Development of the Volunteer Peer Educator Role in a Community Cardiovascular Health Awareness Program (CHAP): A Process Evaluation in Two Communities

Tuakana-teina peer education programme to help Māori elders enhance wellbeing and social connectedness

BACKGROUND

There are significant inequities between Māori (Indigenous people) and non-Māori in ageing outcomes. This study used a strengths-based approach based on the key cultural concept of mana motuhake (autonomy and self-actualisation) to develop a tuakana-teina (literally older sibling-younger sibling) peer education programme to assist kaumātua (elders) in addressing health and social needs. The purpose of this study was to test the impact on those receiving the programme. Three aims identify the impact on outcomes, resources received and the cost effectiveness of the programme.

METHODS

Five Kaupapa Māori (research and services guided by Māori worldviews) iwi (tribe) and community providers implemented the project using a partnership approach. Tuakana (peer educators) had up to six conversations each with up to six teina (peer learners) and shared information related to social and health services. A pre- and post-test, clustered staggered design was the research design. Participants completed a baseline and post-programme assessment of health and mana motuhake measures consistent with Māori worldviews. Open-ended questions on the assessments, five focus groups, and four individual interviews were used for qualitative evaluation.

FINDINGS

A total of 113 kaumātua were recruited, and 86 completed the programme. The analysis revealed improvements in health-related quality of life, needing more help with daily tasks, life satisfaction, paying bills and housing problems. Qualitative results supported impacts of the programme on mana motuhake and hauora (holistic health) through providing intangible and tangible resources. Cost-effectiveness analysis showed that the intervention is cost effective, with a cost per QALY of less than the conventional threshold of three times GDP per capita.

CONCLUSIONS

A culturally-resonant, strengths-based programme developed through a participatory approach can significantly improve health and social outcomes in a cost-effective way.

TRIAL REGISTRY

Clinical trial registry: Trial registration: (ACTRN12620000316909). Prospectively registered 06/03/2020, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=379302&isClinicalTrial=False .

Volunteers: An Effective Medium for Delivering Therapeutic Lifestyle Interventions

PURPOSE

Lifestyle modification programs have been shown to effectively treat chronic disease. The Coronary Health Improvement Program has been delivered by both paid professional and unpaid volunteer facilitators. This study compared participant outcomes of each mode in the United States.

DESIGN

Pre-/post-analysis of CHIP interventions delivered between 1999 and 2012.

SETTING

Professional-delivered programs in Rockford Illinois 1999-2004 and volunteer-delivered programs across North America 2005-2012.

SUBJECTS

Adults ≥21 years (professional programs N = 3158 34.3% men, mean age = 54.0 ± 11.4 years; volunteer programs N = 7115 33.4% men, mean age = 57.4 ± 13.0 years).

MEASURES

Body mass index, blood pressure (systolic and diastolic), blood lipid profile (total cholesterol, high-density lipoprotein, triglycerides, low-density lipoprotein), and fasting plasma glucose.

ANALYSIS

Analysis of Covariance, with adjustment for age, gender, BMI change and baseline biometric and effect sizes.

RESULTS

The professional-delivered programs achieved significantly greater reductions in BMI (.4%, P < .001) and HDL (1.9%, P < .001) and the volunteer-delivered programs achieved greater reductions in SBP (1.4%, P < .001), DBP (1.1%, P < .001), TC (1.4%, P = .004), LDL (2.3%, P < .001), TG (4.0%, P = .006), and FPG (2.7%, P < .001). However, the effect size differences between the groups were minimal (Cohen's d .1-.2).

CONCLUSIONS

Lifestyle modification programs have been shown to effectively treat chronic disease. The Complete Health Improvement Program (CHIP) lifestyle intervention has been delivered by both paid professional and unpaid volunteer facilitators. This study compared selected chronic disease biometric outcomes of participants in each mode in the United States. It found volunteer-delivered programs do not appear to be any less effective than programs delivered by paid professionals, which is noteworthy as volunteers may provide important social capital in the combat of chronic disease.

Impact of peer education on sexual health knowledge among adolescents and young persons in two North Western states of Nigeria

Background

Generally, social development among young people is largely influenced by their peers. Peer education is a proven and effective approach for promoting reproductive health among young people, especially HIV/AIDS education. This study was conducted to assess the effectiveness of a peer-led education intervention in addressing sexual and reproductive health related knowledge and concerns among young people in Kaduna and Kano States, northwest Nigeria.

Methods

A pre and post-test study was conducted among 8930 young people aged 15–24 years who participated in the MTV Shuga Peer Education intervention selected from communities in Kaduna and Kano States. A baseline pre-test was conducted before the education program, and it was followed up with a post-test at the end of the five-day long peer education sessions.

Results

Majority of the respondents, 7846 (87.9%) were adolescents aged 15–19 years while the rest 1084 (12.1%) were young adults aged 20–24 years. A total of 6099 (68.3%) of the respondents correctly stated that condoms prevent pregnancy during the pre-test compared to 6429 (72.0%) peers during the post test. Lower abdominal pain was correctly indicated as a symptom of STI by 6282 (70.3%) and 6984 (78.2%) of the respondents at pre-test and post-test respectively. More males (58.5%) had good knowledge about condom use compared to the females, 51.9% (χ² = 24.62, p < 0.001). while more females (79.6%) compared to 74.7% males opined that going for HIV test with their sexual partner is important to them during the pre-test (χ² = 19.44, p≤ 0.001).However, no significant difference was observed on knowledge of condom use and opinion on going for HIV testing with sexual partner among either gender at post-test.

