Research in Gerontological Nursing

Original Research: Qualitative 

Lay Health Mentors in Community-Based Older Adult Disability Prevention ProgramsProvider Perspectives

Almas Dossa, PhD, MPH; John A. Capitman, PhD

Abstract

In this study, we explored provider perspectives on the benefits of and implementation challenges in using lay health mentor peers in a community-based replication of an efficacious 12-month older adult disability prevention program. In addition, we describe the association of the mentor program with site features and program completion. We conducted semi-structured telephone interviews with nurses, social workers, and site managers and obtained primary data on site features and secondary data on program completion. Major themes included the importance of the health mentor program and implementation challenges. Sites with mentor programs were more likely to have older adults complete the program compared with sites without mentor programs. Rural, small, and less diverse sites were more likely to have health mentor programs than urban, large, and more diverse sites. Implications include a need to fund more lay health mentor programs, obtain adequate staffing including minority staff for health mentor support, and implement strategies to improve program efficiency.

Abstract

In this study, we explored provider perspectives on the benefits of and implementation challenges in using lay health mentor peers in a community-based replication of an efficacious 12-month older adult disability prevention program. In addition, we describe the association of the mentor program with site features and program completion. We conducted semi-structured telephone interviews with nurses, social workers, and site managers and obtained primary data on site features and secondary data on program completion. Major themes included the importance of the health mentor program and implementation challenges. Sites with mentor programs were more likely to have older adults complete the program compared with sites without mentor programs. Rural, small, and less diverse sites were more likely to have health mentor programs than urban, large, and more diverse sites. Implications include a need to fund more lay health mentor programs, obtain adequate staffing including minority staff for health mentor support, and implement strategies to improve program efficiency.

Although recent studies indicate declining disability rates among older adults in the United States, health and social service requirements of disabled older adults represent an increasing challenge due to expected growth in the population of older adults (Manton, Gu, & Lamb, 2006; Stuck et al., 1999). Disability prevention models such as the Chronic Disease Self-Management Programs (CDSMPs) and the Health Enhancement Program (HEP) for older adults with chronic disease are reported to improve functional outcomes, improve exercise tolerance, decrease hospitalization, and improve quality of life (Leveille et al., 1998; Lorig, Ritter, et al., 2001; Lorig, Sobel, Ritter, Laurent, & Hobbs, 2001; Lorig et al., 1999; Phelan et al., 2002; Phelan, Williams, Penninx, LoGerfo, & Leveille, 2004; Phelan, Williams, Snyder, Fitts, & LoGerfo, 2006). These evidence-based programs often use peer support as a low-cost additional resource to assist in program implementation and allow for wider dissemination, but little research explores the implementation challenges and health and social benefits of these peer support programs.

Often, barriers to providing community-based health programs, such as lack of financial resources and inadequate staffing, are addressed by the use of volunteers. These peer volunteers or lay health mentors are also older adults with chronic disease. Studies show that peers with personal experience in coping with illnesses similar to those of program participants can provide emotional support and mentoring to program participants (Dennis, 2003; Resnick, Orwig, Magaziner, & Wynne, 2002). For example, improved mammography attendance rates and health outcomes for older adults have been reported with the use of older adult peers, as well as benefits to the peers, such as greater life satisfaction and emotional well-being (Brunier, Graydon, Rothman, Sherman, & Liadsky, 2002; Butler, 2006; King, Benincasa, Harrop-Stein, & Crossette, 1999; Rabiner et al., 2003). The key to peer support models is the use of peers similar in age, gender, and chronic disease status to the client, such as the model used by Joseph, Griffin, Hall, and Sullivan (2001) in the management of type 2 diabetes, which helped keep clients on track with disease management to improve health outcomes.

Clearly, using peer volunteers is a promising way to enhance health outcomes for older adults. Although many community-based health programs use peer volunteers to address inadequate staffing and lack of financial resources, recruiting and training peer mentors can be time consuming and can add more responsibilities to staff who are already burdened and overextended. In a 2003 Urban Institute survey of 1,354 U.S. nonprofit organizations that use volunteers, a majority of the organizations believed that recruiting sufficient numbers of volunteers, lack of paid staff time to train and supervise volunteers, and lack of funds to support volunteer administration were problems (Hager & Brudney, 2004).

