For residents of southeastern Kentucky, the barriers to managing health care can seem as high as the Appalachian Mountains that serve as a backdrop to their daily lives. Because of a mix of factors including low socioeconomic status, high unemployment rate, and a shortage of healthcare providers, the area has one of the nation’s highest rates of cardiovascular disease (CVD) risk, prevalence, and mortality.

Prior studies have shown that promoting behavioral change can be effective in reducing patients’ CVD risk, but interventions to address multiple risk factors are uncommon in clinical practice, and nearly unheard of in distressed populations.

But now, encouraging results from a PCORI-funded study at the University of Kentucky show that culturally tailored lessons on how to manage CVD risk factors, in collaboration with strong community input, help patients in Appalachian Kentucky significantly reduce CVD risk factors—and keep them reduced.

All 352 patients in the study, which was led by Debra Moser, PhD, RN, FAAN, were referred to primary care doctors with a letter outlining their risk factors. Half of the patients also attended a series of six small-group classes in a program called HeartHealth, which emphasized problem-solving skills for healthy eating, physical activity, stress reduction, and other self-care activities to help manage risk factors.

HeartHealth was developed in consultation with a community advisory board and delivered by community health workers (CHWs), trained laypeople who serve as liaisons between healthcare professionals and patients.

Because Moser wanted a way for patients to measure their progress, patients picked a CVD risk factor to reduce as a goal at the beginning of the study. CHWs recorded patients’ data on their goal and a full spectrum of CVD risk factors when the study began, and then at four and at 12 months later.

The results were striking. Fifty percent of patients in the HeartHealth group met their CVD risk goal, compared to just 16 percent in the usual care group. As a whole, the HeartHealth group showed marked improvement in blood pressure, cholesterol, HDL cholesterol, blood glucose levels, body mass index, and smoking cessation compared to the usual care group. Impressively, these improvements held steady one year after the study.

“Risk modification often isn’t maintained after a study ends,” Moser said. “But we focused on teaching people how to overcome barriers in their environment. You have to do that. Otherwise, these barriers would put them right back on the path to cardiovascular disease risk.”

An unexpected but extremely impactful win came in smoking cessation. At the beginning of the study, 39 percent of patients in the HeartHealth group were smokers. After 12 months, nicotine testing showed that number had dropped to 17 percent, even though only five patients chose smoking cessation as a goal at the beginning of the study.

“People didn’t pick smoking cessation as a goal because they thought it was impossible,” Moser said. “When they were successful with other risk factors, and as they increased their ability to make positive changes, they thought, ‘OK, I can do this.’ People don’t like smoking, and they do want to quit.

“Discovering that they could change risk factors they never thought they could was incredibly powerful.”

Throughout the project, researchers worked closely with local police, fire, and health department representatives, along with church leaders, mayors, and other officials. These visible community leaders helped with recruiting and generating interest in the study, advised on how to best deliver interventions, and drove changes in communities to help residents live healthier lives.

“People in the area are stereotyped as being fatalistic and uninterested," Moser said. “We did interviews with healthcare providers in the area who said, ‘They’re not going to change, they don’t care.’ We found that wasn’t true at all. They were very concerned, especially for their children and grandchildren.

“They were aware that Appalachian Kentucky has a horrible reputation, and they really wanted to change, but they felt like they didn’t have the resources or the support they needed. The whole community rallied around the issue when they realized how much it mattered to everyone.”

The buzz allowed the community to drive its own change, but it also produced practical tips for the research team. Moser planned to deliver HeartHealth lessons in one-on-one settings, but scrapped that when community members said small-group classes would foster social support and a sense of community accountability among participants.

But it’s not enough to just tailor an intervention to the population being treated. Moser’s study proves that who delivers the intervention can be just as important. HeartHealth was based two hours southeast of the University of Kentucky’s campus in Lexington at a facility that deploys CHWs to deliver medical and other services that residents would otherwise go without.

The CHWs used existing connections to help recruit patients to the study. Because they also delivered the interventions, collected patient data, and conducted follow-up sessions, the trust they had with patients grew as the study progressed.

“Community health workers understand the community, understand how they’re viewed in the community, and have a huge impetus to make changes in the community,” Moser said. “A lot of them are so grateful because they have positions they didn’t think would be possible to have. There’s this real sense of investment and pride by community health workers in doing their job well, and we are so grateful to have them.”

The comfort level that CHWs have with members of the local community was reciprocated. People in underserved areas are sometimes skeptical of research, and are more likely to relate to someone from their community who can tailor messaging around specific community needs.

“It is absolutely fundamental to have people from the community who are the interface for the participants in the project, and that really becomes evident when you don’t do it,” Moser said. “If you don’t, there is initially a bit of hostility between the community and the university. In our focus groups before the project started, one of the things that people mentioned over and over was, ‘It would be nice if it was somebody from our community.’”

In addition to empowering the population to take charge of managing its CVD risk, the study led to work that will help future generations of Kentuckians live healthier lives. In just one example, a local Better Business Bureau secured a grant to add a walking path to give residents a safe place to exercise.

“I remember visiting, and it’s really beautiful, but the roads where they live are right next to the river. So there’s the road, there’s the house, and there’s the mountain. The basketball hoops are in the middle of the road, and there was literally no place to walk,” Moser said. “Those are the kind of impediments that we tried to help people overcome, and then businesses and the local community stepped in to continue to help.”

While Moser’s team focused on CVD risk reduction, her work could serve as a blueprint for working with socioeconomically distressed rural areas on an array of health topics.

“Actual research in rural areas is underdone and underappreciated,” Moser said. “You hear a lot about needs, and people do a lot of research describing the dire health and inequities, but they don’t necessarily do a lot of interventions. Such research is really, really essential. There’s a big underserved population that we have to do a much better job figuring out how to reach.”