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

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A timeline displays the sequence of trainings and program adaptations that were implemented between 2018 and 2023. In October 2018, community health workers received an introduction to the behavioral health components via a 3-day workshop. In October 2019, program adaptations were implemented and included additional training on barriers and best practices and the addition of “Road Maps for Change” handouts to the coaching intervention. In March 2022, additional program adaptations were implemented which lowered PHQ-2/GAD-2 thresholds (to ≥2) for full assessments and added psychoeducational stress management materials to the intervention.

Figure 1. Timeline of program implementation of behavioral health components into a lifestyle intervention addressing reduction of risk for cardiovascular disease in rural communities, Colorado Heart Healthy Solutions, 2018–2023. Abbreviations: BH, behavioral health; GAD, Generalized Anxiety Disorder questionnaire; PHQ, Patient Health Questionnaire.

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This figure illustrates the results from the interrupted time series analysis (logistic regression) for each of the behavioral health assessments and the coaching intervention. Figures 2A-C show the initial decline in completion rates for the PSS-4, PHQ-2, and GAD-2 assessments between January and October 2019. All 3 assessments had increased uptake after the first stage of program adaptations made in October 2019, compared with the initial implementation period. These rates were sustained during the rest of the project period. Figures 2D-E show the lowering of the criteria for the PHQ-8 and GAD-7 assessments as part of the second stage of program adaptations in March 2022, which initially led to a decline in the completion rates for both the PHQ-8 and GAD-7 assessments. However, both completion rates continued to improve by years 4 and 5. Figure 2F illustrates the use of the coaching intervention beginning with low usage during the initial implementation period followed by a 9-fold increase in the odds of completion. Although use slowly decreased again during years 2 and 3, use increased after the second stage of program adaptations in March 2022.

Figure 2. Interrupted time-series analysis (logistic regression) of behavioral health assessments and coaching intervention, Colorado Heart Healthy Solutions, 2018–2023. Vertical dashed lines denote interruption events with the first line representing the program adaptations in October 2019 and the second line representing those in March 2022. Circles represent observed completion rates aggregated to 30-day intervals. The solid lines denote predicted trend based on the unadjusted regression model. Abbreviations: GAD, Generalized Anxiety Disorder questionnaire; PHQ, Patient Health Questionnaire; PSS, Perceived Stress Scale.

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