Partenariat Santé : Results of a Community Program to Improve the Cardiovascular Health among Adult Population

Partenariat Santé (PS) launched in Québec in 2016, is inspired from the Cardiovascular Health Awareness Program (CHAP) and consists of a free session held in the community by students coming from different health sciences programs. The program’s mission is to make available early detection of modifiable CVD risk factors, raise awareness of participants about their impact on CVDs, and promote healthy life changes. In order to gather information to optimize the implementation of this program and eventually to enlarge its implementation to other sites, the first objective of this study was to explore the characteristics of the adult population participating in the PS program and to identify the risk factors they want to modify. The second objective was to evaluate one month later the effective implementation of the action plan elaborated during the motivational interview. The third objective was to evaluate the satisfaction of the participants with the PS program. One hundred ten subjects who attended PS sessions during this period were en-rolled in the study. About 30% of participants have blood pressure values ≥ 140/90 mmHg and 40% present a waist circumference associated with higher risk profile. The behaviors to be changed mostly targeted by the participants were physical inactivity and nutrition. A motivational interview was con-ducted with the elaboration of an action plan to support the behavioral/out-comes changes. Sixty participants (54.5%) completed the 0.214), whereas it decreased significantly for those who did not (6.8 ± 2.1 versus 5.8 ± 2.0; p = 0.029). The majority of them agreed that PS program was useful (75%) and led them to change their lifestyle related to cardiovascular health (62%). In conclusion, our results suggest that the PS program can produce benefits on the promotion of cardiovascular health in the community adult population, being evaluated as useful to change the lifestyle related to CVD risk.


Introduction
Cardiovascular diseases (CVDs) are the leading cause of death in the world.
They were responsible for 17.9 million deaths in 2016, representing 31% of worldwide deaths [1]. In Canada, CVDs also represent a heavy burden for health-care systems. They generated nearly $21 billion in direct and indirect costs in 2005 [2]. Moreover, nine Canadians out of 10 over the age of 20 years have at least one risk factor for developing CVDs, and two out of five have three or more [3].
A risk factor is a characteristic of an individual that is associated with an increased risk of developing a disease. Non-modifiable risk factors of CVDs include age, gender, ethnicity, socioeconomic status, diabetes, genetic susceptibility and family history of CVDs. Modifiable risk factors comprise sedentary lifestyle, smoking, excessive alcohol consumption, insufficient intake of fruit and vegetables, excessive intake of salt, fat, and sugar, blood lipid profile, obesity or overweight, and high blood pressure. The World Health Organisation estimates that three-quarters of CVDs could be prevented [1]. Hence, providing early detection of these modifiable risk factors and addressing them, along with raising public awareness, could decrease the epidemic of CVDs and its health and economical impacts.
The understanding of the importance of enlarging the offer of prevention actions to the overall population gave rise to community initiatives such as the Cardiovascular Health Awareness Program (CHAP), which was developed and implemented in Ontario [4]. This program provides free risk assessment and information sessions that are held in places where people work, live and gather, as pharmacies, community health centers, primary care practices, places of worship, shopping centers, workplaces, community events, service group facilities, or other easily accessible locations [4] [5]. This program aims to prevent CVDs through blood pressure measurements, promotion and teaching of healthy lifestyles, and referral to community resources. This initiative has been adapted to different settings and populations, including older adults [6] [7], low and middle-income countries [8] [9], individuals waiting for a family physician [10], as well as hospital employees [11], with promising results. Indeed, in older adults population, CHAP has led to a9% decrease in the hospitalisation rates for cardiovascular-related causes among participants aged 65 years and older [7] and this benefit effect persisted in the first five years [12]. Moreover, participants who attended three CHAP sessions and who were monitored for 18 months recorded a mean reduction of 19 mmHg in systolic blood pressure [13]. In a systematic review aimed at assessing the effectiveness of community programs for the prevention of CVDs, and defined as those targeting multiple CVD risk factors in the whole population living within a certain geographic area, Pennant et al. (2010) reported an average net reduction in 10-year CVD risk of 0.65% [14]. These data inspired the implementation of Partenariat Santé (PS) in 2016. The program's mission is to make available to the adult population of the province of Quebec in Canada the early detection of modifiable risk factors for CVDs, raise awareness about their impact on CVDs, and promote healthy life changes through free sessions held in the community by voluntary students coming from different programs in health-sciences at Université Laval [15].
In order to gather information to optimize and consolidate the implementation of this program and eventually to enlarge its implementation to other sites, the first objective of this study was to explore the characteristics of the adult population participating in the PS program and to identify the risk factors they want to modify. The second objective was to evaluate one month later the effective implementation of the action plan elaborated during the motivational interview. The third objective was to evaluate the satisfaction of the participants with the PS program.

