This study used an implementation-focused case study design to examine the feasibility, operational processes, and outcomes of the HealthStart program over 2 cycles between September 2022 and June 2023. Quantitative and qualitative data were collected to describe participant outcomes and volunteer deployment. The study followed the StaRI (Standards for Reporting Implementation Studies) checklist and the TIDieR (Template for Intervention Description and Replication) extension for complex interventions [14,15].

HealthStart is an initiative by TriGen Ltd [16], a nonprofit organization in Singapore, in collaboration with the Singapore General Hospital Division of Population Health and Integrated Care. The Singapore General Hospital Division of Population Health and Integrated Care is responsible for the population health needs of the approximately 300,000 residents living in the Southeast region [17] and conducts health screening in the community as part of the government’s “Screen for Life” initiative [18]. Individuals aged 40 years and older are invited to attend health screenings conducted in community spaces such as community centers or active aging centers. After undergoing the health screenings, those with ≥1 newly detected or suboptimally controlled chronic condition were invited to participate in the HealthStart program.

HealthStart is a layperson-led health coaching program grounded in self-determination theory (SDT), incorporating the SMART (Specific, Measurable, Achievable, Realistic/Relevant, and Time-bound) framework for goal setting, and delivered through an intergenerational service-learning model. SDT postulates that there are 3 innate psychological needs—competence, autonomy, and relatedness—which, when satisfied, yield enhanced self-motivation and, when thwarted, lead to diminished motivation and well-being [19]. Goal setting via the SMART framework has been theorized to facilitate behavior change by assisting individuals in defining clear and actionable goals [20]. HealthStart aims to increase the engagement and follow-up rates of participants attending a chronic disease community health screening by developing, training, and empowering CHVs to serve as health coaches. Over a 3-month period, CHVs support participants in their journey to improve their health. The program is designed to promote participants’ autonomy by allowing them to identify goals that are important to them and develop personalized action plans. It enhances competency through SMART goal setting and motivational interviewing, which is taught to all CHVs [21]. Finally, the program’s longitudinal and relational nature emphasizes building connections and fulfilling participants’ need for relatedness.

Volunteer training in HealthStart is anchored upon an intergenerational and service-learning approach. Intergenerational theory focuses equal attention on the potential development of all members of each intergenerational dyad to learn as a function of social interaction [22]. Contact theory, a widely cited theory guiding intergenerational program development and study, describes 4 main tenets that increase the likelihood that people will experience positive contact: support of governing bodies, equal group status, intergroup cooperation, and common goals. Service learning encompasses the teaching approach that connects theory and practice by giving learners the opportunity both to participate in a service that meets community needs and to reflect on the experience to gain a deeper understanding and an enhanced sense of civic engagement [23]. Youth CHVs have the opportunity to acquire health care and caregiving skills that could improve their own health and promote transfer of this health-promoting knowledge to their own communities. In the design of the HealthStart program, we built upon the aforementioned frameworks and lessons learned from a previous intergenerational program that was demonstrated to increase health literacy and reduce ageist attitudes [11]. HealthStart activates 2 additional contact theory principles. Equal status is fostered by training all volunteers together and holding them jointly accountable for participant outcomes, while cooperation toward shared goals is achieved when youth CHVs and participants co-create individualized action plans. Throughout the 3-month journey, HCVs serve as clinical mentors, providing guidance while enabling youth CHVs to lead participant engagement.

SDT served as the overarching framework, providing the central mechanism for fostering self-directed, value-driven motivation. Within this framework, contact theory was used to promote equal-status interactions, service-learning pedagogy to encourage civic engagement, and the transtheoretical model to guide stage-matched health coaching. These components were deliberately integrated into a unified theory of change, with each reinforcing the others, to inform both volunteer training and participant-facing activities and ensure a synergistic approach to sustaining behavior change (see Figure 1).

Each HealthStart group consists of 1 HCV and 4 youth CHVs who commit to a period of 3 months. Each youth CHV is required to attend the HealthStart training day and is assigned 2 participants subsequently. They are expected to follow up with participants through either physical or internet-based visits (see Figure 2). With each visit, youth CHVs are required to monitor participants’ progress toward their health goals. HCVs oversee the teams, provide avenues for content clarification, and professional support as necessary. This multimodal, layperson-led health coaching aims to facilitate participants’ need for competence (via greater knowledge about their condition and health-efficacy and increased eHealth knowledge), relatedness (via continual interaction with volunteers and health care professionals), and autonomy (via SMART goal setting).

