Advancing understanding of the sustainability of lay health advisor (LHA) programs for African-American women in community settings

Community Health workers United to Reduce Colorectal cancer and cardiovascular disease among people at Higher risk (CHURCH): study protocol for a randomized controlled trial

BACKGROUND

Colorectal cancer (CRC) is the second most lethal cancer in the United States (U.S.) with the highest incidence and mortality rates among African Americans (AAs) compared to other racial groups. Despite these disparities, AAs are the least likely to undergo CRC screening, have precancerous colorectal polyps removed, and have CRC detected at stages early enough for curative excision. In addition, compelling evidence links inflammatory dietary patterns to increased CRC and cardiovascular disease risk. Studies show that AA churches can successfully engage in health promotion activities including those related to cancer control. The current study seeks to leverage church-placed Community Health Workers (CHWs) to increase CRC screening and reduce CRC risk.

DESIGN AND METHODS

We aim to (1) increase guideline concordant CRC screening uptake using church-placed CHWs trained in screening with a validated instrument, Brief Intervention using Motivational Interviewing, and Referral to Treatment (SBIRT); and (2) reduce dietary risk factors (inflammatory dietary patterns) linked to CRC. The latter will be addressed by culturally adapting an existing, web-based lifestyle program called Alive!. Using a Hybrid Type 1 Implementation-Effectiveness cluster randomized design, we will randomize 22 AA churches into either the dual intervention arm (CHW-led SBIRT intervention plus Alive!) or a usual care arm comprised of CRC prevention educational pamphlets and a list of CRC screening sites. We will recruit 440 subjects and evaluate the effects of both arms on screening uptake (colonoscopy, fecal DNA) (primary outcome) and dietary inflammation score (secondary outcome) at 6-month follow-up, and Life Simple7 (LS7)-a cardiovascular disease (CVD) risk score-at 6 months and 1 year (secondary outcome). Finally, guided by a racism-conscious adaptation of the Consolidated Framework for Implementation Research (CFIR), we will conduct a mixed-methods process evaluation with key stakeholders to understand multi-level influences on CRC screening and CVD risk behaviors.

DISCUSSION

Church-placed CHWs are trusted influential connectors between communities and health systems. Studies have shown that these CHWs can successfully implement health prevention protocols in churches, including those related to cancer control, making them potentially important community mediators of CRC screening uptake and CRC/CVD risk reduction.

TRIAL REGISTRATION

NCT05174286; clinicaltrials.gov; August 31st, 2023.

Community Health workers United to Reduce Colorectal cancer and cardiovascular disease among people at Higher risk (CHURCH): study protocol for a randomized controlled trial

Background: Colorectal cancer (CRC) is the second most lethal cancer in the United States (U.S.) with the highest incidence and mortality rates among African Americans (AAs) compared to other racial groups. Despite these disparities, AAs are the least likely to undergo CRC screening, have precancerous colorectal polys removed, and have CRC detected at stages early enough for curative excision. In addition, compelling evidence links inflammatory dietary patterns to increased CRC and cardiovascular disease risk. Studies show that AA churches can successfully engage in health promotion activities including those related to cancer control. The current study seeks to leverage church-placed Community Health Workers (CHWs) to increase CRC screening and reduce CRC risk. Design and Methods: We aim to (1) increase guideline concordant CRC screening uptake using church-placed CHWs trained in screening with a validated instrument, Brief Intervention using Motivational Interviewing, and Referral to Treatment (SBIRT); and (2) reduce dietary risk factors (inflammatory dietary patterns) linked to CRC. The latter will be addressed by culturally adapting an existing, web-based lifestyle program called Alive!. Using a Hybrid Type 1 Implementation-Effectiveness cluster randomized design, we will randomize 22 AA churches into either the dual intervention arm (CHW-led SBIRT intervention plus Alive!) or a usual care arm comprised of CRC prevention educational pamphlets and a list of CRC screening sites. We will recruit 440 subjects and evaluate the effects of both arms on screening uptake (colonoscopy, fecal DNA) (primary outcome) and dietary inflammation score (secondary outcome) at 6-months follow up, and Life Simple7 (LS7) - a cardiovascular disease (CVD) risk score - at 6 months and 1-year (secondary outcome). Finally, guided by a racism-conscious adaptation of the Consolidated Framework for Implementation Research (CFIR), we will conduct a mixed- methods process evaluation with key stakeholders to understand multi-level influences on CRC screening and CVD risk behaviors. Discussion: Church-placed CHWs are trusted influential connectors between communities and health systems. Studies have shown that these CHWs can successfully implement health prevention protocols in churches, including those related to cancer control, making them potentially important community mediators of CRC screening uptake and CRC/CVD risk reduction. Trial registration: NCT05174286.

