From community activity to population impact: Modelling the health value of culturally tailored cardiovascular prevention

Barnet’s Healthy Heart Peer Support Project is a culturally tailored cardiovascular disease (CVD) prevention programme focused on African, Caribbean and South Asian communities at higher risk of poor outcomes. While community‑based prevention programmes often struggle to demonstrate measurable health impact, Barnet developed a simple, transparent impact‑modelling approach that converts real‑world activity data into credible estimates of cardiovascular events prevented. Using conservative assumptions grounded in published evidence, the modelling shows that small, equitable interventions can deliver meaningful population‑level benefit when scaled. This case study sets out how Barnet linked community delivery, health inequalities and impact modelling to strengthen decision‑making, partner engagement and sustainability.

Cardiovascular disease is a leading cause of premature mortality in Barnet, with marked inequalities by deprivation and ethnicity. Local data indicated a substantial diagnosis gap for hypertension, particularly affecting African, Caribbean and South Asian communities. In response, Barnet Council established a four‑year CVD prevention programme in 2022, with the Healthy Heart Peer Support Project as a core component. The project was designed to address structural and cultural barriers to engagement with prevention services through peer‑led, culturally competent outreach embedded in trusted community settings.

The Healthy Heart project sought to:

• Improve awareness, confidence and self‑management of cardiovascular risk within underserved communities.
• Increase engagement with blood pressure monitoring and primary care support.
• Deliver prevention activity in ways that explicitly address health inequalities.
• Strengthen the evidence base for community‑based prevention by linking activity to health outcomes through transparent modelling.

The project was delivered in partnership with Inclusion Barnet, community organisations and the NHS using trained peer supporters to provide brief, extended brief and multi‑session interventions. Delivery was achieved by a small, specialist team of trained peer supporters and engagement officers, whose trusted relationships with communities enabled repeated, meaningful prevention contacts rather than one‑off engagement. Delivery took place in community venues and faith settings, prioritising accessibility and cultural relevance. Activity data were routinely collected, including type of intervention and participant characteristics, enabling both operational monitoring and subsequent impact modelling. The approach emphasised simplicity, transparency and trust - both with communities and system partners. 

To estimate health impact, Barnet developed a simple, transparent modelling approach that converts real‑world programme activity into expected cardiovascular outcomes using peer‑reviewed evidence. The model used Year 3 Healthy Heart delivery data, including the number and type of interventions delivered (brief, extended brief and multi‑session), and combines these with published meta‑analyses linking reductions in systolic blood pressure to reduced cardiovascular risk.

Based on large trial meta‑analyses, the model assumes that every 10 mmHg reduction in systolic blood pressure is associated with an approximate 20 per cent reduction in major cardiovascular events. Consistent with the literature on community and peer‑led interventions, brief contacts are assumed to produce small average reductions in systolic blood pressure (around three millimetres of mercury (mmHg)), with larger reductions for multi‑session support (around five mmHg). 

These effect sizes were applied to Year 3 participant numbers using conservative assumptions about baseline cardiovascular risk, including the proportion of participants from higher‑risk ethnic groups and the likely prevalence of uncontrolled hypertension. The model deliberately excludes additional pathways of benefit (such as smoking cessation, lipid management, physical activity or improved access to care), meaning estimates represent a lower‑bound, blood‑pressure‑only impact. 

This approach prioritises transparency, credibility and reproducibility over complexity, enabling partners and decision‑makers to understand how community activity translates into population‑level health impact, while clearly acknowledging uncertainty and limitations.

During Year 3, the Healthy Heart Peer Support Project delivered 696 brief and extended brief interventions in community settings, alongside  seven intensive workshops (104 attendees) and three multi‑session courses (40 participants), with strong reach into African, Caribbean and South Asian communities and residents living in more deprived wards.

Under central assumptions, the Year 3 Healthy Heart cohort is estimated to prevent approximately:

• 0.4 major cardiovascular events in the first year
• two events over five years
• four events over ten years.

These estimates reflect blood‑pressure effects alone and deliberately exclude additional benefits such as improved lipid management, smoking cessation or increased physical activity, making the results cautious but credible.

Key learning from this work includes:

• Simple, transparent models can meaningfully bridge the gap between community activity and population health outcomes.
• Conservative assumptions increase credibility with clinical, academic and commissioning audiences.
• Impact modelling strengthens conversations about scale, sustainability and equity, rather than replacing qualitative evidence.

The process itself has been as valuable as the outputs, improving shared understanding across partners.

With hindsight, impact modelling could have been embedded earlier in programme design to shape data collection more proactively. Future iterations will incorporate additional outcome pathways as monitoring systems mature.

The Healthy Heart project continues to inform Barnet’s wider CVD prevention strategy. The modelling framework provides a foundation for future evaluation, funding bids and cross‑system learning, supporting the long‑term sustainability of equitable prevention approaches.

• start with delivery data you already collect and build modelling around it
• be explicit about assumptions and limitations
• use modelling to complement, not replace, lived experience and qualitative insight
• focus on equity: small impacts in high‑risk groups can yield disproportionate benefit when scaled.

This approach is transferable to other preventative programmes beyond CVD. 

The work of the Healthy Heart Peer Support Project would not have been possible without the commitment, expertise, and energy of Inclusion Barnet, particularly Judi Dumont-Barter, Riffat Ahmed, and Salna Abdallah, whose leadership and day-to-day delivery has been central to the project's success. The public health team are also grateful to colleagues across Barnet Council, NHS partners, and community groups whose shared commitment to improving heart health have been vital in shaping and sustaining the project.

Mohammed Jawad, Deputy Director of Public Health, [email protected]