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Social Engagement Framework for Addressing the Chronic-disease-challenge [SEFAC] [738202] - Project
Project abstract

SEFAC supports the actions in the European regions, in alignment with national/EU efforts to reduce the burden of major chronic disease and to increase the sustainability of health systems. SEFAC fosters the involvement of volunteers in a broad community approach initiated by social and health care. The focus of SEFAC is on positive health, prevention, empowerment and self-management, using group and individual approaches, face-to-face and online, supported by user friendly ICT tools.

Four regions in varied European countries will actively participate as SEFAC pilot sites. Citizens of circa 50 years and older, who have a major chronic disease or who want to prevent chronic disease, and social/health professionals, pharmacists and volunteers will co-create communities for the promotion of health, and prevention and (self) management of chronic diseases.

In 4 pilot regions (Rijeka in Croatia, Treviso in Italy, Rotterdam in the Netherlands, and Cornwall in the UK), a total of 1000 citizens (250 per pilot) will be involved through community meetings. In total 360 participants (90 per pilot) will actively participate in a range of prevention and disease management activities; i.e. a series of group activities in addition to individual (volunteer reinforced) care pathways and the use of ICT tools. Stakeholders in the 4 pilot regions will be trained to implement prevention and self-management activities with help of volunteers using a ‘Social engagement toolkit’.

We will apply the CDC-Framework for Program Evaluation including the perspectives of the end-users (citizens who want to prevent/self-manage chronic disease), as well as social/health care providers, pharmacists, volunteers and other stakeholders; a cost-effectiveness analysis will be performed. Using the learnings of this project, a SEFAC toolbox for implementation in European regions will be developed, including policy briefs providing policy makers and public authorities with key points for action.

Summary of context, overal objectives, strategic, relevance and contribution of the action

The major chronic diseases are the main cause of morbidity and mortality in Europe, and due to their social impact and economic implications, their prevention and management are important challenges in realizing the sustainability of health systems in Europe and throughout the world.

Many chronic diseases are related to an ageing society, but it is also known that lifestyle choices such as tobacco use, unhealthy diet and physical inactivity raise significantly the risk of developing many chronic non communicable diseases, even among young and middle-aged citizens, and it is estimated that of the total amount of deaths due to major chronic diseases in 2012, more than 40% were premature, affecting people below the age of 70 (WHO).

SEFAC supports the actions in the European regions, in alignment with national/EU efforts to reduce the burden of major chronic disease and to increase the sustainability of health systems. SEFAC fosters the involvement of volunteers in a broad community approach initiated by social and health care. The focus of SEFAC is on positive health, prevention, empowerment and self-management, using group and individual approaches, face-to-face and online, supported by user friendly ICT tools.

Four regions in varied European countries will actively participate as SEFAC pilot sites. Citizens of circa 50 years and older, who have a major chronic disease or who want to prevent chronic disease, and social/health professionals, pharmacists and volunteers will co-create communities for the promotion of health, and prevention and (self) management of chronic diseases.

In 4 pilot regions (Rijeka in Croatia, Treviso in Italy, Rotterdam in the Netherlands, and Cornwall in the UK), a total of 1000 citizens (250 per pilot) will be involved through community meetings. In total 360 participants (90 per pilot) will actively participate in a range of prevention and disease management activities; i.e. a series of group activities in addition to individual (volunteer reinforced) care pathways and the use of ICT tools. Stakeholders in the 4 pilot regions will be trained to implement prevention and self-management activities with help of volunteers using a ‘Social engagement toolkit’.
We will apply the CDC-Framework for Program Evaluation including the perspectives of the end-users (citizens who want to prevent/self-manage chronic disease), as well as social/health care providers, pharmacists, volunteers and other stakeholders; a cost-effectiveness analysis will be performed. Using the learnings of this project, a SEFAC toolbox for implementation in European regions will be developed, including policy briefs providing policy makers and public authorities with key points for action.

Overall objectives:
1. To develop a European template addressing major chronic diseases through prevention and self-management using social engagement tools within community settings, involving volunteers and enabled by ICT tools where appropriate
2. To develop a SEFAC ICT tool that will support chronic disease prevention and management through a mobile app, connected medical devices and lifestyle sensors and an online platform
3. To define the SEFAC implementation design
4. To develop a SEFAC training toolkit
5. To implement and evaluate the innovative SEFAC template for community based interventions to address major chronic diseases in four European regions
6. To develop policy documents and practical tools that will aid in creating favoring conditions for successful scale-up and long-term impact of existing good practices in the field of chronic disease prevention and management at the community level via social engagement tools.
7. To involve stakeholders and disseminate outcomes and protocols for innovative SEFAC to be applied in European regions and countries

SEFAC focuses on innovations in local network building with the adaptation of a social engagement tool applied to the prevention and management of chronic disease among European cit

Methods and means

The project will identify a cohort of individuals that meet the agreed criteria for inclusion in the SEFAC pilots. Each pilot site will include 250 citizens (4*250=1000 altogether) in community actions; of which 90 per pilot site (4*90=360 altogether) are engaged in long-term (preventive) actions. The study population will be decided upon in collaboration with the health/social professionals in each pilot area who are responsibility for care – e.g. local GP, nurse, or social worker.

