Int. J. Environ. Res. Public Health 2009, 6 2483 health [18]. Health regions in Canada with higher levels of heart disease mortality also have greater prevalence of smoking and obesity than the national average [19]. Ontario is among the provinces with the lowest levels of smoking-attributable mortality and prevalence of CHD risk factors [2]. Previous research indicated the province has regional differences in the prevalence of modifiable risk factors, with higher risk, morbidity and mortality in some areas of northern Ontario [20]. Grace [21] found that, among a sample of Ontario residents with cardiovascular disease, diabetes, or two or more cardiovascular disease risk factors, and who subsequently received risk modification information through a telephone counseling intervention, the frequency of exercise was lower in residents of northern Ontario than in urban residents of southern Ontario. Furthermore, even within regions, risk factors are inequitably distributed. For example, francophone communities in northern Ontario have lower average incomes than anglophone Ontarians and higher prevalence of risk factors, especially cigarette smoking; on average this population is older and reports higher incidence of CHD [22,23]. CHD risk factors are also more prevalent in disadvantaged inner city residents of Toronto than in the general urban population, and inner city residents encounter greater barriers to risk modification [24]. Physical inactivity is more prevalent in the Toronto area than some northern areas of the province [2]. The importance of both approaches lies in their potential to lead us beyond individuated approaches to health behaviour change. For example, “lay epidemiology” draws attention to local and collectively constructed knowledge about heart disease and health behaviour [7-9]. These shared understandings are part of social connectivity and positioning, which in turn may be threatened by shifts of identity posed by health risk or health-related behaviour change. Attention to patterns in particular geographic regions highlights the role of local infrastructures, climate and economic conditions [18]. These contextual circumstances play out differently for sociodemographic groups within the same region because they are afforded different opportunities, barriers and resources for health. Thus, within both streams of research, there is indication that an ecological lens is necessary in understanding the fate of people‟s risk reduction goals. 1.1. Purpose There is a need to illuminate the complex interplay between geographic location (place), sociodemographic position, and people‟s efforts to understand and modify their risk for CHD. We undertook a qualitative study to examine and compare experiences with cardiovascular risk modification in two selected regions: Sudbury and District (northern Ontario) and the Greater Toronto Area (southern Ontario). This was linked with a larger trial (led by RPN) that tested a risk reduction telephone counseling intervention for individuals at high risk for CHD in three regions of Ontario. Trial participants‟ risk for cardiovascular disease was determined based on the Framingham algorithm, using a standardized telephone assessment interview and physician referral form [25,26]. Individuals at elevated risk for cardiovascular disease (i.e., two or more risk factors) were invited to participate in the trial, including those with an existing diagnosis of atherosclerotic heart disease. The purpose of our associated qualitative study was to understand the social and material conditions of health behaviour change from the perspectives of people who had been made aware of their high risk for CHD and had received information about cardiovascular risk modification.