Community health worker roles in intervention delivery: a scoping review of heart disease and stroke prevention trials in the United States

Abstract

Heart disease (HD) and stroke risk can be reduced with adequate cardiovascular disease (CVD) disease prevention as outlined in the American Heart Association's Life's Essential 8 guidelines for modifiable health behaviors. This scoping review examines the roles of community health workers (CHWs) in CVD prevention trials across the United States. In the 24 clinical trials identified, our review emphasizes the effectiveness of CHWs in improving health behaviors and outcomes, particularly for underserved populations with limited access to health care. CHWs were actively engaged in implementing interventions, providing culturally sensitive education, offering health coaching, and supporting lifestyle modifications, such as increased physical activity and medication compliance. Notably, while most studies focused on HD, only three specifically targeted secondary stroke prevention. Beyond their role of delivering behavioral interventions, CHWs supported research efforts by collecting data and maintaining participant involvement. However, their integration into academic teams was inconsistent in terms of scope of practice and level of interprofessional engagement. Furthermore, CHW research contributions were rarely recognized, with a handful acknowledged in publications. Training for CHWs generally included disease-specific knowledge and communication skills. CHW training programs varied considerably in their scope and standards, with unclear role definitions and insufficient collaboration with academic institutions. To enhance CHW-led preventive health care, developing standardized training frameworks, defining CHW responsibilities in clinical and research collaborations and building sustainable community–academic partnerships are suggested. These actions could significantly increase CHWs' role in reducing CVD disparities, thereby promoting more equitable health care across the United States.

Introduction

Cardiovascular disease (CVD), including heart disease (HD) and stroke, remains the leading cause of the global burden of death and disability. This is despite the existence of medical and behavioral strategies that can effectively prevent these cardiovascular events (Martin et al., 2024). The American Heart Association's (AHA) Life's Essential 8 identifies cardiovascular health as driven by key health behaviors of physical activity (PA), nutritious diet, smoking cessation, sufficient sleep, and control of blood pressure, cholesterol, blood sugar, and weight—as vital for preventing CVD (Lloyd-Jones et al., 2022). The burden falls heavily on underserved populations, particularly in low- and middle-income countries (LMICs), which bear more than 80% of stroke-related mortality (Feigin et al., 2021). In high-income settings such as the United States, mortality rates are higher among minoritized communities (Furie, 2020) who face heightened risks due to socioeconomic challenges (Willey et al., 2011). Primary prevention relying on lifestyle changes and medications and secondary prevention after a cardiovascular event using antiplatelet therapy and stricter risk factor management (Boehme et al., 2017) are critical yet difficult to implement in underserved areas due to limited access to health care systems and competing demands that interfere with individual-level health behaviors (Kernan et al., 2014). Furthermore, tertiary prevention to improve health outcomes and reduce disability demands continuous care and rehabilitative services that are often limited in under-resourced communities (Winstein et al., 2016).

Community health workers (CHWs) are public health professionals who are rooted in their communities and use trust and cultural understanding to enhance health care delivery in underserved regions (Rosenthal et al., 2010). They can bridge community and health services to promote health care delivery (Spencer et al., 2010). With a synchronous lens of cultural competency, they can enhance health literacy and reduce health inequities in minoritized populations [American Public Health Association (APHA), 2009]. A systematic review found that CHWs are particularly effective in disease prevention by enhancing knowledge, supporting lifestyle adherence, and improving access to care, thereby supporting both CVD prevention and recovery (Viswanathan et al., 2010).

Although CHWs are increasingly integral to community-based CVD interventions, uncertainties persist about the scope of training needed and the level of integration into team roles. This is important as it directly affects the quality of intervention delivery with respect to the resources allocated for community training and implementation fidelity. While traditional roles include serving as community mediators in improving culturally appropriate education, resources, or direct services, they can also engage as community organizers in leadership development and capacity-building projects (Spencer et al., 2010) and have even directly delivered CVD interventions in LMICs (Irvin and Sentell, 2019). In the United States, where health care is privatized and resources are concentrated in large academic institutions with multilevel health-systems barriers, minoritized communities stand to gain the most support from strategically implemented CHW-led interventions [Spencer et al., 2010; American Public Health Association (APHA), 2009]. This scoping review examines CVD prevention trials conducted in the United States to guide equitable strategies that can maximize CHWs' role and sustained impact.

