Effective strategies to improve health education, food choices, and physical activity are vital for people with intellectual and developmental disabilities (IDD), as their sedentary lifestyles and high fat diets are contributing to poor health, such as cardiovascular disease, osteoporosis, hypertension, Type II diabetes, and obesity. This study examined the effectiveness of a peer-led health promotion program for people with IDD. One group pre/post-test design was used to test the feasibility and effectiveness of the 12-week HealthMessages Program for three groups: peer health coaches (PHCs), mentors, and peer participants. A total of 379 volunteers participated including PHCs people with IDD (n = 33), mentors—staff from community organizations (n = 35), and peer participants—peers with IDD (n = 311). Following the intervention and 12-week HealthMessages Program, PHCs had significant changes in physical activity and hydration knowledge, mentors had significant changes in self-efficacy scores, and peer participants had significant changes in physical activity and hydration knowledge, social supports, and total health behaviors. A dyad approach supported PHCs and mentors to implement a successful HealthMessages Program with their peers.
People with intellectual and developmental disabilities (IDD) are often excluded from community-based health promotion programs. Finding effective strategies to improve health education and health behaviors is vital for people with IDD, as their sedentary lifestyles and high fat diets (Draheim, McCubbin, & Williams, 2002; Rimmer & Yamaki, 2006; Sisirak, Marks, Heller, & Riley, 2007) are contributing to high rates of cardiovascular disease (CVD), osteoporosis, hypertension, Type II diabetes, and obesity (Anderson et al., 2013; Fujiura, Fitzsimons, Marks, & Chicoine, 1997; Rimmer & Yamaki, 2006; Sisirak et al., 2007; Yamaki, 2005). A peer-led educational model is an effective approach to reach underserved populations by involving people who share characteristics, conditions, background, or problems (Fund, 2006; Hendry, Hill, & Rosenthal, 2014; O'Hagan, 2010). Despite studies reporting that peers are the “best health messengers” with unique access to underserved communities (Lettner, Sun, & Gardner, 2013), peer-led interventions have not been systematically tested among people with IDD and little data exists regarding people with IDD serving as peer leaders. This paper provides theoretical and empirical rationale for peer leaders (peer health coaches [PHCs]) to lead a health promotion program designed for people with IDD, HealthMessages Program (HealthMessages). We will provide results from this effectiveness study and discuss practical issues impacting the training of PHCs and their mentors, the delivery of the HealthMessages Program, and the impact on the peers participating in the HealthMessages Program.
The use of peer leaders in health promotion is not a new concept. Studies examining the effectiveness of peer-led programs in the general population support targeting a variety of health-related topics including weight loss (Wang, Willis, & Rodgers, 2014); fitness (Dorgo, Robinson, & Bader, 2009; Stanish & Temple, 2012; Yan, Finn, & Corcoran, 2015); nutrition education (Thompson, Silver, Pivonka, Gutschall, & McAnulty, 2015); heart health education (Willock, Mayberry, Yan, & Daniels, 2015); and cardiovascular issues (Dwyer, Quinton, Morin, & Pitteloud, 2014; Kessler, Egan, & Kubina, 2014; Willock et al., 2015) using online or face-to-face modalities. When compared with non-peer-based initiatives, (Dorgo, Robinson, & Bader, 2009), peer-based initiatives are associated with better outcomes, such as, increased self-esteem, self-efficacy, and sense of personal control to improve health behaviors and healthy lifestyles (Solomon, 2004; Turner, 1999; Wang et al., 2014; Willock et al., 2015).
Peer leaders can impact a range of health conditions, such as anxiety and heart disease (Parent & Fortin, 2000); arthritis (Lorig, Sobel, Ritter, Laurent, & Hobbs, 2001); breast cancer (Ashbury, Cameron, Mercer, Fitch, & Nielsen, 1998); HIV infection (Broadhead et al., 2002); frailness in the elderly (Ezumi et al., 2003); burns (Williams et al., 2002); diabetes (Joseph, Griffin, Hall, & Sullivan, 2001); and support for young people with chronic health problems. Additionally, prevention of various health-related issues, including, HIV prevention, smoking cessation, substance misuse, and unwanted pregnancy is positively associated with peer leadership. The benefits of peer leaders have been demonstrated in a variety of settings, including community settings (Stanish & Temple, 2012; Yan et al., 2015); online (Wang et al., 2014); and prisons (Ross, 2011).
Peer-assisted studies are increasingly being led by people with disabilities, including autism (Kasari, Rotheram-Fuller, Locke, & Gulsrud, 2012); psychiatric disabilities (Acri et al., 2015; Ali, Farrer, Gulliver, & Griffiths, 2015; Castelein, Bruggeman, Davidson, & van der Gaag, 2015; Davidson et al., 1999; Griffiths, Reynolds, & Vassallo, 2015; Lloyd-Evans et al., 2014; Reynolds, Griffiths, Cunningham, Bennett, & Bennett, 2015; Solomon, 2004; Walther, Abelson, & Malmon, 2014), and spinal cord injuries (Ljungberg, Kroll, Libin, & Gordon, 2011; Newman et al., 2014). The unique, positive effects for participants of peer-led interventions (Solomon, 2004), such as increased self-esteem, self-efficacy, and sense of personal control (Solomon, 2004; Turner, 1999; Wang et al., 2014; Willock et al., 2015); reduced isolation, and access to community resources (Kessler et al., 2014); have the same potential to empower and support people with IDD to improve health behaviors, adopt healthier lifestyles, reduce the risk for chronic diseases, and improve life satisfaction.