The project will have a local pilot site leader in each pilot are. The pilot site leader and his/her team will be trained to deliver the social engagement program including support by volunteers based on the Age UK Cornwall model of guided conversation, followed by interventions that arise from the conversation. The interventions will be personal to each participant in the study, but there will also be group activities and connections will be made to existing support groups.

The local pilot site leader and his/her team will work with community based volunteers to provide peer support for those in the program. The volunteers will liaise with the pilot site team regarding activities and the ongoing management of the condition of the participants according to an agreed set of goals and outcomes.

The outcome data will be evaluated in WP8 and this will provide information and evidence on the impact on resources, (financial, human, buildings and infrastructure) and the health and wellbeing of the individuals (loneliness, connectivity, empowerment, self-management).

The learning from the project in the 4 pilot sites will enable the development of a train the trainer program that will bring together the best practice from all sites. The training will be offered to staff from all sectors in the health and social care environment, as well as volunteers working in the program. This training program will be improved during the project.

Work performed during the reporting period

First, a strong action of dissemination was implemented: an attractive and functional project website was established for internal and external communication and dissemination. The site includes links to the social media exchanges (links to Twitter, Facebook), and serves as platform for project results to support stakeholders. Websites in all the 4 pilot sites’ language were created and also Facebook accounts. Several public events were organized in all the pilot sites in order to attract target people, explain the project and recruit citizens and/or volunteers. The methodology of Word Cafè, public conferences, distribution of leaflets were used to organize the public events.

The wp4 objectives about designing and preparing for Scaling up a successful Social Engagement Framework (including the involvement of volunteers) for chronic diseases prevention and management at community level, were finalized.
The current methodologies were reviewed for identifying people at risk of co-morbidities that would respond to a community based service. E.g., risk stratification, use of learning cafes, primary care practitioner applied criteria. Following the determination of the selection methodology, the Living Well ‘guided conversation’ approach was used to identify peoples support and care needs and will be tested against other recognised methodologies.
Following the guided conversation, a care and support plan was developed and will be implemented with voluntary and community services. Also the plan that discusses extensively the implementation question and how to involve the stakeholders in the implementation phase of the scale up process was developed.
In conclusion, the training plan and a train the trainers’ plan for adoption and implementation of the Social Engagement Model (including the involvement of volunteers) was created.
The training programme developed to the pilots’ health professionals, focuses on:
1. Wellbeing.
2. Guided conversation.
3. Communication skills.
4. Tools and techniques.
5. Assessing the achievement of outcomes for individuals.
As a result of participants undertaking the training they are competent to train future trainers to change their practice in line with the Living Well principles and methodology.
In each pilot sites, the training sessions (three modules in one and half a day) for the Social Engagement Model (including the involvement of volunteers) were delivered.

The WP5 work about creating a training plan for healthy lifestyle behaviour adoption was defined. The training methodology to increase among the population the awareness about chronic diseases leading risk factors and main prevention strategies was based on the model of community as agent of change. A methodology to foster the natural supportive
and developmental capacities of the community to find internal resources, in order to better meet the needs of the community members, neighbourhood and volunteering organizations, wellness organizations, peer-to-peer support programmes and social networking were taken into account as possible ways of addressing behavioural changes in an ecological perspective. The toolkit delivered specified the composition of training group target, in particular the percentage of health workers, social workers, volunteers and citizens to involve in the programme in each pilot site.
The integrated plan of actions and training timing schedule to deliver in the community in order to arise the individual awareness and to empower a better self - management of health
was created and developed, connecting the Living Well principles and where applicable
supported by elements of the Mindfulness approach, in order to support people to accept the lifelong development of their health, even when it involves the (self – management of) chronic diseases, frailty and multi - morbidity. The acceptance and the awareness of chronic conditions could positively enhance the motivation to reinforce self-management of heal

The main output achieved so far and their potential impact and use by target group (including benefits)

