Category: 3. Business

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Shareholders to Receive $21.20 Per Share in Cash Representing a 40.0% Premium to Closing Price on December 8, 2025

HONOLULU – Alexander & Baldwin, Inc., (NYSE: ALEX) ( “A&B” or the “Company”), a Hawaiʻi-based owner, operator and developer of high-quality commercial real estate in Hawaiʻi, today announced that it has entered into a definitive merger agreement in which a joint venture formed by MW Group and funds affiliated with Blackstone Real Estate and DivcoWest (collectively, the “Investor Group”) will acquire all outstanding A&B common shares for $21.20 per share in an all-cash transaction with an enterprise value of approximately $2.3 billion, including outstanding debt. As a result of this transaction, A&B will become a private company.

A&B is the largest owner of high-quality, grocery-anchored shopping centers in Hawai‘i. The Company’s portfolio consists of approximately 4.0 million square feet of commercial space, including 21 retail centers, 14 industrial assets and four office properties, as well as fee interests in 146 acres of ground lease assets.

“For 155 years, A&B has grown alongside Hawaiʻi, shaped by the people, values and communities that define these islands,” said Lance Parker, President and Chief Executive Officer of A&B. “Today, we are taking an important step toward our long-term vision for A&B as stewards of Hawai‘i’s premier commercial real estate. As a private company supported by the deep real estate expertise and experience of our new ownership group, A&B will have greater capacity to serve its tenants and communities. In our next chapter, we will continue focusing on real estate that supports the daily lives of residents, overseeing our properties with care and remaining steadfast in our role as partners for Hawai‘i.”

“We’re pleased to reach this agreement, which delivers significant, immediate and certain value to our shareholders while strengthening A&B’s ability to serve the diverse needs of communities across Hawai‘i,” said Eric Yeaman, Chairman of the A&B Board. “The Board is confident that today’s news is in the best interests of all of A&B’s stakeholders. It delivers a substantial cash premium for shareholders and long-term benefits for our valued employees, tenants and communities.”

“As a Hawai‘i-grown company founded over 35 years ago, we have seen firsthand the community contributions and lasting value that Alexander & Baldwin has created across generations,” said Stephen Metter, CEO at MW Group. “We look forward to supporting the Company’s legacy and magnifying our collective impact on the communities we serve.”

Blackstone Real Estate has a long history of responsible ownership in Hawai‘i, including iconic hospitality properties, such as Grand Wailea, The Ritz-Carlton Maui, Kapalua, Turtle Bay and Hilton Hawaiian Village, as well as retail property Pearlridge Center and high-quality rental housing on O‘ahu.

“We’re excited to reach this agreement, which deepens our commitment to Hawai‘i and our long-standing support for its local businesses. Our approach has always centered on operating responsibly and creating new opportunities for community members, including the more than 9,000 jobs created and supported by our investments in Hawai‘i,” said David Levine, Co-Head of Americas Acquisitions for Blackstone Real Estate. “We have a deep appreciation for what the Alexander & Baldwin management team has built, and we look forward to working together going forward.”

“Alexander & Baldwin has built an outstanding portfolio and we look forward to working with our partners and the Company to help continue its success,” said Caleb Cragle, Head of Strategic Investments, DivcoWest.

Continuing A&B’s Legacy as Partners for Hawai‘i

The Investor Group is aligned with the following principles to further the Company’s vision for building a better Hawai‘i, today and for the future:

• Maintaining A&B’s Strong Local Focus: Following the closing of the transaction, A&B will retain its name, brand and Honolulu headquarters.
• Continued Leadership From Local Team: The Company will continue to be led by a Hawai‘i-based team and is committed to strengthening the relationships and community connection that have driven its long-term success.
• Enhancing Existing Portfolio of Properties: A&B will continue to maintain its properties at high standards of quality for its tenants and community members. The Investor Group intends to invest over $100 million across the portfolio to enhance the properties and reinforce their essential role in the communities they serve.

Transaction Details
Under the terms of the agreement, A&B shareholders will receive $21.20 per share in cash for each share of A&B common stock they own. This amount represents a 40.0% premium to A&B’s closing stock price on December 8, 2025, the last full trading day prior to the transaction announcement.

The transaction, which was unanimously approved by the A&B Board of Directors, is expected to close in the first quarter of 2026, subject to customary closing conditions including approval by the Company’s shareholders.

Upon completion of the transaction, A&B’s common stock will no longer be listed on the NYSE.

A&B also announced today that its Board of Directors approved a fourth quarter 2025 dividend of $0.35 per share. The dividend is payable on January 8, 2026, to shareholders of record as of the close of business on December 19, 2025. Under the terms of the merger agreement, the per-share consideration that shareholders will receive at the closing of the transaction will be reduced to reflect this dividend.

Advisors
BofA Securities is serving as A&B’s exclusive financial advisor, and Skadden, Arps, Slate, Meagher & Flom LLP and Cades Schutte LLP are serving as legal advisors. Joele Frank, Wilkinson Brimmer Katcher is serving as strategic communications advisor.

Wells Fargo and Eastdil Secured are acting as Blackstone’s financial advisors. Simpson Thacher & Bartlett LLP and Carlsmith Ball LLP are serving as Blackstone’s legal counsel.

Gibson, Dunn & Crutcher LLP is serving as DivcoWest’s legal counsel.

ABOUT ALEXANDER & BALDWIN
Alexander & Baldwin, Inc. (NYSE: ALEX) (A&B) is the only publicly-traded real estate investment trust to focus exclusively on Hawai‘i commercial real estate and is the state’s largest owner of grocery-anchored, neighborhood shopping centers. A&B owns, operates and manages approximately 4.0 million square feet of commercial space in Hawai‘i, including 21 retail centers, 14 industrial assets, and four office properties, as well as 146 acres of ground lease assets. Over its 155-year history, A&B has evolved with the state’s economy and played a leadership role in the development of the agricultural, transportation, tourism, construction, residential and commercial real estate industries. Learn more about A&B at www.alexanderbaldwin.com.
About MW Group, Ltd.
MW Group, Ltd. is a privately-held, commercial real estate development company based in Honolulu, Hawai‘i. For more than three decades, the company has led the acquisition, development and management of a diverse portfolio of commercial properties valued at over $1 billion, including retail, industrial, office, self-storage facilities and senior assisted living communities. The company is committed to long-term stewardship, community-building, and creating enduring value through strategic partnerships and operational excellence. Learn more at www.mwgroup.com.

