Specific Aims
Cardiovascular Disease Self-Management in Rural Adults: A Pilot Intervention Study Using Technology and RN/Community Health Worker Teams. Principal Investigator: Patrik Johansson
STUDY AIMS:
Heart disease represents the leading cause of death in the US, and a large proportion of these deaths are preventable. In spite of statistical trends that clearly indicate that heart disease-related mortality rates in rural communities are higher in comparison to metropolitan areas 1, there is a gap in the literature specifically related to implementing evidence based cardiovascular disease (CVD) risk reduction in rural settings. Therefore, to address this major public health challenge in rural settings,
we propose to test a culturally adapted rural CVD risk intervention integrating self-management principles to activate patients and reduce CVD risk using virtual technology. Through our work with rural communities, we have conducted focus groups to culturally adapt an urban evidence-based CVD risk reduction intervention using a registered nurse coordinator (RNC)/community health worker (CHW) team to a rural setting. We have also conducted a descriptive study to determine seasonal work pattern impact on health behavior of farmers resulting in developing new recruitment strategies and the feasibility of objectively measuring physical activity. Our next logical step is to conduct a two-group repeated measures pilot study with rural patients at a rural clinic in which we will apply self-management strategies such as goal-setting, decision-
making, and problem-solving to improve clinical biomarkers and health behaviors.
 
Taking our focus group findings, rural Nebraska health professions workforce shortages, and patient distance from health care providers into consideration, we propose a novel systems-based intervention approach that focuses on the employment of an RNC and CHW team to augment and support patient self-management using smart technology (cell phone or iPad) and the internet. Although research is limited, smart technologies represent a promising avenue for increasing access to effective self-management tools in resource-limited settings, including rural communities. While CHWs have been used successfully in rural settings to provide social support, assist with goal setting, tailor strategies, and reinforce education, little research attention has been paid to RNC/CHW teams using smart technology to address CVD risk in rural communities.
 
The study will be conducted in collaboration with a primary care clinic in rural SE Nebraska.This proposal will target two or more of the following risk factors among rural clinic patients: hypertension, hyperlipidemia, and diabetes. The purpose
of this pilot study is to test the feasibility and effectiveness of a 6-month pilot study employing an RNC/CHW team. We will recruit 2 groups of rural patients with two or more CVD risk factors. Patients will be randomized into one of two treatment arms: 1) standard primary care (SPC); or 2) SPC plus a 6-month CVD risk reduction intervention, delivered by the RNC/CHW team. The RNC/CHW team will use smart technology (cell phone, iPad, internet) to provide interactive support for patients to develop self-management strategies (goal setting, self-monitoring and confidence building) using interactive feedback,
tailored skills training materials, and virtual RNC/CHW planned follow-up counseling visits. In the initial assessment the RNC will also use the PAM® that quantifies a patient’s knowledge, skills, and confidence in managing their health. Goals will be tailored according to individual patient activation levels allowing patients to build confidence in the ability to self-manage their health. Participants will be followed over 6 months with assessments at baseline 3, and 6 months post baseline.
The primary outcome is change in CVD biomarkers at 6 months. Our long-term goal is to reduce rural Nebraska CVD risk.
 
The specific aims of our proposed pilot study are to:
11. Compare the RNC/CHW and SPC groups on the following outcomes: biomarkers (serum triglycerides, total cholesterol,
LDL, HDL, blood pressure, HgbA1C, and saliva cotinine), health behaviors ( physical activity, dietary habits , and smoking)
at baseline, 3 and 6 months.
.HYPOTHESES: We hypothesize that the patients in the RNC/CHW + SPC group will have more improvement in biomarkers and health behavior than among SPC patients.
 
2.Examine implementation quality (delivery as intended) over the course of the intervention and potential for maintenance (sustainability) based on: barriers and facilitators for future reach, adoption, and sustainability including cost of the intervention
.