Participants’ baseline health literacy and digital skills were assessed during the initial layperson-led health coaching session using the HealthStart First Visit Form (Multimedia Appendix 1). This structured form captured participants’ understanding of their chronic conditions, experience with digital devices, familiarity with health apps (eg, Healthy365 by the Health Promotion Board), and self-reported confidence in managing their health. The form also captured social history and lifestyle behaviors to guide personalized goal setting. These baseline assessments enabled youth CHVs to tailor their coaching approaches according to each participant’s readiness, capacity, and specific areas of support required.

Youth CHVs support participants to fulfill the following objectives through the HealthStart program:

The participants first meet their youth CHV at a community event where health screening reports are distributed and explained by a community nurse. The youth CHVs then conduct their first session of layperson-led health coaching with the participants and build rapport via questions that cover sociodemographic factors and lifestyle aspects using tools such as a Time Wheel and a Healthy Plate (see Multimedia Appendix 1) to guide SMART goal setting.

Youth CHVs follow up with their participants longitudinally over a period of 3 months through in-person or internet-based visits (ie, video calls) every fortnight (for a minimum of six visits). They use online forms (form.sg) to track the participant’s progress through HealthStart. By fostering meaningful relationships and using motivational interviewing techniques, youth CHVs guide participants in aligning their core values and purpose with their health aspirations, facilitating deeper self-integration.

Youth CHVs also provide digital literacy training using components from a previously described program [8-10]. After teaching the basics of using a smartphone or alternative digital devices, HCVs will guide their participants to download and use health apps to achieve Objective 2 of HealthStart as described above. This is further described in Multimedia Appendix 1 (see volunteer protocol). To close the digital divide, specific guidance is provided to youth CHVs to help participants without digital devices (see Annex S7 in Multimedia Appendix 1). Youth CHVs are provided a step-by-step guide on what to do during each visit (see Table S1 in Multimedia Appendix 2).

Participants who complete the above goals may be discharged from the program before the 3-month mark. When this occurs, youth CHVs are offered the opportunity to take on additional participants. In addition, those with greater experience are encouraged to support more than 2 participants if they are willing. A total of 10%‐20% of youth CHVs return as recurrent volunteers, gradually building a pool of experienced CHVs that expands the program’s scale and capacity. HCVs and youth CHVs convene monthly to reflect on their intergenerational and service-learning experience. During these meetings, youth CHVs report on their participants’ progress, while the HCVs provide guidance and advice.

Quantitative data were collected between September 2022 and June 2023. For older adult participants, data were obtained at program entry and at the 3-month endpoint using a secure FormSG digital survey administered by trained volunteers. Variables included sociodemographic, primary care follow-up status, and open-ended program feedback.

Quantitative and qualitative feedback from volunteers (CHVs and HCVs) was collected at three milestones: (1) completion of training, (2) the youth CHV’s first participant meeting, and (3) program conclusion. After-action reviews involving the organizing team and community partners were conducted at each milestone, with minutes taken and subsequently analyzed alongside volunteer and participant feedback to identify key themes.

Quantitative analyses were conducted using SPSS Statistics (version 27; IBM Corp). The primary outcome was the change in primary care follow-up status before and after participation in HealthStart. Descriptive statistics were reported with SD for calculated means and with percentages for absolute numbers. The McNemar test was used to assess paired categorical data. Missing data was handled via listwise deletion; no imputation methods were applied.

Fidelity was monitored at various levels: (1) volunteer training completion and pass rates, (2) logging of all volunteer-participant encounters on the electronic survey platform (capturing mode, duration, and coaching elements delivered), (3) cumulative visit counts per participant, and (4) participant attrition at various stages of the program. Program fidelity and outcomes will be reported in detail in a separate mixed-methods outcomes paper.

Ethics approval was obtained from the SingHealth Centralized Institutional Review Board (CIRB references 2022/2700 and 2023/2480). All participants provided informed consent and were given a participant information sheet. All data were anonymized and deidentified in the study. No compensation was provided to the participants.

HealthStart was implemented alongside 2 community health screening events in 2022 and 2023. Of 236 eligible individuals, 192 enrolled (79%). The mean age of the participants was 66.9 (SD 9.6) years; 47.9% (92/192) were male and 52.1% (100/192) female. Most participants were of Chinese ethnicity, had completed primary or secondary school education, resided in self-owned flats, and in 3-room public housing (see Table 1).

Follow-up rate with primary care increased from 42.7% (82/148) preprogram to 84.5% (125/148) postprogram (χ²₁=43; P<.001). In models adjusting for demographics and baseline questionnaire scores, effects were greater for older adults (odds ratio [OR] 1.8, 95% CI 1.2‐2.7) and minority ethnic groups (OR 1.6, 95% CI 1.1‐2.3). Postprogram feedback was submitted by 109 participants, including open-ended responses.

