Carolina Heart Alliance Networking for Greater Equity (CHANGE)

Cardiovascular disease (CVD) is the leading cause of mortality and morbidity among North Carolina (NC) and US adults, yet evidence-based CVD prevention interventions are often minimally implemented and poorly integrated across community and clinical settings. To address this gap, we will develop and test a multi-component strategy to help communities effectively implement evidence-based interventions (EBIs) to prevent CVD. We call our strategy the Carolina Heart Alliance Networking for Greater Equity (CHANGE) strategy. The CHANGE strategy will specifically address NC's large underserved, rural population, which is at increased risk for CVD due in part to behavioral risk factors, including physical inactivity, poor diet, and tobacco use.

The CHANGE strategy is designed to improve the dissemination and implementation of CVD EBIs by strengthening clinical-community linkages. Clinics have strengths in identifying individuals at high risk for cardiovascular disease and prescribing medications and behavioral change to mitigate risk. However, clinics only reach those who seek care, and most clinics lack the capacity to deliver behavioral change EBIs. Public health has strengths in implementing behavioral and environmental change EBIs in the communities where people live. Therefore, the core focus of the CHANGE strategy is to create new structures to leverage the complementary strengths of clinics and public health departments, thereby expanding the reach and effectiveness of both clinic- and community-based EBIs. Because of their potential to reach underserved populations, community health workers (CHWs) are at the center of the CHANGE strategy. Working as part of a clinic/public health collaboration, CHWs will deliver a behavioral change EBI (Heart-to-Health). By linking and leveraging clinical and public health prevention activities, new opportunities for individuals and communities to reduce their risk for CVD will be created. CHWs will be equipped with tablet computers that provide decision support for delivering Heart-to-Health and facilitate linkages among clinics, public health, and community services. Linking services within complex systems is challenging, and many good ideas fall short at the level of implementation. Therefore, the study will apply an effectiveness-implementation hybrid design with a primary focus on the effective implementation of the CHANGE strategy and a secondary focus on its effectiveness at reducing CVD risk. With support and input from community stakeholders the investigators will refine the CHANGE strategy (Year 1), test it in one underserved, rural community (Years 2-3) and then replicate it in a second community (Years 4-5).

Guided by key constructs from implementation science53 and the expanded Chronic Disease Model,54 the study's specific aims are as follows:

Aim 1. Refine the CHANGE strategy through community-engaged formative research to:

(a) identify existing CVD-related clinic and community services and barriers to their use, (b) engage stakeholders in designing the CHWs' roles and systems for integrating their work within clinical and public health practice, and (c) assess the tablet's usability for decision-support and data transfer.