Less stick more carrot? Increasing the uptake of deposit contract financial incentives for physical activity: A randomized controlled trial.

BACKGROUND: Financial incentives are a promising tool to help people increase their physical activity, but they are expensive to provide. Deposit contracts are a type of financial incentive in which participants pledge their own money. However, low uptake is a crucial obstacle to the large-scale implementation of deposit contracts. Therefore, we investigated whether (1) matching the deposit 1:1 (doubling what is deposited) and (2) allowing for customizable deposit amounts increased the uptake and short term effectiveness of a deposit contract for physical activity. METHODS: In this randomized controlled trial, 137 healthy students (age M = 21.6 years) downloaded a smartphone app that provided them with a tailored step goal and then randomized them to one of four experimental conditions. The deposit contract required either a €10 fixed deposit or a customizable deposit with any amount between €1 and €20 upfront. Furthermore, the deposit was either not matched or 1:1 matched (doubled) with a reward provided by the experiment. During 20 intervention days, daily feedback on goal progress and incentive earnings was provided by the app. We investigated effects on the uptake (measured as agreeing to participate and paying the deposit) and effectiveness of behavioral adoption (measured as participant days goal achieved). FINDINGS: Overall, the uptake of deposit contracts was 83.2%, and participants (n = 113) achieved 14.9 out of 20 daily step goals. A binary logistic regression showed that uptake odds were 4.08 times higher when a deposit was matched (p = .010) compared to when it was not matched. Furthermore, uptake odds were 3.53 times higher when a deposit was customizable (p = .022) compared to when it was fixed. Two-way ANCOVA showed that matching (p = .752) and customization (p = .143) did not impact intervention effectiveness. However, we did find a marginally significant interaction effect of deposit matching X deposit customization (p = .063, ηp2 = 0.032). Customization decreased effectiveness when deposits were not matched (p = .033, ηp2 = 0.089), but had no effect when deposits were matched (p = .776, ηp2 = 0.001). CONCLUSIONS: We provide the first experimental evidence that both matching and customization increase the uptake of a deposit contract for physical activity. We recommend considering both matching and customization to overcome lack of uptake, with a preference for customization since matching a deposit imposes significant additional costs. However, since we found indications that customizable deposits might reduce effectiveness (when the deposits are not matched), we urge for more research on the effectiveness of customizable deposit contracts. Finally, future research should investigate which participant characteristics are predictive of deposit contract uptake and effectiveness. PRE-REGISTRATION: OSF Registries, https://osf.io/cgq48.

Guide Development for eHealth Interventions Targeting People With a Low Socioeconomic Position: Participatory Design Approach.

BACKGROUND: People with a low socioeconomic position (SEP) are less likely to benefit from eHealth interventions, exacerbating social health inequalities. Professionals developing eHealth interventions for this group face numerous challenges. A comprehensive guide to support these professionals in their work could mitigate these inequalities. OBJECTIVE: We aimed to develop a web-based guide to support professionals in the development, adaptation, evaluation, and implementation of eHealth interventions for people with a low SEP. METHODS: This study consisted of 2 phases. The first phase involved a secondary analysis of 2 previous qualitative and quantitative studies. In this phase, we synthesized insights from the previous studies to develop the guide's content and information structure. In the second phase, we used a participatory design process. This process included iterative development and evaluation of the guide's design with 11 professionals who had experience with both eHealth and the target group. We used test versions (prototypes) and think-aloud testing combined with semistructured interviews and a questionnaire to identify design requirements and develop and adapt the guide accordingly. RESULTS: The secondary analysis resulted in a framework of recommendations for developing the guide, which was categorized under 5 themes: development, reach, adherence, evaluation, and implementation. The participatory design process resulted in 16 requirements on system, content, and service aspects for the design of the guide. For the system category, the guide was required to have an open navigation strategy leading to more specific information and short pages with visual elements. Content requirements included providing comprehensible information, scientific evidence, a user perspective, information on practical applications, and a personal and informal tone of voice. Service requirements involved improving suitability for different professionals, ensuring long-term viability, and a focus on implementation. Based on these requirements, we developed the final version of "the inclusive eHealth guide." CONCLUSIONS: The inclusive eHealth guide provides a practical, user-centric tool for professionals aiming to develop, adapt, evaluate, and implement eHealth interventions for people with a low SEP, with the aim of reducing health disparities in this population. Future research should investigate its suitability for different end-user goals, its external validity, its applicability in specific contexts, and its real-world impact on social health inequality.

