The volunteer peer educator role in a community Cardiovascular Health Awareness Program

1. The volunteer peer educator role in a community Cardiovascular Health Awareness Program Tina Karwalajtys MA PhD(c) Beatrice McDonough MSCN MSc Heather Hall MSc Manal Guirguis-Younger, PhD Larry W Chambers MSc PhD FACE FFPHE Janusz Kaczorowski MA PhD

2. Collaborating Organizations www.CHAPprogram.ca

3. Cardiovascular Health Awareness Program (CHAP) • Promotes cardiovascular health awareness including regular blood pressure (BP) monitoring among older adults • Seeks to identify hidden resources and existing informal relationships within communities, including the potential for senior volunteers to contribute • Involves family physicians, pharmacists, public health units, community organizations, media, volunteers and older adults in communities www.CHAPprogram.ca

4. CHAP continued • Older adults invited to attend several cardiovascular assessment sessions in local pharmacies over 10 weeks • Peer volunteers recruited and trained to take BPs with an automated device and record risk factor information • Protocol for follow-up of persons identified as high-risk • Risk profiles including BP provided to physicians www.CHAPprogram.ca

5. CHAP Development Phase 1: What is the feasibility of offering CHAP in pharmacies? • Dundas pilot (spring 2001) • Ottawa pilot (summer 2002) • Ottawa and Hamilton (CHAT – 2003) Phase 2: Can CHAP work at a community level? • Community-wide implementation in Grimsby & Brockville (CHAP – 2004) • Airdrie Cardiovascular Health Awareness and Management Program (A-CHAMP – 2005-2006, Alberta) Phase 3: Does CHAP work at a community level? • Multi-community implementation and evaluation (C-CHAP – 2006) www.CHAPprogram.ca

6. Peer Volunteer Educators • Volunteers have a vital role as cultural brokers between peers and local health services (Brownstien, 1992) • A meta-analysis of peer-based programs to address health issues found a consistent positive effect on clients’ health-related behaviours and attitudes (Posevac, 1999) • A systematic review found that self-management education programs for chronic diseases delivered by lay persons led to improvements in patients’ confidence to manage their condition, increased engagement in aerobic exercise (Foster G, 2007) • Volunteering can benefit volunteers, contributing to their physical, social, and cognitive well-being (Morrow-Howell, 2003; Van Willigen, 2000; Greenfield, 2004) www.CHAPprogram.ca

7. Peer Health Educators (PHEs) in CHAP • Pilot study – 1 family physician, 5 pharmacies, 5 PHEs trained • RCT (Hamilton & Ottawa) – 14 physicians, 28 pharmacies, ~30 PHEs trained • Community-wide demonstration project (Grimsby & Brockville) – 2 communities, all physicians (56/63), all pharmacies (18), ~78 PHEs trained • Province-wide community-level RCT – 20 program communities, 198 Physicians, 129 Pharmacies, >558 PHEs trained www.CHAPprogram.ca

8. Recruitment • Successful delivery of CHAP sessions in communities depends on recruitment, training, support of volunteers • PHEs recruited through community agencies, advertisements in local media, local seniors clubs, faith establishments, opinion leaders and word of mouth • More female volunteers, and many from a health or leadership background www.CHAPprogram.ca

9. PHE activities • Greet participants, explain program & obtain informed signed consent • Assist participants to measure BP • Record BP and risk factor information • Use recommendation protocol to suggest appropriate follow-up • Provide health information resources for relevant modifiable risk factors • Inform participants about relevant programs/activities in the community www.CHAPprogram.ca

10. CHAP Risk Profile Recording Form www.CHAPprogram.ca

11. Training • PHEs have different experience and interests to contribute and different training needs • CHAP volunteers attend two 2-hour training sessions: • Session 1: discussion of risk factors, and the impact on hypertension and prevention; • Session 2: hands-on activities (forms, using the BP machines), problem solving and role playing www.CHAPprogram.ca

