Process Evaluation of Strong Hearts, Healthy Communities: A Rural Community-Based Cardiovascular Disease Prevention Program

Strategies for improving diversity, equity, and inclusion in cardiovascular research: a primer

This paper aims to empower cardiovascular (CV) researchers by promoting diversity, equity, and inclusion (DE&I) principles throughout the research cycle. It defines DE&I and introduces practical strategies for implementation in recruitment, retention, and team dynamics within CV research. Evidence-based approaches supporting underrepresented populations' participation are outlined for each research phase. Emphasizing the significance of inclusive research environments, the paper offers guidance and resources. We invite CV researchers to actively embrace DE&I principles, enhancing research relevance and addressing longstanding CV health disparities.

Improvements in dietary intake, behaviors, and psychosocial measures in a community-randomized cardiovascular disease risk reduction intervention: Strong Hearts, Healthy Communities 2.0

BACKGROUND

Cardiovascular disease (CVD) prevalence has disproportionately risen among midlife and older female adults of rural communities, partly due to poor diet and diet-related behaviors and psychosocial factors that impede healthy eating.

OBJECTIVES

This study aimed to evaluate the impact of Strong Hearts Healthy Communities 2.0 (SHHC-2.0) on secondary diet-related outcomes between intervention and control participants that align with the dietary goal and behavioral aims of the SHHC-2.0, a CVD risk reduction program.

METHODS

A community-randomized controlled trial was conducted in rural, medically underserved communities. Participants were female adults ≥40 y who were classified as obese or both overweight and sedentary. Communities were randomized to SHHC-2.0 intervention (n = 5 communities; n = 87 participants) or control (with delayed intervention) (n = 6 communities; n = 95 participants). SHHC-2.0 consisted of 24 wk of twice-weekly experiential nutrition education and group-based physical activity classes led by local health educators. Changes between baseline and end point (24 wk) in dietary intake (24-h recalls), dietary behaviors (e.g., Rapid Eating Assessment for Participants-Short Version [REAP-S] scores) and diet-related psychosocial measures (e.g., Three Factor Eating questionnaire) between groups were analyzed using linear mixed-effects multilevel models.

RESULTS

At 24 wk, participants from the 5 intervention communities, compared with controls, consumed fewer calories (mean difference [MD]= -211 kcal, 95% CI: -412, -110, P = 0.039), improved overall dietary patterns measured by REAP-S scores (MD: 3.9; 95% CI: 2.26, 5.6; P < 0.001), and improved psychosocial measures (healthy eating attitudes, uncontrolled eating, cognitive restraint, and emotional eating).

CONCLUSIONS

SHHC-2.0 has strong potential to improve diet patterns and diet-related psychosocial wellbeing consistent with improved cardiovascular health. This trial was registered at www.

CLINICALTRIALS

gov as NCT03059472.

Changes in physical activity outcomes in the Strong Hearts, Healthy Communities (SHHC-2.0) community-based randomized trial

BACKGROUND

Physical inactivity is a risk factor for numerous adverse health conditions and outcomes, including all-cause mortality. Aging rural women are at particular risk for physical inactivity based on environmental, sociocultural, and psychosocial factors. This study reports on changes in physical activity and associated factors from a multicomponent community-engaged intervention trial.

METHODS

Strong Hearts, Healthy Communities 2.0 (SHHC-2.0) was a 24-week cluster (community) randomized controlled trial building on the results from the previous trial of SHHC-1.0. Rural women (n = 182) aged 40 and over living in 11 rural communities in upstate New York were recruited. The intervention consisted of twice-weekly experiential classes focused on exercise, nutrition, and civic engagement. Physical activity outcomes included accelerometry and self-report as well as related psychosocial measures at midpoint (12 weeks) and post-intervention (24 weeks). Data were analyzed using multilevel linear regression models with the community as the random effect.

RESULTS

Compared to participants from the control communities, participants in the intervention communities showed a significant increase in objectively measured moderate to vigorous intensity physical activity: at 12 weeks (increase of 8.1 min per day, P < 0.001) and at 24 weeks (increase of 6.4 min per day; P = 0.011). Self-reported total MET minutes per week also increased: at 12 weeks (increase of 725.8, P = 0.003) and 24 weeks (increase of 955.9, P = 0.002). Several of the psychosocial variables also showed significant positive changes.