We sought to (1) outline CHW roles in CVD prevention trials, separating their delivery of community-based interventions (traditional roles, e.g., health coaching) and participation in research related roles, for example, study documentation; (2) evaluate training approaches for tasks tied to interventions, including those addressing health behaviors; and (3) explore structural and systems-level facilitators and barriers to CHWs' impact among minoritized communities. The findings may inform effective training frameworks, integration methods, and policy recommendations to strengthen CHWs' role in reducing health care disparities.

Methods

We chose a scoping review to summarize key concepts and identify gaps in CHW-integrated preventive interventions. We followed the reporting guidelines of Preferred Reporting Items for Systematic reviews and Meta-Analyses Extension for Scoping Reviews (see Figure 1 and the Supplemental material).

Figure 1

Search strategy

PubMed was the primary database used to search for studies published since the database's inception through October 17, 2024. This was to ensure that we captured the widest audience and the highest impact community-led interventions in the United States. We used all the search terms for CHWs paired with Medical Subject Headings terms for CVD (e.g., coronary artery disease, myocardial infarction, and heart failure) OR cerebrovascular accident OR hypertension OR hyperlipidemia (see the Supplemental material). The studies included all clinical trials, randomized controlled trials, or stand-alone study protocols for trials involving CHWs and interventions to prevent HD or stroke written in English. Systematic/scoping/narrative reviews were originally included to identify additional citations. Articles were excluded if the intervention was not conducted in the United States, if it was a case study or report, if the intervention addressed only individuals with diabetes mellitus, or if the authors did not mention CHW participation.

Literature selection

A data extraction table that included the following was used to pull the relevant information from each fully reviewed paper: authors, article title, publication year, initial reviewer, confirmation reviewer, include/exclude (yes/no), study type, chronic disease targeted, location of the study, CHW roles, study intervention, study outcomes, CHW barriers and facilitators, CHW training (including didactic and skills content areas, hours, competency evaluation, and supervision procedures), and notes for additional information. Two authors (DH, LP) independently conducted the initial search, reviewed titles and abstracts for eligibility, and came to consensus when there was disagreement. All full-text articles for final inclusion/exclusion decision and data extraction by at least two authors (CCB, SRE, and IAN). If discrepancies occurred, agreement was reached through discussion. The search identified 127 records after duplicates were removed. An article title and abstract review yielded 49 studies of potential relevance, requiring full-text review. A total of 24 studies met final eligibility criteria and were included in this review (Figure 1).

Results

General study characteristics

Among the 24 studies, only 3 focused distinctly on secondary and tertiary stroke prevention (see Table 1 and the Supplemental material). Primary outcomes varied, with overlap among studies: 16 studies (Allen et al., 2014; Balcazar et al., 2009; Balcázar et al., 2010; Becker et al., 2005; Commodore-Mensah et al., 2024; Daniels et al., 2012; Ephraim et al., 2014; Heisler et al., 2022; Ibe et al., 2021; Johansson et al., 2023; Katula et al., 2017; Krieger et al., 1999; Levine et al., 2003; Margolius et al., 2012; Shah et al., 2024; Towfighi et al., 2021) mainly aimed to improve blood pressure control, while 12 (Allen et al., 2014; Balcazar et al., 2009; Balcázar et al., 2010; Becker et al., 2005; Ephraim et al., 2014; Johansson et al., 2023; Katula et al., 2017; Krieger et al., 1999; Shah et al., 2024; Towfighi et al., 2021; Islam et al., 2023; Samuel-Hodge et al., 2020) included other risk factor control (see the Supplemental Material).