"They should've talked to us more": lay health advisors' experiences with community-engaged hypertension research

BACKGROUND

Lay health advisors (LHAs) are increasingly being used to increase patient and public involvement in research, disseminate health information, and work toward preventing health disparities within communities at risk. This research explored LHAs' experiences with training and recruiting for a hypertension research project which ended due to minimal enrollment.

METHODS

The methodological design was qualitative description. One face-to-face semi-structured focus group was held with eight African American LHAs in Cleveland, Ohio, in the fall of 2019. The focus group was digitally recorded and transcribed by a professional transcriptionist and thematically analyzed.

RESULTS

Trainees reflected on how much they learned from the training and described feeling passionate and excited about their community work for the project. We identified three key themes from the data: (1) Systemic and Institutional Factors Affected LHAs' Experiences (subthemes: Unnecessarily Burdensome Requirements and Exploitation of Community Members for Research Gain; (2) Feeling Used Yet Unseen: Exclusion from Decision-Making Processes; (3) Worrying that Project Termination Damaged their Reputation; and (4) Disengaging from Research. We share lessons learned, including the need for LHAs' expertise to be integrated into research studies, and for projects to establish clear communication and expectations regarding research rigor and requirements.

CONCLUSION

Our results have implications for future studies attempting to build equitable and strong academic-community relationships to yield rigorous and useful research to reduce health disparities.

Making the connection between health equity and sustainability

Sustainability and health inequities are key challenges in public health and healthcare. Research suggests that only about half of evidence-based interventions (EBIs) are sustained over time, and settings and populations experiencing systemic and structural barriers to health (e.g., poverty, racism, stigma, and discrimination) experience even greater challenges to sustainability. In this article, we argue that an enhanced focus on sustainability in the field of implementation science is critical in order to maximize the long-term health benefits and broader societal impacts of EBIs for all populations and settings. From an equity perspective, a focus on sustainability is particularly critical to prioritize among population sub-groups that have not historically received the benefits of health-related EBIs. We discuss how a health equity framing is essential to sustaining EBIs in under-resourced communities, and requires moving away from a deficit mindset that focuses on why EBIs are challenging to sustain, to one that focuses more on identifying and nurturing existing assets within individuals and communities to increase the likelihood that EBIs are sustained. We conclude with a discussion of future directions as well as recommendations and resources (e.g., frameworks, tools) to advance and make progress toward sustainability from a health equity mindset, including: (1) Actively planning early for sustainability alongside key partners; (2) Tracking progress toward enhancing sustainability and being accountable in doing so equitably for all settings and populations; and (3) Focusing on both equity and engagement early and often throughout the research process and all implementation phases.

Beliefs and knowledge related to human papillomavirus (HPV) vaccine among African Americans and African immigrants young adults

BACKGROUND

Despite the disparate human papillomavirus (HPV) infection rates among sexually active Black young adults, HPV vaccine uptake remains low among this population. This study aimed to explore HPV beliefs, attitudes, and knowledge among Black young adults and provide recommendations on ways to improve vaccine uptake.

