A Community Health Advisor Program to reduce
cardiovascular risk among rural African-American
C. E. Cornell1*, M. A. Littleton2, P. G. Greene1, L. Pulley1, J. N. Brownstein3,
B. K. Sanderson4, V. G. Stalker5, D. Matson-Koffman3, B. Struempler6and
J. M. Raczynski1
The Uniontown, Alabama Community Health
Project trained and facilitated Community
Health Advisors (CHAs) in conducting a the-
ory-based intervention designed to reduce the
risk for cardiovascular disease (CVD) among
rural African-American women. The multi-
phased project included formative evaluation
and community organization, CHA recruitment
and training, community intervention and
maintenance. Formative data collected to de-
velop the training, intervention and evaluation
methods and materials indicated the need for
programs to increase knowledge, skills and
resources for changing behaviors that increase
the risk of CVD. CHAs worked in partnership
with staff to develop, implement, evaluate and
maintain strategies to reduce risk for CVD in
women and to influence city officials, business
owners and community coalitions to facilitate
project activities. Process data documented sus-
tained increases in social capital and commu-
nity capacity to address health-related issues, as
well as improvements in the community’s phys-
ical infrastructure. This project is unique in
that it documents that a comprehensive CHA-
based intervention for CVD can facilitate wide-
reaching changes in capacity to address health
issues in a rural community that include
improvements in community infrastructure
and are sustained beyond the scope of the orig-
inally funded intervention.
African-American women are at greater risk for
cardiovascular disease (CVD) than White women
of comparable socioeconomic status, and they ex-
ceed White women in age-adjusted death rates [1–
4]. Contributing factors to this disproportionate risk
include differences in health-care access [5–7],
knowledge of symptoms and risk factors [8, 9]
and the presence of various risk factors, including
lifestyle behaviors [1, 8–10]. Southern rural Afri-
can-American women have among the highest rates
of CVD mortality, especially for stroke , and
thus health promotion programs are needed to ad-
dress the CVD burden of this group.
Use of community-based approaches has long
been advocated to address the complex of social
disparities that exist in marginalized communities
. Interventions conducted by trained lay people
(known as Community Health Advisors (CHAs),
1Department of Health Behavior and Health Education, Fay
W. Boozman College of Public Health, University of
Arkansas for Medical Sciences, Little Rock, AR 72205, USA,
2Department of Public Health, College of Public Health,
East Tennessee State University, Johnson City, TN 37614,
USA,3Division for Heart Disease and Stroke Prevention,
National Center for Chronic Disease Prevention and Health
Promotion, Centers for Disease Control and Prevention,
Atlanta, GA 30341-3717, USA,4Division of Cardiovascular
Medicine, Department of Medicine,5Department of Health
Behavior, School of Public Health, University of Alabama at
Birmingham, Birmingham, AL 35205, USA and
6Department of Nutrition and Food Science, Auburn
University, Auburn, AL 36849, USA
*Correspondence to: C. E. Cornell. E-mail:
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HEALTH EDUCATION RESEARCHVol.24 no.4 2009
Advance Access publication 1 December 2008
Community Health Workers, promotores de salud
and other names ) working within the context of
obtained ‘best practice’ status for reducing health
disparities, including disparities in CVD risk,
among people living in underserved communities
[6, 13]. Among other successes , CHA pro-
grams have successfully addressed health concerns
[15–20] and chronic diseases, including CVD [21,
22], hypertension [13, 23], diabetes  and cancer
[25–28]. CHAs can facilitate the adoption of health
promotion programs by acting as change agents and
opinion leaders with shared language, culture and
values and extensive knowledge of local resources
and health issues [29–33]. One approach, the Com-
munity Health Advisor Network (CHAN) model
ity’s natural helpers (those to whom community
members already turn for support and advice) to
enhance knowledge and skills required to address
their community’s needs.
