Strong Hearts, Healthy Communities (SHHC)

*Now known as StrongPeople Strong Hearts

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Strong Hearts, Healthy Communities (SHHC) was a community-based intervention trial aimed at cardiovascular disease risk reduction among overweight and obese sedentary women living in rural areas (Funder: NIH/NHLBI; term: 4 years).

​Strong Hearts, Healthy Communities aimed to reduce CVD morbidity and mortality, improve quality of life, and reduce CVD-related health care burden in underserved rural communities through implementation of an innovative community-informed intervention.

The SHHC intervention was designed to target and support behavior change at the individual, social, and community levels. It was a novel fusion of evidence-based programming including progressive strength training, aerobic exercise, and nutrition education components combined with a civic engagement and capacity building initiative tested in 16 rural communities in Montana and New York. The aim was to move beyond individual-level approaches—which have limitations in terms of cost, impact, reach, and sustainability—to effectively reduce rural CVD health disparities using an integrated, multi-level, community-engaged approach.

Strong Hearts, Healthy Communities spanned individual, social, and community levels and included two stages.

Stage 1: Formative Research 
The formative research involved working with local extension educators to conduct community audits, focus groups, and key informant interviews with residents, practitioners,  health educators, and local leadership to gather in-depth data on topics related to CVD awareness and risk factors. These topics included: economic, healthcare, and social/cultural factors, as well as, barriers and facilitators to healthy eating and active living. The community audit and qualitative data gathered during the formative research, as well as feedback from extension educators informed and was incorporated in the development and refinement of the SHHC curriculum.
 
Stage 2: Randomized Control Trial
In the second phase of the project, we evaluated the efficacy of the SHHC curriculum. Sixteen rural communities in Montana and New York were randomly assigned to receive either the full Strong Hearts, Healthy Communities intervention with classes meeting twice per week for 24 weeks or the minimum/ control (Strong Hearts, Healthy Women) intervention with classes meeting once per month for six months.
 
We compared changes in CVD-related anthropometric, physiologic, behavioral, and psychosocial parameters between participants in the 8 full intervention and 8 minimal intervention communities. Measurements of these parameters were taken before and after the intervention and repeated at 6-months, 12-months, and 18-months post intervention. In addition, we evaluated changes in behavior, attitudes, and knowledge among SHHC intervention subjects’ “social network.”

After the conclusion of the first Strong Hearts, Healthy Communities randomized trial, we performed a qualitative evaluation. Using participant outcomes and feedback from participants and leaders, we revised the curriculum and conducted a second randomized trial, which we called SHHC-2.0. SHHC-2.0 was conducted in 11 rural towns in New York, and participants improved many health outcomes to a greater degree than participants in the first randomized trial.

Funding: National Institutes of Health

Looking for the StrongWomen/StrongPeople Program? Click here.

Publications

Szeszulski J, Rolke LJ, Ayine P, Bailey RL, Demment M, Eldridge GD, Folta SC, Graham ML, MacMillan Uribe AL, McNeely A, Nelson ME, Pullyblank K, Rethorst CD, Strogatz D, Seguin-Fowler RA. Process evaluation findings from Strong Hearts, Healthy Communities 2.0: a cardiovascular disease prevention intervention for rural women. Int J Behav Nutr Phys Act. 2024;21:122. DOI: 10.1186/s12966-024-01670-y (Link)

Githinji P, MacMillian Uribe AL, Seguin-Fowler RA, Ayine P, On A, Villarreal DL, McNeely A, Szeszulski J, Rethorst CD. A qualitative exploration of the health needs and goals of urban women to inform the tailoring and adaptation of Strong Hearts Healthy Communities: a community-based cardiovascular disease prevention intervention. BMC Public Health. 2024 Jan 25; 24;269. DOI: 10.1186/s12889-024-17818-1. PMC10811835 (Link)

MacMillan Uribe AL, Demment M, Graham ML, Szeszulski J, Rethorst C, Githinji P, Nelson ME, Strogatz D, Folta SC, Bailey RL, Davis JL, Seguin-Fowler RA. Improvements in dietary intake, behaviors, and psychosocial measures in a community-randomized cardiovascular disease risk reduction intervention: Strong Hearts, Healthy Communities 2.0. Am J Clin Nutr. 2023 Sept 15. DOI: 10.1016/j.ajcnut.2023.09.003. PMC10636233 (Link)

Sriram U, Graham ML, Folta S, Paul L, Seguin-Fowler RA. Integrating civic engagement into a lifestyle intervention for rural women – a mixed methods evaluation. Am J Health Prom. 2023 Apr 14;37(6):807-820. DOI: 10.1177/08901171231168500. PMC10521917 (Link)

Maddock JE, Demment M, Graham M, Folta S, Strogatz D, Nelson M, Ha S-Y, Eldridge G, Seguin-Fowler RA. Changes in physical activity outcomes in the Strong Hearts, Healthy Communities (SHHC-2.0) community-based randomized trial. Int J Behav Nutr Phys Act. 2022;19:159. DOI: 0.1186/s12966-022-01401-1. PMC9795747 (Link)