CONCLUSIONS

The SHHC-2.0 intervention successfully increased physical activity level and related outcome measures. Modifications made based upon in-depth process evaluation from SHHC-1.0 appear to have been effective in increasing physical activity in this at-risk population.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT03059472. Registered 23 February 2017.

Using implementation strategies in community settings: an introduction to the Expert Recommendations for Implementing Change (ERIC) compilation and future directions

In this commentary, we introduce public health practitioners and researchers to implementation science through an established compilation of implementation strategies. We provide terminology and examples for community settings so public health practitioners and researchers can use implementation strategies and document efforts using standard terminology. We also discuss the need for future work to determine the extent to which these implementation strategies work and are most useful in community settings, and ultimately, how health behaviors are impacted. We intend this commentary to serve as a dissemination strategy for implementation strategies and to contribute to knowledge in the growing field of implementation science in community settings.

Improvements and Maintenance of Clinical and Functional Measures Among Rural Women: Strong Hearts, Healthy Communities-2. 0 Cluster Randomized Trial

BACKGROUND

Cardiovascular disease is the leading cause of death in the United States; however, women and rural residents face notable health disparities compared with male and urban counterparts. Community-engaged programs hold promise to help address disparities through health behavior change and maintenance, the latter of which is critical to achieving clinical improvements and public health impact.

METHODS

A cluster-randomized controlled trial of Strong Hearts, Healthy Communities-2.0 conducted in medically underserved rural communities examined health outcomes and maintenance among women aged ≥40 years, who had a body mass index >30 or body mass index 25 to 30 and also sedentary. The multilevel intervention provided 24 weeks of twice-weekly classes with strength training, aerobic exercise, and skill-based nutrition education (individual and social levels), and civic engagement components related to healthy food and physical activity environments (community, environment, and policy levels). The primary outcome was change in weight; additional clinical and functional fitness measures were secondary outcomes. Mixed linear models were used to compare between-group changes at intervention end (24 weeks); subgroup analyses among women aged ≥60 years were also conducted. Following a 24-week no-contact period, data were collected among intervention participants only to evaluate maintenance.

RESULTS

Five communities were randomized to the intervention and 6 to the control (87 and 95 women, respectively). Significant improvements were observed for intervention versus controls in body weight (mean difference: -3.15 kg [95% CI, -4.98 to -1.32]; P=0.008) and several secondary clinical (eg, waist circumference: -3.02 cm [-5.31 to -0.73], P=0.010; systolic blood pressure: -6.64 mmHg [-12.67 to -0.62], P=0.031; percent body fat: -2.32% [-3.40 to -1.24]; P<0.001) and functional fitness outcomes; results were similar for women aged ≥60 years. The within-group analysis strongly suggests maintenance or further improvement in outcomes at 48 weeks.

CONCLUSIONS

This cardiovascular disease prevention intervention demonstrated significant, clinically meaningful improvements and maintenance among rural, at-risk older women.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT03059472.

Cardiovascular Disease in the Peruvian Andes: Local Perceptions, Barriers, and Paths to Preventing Chronic Diseases in the Cajamarca Region

Objectives: Public health interventions can be improved by understanding peoples' explanatory models of disease. We explore awareness and perceptions of cardiovascular diseases (CVD) and options for preventative actions in young adults living in rural Andean communities. Methods: We used convenience sampling to select 46 men and women from communities in Cajamarca (Peru). Subjects participated in eight focus groups where they discussed their understanding and perceived causes of CVD as well as barriers and pathways to healthy lifestyles. Results: Fresh foods, physical activity, unpleasant emotions, and healthcare access were cited as important determinants of healthy lifestyles. Barriers to healthy diets included lacking nutritional knowledge, fluctuating food prices, and limited access to foodstuffs. Women felt particularly vulnerable to CVD and identified gendered barriers to manage stress and engage in sports. Low health literacy, poor doctor-patient relationships, and long distances prevented participants from fully accessing healthcare. Conclusion: CVD prevention interventions should consider local knowledge of these diseases and of healthy lifestyles, and harness ongoing programmes that have successfully promoted good nutrition in children and pregnant women. In concert with public-private parterships, governments should include disease prevention interventions for the entire family.