Conclusion

Significant positive changes in knowledge, views and opinions regarding STIs and HIV, HIV anti-stigma and the use of condoms were observed following exposure to the peer sessions of the MTV Shuga peer education intervention. Sustained exposure and access to informative and enlightening peer education sessions over time have the potential to comprehensively improve SRH knowledge, influence positive opinion change and in turn adoption of positive behaviours among young people.

Peer education is an approach to health promotion, in which community members are supported to promote health-enhancing change among their peers. This approach is being adopted to improve access to comprehensive sexual and reproductive health information among young people. Society for Family Health implemented a peer education intervention (MTV Shuga Naija Peer Education Project) among young people aged 15–24 years in Kaduna and Kano States, Nigeria. This study presents findings on the effectiveness of peer-education in addressing myths, misconceptions and improving knowledge on sexual and reproductive health issues.

The knowledge and opinion of the project beneficiaries were assessed before and after exposure to the project’s interventions (the MTV Shuga drama series and peer education). Findings from both assessments were compared and the results were presented in this article. In total, 8930 persons between the age of 15–24 years were assessed. We observed that more proportion of the respondents after exposure to the project’s intervention correctly identified that condom use can prevent pregnancy and that lower abdominal pain is a sign of sexually transmitted illnesses, when compared to before the intervention. Significant improvement was observed for most of other questions that the respondents were asked about.

We generally observed that the peer education strategy used in this study resulted in the knowledge of HIV/AIDS, sexually transmitted illnesses, contraception, and other reproductive health issues among young people. The use of peer-to-peer education should be encouraged and consistently adopted to improve knowledge of pertinent health issues among young people.

Volunteer engagement to inform research on cardiovascular health awareness, Canada

Volunteers have been extensively used in health promotion programmes. However, they have been less frequently involved in the research process. In its most recent iterations, the Cardiovascular Health Awareness Program (CHAP) integrated volunteers (i) to facilitate CHAP sessions with participating patients for data collection and (ii) to evaluate the intervention. Drawing on the patient and public involvement literature, our research team included volunteers in the data collection and evaluation of CHAP sessions as part of the programme's implementation in the province of Quebec (Canada). We sought volunteers' formal feedback through individual online and phone interviews and through focus groups for each of the four projects conducted in Quebec. We found that volunteers provide valuable insight on the research protocol as well as patient needs. Their feedback led to several modifications to the research protocol and procedures of subsequent CHAP sessions. Changes included involving volunteers at earlier stages of the research process, adding more learning modules and practice sessions during the volunteer training and defining research priorities according to patient needs. Our methodology of engaging volunteers in the research process was useful to gain important and unique insight on patient needs and for future programme planning to modify the research process.

Implementation of Modified Cardiovascular Health Awareness Program for Canadian Adults on a Waiting List for a Family Physician

INTRODUCTION

The Cardiovascular Health Awareness Program (CHAP) was originally developed and evaluated as a community-based cardiovascular diseases (CVD) prevention program in communities where access to family physicians was not a significant issue. Many Canadians now face sub-optimal access to a regular source of primary care. Centralized waiting lists and prioritization based on urgency of medical need were created to address this problem. We aimed to assess the acceptability, CVD risk profile, and potential benefits of offering a modified version of CHAP to adults on the waiting list.

METHODS

The implementation was conducted in Laval (Canada) between March and June 2016, targeting individuals 40 years of age or older who were registered on the waiting list (GACO) and had a priority code of 3. Participants were invited through a personalized letter to attend sessions in community health centers. During the sessions, participants completed CVD risk profiles, risk of type 2 diabetes questionnaire (CANRISK); had their blood pressure, height and weight as well as waist circumference measured. They also received targeted healthy lifestyle and patient education materials and were referred to local programs including a medical follow-up, when required.

RESULTS

A total of 1976 invitation letters were sent resulting in 281 (14.2%) participants. The average age of attendees was 58.1 (SD = 8.2) and a majority were female (58%, n = 163). A third of participants (34.2%, n = 96) had BP ≥140/90 and 11.4% (n = 32) were classified as having a very high risk for developing diabetes. Almost half (41.6%, n = 117) of participants were referred either to health promotion programs offered by local health authorities, to family physicians (4.6%, n = 13) or emergency departments (1.8%, n = 5) for short-term medical assistance.

CONCLUSION

Despite low participation rate, many adults on a waiting list had elevated risk for CVD and would greatly benefit from having a regular source of primary care.

Attendance, activation and health profiles of participants, a prospective study on a regional cardiometabolic disease self-management program in Laval, Canada

Background

Chronic diseases are responsible for over 70% of all deaths globally. While some self-management programs have been shown to be efficacious in preventing or altering trajectories for some chronic conditions, scaling-up and sustaining such programs beyond tightly-controlled study conditions remain a major challenge. CISSS-Laval partnered with the Cardiovascular Health Awareness Program team to co-develop Cible-santé/prévention and evaluate the first cohort of participants enrolled in the program, in order to better understand the program’s implementation and scope. The objective of the current study was to describe the profile of attendees and the level of engagement of participants in a new, region-wide cardiometabolic disease self-management program offered in Laval, Canada.

Methods

This was a prospective study with no comparison group. Potential participants were identified and referred to the program from April to December 2015 by their primary care health professional practicing in one of the city’s interdisciplinary primary care clinics. They had their blood pressure, waist circumference and body mass index measured by trained volunteers, and completed a questionnaire on health habits, level of activation and the risk of developing prediabetes and type 2 diabetes over the next 10 years.

Results

A descriptive analysis of the first cohort of 141 Cible-Santé/prévention participants showed very low attendance. Furthermore, only 1 in 10 of enrolled participants completed the full program. The program typically attracted adults with some risk factors associated with their conditions (high waist circumference, obesity), but with an already high level of knowledge, skills and confidence to participate in self-management activities.