People With IDD Teaching Peers Health Messages
While few studies have examined the impact of peer leaders for people with IDD, two programs focusing on health promotion found significant physiological and behavioral improvements for people with IDD (Stanish & Temple, 2012; Yan et al., 2015). The 15-week exercise program, Team Up For Fitness (TUFF) partnered adolescents with IDD with similarly aged peers without disabilities. The program documented significant improvements with abdominal muscle endurance, aerobic fitness, improved six-minute walk test, and decreased body mass index (BMI) among adolescents with IDD. Stanish & Temple (2012) also found that a peer partner without disability had significant improvements in a six-minute walk test and had lower BMIs. Another study used peer leaders with developmental disabilities to run program activities, which resulted in adults with developmental disabilities living in community settings having improved lifestyles, weight loss, and increased capacity (Bazzano et al., 2009).
Limited research has focused on the benefits of peer leaders for people with IDD. An early study found that leaders with physical disabilities and developmental disabilities (e.g., cerebral palsy, multiple sclerosis, muscular dystrophy, and rheumatoid arthritis) were effective in increasing the knowledge and self-confidence of adolescents' with similar physical and developmental disabilities (only two participants had a mild intellectual disability) (Powers, Sowers, & Stevens, 1995). To date, no empirical studies have examined the peer-led model among people with IDD serving as peer leaders to support healthy behaviors among their peers with IDD.
As noted in other studies, peer support can potentially encourage and support people with IDD to gain the necessary information and skills to learn health-related information and improve their health behaviors. Additionally, people with disabilities can learn from peer leaders how to advocate on their own behalf and improve feelings of self-worth because they are working with a peer who shares their experiences as a person with disabilities and intrinsically understands disability issues (Gill, 1997; Linton, 1998). For people with IDD, a peer-led physical activity and nutrition health education program may be more appealing and foster better adherence to regular physical activity and making healthy food choices.
Dyad Approach for Peer Leaders and Mentors
Because of a culture of interdependency, many people with IDD live their entire lives relying on support from family members as children and young adults and from multiple professional caregivers later in life. (Carnaby, 1998). In addition to the need to build health advocacy skills among people with IDD, building collective self-efficacy among family members, service providers, and volunteers is imperative. Mentors may have an important role in supporting peer leaders; and building self-efficacy may increase confidence to support behavior changes and increase role-modeling to peers.
With adequate preparation (Kirkpatrick & Patchner, 1987) and positive role modeling (Bratter & Freeman, 1990), mentors have the potential to provide support to build leadership skills for people with IDD. Mentors can provide crucial links between changing health behaviors and increasing access to health reinforcing opportunities in the community. Lastly, mentors can dispel stereotypes associated with people with IDD more effectively than health professionals given their unique roles in community-based organizations (CBOs) to support people with IDD across many domains, such as employment, activities of daily living, and health-related activities.
The goal of the present study is to examine the effectiveness of a peer-led health promotion program for people with IDD. We describe the health promotion program and address four research questions: (1) What is the effectiveness of both the HealthMessages Program Train-the-Trainer Webinar for PHCs and mentors and the HealthMessages Program for PHCs and mentors? Specifically, do self-efficacy, health advocacy skills, and knowledge (knowledge was only evaluated with PHCs) improve after the webinar training and the delivery of the HealthMessages Program? (2) What is the impact of HealthMessages Program on peer participants? Specifically, do knowledge, health behaviors, and social support improve after the delivery of the HealthMessages Program? (3) Was peer mentoring with participants with IDD a successful approach in delivering health education program? (4) What are the processes and “lessons learned” to consider for ensuring success of this program?
Ethical Review and Recruitment Procedures
The study was reviewed and approved by the University of Illinois at Chicago Institutional Review Board (IRB) from 2013–2016. Participants with IDD (PHCs) and their mentors in CBOs providing day, residential, and/or employment services, were recruited. Participants with IDD lived in a variety of settings ranging from group homes, supported living arrangements, and with their families. We disseminated a recruitment flyer detailing the study aim, the type of data required, and the nature of the intervention to recruit both PHCs and mentors who were age 18 or older, willing to participate in the research study, able to read and understand English, available on scheduled dates/times for the training webinar, and run a 12-week HealthMessages Program.
