felt that peoplealready know this information. They argued that people generallybelieve the community to be unhealthy but that this has not yetcompelled them towards wellness. For example, P8 said:

“I think there are so many statistics, so many, you know reportsand information [that say,] “Oh our community is unhealthy”…[and] we're still not doing anything about it… we're notalarmed. So I don't think that's the most effective [approach].”

This finding builds upon the results of our first formative study(see Section 4) in which participants were frustrated with discus-sions of how unhealthy the African American population is. YMCAmembers and staff felt that sharing information about how wide-spread health problems are within the community was simply anineffective approach to getting people to eat better.

Similarly, 10 participants said that the “Awareness” card wouldbe ineffective (it suggested showing why eating healthy is impor-tant), in large part because they felt that most people are alreadygenerally aware of the importance of healthy eating. One canquestion just how deep and pervasive this awareness is, but it isimportant to note that there was a desire by several participants tomove beyond such awareness campaigns. At the same time, 15participants felt that providing awareness would be beneficial.However, they clarified that providing more awareness would bebeneficial if the information was individualized. For example, theyindicated that instead of highlighting the general need to eathealthy, it is important to show how real people have beenaffected by the way they eat.

Taken together, the reactions of those that felt positively andnegatively towards providing awareness show that our partici-pants felt that providing impersonal information about the state ofhealth in the community or the importance of eating well is not aproductive approach. If anything, information should be given apersonal touch by showing how real people have, practically, eatenwell in the past and how others can do so in the future.

Identifying issues in the community: We created the “Surfa-cing Community Issues” card to provide another idea for how low-income communities can address challenges such as locating leancuts of meats and low-fat milk products (Sloane et al., 2003). Ourrationale was that surfacing these challenges might help commu-nity members identify solutions for overcoming them. However,only one participant said that discussing community issues was agood idea and 14 people felt that it was an ineffective approach.Participants who were against discussing community issues feltthat the community is already aware of the problems and thattalking about them is a negative endeavor that will not help themmove forward. P12 put it this way:

“I think that's more of a negative way of looking at the problemrather than trying to get the people to think positively aboutchanging, just complaining instead of you knowmoving forward.”

Sharing General Nutrition Tips: Participants also reactednegatively to the “Peer Nutrition Advice” card, which suggestedthat community members provide general nutrition advice to oneanother (nine said this would be an ineffective approach and onlyone person thought it would be effective). In online healthcommunities, people often share questions and advice on healthconditions with strangers (Maloney-Krichmar and Preece, 2005).For this reason, we posed the idea of community residents sharingpeer nutrition advice. However, our participants reacted verynegatively to this strategy. Upon examining their reactions more

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closely, we found that understandably, some participants werewary of peer advice because it is unclear where they have obtainedtheir information, The idea of “advice” implies that the informa-tion giver possesses some verifiable truth or medical trustworthi-ness and some participants did not feel they could guarantee thevalidity of nutritional advice that community members mightshare.

Providing community feedback on eating habits: Similar tothe “Peer Nutrition Advice” card, we were motivated to suggestthe “Community Feedback” card because of social health applica-tions that let individuals comment on the healthiness of theirpeers' habits (Consolvo et al., 2006). “Community Feedback”differed from the “Peer Nutrition Advice” card in that it suggestedresidents provide feedback to one another on their specific eatinghabits (versus general nutrition advice). However, participants feltcommunity members would not care enough to give such cri-tiques. They also doubted that hearing such a critique wouldcompel them to change their habits. For example, P22 said thatif someone gave her feedback on her eating habits she wouldthink,

“Thank you for the encouragement but that's just not gonnamake me want to eat more healthy. I mean in this time whereeverything is so quick and we don't have a lot of time—and

we're seeing people in passing, I just don't think [someonesaying,] ‘Yeah you're eating an apple, you go girl!' is gonnawork.”

5.3. Design implications

Based upon our findings, we derived five design implicationsfor our work.

Support personally reflective information sharing: First, wefound a critical distinction in the type of community-sharedinformation that participants did and did not value. On the onehand, they were excited about increasing the options that peoplehave for healthy eating by allowing them to share their cookingideas and pointing out community resources. However, theyreacted negatively to hearing peer suggestions for how theyshould specifically modify their existing habits. In summary,participants liked the idea of sharing information that waspersonally reflective, meaning that it is about the informationsharer's experiences and ideas, and does not come in the form ofdirected commentary on the habits of others.

Support the sharing of low risk information: While partici-pants valued community-shared information on healthier culturalrecipes, healthy options at fast food restaurants, and other localestablishments, they did not value peer advice on nutrition topics.

Fig. 2. The Community Mosaic Visualization.The Main Screen is shown (top) and the Detail Screen (bottom).

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The latter was seen as questionable in terms of its trustworthiness.For our work, the implication of these findings was that instead ofhelping people share lay nutrition knowledge (e.g., about theeffects of certain nutrients on one's body, which may be harderto assess in terms of its trustworthiness), a future applicationshould support the sharing of more experiential knowledge andthe identification of community resources—information for whichthe stakes are lower in terms of proving its validity.

Make community success visible: Participants indicated thattalking about the challenges in the community was unproductive.In contrast, they felt that showing individuals' successes wasimportant and valuable. Thus, a future system should highlightthe ways in which community members are succeeding at eatinghealthfully. This is in line with the celebratory health technologyapproach (Parker et al., 2011), in which design starts with trying toexamine how to leverage, make more visible or highlight the waysin which people are doing well—and then uses that success aspringboard for encouraging healthier behaviors in the future.

Bring it back to the individual: As the first three designimplications show, our participants felt that while focusing on thecommunity, it is important to show how individuals can and aremaking healthy decisions in the community. A future systemshould help users understand how to translate a general aware-ness that it is important to eat well into their everyday lives.Furthermore, a future system should provide insight into howusers can eat healthfully given their cultural, local and temporalreality.

Support action: Finally, our participants indicated that it isimportant to not simply talk about community health issues.Ultimately, it is critical that a technology encourage actionamongst community members, such as the modification of exist-ing cultural recipes or taking steps to confront the challenges toeating healthfully in the community. While information sharing isimportant, the application's focus should be weighted moretowards actual modification of behaviors than discussion.

5.4. Community mosaic

Based upon these design implications, as well as those obtainedin our first formative study, we created the Community Mosaic(CM) system. Like EatWell, CM users share their healthy eatingexperiences to inspire community members to eat more health-fully. CM has two interface points: the user's personal cell phoneand the visualization software (CM Visualization) that runs on alarge public display (a touch-screen monitor).

The CM Visualization (shown in Fig. 2) greets users with thefollowing prompt: “How are we eating healthfully today? Share yourexperiences. Send pictures, text or both. Inspire others in the com-munity.” To share their experiences, users can send picture (MMS)and text (SMS) messages from their cell phone to the CM phonenumber. These messages can portray foods, people, places—any-thing that the user feels helps them eat well. Messages aredisplayed in the CM Visualization software that runs on a 42”touch-screen monitor. Once a user sends a message, they receive aresponse text message letting them know that their message hasbeen received.

CM Visualization Main Screen: The system moderator mustapprove all incoming messages before they are displayed. In ourdeployment study we moderated messages to ensure that nooffensive content was shared and that messages met the healthstandards of the YMCA (e.g., that people were not promotingsupplements or particular diet programs).