METHODS

We used a mixed-method, convergent design to conduct five focus groups and administered a 40-item electronic survey that was developed with health belief model (HBM) constructs. We assessed HPV and vaccine knowledge, barriers, and attitudes toward vaccination. We analyzed quantitative data using descriptive statistics and bivariate methods. Focus group transcripts were analyzed using content analysis. Results were integrated to obtain a better understanding of the topic.

RESULTS

Forty individuals participated in the study. The mean age was 22.2 ± 4.5 years and 55% identified as African immigrants. Integrated data revealed themes mapped to relevant HBM constructs. Almost one third (32.5%) of participants were unaware of their susceptibility to HPV infection and its severity. From focus group discussions, the majority (75%) believed that vaccines are beneficial. Major cues to action include promoting HPV vaccine uptake via community wide informational sessions, provider recommendation, and social and mass media campaigns.

CONCLUSION

Barriers to vaccine uptake, limited HPV knowledge, and lack of vaccine recommendation are important factors contributing to low vaccine uptake among Black young adults. Interventions to decrease barriers to HPV vaccination, increase HPV knowledge, address misconceptions, and unfavorable beliefs are needed to promote HPV vaccine uptake.

Factors contributing to the sustained implementation of an early childhood obesity prevention intervention: The INFANT Program

Background

The INFANT Program is an efficacious, group-based program for first-time parents, delivered at three-monthly intervals when INFANT are aged 3-18 months through an existing universal care service in Victoria, Australia. Many lessons have been learnt from its origins as a cluster randomized control trial to its small-scale, community-level implementation. This study aimed to describe factors contributing to its sustained implementation to inform large-scale implementation across Australia.

Methods

This study used a multi-site qualitative exploratory approach. INFANT facilitators trained between 2013 and 2017 were sent an online survey, with optional telephone interviews. The Consolidated Framework for Implementation Research (CFIR) was selected as the underpinning theoretical framework as it offered the opportunity to explore a breadth of possible barriers and enablers across patterns of implementation (never, discontinued, ongoing).

Results

All participants were female (n = 31), the majority were Maternal and Child Health Nurses (48%), representing five regional and nine metro local government areas (LGAs), across all patterns of implementation (never implemented n = 4; discontinued implementation n = 5; ongoing implementation n = 5). All consenting participants were interviewed (n = 11) representing four regional and seven metro LGAs, across all patterns of implementation (never implemented n = 3; discontinued implementation n = 4; ongoing implementation n = 4). The main reason for attending INFANT Program training was to become skilled to implement the program. Mapping identified barriers and enablers to the CFIR revealed the inner and outer settings and implementation process to be of greatest influence. Main differences between LGAs with ongoing and discontinued implementation related to funding availability, organizational management support and endorsement, organizational resourcing and capacity, integration into routine practice and establishing role clarity with partner organizations, and planning for sustained implementation from the start.

Conclusion

This study provides important insights into the barriers and enablers to the sustained implementation of an evidence-based intervention (the INFANT Program) during small scale community-level implementation. The authors therefore contend that the pre-requisite for scale-up of a population health intervention is not just proof of effectiveness but also proof of sustained implementation at the local/organizational level. Study findings have broad transferability given their similarity to those identified for health promotion interventions implemented globally, in healthcare, education and community settings.

Qualitative assessment of attitudes toward cervical cancer (CC) screening and HPV self-sampling among African American (AA) and Sub Saharan African Immigrant (SAI) women

OBJECTIVES

Despite the availability of preventive methods for cervical cancer (CC), uptake has been low among African American and Sub-Saharan Immigrant (AA/SAI) women. The purpose of this study was to understand AA/SAI women's values and beliefs of CC screening and explore willingness, acceptability, and concerns related to the HPV self-sampling method for CC.