Setting and Participants
Participants were recruited among individuals who attended the PS program between February and December 2019. During this period, eight sessions were held in Québec, including three in public spaces, four in workplace environments and one in a community sports centre. Posters, emails, and social media publicized the program before the sessions were held. For the sessions in community settings, recruitment consisted of inviting the general public to participate. Recruitment for workplace sessions was done beforehand. Employees interested in participating in the PS program had to schedule an appointment online, on a Doodle send by email by their employer. This information was then transmitted to the PS coordinator responsible for the session and appointments were made with the interested employees. Participants who have identified a risk factor that needs to be changed and have a plan to change it as well as who agree to be contacted one month later were recruited in this study.

Statistical Analysis
All data obtained were entered in a database created in the RedCap international database and transferred to SPSS, version 26.0, for descriptive and inferential analysis. Means and standard deviations were calculated for continuous variables, and percentages were calculated for categorical variables. To compare continuous variables, t-tests were used for normally distributed variables (age, waist circumference and blood pressure) and non-parametric tests were used for the nonnormally distributed variable, i.e., motivation level (Wilcoxon signed-rank and U Mann-Whitney). Chi-square was used to compare categorical variables.

Ethical Aspects
The study protocol was explained to all the participants before signing the con-

Sociodemographic and Clinical Characteristics of Participants
One hundred and ten participants agreed to participate in this research project (67 women; mean age 47.2 ± 13.6 years) (

Risk Factors Targeted and Action Plans
During the PS session, participants were asked to identify which CVD risk factor they wanted to work on, considering their own lifestyle ( Figure 2). The two most identified risk factors were bad eating habits (50.0%) and lack of physical activity (39.1%). High waist circumference and high blood pressure were targeted by 10.9% and 9.1% of participants, respectively, while tobacco and alcohol consumption were identified by 5.5% and 3.6% of participants, respectively. Few participants have not identified any risk factor during the session (5.5%). Note that the percentages adding up to over 100% are due to the fact that 21 participants chose two or three risk factors.
Participants developed different action plans to modify targeted risk factors (see Table 2). These action plans were divided into two large categories -plans directly related to behavioural change and plans related to an outcome. Among the behavioral plans, those related to physical activity and nutrition were far more prevalent. Among the outcome plans, lose weight and maintain or improve health were more frequent. As for the choice of risk factors, 15.5% (17/110) of participants identified more than one intervention in their action plan and were thus included in more than one category.

Implementation of Action Plan Following Partenariat Santé Session
Among the 110 participants recruited during the PS session, sixty (54.5%) completed the questionnaire sent one month later. Forty-one (68.3%) of the participants completing the follow-up reported that they had put their action plans into  Maintain or improve health (in general) 11 Reduce blood pressure 3 Reduce/manage stress 2 practice, while 63.3% claimed that they mostly reached their objectives (≥4, averaging score 3.8/6). At the baseline, participant motivation to implement their action plans was high for most of the participants (7.5 ± 1.9 on a 10-point scale).
As expected, for the 60 participants who completed the follow-up, motivation remained high after one month for the participants who implemented their action plans (7.8 ± 1.9 versus 7.4 ± 1.6; p = 0.214), whereas it decreased significantly for those who did not (6.8 ± 2.1 versus 5.8 ± 2.0; p = 0.029) ( Table 3). Interestingly, the motivation rate during the PS session was higher among participants who put their action plans into practice than among those who did not

