Research Article| Volume 51, ISSUE 2, P138-149, February 2019

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



      To evaluate the implementation of a community-based cardiovascular disease prevention program for rural women: Strong Hearts, Healthy Communities (SHHC).


      Mixed-methods process evaluation.


      A total of 101 women from 8 rural towns were enrolled in the SHHC program; 93 were enrolled as controls. Eligible participants were aged ≥40 years, sedentary, and overweight or obese. Local health educators (n = 15) served as program leaders within each town.

      Outcome Measures

      Reach, fidelity, dose delivered, dose received, and program satisfaction were assessed using after-class surveys, participant satisfaction surveys, interviews with program leaders, and participant focus groups.


      Descriptive statistics, chi-square tests of independence, and thematic analysis were employed.


      Intervention sites reported high levels of fidelity (82%) and dose delivered (84%). Overall reach was 2.6% and program classes were rated as effective (3.9/5). Participants were satisfied with their experience and reported benefits such as camaraderie and awareness of healthy eating and exercise strategies. Common recommendations included increasing class time and enhancing group discussion.

      Conclusions and Implications

      Implementation was good in terms of fidelity, dose delivered, and satisfaction, although low reach. Findings from this research have informed a second round of implementation and evaluation of the SHHC program in rural communities.

      Key Words

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        • Benjamin EJ
        • Virani SS
        • Callaway CW
        • et al.
        Heart disease and stroke statistics—2018 update: a report from the american heart association.
        Circulation. 2018; 137: e67-e492
        • Cossman JS
        • James WL
        • Cosby AG
        • Cossman RE
        Underlying causes of the emerging nonmetropolitan mortality penalty.
        Am J Public Health. 2010; 100: 1417-1419
        • Meit M
        • Knudson A
        • Gilbert T
        • et al.
        The 2014 Update of the Rural–Urban Chartbook.
        2014 (Bethesda, MD;2014)
        • ACOG Committee Opinion No. 586
        Health disparities in rural women.
        Obstet Gynecol. 2014; 123: 384-388
        • Anderson TJ
        • Saman DM
        • Lipsky MS
        • Lutfiyya MN
        A cross-sectional study on health differences between rural and non-rural U.S. counties using the County Health Rankings.
        BMC Health Serv Res. 2015; 15: 441
        • Trivedi T
        • Liu J
        • Probst J
        • Merchant A
        • Jones S
        • Martin AB
        Obesity and obesity-related behaviors among rural and urban adults in the USA.
        Rural Remote Health. 2015; 15: 1-11
        • Lundeen E
        • Park S
        • Pan L
        • O'Toole T
        • Matthews K
        • Blanck H
        Obesity prevalence among adults living in metropolitan and nonmetropolitan counties—United States, 2016.
        Morb Mortal Wkly Rep. 2018; 67: 653-658
        • Dean W
        • Johnson C
        • Sharkey J
        Rural food disparities: availability and accessibility of healthy foods.
        in: Crosby R Wendel M Vanderpool R Casey B Rural Populations and Health. 1st ed. Jossey-Bass, San Francisco, CA2012: 251-266
        • Hansen AY
        • Umstattd Meyer MR
        • Lenardson JD
        • Hartley D
        Built environments and active living in rural and remote areas: a review of the literature.
        Curr Obes Rep. 2015; 4: 484-493
        • Maley M
        • Warren BS
        • Devine CM
        Perceptions of the environment for eating and exercise in a rural community.
        J Nutr Educ Behav. 2010; 42: 185-191
        • Mudd-Martin G
        • Biddle MJ
        • Chung ML
        • et al.
        Rural appalachian perspectives on heart health: social ecological contexts.
        Am J Health Behav. 2014; 38: 134-143
        • Peterson J
        • Schmer C
        • Ward-Smith P
        Perceptions of midwest rural women related to their physical activity and eating behaviors.
        J Community Health Nurs. 2013; 30: 72-82
        • Seguin R
        • Connor L
        • Nelson M
        Understanding barriers and facilitators to healthy eating and active living in rural communities.
        J Nutr Metab. 2014; 2014: 23-25
        • Chrisman M
        • Nothwehr F
        • Yang G
        • Oleson J
        Environmental influences on physical activity in rural midwestern adults: a qualitative approach.
        Health Promot Pract. 2014; 16: 142-148
        • Seguin RA
        • Eldridge G
        • Graham ML
        • Folta SC
        • Nelson ME
        • Strogatz D
        Strong Hearts, Healthy Communities: a rural community-based cardiovascular disease prevention program.
        BMC Public Health. 2016; 16: 86
        • Spring B
        • Ockene JK
        • Gidding SS
        • et al.
        Better population health through behavior change in adults: a call to action.
        Circulation. 2013; 128: 2169-2176
        • Stoddard AM
        • Palombo R
        • Troped PJ
        • Sorensen G
        • Will JC
        Cardiovascular disease risk reduction: the Massachusetts WISEWOMAN project.
        J Womens Health. 2004; 13: 539-546
        • Khare MM
        • Koch A
        • Zimmermann K
        • Moehring PA
        • Geller SE
        Heart Smart for Women: a community-based lifestyle change intervention to reduce cardiovascular risk in rural women.
        J Rural Health. 2014; 30: 359-368
        • Altman R
        • de Ybarra JN
        • Villablanca AC
        Community-based cardiovascular disease prevention to reduce cardiometabolic risk in Latina women: a pilot program.
        J Womens Health. 2014; 23: 350-357
        • Yanek LR
        • Becker DM
        • Moy TF
        • Gittelsohn J
        • Koffman DM
        Project Joy: Faith based cardiovascular health promotion for African American women.
        Public Health Rep. 2001; 116: 68-81
        • Folta SC
        • Lichtenstein AH
        • Seguin RA
        • Goldberg JP
        • Kuder JF
        • Nelson ME
        The StrongWomen-Healthy Hearts program: reducing cardiovascular disease risk factors in rural sedentary, overweight, and obese midlife and older women.
        Am J Public Health. 2009; 99: 1271-1277
        • Moore GF
        • Audrey S
        • Barker M
        • et al.
        Process evaluation of complex interventions: Medical Research Council guidance.
        BMJ. 2015; 350: h1258
      1. Rural Health Information Hub. Rural community health toolkit. Accessed August 28, 2018.

