Motivation, satisfaction and perceived benets of volunteering with the Cardiovascular Health Awareness Program (CHAP): A survey of French-speaking volunteers in Quebec

Background: Locally recruited and trained volunteers are a vital component of the Cardiovascular Health Awareness Program (CHAP), a community-based cardiovascular disease prevention program that has been implemented across different settings and targeting different populations. As part of expanding and adapting CHAP to new settings, we conducted a pragmatic cluster randomized controlled trial to implement CHAP targeting French-speaking elderly residents of subsidized social housing buildings in Québec and Ontario. As there is some evidence that the culture of volunteering might be different for English-speakers than their French-speaking counterparts, our objective was to generate a prole of French-speaking CHAP volunteers and to compare it with English-speaking volunteers in Ontario who participated in an earlier community-based CHAP program and with volunteers in Canada as reported in the Statistics Canada's General Social Survey on Giving, Volunteering and Participating (CSGVP). Methods: A cross-sectional survey was administered online or by telephone to French-speaking volunteers who participated in at least one CHAP session held in subsidized social housing in Montérégie (Québec, Canada) between March 2018 and June 2019. Results: The response rate was 79% (30/38), majority were female (87%, 26/30), retired or semi-retired (83%; 25/30), almost two-thirds (63%, 19/30) had previous work experience in the healthcare eld, and 40% (12/30) had more than 10 years of volunteering experience. These characteristics were similar both to those of general prole of volunteers in Canada and to English-speaking volunteers in Ontario who participated in an earlier pharmacy-based CHAP program. The top 5 reasons for volunteering among French-speaking CHAP volunteers were identical to those reported in CSGVP: making a contribution to the community; using one’s skills and experience; improving one’s sense of well-being or health; exploring one’s own strengths; and networking with or meeting people. The majority of French-speaking CHAP volunteers, like their English counterparts in Ontario, reported a high level of satisfaction with their participation in the program, enjoyed their interaction with participants, and gained new knowledge. Conclusions: French-speaking CHAP volunteers in Quebec share many similarities with English-speaking CHAP volunteers in Ontario and volunteers in Canada