As yet, little is known about provider perspectives on older adult health and social benefits or on implementation challenges related to peer support components within community-based older adult disability prevention programs, such as the HEP replication, a dissemination of the clinical trial (Leveille et al., 1998). Researchers have reported that program noncompletion or refusals can negatively influence health outcomes (Clark, Stump, & Damush, 2003; Minder, Müller, Gillmann, Beck, & Stuck, 2002). Peer support may improve older adults’ program completion, but we did not find studies on the association of peer support with program completion in community-based disability prevention programs. In addition, hospital studies found that smaller site size and urban locations were associated with better health outcomes (Baldwin et al., 2004; Carbonell et al., 2005; Shiekh & Bullock, 2001), but we did not find any research on site feature association (e.g., location, size, or diversity) with peer support program presence.

In this study, we explored nurse, social worker, and site manager perspectives on older adult health and social benefits, as well as implementation challenges, related to using peer support in the HEP replication. We also describe the relationship between peer program presence and site features and older adult program completion. This study was part of a larger mixed-methods study that examined organizational, provider, and client factors on older adult participation and health outcomes in the HEP replication.

Program Background

The HEP was developed by the Northshore Senior Center and the University of Washington, Seattle (Leveille et al., 1998; Phelan et al., 2002). This evidence-based program is now found in more than 200 sites across the country, including senior centers, assisted living centers, hospitals, and continuing retirement communities. Conducted by nurses and social workers in senior centers, HEP was designed to promote health and functioning of community-dwelling older adults with chronic disease who are at risk for functional decline. It consists of comprehensive health reviews, functional assessments, and action plans done by nurses, and support groups conducted by social workers (Leveille et al., 1998; Phelan et al., 2002). The HEP involves client follow-up at 2 weeks to review plans, then at 6 and 12 months for evaluation. Clients attend support groups and fitness programs during this 1-year period. In addition, clients are encouraged to enroll in other evidence-based programs: an exercise class and the CDSMP—a 6-week program including guidelines on goal setting, exercise, medications, coping, symptom management, and communication with health professionals (Leveille et al., 1998; Lorig, Sobel, Ritter, et al., 2001).

The peer support program (hereafter referred to as the health mentor program), a component of the HEP, matches HEP clients with trained older adult peer mentors who provide follow-up calls and support for the health action plan. Under the HEP protocol, all sites were to have health mentor programs. Volunteer older adults for the health mentor programs are trained by the nurses and social workers to provide peer support, assist with follow up, provide socialization to older adult HEP clients, and encourage clients in adopting healthy behaviors (Davis, Leveille, Favaro, & LoGerfo, 1998). These volunteers, working under the direction of nurses and social workers, have been shown to successfully assist the providers, enhancing their effects and allowing for wider program dissemination than is possible using only professional providers. The role of the nurse is further expanded by the health mentors. Using them in this way is a creative strategy to reduce health care costs while improving self-management activities for HEP participants, and allows the providers more time for other activities.

In the clinical trial, the health mentor training program consisted of 12 2-hour training sessions held twice weekly for 6 weeks and led by the nurse and social worker (Davis et al., 1998). Format included lectures, role modeling, review of priority areas for health promotion (i.e., exercise, nutrition, home safety, smoking, alcohol use, medications), and interventions to promote new behaviors. Mentors practiced communication skills and learned motivational interviewing techniques, common coping skills, and tasks of living with chronic conditions. According to the protocol for HEP replication, mentors are matched by common interests, diagnoses, or gender. For example, a mentor who attends the exercise class could be matched with a HEP participant who expresses an interest in attending this class, thus providing an added incentive for the participant to attend that class. Nurses and social workers meet to discuss and ascertain best matches and then hold additional meetings with the mentor and participant.

Method

Using purposeful sampling, we conducted this study from February to June 2005, with all of the providers in all HEP sites in the United States (14 in Washington State, 5 in Michigan, 1 in Maine, 2 in New York). Following University Institutional Review Board approvals, the HEP program coordinator informed all of the nurses, social workers, and site managers at the sites about the study. Next, we contacted the providers via e-mail to obtain informed consent form approval. To understand health mentor program experiences, we conducted semi-structured telephone interviews with providers; these lasted 20 to 90 minutes and were audio recorded. Our interview guide was developed in response to discussions with University of Washington researchers about their need to find out more about health mentor implementation issues.

We explored respondent perceptions of and experiences with the health mentor program based on the questions:

  • What do you know about the Health Mentor Program?
  • What do you think of the Health Mentor Program?
  • How important is the Health Mentor role?
Probes included follow-up questions on number of mentors, matching processes, roles of providers, and recruitment and training procedures.

