Methods
Setting
New Ulm is about 100 miles southwest of the Minneapolis–St Paul, Minnesota, metropolitan area in an agricultural region of the state. The HONU Project, initiated in 2009, is a 10-year initiative primarily designed to target the approximately 7,900 adults aged 40 to 79 years who reside in the zip code that surrounds New Ulm (56073). The long-term goal of the project is to reduce acute myocardial infarction rates and the short-term goal is to reduce the prevalence of 9 modifiable CVD risk factors. The HONU Project is a collaborative partnership of Allina Health, the Minneapolis Heart Institute Foundation, and the community of New Ulm. New Ulm Medical Center, an Allina-owned hospital and clinic, is the primary health care service provider within the target population and a key organization in implementation of many HONU intervention programs.
The HONU Project is designed to implement evidence-informed health improvement practices, based on the community's level of risk and preferences. To establish an understanding of the community's level of risk, comprehensive heart health screenings, similar to those used in prior population-based prevention programs, were offered free to the community in 2009. These screenings served both as a needs assessment tool and as an intervention to educate residents on their risk factors and to offer health coaching around lifestyle changes and guidance for follow-up for managing medical conditions. Results from screenings identified high obesity rates, high prevalence of metabolic syndrome, low fruit and vegetable consumption, and low use of preventive medical therapies as interventions for priority risk factors.
HONU interventions are aligned with a social–ecological model of health determinants and health promotion addressing CVD risk factors at individual, social, institutional, community, and policy levels. Interventions are generally delivered through health care, work sites, and the general community by using best practices from previous interventions delivered in these contexts (Appendix). Health care interventions include a health-care–based telephone coaching program for people at high risk for CVD, kiosks placed in the community to assess risk factors (ie, blood pressure and weight), and education of health care providers. Work site intervention programs targeted the community's largest employers who were asked to implement wellness policies and health-related programs (eg, behavior change programs of 6 to 8 weeks focused on healthy eating and exercise for employees) and education programs for human resources managers on benefits planning, benefits design, and health promotion. Community-wide interventions include social marketing focused on heart health improvement; health challenges focused on increased physical activity, fruit and vegetable consumption, and weight management; educational programs delivered to the community through various venues (eg, a local cooking television show, educational grocery store tours, an electronic and print newsletter, a website with education and program activity resources); a volunteer neighborhood leader program focused on community organizing around increased local health promotion activities; and environmental re-engineering efforts in the food environment.
Screening Procedures
The heart health screening program was free to all people 18 years or older who presented in person at screening sites (eg, work sites, community centers, churches). As described in more detail elsewhere, the 2009 screenings were promoted to residents through letters, advertisements, work sites, and by health care providers at New Ulm Medical Center. Screenings ran from mid-April to mid-December 2009. The screening process was repeated in 2011 using similar methods. The Allina Institutional Review Board approved all procedures for the screenings and approved use of screening data for this study.
Screening participants were asked to fast 12 hours before their appointment. Screening lasted 20 to 30 minutes and included registration and consent, health history and behavioral risk factor survey, anthropometric measures (ie, height, weight, waist circumference, and blood pressure), and venipuncture. Participants were given a personal risk factor report and met with a health coach (ie, registered dietitian or health educator) to review risk factors, discuss health improvement goals, and get guidance on community resources or other health education opportunities and referrals for any immediate medical follow-up.
Design and Measures
This analysis used a longitudinal panel design. Data on people who were screened for CVD risk factors in both 2009 and 2011 were included in the analysis. The primary outcome was BP in 2011, which was categorized as controlled (<140/90 mm Hg) or uncontrolled (≥140/90 mm Hg) based on the Fifth Report of the Joint National Committee (JNC) on Detection, Evaluation, and Treatment of High Blood Pressure and in alignment with criteria used in other population studies. Although the Seventh JNC Report recommends a lower goal (130/80 mm Hg) for high-risk people such as patients with diabetes, a study among people with diabetes found no difference in outcomes based on the lower BP goal compared with a goal of less than 140/90 mm Hg.
Trained staff followed an adaptation of the Canadian Hypertension Society guidelines. They measured each participant's BP using a SunTech 247 device (SunTech Medical, Morrisville, North Carolina) after sitting for 3 minutes. Three BP values were measured, taken 1 minute apart, using an automatic sphygmomanometer. The mean of the last 2 BP measures was used for analytical purposes.
The main predictor was participation in a HONU intervention program between 2009 and 2011. Similar to methods used in previous large community CVD prevention projects, program participation was assessed by self-report during the 2011 screening with a single item where participants indicated which of 12 programs they participated in over the previous 2 years. Program participation was operationalized using 2 independent methods. First, participation was grouped into 5 categories based on program focus and delivery. These were 1) education — read at least 1 HONU newsletter (print or e-mail) or visited the HONU website; 2) physical activity — participated in the community health challenge or neighborhood walking program; 3) healthy eating — participated in at least 1 neighborhood potluck, supermarket tour, or cooking class, or watched at least 1 episode of the HONU healthy cooking television show; 4) clinical — participated in the telephone coaching program or visited a heart health station at 1 of 4 local sites; and 5) work site — participated in at least 1 work site wellness program. Second, to estimate total program exposure, the number of programs participated in by each participant was summed. Several baseline covariates were also included in analytical models based on their previously known or clinically suspected association with BP and program participation. These included age, sex, education level, smoking status, body mass index (BMI), personal history of diabetes or heart disease, and antihypertensive medication use at baseline.
Analysis
All analytical procedures were conducted using SAS (PC SAS 9.2, SAS Institute Inc, Cary, North Carolina). Means and standard deviations for continuous variables and percentages for categorical variables were described. Paired t tests and Bowker's test of symmetry were used to assess changes in BP and medication use between 2009 and 2011. Multivariable logistic regression (PROC LOGISTIC) was used to examine the association between BP and program participation (modeled separately by program type as well as number of programs participated in). To gauge BP improvement versus maintenance of controlled BP, the analytical sample was stratified by those with controlled and uncontrolled baseline BP. Identical procedures were used for both analyses. First, a basic model was created to examine the crude relationship between program participation and BP. Then a full model was created with all covariate terms entered simultaneously. Screening participants who did not participate in any program was the comparison group for the analysis.