12. Research Questions What are the experiences and perspectives of PHEs involved in the program? Are PHEs adequately trained and supported? What is the interest and comfort level with an ‘enhanced’ or expanded role? www.CHAPprogram.ca

13. Developing the PHE Role:CHAP in 2 communities • Demonstration project • Volunteer Survey • Debriefing Focus Group Interviews www.CHAPprogram.ca

14. enjoyment • learning • contribution • understanding/value of program • benefit to community • confidence/training • providing resources • support/session procedures • scheduling/location • enhanced role – session leader SURVEY: PHEs in 2 Communities • Self-administered questionnaire • Distributed at appreciation event or mailed • Focused on meaningfulness of experience, impressions of the program, adequacy of training • Explored interest in ‘enhanced’ role as a CHAP session leader www.CHAPprogram.ca

15. Survey results:2 Communities • 80% (48/60) response rate • 3 highest rated (on a 5-pt Likert scale): • I knew who to contact if I had a question at a CHAP session (4.83) • CHAP was a worthwhile program (4.79) • I enjoyed interacting with seniors at the sessions (4.77) • 3 lowest rated (on a 5-pt Likert scale): • I was able to give CHAP participants useful information (3.98) • My work as a CHAP peer health educator kept me busy (3.88) • I sometimes felt overwhelmed by my responsibilities (2.45) • Did you have the opportunity to distribute any information sheets? • No 47.8% Yes 52.2% www.CHAPprogram.ca

16. Differences between communities • The level of agreement with positive statements of personal benefit was generally high, particularly for the enjoyment volunteers felt when interacting with their peers; • In Community A, volunteers rated the degree of enjoyment of their work as peer health educators and the knowledge gained about heart health significantly higher than volunteers in Community B. • Generally, volunteers in both sites were satisfied with the quality of training and support; • Community A, ratings of procedural items (knowing who to contact with questions, how well questions were handled, having resources that were needed, procedures easy to follow) were significantly higher than in Community B. www.CHAPprogram.ca

17. Inferences / Emerging Q’s • PHEs in Grimsby and Brockville had a positive experience overall and saw value in their involvement • How did understanding of CHAP influence how volunteers delivered the program? • PHEs were not consistently well-supported in their role as educators; e.g. providing resources • How can we better prepare and support PHEs for this role? • There is potential for PHEs to take on different responsibilities • How can we develop these roles? www.CHAPprogram.ca

18. impressions or thoughts about your experience as a volunteer PHE? • impression of the roles of the different people involved in the Program? • impressions or thoughts about the training you received? • thoughts and suggestions about expanded leadership role? • thoughts and suggestions about expanded educator role? Debriefing focus groups:PHEs in 2 Communities • To learn more about volunteers’ experiences • Explored potential of ‘enhanced’ role as educatorsas well as session leaders www.CHAPprogram.ca

19. Debriefing Methods • 5 discussion groups; 27 PHEs • Written, informed consent • Recorded and transcribed • Semi-structured Interview Guide • PHEs raised additional topics • Recruitment • Via community volunteer coordinators • After thank-you lunch, or separate meeting www.CHAPprogram.ca

20. Findings • Volunteers reported an overall positive experience and identified rewarding aspects of their involvement • They felt well prepared but requested more ongoing training. • Understanding of program objectives increased volunteer satisfaction. • Volunteers continued to develop their role during the program • Organizational and logistical factors sometimes limited skill acquisition and contributions. • The prospect of greater involvement in providing tailored health education resources was acceptable to most volunteers. www.CHAPprogram.ca

21. Training • “…some [volunteers] weren’t called for their first time doing [a session] for some time after the training. So then you went there and it was like, ‘Well, stay with me for the first one because I forgot.’” (A.1.P3) • “[It was] only with the questionnaires that I found it was hard. I was completely blank when I got to fill out the first one.” (B.3.P3) www.CHAPprogram.ca