The Uniontown Community Health Project
implemented a theory-based CHA intervention to
reduce CVD risk among African-American women
living in a rural, southern community. In accor-
dance with the CHAN philosophy, the community
was actively engaged in all aspects of the project.
This paper describes the formative and process
evaluations related to community organization,
CHA training, the intervention and the maintenance
of project activities, and it illustrates how a CHA-
based intervention can increase a community’s po-
tential for addressing health issues and mobilizing
environmental changes. Given the dearth of CVD
risk reduction programs in geographically isolated,
this approach may be useful to others undertaking
such programs in similar areas. Primary outcome
measures will be presented elsewhere.
The CHA approach is grounded in Community
Empowerment  and Diffusion of Innovations
theories . Community Empowerment is ‘a so-
cial-action process in which individuals and groups
act to gain control and mastery over their lives in
the context of changing their social and political
environments’ (p. 142) . Diffusion of Innova-
tions describes the process by which innovative
ideas or practices (e.g. health promotion programs)
are disseminated and adopted within a social sys-
tem. The extent to which an innovation is adopted
can be influenced by opinion leaders and change
agents . The CVD risk reduction intervention
was guided by Social Cognitive Theory [37, 38],
which asserts that behaviors are determined by
interactions among personal, behavioral and envi-
ronmental factors. The major behavioral risk factors
for CVD (use of tobacco, unhealthy dietary habits
and physical inactivity) are influenced by cultural
norms and occur within a social context. Thus, pro-
grams that affect risk factor behaviors and environ-
mental supports for heart-healthy behaviors should
effect sustainable change in health risk behaviors.
Community and project overview
Alabama and had a population in 2000 of 1636
(88.2% African-American). Per capita annual in-
the poverty level . In addition to the standard
CHAN curriculum , which focuses on commu-
nity-identified issues, resource identification and
problem solving, CHAs in the Uniontown Project
received health education focused on CVD and
skills training in reducing CVD risk. The interven-
tion included health promotion activities to increase
women’s awareness of their CVD risk, knowledge
of risk factors and strategies to prevent CVD; clas-
ses in heart-healthy nutrition, physical activity and
tobacco cessation and environmental changes. Al-
though evaluation focused primarily on women, all
community residents were invited to participate in
the formative and intervention activities to facilitate
community adoption of the program and to provide
an opportunity for women to include their families.
Competing family responsibilities pose a barrier to
engaging in physical activity interventions for
women, and strategies to address this barrier have
Community Health Advisor Program for CVD risk
been advocated [40, 41]. This project was approved
by the University of Alabama at Birmingham
Institutional Review Board.
The four phases of the project
Phase I: formative evaluation, community or-
ganization, recruitment of CHAs (October
1995 to October 1996)
Table I describes the Phase I strategies used to
gather formative data and to engage community
leaders and residents. These included a town meet-
ing, community inventories, focus groups, key in-
formant interviews and CHA identification and
During the town meeting, attendees completed
a self-administered Community Priorities Survey
 which used closed and open-ended question
formats to identify and prioritize issues residents
considered important for their community, their
families and themselves. Following the town meet-
ing, community leaders distributed the survey
throughout the community.
Focus group moderators’ guides included ques-
tions on one of five topics: (i) knowledge and atti-
tudes about CVD risk and risk reduction strategies,
use and (v) project implementation in the commu-
gender and two gender-specific groups for each of
businesses and other organizations. Groups were
audiotaped, tapes were transcribed and transcripts
nator and investigators who used the constant com-
parative thematic analysis method to identify
common and recurring themes .
Potential CHAs were identified using a ‘snowball
and asking them to identify other natural helpers who
Phase II: CHA training (November 1996 to
Phase II included general training of residents inter-
ested in becoming CHAs to address community and
CVD-related issues and specialized training to lead
activities designed to reduce CVD risk . General
training(November 1996 to April1997) consisted of
10 2-hour group sessions, five focused on commu-
nity issues and five on CVD and its risk factors .