We also asked site managers about site features, including site location (rural/suburban versus urban), site size (based on total senior center average daily attendance and including older adults not in the HEP; small was defined as ≤65 participants and large as >65 participants), and site diversity (homogeneous sites defined as ≥90% total Caucasian senior center attendance and diverse sites as <90% total Caucasian senior center attendance). We obtained program completion data from a 2002–2004 database of 719 older adults in the program. Program completion was defined as client attendance for at least the baseline and 6-month visit or baseline, 6-, and 12-month visit, and program noncompletion as client attendance for the baseline visit only.

Data Processing and Analysis

Interviews were transcribed verbatim and reviewed for accuracy, and the transcriptions were entered into a database using Atlas.ti 5.0 for data management, coding, and analysis. We used a thematic coding technique informed by grounded theory methodology (Creswell, 2007), where we attached labels to specific sections of text. The code list was continually reviewed and revised as new codes were added. Data processing included memo writing to explain and elaborate the coding strategies, sort out major issues, gain insight into key areas, and explain connections among the codes (Coffey & Atkinson, 1996). Codes were collapsed and grouped together on the basis of similarities.

The two authors coded transcript segments and discussed theme formations together to limit threats to validity and examined interpretations for plausibility and coherence (Denzin, 2000). Conclusions drawn were verified through re-examining the transcripts and conferring with a qualitative research consultant. We identified patterns to determine relationships between the presence of the health mentor program with program completion and site features (Miles & Huberman, 1994). Following the formation of themes, we explored differences between types of providers for the themes identified, and differences between site features (e.g., rural versus urban) for the themes identified.

Descriptive Data Results

Our final sample consisted of 20 nurses, 23 social workers, and 18 site managers for the 22 HEP sites. All respondents except for one nurse and two administrators were women (age range = 39 to 65). All were Caucasian, except for one nurse who was Asian. Only one nurse and one site manager refused to participate. All of the sites had experiences using health mentors, but only 8 of 22 sites (36%) had consistently active health mentor programs during 2002–2004. Many sites had dropped the programs or were using them inconsistently because of difficulties they had experienced with recruitment of mentors and lack of staff to monitor the program. Regarding site features (Table), one site had missing data on site type, two had missing data on site size, and one had missing data on site diversity. Overall, 43% of sites were urban, 65% were larger (>65 participants daily), and 33% had diverse clients (<90% total Caucasian attendees). Although specific racial-ethnic data on each client were not available, we did receive aggregate data from the site managers on racial-ethnic groups at each site. The greatest majority was Caucasian (5% to 97%), followed by African American (0% to 88%), Hispanic (0% to 35%), Asian American/Pacific Islander (0% to 33%), and American Indian (0% to 10%).

Descriptive Data on Health Mentor Sites, Program Completion, and Site Features

Table: Descriptive Data on Health Mentor Sites, Program Completion, and Site Features

All but three sites were senior centers. One of these was located in a hospital setting, one served three different areas (a community center and two primary care clinics), and one was based in a variety of community settings, such as churches, without an actual place for seniors to attend the program. Funding sources included private foundation grants; local city, town, and county grants; Area Agency on Aging/Older Americans Act grants; county and city health departments; and local hospitals.

Mentor Programs and Site Features

Rural, smaller, and non-diverse sites were more likely to have health mentor programs than the urban, larger, and diverse sites. Of the 9 urban sites, 2 (22%) had mentor programs; of the 12 rural sites, 6 (50%) had health mentor programs. Of the 13 larger sites, 4 (31%) had mentor programs, and of the 7 smaller sites, 3 (43%) had health mentor programs. Of the 14 non-diverse sites, 7 (50%) had consistent mentor programs, and of the 7 diverse sites, only 1 (14%) had a consistent program.

Mentor Programs and Site Program Completion

High program completion sites had a higher percentage of health mentor programs than low completion sites. Descriptive findings indicated 13 sites with low program completion (<80%) and 9 with high program completion (≥80%). Completion rates ranged from 44% to 100%. Of the 9 high completion sites, 4 (44%) had active health mentor programs, and of the 13 low completion sites, 4 (31%) had active programs. Chi-square tests showed no significant association between program completion and mentor program presence. The Table displays data on the health mentor sites, program completion, and site features.

