Integration of Behavioral Health by Community Health Workers Into a Lifestyle Intervention That Addresses Reduction of Risk for Cardiovascular Disease in Rural Communities

Purpose and Objectives: Cardiovascular disease (CVD) is the leading cause of death and disability in the US, with higher rates in rural areas. Although community health workers (CHWs) are effective in improving CVD outcomes, limited evidence exists on their role in addressing behavioral health needs within lifestyle change interventions. This evaluation assessed the feasibility of integrating behavioral health components focusing on psychologic distress, anxiety, and depression into the Colorado Heart Healthy Solutions program (CHHS) in rural communities by using 3 domains of the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework. Intervention Approach: Beginning in 2018, behavioral health components were added to CHHS: assessments for stress, anxiety, and depression; connections with community-based behavioral health resources; and a health coaching intervention linking physical and mental health. Program adaptations that provided additional CHW training, lowered screening thresholds, and expanded intervention materials were implemented to address local determinants. Evaluation Methods: Reach, implementation, and maintenance were assessed by using completion rates of each behavioral health component from 2019 to 2023. Logistic regression within an interrupted time-series framework evaluated the effects of program adaptations on CHW delivery. Results: CHWs completed 8,077 visits with 5,559 participants in 7 rural communities. Completion rates during the first 10 months ranged from 78.6% to 87.5% for the behavioral health assessments; 51.9% completed the connections to care and 8.2% completed the coaching intervention. Program adaptations in 2019 significantly improved completion of the brief assessments and coaching intervention use (P < .001). Adaptations in 2022 increased intervention use (P < .001) but initially reduced completion of longer assessments. By the final year, assessment completion rates were above 89%, with intervention delivery reaching 42.8%. Implications for Public Health: Integrating behavioral health into a CHW-led program in rural communities was feasible and sustainable. High completion rates suggest that CHWs can effectively deliver behavioral health assessments and support in underserved settings, highlighting the value of flexible, community-informed implementation strategies.