Cost-effectiveness of the SLIMMER diabetes prevention intervention in Dutch primary health care: economic evaluation from a randomised controlled trial.

BACKGROUND: Although evidence is accumulating that lifestyle modification may be cost-effective in patients with prediabetes, information is limited on the cost-effectiveness of interventions implemented in public health and primary health care settings. Evidence from well-conducted pragmatic trials is needed to gain insight into the realistic cost-effectiveness of diabetes prevention interventions in real-world settings. The aim of this study is to assess the cost-effectiveness of the SLIMMER lifestyle intervention targeted at patients at high risk of developing type 2 diabetes compared with usual health care in a primary care setting in the Netherlands. METHODS: Three hundred and sixteen high-risk subjects were randomly assigned to the SLIMMER lifestyle intervention or to usual health care. Costs and outcome assessments were performed at the end of the intervention (12 months) and six months thereafter (18 months). Costs were assessed from a societal perspective. Patients completed questionnaires to assess health care utilisation, participant out-of-pocket costs, and productivity losses. Quality Adjusted Life Years (QALY) were calculated based on the SF-36 questionnaire. Cost-effectiveness planes and acceptability curves were generated using bootstrap analyses. RESULTS: The cost-effectiveness analysis showed that the incremental costs of the SLIMMER lifestyle intervention were €547 and that the incremental effect was 0.02 QALY, resulting in an incremental cost-effectiveness ratio (ICER) of €28,094/QALY. When cost-effectiveness was calculated from a health care perspective, the ICER decreased to €13,605/QALY, with a moderate probability of being cost-effective (56% at a willingness to pay, WTP, of €20,000/QALY and 81% at a WTP of €80,000/QALY). CONCLUSIONS: The SLIMMER lifestyle intervention to prevent type 2 diabetes had a low to moderate probability of being cost-effective, depending on the perspective taken. TRIAL REGISTRATION: The SLIMMER study is retrospectively registered with ClinicalTrials.gov (Identifier NCT02094911) since March 19, 2014.

Effectiveness of the MetSLIM lifestyle intervention targeting individuals of low socio-economic status and different ethnic origins with elevated waist-to-height ratio.

OBJECTIVE: To evaluate whether the lifestyle intervention MetSLIM targeting individuals of low socio-economic status of Turkish, Moroccan and Dutch origin was successful in improving waist circumference and other cardiometabolic risk factors, lifestyle behaviour and quality of life. DESIGN: A quasi-experimental intervention study (Netherlands Trial Register NTR3721). The intervention group participated in a 12-month combined dietary and physical activity programme. Examinations were performed at baseline and after 12 months. Participants underwent anthropometric measurements and blood withdrawal, and completed questionnaires on dietary intake, physical activity and quality of life. SETTING: Socio-economically deprived neighbourhoods in two Dutch cities, involving non-blinded ethnicity-matched and gender-matched research assistants, dietitians and sports instructors. SUBJECTS: Mainly Turkish (49 %) and Dutch (36 %) subjects, aged 30-70 years, with a waist-to-height ratio of >0·5 (intervention, n 117; control, n 103). Dropout was 31 %. RESULTS: At 12 months, the intervention group showed greater improvements than the control group in waist circumference (ß=-3·3 cm, 95 % CI -4·7, -1·8, P<0·001) and other obesity measures. Additionally, greater reductions were observed for total cholesterol (ß=-0·33 mmol/l, 95 % CI -0·56, -0·10, P=0·005) and LDL cholesterol (ß=-0·35 mmol/l, 95 % CI -0·56, -0·14, P=0·001). Dietary changes were significant for fibre intake (ß=1·5 g/4184 kJ (1000 kcal), 95 % CI 0·3, 2·7, P=0·016). Compared with the control group, the intervention group reported a decrease in total minutes of physical activity (ß=-573 min/week, 95 % CI -1126, -21, P=0·042) and showed improvements in the quality-of-life domains 'health transition' and 'general health'. CONCLUSIONS: MetSLIM was shown to be effective in improving waist circumference, total and LDL cholesterol, and quality of life among Dutch and Turkish individuals living in deprived neighbourhoods.