Conclusion

This study provides a portrait of new participants to a self-management cardiometabolic disease program, which highlights the potential of supporting patients ready to make changes but also exposes the difficulty of attracting a larger number and diversity of participants and in encouraging completion of the program.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10558-6.

A case study of using the He Pikinga Waiora Implementation Framework: challenges and successes in implementing a twelve-week lifestyle intervention to reduce weight in Māori men at risk of diabetes, cardiovascular disease and obesity

Background

Māori men have stark health inequities around non-communicable diseases. This study describes the case of a partnership attempting to develop and implement a culturally centred intervention through a collaborative partnership to potentially address the inequities. In particular, the partnership followed a participatory, co-design approach using the He Pikinga Waiora (HPW) Implementation Framework; the study presents lessons learnt in addressing health inequities following this framework.

Methods

The partnership involved a university research team and a Māori community health provider. They engaged with other stakeholders and several cohorts of Māori men through a co-design process to adapt a 12-week lifestyle intervention. The co-design process was documented through meeting notes and interviews with partners. Two cohorts participated in separate single group pre-intervention/post-intervention designs with multi-method data collection. Key outcome measures included weight loss, self-reported health, physical activity, and nutrition. Post-intervention data collection included qualitative data.

Results

The co-design process resulted in a strong and engaged partnership between the university team and the provider. There were significant challenges in implementing the intervention including having two additional partner organisations dropping out of the partnership just after the initial implementation phase. However, a flexible and adaptable partnership resulted in developing two distinct lifestyle interventions run with 32 Māori men (in two different cohorts of 8 and 24). All but one in the first cohort completed the programme. The first cohort had a modest although statistically insignificant improvement in weight loss (d = 1.04) and body mass index (BMI; d = 1.08). The second cohort had a significant reduction in weight loss (d = 1.16) and BMI (d = 1.15). They also had a significant increase in health-related quality of life (d = 1.7) and self-rated health (d = 2.0).

Conclusion

The HPW Framework appears to be well suited to advance implementation science for Indigenous communities in general and Māori in particular. The framework has promise as a policy and planning tool to evaluate and design interventions for chronic disease prevention in Indigenous communities. Despite this promise, there are structural challenges in developing and implementing interventions to address health inequities.

Trial registration

Retrospectively registered, Australia New Zealand Clinical Trials Registry, ACTRN12619001783112.

Kaumātua Mana Motuhake: peer education intervention to help Māori elders during later-stage life transitions

BACKGROUND

Aotearoa/New Zealand has a population that is ageing and there are challenges to health and social outcomes related to related to key life transitions (e.g., retirement, change in health conditions, loss of spouse). Further, there are significant inequities between Māori (Indigenous people) and non-Māori in ageing outcomes. The purpose of this study was to test the impacts and cost effectiveness of a tuakana/teina (peer education) intervention on kaumātua (elders) receiving the intervention. This study was framed by a strengths-based approach based on the key cultural concept of mana motuhake (autonomy and self-actualisation).

METHODS

This study was grounded in principles of Kaupapa Māori and community-based participatory research to bring together a diverse group of stakeholders to co-develop and co-evaluate the intervention. The intervention had tuakana (peer educators) having conversations with up to six teina (recipients) and providing information related to health and social services. The research design was a pre- and post-test, clustered staggered design. Participants completed a baseline assessment of health and mana motuhake measures consistent with Māori worldviews along with two follow-up assessments (one after the first intervention group completed its activities and a second after the second intervention group completed its activities). Additionally, five focus groups and open-ended questions on the assessments were used to provide qualitative evaluation.

FINDINGS

A total of 180 kaumātua were recruited to the intervention with 121 completing it. The analysis revealed improvements over time in the expected direction on most of the variables. However, only three of the variables had statistically significant intervention effects: received support, tribal identity, and trouble paying bills. Qualitative results supported impacts of the intervention on mana motuhake, social connectedness, and tangible/information support related to services. Cost-effectiveness analysis showed that the intervention is cost effective, with a cost per QALY of less than the conventional threshold of three times gross domestic product per capita.

CONCLUSIONS

The findings support the relevancy and importance of kaumātua knowledge to create a strengths-based approach to improve health and social outcomes. This study demonstrates that a contextually based and culturally safe age-friendly environments can facilitate engagement and participation by kaumātua for kaumātua.

TRIAL REGISTRY

Australia New Zealand Clinical Trial Registry (ACTRN12617001396314); Date Registered: 3 October 2017 (retrospectively registered); https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373733&isClinicalTrial=False.

Design and rationale for a pragmatic cluster randomized trial of the Cardiovascular Health Awareness Program (CHAP) for social housing residents in Ontario and Quebec, Canada

BACKGROUND

The Cardiovascular Health Awareness Program (CHAP) uses volunteers to provide cardiovascular disease (CVD) and diabetes screening in a community setting, referrals to primary care providers, and locally available programs targeting lifestyle modification. CHAP has been adapted to target older adults residing in social housing, a vulnerable segment of the population. Older adults living in social housing report poorer health status and have a higher burden of a multitude of chronic illnesses, such as CVD and diabetes. The study objective is to evaluate whether there is a reduction in unplanned CVD-related Emergency Department (ED) visits and hospital admissions among residents of social seniors' housing buildings receiving the CHAP program for 1 year compared to residents in matched buildings not receiving the program.

