Product Details

Author Information

Corresponding Author
Jeffrey Morzinski
Medical College of Wisconsin
Family and Community Medicine
8701 Watertown Plank Rd
Milwaukee, WI 53226
United States
p: (414) 955-4985
jmorzins@mcw.edu

Authors (listed in order of authorship):
Leslie Patterson
Medical College of Wisconsin

Kristyn Ertl
CJ Zablocki Veterans Administration Medical Center

Nancy Wilke
CJ Zablocki Veterans Administration Medical Center

Kathlyn Fletcher
CJ Zablocki Veterans Administration Medical Center

Christine Wurm
Veterans Administration Medical Center

Avery Hayes
CJ Zablocki Veterans Administration Medical Center

Jeff Whittle
CJ Zablocki Veterans Administration Medical Center

Product Description and Application Narrative Submitted by Corresponding Author

What general topics does your product address?

Public Health, Social & Behavioral Sciences

What specific topics does your product address?

Chronic disease, Community engagement, Community health , Community-based education, Curriculum development, Education, Health behavior, Health education , Leadership development , Men’s health, Overweight/obesity, Partnership building , Physical activity/exercise, Prevention, Military Veterans, Program evaluation, Community-based participatory research

Does your product focus on a specific population(s)?

Men, Seniors, Military Veterans

What methodological approaches were used in the development of your product, or are discussed in your product?

Community needs assessment, Community-academic partnership, Community-based participatory research , Focus group , Participatory evaluation, Qualitative research, Quantitative research, Survey, Videovoice

What resource type(s) best describe(s) your product?

Curriculum, Manual/how to guide, Training material

Application Narrative

1. Please provide a 1600 character abstract describing your product, its intended use and the audiences for which it would be appropriate.*

The product described here, the POWER Curriculum, is organized for public access at a website where product descriptions and training materials are located. This product resulted from a partnership titled POWER (Posts Working for Veterans Health), a government-funded project to train members of local veteran service organizations to lead health-focused activities and to model healthy behaviors for their peers, many of whom are experiencing chronic health conditions. The POWER Curriculum contains three main categories of materials:
• The initial 8-hour training session. In this session new peer leaders acquire a foundation of information and resources to plan and conduct health-focused activities.
• Mini-training sessions (MTS). This series of follow-up, 90-minute training sessions cover 12 health topics and provide peer leaders with supportive resources and information.
• Monitoring and evaluation. POWER tools and reports are provided to support on-going evaluation of the processes and products of peer leader training.

This product is a comprehensive curriculum for health-focused, small-group peer leaders. This product will have a wide range of audiences, from a health education team wanting to deliver a longitudinal, sustained health program, to individuals with minimal health experience looking to organize a single health promotion session (see Item 3). To be most effective, we believe that lay persons and appropriately trained health educators should work in partnership to plan and deliver the POWER Curriculum.

2. What are the goals of the product?

The primary goal of the POWER Curriculum is to provide the framework for planning, conducting, and evaluating a community-level training program focused on helping older individuals better manage hypertension and other chronic conditions. The curriculum is delivered through two main components: 1) a full-day (8-hour) training session that orients and prepares peer leaders for their roles and duties, and 2) a series of mini (1 ½ hour) training sessions to provide new materials and regularly support peer leaders over the duration of the longitudinal program.

The goals of the full-day training session are three-fold: 1) provide peer leaders with the knowledge base required to conduct a health-focused endeavor (e.g., definitions, causes and treatment of health condition/s); 2) prepare peer leaders with tools for planning and managing small group activities and interactions within their organizations that focus on chronic disease care; and 2) instill confidence in the peer leaders’ ability to lead and facilitate health and hypertension-related activities at their organization’s monthly meetings.

The main goals for the mini-training sessions (which start out monthly for three months, then occur every other month for the remainder of the program) are to provide on-going education and support for the peer leaders. Mini-training sessions reinforce peer leaders as they coordinate and facilitate health-focused activities within their organizations. Important activities at the mini-training sessions are troubleshooting, preparing peer leaders to present new health topics, and discussing strategies for maximizing the benefits to both passive audience members and active participants.

3. Who are the intended audiences or expected users of the product?

While written for veterans and designed for implementation in their organizations, we believe the POWER Curriculum is adaptable to other communities and/or sites, such as churches or senior centers. As mentioned earlier, the intended audiences for the POWER Curriculum are a range of users interested in improving the health of older individuals through peer support and enhanced self management. Other intended users are qualified health educators who select curricular elements for specific aims.