Discussion
The [11] [19]. In addition, their efficacy in improving cardiovascular health has been reported [7] [13]. Partenariat Santé is based on CHAP and consists of a free session held in the community by students in various health-sciences programs at Université Laval [15]. This study aimed to obtain a general view of the potential results of the PS program, and more specifically: 1) to explore the characteristics of the adult population participating in the program and the risk factors they targeted to modify; 2) to evaluate one month later the implementation of the action plan elaborated during the motivational interview; and 3) to evaluate the satisfaction of the participants with the PS program. 58% of women) and for which a third of participants had blood pressure ≥ 140/90 mmHg [10]. Moreover, 40% of the participants presented a waist circumference associated with a higher risk profile [20]. This indicates that individuals attending PS sessions could profit from this program to improve their cardiovascular profiles.
Participants identified physical inactivity and eating behaviours as the most important cardiovascular risk factors to be addressed. Accordingly, action plans predominantly focused on modifying these two risk factors. This observation is consistent with a report showing that physical inactivity and eating behaviours (specifically, inadequate intake of fruit and vegetables) were the predominant risk factors identified by Canadians [3]. This information will be helpful in en- The majority of participants implemented their action plans (68.3%). According to theories of social psychology, motivation is the most important determinant of behavior. Individuals with a positive motivation are likely to adopt the behavior. Thus, the enhanced motivation that can be achieved with the motivational interview is of importance. In our study, we observed that the participants who implemented their action plan had a tendency to have a higher motivation at baseline and at the one-month follow-up, their intention was even higher than at the baseline. Moreover, the motivation of the participants that failed in implementing their action plan presented a decrease in their motivation one month later. In fact, the literature points that planning is regarded as highly valuable in the process of health behaviour change. It bridges the gap between behavioural intentions and health-related behaviours, enhancing the enactment of these behaviours [21]. Additionally, literature regarding motivational interview shows that intervention effectiveness appears to increase with contact time [22] [23]. In a systematic review on effectiveness of motivational interviewing for health change in primary care settings, the authors suggest that when only one session is held, the duration may need to be longer than a typical primary care consultation time (e.g., >30 minutes) and studies that included only one face-to-face session have demonstrated their efficacy when combined with one follow-up phone call [22]. This is of particular importance since PS program consists of only one face-to-face brief session lasting approximately 15 minutes. It is important to mention that studies reporting favorable effects of CHAP programs on objective cardiovascular outcomes include sessions longer in duration and/or in frequency [7] [12] [13]. The addition of a follow-up phone call could be a feasible and inexpensive intervention to optimize the efficacy of PS program.
Satisfaction with an intervention is a very important point to estimate the feasibility and potential of acceptability of the intervention. Our results point to the high level of satisfaction since 75% of the participants agreed that PS session was useful and most of them (78.3%) would recommend PS to friends.
The results of the present study will be useful for improving the PS program in the future. First, the analysis of the action plans indicates heterogeneity in their formulation, most of them targeting health outcomes and not exactly the behaviors to change. More than aiming to "improve health" or "lose weight", it is important that the action plan target behaviors to change e.g., "to do an activity of at least 30 minutes twice a week". Training of volunteers on the SMART tool and its systematic use during PS sessions will help participants implement their action plan [24]. Another important point is to add the elaboration of coping plans that refers to the mental simulation of overcoming anticipated barriers to action. Participants with higher levels of coping planning are more likely to report higher levels of the behavior later. Thus, it is suggested to include both kinds of planning in interventions at different stages in health behaviour change Open Journal of Preventive Medicine [21]. Second, the community resources recommended during the session (and available on the PS Web site at http://www.partenariat-sante.com/) were rarely used by participants, despite such resources being an essential component of CHAP programs. The reasons for this low use rate of community resources are unclear and require clarification to optimize their use.
This study has certain limitations. First, assessment of the impact of PS sessions was limited to gathering information from participants. This approach is associated with a social desirability bias that can positively favor the impact of PS program. CHAP programs have previously demonstrated their benefits on objectively measured outcomes such as blood pressure and cardiovascular events [7] [13]. Measures of such outcomes will be helpful in documenting the real impact of PS sessions on cardiovascular health in the future. A second limitation of this study concerns the selection bias due to the fact that, among individuals who participated in PS sessions, those who agreed to take part in our study might have been more motivated to change their lifestyles. Third, PS is an initiative based on the voluntary participation of students in health sciences. As such, they received training on assessing CVD risk and the use of motivational interviewing. In our study, we did not consider characteristics of volunteers in the data analysis (for example, the field of study, years of experience, quality of the action-plan formulation, etc.). Lastly, we did not assess differences in our results based on where the PS sessions were held (e.g. workplace, public spaces). This characterization will be helpful in targeting locations where PS sessions are most useful.
The results of this study are indeed not new in terms of the benefits of an intervention to change health-related behaviours. However, the strength and relevance of this study lie in the fact that it presents a community action strategy adapted to the Quebec context and led by university students in a perspective of interprofessional collaboration. This opens up new perspectives for integrating these actions into university training by preparing students for the deployment of collaborative interprofessional work while already having positive impacts on society.
In conclusion, the assessment of PS sessions during 2019 suggests they increased the awareness of individuals about their cardiovascular risk factors and the adoption of healthy lifestyles. There is a need to initiate a comprehensive longitudinal research program to conduct a more in-depth assessment of the impact of PS program on the cardiovascular health of Québec residents, including the evaluation of objective outcomes of cardiovascular health.