About Blackstone Real Estate
Blackstone is a global leader in real estate investing. Blackstone’s real estate business was founded in 1991 and has US $320 billion of investor capital under management. Blackstone is the largest owner of commercial real estate globally, owning and operating assets across every major geography and sector, including logistics, data centers, residential, office and hospitality. Our opportunistic funds seek to acquire well-located assets across the world. Blackstone’s Core+ business invests in substantially stabilized real estate assets globally, through both institutional strategies and strategies tailored for income-focused individual investors including Blackstone Real Estate Income Trust, Inc. (BREIT). Blackstone Real Estate also operates one of the leading global real estate debt businesses, providing comprehensive financing solutions across the capital structure and risk spectrum, including management of Blackstone Mortgage Trust (NYSE: BXMT).

About DivcoWest
Founded in 1993 by Stuart Shiff, DivcoWest, a DivCore Capital company, is a vertically integrated, real estate investment firm headquartered in San Francisco, with offices in Cambridge, Beverly Hills, Menlo Park, Washington DC, Austin, and New York City. Known for long-standing relationships and experience across the risk-spectrum in innovation markets, DivcoWest combines entrepreneurial spirit with an institutional approach to commercial real estate. DivcoWest aims to create environments that inspire ingenuity, promote growth, and enhance health and well-being. Since inception, DivcoWest and its predecessor have acquired approximately 61 million square feet of commercial space – primarily throughout the United States. DivcoWest’s real estate portfolio currently includes existing and development properties in the office, R&D, lab, industrial, retail, and multifamily spaces. Follow @DivcoWest on LinkedIn.

Contacts:

A&B
Investor Contact:
Clayton Chun
(808) 525-8475
[email protected]
Media Contact:
Tran Chinery
[email protected]
MW Group
Dylan Beesley
Bennet Group Strategic Communications
[email protected]

Blackstone
Jeffrey Kauth
[email protected]
Dylan Beesley
Bennet Group Strategic Communications
[email protected]

DivcoWest
Andrew Neilly
A2N2 Public Relations
925.915.0759
[email protected]
Nancy Amaral
A2N2 Public Relations
925.915.0673
[email protected]
IMPORTANT INFORMATION AND WHERE TO FIND IT
In connection with the transaction, the Company will file a proxy statement on Schedule 14A with the Securities and Exchange Commission (the “SEC”). The Company also may file other documents with the SEC regarding the transaction. This communication is not a substitute for the proxy statement or any other document which the Company may file with the SEC. INVESTORS AND SHAREHOLDERS OF THE COMPANY ARE URGED TO READ THE PROXY STATEMENT AND ANY OTHER RELEVANT DOCUMENTS THAT ARE FILED OR WILL BE FILED WITH THE SEC, AS WELL AS ANY AMENDMENTS OR SUPPLEMENTS TO THESE DOCUMENTS, CAREFULLY AND IN THEIR ENTIRETY WHEN THEY BECOME AVAILABLE BECAUSE THEY CONTAIN OR WILL CONTAIN IMPORTANT INFORMATION ABOUT THE TRANSACTION. Investors and shareholders may obtain free copies of the proxy statement and other documents that are filed or will be filed by the Company with the SEC (in each case when available) from the SEC’s website (www.sec.gov), or from the Company’s website (https://investors.alexanderbaldwin.com/sec-filings). Alternatively, these documents, when available, can be obtained for free upon written request to the Company at 822 Bishop Street, Honolulu, HI 96813.

PARTICIPANTS IN THE SOLICITATION
The Company and certain of its directors and executive officers may be deemed to be participants in the solicitation of proxies from shareholders of the Company in connection with the transaction. Information regarding the Company’s directors and executive officers is contained in the Company’s proxy statement for its 2025 annual meeting of shareholders, which was filed with the SEC on March 11, 2025, and any subsequent documents filed with the SEC. To the extent the holdings of the Company’s securities by the Company’s directors and executive officers have changed since the amounts set forth in the proxy statement for its 2025 annual meeting of shareholders, such changes have been or will be reflected on Statements of Change in Ownership on Form 4 filed with the SEC. Additional information regarding the identity of the participants, and their respective direct and indirect interests, by security holdings or otherwise, will be set forth in the proxy statement and other relevant materials to be filed with the SEC in connection with the transaction when they become available. You may obtain free copies of these documents using the sources indicated above.

FORWARD-LOOKING STATEMENTS
This communication includes forward-looking statements, as defined in the U.S. federal securities laws, which involve a number of risks and uncertainties that could cause actual results to differ materially from those contemplated by the relevant forward-looking statements. Words such as “believes,” “expects,” “anticipates,” “intends,” “plans,” “estimates,” “projects,” “forecasts,” and future or conditional verbs such as “will,” “may,” “could,” “should,” and “would,” as well as any other statement that necessarily depends on future events, are intended to identify forward-looking statements. Such forward-looking statements speak only as of the date the statements were made and are neither statements of historical fact nor guarantees of future performance. Forward-looking statements are subject to a number of risks, uncertainties, assumptions and other factors that could cause actual results and the timing of certain events to differ materially from those expressed in or implied by the forward-looking statements. These factors include, but are not limited to, (i) the risk that the merger may not be completed on the anticipated terms and timing, or at all, including the risk that the required approval of the Company’s shareholders may not be obtained or that the other conditions to completion of the merger may not be satisfied, (ii) potential litigation relating to the merger that could be instituted against the Company or its directors or officers, including the effects of any outcomes related thereto, (iii) the risk that disruptions from the merger will harm the Company’s business, including current plans and operations, including during the pendency of the merger, (iv) the Company’s ability to retain and hire key personnel, (v) potential adverse reactions or changes to business relationships resulting from the announcement or completion of the merger, (vi) risks related to diverting management’s attention from ongoing business operations, (vii) potential business uncertainty, including changes to existing business relationships, during the pendency of the merger that could affect the Company’s financial performance, (viii) certain restrictions under the merger Agreement that may impact the Company’s ability to pursue certain business opportunities or strategic transactions, (ix) the possibility that the merger may be more expensive to complete than anticipated, including as a result of unexpected factors or events, (x) the occurrence of any event, change or other circumstance that could give rise to the termination of the merger, including in circumstances requiring the Company to pay a termination fee, (xi) prevailing market conditions and other factors related to the Company’s REIT status and the Company’s business, and (xii) the risk factors discussed in Part I, Item 1A of the Company’s most recent Form 10-K under the heading “Risk Factors,” Form 10-Q and other filings with the SEC (which are available via the SEC’s website at www.sec.gov). The information in this communication should be evaluated in light of these important risk factors. We do not undertake any obligation to update or review the Company’s forward-looking statements, except as required by law, whether as a result of new information, future developments or otherwise.

No matter how much train fares cost under Great British Railways, no one can accuse the government of wasting money on an expensive redesign.

The logo, branding and livery for the impending renationalised and reformed railway will be unveiled by ministers at London Bridge on Tuesday. It is red, white and, yes, blue.

The Department for Transport said passengers will get their “first look at the future” of Britain’s railways – a future that may ring a few bells. Designed in-house at the DfT, the logo is the GBR name in rail typeface accompanied by the double arrow symbol – what the DfT describes as a “nod to Britain’s proud railway heritage”, rather than a direct lift from British Rail.