4. Please provide any special instructions for successful use of the product, if necessary. If your product has been previously published, please provide the appropriate citation below.

To adopt the entire curriculum will require a partnership team, including physicians, health educators and coordinators. We only applied and studied the product in its entirety. While we believe curricular elements could be adapted or used individually, this use of the POWER Curriculum is untested.

There was a “study arm” of POWER that assessed program impact on veterans’ blood pressure and other health indicators. Because this product’s focus is on peer leaders’ training, it does not include details on study methods or control group intervention. Study information from the pilot project, which served as the basis for the full project, has been published (1).

5. Please describe how your product or the project that resulted in the product builds on a relevant field, discipline or prior work. You may cite the literature and provide a bibliography in the next question if appropriate.

Approximately 65 million Americans have hypertension, and the prevalence is increasing (2). Effective treatment reduces health risks (e.g., stroke, coronary artery disease and renal disease), but treatment and control rates remain low. Only 35.1% of people with hypertension are adequately controlled, including just 57.2% of those treated (3). Inadequate control is more common among older individuals with hypertension, particularly older men (2).

The ineffectiveness of traditional care has led to many interventions aimed at improving hypertension control (4). Most efforts have focused on optimizing medical management, but even under the best circumstances results have been inadequate. In the Antihypertensive Lipid Lowering Heart Attack Trial (ALLHAT), 35% of patients were still uncontrolled despite good access to health care and medication, aggressive monitoring, and feedback to providers (5).

Another hypertension control approach is patients’ participation in their own care. Randomized trials have shown that “activated patients”—those actively involved in their own care—have better clinical outcomes with asthma, diabetes, arthritis, and chronic diseases in general (6, 7). Patient education is a key element of activation. While the long-term effects are not well known, patient education has been beneficial when paired with other self-management skills (8).

An innovative patient education method is the use of trained community members, referred to as community health educators, or peer leaders (9). Peer leaders are thought to sustain health activities in a socially supportive environment. Research demonstrates that peer-led education aids healthy behavior changes, including exercise, nutrition, and communication (10-13).

Wisconsin is home to almost half a million veterans, mostly older men: 75% are over 50 years old, and 41% are over 65. Many veterans belong to one or more of 43 congressionally-chartered veterans’ service organizations (VSOs). These organizations originally formed as veteran advocacy groups, but have important social roles as well. POWER builds on the social and peer support available in VSOs with an innovative emphasis on improving the health of community-based veterans.

The need for improved hypertension control among veterans and the evidence that peer support is effective led us to develop and implement the POWER Curriculum.

6. Please provide a bibliography for work cited above or in other parts of this application. Provide full references, in the order sited in the text (i.e. according to number order). .