The Main Screen in the CM Visualization software shows a setof buildings that represent the Atlanta, GA skyline (Fig. 2).As messages are received and approved, the building windowsbegin to illuminate. If the message contains a photo, a small

version of the photo is displayed. If the user has shared a text-onlymessage, the CM logo appears in the window. (The blank bluewindows indicate that no message has been posted to thatposition yet.) Thus, as the community shares an increasing numberof messages, the windows illuminate until all the building win-dows are filled. The metaphor here is that the community workstogether to in a sense, build the city, by sharing their experiences.For aesthetic reasons, the building windows are populated basedupon a pre-defined pattern that ensures messages are spreadrelatively evenly across the buildings.

CM Visualization Detail Screen: Pressing an illuminated build-ing window in the Main Screen reveals the details of the sharedmessage it represents: the photo and/or the text that the user hasshared, the date and time the message was sent, and the numberof times this message has been viewed (Fig. 2). All messages aredisplayed anonymously, meaning that the sender's name andtelephone number are not shown. At the bottom of the DetailScreen, viewers can see this user's history of experience byscrolling through thumbnails that represent the other messagesthe user has sent. Viewers can then press any of the thumbnails toview the Detail Screen for the message it represents.

Viewers can share their reactions to the healthy eating strategyin a message by pressing buttons in the Community ResponsePanel (located on the right side of the Detail Screen). Thesebuttons allow viewers to say: (1) I'm inspired to try this, (2) Iwant to learn more about this or (3) I hope others in thecommunity will try this. Next to each button, a tally shows thenumber of times the button has been pressed. The total number oftimes community members have been inspired to try all ideasshared in CM is displayed at the bottom of the CM VisualizationMain Screen.

Update messages: Once a week, each user is sent a textmessage indicating how many messages were shared during thepast week. This update message is also personalized to let eachuser know how many times people were inspired to try messagesthat they had personally shared. CM calculates this information bytallying the number of times people have pressed the inspiredbutton in the CM Visualization for each user's messages.

When users sent a message to CM, it was processed by SMS/MMS Gateway software that we developed in Java. The gatewayran on a Google Android G1 phone that is equipped with a SIMcard. The gateway parsed the message and extracted the sender,date and time of message, the photo (if any) and the text message(if any). Once this information was extracted, it was sent wirelessly(using the SIM card's data network) to a computer server locatedat our University. On this server, the CM Processing software(which we wrote using PHP and SQL) stored the sender, date,time, text message (if any), and photo (file location, if any)information in a MySQL database. This processing software alsosaved the photo image file on the server. The CM Visualizationsoftware was written in Adobe Flex and PHP and was shown in afull-screen mode web browser on a 42" Samsung TSN-2 touch-screen monitor.

5.5. Incorporating design implications

In this section, we discuss how our design was influenced bythe design guidelines we obtained in our second formative study.First, we incorporated the design guideline, Support the Sharing ofLow Risk Information, by enabling users to share their experiencesrather than nutritional information that might require moreexpertise (e.g., detailed information about how specific nutrientsaffect one's body). Furthermore, by asking people to share howthey are trying to eat well on a daily basis, CM encourages them tonot simply share impersonal recommendations or advice, butrather their lived experience with trying to engage in wellness.

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This aspect of CM addresses the design guideline, Bring it Back tothe Individual by supporting the sharing of personalized eatingstrategies. Indeed, the goal of CM is that people will share personalexperiences that reflect the practical reality of trying to eat wellgiven one's physical environment (local resources), cultural envir-onment (the foods that reflect one's heritage and the more generalculture of eating that one is surrounded by) and their temporalreality (trying to eat well in a world that is often hectic).

By prompting users to share “how they are trying to eathealthfully today”, and document their personal eating experi-ences, CM scaffolds users in sharing reflective information aboutthemselves as opposed to directed commentary about how othersshould be eating. This addresses the design implication, SupportPersonally Reflective Information Sharing. We further addressed thisdesign implication by not including any mechanisms for users todirectly critique CM messages. The only commentary that partici-pants can share is that which is in the messages they senddocumenting their own experiences. Furthermore, the buttons inthe Community Response Panel let viewers share how the mes-sage affected them personally but there are no response buttonsthat allow them to critique messages.

We addressed the design principle Make Success (Not Chal-lenges) Visible in the following ways. First, CM users are encour-aged (through the prompts in the Visualization software) to sharehow they are trying to eat healthfully and to thereby inspire othersin their community. This is in contrast to, for example, encoura-ging people to share their challenges. Sharing one's struggles canindeed be a useful process, as is seen in online health communitieswhere people share and receive support to overcome challenges.However, our participants were more interested in a system thatfocused on the positives. Second, CM makes publically visible thevariety of ways in which community members are succeeding byshowcasing them on a large public display. Our goal is that indoing so, others in the community may be inspired to try the ideasshared in the system or to eat more healthfully in general.

Finally, CM incorporates the Support Action design guideline bydirectly encouraging users to engage in healthy behaviors. First, tocontribute to CM, the system requires users to engage in eathealthfully themselves so that they can document and share theseexperiences with the community. Second, in the “Other MessagesFrom User” section of the CM Visualization Detail Screen, viewerscan see a contributor's history of action. This feature showsconcrete examples of individuals engaging in healthy behaviorsover time, which will hopefully help viewers feel that they havethe ability to do the same thing. Third, Community Response panelbuttons let viewers share, in a lightweight way, their thoughts onmoving the community towards action (the “I hope others in thecommunity will try this” button) and if they were personallyinspired to act upon the information seen (the “I am inspired to trythis” button).

6. Deploying EatWell and Community Mosaic

We now provide a brief overview of the methods we used toevaluate EatWell and CM. For further details on these methods,please refer to (Grimes, 2010; Grimes et al., 2008; Parker et al., 2012).

6.1. EatWell deployment

We evaluated the use and impact of EatWell in an urban Atlanta,GA neighborhood in a field study with 12 people. At the beginning ofthe study, we showed participants how to use EatWell and thenasked them to complete a survey with questions related to threetopics: demographics, nutrition-related attitudes and practices, andcell phone usage. Each participant had access to EatWell for at least

four weeks and during this time we logged how they used thesystem (e.g., date and time of access, what memories they listenedto). In addition, we interviewed each participant one to two times togain deeper insight into how and why they used EatWell. (Our goalwas to interview all participants twice, but due to schedulingconflicts, three participants did not complete their second interview.)In the interviews we covered a number of topics, including whatmotivated participants to create and listen to memories, theirreactions to hearing memories, what they considered to be positiveand negative aspects of the system, and the extent to which they hadtried strategies that they heard in EatWell.

We conducted a thematic, inductive analysis of the interviewtranscripts (Thomas, 2006). Two researchers first examined thetranscripts to derive a set of codes that described the emergentphenomena in the data. We then met to review the codes andreach consensus. Once the final set of codes was extracted fromthe interview data, we came together to iteratively cluster thesecodes and arrive at higher-level themes.

We also conducted a content analysis of participants' audio clips(Krippendorff, 2004). Examples of the memories shared can be foundin Table 2. We first developed a set of codes based on themes thatemerged from the interviews and an initial examination of the clips.In particular, we examined to what extent the clips discussed culturalfoods (Grimes et al., 2010b). To ensure consistent coding between theresearchers, the two raters first met to review the proposed codingprotocol and discuss how the codes would be applied. We thenrandomly selected a subset of the 38 EatWell audio clips (20%E8 clips) to rate. Each rater then independently coded these sampleclips by listening to the audio and reading the transcript of each clip.Transcripts were coded at the sentence level, meaning we looked forthe presence or absence of each code in every sentence in each audioclip. We computed the Kohen's Kappa (k) statistic to determine theinter-rater agreement (Bernard, 2002). We made 560 observations(8 clips x 35 codes x 2 raters) and we computed the agreement to bek¼0.83. Researchers have established that 0.70 or more is consideredan acceptable k value (Landis and Koch, 1977). After establishing thisconsiderable agreement, we randomly divided the 38 clips (19 clipswere analyzed by each rater) and analyzed the dataset.