Overarching Categories

We identified two major categories of consideration describing respondent experiences of the health mentor program: (a) Value of the Health Mentor Program, which described the importance of mentors, their role as peers, and how they contribute to the overall program, and (b) Challenges in Implementing the Health Mentor Program, which described challenges in recruitment and training, staffing, and matching peers to program participants, as well as specific challenges at the diverse sites.

Value of the Health Mentor Program

Four major themes characterized respondents’ assessments of the value of peer mentor programs: Program Importance: “Mentors are the Magic”; Peers Are Friends; It Doesn’t Work for Everyone; and It Helps the Mentors Too.

Program Importance: “Mentors are the Magic.” Program importance was a common theme with the majority of the nurses, social workers, and site managers. Although many respondents faced program difficulties, they agreed on the importance of mentors. Respondents perceived that health mentors were important because of their ability to be in the client’s shoes and to be a role model:

Nurse: They are vital—they know more about what it’s like to be in a client’s shoes.

Social Worker: It is how do we call it, the mentors are the magic. They are really incredibly valuable. There is something so powerful about it. They have been there and believe in you and are a role model.

Site Manager: Because they are the ones who have been through it. And have actually experienced whatever issues you have going on.

Peers Are Friends. Respondents agreed on the importance of peer support for older adults in the program. They perceived the health mentor program to play an important role in the HEP in enhancing the program goals, primarily because of the peer connection and supportive “buddy” roles that mentors have, which is very different from health care professionals telling clients what to do:

Nurse: I think it is a peer generally and not like their kids telling them what to do or their health care provider. It is someone they can relate to and it can be a buddy, a peer who cares about them and someone else to check in, one more person.

Social Worker: They [older adult clients] can look at me and say that you are a professional but what do you know about transitions to aging? Have you lived in a rehab or a nursing home? They have got their peers. And that is where the wisdom is, with their peers.

Site Manager: One of the things that the literature shows is that support group types of things and mentor to mentor people are pretty effective in helping people because they are the ones who have been through it. And have actually experienced whatever issues you have going on.

It Doesn’t Work for Everyone. A few respondents believed the health mentor program did not work for everyone and that program effectiveness depended on the particular older adult. The nurse respondent perceived some clients to be very independent, and the social worker perceived some clients to be self-motivated, thus not needing a health mentor:

Nurse: Yet we have a lot of people, in Site _____, people are very independent. They don’t think that they need a coach if they can do it on their own. For the people who have said yes to a mentor, it has worked tremendously well. I think they are an incredibly valuable aspect of the program.

Social Worker: Well, for some people it may. But not for everybody. I don’t think so. For some people it might be helpful to have a health mentor. But for other people, they become more self-motivating.

It Helps the Mentors Too. In addition, providers perceived the mentor role to be extremely important for health mentors themselves, giving their lives meaning and helping them stay healthy and productive:

Social Worker: I think it is a needy important role for volunteers to help others, and it helps them maintain their own health behaviors. And it gives them meaning and purpose in their life as well. And it is a role that people in HEP can hope to be able to engage in as they graduate from HEP as well.

Challenges in Implementing the Health Mentor Program

The other major category was challenges to implementing the program. Respondents discussed the challenges of staffing, time, recruitment, and training of mentors. Nurses, social workers, and site managers from all sites except one voiced difficulties with the program. The one site that did not voice problems was one where the program had been very well established for a number of years with experienced staff and dedicated volunteers. Six major themes characterized respondents’ assessments of the challenges in implementing the health mentor program: Mentor Program Needs Time from Staff; Mentors Don’t Get Enough Support from Staff; Not Having a Social Worker Is a Problem; Start-Up Training; Matching and Program Sustainability; and Health Mentor Programs Don’t Work in Diverse Sites.

Mentor Program Needs Time from Staff. Respondents agreed with the lack of staffing and lack of time to implement the program. The nurse identified the need for having one person to only manage the mentor program. The site manager agreed that the nurse and social worker had no time to make this program a success. The following quotes primarily address lack of time in general:

Nurse: We just don’t have the time. And we are not peers in order to do that sort of support. Unfortunately it is probably the weakest part of the program overall. We do have some mentors. But we really do need more staff. I mean, I am working far above the hours that our grant will even support. So if we are going to grow and do our jobs well, we need one person alone just to do the mentors. So we do have some challenges to keep them on board. And the three of us are often going like chickens with our heads cut off. I have a huge caseload right now. I don’t have time to do the mentor piece.

Social Worker: And also the staff time, we were pretty focused on just getting people enrolled into the program and developing outreach and so I think that we didn’t devote that much attention into that component of the program [health mentor component].

