Primary research aim
To adapt the elements of the expanded Cardiovascular Health Awareness Program (CHAP) intervention model to low- and middle-income countries (LMICs) and evaluate its effectiveness in preventing diabetes and its complications.
Secondary research aims
To foster uptake of findings from the CHAPP program to other organizations and groups in the Philippines and other LMICs.
Research objectives and methodology
- To identify optimal ways to adapt elements of the CHAP model to fit local LMIC conditions (sociocultural, economic, environmental) while focussing on the prevention and management of diabetes.
- To evaluate the effectiveness, feasibility/acceptability, and cost-effectiveness of the CHAPP intervention for use in rural communities in LMICs
Methodologies: We will use a mixed-methods approach in multiple phases.
Phase 1: Adaptation of CHAPP to the sociocultural and economic setting
Design: Qualitative inquiry to modify and incorporate the CHAP intervention model to best fit the local setting in Zamboanga Peninsula.
Participants: Department of Health Personnel; Provincial Health Office Personnel; Municipal Mayor and barangay (local term for a small village) officials; Municipal Health Officers, Public Health Nurses and Midwives; Local Lead Organization representatives; CHAPP target participants (residents 40 years and older).Three municipalities will be selected from each province for the KII.
Research Instruments: Interview guides for use in individual and group interviews, document abstraction forms (to be developed once key documents have been identified).
Data Gathering Procedure: Document review, Key Informant Interviews (KII), Focus Group Discussions (FGDs), and directed exercises (free listing, pile sort and taxonomy building).
Data analysis and outcome: Thematic Framework Analysis (CITE).
Phase 2: Pilot project of CHAPP in selected rural communities
Design: 6-month prospective pilot project. The CHAPP intervention protocol developed in phase 1 will be pilot tested in selected municipalities in the Zamboanga Peninsula.
Objective: To pilot test feasibility of the CHAPP
The setting and study population: Two eligible communities Region IX. Target participants are permanent resident of qualified municipalities 40 years and older.
Community Participant Sampling: Cluster random sample of 400 residents 40 years of age and older will be generated for each pilot Municipality.
Other participants: CHAPP Local Lead Organizations (LLO) and volunteers, selected CHAPP participants, health workers (doctor, nurse, midwife).
CHAPP intervention: The proposed CHAPP intervention will include:
- Diabetes risk assessment (modified FINRISK and assessment of lifestyle risk behaviours) sessions at least every 2 weeks in accessible community locations, manned by trained volunteers of LLO
- Volunteers educate CHAPP participants regarding their diabetes risk factors and ways to practice healthy lifestyle (including referral to local resources/activities) using diabetes education materials adapted for local context
- Use of an accepted process to have participant data transmitted to a central web database system through a combination of cell-phone and computer-based technology
- Have participant assessment result forwarded to the Municipal Health Officer (doctor) for follow-up and screening
Data Gathering Procedures: Participant survey (risk profile, physical activity, diet), data collected during CHAPP sessions, Community Process Evaluation
Data Analysis and Outcomes: Ease of conduct, difficulties encounters, revisions needed
Phase 3: Effectiveness of CHAPP
Design: Stepped Wedge cluster RCT
Objective: To determine if CHAPP program will significantly improve behaviours related to the prevention and treatment (physical activity, diet, medication use for diabetic patients) of diabetes among residents 40 years of age and older compared to usual care.
Randomization: The CHAPP will be implemented in 20 communities that will be randomly selected, stratified by district and population size and randomly assigned to 1 of 4 wedges (5 communities per wedge).
Participant sampling: A cluster random sample of 400 residents 40 years of age and older will be generated for each of the 20 Municipalities at the onset.
Intervention: The CHAPP intervention will be implemented during intervention periods of selected communities. During control periods, communities will follow usual practice.
Research Instruments: Same research instruments will be used as in Phase 2
Primary outcome: For the general population, outcomes that will be assessed are physical activity measured by the International Physical Activity Questionnaire (IPAQ), Diet measured by the portions of the diet survey lines from the Behavioral Risk Factor Surveillance System (BRFSS) questionnaire. For diagnosed diabetics, outcome will also include medication compliance.
Secondary outcomes: Hospital admission rates and mortality rates due to diabetes and diabetes-related illness (based on International Classification of Disease-9 codes), number of newly diagnosed residents with diabetes, and changes in the BP and BMI of CHAPP participants.
Data collection: All data collection procedures will be similar to Phase 2 or may be modified based on the results of the pilot study and advice from the Advisory Committee.
Statistical analysis: The primary analysis will be to compare communities receiving the CHAPP intervention to those receiving regular care according to the stepped wedge schedule.
Phase 4: Knowledge Translation Activities
- Zamboanga City
- Dipolog City
- Pagadian City
- Fortunato Cristobal, Ateneo de Zamboanga University School of Medicine, Zamboanga City, Philippines
- Lisa Dolovich, McMaster University, Hamilton, Canada
- Gina Agarwal, McMaster University, Hamilton, Canada
- Ricardo Angeles, Ateneo de Zamboanga University School of Medicine, Zamboanga City, Philippines and McMaster University, Hamilton, Canada
- Janusz Kaczorowski University of Montreal, Montreal, Canada
- Dale Guenter, McMaster University, Hamilton, Canada
- Karl Stobbe, McMaster University, Hamilton, Canada
- Lehana Thabane, McMaster University, Hamilton, Canada
- Daria O’Reilly, McMaster University, Hamilton, Canada
- Rosemarie Arciaga, Ateneo de Zamboanga University School of Medicine, Zamboanga City, Philippines
- Jerome Barrera, Ateneo de Zamboanga University School of Medicine, Zamboanga City, Philippines
- Servando Halili Ateneo de Zamboanga University School of Medicine, Zamboanga City, Philippines
- Sheldon Tobe North Ontario School of Medicine, Greater Sudbury, Canada
- Norvie Jalani, Ms Agnes Fernando Department of Health, Manila, Philippines
- Rodelin Agbulos Zamboanga City Health Office, Philippines
- John Smith Khon Kaen University, Khon Kaen, Thailand
- Agarwal G, McDonough B, McLeod B, Dolovich L. Community Health Assessment Program through Emergency Medical Services. [cited February 14, 2014].
- Agarwal, G., Angeles, R., McDonough, B., Marzenek-Lefevre, F., McLeod, B., Dolovich, L., Pirrie, M. (2015). Development of a community health and wellness pilot in a subsidised seniors’ apartment building in Hamilton, Ontario: Community Health Awareness Program delivered by Emergency Medical Services. BMC
- Kaczorowski J, Chambers LW, Dolovich L, Paterson JM, Karwalajtys T, Gierman T et al. Improving cardiovascular health at population level: 39 community cluster randomised trial of Cardiovascular Health Awareness Program. BMJ 2011; 342:d442.
- Kaczorowski J, Chambers LW, Karwalajtys T, Dolovich L, Farrell B, McDonough B et al. Cardiovascular Health Awareness Program (CHAP): a community cluster-randomised trial among elderly Canadians. Prev Med 2008; 46(6):537-544.