1. Hayes A, Morzinski J, Ertl K, et al. Preliminary description of the feasibility of using peer leaders to encourage hypertension self-management. Wis Med J. 2010;109(2):29-34.
2. Hajjar I, Kotchen TA. Trends in prevalence, awareness, treatment and control of hypertension in the United States. JAMA. 2003;290(2):199-206.
3. Cutler JA, Sorlie PD, Wolz M, Thom T, Fields LE, Roccella EJ. Trends in hyperrtension prevalence, awareness, treatment, and control rates in United States adults between 1988-1994 and 1999-2004. Hypertension. 2008;52:818-827.
4. Fahey T, Schroeder K, Ebrahim S. Interventions used to improve control of blood pressure in patients with hypertension. Cochrane Database of Systematic Reviews 2006;18(4):CD005182.
5. Cushman WC, Ford CE, Cutler JA, et al. Success and predictors of blood pressure control in diverse North American settings: the antihypertensive and lipid-lowering treatment to prevent heart attack trial (ALLHAT). Journal of Clinical Hypertension (Greenwich). 2002;4(6):391-392.
6. Bodenheimer T, Lorig K, Holman H, Grumbach K. Patient self-management of chronic disease in primary care. JAMA. Nov 20 2002;288(19):2469-2475.
7. Greenfield S, Kaplan S, Ware JE, Jr. Expanding patient involvement in care. Effects on patient outcomes. Ann Intern Med. Apr 1985;102(4):520-528.
8. Yates T, Davies M, Gorely T, Bull F, Khunti K. Effectiveness of a pragmatic education program designed to promote walking activity in individuals with impaired glucose tolerance: A randomized controlled trial. Diabetes Care. 2009;32(8):1404-1410.
9. Brownstein JN, Bone LR, Dennison CR, Hill MN, Miyong KT, Levine DM. Community health workers as interventionists in the prevention and control of heart disease and stroke. Am J Prev Med. 2005.
10. Fernandez S, Scales KL, Pineiro JM, Schoenthaler AM, Ogedegbe G. A senior center-based pilot trial of the effect of lifestyle intervention on blood pressure in minority elderly people with hypertension. J Am Geriatr Soc. 2008;56(10):1860-1866.
11. Lorig KR, Ritter P, Stewart AL, et al. Chronic disease self-management program: 2-year health status and health care utilization outcomes. Med Care. Nov 2001;39(11):1217-1223.
12. Nine SL, Lakies CL, Jarrett HK, Davis BA. Community-based chronic disease management program for African Americans. Outcomes Management. Jul-Sep 2003;7(3):106-112.
13. Balcazar H, Alvarado M, Hollen ML, Gonzalez-Cruz Y, Pedregon V. Evaluation of Salud Para Su Corazon (Health for your Heart) -- National Council of La Raza Promotora Outreach Program. Preventing Chronic Disease. Jul 2005;2(3):A09.
14. Doak CC, Doak LG, Root JH. Teaching Patients with Low Literacy Skills, 2nd Ed. Philadelphia: Lippincott. 1996.
15. Kirkpatrick D, Kirkpatrick J. Evaluating Training Programs: The Four Levels. 3rd ed. San Francisco: Berrett Koehler; 2006.
16. Marshall C, Rossman GB. Designing Qualitative Research. Vol 3. Thousand Oaks, CA: Sage Publications, Inc.; 1999.
17. Moore D, Tananis C. Measuring change in a short-term educational program using a retrospective pre-test design. American Journal of Evaluation. 2009;30(2):189-202.

7. Please describe the project or body of work from which the submitted product developed. Describe the ways that community and academic/institutional expertise contributed to the project. Pay particular attention to demonstrating the quality or rigor of the work:

• For research-related work, describe (if relevant) study aims, design, sample, measurement instruments, and analysis and interpretation. Discuss how you verified the accuracy of your data.
• For education-related work, describe (if relevant) any needs assessment conducted, learning objectives, educational strategies incorporated, and evaluation of learning.
• For other types of work, discuss how the project was developed and reasons for the methodological choices made.

We developed the POWER Program (and its principal product, the POWER Curriculum) in three stages: 1) Partnership development; 2) Work group activities of the partnership; and 3) Outcome evaluation.

Stage One: Partnership Development
The POWER partnership emerged from a shared interest in veterans’ health and a desire to work together on an innovative, community-based intervention. To establish a working partnership, we felt it was important to engage partners with knowledge of the Veteran’s Administration Medical Center, expertise in health and medical education, and links to the state-level leadership of the largest veteran service organizations in Wisconsin.

To prepare for the pilot (POWER I), the principal investigator (PI) visited 34 Veterans of Foreign Wars (VFW) posts in the greater Milwaukee area. He sought input from post members on how to develop an effective program. The PI then worked with state-level VFW leaders, an educational specialist and a research coordinator from the Medical College, and a consultant from a local VFW post to develop the study intervention and apply for funding. The Healthier Wisconsin Partnership Program (HWPP), a health-focused foundation, provided pilot funds.

POWER II, a refined and expanded version of POWER I, was funded by a 3-year grant from the Department of Veterans Affairs. POWER II continued our partnership with the VFW and the American Legion, as well as several other veterans’ organizations. Our relationships with these organizations enabled us to more than triple the number of posts, from 15 in POWER I to 58 in POWER II. Of the 58 POWER II posts, we randomized 30 to the intervention arm (i.e., received health education delivered by trained peer leaders); the other 28 posts served as controls.

Stage Two: Work Group Activities to Refine and Implement the Curriculum
Prior to peer leader engagement with POWER II, the project team reviewed feedback from POWER I and made refinements (e.g., for the orientation, we added a video clip of experienced peer leaders). Topics for full-day training included the basics of hypertension self-management, including home blood pressure checks, weight monitoring, and pedometer use. We also discussed small group leadership and communication skills, lifestyle modification, and behavior change principles (6-13). Following this initial session, we conducted regular 90-minute mini-training sessions (MTS) with the peer leaders—monthly to start, then every other month after four months. At the MTS we reviewed project-related activities, sought feedback on the right literacy level for materials (14), introduced new scripts, and discussed health-related questions raised by the peer leaders. Each MTS also included time for debriefing and problem-solving. For example, peer leaders shared strategies for communicating with post members who voiced skepticism about the value of health behavior change.