Regarding specific health behavior related interventions to improve outcomes, 12 studies discussed health behavior interactions, including nutrition (8 studies; Balcázar et al., 2010; Ephraim et al., 2014; Katula et al., 2017; Margolius et al., 2012; Shah et al., 2024; Towfighi et al., 2021; Islam et al., 2023; Samuel-Hodge et al., 2020), smoking cessation (4 studies; Becker et al., 2005; Ephraim et al., 2014; Katula et al., 2017; Margolius et al., 2012), lipid profile management (2 studies; Johansson et al., 2023; Katula et al., 2017), diabetes control (7 studies; Allen et al., 2014; Balcázar et al., 2010; Ephraim et al., 2014; Katula et al., 2017; Shah et al., 2024; Islam et al., 2023; Samuel-Hodge et al., 2020), hypertension management (10 studies; Allen et al., 2014; Balcazar et al., 2009; Balcázar et al., 2010; Ephraim et al., 2014; Katula et al., 2017; Krieger et al., 1999; Shah et al., 2024; Towfighi et al., 2021; Islam et al., 2023; Samuel-Hodge et al., 2020), and sleep (1 study; Towfighi et al., 2021), with limited detail on these interactions focusing on CHW promotion of these behaviors. Furthermore, 15 studies encouraged PA, using methods like personalized exercise plans (Allen et al., 2014; Ephraim et al., 2014; Katula et al., 2017; Shah et al., 2024; Towfighi et al., 2021; Islam et al., 2023; Samuel-Hodge et al., 2020), group activities (Balcázar et al., 2010; Ephraim et al., 2014; Katula et al., 2017; Shah et al., 2024; Samuel-Hodge et al., 2020), and motivational interviewing (Allen et al., 2014; Becker et al., 2005; Ephraim et al., 2014; Katula et al., 2017; Krieger et al., 1999; Margolius et al., 2012; Shah et al., 2024; Towfighi et al., 2021; Islam et al., 2023; Samuel-Hodge et al., 2020); 13 studies (Allen et al., 2014; Balcazar et al., 2009; Balcázar et al., 2010; Ephraim et al., 2014; Johansson et al., 2023; Katula et al., 2017; Krieger et al., 1999; Margolius et al., 2012; Shah et al., 2024; Towfighi et al., 2021; Islam et al., 2023; Samuel-Hodge et al., 2020; Dromerick et al., 2011) included PA as a preventive component; and 10 studies (Allen et al., 2014; Balcazar et al., 2009; Balcázar et al., 2010; Ephraim et al., 2014; Katula et al., 2017; Margolius et al., 2012; Shah et al., 2024; Towfighi et al., 2021; Islam et al., 2023; Samuel-Hodge et al., 2020) integrated PA into broader lifestyle interventions aimed at hypertension control, weight management, or diabetes prevention. These cumulative interventions typically included PA alongside diet, medication adherence, and self-monitoring components. While most studies addressed PA through tracking tools or behavioral coaching, none focused solely on PA as the primary intervention target. Instead, PA was often embedded within multicomponent behavioral programs.

Among the three trials for secondary stroke prevention (Towfighi et al., 2021; Dromerick et al., 2011; Kitzman et al., 2017), both PROTECT DC (Dromerick et al., 2011) and the Stroke Unmet Needs and Caregiver Experiences Evaluation and Detail (SUCCEED; Towfighi et al., 2021) tested self-management interventions that included coaching, education, and social support. PROTECT DC was only reported as a feasibility study protocol. SUCCEED reported improvements in self-management and medication adherence. Using PA as an intervention, SUCCEED (Towfighi et al., 2021) reported that 50%−65% of participants engaged in weekly exercise (mean: 30–60 min), while PROTECT DC (Dromerick et al., 2011) promoted PA through coaching but did not quantify engagement. SUCCEED also targeted hypertension control, sodium reduction, and successfully addressed social needs, including assistance with transportation and housing instability, food insecurity, and medication cost. The Kentucky Community Care Coordination by Telehealth (KC3T) study (Kitzman et al., 2017) focused on post-stroke recovery. The researchers found improvements in patient self-management and access to supportive services and fewer hospital readmissions.

CHW roles and responsibilities in interventions

Across the 24 studies reviewed, CHWs played an integral role in delivering interventions, both through traditional responsibilities and research-related tasks. In 17 studies, CHWs acted as the sole intervention deliverer. In the remaining seven (Becker et al., 2005; Heisler et al., 2022; Ibe et al., 2021; Johansson et al., 2023; Katula et al., 2017; Towfighi et al., 2021; Kitzman et al., 2017), they collaborated with nurse practitioners, social workers, pharmacists, or other professionals, highlighting the adaptable nature of CHWs within various multidisciplinary care teams. Overall, CHWs frequently delivered culturally tailored interventions (21 studies), enhanced patient engagement (19 studies), and addressed barriers to care (15 studies), leveraging community ties to improve access and trust. All 24 studies utilized CHWs in traditional roles, with education (23 studies) and health coaching (22 studies) being the most frequent, followed by providing culturally appropriate services (18 studies). Participation in research roles occurred in 21 studies, including active participation to improve compliance with trial procedures (20 studies), data collection (19 studies), and communication with the study's primary care team (9 studies). In the three stroke studies, traditional CHW roles included education, coaching, and cultural tailoring, and research roles encompassed adherence support and documentation, while two included care coordination.