Site Manager: And it is very hard to figure out why it isn’t successful as the other things. I would think that perhaps the time commitment is what is scaring people off, from the health mentor part. Because they are awfully busy folks.

Mentors Don’t Get Enough Support from Staff. It was clear in many cases that mentors did not get enough provider support from the nurses and social workers. The nurse quote below discusses frustrations of the mentors, which included lack of communication from clients and lack of support from the providers. The site manager quote appears to agree that the mentors were probably not receiving enough support. The social workers did not voice these concerns:

Nurse: They [mentors] can get very angry. They are now very angry. They need a lot of communication. They are out there trying to work with people and so it is tough. They might not get calls back. They call and nobody will get back to them, and they need a lot of support. Maybe they have somebody who is quite difficult. The mentors are frustrated because they need a fair amount of support.

Site Manager: I am not sure that we use it to the max. I am just not sure that we are nurturing those mentors enough. The mentors seem to get assigned to somebody but I am not sure that they are getting…[support].

Not Having a Social Worker Is a Problem. According to the HEP protocol, nurses and social workers worked together to train the health mentors and support them. Two sites complained about the lack of a social worker on their sites and how this affected the health mentor program:

Nurse: I am sure that I don’t see everything that I should see, because I am just one set of eyes whereas if there was a social worker at the site and they would say hey did you see so and so yesterday you know, and kind of trigger hey let’s get them in, or let’s get them mentors. And so there is no one to help me recognize some of those kinds of things.

Site Manager: We have never had that [the health mentor program]. We attempted it but it never got up. I believe two things. My understanding is that we weren’t getting people who were interested in being health mentors and some of the staff involvement with the mentors comes from the social work component of the model, and it was part of the social worker’s role, and that I think with not having the social worker really on staff…[program did not happen].

Start-Up Training. The training during the clinical trial was quite intensive and time consuming and was ultimately condensed during the dissemination process. The nurse quote below talks specifically about the difficulties with the original training requirement. The social worker quote agrees there is no time to do the intensive training required. The site manager quote is from a site that dropped the program because of the training requirements:

Nurse: Part of the problem with the health mentor program is that originally the hours that you were to educate them about their role were enormous. We are talking 9 plus hours. I had great difficulty meeting that requirement. They all have to have a background check. That takes time to fill out. They have reduced that training for the mentors to an hour and a half program—much more reasonable.

Social Worker: The mentors that have been used were trained before we got here. One of the reasons is time, because we are only at the center for 8 hours and that is not a whole lot of time to do this kind of training.

Site Manager: I know that it doesn’t work here. Some of it here is the health mentor training is overwhelming to the people that we have who have all these other issues and are dealing with them. So it doesn’t work well here.

Matching and Program Sustainability. Even sites with strong mentor programs had issues with the matching process as a barrier as shown by these nurse quotes:

Nurse: 80% have been matched. The matching process needs improvement and we are struggling with that. But we try and look at mentors who do not have anybody right now and would be willing be take on a new client, and then also look at male-female and some supporting characteristics that would make them get along.

Nurse: Just pairing them up is a challenge.

Other respondents discussed reasons for lack of program sustainability and agreed it was primarily due to the difficulty in finding a balance between HEP participants and health mentors at the same time:

Nurse: But at the same time, if you don’t have people who wish to be a part of it then it is like well, you don’t want to do a lot of training and then not have them have somebody to work with either.

Social Worker: Part of the reason that it died out was that the program was slower to grow in terms of clients than we anticipated. So we had some volunteers—then assigned to clients—couldn’t find good matches for them. So they were unused.

Site Manager: We have had it [the health mentor program]. It fell into disuse because we didn’t really have enough people at one point to really keep the mentors there. It takes a certain volume of clients to keep the health mentors busy. And so we didn’t mentor in the last year. We like to have health mentors. We are not opposed to it. I think a lot of it in theory. But it is just hard to keep all the balls in the air at once. You have to keep training the health mentors, and you train the health mentors and they don’t have any patients. Or you have a lot of patients but not enough health mentors.