The first actual trains to be repainted could arrive from next spring, but fans of pretend ones can see the brand on a Hornby model and a virtual version in the Train Sim World 6 game at London Bridge, and on displays at other leading stations around the country.

The unveiling comes as legislation aimed at reforming the railway is debated in the House of Commons on Tuesday. The government hopes the bill will create a unified, accountable nationalised railway after decades of a fragmented private system.

The transport secretary, Heidi Alexander, said: “The future of Britain’s railways begins today. I’m immensely proud to unveil the new look for Great British Railways as we deliver landmark legislation to nationalise our trains and reform the railway so it better serves passengers.

“This isn’t just a paint job – it represents a new railway, casting off the frustrations of the past and focused entirely on delivering a proper public service for passengers.

“With fares frozen, a bold new look and fundamental reforms becoming law, we are building a railway Britain can rely on and be proud of.”

Seven of England’s former private train operators are already back in public hands, covering a third of all passenger journeys in Great Britain, with the rest due to renationalised by the end of 2027. The new GBR, to be headquartered in Derby, will bring track and train operations together, at arm’s length from the government, and a strengthened passenger watchdog will be set up to monitor service.

The new brand design also features on the GBR ticketing app under development, which the government will roll out as a new one-stop shop for passengers to check on their journeys and to buy tickets for travel across the whole network, without any booking fees. The DfT said the GBR app would also simplify travel for disabled passengers, who will be able to book Passenger Assist services to board and disembark trains in the same app when buying tickets.

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In October, the design of the new Great British Railways station clock was unveiled, also at London Bridge.

Alex Robertson, the chief executive of the current independent watchdog Transport Focus, said: “As well as what is written into law, the success of GBR will depend on its people and culture, and today gives us a glimpse into what that could look and feel like.”

A first big test for state-controlled services comes from next week when hundreds more LNER trains are added each week on a revamped east coast mainline timetable.

Alexander announced last month that rail fares in England will be frozen in 2026 for the first time in 30 years.

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Adam Feuerstein is a senior writer and biotech columnist, reporting on the crossroads of drug development, business, Wall Street, and biotechnology. He is also a co-host of the weekly biotech podcast The Readout Loud and author of the newsletter Adam’s Biotech Scorecard. You can reach Adam on Signal at stataf.54.

Damian Garde is a reporter at large, live and feature journalism, covering the global drug industry and contributing to STAT’s industry-leading events.

This is the online version of ASH in 30 Seconds, STAT’s report from the American Society of Hematology meeting. Sign up for the email version here. 

It rains in Florida. A lot. This ASH meeting started sunny and wonderful, but quickly turned rainy and miserable. It’s just another reason why ASH should camp itself permanently in San Diego each December.

Study suggests Terns leukemia drug could be successor to Novartis blockbuster

Adam Feuerstein/STAT

Terns Pharmaceuticals reported an update on its targeted leukemia drug that maintained and even boosted high molecular response rates in advanced-stage patients.

WASHINGTON — Commodity Futures Trading Commission Acting Chairman Caroline D. Pham today announced the launch of a digital assets pilot program for certain digital assets, including BTC, ETH, and USDC, to be used as collateral in derivatives markets; guidance on tokenized collateral; and withdrawal of outdated requirements given the enactment of the GENIUS Act. Today’s announcement marks a significant milestone in the expanded adoption of digital assets in regulated markets with appropriate guardrails, and follows the tokenized collateral initiative Acting Chairman Pham launched in September as a part of the CFTC’s Crypto Sprint to implement recommendations in the President’s Working Group on Digital Asset Markets report.

“Under my leadership this year, the CFTC has led the way forward into America’s Golden Age of Innovation and Crypto. This imperative has never been more important given recent customer losses on non-U.S. crypto exchanges. Americans deserve safe U.S. markets as an alternative to offshore platforms, and that’s why last week I announced that spot crypto can now be traded on CFTC registered exchanges,” said Acting Chairman Pham. “Today, I am launching a U.S. digital assets pilot program for tokenized collateral, including bitcoin and ether, in our derivatives markets that establishes clear guardrails to protect customer assets and provides enhanced CFTC monitoring and reporting. The CFTC is also providing regulatory clarity through tokenized collateral guidance for real world assets like U.S. Treasuries, and withdrawing CFTC requirements that are now outdated under the GENIUS Act. As I’ve said before, embracing responsible innovation ensures that U.S. markets are the world leader, and drives progress that will unleash U.S. economic growth because market participants can safely put their dollars to work smarter and go further.” 

“The CFTC’s decision confirms what the crypto industry has long known: That stablecoins and digital assets can make payments faster, cheaper, and reduce risk,” said Paul Grewal, Coinbase Chief Legal Officer. “We applaud Acting Chair Caroline Pham and the CFTC for swiftly recognizing that tokenized innovation is the future of finance, and thank Acting Chair Caroline Pham for her leadership and vision. This major unlock is precisely what the Administration and Congress intended the GENIUS Act to enable—and will allow digital innovation to transform and improve traditional areas of finance. We encourage other regulators to quickly follow suit.”

“Circle applauds Acting Chairman Pham’s breakthrough leadership for derivatives markets and responsible innovation,” said Heath Tarbert, President of Circle. “Deploying prudentially supervised payment stablecoins across CFTC-regulated markets protects customers, reduces settlement frictions, supports 24/7 risk reduction, and advances U.S. dollar leadership through global regulatory interoperability. Enabling near-real-time margin settlement will also mitigate settlement-failure and liquidity-squeeze risks across evenings, weekends, and holidays. Acting Chairman Pham and the Commission have set a course for the future in which the United States will continue to have the safest, deepest, and most trusted global derivatives markets.”

“Today marks an important milestone in the history of the crypto industry—we have been given regulatory certainty for the future,” said Kris Marszalek, Co-Founder and CEO of Crypto.com. “The CFTC guidance on tokenized collateral is the latest example of Acting Chairman Pham delivering on the promise of President Trump to make the United States the ‘crypto capital of the world.’ Acting Chairman Pham should be commended for these leadership efforts. For years, we have been able to offer tokenized collateral in markets other than the United States. It has only been because of the leadership of Acting Chairman Pham and the CFTC’s exclusive jurisdiction over our CFTC-regulated clearinghouse that we will now be able to use tokenized collateral to support our CFTC-regulated crypto and predictions market products, as well as our margined derivatives. This means 24/7 trading is a reality in the United States. We are fully open for business and are excited for this new chapter.”