Ripple Effects of a Community-Based Randomized Trial for Rural Women: Strong Hearts, Healthy Communities

OBJECTIVE

This study aimed to examine (1) whether the Strong Hearts, Healthy Communities intervention (SHHC) improved social network members' (SNMs') weight, exercise, and diet and (2) whether SNMs' weight and behavioral changes were modified by their relationship closeness and/or spatial closeness with trial participants.

METHODS

Eight towns received the SHHC intervention, which focused on building individual healthy behaviors and creating supportive social and built environments for exercise and healthy eating. Eight towns received an education-only control intervention. SNMs (n = 487) were recruited to complete a questionnaire at baseline and at 6 months that asked about demographics, weight, height, exercise, and eating habits.

RESULTS

SHHC's effect on SNMs differed depending on their relationship closeness with trial participants. Among SNMs who had a very close relationship with trial participants, those associated with the intervention group lost more weight and decreased BMI more than those associated with the control group (weight [kilograms] between-group difference: Δ = -1.68; 95% CI: -3.10 to -0.25; P = 0.021; BMI between-group difference: Δ = -0.60; 95% CI: -1.16 to -0.04; P = 0.034). Spatial closeness did not modify any of SHHC's ripple effects.

CONCLUSIONS

Relationship closeness, rather than spatial closeness, played an important role in influencing a rural community-based intervention's ripple effects.

The Strong Hearts, Healthy Communities Program 2.0: An RCT Examining Effects on Simple 7

INTRODUCTION

Rural women have higher rates of cardiovascular disease than their nonrural counterparts, partially because of their social and environmental contexts. The study objective is to test a refined version of the multilevel Strong Hearts, Healthy Communities intervention, which used extensive process and outcome evaluation data from the original randomized trial to optimize effectiveness as measured by improved Simple 7 score, a composite measure of cardiovascular disease risk.

STUDY DESIGN

The intervention was implemented in a 6-month, delayed intervention, community-randomized trial; control participants received the program following 24-week outcome assessment. The study was conducted in 2017-2018; data analysis occurred in 2018-2019.

SETTING/PARTICIPANTS

The study was conducted in 11 rural, medically underserved towns in New York. Participants were women aged ≥40 years who were either (1) obese or (2) overweight and sedentary.

INTERVENTION

The intervention group received 24 weeks of hour-long, twice-weekly classes including strength training, aerobic exercise, and skill-based nutrition- and health-related education, as well as civic engagement activities focused on healthy food and physical activity environments.

MAIN OUTCOME MEASURES

Measures included weight and height; blood pressure; blood cholesterol; blood glucose; and self-reported smoking, diet, and physical activity behaviors. Individual Simple 7 components were examined, and mixed linear regression analyses were used to examine change in Simple 7 score.

RESULTS

A total of 182 participants were randomized. Compared with control participants, the intervention group had greater improvements in Simple 7 score (difference=1.03, 95% CI=0.44, 1.61, p<0.001) and 3 of the Simple 7 components (physical activity, healthy diet score, and BMI).

CONCLUSIONS

These findings highlight the importance of rigorously evaluating programs in real-world community settings and, when appropriate, revising and retesting interventions to optimize dissemination potential.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT03059472.

Changes in diet and physical activity resulting from the Strong Hearts, Healthy Communities randomized cardiovascular disease risk reduction multilevel intervention trial

BACKGROUND

Women living in rural areas face unique challenges in achieving a heart-healthy lifestyle that are related to multiple levels of the social-ecological framework. The purpose of this study was to evaluate changes in diet and physical activity, which are secondary outcomes of a community-based, multilevel cardiovascular disease risk reduction intervention designed for women in rural communities.

METHODS

Strong Hearts, Healthy Communities was a six-month, community-randomized trial conducted in 16 rural towns in Montana and New York, USA. Sedentary women aged 40 and older with overweight and obesity were recruited. Intervention participants (eight towns) attended twice weekly exercise and nutrition classes for 24 weeks (48 total). Individual-level components included aerobic exercise, progressive strength training, and healthy eating practices; a civic engagement component was designed to address social and built environment factors to support healthy lifestyles. The control group (eight towns) attended didactic healthy lifestyle classes monthly (six total). Dietary and physical activity data were collected at baseline and post-intervention. Dietary data were collected using automated self-administered 24-h dietary recalls, and physical activity data were collected by accelerometry and self-report. Data were analyzed using multilevel linear regression models with town as a random effect.

