2025 AHA科学声明：社区环境中的心血管疾病预防循证行为干预的实施

METHODS

We conducted a narrative review designed to assess the application of implementation science and implementa-tion strategies to support CVH EBPs in community set-tings(the Data Supplement gives the full search strategy).We searched PubMed for English-language publications from 2014 to July 2024. When evaluating the literature for examples to highlight, we considered the following:study design(preference for systematic reviews or ren-domized controlled trials), evaluation of theory-informed implementation strategies, and setting. The study needed to include a behavioral intervention and could include structural, policy, and environmental interventions in addi-tion to behavioral interventions. All outcomes from the American Heart Association Life's Essential 8(interven-tion outcomes) were included, as were implementation outcomes(Table 1).13,15 Guided by Mazzucca et al,6 we organized the findings by community setting:(1) faith-based organizations,(2) educational settings,(3) work-places, and(4) social service/other settings.

Findings from all settings were synthesized according to the 4 steps and key considerations of the Roadmap for Leveraging Implementation Science to Achieve Cardiovascular Health Equity outlined by Moise et al9;key considerations across the steps of the road map include partnership engagement, equity-informed imple-mentation science methods, incorporation of social or structural determinants, evidence specific to health dis-parities(eg, generalizability), and adaptations made for specific contexts, settings, or populations.

RESULTS

Results for steps 1(select and adapt, EBP) and steps 3/4(select, use, adapt, and evaluate implementation strategies) are described by setting in Table 2. Given the large volume of research describing implementation

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Table 2.Examples of Key Implementation Science Terms Identified by Review Across Settings

|Term|Examples of how terms are operationalized in community settings|||| |---|---|---|---|---| |Term|Faith based|Educational|Workplace|Social service/other| |Setting|*Organizations with religious components in their self- identity, organization, and decision-making21,22|Schools, early care and education settings|A place(eg, office, shop, or factory) where people work|Organizations designed to increase the social well-being of individuals, families, and communities(eg, child development, community resource referrals, nutrition assistance, aging) and other settings such as YMCAs, out-of-school programs, job training, barbersops, restaurants, and partnerships of multiple organizations| |Evidence- based practice (roadmap step 1)|FAN23,24; Therapeutic Lifestyle Reviewing25; spiritual elements26|Nutrition and Physical Activity Self-Assessment for Child Care27,28; mobile health counseling; food marketing29|Nutrition counseling, food provision30; environmental supports for healthy eating and physical activity; sleep health promotion31; promoting stair use32|Out-of-school Nutrition and Physical Activity33; healthy child menu in restaurants34; blood pressure monitoring/referral, health education in barbershops35; B'more Healthy Communities for Kids multilevel, multicomponent(eg, availability of healthier alternatives, youth-led nutrition education sessions)36| |Contextual factors (roadmap step 2)|See Table 3 for examples for each setting|See Table 3 for examples for each setting|See Table 3 for examples for each setting|See Table 3 for examples for each setting| |Implementation strategy (roadmap step 3)|Committee of 3-5 church members with training; plan and budget;kickoff event, committee meetings; implementation of FAN; monthly technical assistance calls; evaluation|Educational materials, for school staff; outreach visits; audit and feedback; implementation planning; action planning; feedback on implementation behavior|Meetings,kickoff events, and working with change agents; educational meetings, tailored interventions and local consensus processes|Community organization and activation; training sessions for implementers(eg, staff,aftercare facilitators,barbers/stylists); learning collaborative meetings;minigrants; social marketing| |Implementation outcomes (roadmap step 4)|Church adoption of EBP; reach; number of EBP activities in participating churches|School adoption of EBP; reach; fidelity; acceptability; environmental change;|Reach, effectiveness, adoption, implementation, maintenance|Fidelity, dose, feasibility, acceptability, implementation (degree of execution), cost| |AHA LEB outcomes|Physical activity, nutrition,sleep health, and blood pressure|Dietary practices, sleep, physical activity,BMI|Physical activity, diet, sleep,BMI, smoking|Blood pressure, cholesterol, blood sugar, diet, physical activity, sleep health,BMI|

AHA LE8 indicates American Heart Association Life's Essential B: (1) eat better,(2) be more active,(3) quit tobacco,(4) get healthy sleep,(5) manage weight,(6)control cholesterol,(7) manage blood sugar, and(8) manage blood pressure; BMI, body mass index;EBP,evidence-based practice; and FAN,Faith,Activity,and Nutrition.

context, results for step 2(contextual factors) are pre-sented collectively in Table 3 rather than separately for each setting. These findings are representative of litera-ture rather than inclusive of all.