METHODS/DESIGN

This is a pragmatic, cluster randomized controlled trial in community-based social (subsidized) housing buildings in Ontario and Quebec. All residents of 14 matched pairs (intervention/control) of apartment buildings will be included. Buildings with 50-200 apartment units with the majority of residents aged 55+ and a unique postal code are included. All individuals residing within the buildings at the start of the intervention period are included (intention to treat, open cohort). The intervention instrument consists of CHAP screens for high blood pressure using automated blood pressure monitors and for diabetes using the Canadian Diabetes Risk (CANRISK) assessment tool. Monthly drop-in sessions for screening/monitoring are held within a common area of the building. Group health education sessions are also held monthly. Reports are sent to family doctors, and attendees are encouraged to visit their family doctor. The primary outcome measure is monthly CVD-related ED visits and hospitalizations over a 1-year period post randomization. Secondary outcomes are all ED visits, hospitalizations, quality of life, cost-effectiveness, and participant experience.

DISCUSSION

It is anticipated that CVD-related ED visits and hospitalizations will decrease in the intervention buildings. Using the volunteer-led CHAP program, there is significant opportunity to improve the health of older adults in social housing.

TRIAL REGISTRATION

ClinicalTrials.gov,NCT03549845. Registered on 15 May 2018. Updated on 21 May 2019.

Kaumātua Mana Motuhake: A study protocol for a peer education intervention to help Māori elders work through later-stage life transitions

Background

The Aotearoa/New Zealand population is ageing and numerous studies demonstrate with this phenomenon comes increases in non-communicable diseases, injuries and healthcare costs among other issues. Further, significant inequities exist between Māori (Indigenous peoples of Aotearoa/New Zealand) and non-Māori around poor ageing and health. Most research addressing these issues is deficit oriented; however, the current research project takes a strengths-based approach that highlights the potential of kaumātua (elders) by asserting mana motuhake (autonomy, identity and self-actualisation). We believe that the esteem of elders in Māori culture signals transformative potential. Specifically, this project utilises a ‘tuakana-teina’ (older sibling/younger sibling) peer-educator model, where kaumātua work with other kaumātua in relation to health and wellbeing. The objectives of the project are (a) to develop the capacity of kaumātua as peer educators, whilst having positive impacts on their sense of purpose, health and wellbeing; and (b) to enhance the social and health outcomes for kaumātua receiving the intervention.

Methods

The research is grounded in principles of Kaupapa Māori and community-based participatory research, and brings together an Indigenous community of kaumātua, community health researchers, and academic researchers working with two advisory boards. The project intervention involves an orientation programme for tuakana peer educators for other kaumātua (teina). The research design is a pre- and post-test, clustered staggered design. All participants will complete a baseline assessment of health and wellbeing consistent with Māori worldviews (i.e., holistic model). The tuakana and teina participants will be divided into two groups with the first group completing the intervention during the first half of the project and the second group during the second half of the project. All participants will complete post-test assessments following both interventions allowing comparison of the two groups along with repeated measures over time.

Discussion

The findings will provide an evidence base for the importance and relevancy of kaumātua knowledge to create contextually based and culturally safe age-friendly environments that facilitate engagement and participation by kaumātua for kaumātua. If the model is effective, we will seek to facilitate the dissemination and scalability of the intervention.

Trial registration

Australia New Zealand Clinical Trial Registry (ACTRN12617001396314); Date Registered: 3 October 2017 (retrospectively registered).

Electronic supplementary material

The online version of this article (10.1186/s12877-019-1041-2) contains supplementary material, which is available to authorized users.

Training Community Residents to Address Social Determinants of Health in Underresourced Communities

Disparities in chronic disease and life expectancy remain a significant public health problem and are largely attributable to social determinants of health. Community health workers (CHWs) promote health equity through individual- and community-level activities, and leadership and advocacy skills training make CHWs more likely to catalyze structural change. CHWs are increasingly being integrated into clinical practices to support care management, creating a need for new grassroots community-level advocates. We adapted for community residents an existing CHW training curriculum focused on social determinants of health and effecting community change. We offered 36 hours of training at community-based locations in New Orleans, Louisiana. We assessed baseline civic and community participation and pre- and postknowledge for each lesson. Among 43 enrollees, 42 completed the program. The majority were Black (92.7%), female (92.7%), and retired or unemployed (77.5%), with a median age of 61.5 years. In the past year, 85% of participants had volunteered, 57.1% had been involved with a community organization, and 32.4% had contacted the city council. Participants demonstrated statistically significant increases in knowledge in 5 of 6 lessons. Our success in increasing knowledge of advocacy among a civically engaged group suggests that trainees may become community leaders in addressing social determinants of health.

The Role of Clinical Psychology and Peer to Peer Support in the Management of Chronic Medical Conditions - A Practical Example With Adults With Congenital Heart Disease

Clinical psychology services and peer to peer support can both contribute in increasing the psychological wellbeing of patients with chronic medical conditions. In this perspective paper, indications are given about the provision these services for the specific case of adults with congenital heart disease. These patients are at an increased risk of psychological distress, neurocognitive deficits, and social challenges. The psychosocial characteristics and mental health treatment preferences of these patients are briefly described, followed by guidelines and indications for the implementation of clinical psychology services. The most structured peer to peer program available for this population is subsequently illustrated and finally, specific benefits and challenges when it comes to the integration of both services are reported.

Reducing the confusion and controversies around pragmatic trials: using the Cardiovascular Health Awareness Program (CHAP) trial as an illustrative example

Abstract

Knowledge translation (KT) involves implementation of evidence-based strategies and guidelines into practice to improve the process of care and health outcomes for patients. Findings from pragmatic trials may be used in KT to provide patients, healthcare providers and policymakers with information to optimize healthcare decisions based on how a given strategy or intervention performs under the real world conditions. However, pragmatic trials have been criticized for having the following problems: i) high rates of loss to follow-up; ii) nonadherence to study intervention; iii) unblinded treatment and patient self-assessment, which can potentially create bias; iv) being less perfect experiments than efficacy trials; v) sacrificing internal validity to achieve generalizability; and vi) often requiring large sample sizes to detect small treatment effects in heterogeneous populations. In this paper, we discuss whether these criticisms hold merit, or if they are simply driven by confusion about the purpose of pragmatic trials. We use the Cardiovascular Health Awareness Program (CHAP) trial - a community randomized pragmatic trial designed to assess whether offering a highly organized, community-based CHAP intervention compared to usual care can reduce cardiovascular disease-related outcomes - to address these specific criticisms and illustrate how to reduce this confusion.