RESULTS

At baseline, both groups fell short of meeting many recommendations for cardiovascular health. Compared to the control group, the intervention group realized significant improvements in intake of fruit and vegetables combined (difference: 0.6 cup equivalents per day, 95% CI 0.1 to 1.1, p = .026) and in vegetables alone (difference: 0.3 cup equivalents per day, 95% CI 0.1 to 0.6, p = .016). For physical activity, there were no statistically significant between-group differences based on accelerometry. By self-report, the intervention group experienced a greater increase in walking MET minutes per week (difference: 113.5 MET-minutes per week, 95% CI 12.8 to 214.2, p = .027).

CONCLUSIONS

Between-group differences in dietary and physical activity behaviors measured in this study were minimal. Future studies should consider how to bolster behavioral outcomes in rural settings and may also continue to explore the value of components designed to enact social and environmental change.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02499731. Registered 16 July 2015.

Strong Hearts for New York: A multilevel community-based randomized cardiovascular disease risk reduction intervention for rural women

BACKGROUND

Rural midlife and older women have high rates of cardiovascular disease (CVD) risk factors and lower access to healthy living resources. The Strong Hearts, Healthy Communities (SHHC) intervention, tailored to the needs of rural women, demonstrated effectiveness on many outcomes. The purpose of the Strong Hearts for New York (SHNY) study is to evaluate the efficacy of an enhanced version of the curriculum (SHHC-2.0).

METHODS

SHNY is a randomized controlled efficacy intervention, comparing participants receiving the SHHC-2.0 curriculum with a delayed intervention control group. SHHC, informed by formative research, includes core elements from three evidence-based programs. Changes based on extensive outcome and process evaluation data were made to create SHHC-2.0. Classes will meet twice weekly for 24 weeks and include individual, social, and environmental components. Overweight women age 40 and over will be recruited from 11 rural, medically underserved communities in New York; data will be collected at baseline and 12, 24, 36, and 48 weeks across individual, social, and environmental levels. Primary outcome is body weight. Secondary outcomes include Simple 7 (composite CVD risk score), anthropometric, physiologic, biochemical, physical activity, and dietary intake measures; healthy eating and exercise self-efficacy and attitudes; and self-efficacy of the social network of participants.

DISCUSSION

The aims of this study are to evaluate the efficacy of the enhanced SHHC-2.0 program for participants, changes among participants' social networks, and the difference in outcomes when participants are and are not provided with technological tools (Fitbit and body composition scale).

Effects of the Strong Hearts, Healthy Communities Intervention on Functional Fitness of Rural Women

PURPOSE

The purposes of these analyses were to determine whether Strong Hearts, Healthy Communities (SHHC), a multilevel, cardiovascular disease risk reduction program for overweight, sedentary rural women aged 40 or older, led to improved functional fitness, and if changes in fitness accounted for weight loss associated with program participation.

METHODS

Sixteen rural communities were randomized to receive the SHHC intervention or a control program. Both programs involved groups of 12-16 participants. The SHHC program met 1 hour twice a week for 24 weeks where participants engaged in aerobic exercise and progressive strength training. Program content addressed diet and social and environmental influences on heart-healthy behavior. The control group met 1 hour each month for 6 months, covering current dietary and physical activity recommendations. Objective measures of functional fitness included the 30-second arm curl, 30-second chair stand, and 2-minute step test. Self-reported functional fitness was measured by the Physical Functioning Subscale of the MOS Short Form-36 (SF-36 PF).

FINDINGS

The SHHC program was associated with increased strength and endurance, as represented by greater improvement in the chair stand and step test; and with increased physical function, as represented by the SF-36 PF. Adjustment for change in aerobic endurance, as measured by the step test, accounted for two-thirds of the intervention effect on weight loss at the end of the intervention.

CONCLUSIONS

SHHC participants experienced improved performance on objective measures of functional fitness and self-reported measures of physical function, and changes in weight were partially accounted for by changes in aerobic fitness.