Finally, in addition to analyzing the interview data, we con-ducted SQL queries of the system usage logs to determine thefrequency and nature of participants' interactions with EatWell.

We recruited participants at the same YMCA branch that weworked with in our second formative study (there was noparticipant overlap). We used flyers to advertise the study anddescribed the study to individuals coming in and out of the YMCA.Since the YMCA is an organization that serves local communities,recruiting there helped us obtain participants who lived, workedin, or frequented the same general area. Participants received a$20 gift card for participating in the study. Twelve peopleparticipated in this study: four male and eight female. Mostparticipants were over 30 years old, though participants camefrom a range of age groups (18–54 years old). Four participantswere married and eight had children. All had access to a cellphone, most used a cell phone three or more times per day, andthey varied in how often they left and listened to voicemailmessages (from a few times each week to multiple times a day).

In terms of their previous nutrition-related behaviors, elevenparticipants had previously taken foods out of their diet and eighthad experience introducing foods into their diet. These findingsshow that our participants had a history of changing their diet, andthis in turn suggested that they would have a set of experiences tospeak about when creating memories in EatWell. In addition,seven participants indicated that they were unsatisfied with theircurrent eating habits and all twelve participants wanted to learnhow to make changes to their current habits. Together, theseattitudes suggested that participants might be particularly interested

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in a system like EatWell as it allows users to learn from the healthyeating strategies of others.

6.2. Community Mosaic Deployment

We conducted a field study to examine the use, effectivenessand impact of CM. The study lasted approximately 12 weeks, fromstart to finish. The first 3 weeks of the study were devoted to pre-deployment data collection, participants used the CM systemduring the next 6 weeks, and we conducted post-study datacollection in the final 3 weeks. The CM Display was installed in apublic location of the same YMCA branch that our secondformative study was conducted at (see Fig. 3). Participants wereasked to send 1–2 messages per month to CM (or more, if theyliked), for the duration of the study.

Participants completed pre and post-deployment surveys thatasked them about their attitudes towards health advocacy. Speci-fically, participants were asked how confident they felt in theirability to advocate healthy eating to others, and how importantthey thought it was to do so. We computed descriptive andinferential statistics to analyze this data. Pre-deployment, partici-pants also completed a validated survey that assessed to theirposition within the Horizontal–Vertical Individualism–Collecti-vism (HV/IC) Framework (Sivadas et al., 2008). This survey con-tained 14 questions, each of which corresponded to a sentimentthat is characteristic of a horizontal collectivist (HC), horizontalindividualist (HI), vertical collectivist (VC) or vertical individualist(VI) orientation (HC¼4 questions, HI¼3 questions, VC¼4 ques-tions, VI¼3 questions). Following the procedure used by Sivadaset al. (2008), for each participant, we examined each subset ofquestions (HC, HI, VC, and VI) and averaged participants' answersfor these questions. This allowed us to arrive at four mean scoresfor each participant, one for their responses to each subset ofquestions. The highest average score determined participants'classification as HC, HI, VC or VI. We discuss the results of ouranalysis in Section 7.3.

As we will discuss later, few EatWell messages describedcultural foods. As such, two researchers conducted a deductivecontent analysis to examine if this trend was replicated in the CMmessages (both the photos and text). After developing our codeset, we randomly selected 56 messages (20% of the total corpus)for each rater to code independently. Once we had each coded thesame 56 messages, we compared our ratings and determined theinter-rater reliability by computing how frequently our ratingswere the same. During our first pass, we had an overall agreementof 94%. We then met to examine the divergences in our ratingsuntil agreement reached 100%. We then randomly split theremaining messages and coded them separately. Once this codingwas complete, we each reviewed the others' codes and identified

areas of disagreement. We then met to discuss these discrepanciesuntil we arrived at 100% agreement.

We complemented this quantitative data with qualitative data;phone interviews (n¼29) and five focus groups (n¼26) wereconducted to better understand how participants used and reactedto CM. We conducted a thematic, inductive analysis of the inter-view and focus group transcripts (Thomas, 2006). We read thetranscripts line by line to derive a set of codes that described theemergent phenomena in the data. We then iteratively clusteredthese codes to arrive at higher-level categories, and eventually,broader themes.

We recruited participants by contacting individuals who hadparticipated in the second formative study (Section 5), makingannouncements in exercise classes at the YMCA, posting flyers atthe YMCA and asking participants to encourage their friends andfamily members to sign up. In total, 43 people participated. Whilewe sought to achieve a balance of female and male participants,more females signed up: we had thirty-four females and sevenmale participants. Most participants were in the 18–47 age range(n¼28) and the remainder were in the 48–57 (n¼9) and 58–67(n¼3) age ranges. Thirty-one were employed, eight were not andtwo were retired. Forty participants self-identified as Black/African–American, two as White, and one as Black/White/Indian. We chosenot to turn away the few non-Black participants who signed up forthe study because while the membership of the YMCA branch thatwe worked with is primarily Black/African–American, there is somecultural diversity. Depending on their level of participation in thestudy (i.e., whether they completed the interviews and focusgroups), participants received between $30 and $60 in gift cards.

7. Reflections on the design of collectivistic tools for foodexperience sharing

In this section we discuss how participants used and reacted toCM and EatWell. In our CM deployment, 278 messages wereshared by 40 participants (three participants did not share anymessages). There was a range of submission frequencies (min¼0,max¼32) and the average number of messages shared was six(see Table 4 for examples of messages shared during our study).More details on CM usage trends can be found in (Parker et al.,2012). CM participants attempted to inspire others to adopthealthy habits and expose them to new and creative, yet practical,ideas for doing so. For example, one participant discussed how shemakes meals ordered at a local restaurant more nutritious bysplitting her order into multiple portions and adding a side salad(see Table 4). Participants purposefully and selectively chose toshare those experiences that might best expand viewers' under-standing of how to eat healthfully.

Fig. 3. Community Mosaic (CM) Installation. The CM Display is showninstalled at the YMCA during our deployment.

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Participants shared 38 voice messages during our deploymentof EatWell (min¼2, max¼10). In total, they accessed the system anaverage of five times (min¼2, max¼8), listened to nine memories(min¼2, max¼38), and created three memories (min¼1, max¼10). The EatWell clips were intimate, short stories in which usersshared how they tried to eat healthfully. These stories were intimateas content creators provided a glimpse into their daily lives, sharingthe large and small victories they had as they attempted to eathealthfully at home and in the community. Participants enjoyedhaving a platform that allowed them to share their favorite healthyeating strategies with others, with all but one saying they would useEatWell in the future (Grimes et al., 2008).

In the following sections, we describe crosscutting themes thatarose in our evaluations. We discuss findings from our formativestudies as well, to show the consistencies and discrepanciesbetween participants' expressed desires for a future system andhow they used our resulting prototypes. Our results highlight thenuance and complexity involved when trying to design for anappreciation of cultural values. Through our evaluations, weidentified several important considerations for, and potentialbenefits of systems designed around the concept of collectivism.We describe participants' desire for a positive portrayal of andinteraction amongst the collective, and the empowerment facili-tated by our systems. We also compare the interaction patterns ofparticipants who were classified as horizontal individualist andthose classified as horizontal collectivist. Finally, we build uponour prior discussions (see Section 4.2) of participants' views oncultural distinctiveness. Specifically, we discuss the dichotomousway in which participants desired but did not share traditionalcultural foods.

