Community-Based Culturally Tailored Education Programs for Black Communities with Cardiovascular Disease, Diabetes, Hypertension, and Stroke: Systematic Review Findings

Background Community-based culturally tailored education (CBCTE) programs for chronic diseases may reduce health disparities; however, a synthesis across chronic diseases is lacking. We explored (1) the characteristics and outcomes of CBCTE programs and (2) which strategies for culturally appropriate interventions have been used in CBCTE programs, and how they have been implemented. Methods A systematic review was conducted by searching three databases to identify empirical full-text literature on CBCTE programs for Black communities with cardiovascular disease, hypertension, diabetes, or stroke. Studies were screened in duplicate, then data regarding study characteristics, participants, intervention, and outcomes were extracted and analyzed. Cultural tailoring strategies within programs were categorized using Kreuter and colleagues’ framework. Results Of the 74 studies, most were conducted in the USA (97%) and delivered in one site (53%; e.g., church/home). CBCTE programs targeted diabetes (65%), hypertension (30%), diabetes and hypertension (1%), cardiovascular disease (3%), and stroke (1%). Reported program benefits included physiological, medication-related, physical activity, and literacy. Cultural tailoring strategies included peripheral (targeted Black communities), constituent-involving (e.g., community informed), evidential (e.g., integrated community resources), linguistic (e.g., delivered in community’s dialect/accent), and sociocultural (e.g., integrated community members’ religious practices). Conclusions CBCTE programs may have beneficial outcomes, but a small sample size limited several. The strategies identified can be adopted by programs seeking to culturally tailor. Future interventions should clearly describe community members’ roles/involvement and deliver programs in multiple locations to broaden reach. Trial Registration PROSPERO CRD42021245772. Supplementary Information The online version contains supplementary material available at 10.1007/s40615-022-01474-5.


Introduction
Chronic diseases are among the top causes of death and disability in many countries worldwide, including Canada and the USA [1][2][3].According to the Center for Disease Control, 60% of adults in the USA have at least one chronic disease, and 40% have two or more [4].A similar trend exists in Canada, with approximately 33% of adults living with a chronic disease [2].Chronic diseases have a high economic burden, requiring significant annual healthcare and indirect costs (e.g., income and productivity loss) [5][6][7].Chronic diseases are a concern as the burden is growing globally due to the aging population [8,9].
Biological factors (e.g., genetic risk factors) only explain some of the disparities in chronic diseases, as multiple indirect and systemic factors also contribute to health disparities [21,25,28,29].Health inequities are partly due to economic, environmental, behavioral, and social factors [21].For instance, statistics reveal that Black adults are less likely to visit a healthcare provider and spend less time engaging in self-care activities (e.g., blood glucose testing) than White adults due to multiple barriers that cause difficulty in managing chronic conditions [22,30,31].These barriers can include the cost of accessing health and social services, a lack of access to physical activity facilities within their communities and difficulties acquiring fresh/healthy food [32,33].Moreover, dietary habits, stress, and negative interactions with the health system (e.g., discrimination) are also potential causes of poorer disease management behaviors [10,21,34].When accessing health services, literature shows that Black adults receive lower quality care than other ethnic groups, and they may experience poor quality of communication and relationships with providers and less satisfaction with health services [5,[35][36][37].Traditional health services may not adequately meet Black communities' needs, as evidenced by multiple calls and initiatives to explore culturally tailored health service models [20,[38][39][40][41][42].
Culturally tailored programs (sometimes used interchangeably with culturally appropriate and cultural targeting) are defined in research as "the adaptation of the study design, materials and other components of the intervention to reflect cultural needs and preferences at the population level" [35,43].Culturally tailored programs have been recommended as a service delivery model to reduce health inequities [20,22,35,43].Prior reviews have examined culturally tailored programs for various communities, including Chinese American [44], Korean American [45], and other culturally diverse communities [43,46,47].Culturally tailored programs can increase disease knowledge, health system access, clinical outcomes, and service satisfaction [35,43,44,47,48].However, one review noted that culturally matched and linguistically appropriate education for immigrant Korean American community members might not be sufficient for chronic disease management, and culturally sensitive support should be provided [45].It is unclear whether prior findings extend to community-based culturally tailored education (CBCTE) programs for Black communities.For purposes of this review, use of the term Black adults/ communities reflects diverse communities who have African ancestry (e.g., African American, African Canadian, African-Caribbean, etc.); however, we acknowledge that the preferred terminology/language to describe one's ethnic and cultural identity (e.g., African American/Black communities and ethnically marginalized communities) may differ among individuals and overtime.
While numerous CBCTE programs have emerged for Black adults with chronic diseases, such as cardiovascular disease [49], hypertension [50], diabetes [51][52][53], and stroke [54], cultural tailoring strategies have not yet been compared across chronic disease programs [55].Two previous reviews examined culturally tailored diabetes interventions for Black adults [31,56] and have added valuable insights into diabetes-specific culturally tailored programs for these communities.However, these findings may not be transferrable to other chronic conditions.A synthesis of programs targeting multiple common chronic conditions (i.e., cardiovascular disease, hypertension, diabetes, and stroke) is warranted to address the knowledge gap in the design and structure of "culturally tailoring" within these programs.This knowledge is necessary to guide the advancement of CBCTE programs to manage the growing burden of these chronic diseases facing Black communities [15][16][17][18][19][20][21].