Investigating Rewards and Deposit Contract Financial Incentives for Physical Activity Behavior Change Using a Smartphone App: Randomized Controlled Trial.

BACKGROUND: Financial incentive interventions for improving physical activity have proven to be effective but costly. Deposit contracts (in which participants pledge their own money) could be an affordable alternative. In addition, deposit contracts may have superior effects by exploiting the power of loss aversion. Previous research has often operationalized deposit contracts through loss framing a financial reward (without requiring a deposit) to mimic the feelings of loss involved in a deposit contract. OBJECTIVE: This study aimed to disentangle the effects of incurring actual losses (through self-funding a deposit contract) and loss framing. We investigated whether incentive conditions are more effective than a no-incentive control condition, whether deposit contracts have a lower uptake than financial rewards, whether deposit contracts are more effective than financial rewards, and whether loss frames are more effective than gain frames. METHODS: Healthy participants (N=126) with an average age of 22.7 (SD 2.84) years participated in a 20-day physical activity intervention. They downloaded a smartphone app that provided them with a personalized physical activity goal and either required a €10 (at the time of writing: €1=US $0.98) deposit up front (which could be lost) or provided €10 as a reward, contingent on performance. Daily feedback on incentive earnings was provided and framed as either a loss or gain. We used a 2 (incentive type: deposit or reward) × 2 (feedback frame: gain or loss) between-subjects factorial design with a no-incentive control condition. Our primary outcome was the number of days participants achieved their goals. The uptake of the intervention was a secondary outcome. RESULTS: Overall, financial incentive conditions (mean 13.10, SD 6.33 days goal achieved) had higher effectiveness than the control condition (mean 8.00, SD 5.65 days goal achieved; P=.002; ηp2=0.147). Deposit contracts had lower uptake (29/47, 62%) than rewards (50/50, 100%; P<.001; Cramer V=0.492). Furthermore, 2-way analysis of covariance showed that deposit contracts (mean 14.88, SD 6.40 days goal achieved) were not significantly more effective than rewards (mean 12.13, SD 6.17 days goal achieved; P=.17). Unexpectedly, loss frames (mean 10.50, SD 6.22 days goal achieved) were significantly less effective than gain frames (mean 14.67, SD 5.95 days goal achieved; P=.007; ηp2=0.155). CONCLUSIONS: Financial incentives help increase physical activity, but deposit contracts were not more effective than rewards. Although self-funded deposit contracts can be offered at low cost, low uptake is an important obstacle to large-scale implementation. Unexpectedly, loss framing was less effective than gain framing. Therefore, we urge further research on their boundary conditions before using loss-framed incentives in practice. Because of limited statistical power regarding some research questions, the results of this study should be interpreted with caution, and future work should be done to confirm these findings. TRIAL REGISTRATION: Open Science Framework Registries osf.io/34ygt; https://osf.io/34ygt.

The Barriers and Facilitators of eHealth-Based Lifestyle Intervention Programs for People With a Low Socioeconomic Status: Scoping Review.