“The CFTC’s actions mark a pivotal moment for integrating digital assets into regulated derivatives markets. By recognizing tokenized digital assets—including stablecoins—as eligible margin, the CFTC is providing the regulatory clarity needed to move the industry forward,” said Jack McDonald, SVP of Stablecoins at Ripple. “This step will unlock greater capital efficiency and solidify U.S. leadership in financial innovation. At Ripple, we look forward to continuing to partner with the CFTC and the industry to ensure the safe and responsible scaling of digital assets.”

Digital Assets Pilot Program and Guidance for Tokenized Collateral

The CFTC’s Market Participants Division, Division of Market Oversight, and Division of Clearing and Risk issued new guidance today on the use of tokenized assets as collateral in the trading of futures and swaps. The guidance highlights that CFTC regulations are technology-neutral, and encourages the analysis of tokenized assets on an individual basis in accordance with the CFTC’s existing regulatory framework and firms’ policies and procedures. The guidance applies to tokenized real world assets, including U.S. Treasury securities and money market funds. Topics include eligible tokenized assets; legal enforceability; segregation, custody and control arrangements; haircuts and valuation; and operational risks.

MPD also issued a no-action position with respect to certain requirements applicable to Futures Commission Merchants (FCMs) that accept non-securities digital assets, including payment stablecoins, as customer margin collateral or hold certain proprietary payment stablecoins in segregated customer accounts. The no-action position provides market participants with regulatory clarity regarding the application of the segregation and capital requirements to FCMs that accept these digital assets as margin collateral, while highlighting the importance of FCMs’ maintaining robust risk management practices. By setting up a framework for registered FCMs to accept and take into account the value of non-securities digital asset customer margin collateral and deposit payment stablecoins as residual interest, the no-action letter establishes a pilot program that fosters responsible financial innovation while providing an opportunity for CFTC staff to closely monitor developments associated with non-securities digital asset collateral.

As set forth in the conditions of the letter, during the first three months from the commencement of an FCM’s reliance on the no-action position, the digital assets that an FCM could accept as margin collateral will be limited to bitcoin, ether, and USDC. In addition, during this initial period, an FCM relying on the no-action letter will be required to provide weekly reporting of the total amount of digital assets held in customer accounts, listing each asset type separately for each of the three customer account classes, and promptly notify CFTC staff of any significant issue affecting the use of digital assets as customer margin collateral. The frequent reporting and notice requirements will provide an opportunity for CFTC staff to assess the proper application of FCM regulatory requirements without unnecessarily limiting the ability of FCMs to accept digital assets as collateral and deposit proprietary payment stablecoins as residual interest in customer accounts.

Finally, MPD withdrew CFTC Staff Advisory No. 20-34, Accepting Virtual Currencies from Customers into Segregation, effective immediately. That advisory, which was issued by MPD’s predecessor division, placed certain restrictions on an FCM’s ability to accept virtual currencies as customer collateral. The substantial developments with respect to digital assets and the use of tokenized collateral in the derivatives markets that occurred in the intervening years since its issuance, including the enactment of the GENIUS Act, have rendered the advisory outdated and no longer relevant. 

These actions are based on significant stakeholder input and public comments, feedback from a CFTC Crypto CEO Forum, and recommendations from the Digital Asset Markets Subcommittee of the Global Markets Advisory Committee, which Acting Chairman Pham sponsors.

Introduction

Many countries are facing an aging population [], with a rising prevalence of chronic diseases []. Community health screenings are key preventive health programs designed to screen, detect, and manage these conditions. However, these screening programs report inconsistent follow-up rates [,], and many patients face barriers to sustaining lifestyle changes, including a lack of knowledge and inadequate community support [,]. In the United States, many cancer screening programs involve fewer than 75% of patients receiving some form of follow-up care []. In 2016, SingHealth, Singapore’s largest public health care cluster, reported that 1 in 4 individuals screened via community-based health screenings had not returned for a doctor’s follow-up after a year []. Loss to follow-up has significant physical and socioeconomic implications, including untreated chronic conditions, physical complications, reduced efficiency of the health care system, and increased financial costs [].

These patterns reveal a critical gap in how traditional screening models are designed, focusing on biomedical detection but often overlooking the motivational, relational, and digital drivers of health behavior change. Research increasingly points to the importance of psychosocial support and person-centered coaching, and digital enablement in facilitating sustainable health outcomes [,]. Community health volunteers, when appropriately trained, have demonstrated potential to complement health systems by engaging individuals, reinforcing health messages, and bridging gaps in service delivery [,]. Community health volunteers can be empowered to guide health screening participants in navigating the health system, increasing follow-up rates, setting specific health-related lifestyle goals, and adhering to them. Previous qualitative studies have shown the benefits of this approach, including improved person-focused coordinated care [], more seamless referrals to appropriate services [], and the promotion of healthy practices []. Experts recommend measuring indicators that predict the success of lay counselors [] and exploring their effectiveness in more complex tasks, such as diagnosis and counseling []. When designed and implemented appropriately, community-based health coaching has the potential to be a significant nonclinical intervention for individual and population health [], simultaneously improving the health literacy of health coaches undergoing training and that of the general public, and facilitating the adoption of healthy practices across generations []. Despite promising findings, the literature on community health volunteers remains largely focused on adult volunteers, with limited research examining the effectiveness of youth community health volunteers (YCHVs), particularly those aged 15‐35 years, in the context of community-based health interventions or screening programs. While youth involvement in aging and intergenerational initiatives is well-documented, many of these programs are broad in focus and do not center specifically on health promotion [-]. The World Health Organization defines youth as individuals aged 15‐25 years, but in Singapore, the Ministry of Culture, Community and Youth adopts a broader definition, classifying youth as those aged 15-35 years []. For the purpose of this study, we adopt the latter definition.

In tandem, digital literacy has emerged as a key determinant of access to health information and services, especially among older adults [,]. This is particularly salient in health systems such as Singapore’s, where national preventive health reforms promote primary care engagement and follow-up via digital platforms [,]. However, many seniors face barriers to adopting digital tools, such as limited confidence, lack of guidance, or unfamiliarity with technology [-]. These barriers risk exacerbating digital exclusion, potentially widening health disparities [,]. As such, there is an urgent need for community-based digital health support integrated with preventive health efforts. YCHVs may be well-positioned to address this dual challenge by providing motivation-based coaching alongside digital enablement.

HealthStart was developed as a response to these gaps. Anchored in Self-Determination Theory (SDT), the program aims to address the core psychological needs of autonomy, competence, and relatedness in health behavior change. HealthStart operationalizes these principles through intergenerational service learning, where YCHVs serve as health coaches guiding older adults through a structured journey of goal-setting and lifestyle change by equipping them with digital health tools and skills.

In this study, we evaluated HealthStart as both a service delivery model and a motivation-based intervention. We used a mixed methods design with independently collected quantitative and qualitative data during the same timeframe, integrated post hoc through joint analysis to assess its impact on primary care providers’ (PCP) follow-up rates, health goal attainment, self-efficacy, and digital and health literacy among older adults. We also explored the perspectives of key stakeholders, including YCHVs, health care volunteers (HCV), and participants, to understand the program’s feasibility, acceptability, and areas for refinement.

