Cardiovascular Disease Prevention in High-risk Rural Communities
Bethesda, Maryland
June 14-15, 2010



Purpose: The objective of the workshop was to provide research recommendations for the development, implementation, and evaluation of family and community interventions to reduce obesity, hypertension, diabetes, and cardiovascular disease (CVD) in rural communities of the United States.


Significant geographic variations in cardiovascular health are evident despite national reductions in heart disease mortality since 2000 in the United States (1, 2). Workshop participants discussed geographic disparities observed in risk factors associated with CVD in high-risk rural communities.  The complexities of defining “rural” were explained and discussed.  While no single preferred definition emerged from the discussion or from the literature (3), the Federal Government’s Office of Management and Budget classification using counties, rural-urban commuting areas based on zip codes, census geography, metropolitan and micropolitan areas (i.e., urban clusters of 10,000 or more persons) was suggested (3). To achieve the objectives of the workshop, a conceptual framework drawn from the Analysis Grid for Elements Linked to Obesity (ANGELO) (4, 5) was suggested to identify environmental (physical, economic and socio-cultural) risks for specific geographic areas, including rural areas. In considering the comprehensive approaches needed for effective interventions to address CVD in rural areas, a strategy ( that incorporates six complementary levels across a spectrum of prevention (6) (i.e., influencing policy and legislation, changing organizational practices, fostering coalitions and networks, educating providers, and promoting community education) was introduced.

Scientists and community investigators engaged in research in rural communities offered their expertise through three panel discussion sessions: (I) Community-based CVD Prevention Approaches, (II) Dissemination and Implementation Research of Evidence-based Interventions, and (III) Cutting Edge Research Projects on Policy and Environmental Interventions. Each session was organized around key risk factors that contribute to obesity, hypertension, diabetes, and CVD from a rural population perspective, with consideration of the challenges, opportunities and resources for achieving and maintaining healthy lifestyles. Findings from the literature and experiences from ongoing research and programs in rural communities were also used to develop the recommendations generated in the two breakout sessions: A) recruitment, intervention, and outcomes; and B) capacity building through community development, training and partnership.

Participants discussed the unique characteristics, issues and opportunities affecting underlying health status and risk in rural communities including 1) the importance of agriculture and natural resources, which are often the mainstay of employment in rural communities; 2) the shortage of health care professionals and preventive care facilities including clinics and recreational resources; 3) limited access to healthy foods; and 4) limited transportation opportunities. They discussed the need for sustained partnerships to build capacity for health promotion and disease prevention including CVD. Participants also discussed the need for leadership to achieve economic development; skill building and training of local health professionals and community members in evidence-based approaches to improving health status and reducing CVD, and the need to evaluate community-level and state-wide or national policy interventions to build the evidence base for further research and practice.

Guiding Principles

As part of the process for developing recommendations for the development, implementation, and evaluation of family and community interventions to reduce obesity, hypertension, diabetes, CVD in rural communities of the United States, participants expressed their beliefs in the following principles:

  • Community engagement is a prerequisite to undertaking any and all phases of research development, implementation and evaluation.
  • Principles of community-based participatory research should be included in all aspects of research in rural communities. This could be accomplished through 1) training of community members to be ambassadors of community-based participatory research (CBPR), and 2) systematic training and development of curricula for researchers prior to their engaging in CBPR.
  • Sustainability should be considered a primary objective in all research and practice improvement activities.
  • Evidence-based approaches should be considered first when looking at options for disseminating and implementing interventions to reduce identified CVD risk, including interventions to improve access to care.
  • Local capacity building at the organizational and individual level is vital for achieving success and sustainability.
  • Partnership (including public-private partnerships) led interventions and policy efforts are keys to community engagement, collaboration and sustainability.
  • Research in rural areas must build on existing community strengths and existing infrastructure (e.g. cooperative extension, WIC, community health centers) whenever possible while recognizing and addressing or accommodating the unique characteristics of each rural place and its inhabitants.;
  • Research in rural areas must address poverty as one of the most important underlying causes of health disparities, through research explorations designed to improve health while creating opportunities for entrepreneurship and economic development.
  • Researchers and community members should define the term “rural” for their proposed work, communicate that definition to all stakeholders and take into account the underlying premises and constraints of their chosen definition when developing, implementing or evaluating an intervention.
  • Researchers should make use of evidentiary/preliminary studies to inform recruitment and planning of efficacy and effectiveness trials.
  • Researchers should consider the use of methodologically sound alternatives to randomized trials where appropriate given the stage of the research and the feasibility of randomization (e.g. regression discontinuity design for efficacy and effectiveness studies, time series designs, multiple baseline designs, and quasi-experimental designs for preliminary studies).
  • Researchers should select appropriate primary outcomes, and design and power studies appropriately recognizing the importance of multiple risk factors to be evaluated as secondary outcomes.
  • Researchers should consider the rural context (e.g., SES of rural communities, built environment, limitations of existing health resources) in intervention design and include a comprehensive quality of life assessment to capture participants' general health status.
  • Researchers should encourage a combination of qualitative and quantitative research to better understand the complexity of factors associated with rural health.

