The Community Health Assessment Program in the Philippines (CHAP-P)

Presented by:Canadian team: Drs Gina Agarwal, Ric Angeles

Filipino team: Drs Dave Arnuco, Monsie Guigona, Gem Durias, Jaime Punzalan

What is CHAP-P?The Community Health Assessment Program in the

Philippines • Based on an evidence-based Canadian program• A community-based intervention: volunteer-led, walk-

in “CHAP-P sessions” for diabetes & cardiovascular health with:– Risk assessment, including BP testing – Education– Referrals to appropriate services when needed

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First CHAP-P GACD Project, DM04, 2014-2019

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Aim of This Project OverallTo adapt the Canadian intervention to an LMIC setting and determine the effect of CHAP-P on the HbA1c of residents from selected communities of the Zamboanga Peninsula, Philippines

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Objectives1. To identify optimal ways to adapt elements of the CHAP

model to fit local LMIC conditions (socio-cultural, economic, environmental) while focusing on the prevention and management of diabetes

2. To evaluate the effectiveness, feasibility/acceptability, and cost effectiveness of CHAP-P for use in LMICs

3. To foster uptake of findings from CHAP-P to other groups in the Philippines and other LMICs

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Four Phases of the 5-Year DM04 Phase 1: qualitative study adapting the program to the sociocultural & economic setting (complete)Phase 2: series of pilot studies testing elements of the intervention (complete)Phase 3: 26-community parallel cluster RCT with 2600 participants (complete)Phase 4: data interpretation, knowledge translation (upcoming presentations, publications, large meeting)

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RCT Outcomes• Primary: mean difference in HBa1c

at 6 months in random sample of individuals from intervention communities compared to control

• Secondary: multiple secondary outcomes

• Also assessed program through: community process evaluation, intervention fidelity assessments, and economic analysis

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RCT Participant Groups1. Community survey & HbA1c test: 100 residents

aged 40+, randomly selected door-to-door (baseline and post-intervention) from all 26 communities (13 intervention and 13 controls)

2. CHAP-P session participants: community residents aged 40+ in intervention communities

3. Volunteer focus groups: community health workers who facilitated CHAP-P sessions

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Community Survey Included topics such as:• Diabetes risk factors• Knowledge about diabetes &

cardiovascular health• Quality of life• Physical activity• Self-efficacy to improve health

behaviours• Health utilization and access

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Preliminary Results: CHAP ParticipantsVariables n=3004 (%)

Age

<45 431 (14.8)45-54 848 (29.1)55-64 837 (28.8)>64 795 (27.3)

Sex Female 2098 (71.5)

BMINormal 1533 (53.8)Overweight 955 (33.5)Obese 364 (12.8)

Elevated waist circumference 1930 (66.3)Low physical activity 1208 (41.1)Low fruit and vegetable intake 2209 (75.2)Elevated BP 1178 (39.0)Diagnosed with Diabetes 387 (13.2)

FINDRISC Category (Only for those without Diabetes)

Low 238 (18.0)

Slightly Elevated 415 (31.5)Moderate 311 (23.6)High 308 (23.4)Very High 47 ( 3.6)

• 3004 community residents attended from 6 urban and 7 rural intervention villages

• 1494 (49.6%) with 2 or more visits

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Preliminary Results: CHAP-P Sessions• Significant decrease in

systolic BP and weight

• Subgroup analysis showed the program was more effective in rural communities

Number of Visits

n=3004 (%)

Mean Systolic BP (95% CI)

Mean Diastolic BP

(95% CI)

Mean Weight in kg (95% CI)

1 1494 (49.6) 136.49 (135.35, 137.62)

78.55 (74.02, 83.09)

58.41 (57.70, 59.13)

2 1520 (50.4) 133.21* (132.08, 134.34)

81.55 (77.02, 86.09)

57.35 (56.63, 58.06)

3 870 (28.9) 131.15* (129.66, 132.65)

75.72 (69.73, 81.71)

56.10* (55.16, 57.04)

4 570 (18.9) 130.54* (128.70, 132.39)

75.03 (67.62, 82.43)

56.35* (55.19, 57.52)

5 397 (13.2) 130.80* (128.58, 133.01)

75.05 (66.18, 83.92)

55.78* (54.39, 57.18)