Training provided to CHWs for intervention delivery

The standard training provided to CHWs included disease-specific education (22 studies), motivational interviewing or related behavioral coaching and cultural sensitivity training (15 studies; Balcazar et al., 2009; Balcázar et al., 2010; Becker et al., 2005; Commodore-Mensah et al., 2024; Ephraim et al., 2014; Heisler et al., 2022; Katula et al., 2017; Margolius et al., 2012; Shah et al., 2024; Towfighi et al., 2021; Samuel-Hodge et al., 2020; Kitzman et al., 2017; Ell et al., 2017), For research roles, frequent intervention-specific trainings were on protocol adherence (Allen et al., 2014; Balcazar et al., 2009; Balcázar et al., 2010; Becker et al., 2005; Commodore-Mensah et al., 2024; Ephraim et al., 2014; Katula et al., 2017; Margolius et al., 2012; Shah et al., 2024; Towfighi et al., 2021; Kitzman et al., 2017; Ell et al., 2017), data collection methods (Allen et al., 2014; Balcázar et al., 2010; Becker et al., 2005; Commodore-Mensah et al., 2024; Ephraim et al., 2014; Katula et al., 2017; Margolius et al., 2012; Shah et al., 2024; Towfighi et al., 2021; Islam et al., 2023; Ell et al., 2017), and data gathering with blood pressure (BP) monitoring techniques (Allen et al., 2014; Commodore-Mensah et al., 2024; Katula et al., 2017; Margolius et al., 2012; Shah et al., 2024; Towfighi et al., 2021; Islam et al., 2023; Ell et al., 2017), reflecting CHWs' critical contributions to study execution. Of these studies, the individualized management for patient-centered tasks (IMPaCT) trial (Kangovi et al., 2017) had the most comprehensive and replicable training model, with detailed online material posted for the highest transparency and fidelity. The challenges to training include inconsistent curricula, limited funding, and unclear roles, while success depends on factors such as community trust, well-defined responsibilities, and institutional backing (O'Brien et al., 2009; Mallaiah et al., 2023; see Table 1 and the Supplemental material).

In non-stroke studies, such as the LINKED-HEARTS program (Commodore-Mensah et al., 2024), CHWs trained in home BP monitoring, telemonitoring via the Sphygmo application, and electronic medical record documentation. They were also trained to deliver telehealth follow-ups and ensure accurate BP data transmission. In the Counseling of Adults for Cardiovascular Health trial (Allen et al., 2014), CHWs were trained to provide tailored education and goal setting. In the CHANGE study (Samuel-Hodge et al., 2020), CHWs were integrated within faith-based networks to promote sustainable dietary and lifestyle modifications.

All three stroke studies provided disease-specific education, motivational interviewing, and protocol adherence training to the CHWs. SUCCEED and KC3T (Towfighi et al., 2021; Kitzman et al., 2017) clearly identified the CHWs' intervention delivery by specifying the training duration, balancing didactic and practical components in the intervention group. SUCCEED trained CHWs in social needs screening and stroke self-management, with monthly coaching to address barriers such as transportation, housing, or medication access. KC3T trained CHWs in stroke education and resource navigation, facilitating in-home follow-ups and access to durable medical equipment, thereby enhancing stroke recovery. CHW training across these studies included practical tools and communication strategies that ensured intervention fidelity, with telehealth (SUCCEED), in-home monitoring (KC3T), nurse collaboration, and resource linkage demonstrating CHWs' flexibility in varied care delivery models.

CHW integration in study teams

CHWs' integration into multidisciplinary teams was noted in 10 studies (Allen et al., 2014; Ephraim et al., 2014; Heisler et al., 2022; Ibe et al., 2021; Johansson et al., 2023; Katula et al., 2017; Shah et al., 2024; Towfighi et al., 2021; Islam et al., 2023; Kitzman et al., 2017). The methods used to engage CHWs in research procedures included regular team meetings (Allen et al., 2014; Ephraim et al., 2014; Katula et al., 2017; Shah et al., 2024; Towfighi et al., 2021), shared decision-making with care providers (e.g., nurses, pharmacists, physicians, Katula et al., 2017; Shah et al., 2024; Towfighi et al., 2021), and clear role definitions, including scope of practice for tasks like BP telemonitoring (Allen et al., 2014; Ephraim et al., 2014; Ibe et al., 2021; Katula et al., 2017; Shah et al., 2024; Towfighi et al., 2021).