BACKGROUND: Promoting health behaviors and preventing chronic diseases through a healthy lifestyle among those with a low socioeconomic status (SES) remain major challenges. eHealth interventions are a promising approach to change unhealthy behaviors in this target group. OBJECTIVE: This review aims to identify key components, barriers, and facilitators in the development, reach, use, evaluation, and implementation of eHealth lifestyle interventions for people with a low SES. This review provides an overview for researchers and eHealth developers, and can assist in the development of eHealth interventions for people with a low SES. METHODS: We performed a scoping review based on Arksey and O'Malley's framework. A systematic search was conducted on PubMed, MEDLINE (Ovid), Embase, Web of Science, and the Cochrane Library, using terms related to a combination of the following key constructs: eHealth, lifestyle, low SES, development, reach, use, evaluation, and implementation. There were no restrictions on the date of publication for articles retrieved upon searching the databases. RESULTS: The search identified 1323 studies, of which 42 met our inclusion criteria. An update of the search led to the inclusion of 17 additional studies. eHealth lifestyle interventions for people with a low SES were often delivered via internet-based methods (eg, websites, email, Facebook, and smartphone apps) and offline methods, such as texting. A minority of the interventions combined eHealth lifestyle interventions with face-to-face or telephone coaching, or wearables (blended care). We identified the use of different behavioral components (eg, social support) and technological components (eg, multimedia) in eHealth lifestyle interventions. Facilitators in the development included iterative design, working with different disciplines, and resonating intervention content with users. Facilitators for intervention reach were use of a personal approach and social network, reminders, and self-monitoring. Nevertheless, barriers, such as technological challenges for developers and limited financial resources, may hinder intervention development. Furthermore, passive recruitment was a barrier to intervention reach. Technical difficulties and the use of self-monitoring devices were common barriers for users of eHealth interventions. Only limited data on barriers and facilitators for intervention implementation and evaluation were available. CONCLUSIONS: While we found large variations among studies regarding key intervention components, and barriers and facilitators, certain factors may be beneficial in building and using eHealth interventions and reaching people with a low SES. Barriers and facilitators offer promising elements that eHealth developers can use as a toolbox to connect eHealth with low SES individuals. Our findings suggest that one-size-fits-all eHealth interventions may be less suitable for people with a low SES. Future research should investigate how to customize eHealth lifestyle interventions to meet the needs of different low SES groups, and should identify the components that enhance their reach, use, and effectiveness.

Cost-effectiveness of a stepwise cardiometabolic disease prevention program: results of a randomized controlled trial in primary care.

BACKGROUND: Cardiometabolic diseases (CMD) are the major cause of death worldwide and are associated with a lower quality of life and high healthcare costs. To prevent a further rise in CMD and related healthcare costs, early detection and adequate management of individuals at risk could be an effective preventive strategy. The objective of this study was to determine long-term cost-effectiveness of stepwise CMD risk assessment followed by individualized treatment if indicated compared to care as usual. A computer-based simulation model was used to project long-term health benefits and cost-effectiveness, assuming the prevention program was implemented in Dutch primary care. METHODS: A randomized controlled trial in a primary care setting in which 1934 participants aged 45-70 years without recorded CMD or CMD risk factors participated. The intervention group was invited for stepwise CMD risk assessment through a risk score (step 1), additional risk assessment at the practice in case of increased risk (step 2) and individualized follow-up treatment if indicated (step 3). The control group was not invited for risk assessment, but completed a health questionnaire. Results of the effectiveness analysis on systolic blood pressure (- 2.26 mmHg; 95% CI - 4.01: - 0.51) and total cholesterol (- 0.15 mmol/l; 95% CI - 0.23: - 0.07) were used in this analysis. Outcome measures were the costs and benefits after 1-year follow-up and long-term (60 years) cost-effectiveness of stepwise CMD risk assessment compared to no assessment. A computer-based simulation model was used that included data on disability weights associated with age and disease outcomes related to CMD. Analyses were performed taking a healthcare perspective. RESULTS: After 1 year, the average costs in the intervention group were 260 Euro higher than in the control group and differences were mainly driven by healthcare costs. No meaningful change was found in EQ 5D-based quality of life between the intervention and control groups after 1-year follow-up (- 0.0154; 95% CI - 0.029: 0.004). After 60 years, cumulative costs of the intervention were 41.4 million Euro and 135 quality-adjusted life years (QALY) were gained. Despite improvements in blood pressure and cholesterol, the intervention was not cost-effective (ICER of 306,000 Euro/QALY after 60 years). Scenario analyses did not allow for a change in conclusions with regard to cost-effectiveness of the intervention. CONCLUSIONS: Implementation of this primary care-based CMD prevention program is not cost-effective in the long term. Implementation of this program in primary care cannot be recommended. TRIAL REGISTRATION: Dutch Trial Register NTR4277 , registered on 26 November 2013.