Faith-Based Organizations

Given their deeply embedded social and cultural networks,faith-based organizations are highly influential pillars of health behavior change in that they authentically reach and meet the needs of parishers and surrounding communities across age and socioeconomic barriers.37-39 Faith-based organizations are cornerstones in Hispanic communities and African-American communities38,40 and play a major role in the integration of public health and faith messaging to promote positive health practices.41

Step 1: Select and Adapt EBPs

In the context of this review, EBPs targeting individual pa-rishioner outcomes from the American Heart Association Life's Essential 8(intervention outcomes) are considered

EBPs. A recent systematic review and meta-analysis26 revealed the effectiveness of church-based interven-tions in addressing obesity and hypertension. An addi-tional review found that church-based EBPs(eg, group education and exercise classes, infusion of spiritual com-ponents, and home monitoring) improved CVD risk fac-tors.26 Furthermore, several empirical studies have shown the effectiveness of faith-based health programs in in-creasing health literacy, preventive screening awareness,and promoting CVH among African-American individu-als.23,25,40,42-44 The literature supported the importance of multicomponent, church-based community-centric designs; intentional engagement of church partners; and linking with the religious context(eg, biblical tenets, spiri-tual hymns) to improve CVH.26,39,45-51

Step 3/4: Select, Use, Adapt, and Evaluate Implementation Strategies

Given the strong evidence for EBPs in this setting, se-lecting, adapting, and evaluating implementation strat-egies can enhance impact. The literature explicitly

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Table 3. Examples of Factors at Multiple Levels That Can Act as Barriers or Facilitators(Contextual Factors) to the Success of Implementation

|Setting|Level of contextual factors|||| |---|---|---|---|---| |Setting|EBP(eg,fit and acceptability)|Implementer(eg, practitioners such as teachers and barbers) perspective|Implementation setting and resources|Broader community environment| |Faith based|Alignment with religious/ spiritual tenets; consistent communication; fun and tailored|Pastor(or other religious community leader) support/buy-in; resistance to change|Deeply embedded social and cultural networks; physical countries; location(eg,“lack of facilities for physical activities at church”); staff transition; church schedule|Sense of ownership| |Educational settings|Alignment with educational setting goals; acceptability by teachers|Educator time constraints(eg, priority for academic achievement)|Institutional support|Children spend a large proportion of their time at school; reliance or dependence on research teams or consultants| |Workplace|Social influences|Social/professional role and identity|Environmental context and resources(eg, physical space for programming); structured environment to recruit and enroll|People spend a large proportion of their time at work; remote work after COVID-19 pandemic, with disparities by race and ethnicity, education level| |Social service/ other settings|Alignment with workflow/ routines; adequate time to deliver intervention content; priority; financial factors(eg, reimbursement; cost); values concerning health promotion and commercial viability|Trust and rapport between implementers(eg, stylists) and clients; awareness of, knowledge of, skills in, attitudes about, confidence in, and beliefs about the intervention; difficulty identifying targeted population|Capacity/readiness for implementation; network, relationships, and communication; physical environment/space; budgets|Assets and needs in the community; consumers' preferences and demand; supply of healthy products; community norms and skills|

EBP indicates evidence-based practice.

developing and testing implementation strategies to sup-port EBPs was limited. Studies including implementer perspectives identified salient themes to facilitate CVH promotion, including co-creation of interventions, im-provement in gaps in CVD risk factor knowledge, and community resource/task sharing(eg, community health workers, lifestyle coaches, primary care linkage).52,53 To explicitly test implementation strategies to implement an EBP(Faith, Activity, and Nutrition) in 59 churches in a rural, medically underserved county in South Carolina,Wilcox et al24 used a group-randomized design.The EBP aimed to improve health behaviors(eg, healthy eating and activity) by targeting policy, systems, and environ-mental change in churches. The implementation strategy included a committee of 3 to 5 members who engaged in activities such as creating and submitting a plan and budget for implementation, holding a kickoff event, hav-ing regular committee meetings, and participating in brief monthly technical assistance calls, and the strategy was compared with a delayed implementation strategy arm.In addition to testing the impact of Faith, Activity, and Nutrition(the EBP) on congregant health behaviors, this study assessed implementation outcomes(eg, churches adopting Faith, Activity, and Nutrition; frequency of fruit and vegetable opportunities).24 Additional studies clear-ly identifying the EBP; specifying the implementation strategy; explicitly testing implementation strategies; and using theories, models, and frameworks from implemen-tation science would greatly advance CVH research in faith-based organizations.