7.1. Desiring positivity

Across our formative and summative studies, we consistentlysaw the theme of positivity arise. In our first formative evaluation,we found that some participants were frustrated with the negative

portrayal of the African American community as being worse offthan other cultural groups. And, as we discussed previously, thisemphasis on positivity also surfaced in our second formativestudy. Our participants were adamant that a future system shouldnot facilitate the discussion of the community's challenges, butrather focus on making healthy eating successes visible. As such,we designed two systems that support the collective pursuit ofgroup wellbeing without undue emphasis on the problems andchallenges that disproportionately affect African Americans inlow-income neighborhoods.

Recent social computing research helps to contextualize thesefindings within the HCI literature. Much research has shown howsocial networking sites allow people to engage in identity perfor-mance (boyd, 2007). Recent work has examined how such perfor-mance happens in the context of health management. Buildingupon the work of Goffman (1959), Newman et al. (2011) show thatFacebook acts as a front stage whereby people project an idealizedidentity, portraying themselves as healthy and fit, and sharingtheir successes. In contrast, struggles are reserved for online healthcommunities, where it is more normative to share challenges andsocial support is expected. Our findings show how participantswanted to our systems to convey a certain image—but theirconcern was for the portrayal of the community not themselves.Future work should further explore how health systems designedfor the collective pursuit of health match users' desires for how thecommunity is portrayed both to those within the community aswell as those outside of it. Another important question to exploreis, how do users' perceptions of their community change (e.g., theavailability of social and material resources, what behaviors arenormative in the community) by using systems that facilitate thecollective pursuit of health?

In our deployment of CM, participants were once again con-cerned with facilitating positivity. Recall that CM provides alimited way for viewers to share their reactions to messagesthrough the Community Response Panel buttons. In our closingfocus groups, we asked participants whether or not CM shouldallow people to share more detailed critiques of the messages. The

Table 4Example CM Messages. Some of the most popular messages are shown, including who shared each message (PID) and the message's photo (if any) and text (if any).

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reactions to this topic were mixed; with some feeling that it wouldbe beneficial and others feeling that it would be detrimental.Participants who were in favor of more detailed critiques said thatsuch feedback would allow for a more diverse set of opinions to beshared. For example, P28 said that having a mechanism for greaterfeedback,

“might have been helpful. I mean I guess then you know wecould have seen- had both sides to it, you know, cause I am surethat everybody didn't like everything that they saw. So, um,I think it would—I think, you know, feedback from both sideswould be good.”

Allowing for feedback, then, might help provide a morebalanced set of perspectives on the message shared, allowingviewers to see that even though an idea was shared, it may notnecessarily be something that everyone in the communityagrees with.

At the same time, some participants felt that allowing critiqueswould be potentially harmful. These participants wanted CM toremain a positive fixture in the community and felt that support-ing more detailed critiques would pave the way for the sharing ofnegative comments. Many participants were wary of this shifttowards negativity. As P3 said,

“You're going to have people that are going to complain aboutthings just because they're not happy or they just want tocomplain. I don't think that [CM] should [allow] too muchcriticism… It's supposed to be a positive thing for our commu-nity… I think that would take away from the positiveperspective.”

P3 discusses the importance of CM not just for herself, but alsofor her community. In the context of designing collaborativesystems for local communities, this comment highlights theimportance of understanding user sentiments not only regardinghow they feel the system is affecting them personally, but alsotheir perspectives on the system's place within the community.Participants were concerned that critiquing messages might dis-courage message senders and prematurely discourage messageviewers from trying out the ideas. For example, as P32 said,someone might dislike a message simply because of his or herown taste preferences—not on the basis of the healthiness of themessage. If that person then shared his or her negative reaction,other viewers could be turned off and kept from trying somethingthat they might like.

There are many ways in which technology can facilitate thecollectivistic pursuit of group wellbeing. For example, one couldimagine a system that helps community residents share theirchallenges, and then connect with residents that can help themovercome them. This is the approach taken in many online healthcommunities where informational, emotional, and instrumentalsupport is shared (Kummervold et al., 2002; Maloney-Krichmarand Preece, 2005). However, our participants wanted somethingdifferent. The design implications that arose from our formativework together with participants' use of and reaction to EatWelland CM, highlight the value they placed on shifting attention awayfrom the community's struggles to its successes. Of course, sharingone's challenges can be a starting point for constructively learninghow to overcome those challenges. An opportunity for future workwould be to compare the effectiveness of a system that places aprimary focus on showcasing community success versus a systemin which community residents discuss and help one anotherovercome their challenges.

7.2. Empowerment through food advocacy

As our participants used CM and EatWell, both the contentproducers and consumers were impacted. We discussed pre-viously that Lay Health Advisor (LHA) interventions have helpedLHAs become more confident in their ability to encourage otherstowards healthier living, and that in doing so they improve thehealth of the community (Auger and Verbiest, 2007; Zuvekas et al.,1999). In our evaluation of the CM system, we examined to whatextent similar benefits could be afforded by a system that affordedtechnologically mediated health advocacy (Parker et al., 2012).We found that most participants (81%) felt that they help toimprove the health of their community by sharing messages inCM. Furthermore, by the end of the study, participants feltsignificantly more strongly that it is important for them toadvocate healthy eating to others (Z¼�2.93, P o .01) and thatthey have the ability to engage in such advocacy (Z¼�2.06,Po .05). These findings are exciting because they highlight thepotential of technologically mediated environments for helpingusers see themselves as valuable and capable advocates for health.

In our evaluation of EatWell, we examined the impact ofviewing shared content (Grimes et al., 2008). Our participantsvalued the memories because they inspired a sense of hope. Theywere encouraged as they heard examples of how others in theircommunity (people who likely faced similar barriers to healthyeating) were trying to eat nutritiously. Participants were encour-aged in part because they felt that they could identify with userswho were from their community. As one participant told us, heliked the fact that,

“the people who were leaving the messages were living in myown community. I liked that idea because there’s a commonconnection, and probably in most cases a common situation oftrying to deal with some of the same issues.”

Furthermore, our participants were excited to see communityresidents working together to encourage one another towardshealthier eating patterns.

Our findings confirm prior work showing that online healthcommunities can be empowering environments, helping membersfeel more informed, an increased sense of control over their future,and more confident in interactions with the healthcare establish-ment (Mo and Coulson, 2010; van Uden-Kraan et al., 2008). Ourwork adds to the body of knowledge in two ways. First, much ofthe prior work on empowerment has examined how onlinesupport groups help members develop the capacity to cope andmanage their own health. We offer evidence to show that partici-pating in these environments can increase users' desire and toencourage others towards healthier behaviors. Second, researchhas shown that online support group members benefit from theexperiential knowledge shared by people from all over the world(Maloney-Krichmar and Preece, 2005; Salem et al., 1997).In contrast, our research highlights benefits for the producersand consumers of content in local community-based systemsfocused on healthy eating. Our systems began to impact howusers saw themselves within their community and how theyviewed the community itself. Participants felt they were engagedin the important work of helping to encourage the communitytowards healthier practices and they were encouraged to see theircommunity rally together by sharing experiences.

7.3. Sharing and viewing messages: collectivists vs. individualists

The previous sections begin to highlight important implicationsfor the design of collectivistic systems. In our evaluation of CMwe more specifically examined to what extent collectivism and

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individualism were values for our participants, and how differentusers engaged with the system. Of the 39 participants whocorrectly completed the HV/IC survey measuring their perspec-tives on collectivism and individualism, 77% expressed agreementwith collectivist values.8 However, when we examined what thestrongest value for participants was (what they expressed thegreatest agreement with), we found that most participants wereindividualist (64%; n¼25)—not collectivist, as we had expected.More specifically, these 25 participants were horizontal individu-alist (HI).