Health Mentor Programs Don’t Work in Diverse Sites. We obtained this perspective only from sites with client diversity. As mentioned above, our descriptive findings show that only one diverse site had a health mentor program. Other diverse sites had discontinued the program, but all had experiences with the program. Our quotes from these diverse sites show that respondents did not believe in the importance of the health mentor program in these sites. They perceived that the health mentor program would not work in these specific sites because of client mistrust issues or clients needing to work on other more important health and lifestyle issues. The following are quotes from two diverse sites:

Site 1, Nurse: I haven’t used the mentors a lot. I do ask people if they would like to have a mentor and I don’t get a lot of response that they would. Well, I think that they do understand what it means. But some people just don’t want somebody else knowing about their health and talking with them. Even if they are lonely, they sometimes don’t want somebody to come in that they don’t know.

Site 2, Social Worker: I have never felt that confident in it [health mentor program] myself. We have very independent people. There is a “stranger” component there that they are suspicious of. It would be hard to make it work. It has never worked. People don’t want to be mentored for the most part. They are barely wanting to work with us let alone having another person calling them or meeting with them. So we have had trouble finding good matches anyway. We might have somebody who seems promising but we might not have anyone for them to work with. So we’ve never really done it.

Site 2, Site Manager: I know that it doesn’t work here. We haven’t had the health mentor volunteers nor any interest in having a health mentor from our client base. Some of it here is the health mentor training is overwhelming to the people that we have who have all these other issues and are dealing with them, they are not going to go to a long-term training. So it doesn’t work well here. Training is part of it and interest is another part. People are not interested in volunteering as a health mentor and people aren’t interested in having a health mentor.

A nurse from a third diverse site talked not so much about the importance of the health mentor program but reflected on the importance of having more minority providers to work with the older adult clients. This site did not continue with the HEP:

Nurse: And at Site _____, they chose not to renew their contract and commitment with us and unfortunately, this had to do with the black/white issue, me being a white nurse. I think it would have been better with an African American nurse. And I did have an African American nurse volunteer who helped me for a while, but then there were some personality conflicts so that didn’t work either.

We did not find any differences between the types of providers (nurse, social worker, site manager) for any of the themes identified.

Discussion

This study provides information on provider experiences about the importance of lay health mentors and challenges in implementing health mentor programs in community-based disability prevention programs for older adults. Except for the quotes from the diverse sites, our findings demonstrated consistency in the value of these programs to both mentees and mentors from the provider perspective, as well as challenges to the program for all but one site. Patterns showed that older adults were more likely to complete the program in sites with mentor programs compared with sites without mentor programs. Rural, smaller, and less diverse sites were more likely to have health mentor programs than urban, larger, and more diverse sites.

The provider quotes discuss the importance of the peer support offered by health mentors. These findings are supported by Whittemore, Rankin, Callahan, Leder, and Carroll’s (2000) study in which the peer advisor role appeared to be a valuable social support intervention for older adults after myocardial infarction. In that study, peers were able to connect to older adults and be supportive because of their own experience with heart disease. Thus, our findings add to the sparse literature on health mentor support for community-based disability prevention programs.

Other studies support our finding from the provider perspective that older adult health mentors also gain benefits from being mentors. One study on lay leader experiences conducting arthritis self-management programs showed that these experiences improve both physical and psychological health, thus supporting the value of volunteerism (Hainsworth & Barlow, 2001). Volunteerism and civic engagement among older adults can be a valuable resource to respond to community needs as the Baby Boomer generation nears retirement (Schneider, Altpeter, & Whitelaw, 2007) and have been shown to improve physical, social, and cognitive well-being of older adults (Fried et al., 2004; Greenfield & Marks, 2004; Van Willigen, 2000).

In the original HEP trial, 59 volunteers were matched with HEP study participants and followed for a year (Davis et al., 1998). Volunteers reported improved health and function. However, the sample was small, and there was no comparison group. Volunteers experienced greater socialization not only through contacts with participants, but also through contacts with each other and the nurses. Thus, volunteering to be a peer is another type of health-promoting intervention for older adults and can be considered as an extension to the HEP or other similar programs.

Our findings regarding the challenges to the health mentor program are an important addition to the sparse literature on health mentor programs for community-based disability prevention programs. These findings are supported by those of other studies. In the Urban Institute survey of U.S. nonprofit organizations, the most frequently cited challenges included recruiting volunteers and lack of funds to pay staff to train and supervise volunteers (Hager & Brudney, 2004). According to that survey, organizations with a greater number of volunteers made more investments in volunteer management, and this type of organization also received the highest net benefits. This is comparable to the one site in our study that had a large number of volunteers, an excellent mentoring program, and a strong disability prevention program. Researchers in the Urban Institute study learned that a staff member or a volunteer specifically designated to manage the volunteer program resulted in greater net benefits to the organization. Here is an important consideration for community programs that are inadequately funded: Whether the dedicated person is paid or unpaid does not matter. Our findings reinforce the need to have one dedicated trained volunteer manage the health mentor program to avoid the challenges experienced by our respondents. This strategy could also address the difficulty of program sustainability voiced by our respondents.