Objectives
The current review will address the following questions, as outlined in our protocol [55]:

Methods
This systematic review was registered on the PROS-PERO International Prospective Register of Systematic Reviews (CRD42021245772) and followed the detailed methods reported in the published protocol of this review [55].Kreuter and colleagues' five strategies for culturally appropriate interventions were used as a framework to evaluate and compare components of CBCTE programs included in this review.As described in Table 1, the five strategies outlined within this framework include (1) peripheral strategies (e.g., marketed to a target group), (2) evidential strategies (e.g., the inclusion of data/evidence to contextualize a health issue in a specific community), (3) linguistic strategies (e.g., language of intervention), (4) constituent-involving strategies (e.g., drawing on community members' experience), and (5) sociocultural strategies (e.g., the inclusion of social or cultural values of target group within intervention) [57].

Searches
The research team, including an information specialist (EMU), created a search strategy using medical subject headings (MeSH) and text words that related to the following concepts: (i) community-based; (ii) culturally tailored education; (iii) cardiovascular disease, hypertension, diabetes, or stroke; and (iv) Black adults.The following databases were searched on September 30, 2021: Medline, Embase (OvidSP), and Cumulative Index to Nursing and Allied Health Literature (EBSCOhost).The searches on these databases are included in the supplementary materials (Supplementary Material 1).In addition, a hand search of reference lists from 10 included studies was conducted to identify relevant articles that may have been missed.

Study Inclusion and Exclusion Criteria
Empirical full-length articles of any design and language were eligible if they were available in English, published on or after the year 2000, and reported the results of a CBCTE program for Black adults (18 years of age and older) who had cardiovascular disease, hypertension, diabetes, or stroke.
To be considered a CBCTE program, the following criteria had to be met, as outlined in the protocol [55]: • Community-based: must be delivered in community settings (e.g., participant's home, a community clinic) and intend to share knowledge and experiences to develop a common understanding and require community members to have a role in the intervention (e.g., advisor, recipient) [58] • Culturally tailored: must recognize a "group's cultural values, beliefs and behaviours" by including at least one of the following five strategies: (1) peripheral; (2) evidential; (3) linguistic; (4) constituent-involving; or (5) sociocultural [57] • Education: must deliver some form of education on managing hypertension, cardiovascular disease, diabetes, or stroke

Study Selection
The results of the database searches were imported into Covidence: a software used to deduplicate the search results and support study screening.After sufficient interrater reliability was achieved (kappa > 0.8), title and abstract screening and full-text review were conducted by in duplicate by two screeners (HS, JF, and/or a research assistant) to identify relevant articles based on the inclusion criteria.Any conflicts were resolved through discussions.

Study Quality Assessment
Two reviewers (MS, HS) independently critically appraised studies using one of the following Joanna Briggs Institute (JBI) Critical Appraisal Tools [59]: Checklist for Randomized Controlled Trials [60], Checklist for Cohort Studies [59], Checklist for Qualitative Research Studies [61], and Checklist for Quasi-Experimental Studies [62].The JBI tools were selected because they offer a range of tools for various study designs and have been developed through an extensive peer review process [63].

Data Extraction Strategy
A research team member (SM) extracted data related to the study characteristics (e.g., year and country of publication, study design), setting, participants (e.g., health condition, age), intervention details (e.g., program name, duration), and outcomes (e.g., evaluation measures and intervention outcomes).A second reviewer (HS) reviewed all extracted data for accuracy.In addition, one reviewer (HS) extracted data related to the cultural tailoring strategies applied within included interventions [57].

