Community-Wide Cardiovascular Disease Prevention Programs and Health Outcomes in a Rural County, 1970-2010 | Journal Scan

Study Questions:

Does a comprehensive cardiovascular risk reduction program improve risk factor control and reduce mortality in a low-income rural community?


This was a long-term (40-year) observational study, which included residents of Franklin County, Maine, a rural, low-income population. The community program targeted cardiovascular risk factors including hypertension, cholesterol, and smoking, in addition to providing counseling on diet and physical activity. This program was sponsored by multiple community organizations, including the local hospital and clinicians. Outcomes of interest were resident participation, rates of diagnosed hypertension and hyperlipidemia, rates of treatment and control of hypertension and hyperlipidemia, and smoking quit rates. Additional outcomes included hospitalization rates from 1994 through 2006, and mortality rates from 1970 through 2010, adjusted for household income and age.


In 1970, the population of Franklin County, Maine was 22,444; as of 2010, the population had grown to 30,768. The cohort was predominantly white. During the 40 years of follow-up, residents had become poorer and older; however, the ratio of residents to primary care physicians had improved. One-on-one interactions between a resident and a nurse or other health coach in any one of several programs were recorded over time. Encounters averaged 5,000 per year from 1974-1994 and 3,000 per year subsequently. By 2010, there were >150,000 encounters, an average of >5 encounters per Franklin County resident, with over 150,000 individual county resident contacts occurring over 40 years. Hypertension control had an absolute increase of 24.7% (95% confidence interval [CI], 21.6%-27.7%) from 18.3% to 43.0%. Control of elevated cholesterol had an absolute increase of 28.5% (95% CI, 25.3%-31.6%) from 0.4% to 28.9%. Smoking quit rates improved from 48.5% to 69.5%, (which was better than state averages); however, in later years, the difference between Franklin County and Maine’s overall quit rate disappeared due to increases in smoking quit rates across the state. Franklin County hospitalizations per capita were less than expected for the measured period, 1994-2006. Franklin was the only Maine county with consistently lower adjusted mortality than predicted over the time periods 1970-1989 and 1990-2010.


The authors concluded that sustained, community-wide programs targeting cardiovascular risk factors and behavior changes to improve a Maine county’s population health were associated with reductions in hospitalization and mortality rates over 40 years, compared with the rest of the state. Further studies are needed to assess the generalizability of such programs to other US county populations, especially rural ones, and to other parts of the world.


These data support the use of community programs to control cardiovascular risk factors and reduce mortality.

Clinical Topics: Dyslipidemia, Prevention, Homozygous Familial Hypercholesterolemia, Lipid Metabolism, Nonstatins, Diet, Hypertension, Smoking

Keywords: Cardiovascular Diseases, Cholesterol, Confidence Intervals, Counseling, Diet, Follow-Up Studies, Hospitalization, Hypercholesterolemia, Hyperlipidemias, Hypertension, Motor Activity, Physicians, Primary Care, Poverty, Residence Characteristics, Risk, Risk Factors, Rural Population, Smoking

< Back to Listings