Training and supervising volunteers takes time and effort. In one study that explored the interaction between the advanced practice nurse (APN) and peer advisor providing supports for older adults after myocardial infarction or coronary artery bypass graft, the partnership between the two enhanced the social support for vulnerable older adults but also took time and commitment from the APN (Winder, Hiltunen, Sethares, & Butzlaff, 2004). Training programs themselves could last from a single session to many weeks, as shown by other studies (Robinson, Rankin, Arnstein, Carroll, & Traynor, 1998; Stewart & Reutter, 2001).

The community-based generic training course for volunteers recommended by Schneider et al. (2007) could be one strategy to help implement volunteer programs. This program was based on program manuals and materials from 10 national evidence-based or best practice older adult health promotion programs that used volunteers. Researchers identified core topics for this type of training, including introduction to volunteerism, overview of evidence-based health promotion with older adults, behavior change/motivational theories, communication skills, group dynamics training, recordkeeping, general health education, and administrative topics including volunteer management/evaluation. While this program still needs to go through many steps before implementation, it is a valuable starting point for the HEP and may help reduce the time that program administrators spend on recruitment and training. Again, having a volunteer in charge of the program would greatly help with recruitment and training.

In another randomized controlled trial, the mentoring model was a success because of the initial structured training of well-motivated volunteers and the building of community alliances with the help of a community coordinator (Coull, Taylor, Elton, Murdoch, & Hargreaves, 2004). Similarly, in the HEP clinical trial, volunteer mentors were given intensive training (Davis et al., 1998; Leveille et al., 1998), but we found that staffing and funding issues were huge challenges to sustaining the health mentor program in the real-world dissemination setting. In addition to having one dedicated volunteer manage the program, low-cost system-level strategies could be used to reduce peer support time, such as telephone, e-mail, and pager contact versus face-to-face contact between the provider and the peer (Winder et al., 2004).

Our study is an excellent example of how a real-world situation during dissemination can differ from rigorous clinical trials. Volunteer mentors appeared to be a definite criterion for the original HEP clinical trial, unlike this real-world setting where health mentor programs varied widely and only 36% of programs had active consistent health mentor programs. Effective dissemination and implementation of evidence-based practices into community settings is challenging, and researchers struggle with the processes involved with translating and implementing these practices (Mendel, Meredith, Schoenbaum, Sherbourne, & Wells, 2008). Glasgow and Emmons (2007) discussed how the intensity of interventions can be a barrier to translation of efficacious evidence-based programs. Few practice settings have the resources required, as was the case for our study compared with the clinical trial. Examples of types of barriers to implementation of evidence-based research include organizational constraints, such as lack of time; financial constraints; resources such as staffing and time; and provider knowledge and attitudes (Glasgow & Emmons, 2007; Grol & Grimshaw, 2003).

Respondents perceived that health mentor programs did not work in diverse sites. In addition, our descriptive patterns showed that fewer health mentor programs existed in diverse sites. The respondent from the one site where the program was shut down discussed the need for more minority providers in these sites, which may then improve participation in the health mentor program. In addressing cultural diversity among older adults, Haber (2005) discussed the lack of trust many ethnic older adults have in health care professionals and noted that this may be due to poor communication skills among health professionals and insensitivity to cultural norms. Alternatively, as our respondents suggested, diverse older adult clients may have too much going on in their lives to deal with health mentors, but we did not find any research to support this.

Our descriptive patterns showed higher program completion rates in sites with health mentor programs. Other studies on associations between lay health worker intervention with program attendance and health outcomes support our findings (Butler, 2006; Coull et al., 2004; King et al., 1999; Lewin et al., 2005; Rabiner et al., 2003). Thus, our findings add to the literature on the importance of the health mentor programs in enhancing completion of community-based disability prevention programs. We cannot fully explain why more rural sites and smaller sites had more health mentor programs and did not find research to support this. It is possible that rural older adults feel the need for more social interaction versus urban older adults who live in a busy environment, and thus, rural older adults cooperated more fully with the providers during the program implementation process. Also, it may be easier for both providers and older adults to network with older adult peers in smaller sites, thus enhancing program sustainability.