Methods

Conceptual Framework

HealthStart is an SDT-based intervention designed to support the Healthier SG initiative, the local government’s policy to promote healthier aging by reshaping the population’s health-seeking behaviors and lifestyle through collaborative, community-based care []. The national reform also emphasizes digital inclusion, aiming to enroll seniors with a PCP through the national digital health apps. The program aims to increase the engagement and follow-up rates of participants attending a chronic disease community health screening by developing, training, and empowering YCHVs to serve as health and digital advocates who accompany participants on their postscreening journey over 3 months.

SDT proposes that personally relevant goals are more internally motivated and are thus more likely to be obtained than goals set due to some external pressure []. It specifies 3 basic psychological needs (ie, autonomy, competence, and relatedness) that provide the basis for motivation and development and are the contextual conditions that facilitate internal motivation and help people integrate their behavior into their everyday lives and sense of self. Autonomy refers to the feeling that one’s actions are the result of one’s own volition, competence is the belief in one’s ability to effect change and achieve desired outcomes, and relatedness is the extent to which one feels a connection with others. Self-integration of behaviors occurs when externally motivated behaviors (ie, behaviors regulated by an external force) become integrated into one’s sense of self; that is, they contribute to one’s overall self-evaluation.

Autonomy is fostered through health coaching and the cocreation of health-related lifestyle goals using the SMART framework (Specific, Measurable, Achievable, Realistic/Relevant, and Time-bound) []. Competency is developed through health education, action planning, and real-time feedback, alongside digital enablement (eg, using health apps to schedule appointments, access results, and track lifestyle goals). Relatedness is cultivated through continuity of follow-up with a dedicated YCHV. These shared decision-making mechanisms constitute the hypothesized mediators linking program activities to behavioral and clinical outcomes.

HealthStart is also anchored on 2 complementary frameworks (intergenerational and service-learning frameworks). YCHVs are taught health knowledge and health coaching skills, which they apply through their interaction with older adults under the guidance of HCVs. This program builds on prior intergenerational program experiences []. It facilitates intergenerational transfer of health knowledge between the different participants by incorporating principles of contact theory (institutional support, equal status, cooperative interaction, and shared goals) []. In addition, HealthStart facilitates the intergenerational transfer of health knowledge when YCHVs share the knowledge and experience gained from the program with their families and communities []. The program uses a service-learning approach, combining learning objectives with community service to create a meaningful learning experience that addresses the needs of older adults in the community [,]. Volunteers’ learning and development are facilitated through guided critical reflection, grounded in Kolb’s experiential learning cycle, which links their community service experience to learning objectives [,]. Finally, HealthStart leverages key components of a previously described digital literacy program shown to be effective in helping older adults acquire digital skills (eg, personalizing digital skills taught according to participants’ goals, having a tiered curriculum, using an aide-memoire, and connecting participants to a digital community) [-].

The program’s theory of change is reflected in .

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Program Implementation

For the participants, the program consisted of a personal review of their health screening results, health goal setting with their assigned YCHVs, follow-up with their PCPs, and completion of their health goals over a 3-month duration. Throughout the process, HCVs oversaw the operations and provided avenues for content clarification and professional support as necessary. Each HealthStart group consisted of 1 HCV and 4 YCHVs. Each YCHV was assigned 2 participants.

To complete the HealthStart program, participants would need to fulfill the following criteria:

1. Enrollment with a PCP.
2. Learn about their chronic diseases with the aid of the Health Promotion Board booklets [].
3. Learn at least 1 digital health app, such as HealthHub, Healthy 365 [,].
4. Set a health-related lifestyle goal and achieve it.

The participants would first meet their YCHVs at a community event where health screening reports were distributed and explained by a community nurse. The YCHVs would conduct their first session of health coaching with the participants and build rapport via questions that covered sociodemographic factors and lifestyle aspects (exercise, smoking, alcohol intake, and dietary habits). YCHVs subsequently taught participants about their newly diagnosed chronic disease via Health Promotion Board educational materials [], guided them in the use of digital health apps [], assisted in setting up an appointment with a PCP through the use of the digital health app HealthHub, and supported the participants in setting a lifestyle goal. YCHVs followed up with their participants one-on-one longitudinally over a period of 3 months through in-person or virtual visits (ie, video calls) every fortnight, where they checked the participants’ progress, motivated them to achieve their goals, and ensured the fulfillment of the program’s 4 goals. YCHVs attended monthly meetings with HCVs to reflect on their intergenerational and service-learning experience. Further details of the program’s implementation are available in an earlier publication [].

Program Outcomes

The primary outcome of the program was residents’ enrollment with a PCP. The secondary outcomes include health goal attainment, self-efficacy, and digital and health literacy among older adults, as well as the acceptability of the program among stakeholders.

Study Design and Rationale

This study used a convergent parallel mixed methods design, guided by the framework proposed by Edmonds and Kennedy [], to evaluate the effectiveness and acceptability of the HealthStart program. Quantitative and qualitative program evaluation data were collected, analyzed, and interpreted simultaneously to develop comprehensive insights into the program’s mechanisms and outcomes.

Overall, 3 key considerations guided the selection of a mixed methods approach. First, while quantitative measures can capture concrete outcomes, such as follow-up rates and goal attainment, qualitative inquiry is essential to understand the relational and motivational mechanisms underlying these changes. Second, the implementation of a novel community health program required a rich contextual understanding, alongside outcome measures, to inform future scaling efforts. Third, the integration of multiple data types allowed us to examine how SDT operated in practice through both measurable outcomes and lived experiences. Both quantitative and qualitative strands were concurrently collected from the same cohort of participants and treated with equal priority in explaining the program’s outcomes.

To ensure quality and coherence across both strands, we applied the Good Reporting of A Mixed Methods Study (GRAMMS) checklist []. The checklist ensured adequate rigor in sampling, design, integration procedures, and comparison between data types. This quality appraisal validated the credibility of emergent meta-inferences and highlighted areas of strength, such as high fidelity in YCHV training and participant engagement.

Participants

Older adults aged 40 years and above who participated in the health screening, YCHVs aged 15‐35 years, and HCVs who participated in the program were eligible for the study. Individuals with medical comorbidities that affected their ability to communicate (eg, severe dementia) were excluded from the study. Individuals who could not speak English, Mandarin, Malay, or Tamil were also excluded.