DESIGN

Thirty AA/SAI women participated in one of six focus groups, each lasted 60-90 min, and were held over Zoom video conferencing. The sessions were audio-recorded, transcribed verbatim, and checked for accuracy by research staff prior to data analysis. Transcripts were content analyzed by two qualitatively trained research staff. NVivo software was used for data management and analysis.

RESULTS

The average age of participants was 33.67 ± 9.03, more than half were not married (53.3%), and less than half reported having health insurance coverage (46.7%). Participants included 16 AA and 14 SAI. Three main themes emerged from data analysis. (1) Beliefs and values related to CC Screening, (2) perceived barriers to attending CC screening, (3) recommendations to motivate regular CC screening. In addition, three factors emerged in the discussion on the HPV self-sampling method: confidence in ability to self-sample for CC, willingness to use HPV self-sampling kit, and result delivery.

CONCLUSIONS

This study identified a variety of reasons for the disproportionately low utilization of CC prevention services among AA/SAI women. Multidimensional approaches including educational and community engagement programs for this population could improve CC screening uptake and adoption of HPV self-sampling among AA/SAI women.

M.I.C.A.H. Project HEAL: Sustainability of a Faith-Based Community Health Advisor Training Program in Urban Underserved Communities in the USA

Faith-based organizations (FBOs) can play an important role in improving health outcomes. Lay community health advisors (CHAs) are integral to these efforts. This paper assesses the sustainability of a CHA training program for congregants in African-American and Latino FBOs and subsequent implementation of educational workshops. The program is unique in that a health care chaplain in an academic medical center was central to the program's development and implementation. Forty-eight CHAs in 11 FBOs were trained to teach workshops on cardiovascular health, mental health, diabetes, and smoking cessation. Two thousand four hundred and forty-four participants attended 70 workshops. This program has the potential to be a model to educate individuals and to address health inequities in underserved communities. Health care chaplains in other medical centers may use this as a model for enhancing community engagement and education.

A Community-Embedded Implementation Model for Mental-Health Interventions: Reaching the Hardest to Reach

The mental-health-care treatment gap remains very large in low-resource communities, both within high-income countries and globally in low- and middle-income countries. Existing approaches for disseminating psychological interventions within health systems are not working well enough, and hard-to-reach, high-risk populations are often going unreached. Alternative implementation models are needed to expand access and to address the burden of mental-health disorders and risk factors at the family and community levels. In this article, we present empirically supported implementation strategies and propose an implementation model-the community-embedded model (CEM)-that integrates these approaches and situates them within social settings. Key elements of the model include (a) embedding in an existing, community-based social setting; (b) delivering prevention and treatment in tandem; (c) using multiproblem interventions; (d) delivering through lay providers within the social setting; and (e) facilitating relationships between community settings and external systems of care. We propose integrating these elements to maximize the benefits of each to improve clinical outcomes and sustainment of interventions. A case study illustrates the application of the CEM to the delivery of a family-based prevention and treatment intervention within the social setting of religious congregations in Kenya. The discussion highlights challenges and opportunities for applying the CEM across contexts and interventions.

Future Directions in Lay Health Worker Involvement in Children's Mental Health Services in the U.S

Nearly half of children meeting criteria for a mental health disorder in the United States (U.S.) do not receive the treatment they need. Unfortunately, lack of access to and engagement in mental health services can be seen at even higher rates for historically marginalized groups, including low-income, racial, and ethnic minority youth. Lay Health Workers (LHWs) represent a valuable workforce that has been identified as a promising solution to address mental health disparities. LHWs are individuals without formal mental health training who oftentimes share lived experiences with the communities that they serve. A growing body of research has supported the mobilization of LHWs to address service disparities around the globe; however, challenges persist in how to scale-up and sustain LHW models of care, with specific barriers in the U.S. In this paper, we describe LHWs' different roles and involvement in the mental health field as well as the current state of the literature around LHW implementation. We integrate the RE-AIM Framework with a conceptual model of how LHWs address disparities to outline future directions in research and practice to enhance equity in the reach, effectiveness, adoption, implementation, and maintenance of LHW models of care and evidence-based practices for historically marginalized communities within the U.S.