Trial registration

Current controlled trials ISRCTN50550004 (9 May 2007).

"We are all one together": peer educators' views about falls prevention education for community-dwelling older adults--a qualitative study

Background

Falls are common in older people. Despite strong evidence for effective falls prevention strategies, there appears to be limited translation of these strategies from research to clinical practice. Use of peers in delivering falls prevention education messages has been proposed to improve uptake of falls prevention strategies and facilitate translation to practice. Volunteer peer educators often deliver educational presentations on falls prevention to community-dwelling older adults. However, research evaluating the effectiveness of peer-led education approaches in falls prevention has been limited and no known study has evaluated such a program from the perspective of peer educators involved in delivering the message. The purpose of this study was to explore peer educators’ perspective about their role in delivering peer-led falls prevention education for community-dwelling older adults.

Methods

A two-stage qualitative inductive constant comparative design was used. In stage one (core component) focus group interviews involving a total of eleven participants were conducted. During stage two (supplementary component) semi-structured interviews with two participants were conducted. Data were analysed thematically by two researchers independently. Key themes were identified and findings were displayed in a conceptual framework.

Results

Peer educators were motivated to deliver educational presentations and importantly, to reach an optimal peer connection with their audience. Key themes identified included both personal and organisational factors that impact on educators’ capacity to facilitate their peers’ engagement with the message. Personal factors that facilitated message delivery and engagement included peer-to-peer connection and perceived credibility, while barriers included a reluctance to accept the message that they were at risk of falling by some members in the audience. Organisational factors, including ongoing training for peer educators and formative feedback following presentations, were perceived as essential because they affect successful message delivery.

Conclusions

Peer educators have the potential to effectively deliver falls prevention education to older adults and influence acceptance of the message as they possess the peer-to-peer connection that facilitates optimal engagement. There is a need to consider incorporating learnings from this research into a formal large scale evaluation of the effectiveness of the peer education approach in reducing falls in older adults.

When it comes to lifestyle recommendations, more is sometimes less: a meta-analysis of theoretical assumptions underlying the effectiveness of interventions promoting multiple behavior domain change

A meta-analysis of 150 research reports summarizing the results of multiple behavior domain interventions examined theoretical predictions about the effects of the included number of recommendations on behavioral and clinical change in the domains of smoking, diet, and physical activity. The meta-analysis yielded 3 main conclusions. First, there is a curvilinear relation between the number of behavioral recommendations and improvements in behavioral and clinical measures, with a moderate number of recommendations producing the highest level of change. A moderate number of recommendations is likely to be associated with stronger effects because the intervention ensures the necessary level of motivation to implement the recommended changes, thereby increasing compliance with the goals set by the intervention, without making the intervention excessively demanding. Second, this curve was more pronounced when samples were likely to have low motivation to change, such as when interventions were delivered to nonpatient (vs. patient) populations, were implemented in nonclinic (vs. clinic) settings, used lay community (vs. expert) facilitators, and involved group (vs. individual) delivery formats. Finally, change in behavioral outcomes mediated the effects of number of recommended behaviors on clinical change. These findings provide important insights that can help guide the design of effective multiple behavior domain interventions.

Evaluation of a peer-led self-management education programme PEP Talk: Diabetes, Healthy Feet and You

PEP (Peer Education Programme) Talk: Diabetes, Healthy Feet and You is a peer-led self-management programme developed to address the problems of growing prevalence of diabetes and its complications, and limited health care dollars. An evaluation of the programme, how it might be situated within a public health perspective and potential bridges for its implementation in communities throughout Canada and worldwide, are presented. The programme consisted of workshops that were conducted by volunteer peer leaders and health care professionals in 12 communities in 10 Canadian provinces; the volunteers were supported through monthly mentoring teleconferences, on-line tips and discussion board conversations. A web portal was developed to be used by the team, volunteers and community participants. Workshop curriculum was developed based on diabetes footcare and self-management best practise guidelines. Community participants answered pre-and post-workshop statements that indicated that learning occurred, as indicated by an increase in the number of statements answered correctly. Participants' feedback about the workshops was positive. In telephone follow-up interviews, 97% of respondents reported having changed their foot self-management behaviours. The portal was commonly used according to website visits, but not as much as expected for registration of community participants. It is recommended that this programme be made widely available and tailored to the specific needs of the communities and that further evaluation be conducted.

Translating evidence into practice in low resource settings: cervical cancer screening tests are only part of the solution in rural India

BACKGROUND

The majority of women in rural India have poor or no access to cervical cancer screening services, although one-quarter of all cervical cancers in the world occur there. Several large trials have proven the efficacy of low-tech cervical cancer screening methods in the Indian context but none have documented the necessary components and processes of implementing this evidence in a low-resource setting.

METHODS

This paper discusses a feasible model of implementation of cervical cancer screening programme in low-resource settings developed through a pilot research project carried out in rural Tamilnadu, India. The programme used visual inspection of cervix after acetic acid application (VIA) as a screening tool, nurses in the primary care centres as the primary screeners and peer educators within Self-Help Women groups to raise community awareness.

RESULTS

The uptake of screening was initially low despite the access to a screening programme. However, the programme witnessed an incremental increase in the number of women accessing screening with increasing community awareness.