Research participants were recruited from different organizations that provide supports for community living services to people with IDD. Letters of support from each participating CBO were obtained. Potential participants (PHCs and mentors) were given a consent form with a statement about the research study, description of any foreseeable risks or discomforts, an explanation of any benefits to the participant or to others which may reasonably be expected from the research, details on the maintenance of their confidentiality, a statement that participation was voluntary, along with contact information of the research personnel. For PHCs with legal guardians, we obtained the guardian's signature and a signature of assent from each adult with IDD participating as a PHC.
A program evaluation for peers with IDD participating in the HealthMessages Program was done to enhance sustainability of the program at a community level, document and share successes, and adapt the program as needed. Participating organizations voluntarily submitted de-identified peer participant surveys to the University of Illinois at Chicago (UIC) team for data entry and analysis. The program evaluation data was collected among peers with IDD over the age of 18 before the program (Time 1) and after the program (Time 2).
Design and Procedures
One group pre/post-test design was used to test the effectiveness of the 12-week HealthMessages Program for three groups: PHCs, mentors, and peer participants. PHCs and mentors attended the 75-minute webinar training ,HealthMessages Program Train-the-Trainer Webinar. Assessments for PHCs and mentors were conducted at baseline (Time 1) before the webinar, immediately after the webinar (Time 2), and after the 12-week HealthMessages Program (Time 3). After the webinar training, PHCs and mentors conducted a 12-week HealthMessages Program with up to ten (10) peers with IDD. Assessments for peer participants were conducted before (Time 1) and immediately after (Time 2) the 12-week HealthMessages Program.
A total of 379 volunteers participated in this study and they included the following: PHCs—people with IDD (n = 33), mentors—staff from community organizations (n = 35), and peer participants—people with IDD (n = 311) receiving services. Background variables were collected at Time 1 for PHCs, mentors, and peer participants and included the following: age, gender, marital status, race/ethnicity, education level, and employment. Table 1 describes the characteristics of the three groups. Participants were recruited through CBOs in the U.S. Before joining the program, eligibility criteria were confirmed and included the following. Participants must be (1) aged 18 or older; (2) available on scheduled dates/times for the training/program; (3) interested in attending the training/program; (4) willing to participate in research; and (5) able to read and understand English.
HealthMessages Program Train-the-Trainer Webinar for PHCs and mentors
The HealthMessages Program Train-the-Trainer Webinar was instructed by the research team (a partnership between staff employed at a University of Illinois at Chicago and at a CBO. Each dyad team, included a PHC with IDD and a mentor who was a staff member from multiple CBOs in two mid-western states across urban and rural areas, participated in one 75-minute webinar. Prior to the webinar, HealthMessages Kits were mailed to each dyad team. Each kit included a Peer Health Coach Coaching Manual, a packet with (1) weekly health message booklets and wristbands for peer participants; (2) posters; (3) weekly sign-in sheets to keep a record of peer participant attendance; (4) peer self review cards to ask participants if they met their weekly goal; and (5) teaching props (i.e., 16 oz. water bottle, 12 oz. soda can, 16 oz. paper cup). The research team reviewed the contents of the HealthMessages Kit, along with instructional strategies for teaching the HealthMessages Program to peers during the webinar. The webinar training also presented the roles for the PHC and mentor (support for PHC), reviewed the weekly health messages lessons, and discussed leaderships skills to facilitate weekly classes (i.e., delivery, audience participation, body language, visual aids, content knowledge) (World Health Organization, 2005). Mentor and PHC dyads worked collaboratively to deliver the HealthMessages Program to the PHCs' peers with IDD. Dyads were instructed to implement the HealthMessages Program over 12 consecutive weeks immediately following the webinar in convenient settings where people were receiving day program services. Each of the ten lessons required about 30 minutes to share the weekly health message and participate in related activity. Weeks 1 and 12 required one hour of time to administer pre- and post-program evaluation surveys to peers participating in the HealthMessages Program.
HealthMessages Program: Health promotion program for peers with IDD
A collaborative community empowerment (CCE) process (Yoo et al., 2004) was used to develop and pilot the HealthMessages Program and the HealthMessages Train-the-Trainer Webinar. CCE is recommended as an effective approach to community group facilitation for empowering active engagement of community members. The development and pilot testing of the HealthMessages Program and the training is described elsewhere (Marks, Sisirak, & Chang, 2013; Marks & Sisirak, 2015). The Peer Health Coach: Coaching Manual used in the HealthMessages Program incorporates Transtheoretical Model (TTM) of Behavior Change (Prochaska & DiClemente, 1983, 1992; Prochaska, DiClemente, & Norcross, 1992; Prochaska et al., 1994) and principles from Bandura's Social Cognitive Theory (Bandura, 1977, 1986) as the theoretical underpinnings for PHCs and mentors to understand how to support health behavior change among peers. The TTM uses the following five stages to support an individual's knowledge gains, skills, motivation, and readiness to modify or change a particular behavior: (1) Precontemplation; (2) Contemplation; (3) Preparation; (4) Action; and (5) Maintenance.