Finding that most participants expressed agreement withstatements reflecting collectivist values confirms prior work.However, finding that individualism was the strongest value formost participants counters much literature that suggests thatAfrican American culture is collectivistic. Instead, we found thatonly 26% (n¼10) of participants had collectivism as their moststrongly held value, with most being horizontal collectivist (HC,23%) and only one participant vertical individualist. No participantswere dominantly vertical collectivist (VC). Four participants couldnot be classified definitively, with one person scoring equally highon HC and VC and three scoring equally high on HC and HI.

An important point to note is that 68% of HI participants alsoscored highly on HC. 9 Thus, for most HI participants, collectivismwas also a value—though it was not as strongly held. The presenceof these dual values is line with recent research arguing thatindividualism and collectivism are not bipolar classifications(Komarraju and Cokley, 2008). Rather, people may hold bothvalues, with one or the other value taking precedence at differenttimes. In Sections 8.2 and 8.3 we discuss further the complexityand nuance required in measuring and characterizing culturalvalues. In the remainder of this section we describe how HCs andHIs used and reacted to CM, as the majority of participants fell intoone of these two categories.

Recall that both HCs and HIs believe in the equality of groupmembers, discouraging competition and attempts to be betterthan one another (a horizontal perspective). However, while HIsvalue personal goals and independence (individualism) HCs valuefulfilling the needs and expectations of the larger group. HCsshared twice as many messages as HIs on average (m¼10.44 forHCs vs. m¼5.72 for HIs), and this difference was statisticallysignificant (po .0001).10 HCs were also more enthusiastic aboutsharing and viewing messages in the future: when asked whetherthey would want to view messages in the future, 100% of HCs saidthat they would, versus 86% of HIs.11 And, when asked whetherthey would want to share messages in the future, 89% of HCs saidthey would, versus 79% of HIs.12 (Though this last finding was notstatistically significant, the trend warrants further examination instudies where the statistical power is increased through the use ofa larger sample size.) Overall, our participants—both HCs and

HIs—were excited about using CM in the future, but HCs wereeven more enthusiastic.

In summary, HCs contributed much more during the study andwere more interested in contributing in the future. These findingsmay be partially explained by the fact that the HC orientationplaces on communal responsibility, interdependence and fulfillingthe needs of the larger community.

7.4. A dichotomy: wanting—but not sharing—cultural dishes

Finally, we encountered the complexity of trying to account forthe influence of users' cultural background on their health-relatedvalues. In our second formative study, participants were mostexcited about promoting healthy eating by sharing ideas for howto prepare soul food dishes in a healthy way. These findings echoresearch noting the criticality of accounting for the value ofcultural foods when designing health interventions (James,2004). However, our evaluation of the content shared in EatWelland CM stands in sharp contrast to our formative study findings.Only a few CM messages described traditional African Americanfoods: 8% of messages contained a description or photo of tradi-tional soul food dishes. The same pattern was identified in ourevaluation of the EatWell memories: only 5% described soul fooddishes.

These findings suggest a mismatch between the informationthat people desired and what users actually shared in our systems.Our data cannot conclusively explain this discrepancy, but we offersome potential explanations. First, we did not evaluate oursystems with the same people who participated in our formativeresearch. As such, our findings could reflect the differing desires ofour participant samples. Alternatively, it may be that our partici-pants rarely ate such foods (and hence had few experiences toshare) or that they did not know how to create healthy versions oftraditional soul food dishes. Indeed, researchers have argued forthe importance of working with communities to develop educa-tional materials showing how soul food recipes can be preparedmore healthfully (Rankins et al., 2007). A final possibility is thatwhile users intended to share healthy soul food dishes, they forgotor missed opportunities to do so. Whatever the reason, the factthat our participants showed such a great interest in learningabout healthier cultural recipes suggests that in our future work,identifying appropriate ways to scaffold the sharing of suchcontent will be important.

We argue that the limited discussion of cultural foods does notmean such foods are not valued, and that they do not have a placein health promotion tools. On the contrary, as we continue toexplore the design of collectivistic health systems, we hope tofurther examine the apparent discrepancy in the value that isplaced on cultural foods and the absence of explicit references tothese foods. An important question is, as tools help individualswith a shared cultural background collectively pursue healthyeating, to what extent should these systems scaffold the sharingand gathering of information about cultural foods? It may be thatwhile culture is valued and shapes who we are and how we act, itis not something that people desire or think to reflect upon in theeveryday use of systems like EatWell and CM. As our researchteam continues to study the culture-food relationship and theplace of technology in that context, one important step will be todirectly ask participants how frequently they actually eat culturalfoods. While there may be a perception that such foods are widelyconsumed, in practice they may rarely be eaten. More broadly,future research should (1) examine the extent to which usersdesire to learn how to manage their health in a way that reflectstheir cultural food traditions and (2) scaffold users in providingculturally contextualized information only to the degree that theyare interested in doing so.

8 Collectivism survey questions asked participants to rate their agreement withstatements that reflect HC, HI, VC, and VI perspectives. The scale for these ratingswas 1–5 (1¼strongly disagree, 5-strongly agree). 77% of participants had anaverage score of 3.75 or higher for HC and/or VC questions. All of these participantsagreed with at least 3 out of 4 of the HC and/or VC questions.

9 68% of participants (n¼17) classified as HI had an average score of 3.75 orhigher for HC and/or VC questions. All of these participants agreed with at least3 out of 4 of the HC and/or VC questions. Thus, while HI was their most stronglyheld value, collectivism was also a value.

10 To compare the two samples, we computed the log of the submissionfrequencies to arrive at a normally distributed data set. We then computed a two-tailed t-test, with social orientation (HC v. HI) as the dependent variable.

11 A one-tailed Mann–Whitney test showed that the differences in HC and HIresponses to the question of whether they would want to view CM messages in thefuture was statistically significant (U¼160, p¼ .04).

12 A one-tailed Mann–Whitney test showed that the differences in HC and HIresponses to the question of whether they would want to share CM messages in thefuture was not statistically significant (U¼175.5, p¼ .06).

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7.5. Summary

Our findings offer insight into how systems can be designed toembody cultural values, and the way in which such systems areused. In both of our formative studies, we found participantsexpressing a shared love for soul food and a desire to have asystem that provides ideas for healthier versions of these foods.These foods are distinct to the African American culture, and whileother cuisines are certainly consumed, cultural foods were dis-tinctly valued. Furthermore, we found that it is important toachieve a balance of acknowledging the uniqueness of a culture(e.g., the importance of soul food) while not overemphasizing itsdistinctiveness and the challenges that the group faces. With theseguidelines in mind, we set out to design two systems that promotehealthy eating practices while embodying the cultural value ofcollectivism. Our formative results also shed light into a variety ofother concerns that were critical to consider as we designedcollectivistic systems. As we evaluated these tools, we gainedfurther insight, for example into the different system interactionsof collectivists versus individualists. Furthermore, our resultscomplicate the widely held assumption that the African Americanculture is collectivist; using the HV–IC framework, we provide amore nuanced picture of the spread of collectivist versus indivi-dualistic values. And finally, our work poses questions regardinghow collectivistic tools focused on specific cultural groups can—forthose who desire it—scaffold the sharing of information aboutcultural foods. We offer our formative and summative findings ascase studies in how cultural issues can be addressed in systemsthat promote healthy eating.

