Table 1 Description of the HWePS intervention: components, theoretical rationale, aims, and implementation information
Component | Theoretical Rationale | Detailed Intervention Description | Specific Aim | Intervention Level |
|---|---|---|---|---|
1. Health literacy intervention based on both community and individual needs assessments | - ECCM: Decision support - Comprehensive HL intervention model | - Community-wide, multi-channel health information delivery service (SMS or postal mail) based on a community health survey and other relevant reports/documents related to community health needs - Individualized needs assessment using interRAI CUSR producing health and functional profiles and risk triggers based on evidence-based algorithms | - Promote health literacy for older people, community lay health leaders (CLHLs), and the care team - Increase health awareness - Facilitate communication between the community and the public health center (the intervention team) | -Individual -CLHLs (peers) & health professionals - Community |
2. Personalized (self-)care management with a nurse-led multidisciplinary team and peer support by community lay health leaders (CLHLs) | - ECCM: Self-management; developing personal skills; delivery system design - SPEC intervention model | - Self-care planning by older people with a nurse coach, based on the CUSR report - Features nurse coaching for self-care goal setting and skill-building education/planning, and peer support (by trained CLHLs) for keeping to the plan - Tailored intervention and information (SMS) programs for one or more triggered/preferred healthy life-style areas (diet, exercise, mood, and social relationship) by multidisciplinary care team - Community-wide walking promotion program - Nurse-led multidisciplinary care conferences (MCCs) attended by both professionals and CLHLs | - Enhance self-care of identified health problems - Improve health behaviors through self-care and coaching from care team and CLHLs - Improve health outcomes and efficacy through self-care and walking promotion - Increase easily accessible resources within the community as a window for health needs and referrals - Strengthen social support in the community | Individual |
3. Healthy-living and healthy-aging community initiative | - ECCM: Creating supportive environments; strengthening community capacity; building community resources, networks & partners - BARHII Framework | - Activities for creating supportive environment (e.g., smartphone subscription program, smartphone education, safety-bar installation for high-risk households) - Activities for strengthening community capacity (e.g., community health education sessions, CLHL training) - Activities for building community resources/networks and community partnersa (e.g., referrals to community center nurse, social welfare center, medical center) | - Improve living conditions for healthy aging, in particular, health and social care service conditions - Address HRSNs and social determinants of health | Community |
4. HWePS information and communications technology (ICT) system | - ECCM: Information systems - SPEC intervention model | - Use of the HWePS project smartphone application (the HWePS app, for research purposes) and a cloud-based website for care management - Use of KakaoTalk for communication between research team, multidisciplinary care team, CLHLs, lay assessors | - Promote effective and efficient information exchange and communication between players - Collect and store electronic data in a secured information system | -Individual - CLHLs (peers) & health professional - Community |