Across two cycles, 207 volunteers were recruited (58 HCVs and 149 youth CHVs). Following training, 48 HCVs and 138 youth CHVs were assessed for deployment readiness. Ultimately, 33 HCVs and 102 youth CHVs were deployed. Nondeployment (15 HCVs and 36 youth CHVs) reflected nonattendance, role-expectation mismatch, or suboptimal formative assessment performance (see Multimedia Appendix 1). Figure 3 summarizes the number of volunteers at each stage of the program (recruitment, training, and deployment). The mean age of the HCVs was 37 years, 24 (72.7%) were female. A total of 26 were nurses, 6 were doctors, and the rest were allied health professionals. The mean age of the CHVs who were deployed was 24 years, and 75 (73.5%) were female. A total of 58 (56.9%) CHVs were students, and the majority were postsecondary students. In addition, 31 volunteers provided postprogram feedback.

HealthStart demonstrates the feasibility of an intergenerational, layperson-led health coaching model embedded in primary care. Engaging youth CHVs with no previous health care experience (an underused resource in the community) was associated with substantial gains in primary care follow-up. Integration of SDT, SMART goals, and service-learning concepts provided a coherent framework for participant engagement and volunteer development. Participation of youth CHVs has the additional benefit of improving their adoption of healthy behaviors and diffusing health knowledge within their own communities, amplifying the impact of the program.

There has been growing interest in the potential of laypersons as health coaches [35]. Peer-led programs such as the Whole Health Action Management (WHAM) model have increased patient activation among adults with behavioral health conditions, outperforming a clinician-delivered self-management program [36]. Among college students, an 8-week peer-coaching intervention raised physical activity, positive affect, and overall well-being [37]. Smartphone-enabled coaching by nonclinicians has also lowered HbA_1c in type 2 diabetes [38].

HealthStart extends these peer-coaching models by adding an intergenerational component, which fosters social cohesion, empowers and expands the scope of volunteers, and introduces mentorship and guidance of these laypersons by the health care professionals. By layering structured goal setting, social prescribing, and digital health coaching onto this intergenerational platform, HealthStart addresses gaps—particularly digital literacy deficits—seldom tackled in earlier lay-coach designs.

Study protocols are being developed evaluating the comparative effectiveness of health coaching by laypersons versus health care professionals; HealthStart’s model may inform such evaluations [39,40].

The study has several limitations. First, the study was conducted within a specific geographical region in Singapore, which may limit its generalizability to other cultural or health care settings. Differences in population demographics and community engagement practices could influence the feasibility and effectiveness of similar programs elsewhere.

Second, the recruitment and retention of youth CHVs posed a challenge. Despite rigorous selection and training processes, a proportion of youth CHVs were found to be unsuitable for deployment, requiring additional training or reassignment to other roles. As a relatively new field, layperson-led health coaching programs are challenged by the lack of a structured framework, reimbursement, and community coalition [41].

Third, the study relied on self-reported outcomes from participants and volunteers, which may introduce response biases, particularly social desirability bias. Although objective measures such as enrollment with a primary care provider were tracked, triangulation with objective metrics was not feasible in this pilot due to limitations in data sharing agreements and system interoperability.

Finally, the absence of a control group limits causal inference. Improvement in primary care follow-up seen may reflect the effect of concurrent initiatives such as HSG.

Building on initial learnings, the next phase of HealthStart will focus on improving scalability, integration, and evaluation rigor.

First, integration with national platforms under HSG will be deepened through formalized referral pathways and alignment of volunteer coaching with individualized health plans. Greater data connectivity will be pursued to enable linkage with electronic medical records and backend analytics (eg, HealthHub and Healthy365) for more robust outcome tracking.

Second, a structured social prescribing framework will be introduced. This includes enhanced baseline assessments to identify social needs (eg, isolation and financial insecurity), and a digital tool to guide volunteers in referring participants to community resources.

Third, comparative research will examine the effectiveness of youth-led versus professional-led coaching models, as well as the cultural adaptability of HealthStart across diverse settings. Digital adaptations for multilingual, underserved populations will also be explored to extend program reach and promote health equity.

Finally, to sustain scale-up, efforts will focus on reducing coordination burden via digital tools and supporting volunteer retention through micro-incentives (eg, digital badges and learning credits), structured recognition, and clearer role progression. Cost-effectiveness analyses and workforce planning will be essential to assess the long-term viability of integrating layperson-led coaching into primary care. These have to be tailored to the resource demands and contextual constraints of the specific community.

HealthStart demonstrates the feasibility and promise of a structured, intergenerational, layperson-led health coaching model integrated within a primary health system. Designed with a foundation in behavior change theory, aligned with community needs, and supported by digital health tools, the program addresses key barriers to chronic disease follow-up. We identified key lessons learned in the conceptualization and implementation of the program. These insights may support efforts to replicate this model of care across diverse health systems.