Background
Volunteers are recognized as an important human resource for health promotion efforts not only in lowand middle-income countries, but increasingly, in high-income countries such as Canada. Indeed, volunteers have been shown to be effective in supporting behavior modi cation to help prevent chronic disease among older adults (1), assist in smoking cessation, or improve management of hypertension and diabetes (2). Frequently, they serve as a bridge between the formal health care system, the patient, and community programs and resources (3,4). Volunteers can play a key role in strengthening health Page 3/13 systems to provide person-centered care that is equitable, culturally appropriate and economically feasible (5).
Older volunteers, in particular, bring a wealth of experience that bene ts their communities but also themselves. Volunteering, particularly by the elderly, may contribute to physical, social, and cognitive health and well-being (6)(7)(8)(9)(10), as well as to an increased quality of life, sense of self-worth and longevity (10,11). The increased social networks, resources, power and prestige, and emotional ful llment that can be gained through volunteering have been documented as some of the additional bene ts (12).
Volunteers who are also members of the target population are well-positioned to overcome social, linguistic and cultural barriers to effectively increase public awareness of health issues. Social cognitive theory suggests that peers are in uential because individuals are more likely to imitate a behavior exhibited by someone who is a realistic model (13). Age-matched peers are particularly effective in programs targeting older adults, perhaps due to enhanced communication and rapport from shared life experiences as a birth cohort (14)(15)(16).
Volunteering in Canada is a deeply rooted tradition tracing back to the European settlers and immigrants from around the world. As a country of immigrants, faced with the wilderness and harsh winters, there has always been a strong emphasis on self-reliance but also on mutual assistance.
In the province of Quebec in Canada, the culture of volunteering appears to be different from the rest of the country. The 2004, 2007, 2010 and 2013 Canada Survey of Giving, Volunteering and Participating (CSGVP) reported that Quebec is the Canadian province with the least amount of volunteering (17). In 2013, 32% of people aged 15 and older volunteered in Quebec, the lowest rate in the country, compared to the Canadian average of 44% (17). Furthermore, the average yearly number of hours volunteered in Quebec in 2013 was 123 hours, the lowest in Canada, compared to a national average of 154 hours (median of 39 and 53 hours, respectively) (17). An analysis of 2012 Statistics Canada data by the Institut de la Statistique du Québec revealed differences in volunteer participation between French-speaking and English-speaking Quebecers (18). The study reported that Quebecers whose language spoken at home is English are more likely to volunteer (47%) than those whose spoken language at home is French (36%) (18).
There are several hypotheses as to why the rate of volunteering is different. One plausible explanation has to do with how volunteering is de ned by different surveys or how it is interpreted by the respondents themselves. It has been suggested, for example, that the French-speaking Canadians are more likely to be involved in more informal volunteer activities focused on friends or neighbors and thus not captured in more formal, organization-based volunteering activities as those reported in the CSGVP.
Our team has been involved in developing, re ning and implementing CHAP for the past 20 years in English Canada (Ontario and Alberta) and as such CHAP represents the main experience that we have working with volunteers. The focus of the current study was speci cally on volunteers who participated in CHAP against the backdrop of broader differences reported by different surveys between English-and French-speaking volunteers in Canada and in Quebec.
The Cardiovascular Health Awareness Program (CHAP: www.CHAPprogram.ca) is a community-based cardiovascular diseases (CVD) prevention and management program that has been implemented across Canada over the past 20 years. It was rst implemented in several English-speaking settings in Canada, predominately in the province of Ontario, and subsequently modi ed and adapted to several different settings and populations, including the French-speaking province of Quebec.
CHAP recruits, trains, and deploys volunteers to assist members of their communities to increase awareness around CVD, monitor their blood pressure and adopt or maintain a healthy lifestyle. Volunteers are a vital component of CHAP as the program relies on locally recruited peer volunteers to: 1) assist program participants with accurate measurement of participants' blood pressure and other physical measures (waist circumference, weight, height and body mass index (BMI)), completing a cardiovascular risk pro le, including a questionnaire-based evaluation of risk of developing type 2 diabetes (CANRISK), 2) provide participants with educational messages about lifestyle modi cations, and 3) loop back with primary care providers and recommend locally available free or low cost programs and resources.
The CHAP model was re ned through a series of studies that demonstrated its implementability, acceptability and ability to reduce participants' BP, encourage lifestyle changes and optimize drug regimens (19)(20)(21)(22)(23)(24)(25). CHAP was rigorously evaluated using a community cluster randomized controlled trial involving 39 medium-sized communities (with populations of 10,000-60,000) in Ontario. Over 13,000 people aged over 65 years in the CHAP communities attended cardiovascular risk assessment and education sessions run by 600 volunteers in community-based pharmacies over a 10-week period. Adjusting for hospital admission rates in the year prior to the intervention, after one year, CHAP was associated with a 9% reduction in hospital admissions at the population level for stroke, acute myocardial infarction and congestive heart failure among residents aged ≥ 65 years (p=0.002) relative to communities that did not implement CHAP (26). CHAP is the main evidence supporting more intense screening for hypertension, recommended by the Canadian Task Force on Preventive Health Care (CTFPHC) (27) and the U.S. Preventive Services Task Force (USPSTF) (28). We estimate that over 100,000 CHAP assessments have been conducted since its inception.
In light of the possible differences regarding culture of volunteering in Quebec, the objective of the current study was to learn more about French speaking Québec volunteers' motivation, satisfaction and perceived bene ts of volunteering. We also wanted to generate a pro le of Quebecers volunteering for CHAP and to compare it with English-speaking volunteers in Ontario who participated in an earlier pharmacy-based CHAP program (19), with volunteers in Canada and in Quebec as reported in Statistics Canada's General Social Survey on Giving, Volunteering and Participating (CSGVP) (17,18), and with the volunteer survey in Quebec conducted by the Réseau de l'Action Bénévole du Québec (RABQ) (29).