Twenty-five individuals (21 women, 4 men, all Af-
rican-American) completed general training.
Specialized trainings (June to September 1997)
focused on (i) heart-healthy food preparation, (ii)
strategies to foster physical activity and smoking
cessation and (iii) cardiopulmonary resuscitation.
Six 3-hour group training sessions were conducted
for each of these three areas (total = 18 hours of
training per area). CHAs who wanted to receive spe-
cialized training could elect to receive training in
one, two or all three of these content areas. Sessions
included didactic instruction and skill practice with
feedback. At the end of specialized training, CHA
action teams and project staff reviewed potential in-
tervention activities and developed or adapted activ-
ities to specifically target the needs and resources of
Uniontown residents. Fourteen persons (12 women,
2 men) completed specialized training in physical
activity, 17 (all women) completed nutrition training
and 7 (6 women, 1 man) completed tobacco cessa-
tion training. Two individuals who completed phys-
ical activity training became certified aerobics
instructors. CHAs were given small incentives for
training such as tee shirts and tote bags.
The site facilitator administered a questionnaire
describing previous experiences as natural helpers
to a subset of CHAs who completed general train-
ing. Some CHAs also completed pre- and post-
training questionnaires developed by the project
team to assess the effects of training on self-effi-
cacy, knowledge and self-reported behaviors re-
lated to giving advice and assistance to friends
and neighbors and taking leadership roles in
addressing community-identified and CVD-rele-
vant issues. Paired t-tests were used to compare
pre- and post-training responses.
Phase III: intervention (October 1997 to Oc-
Phase III consisted of a 12-month intervention in
C. E. Cornell et al.
Table I. Formative research activities conducted and needs and resources identified as a result of Phase I formative evaluation
Method usedConducted by PurposeNeeds and resources identified
Community priorities survey
(n = 313; 75% women)
Site facilitator and
To identify and prioritize
residents’ issues considered
important to their community,
families and themselves.
High-priority community issues
related to economic opportunities,
safety and health.
High-priority family and personal
issues related to CVD and its
Sole local grocery store stocked
foods than high-fat/cholesterol
items (e.g. shelves containing
lard covered 32 square feet).
Prices were higher for some
available lower fat foods than
for higher-fat foods (e.g.
non-fat versus whole milk).
Local eateries offered no
low-fat menu options.
There were no resources for
learning heart-healthy food
Few neighborhoods had
sidewalks; many existing
sidewalks were in disrepair.
There were no opportunities for
adult women to be physically
active (e.g. no exercise classes,
public pools or indoor
locations for walking).
The sole outdoor track was
No resources were available
for tobacco cessation.
Few knew how to prepare
heart-healthy foods that families
Many were confused about which
foods contained cholesterol and
Some said they could not exercise
because they had high blood
Knowledge about some risk
factors (e.g. need to consume
less cholesterol) was relatively
high, while knowledge of other
risk factors was low (e.g. diabetes,
Overall, women did not perceive
themselves at high risk for CVD.
Community inventoriesProject staff, site facilitator
To assess availability and costs
of heart-healthy/unhealthy foods,
opportunities for women to walk
and engage in other physical
activities and resources for
Focus groups (total n = 144;
mean = 9.6 per group;
To inform intervention and
development and to assist
in identifying project
Community Health Advisor Program for CVD risk
community-wide educational events and classes in
nutrition, physical activity and smoking cessation.
Following Social Cognitive Theory and formative
data obtained in Phase I, the intervention was
designed to (i) increase community awareness of
the program, (ii) increase knowledge about CVD
symptoms, risk factors, risk reduction strategies and
promote adherence to screening and recommended
medical regimens for CVD risk factors, (iv) increase
readiness tochange and (v) provide classes and other
CHAs were unpaid volunteers, and as such made
their own decisions about what activities to under-
take and what roles to play in those activities. CHAs
who wished to lead intervention activities were
given everything needed for those activities (e.g.
full sets of cookware and kitchen tools, athletic
wear, etc.). Additional intervention costs (e.g.
boom boxes, CDs, exercise equipment, food costs)
were also covered by the project. CHA leaders
initially co-conducted activities with project staff,
then assumed full responsibility for facilitating
intervention events and classes. Process evaluation
included tracking of participation at events, use of
risk reduction resources and additional activities
conducted by individual CHAs.
