The Washington Heights-Inwood Healthy Heart Program: a third generation community-based cardiovascular disease prevention program in a disadvantaged urban setting.

The Washington Heights-Inwood Healthy Heart Program (WHIHHP) is part of the New York State Healthy Heart Program, which comprises eight community-based programs in different areas of the state. WHIHHP is directed at a population of approximately 200,000 people, predominantly Hispanic and of low socioeconomic status, living in northern Manhattan in New York City. The initial 3 years of experience are presented. Six potential barriers to diffusion of the community-based disease prevention model in disadvantaged inner city communities are discussed: (a) issues of scale and complexity; (b) adaptation of this model to a "community" without geopolitical boundaries or infrastructure; (c) linguistic and cultural diversity; (d) competing problems; (e) the role of evaluation; and (f) sustainability of the program in a poor community. Strategies for addressing obstacles to model adoption are also described, including program legitimization, building program infrastructure, setting realistic expectations, focusing on one risk factor at a time, defining target population segments, and emphasizing a small number of communication channels. Finally, research issues related to the diffusion of the community-based model are discussed, specifically: (a) Does the model work in disadvantaged urban settings? (b) What are the program effects on social class gradients for risk factors? (c) What are the barriers to program adoption in such settings? (d) What changes in the model will facilitate adoption in such settings? (e) What are the best methods for conducting formative evaluation in such programs? (f) What is the best way to select communities that may be ready to adopt the model? Our initial experience implementing this model in a disadvantaged urban setting supports the feasibility of model adoption. Unanswered questions about efficacy in such settings and regarding research issues related to model diffusion will require additional research investment.