8. Discussion

We now reflect upon directions for future HCI research on foodand nutrition. In particular, we discuss the implications of toolsthat mediate food practices while accounting for collectivistic andindividualistic values. We conclude with broader implications forHCI research that examines the cultural context of food practices.

8.1. Designing for collectivism

We define collectivistic systems not simply as social applica-tions; more specifically, collectivistic systems are those in which theprimary goal is helping users work together to benefit the commongood. In this section we offer directions for future work on food-focused systems that incorporate the value of collectivism. Design-ing for collectivism and designing for communities is not the samething. First, collectivistic systems can be realized by focusing onsocial configurations other than the community, for example, thefamily friends, and coworkers are viable groups. Second, the valueof collectivism focuses not simply on engaging in activities with agroup, but rather feeling a sense of communal responsibility forfulfilling the needs and expectations of that group. In contrast,designing more broadly for local communities may or may notinvolve such a focus. For example, one could design individualisticsystems for communities. An individualistic, community-focusedversion of CM might provide users with a personal diet log thatallows them to set personal goals for improving their health andwellness. This system could be community-focused by mining thediet logs of community residents to automatically generaterecommendations for dishes at local eateries. In such a system,the primary feedback mechanism to users is how well they aremeeting their personal goals. Furthermore, users are not intention-ally sharing their food experiences for the benefit of others; ratherthey are recording them to support their own personal reflection—any benefit to others is a side effect. This system could provide a

great deal of value to individual users in, but it is not a collecti-vistic system.

Designing collectivistic systems can yield particular benefits forusers beyond designing for “the community” in general. Forexample, CM and EatWell helped facilitate a sense of empower-ment. After using CM, participants became more confident in theirability to advocate healthy eating to others, and felt more stronglythat it is important for them to be health advocates. The users ofEatWell felt a sense of hope as they saw others in their communitycaring enough about the health of the community to share theirhealthy eating ideas. Both of these outcomes are tied to thecollectivistic nature of the system: as users practiced caring forothers by advocating healthy eating, they developed their capacityto do so. Because users took the time to share their eatingexperiences for the benefit of others in EatWell, the consumersof this content felt hopeful. Our work represents an initial attemptat opening up this design space. Further research is needed toexplore the design of collectivistic tools and the benefits andpotential unintended consequences of such systems.

In the remainder of this section, we offer directions for futurework on collectivistic, food-focused systems.

8.1.1. Positive and negative food experiencesWhen considering how technology can help a group of people

eat more healthfully, one's mind might immediately turn to thechallenges that the group faces. Yet, during our evaluations, wewere struck by participants' consistent desire to avoid focusing onchallenges, struggles, and negative in-system commentary. Parti-cipants' desires are in line with research on positive reinforcementand positive psychology. Positive emotions can facilitate thedevelopment of social, psychological, and intellectual capital thatis vital for engaging in healthy behaviors (Csikszentmihalyi andHunter, 2003; Fredrickson, 2001; Soliah, 2011). As such, focusingon positive experiences may be a beneficial springboard fromwhich to encourage continued healthy eating habits (Parker et al.,2011). Furthermore, receiving praise for engaging in healthybehaviors is associated with continued healthy decision-making(Arredondo et al., 2006). Within HCI research on health, research-ers have found positive reinforcement to be a more effectivestrategy than negative reinforcement (Consolvo et al., 2008; Linet al., 2006). This work has suggested that negative reinforcementmay lead users to reduce their interactions with the system toavoid unpleasant feedback. Our work reinforces this literature; ourparticipants were similarly concerned that negative feedback onmessages could hinder the potential for users to benefit fromsystem content.

Our participants were concerned with systems being positive,in part, because they felt they experience too much negativityalready (both in terms of the media's portrayal of low-income andAfrican American populations, and in their real life encounterswith the barriers to healthy eating in their neighborhood). Otherneighborhoods and populations that do not experience suchnegative discourse and barriers may be less sensitive to this issue.Future work should examine the extent to which positivity is apriority in different kinds of communities, and the potentialbenefits to, and drawbacks of, systems that are mainly positiveversus those that allow the discussion of more negative experi-ences and critiques of content. For example, a mostly positivesystem could make users feel good, but may not help them learnhow to cope with challenging situations.

8.1.2. Collective interactions around personal experiencesSocial networking systems (SNS) have made it commonplace

for people to share their experiences with their existing socialnetwork as well as the broader Internet community. People share

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photos from times past, post status updates indicating what theyare currently doing, and videos documenting everyday andmomentous occasions. And, research has shown that the feedbackpeople receive on this shared information has important implica-tions for their wellbeing and their likelihood to contribute in thefuture. Valkenburg et al. (2006) found that positive feedback onSNS profiles enhanced adolescent self-esteem and negative feed-back had the opposite effect. A study of Slashdot contributorsfound that people who received positive feedback on their posts(in the form readers' replies to, and ratings of, the post) posted asecond comment more quickly (Lampe and Johnston, 2005).

By highlighting our participants' hesitations to receiving feed-back, our findings offer design implications and open questions forfuture work. Participants were interested in sharing and learningabout others' personal experiences with healthy eating, but theywere resistant to receiving directed feedback on this sharedinformation. They desired a personally reflective tone in bothour formative studies and the summative evaluations of oursystems. In part, this desire is likely due to people not caring tohear (or valuing) the evaluations or instructions of everydaypeople who are not health professionals. When people simplyshare their own experiences and suggest what others may do, suchcontent may be easier to receive. In addition, because what we eatis one way in which we convey our identity, suggesting peoplechange that aspect of their identity can be off-putting. As such, wesuggest that designers of food-focused applications carefully con-sider how communication is facilitated about individuals' eatinghabits. Food practices, while often social, can also be quitepersonal; the design of collectivistic systems that encourage thepublic exposition of these personal experiences is thus a delicatespace to work within. Researchers must carefully consider hownew systems allow people to engage with others' eating practices.

8.1.3. Collectivism and individualism: motivating participationWe used the horizontal–vertical individualism–collectivism

(HV/IC) framework to guide our analysis of the CM system. Ourfindings suggest the importance of a nuanced examination ofindividualism and collectivism. First, in-line with prior work, forthe vast majority of our participants, collectivism was a value(though for most it was not the strongest value). The pervasive-ness of this value may be one reason why CM was well receivedand why participants were excited about using it in the future.Those participants for whom collectivism was the strongest valueshared more messages and were more enthusiastic about usingCM in the future. Our findings are in concordance with the HV/ICframework's definition of collectivistic values. These results sug-gest that enjoying and seeing the value in a collectivistic systemmay only require that collectivism be a value, not one's moststrongly held value. Instead, value dominance may be more pre-dictive of system participation. Future work is needed to explorethese hypotheses.

Our work suggests additional directions for researchers inter-ested in designing collaborative, nutrition-focused tools. In parti-cular, during the requirements gathering stage of future researchprojects, it may be useful to include an evaluation of the extent towhich participants have collectivistic and individualistic values.Gaining such an understanding can help designers include systemfeatures that better appeal to users' sensibilities. The HV/IC frame-work provides researchers with a number of attitudes to examine,particularly how people relate to the collective, the responsibilitythey feel to help others, and how they feel others can help them.