Educational Settings

Schools and early care and education settings offer op-portunities to promote and maintain the CVH of chil-dren and youth. These are settings where children from diverse backgrounds and communities spend a large proportion of their time, offering an opportunity to build behaviors supporting lifelong CVH.

Step 1. Select and Adapt EBPs

For the youngest children, a review indicates that a num-ber of early care and education-based EBPs have been shown to improve diet and physical activity behaviors and to prevent excessive weight gain.54 For school-aged chil-dren, 2 recent Cochrane systematic reviews evaluated interventions in young(5-11 years of age) and older(12-18 years of age) children.55,56 Findings on body mass index were mixed; dietary-only interventions ap-peared ineffective in reducing body mass index, whereas interventions focused only on physical activity had some effectiveness in decreasing body mass index, particularly in younger children. Beyond body mass index reduction,other reviews have found positive impacts on dietary behaviors such as reducing intake of sugar-sweetened beverages, increasing fruit and vegetable intake, 57,58 and promoting sleep health.59,60

Step 3/4: Select, Use, Adapt, and Evaluate Implementation Strategies

Given the evidence on early care and education settings,implementation strategies to support EBPs have potential

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for widespread impact and for advancing health equity.54 The strategies found to be effective in a review by Wolfen-den et al54 are listed here with examples of how these strategies were used to implement an EBP, the Nutrition and Physical Activity Self-Assessment for Child Care.27,28 The EBP improves diet and activity behavior in childcare settings.2728 The strategies include(1) educational ma-terials(eg, a“tips and materials tool enables" education),(2) educational meetings(eg, workshops with childcare providers and staff such as cooks and administrators),(3)outreach visits(eg, childcare health consultants who are part of the existing public health infrastructure),(4) audit and feedback(eg, self-assessment"allowing ECE[early care and education] program administrators to evaluate their current performance“28”,(5) opinion leaders, and(6)small incentives/grants. Implementation was successful across early care and education settings. Despite the use of implementation strategies, only half of the studies that Wolfenden et al54 identified used theory to develop the strategies, and many focused on "one-off training or re-source provision"-clear areas for improvement.

Barnes et al61 found wide variation in effectiveness across 21 studies that tested educational materials and meetings tested in combination with other strategies in schools. Ryan et al62 evaluated school staff training(1 type of implementation strategy) to define features associated with better intervention fidelity. They categorized training strategies by one of the compilations for implementation strategies(the Behaviour Change Technique taxonomy) and found that the most common behavior change techniques used were“instruction on how to perform the behaviour.”A meta-regression of 15 studies found that helping teach-ers with detailed plans to implement the intervention(ie,“action planning”), monitoring implementation and provid-ing feedback on performance( ie,“feedback on behaviour”),and the total number of techniques used were associated with physical activity outcomes.10,62 Much of the research on strategies in school settings focused on training teachers and school staff; however, a recent review identified that training of implementers may not be adequate and empha-sized the importance of combining individual and system-level changes, suggesting that greater research is needed on implementation strategies at multiple levels.29

Workplace Settings

Workplace settings(eg, an office, shop, or factory) have long been favored for CVH promotion interventions.Peo-ple spend a large proportion of their time at work, and the setting provides a structured environment to reliably recruit and enroll participants. Workspaces often provide a convenient physical space for programming.

Step 1: Select and Adapt EBPs

The American Heart Association Life's Essential 8 has been the subject of workplace interventions studies

that have been widely reviewed,63-67 including increas-ing physical activity,32 improving diet,30 reducing obesity,reducing smoking,69 and improving sleep.31 They have been studied in various workplace environments and within different workforces such as agriculture and mari-time worksites and health care and education settings.70 However, some reviews have found mixed intervention impacts.32,71

An important caveat to generalizing these findings in the mid-2020s is that most cited studies were conducted before the COVID-19 pandemic. Today, 1 in 5 employ-ees works remotely and is more likely to be a woman, an older adult, and Asian and White.72-74 Therefore, EBPs introduced before the pandemic should be revisited with a particular eye toward equity. For example, data since COVID show that internet-delivered sleep interventions can be as effective as in-person approaches. ${}^{75}$