A Review of Research on Disparities in the Care of Black and White Patients With Cancer in Detroit

Racial disparities in cancer incidence and outcomes are well-documented in the US, with Black people having higher incidence rates and worse outcomes than White people. In this review, we present a summary of almost 30 years of research conducted by investigators at the Karmanos Cancer Institute's (KCI's) Population Studies and Disparities Research (PSDR) Program focusing on Black-White disparities in cancer incidence, care, and outcomes. The studies in the review focus on individuals diagnosed with cancer from the Detroit Metropolitan area, but also includes individuals included in national databases. Using an organizational framework of three generations of studies on racial disparities, this review describes racial disparities by primary cancer site, disparities associated with the presence or absence of comorbid medical conditions, disparities in treatment, and disparities in physician-patient communication, all of which contribute to poorer outcomes for Black cancer patients. While socio-demographic and clinical differences account for some of the noted disparities, further work is needed to unravel the influence of systemic effects of racism against Black people, which is argued to be the major contributor to disparate outcomes between Black and White patients with cancer. This review highlights evidence-based strategies that have the potential to help mitigate disparities, improve care for vulnerable populations, and build an equitable healthcare system. Lessons learned can also inform a more equitable response to other health conditions and crises.

Long-term effects of a lay health advisor intervention on immigrant children's dental caries and maternal preventive behaviour: A randomized controlled trial

OBJECTIVES

An oral health disparity exists between native and immigrant children in Taiwan. This study evaluated the long-term effectiveness of a lay health advisor (LHA) intervention on immigrant children's dental caries and maternal preventive behaviours.

METHODS

Fifty-one immigrant mother-child pairs were randomly assigned to LHA intervention (n = 23) and control (n = 28) groups. Mothers in the LHA group received a four-chapter one-on-one lesson plan, which included dental caries-related knowledge, brushing techniques, caries prevention and free preventive services, from the LHA over 4 weeks. Mothers in the control group received only a health brochure. Baseline and 1-week, 2-month, and 8-month follow-up information was collected using dental examinations and questionnaires.

RESULTS

The mean ages of the children in the LHA and control groups were 4.0 ± 1.4 and 4.2 ± 1.5, respectively. The decayed, missing due to caries, filled teeth (dmft) index in the LHA and control groups was 4.8 ± 6.0 and 5.4 ± 5.4, respectively, at baseline. At the 8-month postintervention follow-up, the number of filled teeth (ft) in the LHA group was higher than that in the control group (β = 8.3, P = .033). The effect size (ES) demonstrated an upward trend at 1-week, 2-month and 8-month follow-ups in ft (ES = 0.21, 0.50 and 0.59, respectively) and a decrease in the number of decayed teeth (dt) (ES = 0.30, 0.43 and 0.57, respectively). The mothers in the LHA group were observed to be 10.9 times more likely than control mothers to assist their children in toothbrushing for 3 min at the 1-week follow-up (95% CI = 1.98-59.40, P = .006).

CONCLUSIONS

The LHA intervention strategy had positive effects on the immigrant children's new dt and ft and on maternal preventive behaviour, such as assisting their children in toothbrushing.

Trust and Mistrust in Shaping Adaptation and De-Implementation in the Context of Changing Screening Guidelines

Objective

To understand barriers and facilitators to the adaptation of programs reflecting changing scientific guidelines for breast/cervical cancer screening, including factors influencing the de-implementation of messaging, program components, or screening practices no longer recommended due to new scientific evidence.

Setting

National sample of NWP sites from across the United States.