Quantitative Data Collection and Analysis

Quantitative data collection took place between September 2022 and January 2024. All eligible older adults attending the health screening were invited to participate in the study. Data were collected at the start of the first health coaching session and at the end of the program through a digital survey administered by a trained volunteer or member of the research team via FormSG (Government Technology Agency of Singapore), a secure, encrypted, web-based government form with the following predesigned fields:

1. Sociodemographic variables: age, sex, race, marital status, highest education level, and residential type.
2. Primary outcome: follow-up with a primary care doctor, measured as “Yes” or “No.”
3. Secondary outcomes:
   • Knowledge questionnaire: a 12-item true or false questionnaire on chronic conditions that is an abbreviated version of the 15-minute chronic disease questionnaire [], adapted to the local context using information from the Health Promotion Board brochures.
   • Patient Activation Measure (PAM-13): a 13-item questionnaire measuring individuals’ ability to self-manage chronic disease through self-reported knowledge, skills, and confidence validated in the local context [].
   • eHealth Literacy Scale (eHEALS): an 8-item questionnaire assessing respondents’ perceived skills in using information technology for health [].
   • SMART [] health goal attainment: self-rated achievement of lifestyle goals, measured as a “Yes” or “No.”
   • Program satisfaction: “To what extent are you satisfied with the program?” with 4-level Likert scale response options (not at all satisfied, slightly unsatisfied, slightly satisfied, and very satisfied).

Descriptive statistics were computed for the study population. The program implementation fidelity was tracked by logging the number of volunteer-participant encounters and the electronic survey responses (including engagement mode, duration, and coaching elements delivered) along with the number of final assessments conducted. The McNemar test was used to examine differences in the proportion of primary care follow-up before and after the program. Pre- and postintervention differences in secondary outcomes were compared using paired t tests. One-way ANOVA and linear trend tests were used in the subgroup analysis to evaluate the relationships between the secondary outcomes and the number of follow-up visits the residents received. A binomial logistic regression was performed with primary care follow-up as the outcome variable and demographics and baseline questionnaire scores as the independent covariates. All the statistical analyses were performed via Stata (version 15, release 15; StataCorp, 2017). Statistical significance was set at P<.05.

Qualitative Data Collection and Analysis

Qualitative data were collected post-program through one-to-one, semistructured interviews with older adults, HCVs, and YCHVs. Purposive sampling was used to recruit older adults who completed the program and quantitative study, based on the following criteria to ensure the representativeness of each group: age, sex, race, education level, number of follow-up visits within the program, and postprogram primary care follow-up status. The entire cohort of HCVs and YCHVs was sampled; all HCVs and YCHVs who completed the program were approached and recruited for the study. The interview guides were formulated based on the theory of change to elicit perceptions of the program, the health advocacy process with older adults, and the volunteer training program (-).

The interviews were conducted between November 2023 and January 2024, either face-to-face or via Zoom Web Conferencing (Zoom Video Communications, Inc.), by 4 project team members who were trained and supervised by the qualitative lead coinvestigator. Each interviewer was trained in qualitative data collection techniques. All interviews were audio-recorded and transcribed using an automated transcription software service, and then reviewed by a project member to ensure verbatim accuracy and redact identifiable information. The 4 team members coded the transcripts using a deductive-abductive approach, focusing on perceptions of the program, the health advocacy process, and volunteer training, while allowing new themes to emerge. Thematic analysis, following the framework of Braun and Clarke [], was used by 4 coders to analyze the transcripts. After independently coding the transcripts, a secondary coder reviewed them to address discrepancies and finalize the coding. QSR NVivo 14 software (Lumivero) was used for data management and analysis. Data triangulation was used to identify areas where qualitative themes aligned with quantitative data findings on program implementation fidelity and program outcomes.

The 4 team members affiliated with the research and evaluation arm of the Division of Population Health and Integrated Care at Singapore General Hospital were involved in the qualitative study. All of them are public health researchers or researchers-in-training with an interest in community health, and they acknowledged that their institutional roles and prior involvement in the program may have influenced the interpretation of the findings. To enhance reflexivity, interviewers engaged in pre- and postinterview debriefs, used semistructured guides to maintain consistency, and had responses cross-checked by multiple investigators to surface diverse perspectives. The team members remained attentive to potential power dynamics, reassured participants that their views would be received openly, and critically interrogated their positionality throughout data collection, analysis, and reporting to mitigate bias.

Data Integration

The data analysis and integration process occurred in 3 phases (). Quantitative and qualitative data were collected from the same cohort of participants in the same phase of the study. Regular meetings between project team members established preliminary findings from each strand. Thereafter, in the integration phase, joint displays were developed to map qualitative themes to quantitative outcomes, and patterns of convergence and divergence were systematically examined. Meta-inferences were generated with particular attention to how qualitative findings explained variations in quantitative outcomes. Validity was enhanced via iterative checks on integrated interpretations.

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Quality assurance measures included the application of the Good Reporting of A Mixed Methods Study (GRAMMS) [], regular team meetings to discuss emerging patterns, an independent review of integration conclusions, and systematic documentation of integration decisions. This rigorous approach to integration enabled us to develop a more nuanced understanding of program mechanisms than would have been possible through either method alone.

Ethical Considerations

This project received approval from the SingHealth Centralised Institutional Review Board (CIRB reference number 2022/2700). All participants provided informed consent and were given a participant information sheet. Parental consent was obtained for participants below the age of 21 years. Individuals who took part in the qualitative interviews received a reimbursement of US $23. All quantitative and qualitative data collected were deidentified and stored on a set of electronic devices that were only accessible by the evaluation team. No data related to any individual, in any form, are included in this publication.

Results

Overview

HealthStart reached out to 192 older adults via 33 HCVs and 102 YCHVs over 2 health screening cycles conducted in 2022 and 2023, respectively. A total of 424 participants underwent the community health screening program, with 192 of them being eligible and subsequently recruited for the study. illustrates the flowchart of the program participants. Among the 192 study participants, 158 completed the study. The demographics of the study participants are summarized in . The mean age of the study participants was 66.9 (SD 9.6) years, and the sex distribution was approximately equal. Most of the participants were of Chinese ethnicity, had completed primary or secondary school, and resided in self-owned flats. A total of 36 semistructured interviews were conducted with older adults, HCVs, and YCHVs, achieving thematic saturation. The characteristics of the subjects can be found in .

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Integrated Program Outcomes

Our mixed methods analysis revealed substantial program impacts across multiple domains, with strong convergence between quantitative outcomes and qualitative insights. The integration of findings provided a deeper understanding of the program’s mechanisms and contextual factors influencing its effectiveness. We present these findings through an integrated analysis of each outcome, highlighting areas of convergence and divergence between data types.

PCP Follow-Up

Quantitative analysis demonstrated a significant improvement in PCP follow-up, increasing from 42.7% to 84.5% (χ²₁=43; P<.001). This effect was particularly pronounced among older adults (OR 1.8, 95% CI 1.2‐2.7) and participants from minority ethnic groups (OR 1.6, 95% CI 1.1‐2.3).