Personalized prevention approach with use of a web-based cardiovascular risk assessment with tailored lifestyle follow-up in primary care practice--a pilot study.

AIMS: The aim of this prospective implementation study is to evaluate feasibility of a personalized prevention approach with use of a web-based health risk assessment for cardiovascular diseases combined with tailored lifestyle feedback and interventions in the community setting. METHODS: A random sample of 800 inhabitants of Leidsche Rijn (a newly built residential area in the city of Utrecht) between 45 and 70 years old was invited by their general practitioner to participate in this study and sent a web-based health risk assessment containing a questionnaire, covering socio-demographic variables, family and personal medical history, lifestyle behaviour and psychological variables. The system generates an individual cardiovascular risk based on prognostic modelling. In the case of increased risk further biometric and laboratory evaluation is advised. All participants received tailored web-based feedback with an electronic referral to available medical, psychological and lifestyle interventions in the neighbourhood, or online interventions, and a follow-up questionnaire after six months. RESULTS: The participation rate was 29% (230/800) of which 39% (89/230) were at increased risk for cardiovascular disease and were advised to perform biometric measures, of which 36% (32/89) actually did. Of these respondents 25% (8/32) had increased blood pressure (≥140/90), 56% (18/32) increased total cholesterol (>6.0 mmol/l).One-third of the participants started changing their lifestyle, 20% indicated planning to do this later; 32% (41/129) increased their physical activity and 28% (36/129) were eating healthier. Seventy-nine per cent of the responders stated their participation was 'meaningful'. CONCLUSIONS: The personalized prevention approach offers a system for integrated risk profiling and individualized health management that was well received in general practice. The client-centred approach, which was embedded in a local community setting, using a web-based health risk assessment with tailored feedback and linkage to regional health management and lifestyle providers proved feasible, and successful. Participating in the health risk assessment elicited actual behaviour change among follow-up survey respondents.

Design of the INTEGRATE study: effectiveness and cost-effectiveness of a cardiometabolic risk assessment and treatment program integrated in primary care.

BACKGROUND: The increasing prevalence of cardiometabolic disease (CMD) in combination with an ageing population is a major public health problem. Early detection and management of individuals at risk for CMD is required to prevent future health problems with associated costs. General practice is the optimal health care setting to accomplish this goal. Prevention programs for identification and treatment of patients with an increased risk for CMD in primary care have been proven feasible. However, the effectiveness and cost-effectiveness have yet to be demonstrated. The 'Personalized Prevention Approach for CardioMetabolic Risk' (PPA CMR) is such a prevention program. The objective of the INTEGRATE study is to investigate the effectiveness and cost-effectiveness of PPA CMR, as well as to establish determinants for participation and compliance. METHODS: The INTEGRATE study is designed as a stepped-wedge randomized controlled trial with a waiting list control group. In approximately 40 general practices, all enlisted patients without CMD aged 45-70 years, are invited to participate in PPA CMR. After an online risk estimation, patients with a score above risk threshold are invited to the GP for additional measurements, detailed risk profiling and tailored treatment of risk factors through medication and/or lifestyle counseling. At baseline and after twelve months of follow-up lifestyle, health and work status of all participants are established with online questionnaires. Additionally after twelve months, we will determine health care utilization, costs of PPA CMR and compliance. Primary endpoints are the number of newly detected patients with CMD and changes in individual risk factors between the intervention and waiting list control group. Medical data will be extracted from the GPs' electronic medical records. In order to assess factors related to participation, we will send questionnaires to non-participants and assess characteristics of participating practices. For all participants, additional demographic characteristics will be available through Statistics Netherlands. DISCUSSION: The INTEGRATE study will provide insight into the effectiveness and cost-effectiveness of PPA CMR as well as determinants for participation and compliance, which represents essential information to guide further large-scale implementation of primary prevention programs for CMD. TRIAL REGISTRATION NUMBER: NTR4277, The Netherlands National Trial Register, 26-11-2013.