CONCLUSIONS

The investigators recommend 4 key components to programme implementation in low-resource setting: 1) Evidence-based, cost-effective test and treatment available within the reach of the community; 2) Appropriate referral pathways; 3) Skilled health workers and necessary equipment; and 4) Optimisation of health literacy, beliefs, attitudes of the community.

A Multilevel Framework

This article reviews the literature on the micro (i.e., individual level) and macro levels (i.e., organizational level) of positive behavior to propose a framework that includes seven levels of positive behaviors—individual, dyadic, team/group, organizational, community, societal, and environmental levels. The micro level of positive organizational behavior is extended from the individual level to include the dyadic and team/group levels. The macro level of positive organizational scholarship is extended from the organizational level to include the community, societal, and environmental levels. The role of leadership as antecedents to positive behaviors is also developed. Three positive forms of leadership (i.e., transformational leadership, servant leadership, and authentic leadership) are used as antecedents, and the potential multilevel outcomes associated with positive behavior are explored. This article provides testable propositions and sets the stage for future empirical research.

Developing a Theoretical Framework for Complex Community-Based Interventions

Applying existing theories to research, in the form of a theoretical framework, is necessary to advance knowledge from what is already known toward the next steps to be taken. This article proposes a guide on how to develop a theoretical framework for complex community-based interventions using the Cardiovascular Health Awareness Program as an example. Developing a theoretical framework starts with identifying the intervention’s essential elements. Subsequent steps include the following: (a) identifying and defining the different variables (independent, dependent, mediating/intervening, moderating, and control); (b) postulating mechanisms how the independent variables will lead to the dependent variables; (c) identifying existing theoretical models supporting the theoretical framework under development; (d) scripting the theoretical framework into a figure or sets of statements as a series of hypotheses, ifthen logic statements, or a visual model; (e) content and face validation of the theoretical framework; and (f) revising the theoretical framework. In our example, we combined the “diffusion of innovation theory” and the “health belief model” to develop our framework. Using the Cardiovascular Health Awareness Program as the model, we demonstrated a stepwise process of developing a theoretical framework. The challenges encountered are described, and an overview of the strategies employed to overcome these challenges is presented.

Factors associated with faith-based health counselling in the United States: implications for dissemination of evidence-based behavioural medicine

Health counselling is an evidence-based behavioural medicine approach and the most commonly reported form of faith-based health interventions. Yet, no research has explored the factors influencing the implementation of faith-based health counselling. Therefore, this study examined individual, organisational and environmental factors associated with offering/not offering faith-based health counselling programmes within faith-based organisations. A national, internet-based, opt-in, cross-sectional survey of faith leaders (N = 676) was conducted (March-December 2009) to assess faith leaders' demographic information, health status, fatalism, health-related attitudes and normative beliefs, attitudes towards health counselling, institutional and occupational information, and perceptions of parent organisation support for health and wellness interventions. Most faith leaders reported offering some type of health counselling in the past year [n = 424, 62.7%, 95% CI (59.0, 66.3)]. Results of a multivariate logistic regression showed that faith leaders reporting greater proxy efficacy (OR = 1.40, P = 0.002), greater comfort in speaking with church members about health (OR = 1.25, P = 0.005), greater perceived health (OR = 1.27, P = 0.034), and who worked at larger churches (OR ≥ 3.2, P ≤ 0.001) with greater parent organisation support (OR = 1.33, P = 0.002) had significantly higher odds of offering faith-based health counselling. Church size and parent organisation support for faith-based health interventions appear to be important factors in the presence of faith leader health counselling. The content of faith leader health counselling training should aim to increase faith leaders' confidence that church members will successfully change their health behaviours as a result of the health counselling and increase faith leaders' comfort in speaking with church members about health. Future research is needed to examine efficacious and effective dissemination methods such as the use of internet trainings, CD ROM materials and incorporating health counselling into seminary school.

Community Mobilization, Participation, and Blood Pressure Status in a Cardiovascular Health Awareness Program in Ontario

Purpose.

To determine the feasibility of a community-wide approach integrated with primary care (Cardiovascular Health Awareness Program [CHAP]) to promote monitoring of blood pressure (BP) and awareness of cardiovascular disease risk.

Design.

Demonstration project.

Setting.

Two midsized Ontario communities.

Participants.

Community-dwelling seniors.

Intervention.

CHAP sessions were offered in pharmacies and promoted to seniors using advertising and personalized letters from physicians. Trained volunteers measured BP, completed risk profiles, and provided risk-specific education materials.

Method.

We examined the distribution of risk factors among participants and predictors of multiple visits and elevated BP.

Results.

Opinion leaders aided recruitment of family physicians (n = 56/63) and pharmacists (n = 18/19). Over 90 volunteers were recruited. Invitations were mailed to 4394 seniors. Over 10 weeks, there were 4165 assessments of 2350 unique participants (approximately 30% of senior residents). 37.5% of attendees had untreated (16%; 360/2247) or uncontrolled (21.5%; 482/2247) high BP. Participants who received a letter (odds ratio [OR] 2.5, 95% confidence interval [CI] 2.1–3.0), had an initial elevated BP (OR 1.2, 95% CI 1.0–1.5), or reported current antihypertensive medication (OR 1.4, 95% CI 1.1–1.6) were more likely to attend multiple sessions (p ≤ .05 for all). Older age (≥ 70 years; OR 1.5, 95% CI 1.3–1.8), BMI ≥ 30 (OR 1.7, 95% CI 1.4–2.2), current antihypertensive medication (OR 1.6, 95% CI 1.3–1.9), and diabetes (OR 2.4, 95% CI 1.9–3.2) predicted elevated BP (p < .001 for all).