        • Saunders RP
        • Evans MH
        • Joshi P
        Developing a process-evaluation plan for assessing health promotion program implementation: a how-to guide.
        Health Promot Pract. 2005; 6: 134-147
        • Lloyd J
        • Dean S
        • Creanor S
        • et al.
        Intervention fidelity in the definitive cluster randomised controlled trial of the Healthy Lifestyles Programme (HeLP) trial: findings from the process evaluation.
        Int J Behav Nutr Phys Act. 2017; 14: 163
      2. Farquhar SA, Parker EA, Schulz AJ, Israel BA. Application of qualitative methods in program planning for health promotion interventions. Health Promot Pract. 2006;7:234-42.

        • Sriram U
        • Morgan E
        • Graham M
        • Folta S
        • Seguin R
        Support and sabotage: a qualitative study of social influences on health behaviors among rural adults.
        J Rural Health. 2017; 34: 88-97
        • Lo BK
        • Morgan EH
        • Folta SC
        • et al.
        Environmental Influences on physical activity among rural adults in Montana, United States: views from built environment audits, resident focus groups, and key informant interviews.
        Int J Environ Res Public Health. 2017; 14: E1173
        • Seguin RA
        • Economos CD
        • Nelson ME
        • Hyatt R
        • Palombo R
        • Reed PNT
        Design and national dissemination of the StrongWomen community strength training program.
        Prev Chronic Dis. 2008; 5: A25
        • Seguin RA
        • Folta SC
        • Sehlke M
        • et al.
        The StrongWomen Change Clubs: engaging residents to catalyze positive change in food and physical activity environments.
        J Environ Public Health. 2014; 2014162403
      3. Glanz K, Rimer B, Viswanath K. Health Behavior and Health Education: Theory, Research, and Practice. 5th Edition. San Francisco, CA: Jossey-Bass; 2015.