For example, if individualism is a stronger value within thetarget user group, designers might choose to include morefeatures that focus on affirming the uniqueness and distinctivevalue of users' contributions. An important concept in public

health interventions is tailoring, whereby interventions are perso-nalized for individuals based upon their characteristics (demo-graphic, personality, cultural background, etc.). Similarly, tailoredsystems could provide a unique experience for individualists andcollectivists, foregrounding system features that may appeal moreto the user depending upon his or her social orientation. Giventhat most of our participants expressed both collectivistic andindividualistic values, future work should also examine howsystems can be designed to reflect these dual values. Our findingscontribute to literature examining the motivations of user-generated content contributors; research in this area has exam-ined the diverse platforms of Wikipedia, Facebook, and MechanicalTurk (Burke et al., 2009 ; Kaufmann et al., 2011 ; Yang and Lai,2010). Here we suggest that cultural values may be an importantfactor when considering how to motivate participation in socialhealth promotion tools.

While our focus has been on promoting health and wellness,researchers are becoming increasingly interested in tools thatmediate food experiences more broadly. From systems that sup-port the documentation and sharing of meal preparations, to toolsthat mediate gardening practices, interest in food-focused tech-nologies is increasing (DiSalvo et al., 2011; Terrenghi et al., 2007).Studying collectivism and individualism can be a useful endeavorfor this broader domain of study as well. For example, consider atool that lets people document their experimentation with recipes.An individualistic person might value features that help him sharea personal cooking journal so that friends can see how his bakingskills have evolved over time. Conversely, an expert cook forwhom collectivism is a value might enjoy helping others developtheir cooking abilities by collaboratively and iteratively refiningrecipes.

Finally, in contrast to much prior work, we found that whilemost participants agreed with values associated with horizontalcollectivism, horizontal individualism was the strongest value formost. Rather than undermine our focus on collectivism, thesefindings show the complex nature of values and the need for acareful and nuanced examination of them. In the next section weunpack the implications of our findings further.

8.2. Exploring Horizontal and vertical Perspectives

While the African American culture as a whole is oftencharacterized as collectivistic, we examined exactly how ourparticipants were located within the horizontal–vertical individu-alism–collectivism (HV/IC) framework. As noted previously, mostparticipants were in agreement with collectivistic values. Yet,surprisingly, we found that while African Americans are oftencharacterized as collectivistic, most participants (64%) were hor-izontal individualists (meaning they agreed most strongly withthis perspective). Of the remaining participants, most (23%) werehorizontal collectivists (HC). In this section, we discuss three waysin which our participants' positioning in the HV/IC framework isintriguing and suggest directions for future work.

First, researchers have characterized U.S. culture as VerticalIndividualist (VI) because of its tendency to value autonomy,independence, competition, and attempting to be the “best”. Yet,we found that only one person in our study was VI. Our resultsecho a recent study that counters much prior work on collecti-vism; researchers found that while European Americans surveyrespondents scored highly on VI, African Americans scored highlyon the HI dimension of the HV/IC framework (Komarraju andCokley, 2008). Our work suggests that there is value in under-standing users' specific social perspectives and not acceptingbroad cultural generalizations, particularly when examining eth-nically diverse nations such as the U.S.

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Second, most of our participants were HIs, and few were HCs.There are several potential explanations for this result, thoughfurther study is needed to better unpack these findings. Oneexplanation is that the survey we used to measure participants'position within the HV/IC framework may have been ineffective.In the next section, we discuss how using a survey alone is a limitedapproach of studying cultural values. Another explanation is thatwhile the African American culture has traditionally been describedas collectivistic, researchers have argued that previous work hasunderestimated the value of individualism in this population. Forexample, some researchers argue that many in the African Amer-ican culture value expressive individualism whereby people breakaway from the monolithic cultural label of being “Black” by showingtheir uniqueness through, for example, showcasing their personalsense of style (Jones, 1997; Komarraju and Cokley, 2008). Indeed,expressions of individualism within this culture exist, just in waysthat are different from what researchers have traditionally lookedfor. Yet, many previous health interventions have been motivated byan assumption of collectivistic values within the African Americanculture. For researchers examining collectivism in the context oftechnology design, our work suggests the importance of studyingindividual perspectives on the individual and the group, instead ofaccepting cultural generalizations.

The fact that most participants were individualists and notcollectivists also begs the question of whether designing forcollectivism was a productive approach for us. We offer that thebenefits yielded by our systems (e.g., the sense of empowerment itfacilitated) indicate that designing for collectivism was a fruitfulendeavor. Furthermore, the fact that most participants agreed withcollectivistic values suggests that our approach was warranted.Still, further work is needed to examine appropriate designapproaches for users who may have dual values of individualismand collectivism as most of our participants did. And, as we discussin the next section, it is important to more richly understandusers' perspectives on individualism and collectivism. Further-more, a comparative study examining the impacts of an indivi-dualistic and a collectivistic system would yield important insightsinto the potential benefits of each design.

A final point to consider is how prevalent the horizontalperspective was amongst our participants. Only one person wasVI and no one was completely Vertical Collectivist (VC) (oneperson scored equally high on HC and VC). Individuals with ahorizontal perspective view in-group members as being equal instatus to them and tend to discourage competition and attempts tobe better than others. Even HIs, who value their uniqueness, tendto do so without comparing themselves to others (thus maintain-ing an equal status with other group members). In contrast, VIsmay focus more on the relative superiority of group members (e.g.,in terms of intellect, social status or class). The fact that almost allparticipants were horizontal may explain why they generallyaccepted and enjoyed CM, a system that placed all users on aneven playing field. That is, anyone could share their ideas, regard-less of their social status, experience with health or educationallevel. While participants in our second formative study didindicate a preference for getting experiential knowledge fromcommunity members as opposed to more specific medical knowl-edge, they saw value in the ideas peers might have regardingtopics such as healthy recipes. And, in our evaluation of CM,participants indicated that they saw value in CM messages andwere enthusiastic about viewing them in the future. Their hor-izontal values may have made them more accepting of receivingthese ideas from peers—individuals who are not necessarilytrained health experts. An interesting direction for future workwould be to examine the extent to which horizontal and verticalorientations affect people's willingness and desire to accept thehealth and wellness ideas from peers versus medical experts.

8.3. Measuring cultural values

Various HCI researchers have studied the relationship betweenculture and technology, particularly in cross-cultural studies com-paring how individuals in different countries use ICTs (Kayan et al.,2006; Lewis et al., 2010; Setlock and Fussell, 2010; Vatrapu, 2010).Research on developing countries has also explored the range ofcultural considerations that arise as researchers venture into newdesign settings (Brewer et al., 2006; Irani et al., 2010;Ramachandran et al., 2010). However, there have been two impor-tant omissions within the body of HCI research on culture. First,much of the work has focused on the way a country's macro-cultureshapes technology use but few researchers have looked at thesubcultures that exist within the countries studied (Irani et al.,2010; Recabarren et al., 2008). Second, within the context of health,few HCI researchers—particularly those focused on health in thedeveloped world—have examined the role that culture plays (var-ious projects in the developing world are notable exceptions, e.g.see (Ramachandran et al., 2010)).

These two limitations of previous work must be addressed ifthe field of HCI is to realize a comprehensive health-focusedresearch agenda. Researchers in the health sciences have longargued that culture shapes behaviors and attitudes and thatunderstanding this relationship is critical to developing effectiveinterventions for a diverse group of people (Campbell et al., 1999;Karanja et al., 2002; Kreuter et al., 2003). This is because a person'scultural background shapes (both directly and indirectly) healthbehaviors, health outcomes and perceptions of medical care andprofessionals (James, 2004; Kreuter and McClure, 2004; LaVeistet al., 2000; Lillie-Blanton et al., 2000). In future work, it is criticalthat HCI designers closely examine the interplay of culture, eatingpractices, and health and how technology might disrupt, resonatewith, reflect or reject this interplay.