Step 3/4: Select, Use, Adapt, and Evaluate Implementation Strategies

Several reviews of implementation strategies have ex-plored their impacts on supporting implementation of EBPs in the workplace. A review by Garne-Dalgaard et al76 found information meetings, kickoff events, and working with changes agents to be the most common strategies to support EBP implementation. A recent scoping review considered participatory research(ie, re-search that engages end users and decision makers in co-creation) as a tool to develop engagement and adher-ence strategies77 and found 4 types of approaches that contributed to improved physical activity and reduced sedentary behavior: incorporating end-user focus groups,involving management, having researcher facilitators,and engaging workplace champions in program design.77 Last, in a review of strategies, Wolfenden et al67 included 6 trials of strategies to support implementation of EBPs for healthy eating and activity(eg, healthy catering poli-cies, point-of-purchase nutrition labeling, environmental supports). The authors identified educational meetings,tailing of interventions for the context or population,and local consensus processes as the most common implementation strategies. Although a meta-analysis of 3 randomized controlled trials found no benefit of imple-mentation support, nonrandomized trials showed mixed effects in improvements in implementation.67 As with educational settings, supporting EBP implementation in the workplace may require multilevel strategies.

Social Service/Other Settings

Social service/other settings are defined as agencies" broadly designed to increase social well-being of indi-viduals, families, and communities"(eg, foster care and adoption, child development, community resource re-ferrals, nutrition assistance, aging), as well as settings such as recreational sports organizations, barbersops,

CLINICAL STATEMENTS AND GUDEGLINES

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after-care programs, and partnerships across multiple organizations in a community.6

Step 1: Select and Adapt EBPs

Given the diverse set of organizations that are the focus of this section, numerous EBPs have been evaluated.However, although numerous empirical studies have tested interventions across diverse community-based settings, we did not identify summary reviews system-atically summarizing intervention effectiveness, making it difficult to summarize and define the EBPs to be select-ed or adapted. Examples of the types of organizations in which interventions have been shown to benefit CVH include after-school programs(eg, YMCAs),33 sit-down restaurants,34 barbershops/hair salons,35 and multiple or-ganizations within a community.

Step 3/4: Select, Use, Adapt, and Evaluate Implementation Strategies

This review identified studies testing individual and multi-level implementation strategies for improving the uptake of EBPs in service settings, particularly settings that target social determinants of health; however, results were mixed. Informed by the socioecological framework,1 cluster randomized controlled trial of 8 independently owned sit-down restaurants compared a group with the EBP(curating a new healthy child menu) plus an imple-mentation strategy(healthy food campaign/promotional materials/staff training) with a comparison group(EBP alone) and found similar outcomes in both groups: an immediate increase in sales of new healthy child menu items, followed by a decrease in the postintervention pe-riod with high overall fidelity.34

Several strategies also were tested in after-school settings using randomized designs and found to have positive impacts on implementation.33,78 As an example, 1 three-arm group randomized trial by Lee et al33 compared the effectiveness of 2 implementation strategies to sup-port YMGA implementation of an EBP(Out-of-School Nutrition and Physical Activity) to promote healthy eat-ing and activity. Fifty-three after-school sites were ran-domized to(1) in-person train-the-trainer modules(eg,training sessions, learning collaborative meetings) for YMCA facilitators,(2) self-paced monthly learning mod-ules/facilitated discussion boards for facilitators, and(3)control to compare the effectiveness on EBP implemen-tation. This study found that the in-person implementa-tion strategy achieved more goals than the control and that the online training arm was not significantly different from the control arm.33

To implement EBPs(eg, hypertension management,blood pressure monitoring, lifestyle counseling)79 in bar-bershops/hair salons, investigators have trained barbers and stylers as lay health educators or community health advocates who promote physician follow-up and deliver basic lifestyle advice. In these studies, the EBPs were embedded into regular business operations; however,

some barbers reported disruptions to their workflow and identified a need for alternative implementation strate-gies. Future research should address the optimal role of the barber/stylist and identify implementation strategies that address the fit of EBPs with barbersops/salons.

Several studies took place across multiple organiza-tions within a community.36,80-82 Moore et al80 compared fiscal strategies using a pair-matched design with a delayed implementation strategy comparison. The study compared low-cost, high-reach minigrants to grantees across North Carolina counties implementing multilevel community interventions to improve activity levels among fourth- to eighth-grade youth in community settings and found that this strategy can have a small but meaning-ful effect on children's moderate to vigorous physical activity, with greater effects seen in younger children.80 In another example, Sato et al81 found that youth leader-delivered trainings in recreation centers resulted in moderate to high rates of dose(number of interactive sessions and taste tests, giveaways, and handouts per session), fidelity(num-because, fewaways, and handouts per the entire intervention and per session), and reach(num-ber of interactions with the target population). Last, in the community-based participatory research-informed ran-domized controlled trial SAHELI(South Asian Healthy Lifestyle Intervention Study; n=549), an EBP was implemented at multiple community sites, including a community-based organization providing social services to immigrants and a school district serving many immimi-grant families. The EBP reached a diversity of individuals(ie, those with non-English-language preference, lower education levels) and led to modest improvements in diet and physical activity. Key implementation strategies included EBP delivery in trusted community settings, cul-turally and linguistically concordant lay health educators,and culturally adapted experiential activities, which pro-moted knowledge and behavior change.82