Qualitative findings supported these findings. Older adults credited YCHVs with demystifying health screening results, reinforcing the importance of follow-up with a primary care doctor, and providing support that bolstered their commitment to seeing a doctor. This had a specific impact on often underserved groups of older individuals and minority ethnic groups, many of whom were not connected to primary care to begin with. One participant shared:

(YCHV) asked me to see [a] doctor… Then I go to poly(clinic), then I go check and take the medicine, cholesterol medicine, I take. Before that I never take. Before that (health screening) I never thought to see [a] doctor…
[OA13, Female, 60-70 years]

The integration of quantitative and qualitative data suggested that the relationship-based support model was instrumental in overcoming traditional barriers to health care access. YCHVs served as cultural bridges, combining practical assistance, such as appointment scheduling and reminders with emotional support. In doing so, they enhanced participants’ sense of competence in managing health information and navigating the system, while fostering autonomy by encouraging informed and self-directed health care choices. This finding was particularly notable among participants who had previously reported low engagement with the health care system.

Health Behavior Change and Goal Attainment

A dose-response relationship was observed between the number of YCHV follow-up sessions and SMART goal attainment. A statistically significant linear-by-linear trend (Z=2.44; P=.02) was observed between health goal achievement and those with none (58.46%), 1 (65.91%), or 2 or more (87.5%) YCHV follow-up visits. A total of 66.2% (92/139) of participants achieved their health goals, and 81.3% (113/139) reported satisfaction with the program. There were no statistically significant changes in the scores before and after the intervention for knowledge (t₁₉₀=0.418; P=.68) and PAM-13 (t₁₉₀=−1.99; P=.05). There were no statistically significant changes in knowledge (F_2,130=0.61; P=.54) or PAM-13 scores (F_2,130=2.07; P=.13) via one-way ANOVA between groups stratified by the number of YCHV follow-up visits received.

Qualitative findings supported and deepened the understanding of these results. The participants mentioned achieving various lifestyle changes, including reducing the intake of unhealthy foods, increasing the consumption of healthier dietary options, and engaging in more physical activity. They reported additional health benefits that were not captured in the quantitative outcomes, such as weight loss, improvements in health markers, and an overall sense of well-being. While some older adults were unable to articulate specific facts on chronic diseases, this did not hinder their understanding of the importance of adopting healthier lifestyle choices. These behavior changes were often framed as internally motivated, goal-oriented efforts, consistent with HealthStart’s SDT framework. One participant described:

Eating vadai (savory Indian fried snack) … my favorite…I cut down a lot. One day Roti Prata (fried Indian flatbread) I also cut down eh… I think I changed a lot… What they told me I just listen, just keep in mind what they told me, just try my best… I feel that consulting with [YCHV], I feel [I had learnt] something
[OA02, Male, 60-70 years]

While many participants credited YCHVs for facilitating conversations that increased their awareness of healthy habits and motivation to make meaningful changes in their daily routines, specific measures or support systems to improve confidence and efficacy in managing one’s health were lacking for some participants. One participant described:

…about setting targets, there is no point… It is like I am in school and the teacher asked you to follow the timetable, would you?.,. If the patient doesn’t follow, it is of no use as well
[OA10, Male, 60-70 years]

Meta-inference development identified 3 key mechanisms of behavior change: (1) relationship-based accountability, (2) culturally contextualized health messaging, and (3) practical problem-solving support. These mechanisms were consistently present in successful cases, with more that can be done in the area of practical measures and support systems, as evidenced by both quantitative goal achievement data and qualitative narratives.

Digital Health Literacy and Technology Adoption

Analysis of eHealth Literacy Scale (eHEALS) scores revealed a threshold effect in smartphone health app adoption via follow-up visits by YCHVs. While there was a statistically significant increase in eHEALS scores in the groups that experienced more follow-up sessions, as determined by one-way ANOVA (F_2,130=6.06; P=.003), the Tukey post hoc test revealed a statistically significant increase in eHEALS scores in those with more than 1 YCHV follow-up (mean 30.4, SD 8.4; P=.002) compared with those with no follow-up (mean 23.5, SD 8.4) and no significant difference between those with more than 1 YCHV follow-up and those with only 1 YCHV follow-up (mean 26.3, SD 8.7; P=.15). Qualitative data deepened understanding in this area. While there were many participants who already had health apps on their phones and felt there was no significant impact from the program, a number were introduced and oriented to apps of practical use for scheduling appointments with PCPs, tracking, and accomplishing health goals, which they found beneficial.

The integration of findings suggested that digital health adoption followed a threshold effect, with meaningful improvements occurring only after onboarding, establishing rapport, and providing hands-on guidance.

Stakeholder Experiences and Program Implementation

Overall, 81.3% (113/139) of the residents reported feeling “Satisfied” or “Very Satisfied” with the program. A summary of the above outcomes can be found in .

Qualitatively, older adults appreciated the program for several reasons, including the health knowledge and benefits gained, the support from YCHVs in achieving their health goals, the meaningful connections formed, the opportunity to participate free of charge, and the promotion of healthier lifestyles for both younger and older Singaporeans. The majority of YCHVs expressed that being a lay health volunteer was fulfilling and enriching. Many valued the meaningful connections formed with older adults, the ability to impact their health positively, and the opportunity to acquire health knowledge and interpersonal skills. Most YCHVs reported that they were keen to volunteer again in the program and would encourage their peers to participate. HCVs are also encouraged by YCHVs’ ability to impact older adults’ health positively and to have the opportunity to mentor them as effective health advocates.

Integration with quantitative satisfaction data revealed that program acceptability was linked to the quality of YCHV-participant relationships and the practical value of health coaching support. The joint analysis of both data types suggested that program success depended on both technical competence and interpersonal effectiveness of YCHVs.

presents a joint display integrating quantitative results and qualitative themes. Meta-inferences generated through convergence and divergence analysis highlight the mechanisms of change observed in the HealthStart program, particularly the motivational impact of YCHVs’ coaching in reinforcing autonomy, competence, and relatedness.

Participants who dropped out of the program were analyzed to identify differences between those who completed the program and those who did not. Participants who dropped out of the program were statistically younger in age and had higher baseline PAM-13 scores (Table S5 in ). Individuals with higher baseline confidence in self-managing their health may not perceive the immediate benefits of the program and may therefore experience a higher dropout rate.

Discussion

Principal Findings

This mixed methods evaluation of HealthStart demonstrated that a structured, layperson-led, intergenerational health coaching intervention program was both feasible and acceptable to older adults and YCHVs, and effective at improving primary care follow-up rates and supporting behavior change. Our analysis revealed both the measurable impacts of the intervention and the underlying mechanisms that facilitated these changes, while also highlighting important considerations for future community health initiatives.