For each MTS, the study team developed health scripts (detailed narratives that peer leaders could use to guide their presentations) on a specific topic to promote self-management among post members. Scripts were designed to be delivered by peer leaders in ten minutes or less. Scripts included information about a health-related topic (e.g., reading a food label, using an exercise band), as well as guidance for script delivery (e.g., when to ask for audience questions).

Stage Three: Curriculum Evaluation
The curriculum evaluation team was composed of the project PI, one co-investigator, two educational specialists, and one study coordinator. Evaluation followed a model that called for data collection at multiple process and outcome levels (15), including reactions to training, learning (e.g., new knowledge and skills to deliver scripts), behavior change (e.g., peer leader performance at their post meetings) and impact. Primary methods used were surveys, focus groups, and direct observation of peer leader performance, following published methods (16).

8. Please describe the process of developing the product, including the ways that community and academic/institutional expertise were integrated in the development of this product.

We incorporated expertise from academics, clinicians, allied health professionals, administrative staff, and community partners in the development of this product. The team process we used consisted of a mix of twice-monthly, monthly, and quarterly meetings, as well as electronic document sharing and updating of materials by appropriate project team members. The academic partners with significant expertise in social support, training, and curricula development took a lead role in the creation and implementation of the POWER Curriculum. Co-investigators from the college with backgrounds in quantitative and qualitative evaluation provided measurement expertise. The project’s primary investigator and colleagues from the field of internal medicine wrote and delivered the medical and scientific content and answered peer-leader questions in these areas. Team members with special skills in nutrition, exercise, and stress management—including an occupational therapist and a psychologist—contributed to the written content and skills training in these areas. The study coordinator for the pilot study brought her substantial experience, administrative skills, and relationship-building capacity to the coordination of POWER II.

We gathered input from our community partners in several ways. Firstly, we convened a formal Community Advisory Board on a quarterly basis. Board members included district-level representatives from the American Legion, Elks, and VFW; the associate director from the Milwaukee VA Medical Center; a family physician in Milwaukee; a masters-level academician with expertise in health partnership formation; and the coordinator of a special program to help military families. We asked members to provide input on ways to integrate community and institutional resources. We also engaged the Board members in discussions of the POWER Curriculum and requested formative feedback on product content.

At each MTS we asked the peer leaders to comment on the script that we provided. We asked about the scripts’ subject matter, language use, and format. We used their input to improve the scripts. The scripts themselves were a result of the feedback we received from the peer leaders in our pilot project. For example, pilot project input resulted in clarified and simplified presentation guidelines. For POWER II, we worked to make the scripts both structured enough to relieve possible peer-leader anxiety about presenting, but also sufficiently flexible that the leaders could tailor them to the needs and temperament of their particular posts.

We asked the peer leaders to gather health questions from their post members for the “Answers to Questions from Previous Sessions” segment of the MTS. The questions they gathered were often not directly related to hypertension control, but often involved a medical theme and were addressed by one of our physician team members. These discussions connected the project to the concerns of our community partners, helped point out inter-relationships among health issues, and kept health questions “top of mind” for both the peer leaders and their fellow post members.

Finally, we used the evaluation and process data provided by our community partners in the pilot project to improve the POWER Curriculum. For example, the focus group results from the pilot showed that it was crucial for Post Commanders (leaders of the organization) to support the program and to make time on the regular meeting agenda for POWER-related presentations and activities. In response, we included a special planning activity in the 8-hour training session for POWER II that guided the peer leaders through the process of enlisting the support of the Post Commander and getting on the agenda; they left the 8-hour session with a written, actionable plan to accomplish this task. Also, one of the scripts in the pilot project promoted the use of an exercise DVD, but we learned from the peer leaders that many post members didn’t have a DVD player and were reluctant to acquire one for this purpose. We revised the script for POWER II to include several exercise alternatives for people without DVD players.

9. Please discuss the significance and impact of your product. In your response, discuss ways your product has added to existing knowledge and benefited the community; ways others may have utilized your product; and any relevant evaluation data about impact, if available. If the impact of the product is not yet known, discuss its potential significance.

We determined product significance and impact by examining outcomes in four levels: reaction, learning, behavior change, and impact on the veterans and community (15). (See additional details on the POWER website).