System-level/multilevel strategies are needed to improve effectiveness and sustainability of CVH EBPs in community settings. One systematic review highlighted several theory-informed community-based interventions for reducing CVD risk, with key strategies including edu-cational programs provided through multiple educational channels and instruments, community organization and activation, creation of social and institutional support for educational goals, and environmental changes, with the authors concluding that“the simpler and cheaper an intervention is, and the higher the proportion of the com-munity population covered by the intervention, the more sustainable a program will be."

DISCUSSION AND IMPLICATIONS

CVH interventions that are implemented in commu-nity settings are needed to enhance CVH equity in the United States.69,17,18,84 This review found tailored EBPs

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CLINICAL STATEMENTS AND GUIDELINES

tested in faith-based organizations and in some social service/other settings(eg, barbersports/hair salons), but knowledge about effective implementation strategies is lagging. More implementation research was identi-fied in workplace, school, and some social service/other settings(eg, after-school programs); this highlights the more limited implementation research in faith-based organizations, which has implications for equity. To fully realize the potential of community settings in improving CVH equity, implementation science can help close gaps in several areas: theory-informed strategy selection, en-gagement of implementers and organizations, inclusion of strategies beyond training implementers(eg, teach-ers), and use of frameworks to more rigorously assess implementation outcomes. It is not enough to know that an intervention is efficacious/effective; to affect popula-tion health, knowledge of implementation strategies that are effective, sustainable, and scalable is needed.

The Figure summarizes the bright spots and opportu-nities for research considering the steps on the road map outlined by Moise et al.9 In sum for step 1, EBPs have been tested in community settings, with some evidence for effectiveness. This suggests that there are EBPs for which the impact can be enhanced through application of implementation science. Equity is a cornerstone of implementation efforts, and this review identified inter-ventions and adaptations aimed at improving outcomes in groups that have historically been excluded by the health care system, a critical consideration in the road map.9 EBPs were often adapted or tailored to those that the EBP was intended to reach, and many studies con-sidered level, quality, and generalizability of EBPs spe-cific to CVD disparities, although this could be expanded in future research.

Involvement of partners, particularly using engaged approaches to perform research, is another critical con-sideration in the road map.9 Although it was conceptu-alized somewhat differently(eg, participatory research in worksites, community engagement in faith-based settings), a consistent finding across community set-tings was that partner engagement at multiple levels(eg, leadership, management, employees, students,teachers, preachers) improves both the intervention and its implementation.397783,85-87 However, few studies described specific multilevel partner engagement strate-gies, which may be particularly important for community settings, which differ considerably from clinical settings where many CVH EBPs are developed. Along with community-engaged research methods, the implemen-tation science method Designing for Dissemination and Sustainability(D4DS)89-93 can support a more engaged approach. A key principle of D4DS is that the research designer begins with a focus on the end goal, dissemi-nation and sustainability.92,93 The 3 core components of D4DS are as follows:(1) developing an EBP to meet the needs, resources, workflows, and contexts of the target

audience and setting;(2) planning for an active approach of spreading EBPs to the target audience and settings;and(3) aligning with the systems, resources, and values to support sustained use of the EBP in the real world.Considering these pillars of the D4DS approach can support studies that engage partners, considers context across levels(ie, not limited to community members but considering community-based practitioners and orga-nizations as well), and could lead to implementation of EBPs that fit the expertise and constraints community-based contexts.

For step 2, the contextual factors identified in this review(described in Table 3) are summarized at the level of the EBP. This includes the implementers(ie, practitio-ners such as teachers and barbers), the implementing organization, and the broader community/policy environ-ment. Many of these factors(eg, social influence, com-munity leadership buy-in, implementer time constraints)are best elucidated with qualitative or mixed methods.Across settings, the review found contextual factors such as alignment between the EBP and the implementing practitioners/organization's resources and capacity can be important influences on implementation. For example,an EBP selected/adapted to align with an organization's values, priorities, and workflows facilitates implementa-tion,yet if alignment is lacking, this can be a barrier.9 Con-cordant with the involvement of partners and the D4DS approach described previously, it is also important to center the capacity and values of the community-based settings to implement EBPs with the implementing prac-titioners/organizations to foster adoption and sustain-ability. Engaging partners early allows the EBP to be developed to align with the organization's capacity and resources, including low-resource settings. Furthermore,development of the implementation strategy must involve engagement with those who will be asked to implement the intervention and the organization in which it will be implemented.