A lifestyle intervention study targeting individuals with low socioeconomic status of different ethnic origins: important aspects for successful implementation.

BACKGROUND: Evaluation of the implementation process of trials is important, because the way a study is implemented modifies its outcomes. Furthermore, lessons learned during implementation can inform other researchers on factors that play a role when implementing interventions described in research. This study evaluates the implementation of the MetSLIM study, targeting individuals with low socioeconomic status of different ethnic origins. The MetSLIM study was set up to evaluate the effectiveness of a lifestyle programme on waist circumference and other cardio-metabolic risk factors. The objective of this evaluation was to identify components that were essential for the implementation of the MetSLIM study and to inform other researchers on methodological aspects when working with inadequately reached populations in health research. METHODS: In this evaluation study the experiences of health professionals, study assistants, a community worker and regional research coordinators involved in the MetSLIM study were explored using semi-structured interviews. Questionnaires were used to evaluate participants' satisfaction with the lifestyle intervention. RESULTS: Our analyses show that a flexible recruitment protocol eventually leads to recruitment of sufficient participants; that trust in the recruiter is an important factor in the recruitment of individuals with low socioeconomic status of different ethnic origins; and that health professionals will unavoidably shape the form of intervention activities. Furthermore, our evaluation shows that daily practice and research mutually influence each other and that the results of an intervention are a product of this interaction. CONCLUSIONS: Health promotion research would benefit from a perspective that sees intervention activities not as fixed entities but rather as social interaction that can take on numerous forms. Analysing and reporting the implementation process of studies, like in this evaluation, will allow readers to get a detailed view on the appropriateness of the (intended) study design and intervention for the targeted population. Evaluation studies that shed light on the reasons for adaptations, rather than describing them as deviation from the original plan, would point out methodological aspects important for a study's replication. Furthermore, they would show how various factors can influence the implementation, and therewith initiate a learning cycle for the development of future intervention studies. TRIAL REGISTRATION: Netherlands Trial Register NTR3721 (since November 27, 2012).

Exploring strategies to reach individuals of Turkish and Moroccan origin for health checks and lifestyle advice: a mixed-methods study.

BACKGROUND: Low participation rates among ethnic minorities in preventive healthcare services are worrisome and not well understood. The objective of this study was to explore how adults of Turkish and Moroccan origin living in the Netherlands, aged 45 years and older, can be reached to participate in health checks for cardio-metabolic diseases and follow-up (lifestyle) advice. METHODS: This mixed-methods study used a convergent parallel design, to combine data of one quantitative study and three qualitative studies. Questionnaire data were included of 310 respondents, and interview data from 22 focus groups and four individual interviews. Participants were recruited via a research database, general practitioners and key figures. Quantitative data were analysed descriptively and qualitative data were analysed using a thematic approach. RESULTS: Regarding health checks, 50 % (95 % CI 41;59) of the Turkish questionnaire respondents and 66 % (95 % CI 57;76) of the Moroccan questionnaire respondents preferred an invitation from their general practitioner. The preferred location to fill out the health check questionnaire was for both ethnic groups the general practitioner's office or at home, on paper. Regarding advice, both groups preferred to receive advice at individual level rather than in a group, via either a physician or a specialised healthcare professional. It was emphasised that the person who gives lifestyle advice should be familiar with the (eating) habits of the targeted individual. Sixty-one percent (95 % CI 53;69) of the Turkish respondents preferred to receive information in their native language compared to 37 % (95 % CI 29;45) of the Moroccan respondents. Several participants mentioned a low proficiency in the local language as an explanation for their preference to fill out the health check questionnaire at home, to receive advice from an ethnic-matched professional, and to receive information in their native language. CONCLUSIONS: The general practitioner is considered as a promising contact to reach adults of Turkish and Moroccan origin for health checks or (lifestyle) advice. It might be necessary to provide information in individuals' native language to overcome language barriers. In addition, (lifestyle) advice must be tailored. The obtained insight into preferences of Turkish and Moroccan adults regarding reach for preventive healthcare services could help professionals to successfully target these groups.

