The SEFAC Project will adapt an effective and efficient social engagement model for the prevention and (self) management of major chronic diseases and implement a community-based intervention and in particular will:

  • Promoting ‘screening’ in four different European pilot regions, using effective tools in collaboration with the existing primary health care system; a sample of middle-aged and older citizens living in the community will be informed about, and when appropriate engaged in existing possibilities for screening for the risk of developing or having major chronic diseases such as Coronary Heart Disease and Type 2 Diabetes Mellitus (CHD and T2DM); the preferences and social participation of the participants will be taken into account.
  • Identifying middle-aged and older adults in the 4 pilot sites living with one of the major chronic diseases under study and collecting and analyzing information related to patterns and preferences of social participation of the participants.
  • Design of SEFAC interventions to promote healthy lifestyles, increasing empowerment, promoting self-efficacy, and increasing self-management of participants with regard to modifiable risk factors for the chronic diseases in the study; cultural differences and the particularities of the regional health and social care system context will be taken into account.
  • Adapt, implement and test a community-based intervention template in community-dwelling for middle-aged and older citizens (circa over 50 years old) both at risk for CHD and T2DM, and CHD and T2DM patients. The approach will consist of local, social engagement and participation activities. A social engagement/participation toolkit already tested successfully in the UK ,will be adapted to the needs and particularities of each pilot site and will allow care providers and health organizations to screen (when appropriate) and implement group interventions for prevention and self-management of major chronic diseases; by doing so, an extensive population of middle-aged and older citizens will be reached, thanks to volunteers’ recruitment and training for connecting social services, primary health care and social services and participants according to the toolkit guidelines.
  • Develop a chronic disease prevention, self-management and empowerment ICT tool, based on ICT, with which the participants can easily and quickly assess their health behavior and health status, setting of targets regarding health promotion activities and management of chronic diseases, and to achieve targets set in the (preventive) care plan together with the volunteer and the support team, and set new target towards success. This way, participants are motivated and empowered to adopt a healthier lifestyle and to increase self-management practices, while getting remote support when needed.
  • Develop policy recommendations to identify key leverage for change and to support actions, in the regions of the European Union, to address chronic diseases, giving new approaches to potential needs for legislations, stakeholders’ coordination, methods for involvement of volunteers and end users, ensuring thus sustainable impact of the project’s outcomes, saving costs from the perspective of the citizens at risk for or with major chronic diseases such as T2DM and CHD, the health system itself and provide evidence to health policy makers in order to propose reforms towards more effective and efficient models of chronic care prevention and management.

During the project, a strong communication and optimal dissemination strategy will be applied by sharing the significant learning from the project and by promoting the recognition of significant successes/outcomes. A mix of project specific and EU dissemination channels will be activated to share information, practical tools and protocols.
Resources will be allocated for publishing results in relevant professional, policy and scientific journals.

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