Design and Methods

We conducted a convergent mixed-methods design in partnership with The National Witness Project (NWP), a nationally implemented evidence-based lay health advisor (LHA) program for breast/cervical cancer screening among African American (AA) women. Surveys were conducted among 201 project directors (PDs) and LHAs representing 14 NWP sites; in-depth interviews were conducted among 14 PDs to provide context to findings. Survey data and qualitative interviews were collected concurrently from January 2019-January 2020.

Results

Trust and mistrust were important themes that arose in quantitative and qualitative data. Common concerns about adapting to new guidelines included: 1) perceptions that new guidelines misalign with the personal values and beliefs of AA women; 2) mistrust of guidelines, providers, medical organizations; 3) confusion about inconsistent guidelines and concern they are based on studies that don't reflect the experience of AA women (who experience more aggressive tumors at younger ages); and 4) belief that breast self-exam (BSE) is an empowerment tool for AA women and should be included to promote awareness, given many women discovered lumps/cancer through BSE.

Conclusion

Findings highlight that trust and mistrust are important but understudied social determinants of health among AAs that should be considered in implementation science as they: 1) have critical implications for shaping health inequities; and 2) help explain and contextualize why new screening guidelines may not be fully embraced in the AA community.

Examining aspects of successful community-based programs promoting cancer screening uptake to reduce cancer health disparity: A systematic review

Certain minorities in the US are disproportionately burdened with higher cancer incidence and mortality rates. Programs encouraging timely uptake of cancer screening measures serve to reduce cancer health disparities. A systematic literature review was conducted to assess the effectiveness and the qualities of these programs, and to elucidate characteristics of success programs to aid in designing of future ones. We focused on community-based programs rather than clinic-based programs as the former are more likely to reach disadvantaged populations, and on prevention programs for breast, cervical, and/or colon cancers as longstanding screening recommendations for these cancers exist. PubMed, CINAHL and EBSCO databases were searched for articles that utilized community organizations and community health workers. Fourteen programs described in 34 manuscripts were identified. While 10 of 14 programs reported statistically significant increases in cancer prevention knowledge and/or increase in screening rates, only 7 of them enrolled large numbers of participants (defined as ≥1000). Only 7 programs had control groups, only 4 programs independently verified screening uptake, and 2 programs had long-term follow-up (defined as more than one screening cycle). Only one program demonstrated elimination of cancer health disparity at a population level. While most community-based cancer prevention programs have demonstrated efficacy in terms of increased knowledge and/or screening uptake, scalability and demonstration in reduction at a population level remain a challenge.

Community Empowerment Partners (CEPs): A Breast Health Education Program for African-American Women

Peer educators have been shown to provide effective interventions in breast cancer screening. Few studies have compared the effects of peer education on breast cancer knowledge among peer educators and the community members who are subsequently reached through the peer education. Further, little is known as to whether those who received the education then go on to educate others in the community. The purpose of this study is to address those gaps. Using a pre- and post-test study design, we trained peer educators, provided the educators with resources to train community members, and assessed changes in knowledge. We sought to train ten educators and recommended each train ten community members in breast cancer knowledge and screening strategies. A total of 14 peer educators were trained, who subsequently trained a total of 121 community members, of whom 94 were African American women. Peer educators and community members, showed comparable increases in knowledge. Community members who were educated also increased intention to discuss breast cancer and breast cancer screening with their family, friends, and acquaintances. Our study suggests that it is feasible to train peer educators to increase knowledge among community members to the same level that they themselves experience when trained. Further, community members are interested in sharing information learned related to how much they learn from peer educators.

Regular Mammography Screening Among African American (AA) Women: Qualitative Application of the PEN-3 Framework

Introduction: Breast cancer mortality rates among African American (AA) women are at 29.2 deaths per 100,000 persons compared with 20.6 deaths per 100,000 persons among Caucasian women. Regular mammography screening may significantly reduce breast cancer mortality and narrow this disparity. This study guided by PEN-3 model aims to explore the relationships and expectations domain and identify perceptions, enablers, and nurturers of regular mammography among AA women. Method: As part of an intervention study, in-depth interviews were conducted with 39 AA women recruited from the emergency department of a public university hospital. Results: Women's perceptions included fear and limited knowledge. Enablers identified were cost, socioeconomic, and race-related discrimination, and health care previous experiences. Nurturers identified included observation of family experiences and lack of health-related social support. Discussion: Findings underscore the need to develop culturally tailored interventions to address the issues salient to this population.