Evaluating a web-based health risk assessment with tailored feedback: what does an expert focus group yield compared to a web-based end-user survey?

BACKGROUND: Increasingly, Web-based health applications are developed for the prevention and management of chronic diseases. However, their reach and utilization is often disappointing. Qualitative evaluations post-implementation can be used to inform the optimization process and ultimately enhance their adoption. In current practice, such evaluations are mainly performed with end-user surveys. However, a review approach by experts in a focus group may be easier to administer and might provide similar results. OBJECTIVE: The aim of this study was to assess whether industrial design engineers in a focus group would address the same issues as end users in a Web-based survey when evaluating a commercial Web-based health risk assessment (HRA) with tailored feedback. METHODS: Seven Dutch companies used the HRA as part of their corporate health management strategy. Employees using the HRA (N=2289) and 10 independent industrial designers were invited to participate in the study. The HRA consisted of four components: (1) an electronic health questionnaire, (2) biometric measurements, (3) laboratory evaluation, and (4) individually tailored feedback generated by decision support software. After participating in the HRA as end users, both end users and designers evaluated the program. End users completed an evaluation questionnaire that included a free-text field. Designers participated in a focus group discussion. Constructs from user satisfaction and technology acceptance theories were used to categorize and compare the remarks from both evaluations. RESULTS: We assessed and qualitatively analyzed 294 remarks of 189 end users and 337 remarks of 6 industrial designers, pertaining to 295 issues in total. Of those, 137 issues were addressed in the end-user survey and 148 issues in the designer focus group. Only 7.3% (10/137) of the issues addressed in the survey were also addressed in the focus group. End users made more remarks about the usefulness of the HRA and prior expectations that were not met. Designers made more remarks about how the information was presented to end users, quality of the feedback provided by the HRA, recommendations on the marketing and on how to create more unity in the design of the HRA, and on how to improve the HRA based on these issues. CONCLUSIONS: End-user surveys should not be substituted for expert focus groups. Issues identified by end users in the survey and designers in the focus group differed considerably, and the focus group produced a lot of new issues. The issues addressed in the focus group often focused on different aspects of user satisfaction and technology acceptance than those addressed by the survey participants; when they did focus on the same aspects, then the nature of issues differed considerably in content.

Determinants of participation in a web-based health risk assessment and consequences for health promotion programs.

BACKGROUND: The health risk assessment (HRA) is a type of health promotion program frequently offered at the workplace. Insight into the underlying determinants of participation is needed to evaluate and implement these interventions. OBJECTIVE: To analyze whether individual characteristics including demographics, health behavior, self-rated health, and work-related factors are associated with participation and nonparticipation in a Web-based HRA. METHODS: Determinants of participation and nonparticipation were investigated in a cross-sectional study among individuals employed at five Dutch organizations. Multivariate logistic regression was performed to identify determinants of participation and nonparticipation in the HRA after controlling for organization and all other variables. RESULTS: Of the 8431 employees who were invited, 31.9% (2686/8431) enrolled in the HRA. The online questionnaire was completed by 27.2% (1564/5745) of the nonparticipants. Determinants of participation were some periods of stress at home or work in the preceding year (OR 1.62, 95% CI 1.08-2.42), a decreasing number of weekdays on which at least 30 minutes were spent on moderate to vigorous physical activity (OR(dayPA)0.84, 95% CI 0.79-0.90), and increasing alcohol consumption. Determinants of nonparticipation were less-than-positive self-rated health (poor/very poor vs very good, OR 0.25, 95% CI 0.08-0.81) and tobacco use (at least weekly vs none, OR 0.65, 95% CI 0.46-0.90). CONCLUSIONS: This study showed that with regard to isolated health behaviors (insufficient physical activity, excess alcohol consumption, and stress), those who could benefit most from the HRA were more likely to participate. However, tobacco users and those who rated their overall health as less than positive were less likely to participate. A strong communication strategy, with recruitment messages that take reasons for nonparticipation into account, could prove to be an essential tool for organizations trying to reach employees who are less likely to participate.

Evaluation of end-user satisfaction among employees participating in a web-based health risk assessment with tailored feedback.

