IMPORTANCE Few comprehensive cardiovascular risk reduction programs, particularly those in rural, low-income communities, have sustained community-wide interventions for more than 10 years and demonstrated the effect of risk factor improvements on reductions in morbidity and mortality. OBJECTIVE To document health outcomes associated with an integrated, comprehensive cardiovascular risk reduction program in Franklin County, Maine, a low-income rural community. DESIGN, SETTING, AND PARTICIPANTS Forty-year observational study involving residents of Franklin County, Maine, a rural, low-income population of 22 444 in 1970, that used the preceding decade as a baseline and compared Franklin County with other Maine counties and state averages. INTERVENTIONS Community-wide programs targeting hypertension, cholesterol, and smoking, as well as diet and physical activity, sponsored by multiple community organizations, including the local hospital and clinicians. MAIN OUTCOMES AND MEASURES Resident participation; hypertension and hyperlipidemia detection, treatment, and control; smoking quit rates; hospitalization rates from 1994 through 2006, adjusted for median household income; and mortality rates from 1970 through 2010, adjusted for household income and age. RESULTS More than 150 000 individual county resident contacts occurred over 40 years. Over time, as cardiovascular risk factor programs were added, relevant health indicators improved. Hypertension control had an absolute increase of 24.7%(95%CI, 21.6%–27.7%) from 18.3%to 43.0%, from 1975 to 1978; later, elevated cholesterol control had an absolute increase of 28.5% (95%CI, 25.3%-31.6%) from 0.4% to 28.9%, from 1986 to 2010. Smoking quit rates improved from 48.5% to 69.5%, better than state averages (observed − expected [O − E], 11.3%; 95% CI, 5.5%–17.7%; P < .001), 1996–2000; these differences later disappeared when Maine’s overall quit rate increased. Franklin County hospitalizations per capita were less than expected for the measured period, 1994–2006 (O − E, −17 discharges/1000 residents; 95% CI −20.1 to −13.9; P < .001). Franklin was the only Maine county with consistently lower adjusted mortality than predicted over the time periods 1970–1989 and 1990–2010 (O − E, −60.4 deaths/100 000; 95%CI, −97.9 to −22.8; P < .001, and −41.6/100 000; 95% CI, −77.3 to −5.8; P = .005, respectively). CONCLUSIONS AND RELEVANCE 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.

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Key Points Question Do improved healthy behaviors and mortality in a rural county persist after community-wide interventions to mitigate behavioral and medical mortality risk factors have been ended or reduced? Findings In this cross-sectional study of a rural Maine county, increasing mortality and smoking rates were observed within 5 to 10 years of program reductions. Also, mortality rates in Maine counties were more strongly associated with income in 2006 to 2015 than in previous decades. Meaning This study suggests that there is a need for ongoing community population health assessments and prevention program adjustments to maintain reduced risk and positive outcomes.

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