Seguin-Fowler RA, Eldridge GD, Rethorst C, Graham ML, Demment M, Strogatz D, Folta SC, Maddock JE, Nelson ME, Ha S. Improvements and maintenance of clinical and functional measures among rural women: Strong Hearts, Healthy Communities-2.0 cluster randomized trial. Circ Cardiovasc Qual Outcomes. 2022;15:e009333. DOI: 10.1161/CIRCOUTCOMES.122.009333. PMC9665948 (Link)

Lo B, Graham M, Folta S, Strogatz D, Parry SA, Seguin-Fowler RA. Physical activity and healthy eating behavior changes among rural women: an exploratory mediation analysis of a randomized multilevel intervention trial. Transl Behav Med. 2021 Jan 23. DOI: 10.1093/tbm/ibaa138. PMC8541698 (Link)

Lo BK, Graham ML, Eldridge G, Donoso MR, Folta SC, Strogatz D, Nelson ME, Paul LC, Parry SA, Seguin-Fowler RA. Ripple effects of a community-based randomized trial for rural women: Strong Hearts, Healthy Communities. Obesity. 2020 Jul;28(7):1224-34. DOI: 10.1002/oby.22817. PMC7311263 (Link)

Seguin-Fowler RA, Strogatz D, Graham M, Eldridge GD, Marshall GA, Folta SC, Pullyblank K, Nelson ME, Paul, L. The Strong Hearts Healthy Communities Program 2.0: a randomized controlled trial examining effects on Simple 7. Am J Prev Med. 2020 May 7. DOI: 10.1016/j.ampre.2020.01.027. PMC7311302 (Link)

Pullyblank K, Strogatz D, Folta SC, Paul L, Nelson ME, Graham ML, Marshall GA, Eldridge G, Parry SA, Mebust S, Seguin RA. Effects of the Strong Hearts, Healthy Communities intervention on functional fitness of rural women. J Rural Health. 2019;104–110. DOI: 10.1111/jrh.12361. PMC6744363 (Link)

Folta SC, Paul L, Nelson ME, Strogatz D, Graham M, Eldridge GD, Higgins M, Wing D, Seguin-Fowler RA. Changes in diet and physical activity resulting from the Strong Hearts, Healthy Communities randomized cardiovascular disease risk reduction multilevel intervention trial. Int J Behav Nutr Phys Act. 2019;16:91-102. DOI: 10.1186/s12966-019-0852-z. PMC6815048 (Link)

Seguin RA, Graham ML, Eldridge G, Nelson ME, Strogatz D, Folta SC, Paul L. Strong Hearts for New York: a multilevel community-based randomized cardiovascular disease risk reduction intervention for rural women. Contemp Clin Trials. 2019;82:17-24. DOI: 10.1016/j.cct.2019.05.005. PMC6606389 (Link)

Wang H, Kenkel D, Graham ML, Paul LC, Folta SC, Nelson ME, Strogatz D, Seguin RA. Cost-effectiveness of a community-based cardiovascular disease prevention intervention in medically underserved rural areas. BMC Health Serv Res. 2019;19:315. DOI: 10.1186/s12913-019-4117-y. PMC6524317 (Link)

Sriram U, Sandreuter KJ, Graham ML, Folta S, Pullyblank K, Paul L, Seguin RA. Process evaluation of Strong Hearts, Healthy Communities: a rural community-based cardiovascular disease prevention. J Nutr Educ Behav. 2019;51(2):138-149. DOI: 10.1016/j.jneb.2018.10.011. PMC6422156 (Link)

Lo BK, Graham ML, Folta SC, Paul L, Strogatz D, Nelson ME, Parry SA, Carfagno ME, Wing D, Higgins M, Seguin RA. Examining the associations between Walk Score, perceived built environment, and physical activity behaviors among women participating in a community-randomized lifestyle change intervention trial: Strong Hearts, Healthy Communities. Int J Environ Res Public Health. 2019;16:849. DOI: 10.3390/ijerph16050849. PMC6427661 (Link)

Seguin RA, Paul L, Folta SC, Nelson ME, Strogatz D, Graham ML, Diffenderfer A, Eldridge G, Parry SA. Strong Hearts, Healthy Communities: a community based randomized trial for rural women. Obesity. 2018;26(5):845-853. DOI: 10.1002/oby.22158. PMC5915907 (Link)

Lo BK, Morgan EH, Folta SC, Graham ML, Paul LC, Nelson ME, Jew NV, Moffat LF, Seguin RA. 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;14:1173. DOI: 10.3390/ijerph14101173. PMC5664674 (Link)

Sriram U, Morgan EH, Graham ML, Folta SC, Seguin RA. Support and sabotage: a qualitative study of social influences on health behaviors among rural adults. J Rural Health. 2017;12232. DOI: 10.1111/jrh.12232. PMC6656359 (Link)

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. DOI: 10.1186/s12889-016-2977-1. PMC4827235 (Link)

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. DOI: 10.1186/s12889-016-2751-4. PMC4730587 (Link)