Conclusion.

The program yielded learning about community mobilization and identified a substantial number of seniors with undiagnosed/uncontrolled high BP.

Type 2 diabetes patients educated by other patients perform at least as well as patients trained by professionals

BACKGROUND

Diabetes education can improve the quality of care of people with diabetes, but many organizations are not equipped to manage its implementation. Involving people with diabetes in the education process can overcome the problem. Thus, we compared clinical, metabolic and psychological outcomes in people with type 2 diabetes 1 year after attending a structured diabetes education programme implemented by professional educators versus the same programme implemented by trained peers with diabetes that also provided ongoing peer support.

METHODS

People with type 2 diabetes (25-75 years) were randomly assigned to attend a 4-week structured diabetes education course delivered by professional educators (control) or previously trained peers (peer). Peers also received continuing psychological support, including examples on how to apply diabetes knowledge in daily life via weekly peer cellular phone calls and bimonthly face-to-face interviews in small groups (ten patients), using a structured questionnaire related to the patient's clinical, metabolic and psychological progress. Identical outcome data from both groups were used for follow-up.

RESULTS

Both groups had a comparable positive effect on clinical, metabolic and psychological indicators immediately following the programme. Over the following year, peer-educated subjects had lower A(1C) and systolic blood pressure and showed higher adherence to physical activity and better control of hypoglycaemic episodes.

CONCLUSION

The non-inferiority of the peer outcomes and the mentioned improvements in this group suggest that volunteer trained peer educators and ongoing support can be successful. This approach provides an effective alternative method of education, especially in areas with limited availability of professionals and economic resources.

Economic appraisal of a community-wide cardiovascular health awareness program

BACKGROUND

Cardiovascular disease (CVD) is a leading cause of hospitalizations, death, and health care costs. Although studies have shown that modifying CVD risk factors at the patient level improves patient prognosis, the effect of community-wide interventions at the population level has been uncertain.

OBJECTIVE

To evaluate the resource use and cost consequences of a community-wide Cardiovascular Health Awareness Program (CHAP).

METHODS

Thirty-nine medium-sized communities in Ontario, Canada, participated in a community cluster randomized controlled trial stratified by population size and geographic location. All community-dwelling elderly residents (>65 years) in each community were included. Family physicians, pharmacists, community nurses, local organizations, and volunteers in the intervention communities implemented the program. Rates and costs of CVD hospitalizations, all hospitalizations, emergency department visits, physician visits, and prescription medication use in the year before and after the intervention were compared for the 19 control and 20 CHAP communities by using province-wide linked administrative databases. The cost of implementing and administrating CHAP in each community was combined with total community health care cost to determine the net cost effect.

RESULTS

CHAP was associated with a reduction in CVD hospitalization costs. There were no differences in utilization rates or costs for overall hospitalizations, in visits to emergency rooms, physicians, or specialists, or in the use of prescription medications. Results were robust over a range of cost assumptions.

CONCLUSIONS

A community-wide CVD awareness program can be implemented and can reduce CVD-related hospitalization costs at the level of the community without a corresponding increase in overall health care costs.

Cost-effectiveness of a health-social partnership transitional program for post-discharge medical patients

BACKGROUND

Readmissions are costly and have implications for quality of care. Studies have been reported to support effects of transitional care programs in reducing hospital readmissions and enhancing clinical outcomes. However, there is a paucity of studies executing full economic evaluation to assess the cost-effectiveness of these transitional care programs. This study is therefore launched to fill this knowledge gap.

METHODS

Cost-effectiveness analysis was conducted alongside a randomized controlled trial that examined the effects of a Health-Social Transitional Care Management Program (HSTCMP) for medical patients discharged from an acute regional hospital in Hong Kong. The cost and health outcomes were compared between the patients receiving the HSTCMP and usual care. The total costs comprised the pre-program, program, and healthcare utilization costs. Quality of life was measured with SF-36 and transformed to utility values between 0 and 1.

RESULTS

The readmission rates within 28 (control 10.2%, study 4.0%) and 84 days (control 19.4%, study 8.1%) were significantly higher in the control group. Utility values showed no difference between the control and study groups at baseline (p = 0.308). Utility values for the study group were significantly higher than in the control group at 28 (p < 0.001) and 84 days (p = 0.002). The study group also had a significantly higher QALYs gain (p < 0.001) over time at 28 and 84 days when compared with the control group. The intervention had an 89% chance of being cost-effective at the threshold of £20000/QALY.

CONCLUSIONS

Previous studies on transitional care focused mainly on clinical outcomes and not too many included cost as an outcome measure. Studies examining the cost-effectiveness of the post-discharge support services are scanty. This study is the first to examine the cost-effectiveness of a transitional care program that used nurse-led services participated by volunteers. Results have shown that a health-social partnership transitional care program is cost-effective in reducing healthcare costs and attaining QALY gains. Economic evaluation helps to inform funders and guide decisions for the effective use of competing healthcare resources.

Process evaluation of a positive youth development program in Hong Kong based on different cohorts

There are only a few process evaluation studies on positive youth development programs, particularly in the Chinese context. This study aims to examine the quality of implementation of a positive youth development program (the Project P.A.T.H.S.: Positive Adolescent Training through Holistic Social Programmes) and investigate the relationships among program adherence, process factors, implementation quality, and perceived program success. Process evaluation of 97 classroom-based teaching units was conducted in 62 schools from 2005 to 2009. Findings based on different cohorts generally showed that there were high overall program adherence and implementation quality. Program adherence and implementation process were highly correlated with quality and success of the program. Multiple regression analyses further showed that both implementation process and program adherence are significant predictors of program quality and success. Theoretical and practical implications of the findings are discussed.