*significantly decreased (p<0 05) compared to T1(HLM)R

Preliminary Results: RCT OutcomesVariables Control

n=1299 (%)Interventionn=1303 (%)

Age

<45 283 (21.8) 226 (17.3)45-54 409 (31.5) 427 (32.8)55-64 318 (24.5) 329 (25.2)>64 287 (22.1) 321 (24.6)

Sex Female 804 (61.9) 828 (63.5

Education

Some highschool or less 861 (66.3) 919 (70.5)Completed highschool 199 (15.3) 201 (15.4)Some college or university 79 (6.1) 72 (5.5)College/ University Degree or higher

160 (12.3) 111 (8.5)

Has:

Heart Problems 138 (10.6) 112 (8.6)High BP 490 (37.7) 500 (38.4)High Cholesterol 56 (4.3) 56 (4.3)Stroke 37 (2.8) 50 (3.8)Diabetes 107 (8.2) 99 (7.6)

Variables Controln=1299 (%)

Interventionn=1303 (%)

BMINormal 730 (56.6) 742 (57.7)Overweight 408 (31.7) 389 (30.2)Obese 151 (11.7) 155 (12.1)

Elevated waist circumference 709 (54.6) 710 (50.7)Low physical activity 327 (25.2) 269 (20.7)Low fruit and vegetable intake 501 (38.6) 498 (38.2)Smoker 203 (15.6) 219 (16.8)

FINDRISC Category (Only for those without Diabetes)

Low 477 (41.0) 486 (41.9)Slightly Elevated 484 (41.6) 464 (40.0)Moderate 134 (11.5) 128 (11.0)High 64 (5.5) 80 (6.9)Very High 4 (0.3) 2 (0.2)

Poor-Fair Perception of health 248 (19.1) 290 (22.2)

Has Problem with:

Mobility 333 (25.7) 336 (25.8)Self-care 128 (9.8) 117 (9.0)Doing Usual Activities 270 (20.8) 235 (18.0)Pain 702 (54.0) 686 (52.6)Anxiety and Depression 569 (43.8) 557 (42.7)

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Next Steps• Complete formal analysis of the

RCT results• Interpret results with bilateral

Canadian and Filipino team meetings

• Large meeting in the Philippines in March 2020 for knowledge translation of results to local, national, and international stakeholders

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Second CHAP-P GACD Project, SU11, 2019-2024

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To assess the scalability of CHAP-P in the Zamboanga Peninsula Region,

Philippines

General Scale-Up Objective

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Specific Scale-Up Objectives1. To assess scalability of CHAP-P in the Zamboanga Peninsula in

terms of: acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, cost-analysis, penetration, and sustainability

2. To identify factors and processes affecting acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, cost-analysis, penetration, and sustainability of CHAP-P in communities in the Zamboanga Peninsula Region

3. To develop a guide for scaling up CHAP-P nationally in the Philippines and in other similar low- and middle-income countries

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Stages of Research Implementation1. Strategic Planning: involving stakeholders

across all levels to plan the best way to scale-up CHAP-P region-wide

1. Implementation & Quality Improvement: where the program will be implemented andbest practices learned from early adopters willbe integrated into the program

1. Research Evaluation & Knowledge Translationinclude readiness assessments in selected partner countries (to potentially include Thailand, Tunisia, and Peru).

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Process Model• The Knowledge-to-Action (KTA) Framework will be

used• Will guide implementation planning,

implementation, & evaluation process as a whole• Provides conceptual clarity and a path to follow in

translating health services research knowledge to real-world settings

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Evaluation FrameworkOutcome Method of Evaluation Participants/Data Source

Acceptability Interviews, survey CHAP-P participants & facilitators

Adoption Observation, research tracking Community reports, CHAP-P database

Appropriateness Survey CHAP-P participants & facilitators

Fidelity Observational checklist, research tracking Community reports, CHAP-P database,

Implementation cost Economic analysis Finance data

Penetration Program tracking (N participants, referrals, etc)

Community reports, CHAP-P database

Sustainability Program tracking (N municipalities maintaining CHAP-P )

Community reports, research data

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Next Steps• Planning for implementation of scale-up in

bilateral Canadian and Filipino team meetings• Large meeting in the

Philippines in March 2020 for collaborative planning and preparation for the scale-up with local, national, and international stakeholders ADZU Research Team

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