Data Synthesis and Presentation
Extracted data relating to study characteristics, settings, participants, intervention details, and outcomes were descriptively reported in textual and table summaries.In addition, an inductive thematic analysis of each included study's methods, results, and discussion completed by HS and JF was used to examine the application of cultural tailoring within programs [57,64].
Sample sizes: The total sample size of the programs ranged from 9 to 638.

Program Outcomes
Table 3 reports examples of outcome measures used within included studies by category.Various outcome measurements were used to evaluate interventions, including participant-level (e.g., health-related outcomes, health literacy, medication adherence, psychosocial measurements) and program-specific outcome measures (e.g., program adherence, satisfaction).Most studies (n = 50/74; 67.6%) examined a type of physiological outcome measure (e.g., hemoglobin A1C, weight/body mass index); however, health care satisfaction, involvement, disparity, and use were rarely measured (n = 8/74; 10.8%).In addition, some participant-level outcome measures were culturally tailored to community members.For instance, researchers used outcome measures adapted for use with African Americans (e.g., Community Healthy Activities Model Program for Seniors physical activity questionnaire modified for African Americans and an adaption of Food Habits Questionnaire for participants) [52,111].Others reported that the outcome measure was reliable and validated for use by this community [94,119].See Supplementary Material 4 details the outcome measures used in each study.

Research question 2: Which of the Kreuter and colleagues' culturally appropriate strategies have been used in CBCTE programs for Black adults with cardiovascular disease, hypertension, diabetes, or stroke, and how have they been implemented in these programs?
Table 4 categorizes cultural appropriateness strategies used within studies by the Kreuter et al. framework [57].
All studies within this review employed peripheral strategies because our inclusion criteria required studies to report a CBCTE program for Black communities (i.e., marketed to Black adults).Evidential strategies included incorporating resources developed for the target community within the intervention [131] (e.g., 7 Steps to a Healthy Heart for African Americans [116]).
Translation of intervention materials to a different language was not apparent in any of the interventions.However, linguistic strategies included recruiting local community members to ensure that the intervention was delivered in the dialect and accent of the target community (e.g., rural southern accent, vernacular, and idioms), which is believed to foster trust between the intervention provider and the recipient [67].Other linguistic strategies included having materials delivered by a Black community member (e.g., voice recording by an African American adult) [52,121].Some studies also integrated the community's religious practices into the program communication; this strategy also overlapped with sociocultural strategies [71,78].For example, one study indicated that they opened and closed the sessions with prayer, and activities included reading scriptures [71].In addition, some studies tailored to target participants' social determinants of health, such as literacy levels (e.g., by simplifying intervention materials) [52,90,109,110].
Sociocultural strategies involved intervention logistics, such as the delivery format, location, and program timing.For instance, virtual delivery facilitated participation and retention by removing barriers, such as transportation (e.g., costs) and competing roles priorities (e.g., caretaking responsibilities).Locations such as churches and barber shops were perceived as ideal locations to reach these communities as these were commonly attended locations and were seen as cultural hubs [65,76,78,129].In terms of program timing, flexible schedules during weekends and evenings accommodated work schedules and reduced participation barriers.Finally, sex-based differences should be considered in chronic disease as the authors indicated that their samples included a greater proportion of females [70] and recommended oversampling for males given poorer chronic disease management (e.g., blood pressure control) [115].Sociocultural strategies also consisted of the inclusion of gospel music [88], spiritual messages with participants [49], incorporating oral transition of storytelling and religious tradition of testifying [90], and prayer and spiritual messages [49].
Other social determinants of health were considered in CBCTE programs.For instance, researchers restricted their inclusion to a specific education level (e.g., ≥ eighth grade) while noting that this education level might not be attained by all target community members, such as those in lower socioeconomic strata or older individuals, but it was required as the intervention was delivered online and comprised of reading materials [70].Some studies specifically targeted individuals with low income [87,95,98,123].Finally, researchers individually tailored some interventions to intervention components relevant to each participant's specific needs, preferences, diet, goals, medication adherence, barriers, and life experiences to effectively address multiple intersecting factors influencing participants' needs [53,72,74,75,77,79,85,95,99,110,111,115,117,123,131].