The variability in available literature on step 3(select-ing, using, and adapting implementation strategies)across settings suggests that more research developing and testing strategies to support implementation of CVH programs in community settings is needed. The pres-ent review categorized interventions that improve health behaviors(eg, intervention with evidence to improve diet) as the EBP and the approach to execute the EBP in a community setting as the implementation strategy.This is challenging, given that many behavioral interven-tions for CVH are complex, which may make distinguish-ing the behavioral intervention and the implementation strategy difficult. Greater specifications of EBPs and implementation strategies, as recommended by Proc-tor et al19(ie, detailing who is involved in delivering the implementation strategy, what is delivered, in what dose is the strategy delivered) would allow deeper analysis of optimal strategies to promote EBP implementation,

CLINICAL STATEMENTS AND GUEDEIMINES

Implementing Community Interventions for CVD

|||Bright Spots|Research Opportunities| |---|---|---|---| |Identify Barriers and Facilitators to Implementation|● Evidence for the effect of interventions delivered in community settings to improve CVH-related behaviors is emerging in most settings ● Evidence-based practices(EBPs) with community engagement were identified, selected, and culturally adapted, particularly in faith-based and social service and other settings (eg, salons/barbersops) ●EBPs in community settings leverage assets and strengths of organizations and practitioners (eg, community trust, reach)|● Additional evidence needed for intervention effectiveness in the community settings explored ● Employ a Designing for Dissemination and Sustainability(D4DS) approach to support engagement with intervention implements and delivery settings in addition to those whom the EBP is designed to impact|| |Identify Barriers and Facilitators to Implementation|● Contextual factors of implementation at the intervention and practitioner level have been very well characterized for several settings(see Table 2) ● Contextual factors such as aligning the EBP with the values and priorities of the organization and building buy-in from leadership are common and can act as barriers or facilitators|● Additional evidence needed for intervention effectiveness in the community settings explored ● Employ a Designing for Dissemination and Sustainability(D4DS) approach to support engagement with intervention implements and delivery settings in addition to those whom the EBP is designed to impact|| |Identify Barriers and Facilitators to Implementation|● Contextual factors of implementation at the intervention and practitioner level have been very well characterized for several settings (see Table 2) ● Contextual factors such as aligning the EBP with the values and priorities of the organization and building buy-in from leadership are common and can act as barriers or facilitators|● Greater focus on fitting the EBP to the community setting and its assets rather than focusing on fitting community organization to EBP (ie, does the organization have 'capacity') ● A D4DS approach supports consideration of contextual factors (eg, alignment of EBP with settings' mission and workflow, time, and priorities), in selecting and adapting EBPs to avoid misalignment between community setting and EBP|| |Identify Barriers and Facilitators to Implementation|● 3&4 ● Across settings, strategies incorporating community, organization, practitioners, and end-user engagement; some evidence these are effective ● Numerous strategies tested in educational settings and growing literature in faith based, workplace, and social services/other organizations (eg, barbersops, after-care programs) ● In educational settings, implementation strategies combining organizational level changes with individual implementer (eg, teacher) change are more beneficial than strategies at the individual implementer level alone|● Greater focus on fitting the EBP to the community setting and its assets rather than focusing on fitting community organization to EBP (ie, does the organization have 'capacity') ● A D4DS approach supports consideration of contextual factors (eg, alignment of EBP with settings' mission and workflow, time, and priorities), in selecting and adapting EBPs to avoid misalignment between community setting and EBP|| |Critical Considerations for Every Step|● Some EBPs involve key partners, particularly in intervention selections and adaptation of EBPs with some EBP generalizability ● Reviews have identified level, quality, and generalizability of EBPs specific to CVH ● Engagement with partners supported EBPs and implementation strategies that were culturally appropriate and context-aligned sustained implementation|● Incorporating key partners across multiple levels (ie, community, organization, implementer, individuals whom the EBP is designed to impact) using D4DS approaches may be effective across settings ● Partners can be involved in selecting and adapting EBPs to fit with the organization and in developing and adapting implementation strategies ● Review identified less research specific to disparities and whether/how EBPs address health equity||

Figure. Summary of bright spots and research opportunities across the Roadmap for Leveraging Implementation Science to Achieve Cardiovascular Health Equity.