Healthy families Brooklyn: working with health advocates to develop a health promotion program for residents living in New York City housing authority developments

Decreasing health disparities must increase access to care, improve health education and ease navigating the health care system. Community Health Workers (CHW) take on these tasks in professional and culturally competent manners. The Healthy Families Brooklyn (HFB) Program serves residents in two public housing developments in Brooklyn, NY. Healthy Families Advocates (HFA), a type of CHW, are at the core of HFB. Curriculum development for, training of and services provided by the 10 HFA over 19 months are described. Pre and post knowledge assessments of HFAs are analyzed. Data from HFA surveys regarding training were analyzed using grounded theory methods. HFA served 172 unique clients at 222 visits. Services offered include accessing public benefits, health education, and connection to hospitals. There was a significant increase between pre and post assessment knowledge scores (P < 0.01). Taking temperature, building trust, and communicating care and connection emerged as themes related to interpersonal skills used by the HFA. The HFA are committed to moving clients forward in their health knowledge and behaviors. Themes from the HFA survey closely mirrored the HFA training curriculum. Lessons learned pertaining to training needs, data collection, and supervision are explored. The HFB program is a model way of working in communities in New York City and expansion with faith-based groups and other housing development communities is underway. Engaging communities to improve access, screening, prevention and treatment is paramount to the nation's health and the success of the 2010 Affordable Care Act. CHW's role in this mission is integral.

East meets West: a brief report of a culturally sensitive breast health education program for Chinese-Australian women

Chinese-Australian women are less likely to undergo breast health examination compared to women born in Australia, and cultural beliefs have been identified as a barrier to screening participation and breast health practices. We sought to promote awareness using trained lay health advisers (breast health advocates). This paper discusses the impact of the training program on advocate knowledge and beliefs, and women's experience as advocates. Thirty-seven of 50 women approached participated in an education program. The education was delivered over one full day and one half-day follow-up. Data were collected using questionnaires, focus groups and interviews. The program increased participant knowledge of breast health, decreased misperceptions about breast cancer and enhanced participants' readiness to discuss these topics with other Chinese women. Advocates enjoyed the role but did not always remember to promote awareness. The program appears effective and is suitable for further, more widespread testing.

Improving cardiovascular health at population level: 39 community cluster randomised trial of Cardiovascular Health Awareness Program (CHAP)

OBJECTIVE

To evaluate the effectiveness of the community based Cardiovascular Health Awareness Program (CHAP) on morbidity from cardiovascular disease.

DESIGN

Community cluster randomised trial.

SETTING

39 mid-sized communities in Ontario, Canada, stratified by location and population size.

PARTICIPANTS

Community dwelling residents aged 65 years or over, family physicians, pharmacists, volunteers, community nurses, and local lead organisations.

INTERVENTION

Communities were randomised to receive CHAP (n = 20) or no intervention (n = 19). In CHAP communities, residents aged 65 or over were invited to attend volunteer run cardiovascular risk assessment and education sessions held in community based pharmacies over a 10 week period; automated blood pressure readings and self reported risk factor data were collected and shared with participants and their family physicians and pharmacists.

MAIN OUTCOME MEASURE

Composite of hospital admissions for acute myocardial infarction, stroke, and congestive heart failure among all community residents aged 65 and over in the year before compared with the year after implementation of CHAP.

RESULTS

All 20 intervention communities successfully implemented CHAP. A total of 1265 three hour long sessions were held in 129/145 (89%) pharmacies during the 10 week programme. 15,889 unique participants had a total of 27,358 cardiovascular assessments with the assistance of 577 peer volunteers. After adjustment for hospital admission rates in the year before the intervention, CHAP was associated with a 9% relative reduction in the composite end point (rate ratio 0.91, 95% confidence interval 0.86 to 0.97; P = 0.002) or 3.02 fewer annual hospital admissions for cardiovascular disease per 1000 people aged 65 and over. Statistically significant reductions favouring the intervention communities were seen in hospital admissions for acute myocardial infarction (rate ratio 0.87, 0.79 to 0.97; P = 0.008) and congestive heart failure (0.90, 0.81 to 0.99; P = 0.029) but not for stroke (0.99, 0.88 to 1.12; P = 0.89).

CONCLUSIONS

A collaborative, multi-pronged, community based health promotion and prevention programme targeted at older adults can reduce cardiovascular morbidity at the population level. Trial registration Current controlled trials ISRCTN50550004.

Using process evaluation for program improvement in dose, fidelity and reach: the ACT trial experience

Background

The purpose of this study was to demonstrate how formative program process evaluation was used to improve dose and fidelity of implementation, as well as reach of the intervention into the target population, in the "Active by Choice Today" (ACT) randomized school-based trial from years 1 to 3 of implementation.

Methods

The intervention integrated constructs from Self-Determination Theory and Social Cognitive Theory to enhance intrinsic motivation and behavioral skills for increasing long-term physical activity (PA) behavior in underserved adolescents (low income, minorities). ACT formative process data were examined at the end of each year to provide timely, corrective feedback to keep the intervention "on track".

Results

Between years 1 and 2 and years 2 and 3, three significant changes were made to attempt to increase dose and fidelity rates in the program delivery and participant attendance (reach). These changes included expanding the staff training, reformatting the intervention manual, and developing a tracking system for contacting parents of students who were not attending the after-school programs regularly. Process outcomes suggest that these efforts resulted in notable improvements in attendance, dose, and fidelity of intervention implementation from years 1 to 2 and 2 to 3 of the ACT trial.

Conclusion

Process evaluation methods, particularly implementation monitoring, are useful tools to ensure fidelity in intervention trials and for identifying key best practices for intervention delivery.