Discussion
This systematic review provides insights into the characteristics of CBCTE programs for Black adults with diabetes, hypertension, cardiovascular disease, and stroke.More studies have been published each year since 2000 (e.g., 19% of articles included in this review were published Peripheral strategies -marketed as a culturally specific program for Black/African Americans (all included studies) -cookbooks designed for African Americans [68] -showed videos, cases, stories, or vignettes of African American individuals (e.g., lay individuals and key celebrities such as Yolanda King) sharing information about the target condition, management strategies, and health challenges to share relatable examples [65,78,90,114] -incorporated voice messages [114], images, illustrations, and videos of African American individuals engaging in target behaviors (e.g., hypertension management; peer-modeling) [74,80,106,114] -shared letters containing spiritual messages with participants [49] -incorporated symbols or themes into intervention content [106] Evidential strategies -use of the African American Health and Dairy Foods Nutritional Fact Sheet, 7 Steps to a Healthy Heart for African Americans [116], National Diabetes Clearinghouse article Diabetes in Black Americans, Black Quilt Cookbook [74], American Heart Association's (AHA) "High Blood Pressure in African Americans" [119] -discussion of race-specific health strategies (e.g., foot care for the skin of color) [74] Linguistic strategies -use of local providers for intervention delivery to minimize linguistic barriers and align with the dialect and accent of the target community (e.g., rural southern accent, vernacular, and idioms) to foster trust between intervention provider and recipient [67] Constituent-involving strategies -showed a video of African American individuals (e.g., lay individuals and key celebrities such as Yolanda King) sharing information about the condition and management strategies [78,114] -presentations conducted by racially concordant research team members and health providers [ -cookbooks designed for African Americans (e.g., Soul Sensation Cookbook) [68,74] -shared letters containing spiritual messages with participants [49] -dance classes choreographed to gospel music [88] -use of cultural recipes (e.g., Soul Food) [74] -discussion of cultural reinforcements and barriers to health management (e.g., dietary modification, diabetesrelated self-care) [74,90] -educational materials posted in the church to reinforce education [132] -nutritional instructions/education aligned to the target group's shopping and dietary patterns [90] -intervention advertised or delivered in faith-based organizations (e.g., churches) and community organizations serving the target population [65,76,78,96] -involvement of family members in the intervention [67,90,97,107] -incorporate oral transition of storytelling and religious tradition of testifying [90] -inclusion of prayer and spiritual messages with participants [49] -delivering in barber shops [129,130] -social determinants (e.g., income, literacy level) [52,66,70,87,96,123] between 2000 and 2005 compared to 32% in 2016-2021).This finding may be a product of more attention and interest in health disparities in the USA [133].The Kreuter and colleagues framework helped identify and categorize the various strategies used to tailor CBCTE programs to Black communities with cardiovascular disease, hypertension, diabetes, or stroke.These strategies can be adopted by existing and future programs seeking to culturally tailor.The strategies align with many of the approaches identified in a review by Wadi and colleagues in which the Facilitator-Location-Language-Messaging (FiLLM) framework was used to identify the cultural tailoring of methods in diabetes programs for Black communities.Their review suggested that the following aspects of programs were tailored: the materials (e.g., messages, written materials), location (e.g., churches), and constituents (e.g., community members) [31].Our review extends findings from Wadi and colleagues as we examined programs beyond diabetes, including programs that target cardiovascular disease, hypertension, and stroke management.Interestingly, prior literature indicates that tailoring multiple components resulted in more effective interventions [31].We highlight the variability of strategies used within the CBCTE program, especially with sociocultural strategies, which can overlap into multiple categories.
Based on reported results from the included studies, we noted that CBCTE programs have beneficial outcomes, such as improving diabetes knowledge and literacy [99,101,110], health knowledge and literacy [49,51], self-efficacy [91], and self-management [100,110].Moreover, researchers reported small sample sizes as a limitation that may have caused some insignificant program impacts [49,54,69,78,79,101,108,110,112,131,132].This finding is consistent with previous literature on culturally tailored health interventions [43,47,48].
Our analysis noted two critical knowledge gaps that should be addressed in future research.First, we noted that contextual knowledge gaps exist since most programs were conducted in the USA.This finding resonates with a systematic review of diabetes interventions tailored to communities of Black African ancestry [31].Since Black communities experience health disparities in other countries (e.g., UK [134] and other European countries [135,136], and Canada [137]), more research from locations beyond the USA is needed to account for possible contextual differences (e.g., differences in public and private health systems/resources).Second, we found a limited number of CBCTE programs for managing stroke and cardiovascular conditions, as most CBCTE programs included in our review targeted diabetes or hypertension.This gap should be addressed in future interventions as Black communities are at a greater risk for stroke [138][139][140] and cardiovascular disease [141][142][143], experience worse outcomes [144,145], and have lower use of health services than other ethnic groups [146][147][148].Three additional insights from our review are discussed in detail below.