BACKGROUND: Web technology is increasingly being used to provide individuals with health risk assessments (HRAs) with tailored feedback. End-user satisfaction is an important determinant of the potential impact of HRAs, as this influences program attrition and adherence to behavioral advice. OBJECTIVE: The aim of this study was to evaluate end-user satisfaction with a web-based HRA with tailored feedback applied in worksite settings, using mixed (quantitative and qualitative) methods. METHODS: Employees of seven companies in the Netherlands participated in a commercial, web-based, HRA with tailored feedback. The HRA consisted of four components: 1) a health and lifestyle assessment questionnaire, 2) a biometric evaluation, 3) a laboratory evaluation, and 4) tailored feedback consisting of a personal health risk profile and lifestyle behavior advice communicated through a web portal. HRA respondents received an evaluation questionnaire after six weeks. Satisfaction with different parts of the HRA was measured on 5-point Likert scales. A free-text field provided the opportunity to make additional comments. RESULTS: In total, 2289 employees participated in the HRA program, of which 637 (27.8%) completed the evaluation questionnaire. Quantitative analysis showed that 85.6% of the respondents evaluated the overall HRA positively. The free-text field was filled in by 29.7 % of the respondents (189 out of 637), who made 315 separate remarks. Qualitative evaluation of these data showed that these respondents made critical remarks. Respondents felt restricted by the answer categories of the health and lifestyle assessment questionnaire, which resulted in the feeling that the corresponding feedback could be inadequate. Some respondents perceived the personal risk profile as unnecessarily alarming or suggested providing more explanations, reference values, and a justification of the behavioral advice given. Respondents also requested the opportunity to discuss the feedback with a health professional. CONCLUSIONS: Most people were satisfied with the web-based HRA with tailored feedback. Sources of dissatisfaction were limited opportunities for providing additional health information outside of the predefined health and lifestyle assessment questionnaire and insufficient transparency on the generation of the feedback. Information regarding the aim and content of the HRA should be clear and accurate to prevent unrealistic expectations among end-users. Involving trusted health professionals in the implementation of web-based HRAs may enhance the use of and confidence in the HRA.

Effectiveness of a web-based health risk assessment with individually-tailored feedback on lifestyle behaviour: study protocol.

BACKGROUND: Physical inactivity, unhealthy dietary habits, smoking and high alcohol consumption are recognized risk factors for cardiovascular disease and cancer. Web-based health risk assessments with tailored feedback seem promising in promoting a healthy lifestyle. This study evaluates the effectiveness of a web-based health risk assessment with individually-tailored feedback on lifestyle behaviour, conducted in a worksite setting. METHODS/DESIGN: The web-based health risk assessment starts with a questionnaire covering socio-demographic variables, family and personal medical history, lifestyle behaviour and psychological variables. Prognostic models are used to estimate individual cardiovascular risks. In case of high risk further biometric and laboratory evaluation is advised. All participants receive individually-tailored feedback on their responses to the health risk assessment questionnaire. The study uses a quasi-experimental design with a waiting list control group. Data are collected at baseline (T0) and after six months (T1). Within each company, clusters of employees are allocated to either the intervention or the control group. Primary outcome is lifestyle behaviour, expressed as the sum of five indicators namely physical activity, nutrition, smoking behaviour, alcohol consumption, and symptoms of burnout. Multilevel regression analysis will be used to answer the main research question and to correct for clustering effects. Baseline differences between the intervention and control group in the distribution of characteristics with a potential effect on lifestyle change will be taken into account in further analyses using propensity scores. DISCUSSION: This study will increase insight into the effectiveness of health risk assessments with tailored feedback and into conditions that may modify the effectiveness. This information can be used to design effective interventions for lifestyle behaviour change among employees. TRIAL REGISTRATION: Dutch Trial Register NTR8148.

Revision of the Dutch clinical algorithm for assessing patient needs in cardiac rehabilitation based on identified implementation problems.