22. Program objectives • “…I believe we were talking to the educated… when we should have been talking to the uneducated.” (A.1.P7) • “I was hoping that…more people would walk by or just drop in because most of them were invited by the doctor so, you know, they were already in the care of their doctor; the doctors were pretty much aware of how their blood pressure was, at the office anyway…” (A.2.P2) • “But success is... if you help one person. That is our motto with our heart group. If you help one person, that is a success.” (A.1.P4) www.CHAPprogram.ca

23. Role development • “I always ask them when was the last time you had seen your family doctor and when are you likely to see him again?” (A.1.P7) • “If we called for the nurse [then] that was the end for the testing for whoever discovered [it], because from that point onwards they would just sit and chat with that person until the nurse came out. There might be another half a dozen waiting but we all felt the same thing: someone is now under pressure, and we would just sit and talk to them, even if it took ten minutes before the nurse got there.” (A.2.P6) • “So what we were telling people is that if you are coming back, as much as possible come in at the same time next week and do what you do in the morning, about as close as possible; in other words, to try not to get any variation… (A.2.P6) www.CHAPprogram.ca

24. Logistics & Organization • “Because, you couldn’t let the, ah, chairs get cool. We had to get the next person in right away otherwise people would be waiting…” (B.3.P1) • “…we needed to have a, a little more time to talk to people. To, to reassure them, if that’s what they needed, or to answer their questions.” (B.3.P1) • “I did not have time to answer questions, to even do a good enough job of explaining what stage [BP] they were in, just because of time constraints.” (B.3.P1) • “If there are three of us...maybe we need four of us, [so] you can take that little bit of extra time...” (A.1.P7). www.CHAPprogram.ca

25. Educator role • P1: …so then the volunteer can just go up and say, ‘Okay, this is proper for you and applicable to you’, and not take all 13 [handouts], but just three or four. • P2: Because in that questionnaire, we already know whether they’ve had a heart attack or stroke. We know whether…they have diabetes or not. We know they’re on cholesterol or blood pressure [medication]…and then we know what the blood pressure is… • P4: Yeah, so when you finish taking my blood pressure, you give me my form back and I take it to [another volunteer], who [is] now going to quickly peruse my questionnaire and answers and blood pressure… • P2: …and say, “Okay, I think this and this and this and this.” (B.4. P1, P2, P4) www.CHAPprogram.ca

26. Anticipating challenges • Display stands or other dedicated space for resources • Targeted distribution of resources based on risk profile • Training PHEs for an ‘enhanced educator role’ • Target volunteers with previous related experience • Encouraged for all PHEs • ‘Education Station’ after assessment • Delivery of risk factor information based on Stages of Change www.CHAPprogram.ca

27. Developing the PHE Role:CHAP in 20 communities • Community-level RCT • 20 program, 19 control communities • Administrative data used to compare program and control communities across outcomes • Refining recruitment and training • Introduction of enhanced role educators • Volunteer Survey • Final Reports + Coordinator Interviews www.CHAPprogram.ca

28. SURVEY 2: 20 Communities • Distributed by coordinators post-program • Continued focus on meaningfulness of experience, impressions of the program, adequacy of training • Explored interest in ‘enhanced’ role as a CHAP enhanced role educator www.CHAPprogram.ca

29. Survey Results:20 communities • 63% (345/547) response rate Comparing 20 communities to survey in 2 communities: • Nearly all items showed improvement: • Understanding of program objectives (4.80 vs. 4.62) • Availability of resources (4.64 vs. 4.27) • Support provided to volunteers (questions handled well) (4.82 vs. 4.27) • Feeling overwhelmed by responsibilities (1.91 vs. 2.45) (less often) • Items rated lower: • Volunteers’ confidence in their role (4.43 vs. 4.64) www.CHAPprogram.ca