The first section in the PHC manual, Making Healthy Choices, corresponds to the Precontemplation Stage (e.g., people are unaware or under-aware of the need to change their behavior) and the Contemplation Stage (e.g., people are more aware that they should change their behavior but have not made a commitment to take action). In this section, PHCs and mentors discuss the significance of health, physical activity, and hydration and the impact of health knowledge, attitudes, self-confidence, and environment on physical activity, exercise, and hydration among people with IDD. The concepts of health, physical activity and exercise, and hydration were identified in a pilot study as important for people with IDD (Marks & Sisirak, 2015). Additionally, daily soda and coffee drinking is very common among people with IDD with nearly 60 percent reportedly drinking a 12-ounce can of regular soda one to two times per day (Hsieh, Rimmer, & Heller, 2013). Increasing knowledge regarding the importance of hydration via drinking water and consuming foods with the highest amount of water content (fruits and vegetables) was used to potentially displace intake of sweetened beverages and less-healthy foods.
The second section, Changing Lifestyles, incorporates concepts in the Preparation Stage and the Action Stage. In this section PHCs and mentors review strategies to support people with IDD to develop their health and wellness goals to change or modify their physical activity and hydration choices within their daily activities. The third and last section, Keeping Our New Lifestyle, incorporates concepts of the Maintenance Stage for PHCs and mentors to implement practical strategies that motivate people with IDD to employ healthy behaviors, avoid unhealthy behaviors, and maintain healthy behaviors.
The principles of Bandura's Social Cognitive Theory (Bandura, 1977, 1986) were also integrated throughout all of the modules in the Peer Health Coach: Coaching Manual. Using Social Cognitive Theory, the PHCs and mentors learned how change in health behavior relates to the following: (1) perception of the pros and cons related to behavior change; (2) confidence in being able to change; and (3) perceived amount of social support in adopting a new behavior (Bandura, 1997). Each HealthMessages Kit included 11 HealthMessages Peer Booklets (the first class is a welcome class and did not have a health message or peer booklet) and 11 HealthMessages Wristbands that corresponded to the weekly health message (two wristbands were given to each peer participant—one to keep and one to “pass on the message” by giving it to a friend, family member, co-worker, etc.). By “passing on the message” each week, participants were encouraged to repeat the information learned and to identify and interact with potential supports in their social networks (e.g., friends, family, supports) to positively influence their decisions to make healthy choices (Freimuth & Quinn, 2004). The titles of the 11 booklets were: Week 2 – Stay Healthy, Be Wealthy!; Week 3 – Get Ready, Be Active!; Week 4 – Drink Water, Be Hydrated!; Week 5 – Do FABS!; Week 6 – Finding my Exercise Groove!; Week 7 – Water is the Best, Forget the Rest!; Week 8 – Cool as a Cucumber!; Week 9 – When It's Hotter, Drink Water!,;Week 10 – Team Up and Set Goals!; Week 11 – Take Charge of Your Health; Week 12 – Stay on Track, Stay HEALTHY!. Each peer booklet was divided into three parts: (1) assessment; (2) goal setting (take charge); and (3) action (“passing on” the health message).
Data collection and assessments were conducted across the two phases of the study (Table 2). In Phase 1, the research team collected data from PHCs and mentors before (Time 1) and immediately after (Time 2) of the HealthMessages Program Train-the-Trainer Webinar and after the 12-week HealthMessages Program (Time 3) evaluation. In Phase 2, program evaluation data was collected from the peers by the PHCs and mentors at baseline before (Time 1) and immediately after (Time 2).
The Self-Confidence in Teaching Health Messages Scale (Marks, Sisirak, & Donohue Chase, 2008) evaluated PHCs' (10 items) and mentors' (9 items) perception of their self-confidence during Time 1, Time 2, and Time 3 on the following: (1) doing specific types of health promotion activities; (2) teaching people with IDD; and (3) implementing health promotion activities. The measure is a 3-point Likert scale (1 = Not at all confident, 2 = Little confident, 3 = Totally confident). The scores ranged between 10–30 points for PHCs and 9–27 points for mentors. Higher score indicates greater self-confidence. For the PHCs' self-confidence scale, Cronbach's alpha for the 10-item scale was 0.80 at Time 1. For the mentors' self-confidence scale, Cronbach's alpha for the 9-item scale was 0.80 at Time 1.
Promoting healthy lifestyles (advocacy)
The adapted Health Advocacy Scale (Brashers, Haas, & Neidig, 1999) evaluated PHCs' (12 items) and mentors' (11 items) capacity for supporting peers to advocate for health and health promotion activities. The measure is a 4-point Likert scale (1 = Strongly disagree, 2 = Disagree, 3 = Agree, 4 = Strongly agree). The scores ranged between 12–48 points for PHCs and 11–44 points for mentors. Higher scores indicate higher advocacy. These measures were taken during Time 1, Time 2, and Time 3. For the PHCs' Health Advocacy Scale, the Cronbach's alpha for the 12 item scale was 0.92 at Time 1. For mentors' Health Advocacy Scale, Cronbach's alpha for the 11 items was 0.90 at Time 1.