Understanding health decision making: An exploration of homophily

The phenomenon of homophily first was described in Lazarsfeld and Merton's classic 1954 friendship analysis as a tendency for friendships to form between those who are alike in some respect. Although theories of decision making address a host of factors that affect the process, the influence of individuals with homophilic ties remains unaccounted for and unexplained. The purpose of this paper is to review theories relevant to decision making and describe what is known about the relationship between homophily and health care decision making. Further, we provide new evidence suggesting the influence of homophily on decision making in results from a randomized, multi-center clinical trial of American men with localized prostate cancer. A diverse sample of 293 men with a new diagnosis of localized prostate cancer reported relevant personal factors influencing the care management decision before randomization to a decision aid or usual care, between 2013 and 2015. Among these personal factors were the level of influence or importance ascribed to various individuals at the time of the treatment decision. One month later, participants reported how prepared they were for decision making. 123 men (42%) reported friends and/or coworkers as information sources, of which 65 (53%) indicated that friends and/or coworkers influenced the care decision. Men who reported friends/coworkers as information sources had significantly higher one-month preparation scores. Our review of decision making theories and practical applicability suggests the influence of homophilic relationships manifests in health care decision making. Faced with a list of options to manage health conditions, decision makers turn to known individuals in their environments, particularly those individuals with whom the decision maker can identify. Clinicians may solicit information from patients about influential others and explain how that support fits into the health decision at hand without dishonoring the importance of the homophilic relationship.

Reducing Cardiovascular Disparities Through Community-Engaged Implementation Research: A National Heart, Lung, and Blood Institute Workshop Report

Cardiovascular disparities remain pervasive in the United States. Unequal disease burden is evident among population groups based on sex, race, ethnicity, socioeconomic status, educational attainment, nativity, or geography. Despite the significant declines in cardiovascular disease mortality rates in all demographic groups during the last 50 years, large disparities remain by sex, race, ethnicity, and geography. Recent data from modeling studies, linked micromap plots, and small-area analyses also demonstrate prominent variation in cardiovascular disease mortality rates across states and counties, with an especially high disease burden in the southeastern United States and Appalachia. Despite these continued disparities, few large-scale intervention studies have been conducted in these high-burden populations to examine the feasibility of reducing or eliminating cardiovascular disparities. To address this challenge, on June 22 and 23, 2017, the National Heart, Lung, and Blood Institute convened experts from a broad range of biomedical, behavioral, environmental, implementation, and social science backgrounds to summarize the current state of knowledge of cardiovascular disease disparities and propose intervention strategies aligned with the National Heart, Lung, and Blood Institute mission. This report presents the themes, challenges, opportunities, available resources, and recommended actions discussed at the workshop.

The Sustainability of Evidence-Based Interventions and Practices in Public Health and Health Care

There is strong interest in implementation science to address the gap between research and practice in public health. Research on the sustainability of evidence-based interventions has been growing rapidly. Sustainability has been defined as the continued use of program components at sufficient intensity for the sustained achievement of desirable program goals and population outcomes. This understudied area has been identified as one of the most significant translational research problems. Adding to this challenge is uncertainty regarding the extent to which intervention adaptation and evolution are necessary to address the needs of populations that differ from those in which interventions were originally tested or implemented. This review critically examines and discusses conceptual and methodological issues in studying sustainability, summarizes the multilevel factors that have been found to influence the sustainability of interventions in a range of public health and health care settings, and highlights key areas for future research.