Primary Outcome

The postprogram PCP follow-up rate was 84.5%, higher than previously reported rates in health screening programs [,], with a significant increase among older participants and minority ethnicities. Older adults and minority race groups have been shown to have lower screening follow-up rates than younger age and majority race groups in previous studies []. HealthStart deliberately linked YCHVs with older adults who spoke the same mother tongue and provided an educational booklet in the older adult’s mother tongue to facilitate accessibility, communication, and understanding, which likely helped reduce age and racial inequity. This finding is consistent with those from similar community health initiatives [], which underscore the importance of culturally and linguistically appropriate support.

Integrating Study Findings With the Theory of Change

By mapping quantitative outcomes onto the Theory of Change and examining qualitative data for mechanisms of action, we offer insight into why HealthStart achieved its desired outcomes.

Setting a lifestyle goal was a mandatory requirement for all participants. The health goal attainment rate was 66.2%, with individuals being more likely to achieve them if they had more YCHV follow-ups; the majority of goals centered on improving one’s diet or physical activity. A total of 54.5% of a group of 33 participants achieved their set health goal in a previous community outreach health coaching program conducted by certified health coaches in Missouri []. This study revealed similar rates of health goal attainment among older adults who received abnormal health screening results, with their postscreening journey facilitated by YCHVs. The qualitative findings highlighted a key takeaway of the program being understanding, planning for, and achieving healthy lifestyle changes, facilitated by health coaching. As encompassed by the SDT framework [], the program built on residents’ autonomy through individualized goal-setting and competence through health knowledge, self-efficacy, and digital health literacy to achieve health-related lifestyle changes.

Sharing knowledge about their health condition, tips on how to manage it, and onboarding relevant health digital apps was a core component of the curriculum YCHVs underwent and subsequently engaged participants with during their service in HealthStart. While there was no significant change in the pre-post scores in knowledge, qualitative analysis revealed that participants shared increased awareness and practice of healthy habits in domains such as diet and exercise. The participants in this study were noted to have high baseline knowledge (8.81/12, SD 1.58) and high baseline PAM-13 scores (68.8/100, SD 1.56), reflecting readiness to adopt new behaviors but potentially having difficulty sustaining change. The lack of a statistically significant difference could also reflect a ceiling effect of both scores []. Additionally, research shows that only specific aspects of higher level health literacy, such as communicative and critical health literacy, are associated with health-related lifestyle behaviors []. A knowledge score on general chronic conditions may not have reflected this change that occurred in participants. The qualitative analysis also revealed areas in which the program could be improved in supporting participants’ confidence and self-efficacy. A key recommendation was to consider social prescription, a structured system that allows YCHVs to link participants to community resources that can better support and sustain their goals for healthy living [], which is planned to be implemented in future iterations of the program.

While there was no significant overall improvement in digital health literacy scores, subgroup analysis showed improvement among those with ≥1 YCHV follow-up (F_2,130=6.06; P=.003). The findings suggest that onboarding digital health apps may be sufficient to impact health behavior. The qualitative findings support this; several participants set goals to learn digital health apps so that they could track their health-promoting behaviors or connect with a group or health system to sustain healthy behaviors. Previous research corroborates the need for initial support and familiarization with digital apps for older adults, as this lowers the barrier for adoption of digital health, which in turn can reshape health-seeking behaviors and lifestyles [,]. Therefore, the integration of digital health coaching into HealthStart reflects not only a programmatic innovation but also a response to national and global priorities around digital inclusion for older adults. As platforms like HealthHub become increasingly central to Singapore’s preventive health ecosystem, programs like HealthStart offer a scalable and person-centered model to bridge the digital divide and empower seniors to take greater ownership of their health.

Our findings substantiate HealthStart’s Theory of Change and its SDT underpinnings. Participants’ narratives highlighted the 3 SDT psychological needs, increased autonomy, competence, and relatedness, which are associated with sustained behavior change and health engagement. The increase in PCP follow-up rate was primarily influenced by individually tailored goal setting and relationship building, which leveraged motivational interviewing to support intrinsic motivation. The program’s primary outcome was, to a lesser extent, influenced by digital health onboarding and possibly improvements in health awareness and practices. Participants’ self-efficacy could have been enhanced with a structured social prescription framework.

Acceptability and Feasibility

High satisfaction scores were reported by older adults participating in the program (81.3%), and qualitative reports demonstrated the acceptability and appreciation for the program from both volunteers and older adults. YCHVs felt it was a rich experience and expressed interest in volunteering in similar programs again. Older adults valued the new health insights gained and reported improvements in their health and lifestyles. A qualitative study in Canada, which integrated community volunteers as extensions of the primary care team to support older adults, yielded similar findings. These community volunteers deepened the primary care team’s understanding of their patients and facilitated the delivery of person-centered care, demonstrating the potential for integrating community volunteers into the primary care setting []. A separate study conducted in Canada revealed that community volunteers can play a role in increasing older adults’ understanding of community resources and navigating the system []. YCHVs are potentially untapped resources that can effectively engage and promote healthier living among older adults.

Given the effectiveness, acceptability, potential reach, and adoption of HealthStart, the evaluation demonstrates the potential to scale community programs involving laypersons in population health initiatives []. Program sustainability is further strengthened by collaborative work with local grassroots organizations and alignment with the national strategic context of promoting healthier aging []. However, our findings also highlight the importance of adequate volunteer training, attention to cultural and linguistic matching, and the potential application of a structured social prescription framework based on individualized preintervention health and social needs to promote sustainable health behaviors.

Strengths and Limitations

This study’s mixed methods approach is a notable strength, allowing triangulation of data to capture both the breadth and depth of HealthStart’s impact, including experiences that standard instruments cannot easily quantify. However, this study has several limitations. First, the observed improvements could not be attributed to the program due to the absence of a control group. More rigorous designs, such as quasi-experimental or step-wedge trials, can be considered in future research to establish causality. Second, the majority of the studies’ quantitative outcomes were based on self-reported scales. This may not have adequately captured the depth and nuance behind participants’ motivation and progress as described in the qualitative arm. Future studies may adopt a sequential design with follow-up qualitative research conducted for each quantitative finding and corroborate the findings with other objective data, such as electronic medical records, biometric measures (eg, blood pressure, weight, and HbA_1c), field observations, and multimodal assessments, including neurophysiological changes, cognitive, behavioral outcomes, and integration of caregiver perspectives as secondary informants that enhance understanding of health impact to older adults beyond traditional measures []. Additionally, selection bias may be present in YCHVs who completed the program, potentially influencing overall program outcomes such as goal achievement, participant, and volunteer satisfaction.

Conclusions

This study demonstrated the feasibility of using YCHVs and SDT principles to improve PCP follow-up rates and promote healthier lifestyles among older adults participating in community health screening. The high acceptability of this model among stakeholders highlights the potential of harnessing laypersons, an untapped and valuable community resource, in population health initiatives.