CVH indicates cardiovascular health; D4DS, Designing for Dissemination and Sustainability; and EBP, evidence-based practice. Adapted from Moise et al. ${}^{9}$ Copyright© 2022, American Heart Association, Inc.

facilitating comparison between what strategies were tested and the effect of the strategy. As an example of the benefit of providing specifications, Barnes et al'61 were able to compare the effect size of implementation strategies tested in school settings with those in child-care and workplaces.

In a recent review of studies that were primarily in clinical settings, consistent reporting of implementation

strategies allowed Ashcraft et al20 to compare the effectiveness of implementation strategies and showed that“conducting educational meetings and distribut-ing educational materials" were 2 of the most common strategies that showed generally positive results on implementation outcomes.20 Similarly, the current review found that most studies rely on implementation strate-gies focused on educational strategies for implementers

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(eg, teachers, barbers, staff). However, Ashcraft et al, ${}^{20}$ Samad et al, ${}^{29}$ and Grimshaw et al ${}^{94}$ note that these indi-vidual implementer-focused strategies are‘necessary but not sufficient for success, highlighting the need to focus on multilevel strategies in future research in community-based settings. Furthermore, a critical con-sideration in the road map by Moise et al is incorporating strategies that can improve EBP implementation among populations who experience adverse social and struc-tural determinants of health, many of which are situated at multiple levels inside and outside community settings.

The road map further suggests explicit application of equity-focused implementation science theories, models,and frameworks as a critical consideration.9 There were examples of framework application for step 4(evaluat-ing implementation success); the Reach, Effectiveness,Adoption, Implementation, and Maintenance framework was used to explore external validity and to evaluate implementation strategy success(Table 2) in many set-tings.24,95-99 However, this review found opportunities for application in understanding the implementation con-text, developing implementation strategies, and evalu-ating implementation outcomes. We found few studies that explicitly linked implementation strategies to effec-tiveness or implementation outcomes for community settings.To further support heath equity, there are equity-focused adaptations of several implementation frame-works.100 Such frameworks help users rigorously assess implementation strategies to better reach and engage populations who experience health disparities.

CONCLUSIONS

The focus of this review of implementation of CVH EBPs within community settings was explicitly selected given the potential of community settings to affect popula-tions who are often excluded by the health care system.We identified a growing body of literature describing implementation strategies to support CVH EBPs in di-verse community settings, as well as research gaps and

opportunities in which implementation science can sup-port CVH EBP implementation outside of clinical set-tings to advance CVH equity.

ARTICLE INFORMATION

The American Heart Association makes every effort to avoid any actual or poten-tial conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Spe-cifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.

This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on May 5, 2025, and the American Heart Association Executive Committee on June 18, 2025. A copy of the document is available at https://professional/heartorg/statements by using either"Search for Guidelines& Statements" or the Browse by Topic" area. To purchase additional reprints, call 215-356-2721 or email Medithedman.Edelman@wolterskuwer.com

The American Heart Association requests that this document be cited as fol-lows:Tabak RG,Kandula NR,Angell SY,Brewer LPC,Grandner M,Hayman LL,Ing C,Joseph JJ,Moise N,Nelson SE,Tran AH; on behalf of the American Heart Association Implementation Science Committee of the Council on Epidemiology and Prevention; Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; Council on Lifestyle and Cardiometabolic Health; Council on Quality of Care and Outcomes Research; and Stroke Council. Implementation of evidence-based behavioral interventions for cardiovascular disease prevention in community settings: a scientific statement from the American Heart Association.Circulation.2025;152:e--e--...doi:10.1161/CIR.0000000000001349

The expert peer review of AHA-commissioned documents(eg, scientific statements, clinical practice guidelines, systematic reviews) is conducted by the AHA Office of Science Operations. For more on AHA statements and guidelines development, visit https://professional.heartorg/statements. Select the“Guide-lines& Statements" drop-down menu, then click“Publication Development”

Permissions: Multiple copies, modification, alteration, enhancement, and dis-tribution of this document are not permitted without the express permission of the American Heart Association. Instructions for obtaining permission are located at https://www.heart.org/permissions.A link to the"Copyright Permissions Request Form" appears in the second paragraph(https://www.heart.org/en/about-us/statements-and-policies/copyright-request-form).