Phase IV: maintenance (October 1998 to Oc-
Following the 12-month intervention, the project
decided which activities to continue and then modi-
fied those activities as desired. Project staff served as
consultants and collected process data in collabora-
tion with the CHAs. Process measures tracked main-
tenance of activities and changes in community
capacity for addressing health and related issues.
As detailed in Table I, Phase I activities identified
high-priority issues as well as needs and resources
for training and intervention.
Table I. Continued
Method used Conducted byPurposeNeeds and resources identified
Key informant interviews with
Project staffTo obtain assistance in navigating
the community’s political,
business and social structures
and in finding potential
steering committee members,
CHAs and physical resources
for project activities.
Full-time, paid site facilitator
identified and hired to
Three AmeriCorps Volunteers
in Service to America recruited
to assist facilitator.
Uniontown CHC was formed
to serve as a steering committee.
City leaders identified space for
project office, training sessions
and physical activity and
Community leaders provided
ongoing assistance by
broadcasting project events and
classes on local cable television
station, providing space for town
meetings and health fairs,
partnering with CHAs to make
environmental changes and
keeping the city council
informed about the project.
C. E. Cornell et al.
Community inventories revealed multiple needs
for community resources to support changes in risk
behaviors. This lack of local resources posed a sig-
nificant barrier because Uniontown is ;20 miles
from any larger town over isolated roads and many
residents lack reliable transportation. Focus group
data indicated that many residents knew generally
what to do (e.g. consume less cholesterol, salt and
fat), but not how to lower their CVD risk; confirm-
ing that training and intervention activities needed
to include a focus on increasing risk reduction
knowledge and awareness.
Key informant interviews identified personnel
and space required for the project and garnered
support from influential community leaders. The
mayor agreed to serve as principal investigator for
the project’s subcontract, members of the city coun-
cil completed CHA training and city leaders agreed
to serve on and recruit others for the Uniontown
Community Health Council (CHC), a coalition of
community leaders that was formed to serve as
a project steering committee. Key informants also
continued to provide personal assistance through-
out the project. For example, city leaders volun-
teered time and personal resources to supplement
grant funding for renovations needed to accommo-
date intervention activities.
The Phase I CHA identification process recruited
33 persons to the initial CHA meeting in which
ground rules for the training process were jointly
developed by attendees and staff and topics for the
general training sessions were finalized based on
issues identified in the Community Priorities Sur-
vey. Resulting topics addressed crime, unemploy-
ment, neighborhood cleanup, sexually transmitted
diseases, drug and alcohol abuse, heart disease and
stroke, stress and high blood pressure, tobacco use,
nutrition and physical activity .
The 19 CHAs who completed the CHA profile
reported a variety of previous experiences as natural
helpers (Table II), including 19 community and 15
church leadership positions. CHAs thought that peo-
ple turned to them for help because they were trusted
and good listeners and because they gave good ad-
vice. Demographic data from the profile showed that
these CHAs had lived in Uniontown for an average
of 25 years (range = 5–51) and had a mean house-
holdsize of3.6 people(range = 2–9). Table III sum-
marizes other profile demographics in comparison
with the overall Uniontown community.
CHAs completing both pre- and post-training
questionnaires (n = 10) demonstrated increases in
Table II. Profiled CHAs’ previous roles as natural helpers (n = 19)
Who comes to
you for advice?
Where do you
With what are
you asked for help?
How do you give help?
