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Oct 20

Impact of transitioning to virtual delivery of a cardiovascular health improvement program for Latinos during the COVID-19 pandemic – BMC Public…

As shown in Table 1, the majority of participants in both cohorts were women (88.8%) in their 40s (39.1%). Most identified Mexico as a country of origin (83.4%) and preferred to speak Spanish (95.7%). The majority lived in the U.S. for more than 10 years (83.4%). 48% of participants had a family income of <$20,000 per year.

The response rate for the pre-survey was 100%. Examination of the pre- and post-survey data for the virtual CHARLAR cohort show significant improvements in days of exercise per week (+1.52 days), daily fruit consumption (+1.35 servings), daily vegetable consumption (+0.56 servings), and self-reported general health (+0.38) (all p<0.05). There was no significant change in daily exercise time and sugar sweetened beverage consumption for the virtual cohort. In comparison, the historical cohort also exhibited increase in days of exercise per week (+0.91 days), exercise time (+7.78min per day), daily fruit consumption (+0.244 servings), and daily vegetable consumption (+0.282 servings) (all p<0.05). There was no significant change in self-reported general health and daily sugar sweetened beverage consumption for the historical cohort (Table 2). Additionally, within the virtual cohort, there was a numeric decrease in anxiety (-0.83, p=0.568) and depression (-1.07, p=0.067) scores (Fig.1). In the historical cohort, there was a significant decrease in depression scores(-1.89). Changes in anxiety scores (-0.972) were not significant (p=0.052).

Mean Change in Anxiety and Depression Scores. Although not statistically significant, the change from baseline (pre-program) in both anxiety and depression scores were directionally similar for both in-person and virtual program delivery. The Y-axis is change in mean points for both anxiety (blue) and depression (red) scores. *GAD=Generalized Anxiety Disorder 7 item inventory. PHQ=Patient Health Questionnaire 8 item inventory.

Analysis of attendance data from virtual CHARLAR classes show that on average, participants attended four out of six (67%) of the virtual CHARLAR sessions, compared to five out of the last six classes (78%) of the historical in-person cohort. Of the 11 classes overall, mean participant attendance was eight of 11 sessions (73%) in the cohort with virtual classes compared to nine of 11 sessions (82%) in the historical cohort (p=0.613).

The participant interviews revealed more detailed information about the impact of the virtually delivered CHARLAR program. A total of five participant themes were identified: (1) improving health habits, (2) mental health, (3) delivery challenges, (4) adaptability and flexibility, and (5) interpersonal connection. Quotes supporting these themes are provided, with edits for clarification indicated by square brackets.

When asked how the CHARLAR program impacted their health, participants reported that through the program they learned new information about CVD and diabetes, their health status, and how diet and exercise can impact health. This information empowered many participants to implement lifestyle changes focused on improving CVD risk factors. Participant 2 states:

"It has helped to motivate me to eat more healthy and to do exercise."

Participant 3 also shared how CHARLAR helped her to change her habits in a manageable way. She stated:

"Yes. Um, I feel like the class actually has helped me like learn how to change my habits on how to eat and stuff and whats bad and whats not bad and little by little Im getting things into my head and sticking into the goals that okay, Im gonna walk 20 minutes every day you know, for the whole week."

When asked how the online program impacted both understanding and behaviors related to mental health, some participants noted the program helped them to learn more about anxiety and depression. Participant 6 shared:

"It was really good for [my] mental health, because [I] started doing exercises for relaxation and breathing, and [I] also learned more about anxiety and depression. And so that was helpful."

Another participant shared that CHARLAR was beneficial to her mental health as weekly goal setting helped her focus on gratitude and how positive thinking can impact her physical health. Still, others appreciated the extra support in general. Participant 2 shared how being asked about mental health allowed her to see how it could impact her home life:

"They asked about my mental health like if I had fears, if I had stress, if we were well and how we were doing and I dont always associate those things with home life and so it opened my mind to that."