Methods
As part of a pragmatic cluster randomized controlled trial (RCT), CHAP has been implemented in 14 social housing buildings in Montérégie (Quebec, Canada) and the Niagara region (Ontario, Canada) targeting residents aged 55 and over (30). The current study focuses on volunteers from the Quebec arm of the trial. The CHAP program adapted to this speci c context was rst pilot-tested in four different senior social housing buildings in Montérégie in March and April 2018 and CHAP sessions, as part of the RCT, were offered from September 2018 to June 2019.
In Quebec, 38 peer volunteers have been recruited through advertisements in local newspapers and by collaboration with local Volunteer o ces (Montérégie, Québec, Canada). The o ces sent out to their registered volunteers' information regarding the CHAP and invited them to participate in the project. They conducted interviews with existing volunteers and with the new candidates who responded to advertisements and updated or facilitated criminal background checks, as appropriate.
Volunteers then participated in a 3-hour training course, facilitated by nurses and the research team. Given that the CHAP sessions were offered over several months period, and that volunteer recruitment took place throughout the project, 6 training courses were held between March 2018 and March 2019. The CHAP volunteer training included a theoretical section, which consisted of describing the program and its foundations and a second practical section, which simulated a CHAP session. During the training, volunteers were introduced to the CHAP program and explained their role as a volunteer, the risk factors for CVD, the materials used and the procedures to follow during a CHAP session. They were then able to practice blood pressure measurement using an automated device as recommended by Hypertension Canada guidelines, waist circumference, weight, height, and administering the risk of developing diabetes questionnaire. A volunteer guide containing all the information provided during the training was given to volunteers. It was also during this training course that volunteers signed the con dentiality and consent forms.
Our intervention targeted the elderly residents of social housing buildings in Montérégie -a predominately French-speaking region of Quebec. As a result, only French-speaking volunteers were recruited and trained. English-speaking volunteers in Ontario who participated in an earlier pharmacy-based CHAP program (17)(18)(19). Those aged 55 and over, and females were more likely to volunteer (17,18) and their involvement was more likely to be related to the healthcare eld (17). In the Ontario CHAP program, the average age of volunteers was 64, 88% (35/40) were female, 48% (19/40) reported background in healthcare, and on average they had volunteered for 19.5 years (19).

Motivation for volunteering
Although motivations for volunteering in general were varied, the ve most frequently reported reasons were as follows: 1) To make a contribution to one's community; 2) To make the most of one's skills and experience; 3) To improve one's sense of well-being or health; 4) To explore one's own strengths and 5) To network with or meet people ( Table 1). The rankings as well as the percentage of respondents selecting these reasons were virtually identical as those reported in the CSGVP survey (17). To make a contribution to the community 83 (1) 93 (1) To use your skills and experience 77 (2) 77 (2) To improve sense of well-being or health 53 (3) 52 (3) To explore your own strengths 50 (4) 49 (4) To network with or meet people 47 (5) 47 (5) Most respondents (22/30, 73%) de ned volunteering as a means of helping themselves and others. Onethird (10/30, 33%) described volunteering as a way to donate their time and experience. Nearly one-third (9/30, 30%) volunteered for personal ful llment, an experience to try out something new, or a way to share with others. While the question on reasons for volunteering were taken from the Statistics Canada's General Social Survey -Giving, Volunteering and Participating, 2018 (31), it was not possible to make comparisons as the results of that survey are not yet publicly available.
Volunteering experience and satisfaction with CHAP When asked why they chose to volunteer with CHAP, respondents provided a range of answers. After grouping them into categories, the three most frequently stated categories were: 1) It's in the realm of my profession (40%; 12/30); 2) To support a good cause (27%; 8/30); and 3) Personal interest in the topic (20%, 6/30). There were no comparable questions asked to Ontario CHAP volunteers.
In general, the level of French-speaking volunteer satisfaction with CHAP was very high. The vast majority reported being "somewhat satis ed" or "very satis ed" with the recruitment and training, logistics, communication, and overall experience with the program (Figure 1). The open-ended comments made by some respondents included "good teamwork", "good team spirit" and "interesting project". CHAP volunteers involved in an earlier community-wide demonstration project in two mid-sized communities in Ontario also reported a high level of satisfaction with their participation in the program and enjoyed their interactions with seniors at the sessions (19).

Impact of volunteering with CHAP
The vast majority of respondents (77%; 23/30) felt that they learned from their volunteer experience and that it met their expectations (93%; 28/30). When asked about what they gained from their CHAP volunteer experience, respondents indicated several items from the options list provided. Each of the response options was selected by at least one-third of respondents with the exception of "power and prestige" ( Table 2). The most frequently selected item, reported by 63% (19/30) of respondents, was "a better understanding of cardiovascular health". The ve respondents who selected the option "others" ( Table 2) speci ed it by adding: "better understanding and empathy for people living in social housing", "feeling useful and contributing to the program", " there are many sick people, especially among the elderly", "seeing people and feeling useful to the community" and "beautiful human experience". The English-speaking volunteers in Ontario reported that they felt con dent in their role and thought that their contribution was important to the community and rewarding. They also reported becoming more informed about heart health and felt that CHAP was a worthwhile program (mean scores >4.7 on a 5point Likert scales) (19).