Reducing teen pregnancy
Reducing high school
Blood pressure screening
Youth enrichment program
Red Cross volunteer
Over the phone
In my home
At someone else’s home
Using health services
Using welfare services
Give direct help
Refer to services
Community Health Advisor Program for CVD risk
knowledge about reducing CVD risk (t = ?2.43, P
< 0.05), and in self-efficacy (t = ?5.00, P < 0.001)
and behaviors (t = ?3.19, P < 0.01) related to giv-
ing advice and assistance about risk reduction strat-
egies to others. Pretraining self-efficacy, beliefs and
behaviors related to general community issues were
already high and pre- to post-training changes were
not significant for those measures (P > 0.05).
Community-wide health promotion events and
As a group, CHAs facilitated and monitored use of
the outdoor track (total n = 35 regular walkers;
mean = 15 per day) and hosted two community
health fairs (total n = 261); two fun walks (total
n = 61); a low-fat food fair (n = 114); two
smoke-free days (total n = 20 pledges to quit); on-
going blood pressure checks in the project office
(total n = 80; mean = 3 per day) and a clinic pro-
gram to obtain free nicotine patches for smokers
trying to quit. In addition, CHAs independently ini-
tiated low-fat church dinners, neighborhood walk-
ing groups, nutrition and exercise activities for
senior citizens, anti-smoking skits in local schools
and informal information sharing.
CHAs and project staff worked with city officials to
repair lights and clean up the outdoor track for
walking; install new appliances for nutrition activ-
ities; renovate the facility for physical activity clas-
ses and establish a health and wellness section in
the city’s library. CHAs also persuaded the local
‘dollar store’ to stock items required for heart-
healthy cooking, including non-stick cooking
sprays and skillets, kitchen shears and spices. To
address the community goal of making the down-
town area more attractive, CHAs organized neigh-
borhood beautification projects to clean up trash
and plant trees and flowers, which also provided
lifestyle exercise to participating residents. As the
project progressed, CHAs compiled a resource di-
rectory that listed local venues and partners for pro-
ject activities and provided contact information for
subsequent community projects.
Risk reduction classes
During the intervention phase, CHAs with physical
activity training led a total of 108 aerobics classes
(two to three classes per week), which were
attended by a total of 107 persons (97% women),
74.7% of whom attended four or more classes per
month. Mean intervention year attendance was
17.75 persons per class.
CHAs with nutrition training hosted monthly
‘cooking clubs’ in their homes or other convenient
locations. Club members altered favorite recipes to
Table III. Demographic characteristics of CHAs who
completed a profileabcompared with the Uniontown
CHA, % Uniontown, %
Sex (n = 19)
Age 40+ years (n = 18)
Age 35+ years
Highest grade completed
(n = 19)
Marital status (n = 16)
$ (n = 17)
10 000–19 999
20 000–29 999
30 000–39 999
aNot all CHAs completed every question of the profile.
operator, writer/photographer, teacher, outreach worker, bus
driver, recreation director, AmeriCorp Volunteers in Service to
America volunteer, telecommunications operator, nursing home
worker, student, homemaker, cashier and nun.
cU.S. Bureau of the Census. Census 2000.
dNot available in this form in census database.
C. E. Cornell et al.
taste good while containing less fat and salt. The
cooking clubs were attended by a total of 76 com-
munity residents (75% women), most of whom
were regular attendees (mean attendance = 10.14
persons per club).
CHAs used the successful cooking club recipes
for monthly community dinners held in the town’s
recreation center. While residents dined, CHAs dis-
tributed recipes and demonstrated techniques used
in recipe preparation. Attendees completed taste
ratings for each dish and indicated whether they
would serve that dish to their families. The highest
rated recipes were compiled in a cookbook which
CHAs distributed throughout their county and be-
yond. During the intervention phase, a total of 137
residents (66% women) attended the community
dinners, with most attending multiple dinners
(mean = 64.5 residents per dinner).