Topic-specific items (Physical Activity Knowledge Scale and Hydration Knowledge Scale) related to health knowledge were developed using the Perception of Health Promotion Knowledge (Marks et al., 2008) and Nutrition and Activity Knowledge Scale (Illingworth, Moore, & McGilivray, 2003; Sisirak et al., 2007; Sisirak, Marks, Riley, & Heller, 2008) to asses PHCs' and peer participants' understanding of fundamental principles of physical activity (7 items) and hydration (6 items). The scores ranged from 0–7 for physical activity and 0–6 for hydration. Higher scores indicate greater health knowledge. These measures were taken during Time 1, Time 2, and Time 3 for PHCs and Time 1 and Time 2 for peer participants.
Five frequency questions related to health behaviors were developed to measure how much water (1 16 oz. bottle), soda (1 12 oz. can), and coffee (1 16 oz. cup) peer participants enrolled in the HealthMessages Program drank each day at Time 1 and Time 2. PHCs and mentors used the water bottle, soda can, and coffee cup “prop” to teach and assess behavior change among peer participants. Responses consisted of “none,” “1–2,”and “3–4.” Peers were also asked about the amount of exercise and physical activity they did each week at Time 1 and Time 2. Responses ranged from “none,” “1–3 days/week,” and “4–6 days/week.” Scores ranged from 0–10 for total health behaviors. Measures were taken at Time 1 and Time 2 for peer participants.
The Exercise Social/Environmental Support Scale (Heller, Marks, & Ailey, 2001) and the Social Supports for Exercise and Diet Behaviors (Sallis, Grossman, Pinski, Patterson, & Nader, 1987) evaluated peer participants' level of social support for exercising and physical activity. The scale included 13 items with possible range of 0–39. Higher scores had greater social support. Measures were taken during Time 1 and Time 2. Cronbach's alphas for the 13 items on the Social Supports scale was .90 at Time 1.
Process evaluation: Satisfaction and impact
PHCs and mentors' satisfaction with the HealthMessages Program Train-the-Trainer Webinar and impact on participation was obtained immediately after the workshop (Time 2). Questions were related to satisfaction with the webinar, activities, room (space for webinar participation), and materials. Satisfaction with the HealthMessages Program was also assessed at Time 3. Peer participants' satisfaction with the HealthMessages Program and program impact was obtained immediately post intervention (Time 2). Sample items include whether peer participants like getting messages from their PHCs, are PHCs being well received as carriers of health promotion messages.
Descriptive statistics were obtained for all study variables. This included proportional frequency distributions, estimates of variance, and correlations between variables. Tests of significance were based on an alpha level of .05. Baseline descriptive statistics of demographics with confidence intervals were used to profile the three groups and assess comparability. Repeated measures ANOVA were used for PHCs and mentor outcome measures of self-efficacy, physical activity knowledge, hydration knowledge, and advocacy. Because repeated measures ANOVA (within-subject factors) is susceptible to the violation of the assumption of sphericity (condition where variances of the differences between all combinations of within-subject conditions are equal), we have determined whether sphericity has been violated by using Mauchly's Test of Sphericity (Mauchly, 1940). If the assumption of sphericity is violated, the F-statistic is positively biased increasing the risk of a Type I error. To vanquish this problem and obtain valid F-value, we have used Greenhouse-Geisser correction (Greenhouse & Geisser, 1959) and the Huynh-Feldt correction (Huynh & Feldt, 1976). To determine the mean difference for the peer participant measures, the paired sample t test was used.
All quantitative data was entered in SPSS v19. Following data entry, we carried out the usual checks for data quality including standard descriptive statistics. We also computed descriptive regression models (OLS or logistic as appropriate) as a means of detecting outliers and influential observations via Cook's D, leverage statistics and other methods.
HealthMessages Program Train-the-Trainer Webinar
To test sphericity, we reviewed Mauchly's Test, which tests for the equivalence of the hypothesized and observed variance/covariance patterns for each variable. The test was not significant for Hydration Knowledge (W = .945, χ2 (2) = 1.41, p = .494), and Advocacy, (W = .982, χ2 (2) = .450, p = .799), marginally significant for Self-Efficacy (W = .821, χ2 (2) = 6.097, p = .047), and highly significant for Physical Activity Knowledge (W = .668, χ2 (2) = 11.72, p = .003). These findings suggest that the observed matrix does not have approximately equal variances or equal covariances; and, the use of an uncorrected RM-ANOVA F-test might result in an inflation of Type I errors and a rejection of the null hypothesis. Proposed corrections include the Greenhouse-Geisser and Huynh-Feldt epsilon corrections. While these do not affect the computed F-statistic, the critical F value needed to reject the null hypothesis is raised. For our data, Table 3 summarizes the results of the RM-ANOVA analysis including Greenhouse-Geisser and Huynh-Feldt corrections for PHC measures. The column labeled F gives the F value of the test followed by three columns of significance values. The last two columns (Greenhouse-Geisser and Huynh-Feldt) are the corrected significance levels for the observed statistic with the above reported corrective coefficients. A significant change in the Hydration Knowledge from Time 1 to Time 3 time points is observed, along with an approaching significance from Time 1 to Time 3 in Physical Activity Knowledge. Self-Efficacy and Advocacy were not significant.