Reaction-level data indicated that peer leaders were highly satisfied with the POWER Curriculum. Using a scale where 7=excellent and 1=poor, peer leaders rated overall satisfaction with all 12 MTS topics as 6.4. “Health Support” and “Get Fit for Life” were lower rated topics, while highest rated were “Eating Out” and “Exercise Bands.” Training satisfaction is important because adults “vote with their feet” and engage in activities that they feel are worthwhile.

Peer leaders’ responses to retrospective “pre/post” program assessments (17) showed that the POWER Curriculum had an impact on their learning. All eight end-of-program comparisons of peer leaders’ self-reported knowledge and skills were positively and significantly improved (paired t-test, p<.00) from “pre-program” to “post-program” (scale anchors: 1=no experience or confidence, and 6=exceptional experience and confidence). The greatest difference scores (increasing from 2.7 “pre” to 2.9 “post”) concerned the ability to use the health scripts, the ability to co-lead hypertension-related health activities, the belief that peer support among post members encourages healthy behaviors, and the belief that it helps veterans and their families to have health-related handouts and brochures available at the VSO posts.

Training contributed to peer-leaders’ behavior change. The strongest evidence of this came from data collected at planned observation visits (two per site) during scheduled post meetings. We used a pre-tested data collection form to record meeting details (e.g., attendance, length) and specific peer leader activity and behavior, consistent with their training. For example:

• We asked peer leaders to set up and keep stocked a “Health Corner” at their post. Key elements included a hypertension poster and a plastic caddy filled with health-related handouts and brochures. We observed well-stocked Health Corners in 47 of 60 visits (78%).
• We trained peer leaders to set out blood pressure cuffs and weight scales for post member use at each meeting. We noted that the blood pressure cuffs were set out at 51 visits (85%), and the scales were set out at 34 visits (57%).
• A key element of training was the delivery of a 10-minute health script (see #7 above) on topics such as pedometer use, counting calories, and hypertension myths. We expected peer leaders to deliver one script at each post meeting. We observed that the leaders completed a script-guided presentation at 56 of 60 (93%) observation visits.

Preliminary focus group findings suggest that the peer leaders’ training had a positive impact on their lives, the lives of family members, and their organizations. Peer leaders who participated in the end-of-program focus groups discussed the positive impact they witnessed on post members’ health due to weight loss, lowered blood pressure, improved stamina and fitness, and a greater confidence to successfully participate in health improvement initiatives. Some focus group participants noted that post members’ families shared in the health benefits because the post members brought materials home, such as pedometers, stretch bands, and exercise DVDs.

We conclude that POWER Curriculum training resulted in new information in three main areas. Military veterans serving as health peer leaders reacted positively and learned important skills during the POWER training series. We learned new information about health promotion behaviors that peer leaders enact at their community sites. Finally, we learned that peer-leader training positively influenced the health of post members and their families. Our results are preliminary, analysis is continuing and updates will be posted on the POWER website.

10. Please describe why you chose the presentation format you did.

We selected a website as the presentation format for the POWER Curriculum because it could hold a large amount of material, would be highly accessible to potential users, and would allow for as-needed updates. As applied in the community, we presented the POWER Curriculum using mixed methods over two primary instructional delivery formats (full-day and mini-training sessions) in order to accommodate peer leader objectives to learn and implement new practices in quick succession.

Presentation formats during the full-day training session relied upon slide presentation, discussion, role-play, and video demonstration of “lessons learned” from prior peer leaders. These mixed formats provided learners with a foundation of awareness for factual science and common myths of hypertension. The methods also provided variety to heighten learners’ energy and attention. We devised these formats to emphasize preparation for practice, with worksheets and role plays that simulated essential steps for success that would be required once the learner assumed the peer leader role.

The mini-training sessions (MTS) also followed this guiding principle of practical preparation for the peer leader roles. The formats for MTS included open dialogue time for peer leaders to share their experiences and problem-solve together, opportunities to ask questions, and an emphasis on the delivery of prepared health scripts. We learned from the peer leaders that it was important to use credible presenters with expertise in several content areas, including medicine, nutrition, and health support.

11. Please reflect on the strengths and limitations of your product. In what ways did community and academic/institutional collaborators provide feedback and how was such feedback used? Include relevant evaluation data about strengths and limitations if available.