CHAs trained in smoking cessation held two multi-
session stop-smoking classes, which were attended
by a total of six people. The low attendance moti-
vated CHAs and staff to redirect their efforts toward
increasing community awareness about the health
risks of smoking and exposure to secondhand
smoke and providing one-on-one information and
advice about cessation.
During the maintenance phase, CHAs continued to
host CVD risk reduction activities, formed new
coalitions and partnered to obtain funding for addi-
tional research and service projects. CHAs indepen-
dently retained all activities begun during the
intervention phase except the cooking clubs and
even trained a new aerobics leader themselves. At-
tendance at the community dinners decreased from
that observed during the intervention phase (mean
maintenance attendance = 41.63 persons per din-
ner), but aerobics class attendance increased
(mean = 26.75 persons per class) due in part to
completion of the physical activity room renova-
tions, which included the installation of air condi-
tioning. Community groups also began using the
renovated areas for new events, including after-
school karate and African dance classes for youth.
CHAs, CHC members and project staff partnered
to seek funding for sustaining and expanding the
CVD risk reduction activities. CHAs obtained
small donations from local businesses and accepted
contributions from participants who wanted to give
something. In addition, substantial funding was
obtained by the Alabama Department of Public
Health and the Alabama Cooperative Extension
Service that subsidized the ongoing events and clas-
ses and funded new activities built on the infrastruc-
ture (trained CHAs, an experienced coordinator and
active community coalitions) created by the present
project (Table IV).
The community’s enthusiasm and interest in
addressing other health issues has attracted funding
for seven new research and service programs that
have provided additional support for CHAs and for
the project office and other facilities. Three of these
programs included investigators from the present
project; investigators for the other programs were
new to the community. CHAs and CHC members
also formed new coalitions who worked with ex-
isting and new partners to address community-
identified needs. Among other successes, coalition
and attracted a new industry, which created more
than 70 jobs. Ms Stalker continues to work with
the Uniontown CHAs on a large dental health pro-
ject, which is headquartered in the original Union-
town Project office and focuses on children and
adults throughout the community. The renovated fa-
cilities are still being used by the city, but CVD risk
The Uniontown Project is unique in that it inte-
grated training in CVD risk reduction with the tra-
ditional CHA focus on general community issues,
and it combined the grassroots CHA model with the
CHC, a coalition of local leaders. Although previ-
ous studies have used lay helper models to address
other health issues in rural women [30, 31] and to
address single and multiple CVD risk factors in
Community Health Advisor Program for CVD risk
urban African-American populations [13, 21–24,
45], no other published studies have reported on
a program targeting multiple CVD risk factors in
rural African-American women, and none has
documented wide-reaching changes in community
capacity to address health issues beyond the scope
of the original project. This is also the first docu-
mentation that CHAs working in the context of
a chronic disease intervention project can lead
efforts to improve a community’s physical infra-
structure. Examples in Uniontown include reno-
vated facilitiesfor physical
beautification and farmers markets.
Taken together, the project partners’ ability to
obtain resources to sustain and expand efforts to
reduce CVD risk; attract new research and service
projects to address additional health issues and de-
velop new coalitions, partnerships and funding for
community-identified needs provides substantial
evidence for increased community capacity to ad-
dress health-related issues [46, 47]. At the outset of
the project, Uniontown possessed assets on many
dimensions of community capacity , including
leadership and access to power, rich community
support networks, a strong sense of community
and an understanding of community history. The
Uniontown Project facilitated increases in addi-
tional dimensions of capacity including expanding
citizen participation, enhancing residents’ skills,
expanding community resources and promoting
new partnerships within the community as well as
with new external partners.
This project may be viewed as a successful com-
munity empowerment program that encourages res-
idents to educate themselves, define their own
problems, set their own priorities, develop their
own programs and, as necessary, engage the power
structure to remove barriers or provide assistance
[49–53]. In Phase 1, project staff supported com-
munity empowerment [54, 55] by addressing com-
munity priorities; working to gain trust and build
relationships; engaging residents in formative work
and identifying, training and mentoring grassroots
community change agents. Phase I activities also
initiated the community mobilization process, as
many residents who took part in the formative
Table IV. New projects that maintained and expanded activities to reduce the risk of CVD
Project name Funding partner/sponsorProject description
Core capacity CVD project (funded in
Alabama Department of Public
Implemented environmental and policy
interventions to reduce CVD risk, including
initiation of a Uniontown farmer’s market.