        • Morgan EH
        • Graham ML
        • Folta SC
        • Seguin RA
        A qualitative study of factors related to cardiometabolic risk in rural men.
        BMC Public Health. 2016; 16: 305
        • Seguin RA
        • Paul LC
        • Folta SC
        • et al.
        Strong Hearts, Healthy Communities: a community‐based randomized trial for rural women.
        Obesity (Silver Spring). 2018; 26: 845-853
      4. Health Resources and Services Administration. Medically Underserved Areas and Populations (MUA/Ps). Accessed October 12, 2018.

      5. American Fact Finder. American Community Survey, 2012-2016, 5-Year Estimates. (2016) Table S0101. Accessed November 18, 2018.

      6. Centers for Disease Control and Prevention. Policy Map. CDC Behavioral Risk Factor Surveillance System 2013. Accessed November 18, 2018.

        • Allen MD.
        Telephone focus groups: strengths, challenges, and strategies for success.
        Qual Soc Work. 2013; 13: 571-583
        • Frazier LM
        • Miller VA
        • Horbelt D V
        • Delmore JE
        • Miller BE
        • Paschal AM
        Comparison of focus groups on cancer and employment conducted face to face or by telephone.
        Qual Health Res. 2010; 20: 617-627
        • Tolhurst H
        • Dean S
        Using teleconferencing to enable general practitioner participation in focus groups.
        Prim Heal Care Res Dev. 2004; 5: 1-4
      7. Saldaña J. The Coding Manual for Qualitative Researchers. Thousand Oaks, CA: SAGE Publications, Inc; 2016.

        • Bopp M
        • Wilcox S
        • Hooker SP
        • et al.
        Using the RE-AIM framework toevaluate a physical activity intervention in churches.
        Prev Chronic Dis. 2007; 4: A87
        • Rosecrans AM
        • Gittelsohn J
        • Ho LS
        • Harris SB
        • Naqshbandi M
        • Sharma S
        Process evaluation of a multi-institutional community-based program for diabetes prevention among First Nations.
        Health Educ Res. 2008; 23: 272-286
        • Wang HE
        • Lee M
        • Hart A
        • Summers AC
        • Anderson Steeves E
        • Gittelsohn J
        Process evaluation of Healthy Bodies, Healthy Souls: a church-based health intervention program in Baltimore City.
        Health Educ Res. 2013; 28: 392-404
        • Folta SC
        • Seguin RA
        • Chui KH
        • et al.
        National dissemination of StrongWomen–Healthy Hearts: a community-based program to reduce risk of cardiovascular disease among midlife and older women.
        Am J Public Health. 2015; 105: 2578-2585
        • Ory MG
        • Lee S
        • Han G
        • et al.
        Effectiveness of a lifestyle intervention onsocial support, self-efficacy, and physical activity among older adults: evaluation of Texercise Select.
        Int J Environ Res Public Health. 2018; 15: E234
        • Eyler AA
        Personal, social, and environmental correlates of physical activity in rural Midwestern white women.
        Am J Prev Med. 2003; 25: 86-92
        • Mercer K
        • Giangregorio L
        • Schneider E
        • Chilana P
        • Li M
        • Grindrod K
        Acceptance of commercially available wearable activity trackers among adults aged over 50 and with chronic illness: a mixed-methods evaluation.
        JMIR Mhealth Uhealth. 2016; 4: e7
        • Cadmus-Bertram LA
        • Marcus BH
        • Patterson RE
        • Parker BA
        • Morey BL
        Randomized trial of a Fitbit-based physical activity intervention for women.
        Am J Prev Med. 2015; 49: 414-418
        • Breitenstein SM
        • Gross D
        • Garvey C
        • Hill C
        • Fogg L
        • Resnick B
        Implementation fidelity in community-based interventions.
        Res Nurs Health. 2010; 33: 164-173

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      • National Heart Health Month
        Journal of Nutrition Education and BehaviorVol. 51Issue 2
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          I realize that all of JNEB's readership knows that February is National Heart Healthmonth. Most of us have taught programs on lower saturated fat, lower sodium, or higher fruit and vegetable eating patterns. In 2015, JNEB published a systematic review and meta-analysis on the effects of the Mediterranean Diet on hypertension, reporting that a positive, significant effect was found between the Mediterranean Diet and blood pressure although the effect was small.1 At that time only 6 trials were available.
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