Insight 1: Unclear Roles and Degrees of Involvement of Communities
There were varying community member roles and unclear degrees of community member involvement within interventions.The included studies failed to report community members' roles, decision-making processes, and community member training consistently and comprehensively.For instance, some researchers adapted existing programs, whereas others designed programs with members of the communities.
Involving members of the communities and communitybased organizations in the design and delivery was a common strategy in CBCTE programs.This finding is unsurprising as this strategy has been widely used to promote health research participation for Black communities by reducing participation barriers such as mistrust, continuing discriminatory events, and staff competence [149][150][151][152][153]. Including community members in health research can also foster participants' trust in the research/researchers, help create culturally appropriate designs and community ownership, improve participant outcomes, and increase participants' self-efficacy and empowerment [150,154].Moreover, community-based organizations that serve the target populations can advocate on the community's behalf to ensure programs align with communities' needs [155].
However, community members' involvement in research tends to be poorly defined [150].This finding is problematic because traditional top-down research approaches may not be effective with ethnically marginalized communities as they may not be conducive to shared decision-making and can fail to honor the expertise of community members [150].Moreover, unclear descriptions of community members' involvement can limit the replicability and evaluation (e.g., tokenism) of CBCTE programs.For instance, it is unclear whether/how community members' perspectives were meaningfully included, whether/how they were adequately trained, and decision-making processes when perspectives contradicted the researchers [155].Future research should critically reflect on and transparently report how community members can be meaningfully involved throughout the design process [155].Moreover, evaluating the impact of community members' involvement on community and individual-level outcomes is necessary to ensure continued dedication in future research [155,156].This finding begs the question: What are the hallmarks of meaning engagement?
CBCTE programs have integrated community members' perspectives using various approaches, including codesign.Codesign, often used interchangeably with coproduction and community or patient engagement, has gained popularity [155].However, researchers encourage future interventions to critically reflect on whether community members are meaningfully involved in research [155].Moreover, when working with historically marginalized communities, researchers must address power differences to facilitate a safe and inclusive collaborative space and be open to perspectives that diverge from the status quo [149,155].Design justice is an approach that can be used to create CBCTE programs to attend to these factors because it challenges structural inequalities, considers the complex relationship between design, power, and social justice, and enables marginalized communities to lead the design [157].

Insight 2: Program Location Matters
The location appeared to be a critical consideration in CBCTE programs.CBCTE programs were often conducted in single sites (e.g., a participant's home or the church) and, less commonly, health clinics.Health clinics may not be as common location for CBCTE programs given that Black communities tend to have lower use of primary care than White adults for many complex reasons, including medical mistrust and experiences of healthcare discrimination [158,159].Members of Black communities are more likely than other ethnic groups to attend church [160][161][162].Integrating religiosity and social support/structure from the church is a well-known way to build trust in Black communities [149].Due to churches' valuable role and influence on Black communities, there has been a growing demand for engaging churches in health promotion and education interventions to reduce health disparities [149,[163][164][165][166].However, researchers delivering single-site programs must consider which groups are underrepresented, as there is heterogeneity and varying needs among Black communities and intersectionality considerations must be considered.For instance, Black men may be less religious as they are found to have lower rates of church attendance than Black women [167,168].Sex differences in church attendance may explain why church-based CBCTE programs had a higher proportion of female participants, despite Black males having higher chronic disease presence and poorer prognosis than other ethnic groups [138][139][140][141][142][143].
One study was conducted in a barbershop to reach Black men [130].Barbershops have been leveraged for health education and promotion interventions because it is a staple "in the African American community" [149,169].Barbershops are attractive sites for health interventions because they are culturally appropriate, and community members may stay for hours per visit to socialize and engage in productive activities, such as selling and advertising products [169].The owners are often included in the interventions as they tend to be respected and influential community members [149].Men attend barbershops, whereas their equivalent is hair salons attended by women [149].While no CTCE programs included in this review were conducted at hair salons, other health interventions have been conducted at a hair salon (e.g., breast cancer [170][171][172]).Although barbershops and hair salons show promise for health interventions (e.g., cancer screening and hypertension management), more research is needed to ensure such interventions are acceptable and sustainable [169].
A third (30%) of CBCTE programs included in this review were conducted in multiple locations (e.g., church and community centers).Delivering interventions in multiple sites may increase the representativeness of various groups.Therefore, an implication is that researchers carefully consider which location site they will deliver the program and report the characteristics of individuals who are not included in their interventions.It is also worthwhile to explore the characteristics of community members recruited from each site location and test/evaluate whether program outcomes differ based on the delivery site.
Sustainability data can help determine the continued benefits and maintenance of community partnerships [173] and at the individual level (e.g., long-term impact of the program on patient outcomes) [174].However, few studies included in this review evaluated intervention sustainability.For instance, Victor and colleagues found that blood pressure reduction was sustained in education provided by Black barbers [130].However, more research is needed to evaluate CBCTE interventions' sustainability and cost-effectiveness to support informed decisions about program sustainability [48].