Three studies (Heisler et al., 2022; Islam et al., 2023; Kitzman et al., 2017) reported the integration of CHWs into their academic institutions. Five studies reported barriers like institutional review board (IRB) challenges (Heisler et al., 2022; Towfighi et al., 2021; Kitzman et al., 2017) and salary support (Heisler et al., 2022; Islam et al., 2023). To facilitate research roles, only five studies (Ephraim et al., 2014; Heisler et al., 2022; Islam et al., 2023; Kitzman et al., 2017; Towfighi et al., 2017) trained CHWs in consent processes, with IRB-directed training for the conduct of study procedures. Among the three stroke studies, two (Towfighi et al., 2021; Kitzman et al., 2017) reported CHW IRB training, with one (Towfighi et al., 2021) involving participant consent. Institutional facilitators included team meetings (Katula et al., 2017; Shah et al., 2024; Towfighi et al., 2017) and role clarity (Margolius et al., 2012; Samuel-Hodge et al., 2020; Kitzman et al., 2017), while IRB delays were a barrier for one study (Kitzman et al., 2017).

Based on our review of co-authors' lists in the 24 trial results publications, CHWs were listed as co-authors in two of the included studies (Balcazar et al., 2009; Kitzman et al., 2017). Four studies included them in the acknowledgment section (Heisler et al., 2022; Islam et al., 2023; Kitzman et al., 2017; Ibe et al., 2019).

Discussion

We reviewed 24 studies that targeted CHW-engaged cardiovascular health promotion to prevent CVD in the United States. We found that all studies included some, if not all, components of the AHA Life's Essential 8 health behavior change recommendations (Lloyd-Jones et al., 2022). CHWs served alongside other disciplines in traditional roles to conduct these lifestyle interventions, of which PA and hypertension control were most emphasized. All CHWs were trained in disease-specific education, and in most studies (17 of 24), they were trained for effective communication and cultural competency, but didactics and practical training methods varied. While most studies (23 of 24) engaged CHWs in essential research roles, such as intervention adherence, study documentation, and team coordination, only half documented research training, and only four acknowledged one or more CHWs in study publications. Only 3 of the 24 papers specifically engaged stroke populations.

We found that CHWs perform a crucial role in health services outreach across the spectrum of community-based research (Key et al., 2019). Furthermore, they can catalyze behavioral modifications for vascular risk factors that are widely applicable to CVD prevention for multiple chronic diseases. Evidence from systematic reviews shows that CHWs can lower systolic blood pressure by 5–10 mmHg and boost medication adherence by up to 20% in underserved groups (Brownstein et al., 2007; Jacob et al., 2019). CHWs have been engaged in effectively promoting health behaviors, advocating for health access, and aiding adherence to treatments for chronic conditions like hypertension and diabetes, both major heart disease and stroke risk factors since the 1960s (Viswanathan et al., 2010; Perry et al., 2014). While most studies included CHWs engaged behavioral modifications to target these conditions, only three studies utilized CHWs specifically for secondary stroke prevention (Towfighi et al., 2021; Dromerick et al., 2011; Kitzman et al., 2017).

Gaps and opportunities

CHW training to conduct CVD interventions is essential but varies widely. Intervention-specific training, combining theoretical knowledge (e.g., disease mechanisms and behavioral theories) with practical skills (e.g., blood pressure monitoring and data recording), varied considerably (O'Brien et al., 2009; Allen et al., 2015). Differences in training rigor suggest that thoughtful transfer of knowledge and skills training for CHWs is needed to extend their skill set beyond traditional roles or fundamental research roles tailored to each intervention. It also highlights a need for rigorous assessment tools to evaluate CHWs' knowledge and skills to optimize their performance and enhance their credibility in CVD interventions, as previously noted by (Mallaiah et al. 2023).

From our included studies, it is apparent that CHWs were incorporated into multidisciplinary intervention teams. Within multidisciplinary teams, CHWs have been previously found to improve patient engagement, as demonstrated in initiatives targeting stroke risk factors (Towfighi et al., 2021; Kitzman et al., 2017). Harnessing their expertise to bridge health care delivery and provide social support at a time when health care is most fragmented, such as transitions of care from the hospital into the community (Reeves et al., 2023), may be particularly beneficial and cost-effective. However, working collaboratively in teams should be reflected in their training. For example, for future secondary stroke prevention interventions, CHW training would need to include didactics and practical training for physical and cognitive disabilities among stroke patients. As the length of stay in the hospital (Bettger et al., 2019) and first-year post-stroke rehabilitation services are low in the United States (Young et al., 2023), patients are more vulnerable to ineffective community reintegration and poor recovery. These gaps can be bridged by CHWs, who should engage with other health care professionals, such as rehabilitation clinicians, to provide training for safe and effective transfer of knowledge and skills. CHWs could then be leveraged in stroke trials to develop stroke-specific competencies in stroke disability accommodations and care transitions from facilities to home for safety assessments and rehabilitation services.