Discussion
Our objective was to draw a portrait of French-speaking CHAP volunteers in Quebec and to compare our results with existing survey data. For this reason and despite the small number of volunteers involved, we chose to use a survey rather than focus groups or individual interviews, which had already been conducted in the past with CHAP volunteers in order to obtain their feedback and make changes to the program (19,32).
CHAP volunteers in the Montérégie region were mostly retired or semi-retired women who had worked in the healthcare eld before and had several years of volunteering experience. This is similar to English-speaking CHAP volunteers in Ontario and volunteers in Canada and in Quebec in general. Namely, that those aged 55 and over, females, and people who worked in healthcare are more likely to volunteer (17,19,29). The ve most frequent reasons for volunteering reported by the French-speaking CHAP volunteers were virtually identical as those reported in the CSGVP survey (17).
Most CHAP volunteers in Quebec de ned volunteering as means of offering help, sharing their time and experience which contributed to their sense of ful llment. While the data collected by the Réseau de l'Action Bénévole du Québec (RABQ) showed that helping was not the top reason for volunteering in Quebec (29), the remaining reasons were very similar and included making a contribution to their community and to use their skills and experience (29). The RABQ study reported that incentives for volunteers in Quebec to get involved were mainly pleasure or interest in a particular activity or cause, the opportunity to socialize, exchange and develop a sense of belonging to a group with whom one shares a common interest, and the realization of a social project or civic cause that was dear to them (29). Similarly, the CHAP volunteers in Ontario reported that they were contributing to the community and that their contribution was important and rewarding (19).
Although health care workers were not explicitly targeted to volunteer for CHAP and there was no requirement to have any medical background, almost half were retired nurses. One plausible explanation is that, given the focus of CHAP intervention on health, retired healthcare workers were particularly drawn to the program. This had both some advantages and disadvantages. On the one hand it meant that many aspects of training or running the actual CHAP sessions such a con dentiality, obtaining informed consent, or conducting physical measures were familiar for many volunteers. On the other hand, it also meant that we needed to emphasize that volunteers should be careful not to overstep the boundary of their roles and had a good grasp of the scope of their contributions.
A recent study on the involvement of French-speaking CHAP volunteers revealed that engaging volunteers in the research process was useful to gain important and unique insight on areas of improvement of the research protocol and how to better address needs of CHAP participants (32). The volunteers' feedback led to several adaptations to the research protocol and procedures of CHAP sessions.
The level of satisfaction of CHAP volunteers in Quebec was very high, as was the case with CHAP volunteers in Ontario. In addition to making a contribution to the community, in this case a vulnerable senior population, volunteers also bene ted from the experience. The majority reported having learned from their involvement in the program and felt the program met their expectations. Both French-speaking volunteers in Quebec and Ontario CHAP volunteers reported having a better knowledge of cardiovascular health as a result of their involvement with CHAP.
Despite differential rates of volunteer participation reported in the literature, our experience of working with English and French speaking volunteers to implement CHAP indicates that language spoken by the volunteers makes little difference as far as motivation, satisfaction and perceived bene ts of volunteering with CHAP are concerned.
This study was not meant to make broad comparisons between the culture of volunteerism among English and French-speaking volunteers in Canada. Our intent was to re ect on differences and similarities between volunteers who worked with us to implement CHAP. It was not meant to provide population-based, representative comparisons with respect to volunteering. Although the volunteers who were surveyed involved the total number of volunteers that we have worked with to implement CHAP as part of a cluster randomized trial involving the French-speaking elderly residents of social housing in Quebec, this is a very small and distinct sample of French-speaking volunteers in Quebec. Consequently, the results are not likely to be generalizable to other French-speaking volunteers in Quebec and should be interpreted with caution.

Conclusions
This study pro led CHAP volunteers involved in an RCT in social housing in the Montérégie region of Quebec, Canada. Although the rates of volunteering and average annual hours of involvement are the lowest in Canada in the province of Quebec (13)