The POWER II website curricular content benefited tremendously from the curriculum’s “trial run” as POWER I. For example, the current curriculum adopted content and a more simplified script design based on feedback from POWER I participants. The curriculum development team met regularly (at least once a month, but usually twice) to discuss the arrangement of topics, the content, and the methods of presentation. At each team meeting, members would review and discuss the proposed curricular materials. The project coordinator would incorporate the agreed-upon curricular revisions and circulate the revised versions to team members for additional feedback. This back and forth process would continue until we reached consensus. Every three months the project team would meet with our Community Advisory Board and present a sample of the curricular materials for their preview and input.

We designed each MTS to “stand on its own,” with the common thread of blood pressure control. This ensured that a missed session did not put a leader so far behind as to discourage continuation. This also meant that the order of session topics could be re-arranged to suit the needs of a particular audience. Each MTS was also a chance to ask peer leaders to preview scripts and other educational material to ensure they were at an appropriate literacy level for post members.

The POWER Curriculum relied on a team of experts and was delivered as a comprehensive program. As mentioned previously, peer leaders appreciated opportunities to interact with medical doctors. A limiting factor for future users of this curriculum may be the cost and access to clinical experts as presenters. We are confident that several program elements would be useful in a less comprehensive program and by trainers with different backgrounds and experience, but we have no experience delivering this program with these substantial modifications.

Another limitation is that the POWER Curriculum has only been employed in the training of military veterans, the majority of whom are older white males. This may reduce its applicability and appeal to more diverse audiences. However, we believe that the topics themselves—which focus on lifestyle modifications to improve health—are pertinent to a much larger audience. Tailoring the curriculum to new audiences could be achieved in several ways. Some of these changes might be wording changes inside the educational materials, the use of different personal examples, updated examples of nutritional information that matches local habits and customs, and refining and updating graphics.

Full implementation of the POWER Curriculum requires a significant time commitment on the part of peer-leader trainees (eight hours initially, plus 18 hours for the mini training sessions). Though 26 hours spread out over several months worked for our peer leaders, it may be restrictive for others who are juggling careers, family responsibilities, and/or other community activities.

Though the 26 hours required for the program may be burdensome to some volunteers, it may not be enough time to effectively cover topics of particular interest to others. There were several instances during the training when sessions were at risk of running overtime. It is important to set agendas agreeable to all partners and keep training events on-time.

12. Please describe ways that the project resulting in the product involved collaboration that embodied principles of mutual respect, shared work and shared credit. If different, describe ways that the product itself involved collaboration that embodied principles of mutual respect, shared work and shared credit. Have all collaborators on the product been notified of and approved submission of the product to CES4Health.info? If not, why not? Please indicate whether the project resulting in the product was approved by an Institutional Review Board (IRB) and/or community-based review mechanism, if applicable, and provide the name(s) of the IRB/mechanism.

Project collaboration was a hallmark of the POWER Program. POWER team members frequently exhibited the principles of mutual respect, shared work, and shared credit. Several examples show commitment to these principles. First, we learned from and gave credit to the efforts of peer leaders from the POWER I pilot project. Several peer leaders from POWER I provided input that is now incorporated into the POWER Curriculum. For example, two peer leaders from the pilot agreed to be videotaped presenting a POWER script at their post; two other leaders agreed to be part of an on-camera interview about their experiences with POWER I. We used these two video clips to orient the new POWER II leaders to their roles during the initial 8-hour training session.

The project team frequently interacted with the veterans’ posts and their peer leaders as experts within the veteran community. This was done formally and respectfully when first seeking project planning ideas, and, as the project was delivered, by seeking input on topics and questions that project staff could address. Peer leaders and posts were also reimbursed financially for the time they provided to the project. As an additional measure of respect and protection as research contributors, we obtained IRB approval though the Human Studies Subcommittee of the Research and Development Committee, Clement J. Zablocki VA Medical Center, and formally acquired informed consent from peer leaders.

The project team also shared work among themselves, and progress was monitored by frequent staff meetings and email communications. For example, it was common that instructional materials such as the MTS scripts would undergo five or more revisions by academic, coordinating and research staff members before being finalized. While work roles were well-differentiated, there was mutual respect for the project contributions made by research assistants, faculty, student-interns, and coordinators. This was demonstrated by recognizing and including their ideas in all facets of the project. Project team members are kept informed of project products (such as this submission and the associated website “product”) and fully approve.

Finally, members of the Community Advisory Board and peer leaders contributed useful ideas adopted during the preparation and implementation of the POWER Curriculum. An expressed sentiment was that peer leaders felt they had a stake in the project and its outcomes. Several community members participated in project presentation and publishing activities to ensure that the work expressed the voices of the entire project team and the communities they serve.