Adapting an effective lifestyle intervention towards individuals with low socioeconomic status of different ethnic origins: the design of the MetSLIM study.

BACKGROUND: People with low socioeconomic status (SES) and some ethnic minorities are often underrepresented in lifestyle programmes. Therefore, a lifestyle programme was developed especially targeting these groups. Developing this lifestyle programme and designing an intervention study to test the effectiveness of this programme was an informative process in which several obstacles were encountered and choices had to be made. Study protocols, however, rarely describe these obstacles encountered in the protocol design process, and it is not always clear why researchers made certain choices. Therefore, the aim of this article is to describe both the final MetSLIM study protocol and the considerations and choices made in designing this study protocol. METHODS/DESIGN: The developed MetSLIM study has a quasi-experimental design, targeting 30- to 70-year-old adults with an elevated waist circumference, living in deprived neighbourhoods, of Dutch, Turkish or Moroccan descent. The intervention group participates in a 12-month lifestyle programme consisting of individual dietary advice, four group sessions and weekly sports lessons. The control group receives written information about a healthy lifestyle and one group session provided by a dietician. The study contains an elaborate effect, process and economic evaluation. Outcome measures are, among other things, change in waist circumference and the other components of the metabolic syndrome. DISCUSSION: Matching the preferences of the target group, such as their preferred setting, has implications for the entire study protocol. The process evaluation of the MetSLIM study will provide insight into the consequences of the choices made in the MetSLIM study protocol in terms of reach, acceptability and delivery of the programme, and the effect and economic evaluation will provide insight into the (cost)effectiveness of the lifestyle programme in order to reduce waist circumference among individuals with low SES of different ethnic origins. TRIAL REGISTRATION: Netherlands Trial Register NTR3721 (since November 27, 2012).

Perceptions on healthy eating, physical activity and lifestyle advice: opportunities for adapting lifestyle interventions to individuals with low socioeconomic status.

BACKGROUND: Individuals with low socioeconomic status (SES) are generally less well reached through lifestyle interventions than individuals with higher SES. The aim of this study was to identify opportunities for adapting lifestyle interventions in such a way that they are more appealing for individuals with low SES. To this end, the study provides insight into perspectives of groups with different socioeconomic positions regarding their current eating and physical activity behaviour; triggers for lifestyle change; and ways to support lifestyle change. METHODS: Data were gathered in semi-structured focus group interviews among low SES (four groups) and high SES (five groups) adults. The group size varied between four and nine participants. The main themes discussed were perceptions and experiences of healthy eating, physical activity and lifestyle advice. Interviews were transcribed verbatim and a thematic approach was used to analyse the data. RESULTS: In general, three key topics were identified, namely: current lifestyle is logical for participants given their personal situation; lifestyle change is prompted by feedback from their body; and support for lifestyle change should include individually tailored advice and could profit from involving others. The perceptions of the low SES participants were generally comparable to the perceptions shared by the high SES participants. Some perceptions were, however, especially shared in the low SES groups. Low SES participants indicated that their current eating behaviour was sometimes affected by cost concerns. They seemed to be especially motivated to change their lifestyle when they experienced health complaints, but were rather hesitant to change their lifestyle for preventive purposes. Regarding support for lifestyle change, low SES participants preferred to receive advice in a group rather than on their own. For physical activities, groups should preferably consist of persons of the same age, gender or physical condition. CONCLUSIONS: To motivate individuals with low SES to change their lifestyle, it may be useful to (visually) raise their awareness of their current weight or health status. Lifestyle interventions targeting individuals with low SES should take possible cost concerns into account and should harness the supportive effect of (peer) groups.

Digital health interventions to improve eating behaviour of people with a lower socioeconomic position: a scoping review of behaviour change techniques.