Test of sphericity was significant for Self-Efficacy (W = .642, χ2 (2) = 13.74, p = .284) indicating that the observed matrix does not have approximately equal variances or equal covariances and is not significant for Advocacy (W = .922, χ2 (2) = 2.52, p = .001), therefore using Greenhouse-Geisser and Huynh-Feldt epsilon corrections. Table 4 summarizes the results of the RM-ANOVA analysis including Greenhouse-Geisser and Huynh-Feldt corrections for mentor measures. It presents a significant change in the Self-Efficacy measure across Time 1 and Time 2, and between Time 1 and Time 3. Advocacy was not significant across time.
HealthMessages Program: Health Promotion Program for Peers With IDD
Table 5 summarizes the results of Paired Sample t Tests for peer participants. The measures across the two time points for Physical Activity Knowledge, Hydration Knowledge, Social Supports, and Health Behaviors were statistically significant. The last column in the table presents percent changes in scoring, showing all measures demonstrated improvements. Peer participants improved Physical Activity Level and Hydration Knowledge by 11% and 26% respectively, after participating in the HealthMessages Program. Additionally, social support increased by 39%. Total Health Behavior Score increased by 11%. While the total Health Behavior Score was statistically significant, examination of each behavior found that peer participants had the greatest improvements after the 12-week program with exercise, drinking more water, and physical activity. Mean scores for consumption of coffee and soda remained unchanged.
Process Evaluation for
HealthMessages Program TtT Webinar and Peer Coaching
Process evaluation consisted of examining PHCs' and their mentors satisfaction with the webinar training for the HealthMessages Program. Also, satisfaction with the 12-week HealthMessages Program was assessed with PHCs, mentors, and peer participants.
PHCs reported a variety of positive outcomes ranging from confidence, expectations, and responsibilities as a PHC, as they built leadership skills in teaching their peers to be healthy. PHCs also gained confidence in working with people who had a range of disabilities, including vision, hearing, and speech. Regarding expectations of becoming a PHC, the responses were mostly positive with 82% of PHCs reporting the webinar training was great, 70% felt the activities during the training were great, 80% rated materials as great, and 93% stated that they would recommend the HealthMessages Train-the-Trainer Webinar to someone else to become a PHC. About 11% of the PHCs felt that the webinar was a “little too long.” One PHC commented on wanting to go through the whole book, a few mentioned wanting an extra time to meet with their mentors during the training. Three mentors reported wanting a shorter webinar session and one commented on slowing down “don't go fast with the new info” during the training.
After the 12-week HealthMessages Program 91% of PHCs felt that the program was ‘fun,' 82% wanted to repeat the program, and 85% wanted to continue being PHCs. Upon completion of the program, when asked what would improve the program delivery, the responses ranged from having a longer program with more lessons, more activities, more topics, having “more people that are willing to do this” and “involving more people to participate” to wanting a shorter program and commenting that some classes were too similar. PHCs were asked what supports they needed before and after the program. Their responses included supports to address the group (e.g., “I'll need reminders on how to approach peers in a positive manner to get them on the right track.”) and speaking up, reading the materials, and general support from a mentor “because they would help me with my words when I am stuck in mid-sentence.”
Mentors largely rated the webinar as “great” (66%) and reported that 70% of activities and 81% materials were “great.” Eighty-nine percent (89%) felt the webinar was worth their time and 94% would recommend the webinar training to others to become mentors. The following three themes emerged from mentors' comments as to how the webinar training could be improved: (1) reduced length of the webinar training; (2) technical issues with the webinar; and (3) additional practical applications of the HealthMessages Program. About 10% of mentors wanted a shorter webinar. Seventeen percent (17%) of the mentors noted technical difficulties with the webinar. Oftentimes, organizations were not set up to easily access the webinar platform. Even though practice sessions were conducted prior to the webinars, some participants still struggled with logging on to the webinar. The issues were mainly with the ability to hear the speakers, one of the organizations had difficulty with the audio because their phone lines were down and they had to use a cell phone. Practical applications included being able to see an actual class being taught, short videos during the webinar presentation, more examples on physical activity and water intake, and more detailed instructions on each lesson.
The three themes reported by mentors' as to what would improve their experiences with the 12-week HealthMessages Program included: (1) additional visual aids and examples; (2) increased accessibility of the material; and (3) reducing lesson repetition. Mentors wanted additional visual aids and interactive activities to improve the program, additional activities geared towards non-ambulatory participants and more hands on learning activities to keep the peers engaged. Three mentors felt that the lessons were too repetitive. Additionally, after the HealthMessages Program, mentors reported positive outcomes related to their role in supporting people with IDD to be PHCs including growth in PHCs leadership skills, collaboration skills, and nurturing. For example, “In the beginning the PHC struggled with a few leadership skills but I observed her overcoming those struggles. I truly was a role model for her and guide to build her leadership skills.” Collaborative skills were enhanced during the program, as noted by a mentor stating “It opened new door to my teaching experience—collaboration!” Nurturing support was another concept conveyed by a mentor stating “It is truly guiding someone to take what they know or are learning and share the information to the best of their ability. It is a nurturing supporting role.” After the program ended, 86% of the mentors rated the program as “fun”, 78% were interested in running more programs, 64% wanted to continue being mentors, 89% felt the program was worth their time, 87% would recommend the program to other people with IDD, and 82% would recommend other staff to become mentors.