Research Priorities

Through the presentations and discussions, workshop participants made recommendations for future research and practice that included activities to 1) facilitate community development, training and partnerships; and 2) encourage effective recruitment (community and/or participant), intervention design, implementation and outcomes. The Working Group deemed the following three recommendations to be the highest priorities:

  • Test strategies to improve policies and infrastructure shown to reduce CVD risk, e.g., modify the built environment to increase the likelihood of exercise, increase access to healthy foods, assure regulation of tobacco sales and promotion laws, and increase the number of public smoke-free places.
  • Test strategies to improve the development, testing, and adoption of evidence-based and practiced-tested interventions for CVD prevention in rural communities.
  • Develop and test models to facilitate active community engagement in planning, implementing, and evaluating community-based interventions for CVD risk reduction.

All Recommendations

Facilitate Community Development, Training and Partnerships Research:

  • Support research that:
    • addresses how to best facilitate community development, training and partnerships in support of CVD prevention.
    • determines approaches to develop effective collaborations across local, state, and national entities.
    • explores the use and impact of flexible funding schemes (e.g., capacity building or planning grants) and diverse level and type of funding (e.g., pilot, “natural experiments”, prototype, implementation, and dissemination).
    • incorporates mechanisms to provide funds for community leader involvement and assesses the effectiveness of such approaches (e.g., as subcontractors to allow community-based organizations and/or leaders to obtain indirect costs for their services).
    • designates research support, including K-Awards for clinicians residing in rural communities and facilitates coordination of research among health-care providers.
  • Develop and test strategies to improve policies and infrastructure shown to reduce CVD risk (e.g., modify the built environment to increase the likelihood of exercise, increase access to healthy foods, assure regulation of tobacco sales and promotion laws, and increase the number of public smoke-free places).
  • Develop and evaluate the cost effectiveness, sustainability, and impact of supporting community coordinators through grant-writing initiatives and through community-researcher partnership development (e.g., in data collection, determination of priority health needs, and communication of community health status to researchers and community members).
  • Explore the most effective role for community health workers, community champions, and care coordinators in advancing the adoption of evidence-based approaches to reduce CVD burden.
  • Evaluate unique approaches to engage community members in intervention and policy change to increase the likelihood that policies and evidence-based approaches to reduce CVD are acceptable to community members.
  • Explore options for modifying efficacious interventions in non-rural settings for use in rural communities.
  • Explore options for “taking to scale” those interventions demonstrated to work in rural and other settings.
  • Evaluate how existing networks/systems can work to foster dissemination. For example, create mechanisms to utilize research funds (e.g., rapid response funds) for “natural” experiments and short-term intervention studies to evaluate their successes and failures.
  • Evaluate the utility of various technologies for prevention activities in rural communities (e.g., telemedicine, electronic medical records).

Encourage Effective Recruitment, Intervention Design, Implementation and Dissemination

Recruitment (individual participant and community)

  • Develop and evaluate targeted approaches to study recruitment in rural communities. Such approaches should follow (or be tailored to) the type of intervention proposed. (e.g., for studies on childhood obesity, target caregivers or families but not children alone).
  • Conduct research on how to make recruitment relevant and meaningful to target population groups (e.g., for some, appearance may be more motivating than health for weight management) while maintaining or improving recruitment.
  • Study Design and Intervention Implementation

  • Conduct studies that would examine the impact of national recommendations (e.g., the Institute of Medicine’s school nutrition recommendations and the USDA/DHHS Dietary Guidelines for Americans) in rural areas.
  • Conduct research that will explore approaches to translating proven and efficacious studies into practice in rural communities. Examples of possible implementation studies in rural communities include extension of CDC best practices for tobacco control, of the Diabetes Prevention Program (DPP), the Dietary Approaches to Stop Hypertension (DASH) and the coordinated school wellness mandate.
  • Conduct research to understand effective components of successful efficacy trials and how these components might be adapted in rural areas (e.g., test content or process of DPP).


  • Explore ways to use successful programs to develop evidence for dissemination (e.g., modify efficacy trials to develop effectiveness trials in rural areas).
  • Conduct research to examine the effectiveness of existing programs in rural areas.

    Outcomes and Metrics

  • Use secondary outcomes as the basis for evidentiary trials and encourage the assessments of mediators and moderators of interventions (e.g., intervention effect modifiers).


  1. Brown JR, O’Connor GT. Coronary Heart Disease and Prevention in the United States. N Eng J Med. 2010;362(23):2150-2153.
  2. Murray CJL, Kulkarni S, Ezzati M. Eight Americas New Perspectives on U.S. Health Disparities. Am J Prev Med. 2005;29(5S1):4-10.
  3. Coburn AF, MacKinney AC, McBride TD, Mueller KJ, Slifkin RT, Wakefield MK. Choosing Rural Definitions: Implications for Health Policy. Rural Policy Research Institute Health Panel. 2007; Issue Brief #2.
  4. Swinburn B, Egger G, Raza F. Dissecting Obesogenic Environments: the Development and Application of a Framework for Identifying and Prioritizing Environmental Interventions for Obesity. Prev Med. 1999;29:563-570.
  5. Yancey AK, Kumanyika SK, Ponce NA, McCarthy WJ, Fielding JE, Leslie JP, Akbar J. Population-based Interventions Engaging Communities of Color in Healthy Eating and Active Living: A Review. Preventing Chronic Disease. 2004;1(1):1-18.
  6. Cohen L, Swift S. The Spectrum of Prevention: Developing a Comprehensive Approach to Injury Prevention. Injury Prevention. 1999; 5:203-207.

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