Limitations

One important limitation is that we were only able to obtain the perspectives of the nurses, social workers, and site managers on the health mentor program. Further, this study can be generalized only to community-based programs. Since our sample was small, we did not have enough power to determine statistical differences in associations between presence of a mentor program and program completion, but our descriptive patterns did show important trends.

Recommendations for Future Research

Future studies need to explore in depth minority and non-minority clients’ perspectives on health mentor programs, what works best for older adults, and how and why this program enhances their participation and health outcomes in community-based older adult disability prevention programs. Larger quantitative studies could include the effects on health outcomes in programs with and without health mentors, and specifically for minority clients, with minority and non-minority mentors and providers. In addition, health mentors could be interviewed to find out their perspectives and experiences about the program. Research is also needed to identify systemic strategies to enhance implementation of health mentor programs, such as using a paid or unpaid volunteer and use of e-mail or telephone contact with providers, to be better able to implement these programs in real-world settings.

Conclusions and Implications for Policy Practice

Our study of provider perspectives on health mentor programs provides in-depth information about the importance of peer support and challenges in implementing these programs in community-based settings. To our knowledge, there is no other research on lay health mentor programs in community-based disability prevention programs. Policy makers and community-based site administrators need to be aware of the need to train and fund more lay health mentor programs to ensure program participation and improve health outcomes of older adults in community-based health promotion programs. Adequate staffing is needed to develop and sustain these programs, recruit and train mentors, and give the health mentors the support they need. A dedicated volunteer manager needs to be assigned to the program, and more efficient strategies need to be used to support the mentors. Policy makers and site administrators also need to recognize the need to train and fund more minority providers and health mentors, which could ensure better program participation and improved health outcomes for older minority clients in diverse sites. These implications and recommendations will help providers gain more knowledge on how to retain these groups in health promotion programs, improve health outcomes, reduce disparities, and improve participation in health promotion programs.

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Descriptive Data on Health Mentor Sites, Program Completion, and Site Features

Site ID# Health Mentor Program Program Completion Ratea Site Type Site Sizeb Site Diversityc
1 Yes High Rural Larger No
2 No Low Urban Smaller Yes
3 No Low Missing Missing Missing
4 Yes Low Rural Larger No
5 Yes High Rural Larger No
6 Yes Low Rural Smaller No
7 Yes Low Urban Smaller Yes
8 Yes High Urban Missing No
9 No High Urban Smaller Yes
10 No Low Urban Larger No
11 Yes Low Rural Smaller No
12 No High Rural Larger No
13 No Low Rural Larger No
14 No High Rural Larger No
15 No Low Rural Larger Yes
16 No High Rural Smaller No
17 No Low Urban Larger Yes
18 No Low Urban Larger Yes
19 No Low Urban Larger Yes
20 Yes High Rural Larger No
21 No Low Rural Smaller No
22 No High Urban Larger No
Authors

Dr. Dossa is Postdoctoral Health Services Research Fellow, Center for Health Quality, Outcomes, and Economic Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts; and Dr. Capitman is Executive Director, Central Valley Health Policy Institute, and Professor of Public Health, College of Health and Human Services, California State University, Fresno, Fresno, California.

The authors disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity. This research was supported in part by a grant from the Foundation for Physical Therapy.

This research was conducted in partial fulfillment of PhD requirements for Dr. Dossa at the Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts. The authors thank the other dissertation committee members, Suzanne Leveille, PhD; Walter Leutz, PhD; and Sarita Bhalotra, PhD, for their participation. They also acknowledge the following: Susan Snyder, Vice President, Senior Services, Seattle, Washington, for her guidance and help in administering this project, recruiting the participants, and providing information about the project; University of Washington, Seattle, researchers Elizabeth Phelan, MD, who provided project guidance, instrument validity, and administrative assistance, and Barbara Williams, PhD, who provided the database for the project and guidance in its use; Silvana di Gregorio, PhD, SdG Associates, for her assistance with the qualitative analysis; and the nurses, social workers, and site administrators who participated in the study. The authors also thank Dr. Barbara Bokhour at the Center for Health Quality, Outcomes, and Economic Research for her guidance and assistance in writing this paper.

Address correspondence to Almas Dossa, PhD, MPH, 92 Francis Street, Brookline, MA 02446; e-mail: adossa@bu.edu.

Received: July 13, 2009
Accepted: March 22, 2010
Posted Online: August 31, 2010

10.3928/19404921-20100729-01

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