Peers were overwhelmingly positive about the HealthMessages Program taught by their peers. For example, one peer stated “I didn't think it was going to be fun and then it turned out to be fun.” At the completion of the program, peers were asked several questions about the program. Eighty seven percent (87%) felt the program was worth their time, 82% would definitely recommend the program to someone else, 88% rated program as ”fun,” 86% liked having a peer coach, 80% would repeat the program, 77% wanted to learn more and new topics, and 54% wanted to become PHCs themselves.
When asked about the support they would need to continue to be more physically active and drink more water, most respondents focused on needing support of friends and/or staff to continue their healthy lifestyle. Some peers mentioned additional equipment and materials such as DVDs, visual aids, and resistance bands. Additionally, when asked about their expectations of the program, the majority of peers stated that their expectations were met or exceeded. However, a few peers mentioned wanting more hands-on exercises and more in-depth information and fun facts about nutrition and healthy eating. Some peers felt that learning new exercises or exercising with a friend would have made their experience more exciting. When asked about any new topics they would be interested in learning, peer participants focused on nutrition and physical activity including weight loss and sleep. Nutrition topics that they wanted to learn more about included healthy foods and snacks, portion sizes, meal planning, grocery shopping, and meal preparation. Physical activity topics included learning different sports such as basketball, bike riding, running, and learning how to do specific exercises such as weight lifting, balance, exercises for older residents and people who use wheelchairs.
This is a first study examining the effectiveness of a peer-to-peer health promotion program taught by people with IDD and their mentors to impact health outcomes among people with IDD. Both impact measures (e.g., improved hydration and physical activity knowledge, increased social support) and process evaluation measures (e.g., high satisfaction) support the effectiveness of a peer-led dyad approach among PHCs and mentors to teach a health promotion program. Because daily soda and coffee drinking continues to be very common among people with IDD, this study has promising practical significance. Sweetened beverage consumption is associated with higher rates of obesity (Malik et al. 2006). People who consume more soda and are less physically active have higher rates of obesity (Hsieh, Rimmer, Heller, 2014). Furthermore, increasing the understanding of the importance of hydration via drinking water and consuming foods with the highest amount of water content (fruits and vegetables) was used to potentially displace intake of sweetened beverages and less-healthy foods. This study is consistent with other peer-to-peer programs documenting the positive impact of peer support on health behavior. Having peers with IDD working as health coaches may be a useful and economical approach for providing social support for people with IDD to: (1) improve their knowledge related to the benefits of water, physical activity, and exercise; (2) drink more water each day; (3) reduce consumption of soda and coffee; (4) increase exercise activity each week; and, (5) be more physically active each week. This study also contributes to the general peer-led health education literature by including a webinar platform to implement a peer-led initiative for people with IDD and their mentors.
Dyad Approach for Peer Health Coaches and Mentors
Overall, the HealthMessages Train-the-Trainer Webinar and the HealthMessages Program was successful. Analyses of PHC data from the peer-led HealthMessages Program demonstrated statistically significant changes in Hydration Knowledge. Although the results from Physical Activity Knowledge and Self Efficacy scales did not show statistical significance for PHCs, the means changed in the expected direction supporting the benefits of a peer-led health education program. A larger sample size of dyads of PHCs and mentors may yield stronger a stronger relationship for knowledge of exercise and self-efficacy. Of note, the PHCs' mean scores for the Hydration Knowledge scale was higher than peer participants' scores. This may have also have limited the knowledge gains related to hydration for PHCs. For peer participants, future research needs to examine the pathways of how perceived social support relates to knowledge (cognitive appraisals) and the impact on health behavior changes. Researchers report that the level of knowledge has a negative correlation with the appraisal of a disease as harmful; whereas, social support is positively correlated with disease-related appraisals related to profit, challenge, and value. (Szymona-Palkowska et al., 2016).
A dyad approach with PHCs and mentors supported PHCs in learning how to use a variety of teaching and leadership skills with each health message, such as the following: (1) delivery skills; (2) visual aids; (3) body language; (4) audience participation; and (5) content knowledge. PHCs focused on one of the five skills each week. For example, mentors assisted PHCs to use pictures, explain unknown words, use “everyday” language, answer questions from peer participants, encourage participation, and use body language to communicate health messages.