Insight 3: Individualizing Culturally Tailored Interventions toto Address Social Determinants of Health and Culture as Dynamic and Experienced Differently by People
In addition to culturally tailoring CBCTE programs to the needs of Black communities, many researchers also individualized the programs to participants' needs (e.g., literacy level, economic status).Individual-level tailoring approaches consider group heterogeneity and intersectionality, the latter referring to the multiple identities and experiences that a person has, such as race/ethnicity, gender, age, and migration status, that can impact disparities [175,176].Heterogeneity and intersectionality of a group/community may also require individualization beyond or integrated alongside group-based cultural tailoring approaches [176].The purpose of cultural tailoring (population level) is to adapt the "study design, materials and other components of the intervention to reflect cultural needs and preferences at the population level" [35].In contrast to population-level cultural tailoring, individualization involves creating program content "based on individuals' existing behaviors, stages of behavior change, preferences, barriers, and other recognizable features interventions" [177,178].Individual-level tailoring seemingly addressed participants' social determinants of health and individual preferences, such as their health literacy, individual diet, and program schedule.Individuallevel tailoring and cultural tailoring to specific groups may be needed to address the needs of our increasingly diverse populations and the intricacies of Black cultures, which is not homogenous [179].Additionally, given the variability noted in this review, future research is needed to examine the process and impact of variable representations of race and culture within research.

Strengths and Limitations
This review has some limitations.First, as with all reviews, there is a risk of missing relevant studies.Relevant studies could have been inadvertently missed for reasons such as our search strategy or data screening errors.To reduce the risk of missing relevant studies, we created the search strategy in consultation with an experienced librarian, searched multiple databases, screened titles, abstracts, and full texts in duplicate, and performed a hand search based on the reference lists of included studies.Second, there is a risk of data errors during extraction.Two reviewers were involved in data extraction to reduce the risk of data error (one extracting and the second checking accuracy).Third, we limited the inclusion to empirical studies, excluding development studies and protocols.Some details about CBCTE programs' design and delivery may have only been reported in the protocol paper and not in the empirical papers.Fourth, we did not perform a meta-analysis, given the heterogeneous study designs and outcome measures used within the included studies [47].However, we could provide some insights into program outcomes based on results from the included articles.Fifth, this review is limited to CBCTE programs within community-based settings, and programs in other settings require further investigation.Finally, these findings must be interpreted with caution as they are based on studies which vary in methodological quality, based on our critical appraisal using the JBI critical appraisal checklists.

Conclusion
This systematic review provides insights into the characteristics and cultural tailoring strategies used within culturally tailored community-based education interventions for Black adults with diabetes, hypertension, cardiovascular disease, and stroke.Several gaps and insights were revealed in this review.These findings can inform the modification of existing or development of new programs.

1 )
What are the program characteristics and outcomes of CBCTE programs designed to improve health outcomes in Black adults with cardiovascular disease, hypertension, diabetes, or stroke?2) Which of the Kreuter and colleagues' culturally appropriate strategies have been used in CBCTE programs for Black adults with cardiovascular disease, hypertension, diabetes, or stroke, and how have they been implemented in these programs?

Table 1
Kreuter and colleagues' five strategies for culturally appropriate interventions To draw on community members' experiences by involving them in an intervention Sociocultural Discussion of health issue/intervention material in the target group's social context and cultural values, beliefs, and behaviors

Table 3
Examples of outcome measures used within included studies