Our research revealed several ways in which the study of culturein the context of technology design is a complex process, requiringgreat care and in-depth study. For example, our survey researchinstrument limited our ability to comprehensively evaluate partici-pants' views on individualism and collectivism. As we discussedearlier, we used a survey developed by Sivadas et al. (2008) toexamine participants' position within the HV/IC Framework. How-ever, classifying participants in this way did not tell us the root andnature of their values. Understanding the reasons behind theirvarying perspectives would have helped to better contextualizetheir subsequent use of and reaction to the our system.

In addition, the survey we used did not unpack to what extentparticipants' collectivistic and individualistic views persisted indifferent contexts. Some researchers have argued that people arenot always collectivistic or always individualistic (Komarraju andCokley, 2008). Instead, people may possess both values and eachvalue may be activated in different settings. Thus, whereas a personmight feel individualistic when it comes to thinking about theirfinances and to what extent it is important for them to help outfamily and friends in economic need, they may feel collectivisticwhen it comes to the topic of helping fellow community members tomanage their health more effectively. The survey that we used, whilea validated instrument, did not ask questions that would tease apartrespondents' collectivistic versus individualistic views on health.

Furthermore, even if the survey had asked questions of this sort, itwould provide only a surface understanding of participants' values.While quite useful for identifying trends amongst participants, whentrying to understand cultural values and perspectives, supplementingsurvey data with more in-depth qualitative data is crucial. Forexample, through our qualitative data we were able to uncoverissues such as the concern that some participants had that AfricanAmericans are often negatively portrayed in the current medicaldiscourse. As HCI researchers continue to examine the relationship

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between culture, eating habits, and health, and what this means fortechnology design, it will be important to conduct mixed methodstudies. Such studies can leverage the benefits of quantitativemethodologies, which provide useful trending information, andqualitative methods, which provide deeper and richer insight intothe meaning, values and perspectives that underlie those trends.

One important extension of our work would be to study partici-pants' views on individualism and collectivism in more depth priorto having them use our systems. By supplementing survey data withinterviews, ethnographic observations or cultural probes (Gaver et al.,1999), we would gain a richer understanding of the extent to whichparticipants felt that caring for the health of their community wassomething important for them to do, particularly as a result of theirshared membership in the African American cultural group. Recallthat in our second formative study, we presented participants with aset of cards describing different ways that residents could, collec-tively, care for the health of their community. Participants wereasked which strategies would be most and least effective. Anotherapproach would have been to distribute four card sets, one for eachof the HC, HI, VC, and VI social orientations. Studying participants'reactions to these strategies would be a useful opportunity to betterunderstand their collectivistic and individualistic values, specificallyas they relate to pursuing healthier eating practices. In sum, thesecomplementary data sets would help to better contextualize parti-cipants' subsequent use of and reaction to a collectivistic healthsystem such as CM.

The design space for technologies that promote healthy eatingpractices is wide open. There are many aspects of ethnic culturethat remain to be explored in terms of how values, traditions andbeliefs may affect the design and adoption of health systems. Onestarting point for future work would be to build upon the work ofHofstede et al. (2010) who identified a set of dimensions acrosswhich cultural groups can be compared. These dimensions char-acterize, for example, a culture's views on masculinity andfemininity, and the extent to which gratification of enjoyment-related desires are allowed or regulated. Hofstede's dimensionsoverlap with cultural traits that have been explored within thehealth literature and as such provide one example of howresearchers can systematically examine the relationship of cultureand health.

While Hofstede et al. provide a useful framework, someresearchers have argued that such a taxonomic approach tocharacterizing culture is not ideal (Irani et al., 2010; Marsdenet al., 2008). Alternative approaches include generative ones thatexamine how culture is dynamic—not a static characterization—and as such is reproduced and continually unfolding as peopleexperience and interact with the world. As we mentioned earlier,our work suggests the need for future work to not just examinethe presence or absence of a trait such as collectivism but thereasons why individuals have such values and the way in whichcultural perspectives shape how people use technology. Variousapproaches to cultural study have their strengths and weaknesses,and future work should examine which are particularly useful forunderstanding the interplay of culture, eating practices, andtechnology design. The taxonomic view of culture put forth byresearchers such as Hofstede et al. (2010) may provide a usefulstarting point, helping researchers orient themselves and identifyan initial area of focus. Continuing one's examination of culturewith a generative approach may then yield a richer understandingof end-users' views and socio-technical interactions.

Studying culture involves understanding the beliefs, values,practices and other social regularities that characterize the generalgroup but also how the cultural nuances are played out in the livesof individual people under study. Indeed, as we found in ourresearch, and as has been pointed out by others (Irani et al., 2010;Marsden et al., 2008), it is critical to not simply understand broad

cultural traits but how such traits play out in the lives of theindividuals we study. To make significant progress in this area,future work should seek to systematically develop theories ofexplaining and studying socio-technical interaction in differentcultural contexts to help ground future system development andevaluation. Such theories should account not only for the identi-fication of broad cultural traits but also micro-level variations inhow these traits are manifested.

9. Limitations

Given that lay people share the content in CM and EatWell, onelimitation of our work is that we did not examine the nutritionalaccuracy of this content. To minimize the potential spread ofmisinformation, vetting the messages shared by those withoutformal medical training is important. While we lightly moderatedthe shared content, in our future work we hope to explore howsuch vetting can be done in a more sustainable and community-driven manner. For example, one approach would be to traincommunity moderators who are responsible for identifying inap-propriate or inaccurate recommendations.

Our studies were small in size and relatively short in durationand as such our findings cannot be generalized at this point.Instead, our work offers insights in an under-explored space andrepresents a set of first steps. An important step for future workwill be to conduct larger clinical trials testing the impact of oursystems on eating behaviors. In addition, as our results suggestthat using CM helped users develop their identity as healthadvocates, we hope to confirm these findings through largerexperiments and examine if such an identity shift translates intoincreased advocacy efforts within users' communities.

10. Conclusion

The relationship that people have with food is complex and multi-faceted. Understanding this relationship requires an examination ofthe psychological, social, and cultural influences on food preferences,attitudes, and experiences. Our work has explored two such facets: thevalue of cultural foods and the construct of collectivism. We specifi-cally focused our research on African Americans within low-income,neighborhoods in the Southern U.S. Through two formative studies weidentified implications for the design of systems that help promotehealthy eating habits in a collectivistic way; for example, the impor-tance of acknowledging community expertise and sensitively account-ing for cultural uniqueness.

We translated these design implications into two systems thatsupport the sharing of healthy eating experiences. Through ourevaluation of these tools we identified several crosscutting themesthat characterize how participants used our systems (e.g., thediffering participation of those with individualistic and collecti-vistic perspectives), and the sense of empowerment that the toolshelped facilitate. Finally, we presented recommendations forfuture research on the design of food-focused collectivistic toolsand, more broadly, for HCI research that attempts to examine therelationship between cultural values and eating practices. Wehope that our findings and recommendations will prove to be auseful resource for HCI researchers interested in developing thenext generation of food-focused technologies.

Acknowledgments

This work would not have been possible without the tirelesssupport of the wonderful community health organizations that we

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worked with: REACH for Wellness Atlanta and the YMCA ofAtlanta. We also thank our participants for sharing their timeand stories with us, the members of the Audiotree project and theWesley Center for New Media, and members of the Georgia TechGVU Center for their feedback on this work from the early stages ofdesign through to our final evaluations. Thank you to Jay Bolter,and the many students who collaborated with us on this work.Finally, we are grateful to Humana for funding this research, and tothe Ford Foundation, Google, Microsoft Research, and the NationalScience Foundation for their graduate research funding.

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