Specific approaches are needed to reach and support people with a lower socioeconomic position (SEP) to achieve healthier eating behaviours. There is a growing body of evidence suggesting that digital health tools exhibit potential to address these needs because of its specific features that enable application of various behaviour change techniques (BCTs). The aim of this scoping review is to identify the BCTs that are used in diet-related digital interventions targeted at people with a low SEP, and which of these BCTs coincide with improved eating behaviour. The systematic search was performed in 3 databases, using terms related to e/m-health, diet quality and socioeconomic position. A total of 17 full text papers were included. The average number of BCTs per intervention was 6.9 (ranged 3-15). BCTs from the cluster 'Goals and planning' were applied most often (25x), followed by the clusters 'Shaping knowledge' (18x) and 'Natural consequences' (18x). Other frequently applied BCT clusters were 'Feedback and monitoring' (15x) and 'Comparison of behaviour' (13x). Whereas some BCTs were frequently applied, such as goal setting, others were rarely used, such as social support. Most studies (n = 13) observed a positive effect of the intervention on eating behaviour (e.g. having breakfast) in the low SEP group, but this was not clearly associated with the number or type of applied BCTs. In conclusion, more intervention studies focused on people with a low SEP are needed to draw firm conclusions as to which BCTs are effective in improving their diet quality. Also, further research should investigate combinations of BCTs, the intervention design and context, and the use of multicomponent approaches. We encourage intervention developers and researchers to describe interventions more thoroughly, following the systematics of a behaviour change taxonomy, and to select BCTs knowingly.

Is the success of the SLIMMER diabetes prevention intervention modified by socioeconomic status? A randomised controlled trial.

AIM: To explore the role of socioeconomic status (SES) in participation, programme attendance, programme acceptability, adherence to lifestyle guidelines, drop-out, and effectiveness in the SLIMMER diabetes prevention intervention. METHODS: SLIMMER was a randomised controlled intervention, carried out in a real-world setting, targeting 40- to 70-year-old adults at increased risk of developing type 2 diabetes (n=316). The intervention group participated in a 10-month combined dietary and physical activity programme. Measurements were carried out at baseline, 12months, and 18months. Effectiveness was determined for fasting insulin, HbA1c, weight, BMI, waist circumference, and waist-to-height-ratio. Differences between the low SES (no, primary, or lower secondary school) and higher SES group were tested using logistic regression and ANCOVA. RESULTS: Fifty-two percent of the SLIMMER participants had a low SES. No differences in participation were observed between the low and higher SES group. The most important reason for non-participation in the low SES group was 'lack of interest' (32%), whereas in the higher SES group this was 'I already exercise enough' (31%). Attendance, acceptability, adherence, drop-out, and effectiveness after 12months were similar in the low and higher SES group. After 18months, the low SES group seemed to maintain slightly better effects for fasting insulin, HbA1c, and waist circumference. CONCLUSIONS: The current study showed that participation, attendance, acceptability, adherence, drop-out, and effectiveness of the SLIMMER intervention were in general not modified by socioeconomic status. The SLIMMER intervention can contribute to health promotion for individuals in both low and higher socioeconomic groups.

Challenges of a healthy lifestyle for socially disadvantaged people of Dutch, Moroccan and Turkish origin in the Netherlands: a focus group study.

Lifestyle interventions often fail to successfully reach individuals with lower socio-economic status (SES), possibly because of the individual behavioural orientation to health behaviour and because limited research has included the target groups' perspectives in the development of interventions. Certainly, in order to make lifestyle interventions more applicable, target groups' viewpoints should to be taken into account. In order to tailor an effective lifestyle intervention to groups with lower SES of different ethnic origins, 14 focus group interviews were conducted with Turkish, Moroccan and Dutch male and female groups. The target groups' responses highlight their viewpoint and their dilemmas with regard to physical activity behaviour and healthy eating. Exploration of the target groups' behaviour in terms of their own logic revealed three prominent themes. Firstly, some individuals find it difficult to maintain healthy eating habits and regular physical activities, as their concept of a healthy life comprises competing values and activities. Secondly, social norms and social practices of others influence health behaviour. Thirdly, respondents' answers reflect how they deal with the dilemma of competing values and norms. They use different ways of reasoning to make sense of their own (health) behaviour. Taken together, the results of this study suggest that considering physical activity and eating as collective social practices rather than as determinants of health will provide new opportunities to initiate healthy lifestyles and to make lifestyle interventions more applicable to target groups' realities.