The HealthMessages Program aims to present basic (fundamental) knowledge to build skills to improve health behaviors in order to be accessible to a heterogeneous group of participants. Some PHCs and peer participants found some of the lessons in the HealthMessages Program to be redundant. HealthMessages Program may not be an all-encompassing health education curriculum to address increasing health knowledge; however, evidence supports the use of the HealthMessages Program as an effective and fun “launching point.” Mentors or program staff may need to provide additional information and support to PHCs so they can continue the HealthMessages Program depending on participants' interests. Researchers may develop additional health messages modules (e.g., reducing intake of sugary drinks and coffee, weight lifting, balance exercises) to see if a health messages program maintains interest over time and achieves greater health benefits. Additionally, teaching modules may also provide more in-depth health education information for peer learners. Lastly, in developing more online, eLearning modules that are available on demand, studies may examine the level of support needed for PHCs to teach classes independently as PHCs may become certified to implement a HealthMessages Program in their communities (e.g., recreation centers, schools, churches, non-profit organizations) as an employee or volunteer.
Anticipatable Incidental Findings
The webinar platform was not the focus of this study. Results from the HealthMessages Train-the-Trainer Workshop for PHCs with IDD and their mentors demonstrated significant findings for PHCs and their mentors across measures of self-efficacy for mentors, knowledge among PHCs, and satisfaction among PHCs and their mentors with the train-the-trainer webinar. While improved self-efficacy was not statistically significant for PHCs, similar to their mentors, the means changed in a positive direction for PHCs after the webinar and remained consistent following the 12-week HealthMessages Program. A larger sample size of PHC and mentor dyads has the potential to yield statistically significant findings related to self-efficacy for the PHCs. The scores on the Health Advocacy Scale did not demonstrate significant changes at T2 or T3 for the PHCs or mentors. The scores were moderately high at baseline for PHCs and mentors suggesting that they may have already believed in the need to advocate for health and health promotion activities. Future research may evaluate the relationship of health advocacy in a peer-to-peer health promotion program and the need to measure health advocacy among PHCs and mentors. Revising the items on the scale to align with the health messages of hydration, physical activity, and exercise rather than focusing on health promotion and healthy lifestyles as a general concept may also be useful. Research is needed to refine the items to relate to specific health messages being taught.
Process evaluation feedback demonstrated support for using a web-based platform. For all of the PHCs, this was the first time that they had participated in a webinar and the first time they were learning to be PHCs. Although PHCs were selected based on their interest in becoming a health coach, none of the PHCs had any previous health-related training. More research is needed to determine if an eLearning, asynchronous webinar (on-demand without “live” instructors) yields the same level of satisfaction and if peer participants achieve psychosocial and physical health benefits.
Limitations and Future Research
PHCs and their mentors were successful in implementing HealthMessages Program with their peers. Several limitations were noted with the implementation of HealthMessages Train-the-Trainer Webinar and the HealthMessages Program. First, small sample size among the dyad pairs of PHCs and mentors may have restricted significant group differences in some of the outcome variables. Second, the following methodological issues related to the program evaluation among peer participants may limit the generalizability of the findings: (1) reliability of the program implementation; (2) low statistical power; (3) random differences in the program setting; and (4) collection of data by non-researchers in a community setting. As noted in Table 5, the data collected among peers regarding knowledge, social support, and health behaviors was limited compared to the total number of peer participants. This finding may be related to the challenges of participants in being able to accurately recall and report health-related behaviors over time. Third, because participants were required to read and speak English, generalizability is limited to people with IDD who read and speak English.
The impact of the HealthMessages Program on health was particularly strong with peer participants increasing the amount of time that they exercised per week. peer participants had the least amount of change with their intake of soda and coffee. Of note, none of the weekly health messages targeted the need to reduce soda or coffee intake. Future classes may want to include these as a specific lesson and corresponding goal aimed at reducing soda and coffee. Additionally, data collection related to the intake of fluids is difficult due to recall bias, along with inconsistent sizes of cups, cans, and bottles. Future research may consider including health messages that specifically target reduction of soda and coffee intake as this may result in a more significant reduction of soda and coffee. We found that peer participants who reported weight loss during the program were more likely to state that they wanted to learn more about the topics taught, wanted to learn new health topics, and wanted to become a PHC.
With our study, the small sample size most likely resulted in reduced power to detect statistical differences, along with the ability to detect an effect among PHCs. Looking at implementation consistency, while we attempted to maintain fidelity of the 12-week HealthMessages Program, with the community-based nature of this study, PHCs and mentors may not have implemented the intervention in a standardized manner. Future research should continue the inclusion of community partners in the research process to develop health promotion programs that can be implemented in CBOs while maintaining fidelity and ensuring sustainability.
The authors wish to thank Corina Ronneberg for her work with the literature review in preparing the manuscript.
The research for and the preparation of this article was supported in part by the United States Department of Health and Human Services, Administration for Community Living (ACL), National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) Grant # 90RT5020-01-00. The content does not necessarily represent the policy of the U.S. Department of Education, and endorsement by the Federal Government should not be assumed. Research approved through the University of Illinois Office for the Protection of Research Subjects (OPRS).