The qualitative interviews captured some of the challenges of pivoting to a new mode of delivery. Although the online classes broadcasted over Zoom and Facebook Live used the original curriculum, the majority of the educational content was condensed into a 30-minute recorded video, which was followed by 30-minute group discussions. Pivoting to a remote learning platform created several technological challenges. Previously, participants and promotoras had varied information technology experience and had challenges and apprehension downloading and operating the online software. Promotora 3 states:

So, my apprehension was with me, me personally, I just wasnt comfortable. Ive been doing classes and teaching for over 2530 years and so this was very different for me. I need that personal one-on-one contact. And so, it was hard for me to kind of just accept it and go with the flow, but it was better for me to learn it and help explain it than them not getting the class at all.

Despite the difficulties, over time it became less daunting, and even had the unintended benefit of helping people become more comfortable around technology. Promotora 3 explains how, with time, using technology became more manageable:

"Like I said [using technology] was practice, it got easier. And it got easier to explain as well, because if I didnt know what were some of the chat and all these other things I was able to explain it the best way that I knew how and as simple as I knew how to explain it so that way, folks could get the best, you know, the best experience."

Promotoras suggested that the CHARLAR program offer more training for promotoras in facilitating discussions through virtual formats. Additional information to improve the virtual delivery of the program could be incorporated into future trainings.

Irrespective of the inherent loss of face-to-face connection, all of the promotoras and participants recognized that technology challenges were to be expected and they expressed general acceptance of the platform given the inherent necessity. However, all promotoras and participants expressed a preference for in-person classes. Across all nine interviews there were a total of 13 references from participants and promotoras expressing a preference for in-person classes.

Promotoras were flexible and willing to learn to implement virtual CHARLAR and adapt to new situations. This greatly benefited the program, as it allowed for adaptation as promotoras, and program staff learned how to improve the online format. Initially, participants were watching the main video content independently and then coming on to video chat platforms for discussion as a larger group. When promotoras realized that discussion was difficult with such a large group, they quickly pivoted to smaller discussion groups. Promotora 2 explains how small groups impacted participants:

Yeah, its easy and I think the participants they feel more comfortable to speak with three or four people than more than 20.

Furthermore, promotoras and participants adjusted to the new technology with practice. Some participants were able to receive help from children or family members who were more familiar with technology. Participant 3 explained how her son was able to assist her when she needed help operating Zoom. She shared:

At first, it was hard. I couldnt figure it out. I just didnt know how to be unmuted. I didnt know. I was like messing with it. It was hard. I was asking my teenager. Im like help me with this. And Im not that old. But I dont use this. I dont do this, so Im like, 'Help me. I dont know how to do this.' It was a little difficult.

Promotoras have also expressed interest in making further adaptations to achieve better outcomes. When asked about suggested improvements to virtual program delivery, promotoras suggested experimenting with longer class times.

Transitioning to a virtual platform had effects on personal connectedness. Overall, participants and promotoras expressed initial challenges developing an in-depth connection with the participants. Promotora 2 explains these challenges:

"A lot of times Hispanics will speak with their eyes or with their faces and it can be a little bit difficult to connect with people when youre having conversations with them online. So, sometimes those conversations can seem a little bit more cold, and theres not as much of that humanity there that you would have in person."

While technology initially served as a barrier to connectedness, the promotoras adapted through additional follow-up calls. In addition to the videos and small group discussions, the promotoras checked-in with participants after each class. These weekly telephone check-in sessions allowed the promotoras to answer questions and ensure that the participants were able to access the class. The calls had the added function of helping to sustain rapport between promotoras and participants. Furthermore, small groups combined with video and follow-up calls have allowed CHALAR to reinforce information from each session via various modalities. Promotora 1 states:

"We feel that between the videos, that way we have all the integrity of the program, so that we really are passing the message in the way that is designed and the small groups and the calls we are the, you know, having all the components that we needed for CHARLAR."

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Impact of transitioning to virtual delivery of a cardiovascular health improvement program for Latinos during the COVID-19 pandemic - BMC Public...

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