1. Development of the fine-tuned and user-validated mobile app that will support chronic disease prevention and self-management. The SEFAC APP is based on the same models of wp5 and wp4 training, this is why the target group that is going to use it, could have several benefits. The aim of the app is to improve and coach, through a psychological motivational approach, the behavior of the participants related to the management of their health. The aim is also to measure the more effectiveness of the intervention using the app, in respect to not use it to prove the importance of a motivational coaching of the ICT. The effectiveness and usefulness of the app will be measured through users experience’s evaluation at the end of intervention;
2. SEFAC training toolkit for train the trainers in Social Engagement method adoption for community based intervention. The training course by Age UK was developed in three modules in Rotterdam and spread to all the trainees in all the pilot sites. It was mainly focused on the engagement of volunteers (through some specific methods i.e. guided conversation) and stakeholders. With the learning achieved by trainees and the skills developed, the trainees are able to manage the training of citizens in the pilot site.
3. SEFAC training toolkit for train the trainers for the adoption of healthy lifestyles. The training by ISRAA was developed in three days in Rotterdam and then spread to all the trainees in each pilot site. The training gave the ability to conduct a 7 workshops program based on mindfulness practices applied in health fields as nutrition, physical activity, relationships, habits and mindset. With the learning achieved by trainees and the skills developed, the trainees are able to manage the training of citizens in the pilot site.
4. SEFAC handbook “START FROM YOURSELF” for the adoption of healthy lifestyles. The handbook consisted in a guideline for the citizens that shows the workshops that will be implemented with mindfulness practices and coaching exercises that trainers can use during the training of participants
5. Development of “social engagement” plan containing a time table for local meetings. The benefits of planning several meetings is to involve the population on positive health and prevention and management of chronic disease and this may help to recruit volunteers and citizens that will participate in the implementation of the pilot sites

Achieved outcomes compared to the expected outcomes

The achieved outcomes so far are in line with the expected outcomes.

Dissemination and evaluation activities carried out so far and their major results

Highlights on main events and activities.
During this first period of the project SEFAC has been promoted through
3 European Networks the ENSA European Network of social Authorities, the ELISAN, European Local Inclusion and Social Action Network and the European Covenant on Demographic Change.
In addition its topics have been added to the EIP European Innovation Partnership on Active and Healthy Ageing working groups within the spirit of the 2013 Dublin Declaration on Age-Friendly Cities and Communities in Europe. Connections have been made with the WHO Global Network on Age-Friendly Cities and Communities.

European Networks meetings where SEFAC has been promoted:
General Assembly of the ELISAN Network that took place in the city of Marseille jointly with the consortium meeting of the FILO Fighting Against Loneliness Erasmus funded project at the Département des Bouches du Rhone from the 12 to the 15th of November 2018.

General Assembly of the ENSA European Network of Social Authorities that took place from the 5th to the 7th December 2018 in Sweden (Vanersborg) on the topic of the implementation of the European Pillar of Social Rights at Local level.

More widely the ENSA has included the topic of Addressing the Chronic Disease Challenge on the agenda its two thematic working groups dedicated to elderly and persons with disabilities. The ELISAN follows up this topic with its policy makers, at the Council of Europe and at the UN Commission for Social Policies.

Among the most relevant initiatives the SEFAC project has been presented on the 23rd and 24th of May 2018 in Rijeka, Croatia within the Health City Programme, entitled “Rijeka - Healthy City" and the National Programme “Healthy Living The organizers were the Teaching Institute of Public Health of the Primorsko-Goranska County and the City of Rijeka in cooperation with the Faculty of Health Studies in Rijeka, the Croatian Medical Chamber and the Faculty of Medicine of the University of Rijeka. The purpose was to empower and involve people of 50 and 50+ who have or are at risk of a chronic disease to take control over their own health including them in the SEFAC activities.

Another significant Stakeholder meeting has been organized in Treviso on June 13 2018. Among the participants there were Public Health and Local Volunteering Associations dealing with aging and chronic diseases, such as: the Department of Prevention, the Diabetic Association, the Italian Association of Culture and Sport (AICS TV), Informatics Without Frontiers (ISF), the volunteering association AUSER TV, the Volunteer Service Centre (CSV TV), the Hospital Volunteering Association (AVO) and the Italian Red Cross- department (CRI TV).

Let’s highlight the success and the importance of “World cafés” held by each pilot with the aim of taking control about your own health. They were directed to citizens and had as objective to identify participants and local stakeholders who would engage in the training.

Communication campaigns
News about the SEFAC project were published through articles on the website of the official press Italian agency (ANSA), on the Croatian Novi List - daily newspaper website, on the Poliebenestar Spanish platform, due to the synergy with the project “Effichronic”, and on the Veneto Region website with two editions of its monthly bulletin distributed to a data base of 4500 stakeholders.
During the open event “the Healthy Cities Day” in central park of the city of Rijeka, the Croatian TV Channel HRT did two interviews to Prof. Tomislav Rukavina and Prof. Vanja Vasiljev Marchesi in a communication campaign open to high education, researchers, clinicians, public, regional and national stakeholders.
The leaflet and newsletters of SEFAC project were distributed during international, regional and local events, such as pitch events in Treviso (Italy), Rijeka, Ivanic Grad, Kostrena (Croatia) and the General Assembly of the ENSA network (5-7 December 2018, Van