30. Final Reports & Interviews • Most successful recruitment methods in communities: • Existing volunteer base from the LLO (11) • Newspaper ads (10) • Talks at Seniors Clubs, Organizations, etc. (7) • Training: • Both training sessions were informative, useful, fun, well-received, easy to use (15) • Refresher was imperative (1) • More time should be devoted to hands on practice with BpTRUs and forms (4) • Session 1 Presentation contained too detailed medical information (6) • 6 communities (~69 PHEs) used the enhanced role educator training • Innovations: 1 trained all PHEs • Challenges: no room available for separate stations in the pharmacies • Session logistics: • Innovations: ‘floater’ PHE who helped out as needed (1) • Challenges: Space was a barrier for privacy, session set-up (3) www.CHAPprogram.ca

31. Conclusions • CHAP has evolved into a large-scale, community-driven, volunteer-led cardiovascular health promotion program. • Learning about recruiting, training, and retaining volunteers is ongoing (CHAP+AP = peer health mentors) • Continued refinement of strategies to recruit, train, retain and support volunteers strengthened the peer education component over several implementations of CHAP. • Our learning can inform similar volunteer-led community-based health promotion initiatives in Canada. www.CHAPprogram.ca

32. www.CHAPprogram.ca www.CHAPprogram.ca

33. References • Brownstein, J. N., Cheal, N., Ackerman, S. P., Bassford, T. L., & Campos-Outcalt, D. (1992). Breast and cervical cancer screening in minority populations: A model for using lay health educators. Journal of Cancer Education, 7(4), 321-326. • Greenfield E, Marks N. Formal volunteering as a protective factor for older adults' psychological well-being. Journal of Gerontology: Social Sciences 2004;59B:S258-S264. • Morrow-Howell N, Hinterlong J, Rozario PA, Tang F. Effects of volunteering on the well-being of older adults. J Gerontol B Psychol Sci Soc Sci 2003;58(3):S137-S145. • Posavac EJ, Kattapong KR, Dew DEJ. Peer-based interventions to influence health-related behaviors and attitudes: A meta-analysis. Psychol Rep 1999;85: 1179-1194. • Van Willigen M. Differential benefits of volunteering across the life course. J Gerontol B Psychol Sci Soc Sci 2000;55(5):S308-S318. www.CHAPprogram.ca

34. Abstract Objectives: • To describe the peer education component of the Cardiovascular Health Awareness Program (CHAP; www.CHAPprogram.ca) and to report on assessment of the volunteer peer educator role. Methods: • In CHAP communities, family physicians invite their older adult patients to attend sessions run by peer health educators in pharmacies. CHAP seeks to identify hidden resources and existing informal relationships within communities, including the potential for senior volunteers to contribute. The CHAP peer educator role evolved through process learning and volunteer feedback. Five debriefing discussions involved 27 volunteers. A post-program questionnaire was completed by 48/60 volunteers in 2 demonstration communities and 385/577 volunteers in 20 additional communities. Findings for Research, Practice & Policy: • Iterative information gathering with volunteers enabled CHAP to anticipate challenges, strengthen support for volunteer activities and expand the peer educator role. Debriefing revealed that volunteers felt well-prepared but would benefit from more refresher training; understanding of program objectives influenced volunteer satisfaction; logistical factors sometimes limited volunteer contributions; and, the prospect of greater involvement in providing participants with tailored health education resources was acceptable to most volunteers. Questionnaire responses were highly positive. Understanding of program objectives and support provided to volunteers were items that showed improvement, while volunteers’ confidence in their role and availability of resources were rated lower across 20 CHAP communities compared to 2 demonstration communities. Continued refinement of strategies to recruit, train, retain and support volunteers strengthened the peer education component over several implementations of CHAP. Our learning can inform similar volunteer-led community-based health promotion initiatives in Canada. www.CHAPprogram.ca

35. PHEs in 20 communities www.CHAPprogram.ca

36. Q in 2 communities www.CHAPprogram.ca