CHAs helped to organize and advertise the
market and assisted in collecting data to track
the market’s success. Provided signs and
other marketing materials for many existing
activities for reducing CVD risk, including
Hired one of the nutrition-trained CHAs to
conduct nutrition education throughout the
county. Funded a variety of activities in
nutrition education, including those in
Provided diabetes education through
community churches. Topics included
general diabetes management and
related information, such as diabetes
as a risk factor for CVD, the role of
obesity and the importance of healthy
habits in nutrition and physical activity.
Nutrition education program (funded in
Alabama Cooperative Extension
Service/US Department of
Church-based African-American diabetes
program (funded in approximately 2000)
University of Alabama at
Birmingham and Alabama
Department of Public Health/CDC
C. E. Cornell et al.
evaluation continued to be involved in risk reduc-
tion efforts as leaders or participants. In Phases II
and III, the community mobilized to work toward
common goals as demonstrated by participation in
CHA training, risk reduction classes and commu-
nity-wide events. During Phases III and IV, CHAs
took leadership roles in planning and implementing
the intervention and maintaining risk reduction ac-
tivities, growing new coalitions and service pro-
grams and attracting new research.
Residents used infrastructure developed by the
CVD project to address additional priorities, an in-
frastructure that consisted of new social capital in
the form of coalitions and informal working groups
as well as added physical resources. The continuing
employment and volunteer work of the CHAs and
other residents made possible through new research
and service programs, and the ongoing use of the
project’s physical facilities provide evidence that
this infrastructure continues to be a health resource
for the community.
This study included only one intervention commu-
nity with strong advocates in city government and
a core of citizens ready to work for community
change. The results obtained here may not general-
ize to communities with lower levels of existing
community capacity. Although outcome surveys
were conducted in a matched control community,
process data were not collected in that community.
Nevertheless, anecdotal information from partners
in the comparison community indicates that similar
activities and initiatives have not occurred there.
The project team failed to make aggressive
efforts to obtain data from CHAs who were absent
when training questionnaires were administered.
A greater emphasis in the training sessions on
the importance of obtaining complete assessment
data and more substantial efforts (e.g. providing
incentives for completing questionnaires) to ob-
tain complete data from CHAs who were absent
at the time of initial questionnaire administration
would likely have decreased the volume of miss-
ing training data.
The Uniontown Project demonstrates that a partner-
ship between academic researchers, community-
based organizations and lay community leaders
can facilitate creative approaches based on robust
theories of health promotion for engaging members
of underserved populations to implement a CVD
risk reduction program. Such a program can cata-
lyze community change and increase capacity to
address health-related issues. While this study pro-
vides a model for mobilizing communities with
minimal economic and health-care resources, addi-
tional research is needed to identify community
characteristics needed for adoption and mainte-
nance of risk-reducing strategies. Future research
should explore the effectiveness of this model in
rural communities with lower levels of initial com-
munity capacity and resident support.
National Heart, Lung, and Blood Institute; National
Institutes of Health and Centers for Disease Control
and Prevention (U48/CCU409679 to J.M.R.).
Special thanks to Dr Francis Taylor and other fac-
ulty from the Department of Social Work, Tuskegee
University, for conducting the focus groups and to
Martha Cole, Sharhonda Love and Venus Smith for
assistance in preparation of the manuscript. The
findings of this paper are those of the authors and
do not necessarily represent the views of the
Centers for Disease Control and Prevention.
Conflict of interest statement
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Received on March 20, 2008; accepted on September 29, 2008
Community Health Advisor Program for CVD risk