In the United States, CHW integration can be expanded to improve care among minoritized populations. While CHWs have been prominently engaged in LMICs with a focus on eliminating health care disparities, CHW interventions have now emerged as a promising approach among underserved settings in the United States (Spencer et al., 2010). Their role in low-resource and income settings can be instrumental to creating health care equity for community resource building. They can lift the community they serve and expand their impact if equipped with leadership roles by academic partnerships in community-based participatory research (CBPR). For example, in the REACH Detroit Partnership Family Intervention, CHWs played a major role in the development and implementation of the project's culturally tailored Journey to Health/Camino a la Salud diabetes education curriculum (Feathers et al., 2007).

Furthermore, our scoping review shows that while CHWs can be engaged in traditional roles to support communities, research-supported roles that are primarily acquired through institution-based training in an academic center need to be improved. While all interventions provided some training for these roles, these were not clearly reported. Transparency in academic center training for CHWs to engage with the community would be helpful to standardize this approach across institutions. Providing CHW training beyond preventive care to skills so that they can serve as paraprofessionals within defined interventions and extending licensed health care professionals can serve to propel health services research after a cardiovascular or cerebrovascular event. This would also help create a bidirectional capacity-building framework for community-based health workers and academic institutions, expanding the role of community health workers in an academic institution as well as providing further support in the community. The training framework suggested by the U.S. Agency of International Development for the CHW Assessment and Improvement Matrix provides a clear toolkit for implementing and strengthening CHW programs and services, allowing them to serve as key health care workers in underserved areas (Crigler et al., 2013). Furthermore, established frameworks in implementation science, such as the Consolidated Framework for Implementation Research, can be utilized to evaluate intervention delivery by CHWs, specifically in the context of training, fidelity, and sustainability (Damschroder et al., 2022). Thus, by expanding their roles in a standardized framework, facilitated by the academic institution, CHWs can have a central role in culturally congruent interventions across the CBPR spectrum.

CHW interventions can serve as a low-cost investment to provide academic institutions with the incentive and scope to develop interventions that best serve underserved populations to improve health care utilization and therefore provide equitable care. Having trained CHWs utilize billing codes under Medicaid, together with research funding for preventive interventions, may make clinical care more cost-effective and sustainable to maintain (HealthySteps National Office Policy Finance Team, 2024). However, the eligibility of CHW services for Medicaid billing varies by state, and reimbursement is nuanced by the services delivered and the burden of documentation. Therefore, by intentionally expanding the engagement of CHWs with academic institutions, bidirectional capacity building can be encouraged to lift community members who can serve their communities with longitudinal and long-term support from academic institutions that may be well-placed in these communities to serve them.

Study limitations

Our review has several limitations. First, it is limited by challenges related to utilizing one database with a search methodology using keywords, which can be inconsistent in terminology across the literature. However, we used several broad keywords and reviewed the reference literature to ensure that our search was as robust as possible. Second, we only included articles published in English, possibly excluding studies not published with an English translation. Because our scope of interest was to include studies in the United States, where the primary language is English, we hope that we were able to capture all studies involving U.S. settings. Furthermore, studies serving non-English-speaking U.S. populations were still included as they were published in English. Third, publication bias is very possible as smaller trials with null results may have been less likely to have been published. Finally, we did not include literature on CHW perspectives on the interventions conducted, as it was outside the scope of this review, but we have included CHWs as co-authors of this review for their opinions.

Conclusion

In summary, CHWs play an important role in bridging health care delivery to improve cardiovascular health. Growing CHW competencies and integration in multidisciplinary teams has the potential to address gaps in secondary stroke prevention trials, forging a pathway for robust academic institution–community partnerships and equitable care. As tangible next steps, developing CHW-led interventions that utilize standardized frameworks for CHW training may improve intervention fidelity, and establishing norms for CHW co-authorship may promote equity among health care workforces.

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