The Role of Context in the Implementation of a Rural, Church-based, CVD Risk-reduction Intervention

Rural US adults experience higher cardiovascular disease (CVD) rates and are less likely to engage in health promoting behaviors than non-rural counterparts. Efficacious health promotion interventions have demonstrated limited effectiveness with rural populations, indicating a need for improved implementation research. This study examined context in the implementation a CVD risk-reduction intervention in 12 rural churches using a mixed-methods, multiphase, case study approach. Heart Smart for Women (HSFW), a weekly, 12-session intervention, was followed by Heart Smart Maintenance (HSM), a 24-month maintenance intervention. In phase one, 41 pre- and post-intervention stakeholder interviews and program documents provided qualitative data to identify contextual characteristics in intervention churches. Qualitative findings informed the development of a conceptual model proposing associations between church contextual characteristics and intervention implementation. In phase two, quantitative analyses examined these associations. Implementation was measured using HSFW participant attendance and completion (n = 133), HSFW attendees’ participation in HSM, and HSM participant attendance (n = 136). Church-specific differences in intervention implementation were examined using single-level, fixed effects modeling. Associations between church contextual characteristics and intervention implementation were assessed using linear and logistic regression generalized estimating equation modeling with church-level clustering. Two categories of church contextual characteristics emerged from the qualitative analysis. “Organizational culture and structure” included religious basis for health promotion, history of health activities, congregational support for the intervention, engagement of the HSM coordinator (the research team’s liaisons with churches), and pastor involvement. “Interpersonal context” included social connectedness within churches and participants’ connections with HSM coordinators. Implementation measures, when examined using quantitative analyses controlling for participants characteristics, indicated church differences in participation and attendance. Congregational support and social connectedness were associated with HSFW attendance (p’s < .001). Congregational support was associated with HSFW completion (p = .034). Congregational support and a religious basis for health promotion were associated with higher odds of HSM participation among HSFW attendees (p = .008 and .026, respectively). No statistically significant associations between church contextual characteristics and HSM session attendance were found. Community-based interventions can help address rural health disparities. To improve implementation effectiveness, it is important to understand how implementation context within and across organizations, such as organizational support for the intervention and social connectedness, contributes to intervention success.