Acknowledgments

Author contributions: Dr Tabak: full access to all data in the study and takes responsibility for integrity of the data and accuracy of the data analysis. Study concept and design: Drs Tabak, Moise, and Kandula. Acquisition of data: Drs Ta-bak and Kandula. Analysis and interpretation of data: Drs Tabak, Kandula, Angell,Brewer, Grandner, Hayman, Ing, Joseph, Moise, the manuscript: Drs Tabak, Kandula, Angell, Brewer, Grandner, Hayman, Joseph, Noise,Nelson, and Tran. Critical revision of manuscript for important intellectual content: Drs Tabak, Kandula, Angell, Brewer, Grandner, Hayman, Joseph, Moise,Nelson, and Tran. Study supervision: Drs Tabak and Kandula. The writing group acknowledges Shelly Kannuthurai for editing/formatting and Brittny Sandler for advising on and conducting the literature search.

Disclosures

Writing Group Disclosures

|Writing group member|Employment|Research grant|Other research support|Speakers bureau/noraria|Expert witness|Ownership interest|Consultant/ advisory board|Other| |---|---|---|---|---|---|---|---|---| |Rachel G. Tabak|Washington University in St. Louis|NIH(co-l and is Pl for several NIH-funded research grants, including salary support)*|None|None|None|None|None|None| |Namratha R. Kandula|Northwestern University, Feinberg School of Medicine|NIH+|None|None|None|None|American Diabetes Associationt|None| |Sonia Y. Angell|Bloomberg School of Public Health, Johns Hopkins University|None|None|None|None|None|None|None|

(Continued)

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CLINICAL STATEMENTS

Writing Group Disclosures Continued

|Writing group member|Employment|Research grant|Other research support|Speakers bureau/noronia|Expert witness|Ownership interest|Consultant/ advisory board|Other| |---|---|---|---|---|---|---|---|---| |LaPrincess C. Brewer|Mayo Clinic|NIH/NIMHD(P50 supplement grant,PI) t;AHA(Second Century Implementation Science Award, PI)t;AHA (Clinical Investigator Leadership Award)t; PCORi(co-l)*;NIH/NHLBI(co-l)*|None|None|None|None|None|None| |Michael Grandner|University of Arizona College of Medicine|None|None|None|None|None|None|None| |Laura L. Hayman|UMass Boston Manning College of Nursing and Health Sciences|None|None|None|None|None|None|None| |Claire Ing|University of Hawaii at Manoa|None|None|None|None|None|None|None| |Joshua J. Joseph|The Ohio State University Wexner Medical Center|None|None|None|None|None|None|None| |Nathalie Moise|Columbia University Medical Center|None|None|None|None|None|None|None| |Sarah E. Nelson|Tufts Medical Center|None|None|None|None|None|None|None| |Andrew H. Tran|Nationwide Children's Hospital The Heart Center|None|None|None|None|None|None|None|

This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be"significant" if(a) the person receives$5000 or more during any 12-month period, or 5% or more of the person's gross income; or(b) the person on 5% or more of the voting stock or share of the entity, or owns$5000 or more of the fair market value of the entity. A relationship is considered to be"modest" if it is less than"significant" under the preceding definition.*Modest.

*Modest.

tSignificant.

Reviewer Disclosures

|Reviewer Disclosures|Research grant|Other research support|Speakers' bureau/noronia|Expert witness|Ownership interest|Consultant/advisory board|Other|| |---|---|---|---|---|---|---|---|---| |Laura Balis|Center for Nutrition|National Cancer Institute, National Institutes of Health(principal investigator)t; Special Olympics Systems Change for Inclusive Health Subgrant, Centers for Disease Control and Prevention(principal investigator)t; Novo Nordisk(Co-Investigator)t;|None|None|None|None|None|None| |National Collaborative on Children||||||||| |Rebekka Lee|Harvard University|None|None|None|None|None|None|None| |Courtney Luecking|University of Kentucky|None|None|None|None|None|None|None| |Justin D.|University of Utah|None|None|None|None|None|None|None|

This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Ques-$$\text{ tonnaire, which all reviewers are required to complete and submit. A relationship is considered to be"significant" if(a) the person receives$5000 or more during any}$$12\text{-month period, or 5\% or more of the person's gross income; or(b) the person owns 5% or more of the voting stock or share of the entity, or owns$5000 or more of}$$\text{ the fair market value of the entity. A relationship is considered to be"modest" if it is less than"significant" under the preceding definition.}$

*Modest.

+Significant.

Tabak et al

Implementing Community Interventions for CVD

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