BACKGROUND: Despite all available evidence of its effectiveness, cardiac rehabilitation and secondary prevention (CRSP) is still insufficiently implemented in current clinical practice. Based on an analysis of implementation problems, recently the Dutch clinical algorithm for the assessment of patient's CRSP needs was revised. The purpose of this paper is to describe the revision process and its results to improve CRSP guideline implementation. METHODS: The National Institute for Health and Clinical Excellence (NICE) guidelines manual for conducting guideline revisions was followed. Information on the use of the algorithm in practice was collected from electronic medical records and by conducting semi-structured interviews. Next, an expert advisory group identified the problems for use in daily practice and defined the scope for the revision. A multidisciplinary guideline development group subsequently wrote the revised algorithm. RESULTS: A large variation in assessed patient needs was observed between CRSP clinics. Assessment based on clinical judgement was found to be a source of practice variation and is therefore avoided in the revised algorithm. It was decided to add assessment instruments for anxiety and depression, cardiovascular risk factors, stress, attitude of partner and lifestyle parameters. CONCLUSION: The Dutch clinical algorithm for assessing patient needs for CRSP was revised using a combination of patient data from routine practice, knowledge from academic experts and experience from field experts. The revised algorithm is a practical tool consisting of assessment instruments to improve CRSP guideline adherence in the Netherlands. This algorithm may also be useful for other Western countries to organize their CRSP needs assessment procedure.

Initiation of health-behaviour change among employees participating in a web-based health risk assessment with tailored feedback.

BACKGROUND: Primary prevention programs at the worksite can improve employee health and reduce the burden of cardiovascular disease. Programs that include a web-based health risk assessment (HRA) with tailored feedback hold the advantage of simultaneously increasing awareness of risk and enhancing initiation of health-behaviour change. In this study we evaluated initial health-behaviour change among employees who voluntarily participated in such a HRA program. METHODS: We conducted a questionnaire survey among 2289 employees who voluntarily participated in a HRA program at seven Dutch worksites between 2007 and 2009. The HRA included a web-based questionnaire, biometric measurements, laboratory evaluation, and tailored feedback. The survey questionnaire assessed initial self-reported health-behaviour change and satisfaction with the web-based HRA, and was e-mailed four weeks after employees completed the HRA. RESULTS: Response was received from 638 (28%) employees. Of all, 86% rated the program as positive, 74% recommended it to others, and 58% reported to have initiated overall health-behaviour change. Compared with employees at low CVD risk, those at high risk more often reported to have increased physical activity (OR 3.36, 95% CI 1.52-7.45). Obese employees more frequently reported to have increased physical activity (OR 3.35, 95% CI 1.72-6.54) and improved diet (OR 3.38, 95% CI 1.50-7.60). Being satisfied with the HRA program in general was associated with more frequent self-reported initiation of overall health-behaviour change (OR 2.77, 95% CI 1.73-4.44), increased physical activity (OR 1.89, 95% CI 1.06-3.39), and improved diet (OR 2.89, 95% CI 1.61-5.17). CONCLUSIONS: More than half of the employees who voluntarily participated in a web-based HRA with tailored feedback, reported to have initiated health-behaviour change. Self-reported initiation of health-behaviour change was more frequent among those at high CVD risk and BMI levels. In general employees reported to be satisfied with the HRA, which was also positively associated with initiation of health-behaviour change. These findings indicate that among voluntary participating employees a web-based HRA with tailored feedback may motivate those in greatest need of health-behaviour change and may be a valuable component of workplace health promotion programs.

Effects on cardiovascular disease risk of a web-based health risk assessment with tailored health advice: a follow-up study.

INTRODUCTION: A large proportion of the cardiovascular disease (CVD) burden can potentially be prevented by primary prevention programs addressing major causal risk factors. A Web-based health risk assessment (HRA) with tailored feedback for individual health promotion is a promising strategy. We evaluated the effect on CVD risk of such a program among employees of a Dutch worksite. METHODS: We conducted a prospective follow-up study among 368 employees who voluntarily participated in a Web-based HRA program at a single Dutch worksite in 2008. The program included a multicomponent HRA through a Web-based electronic questionnaire, biometrics, and laboratory evaluation. The results were combined with health behavior change theory to generate tailored motivational and educational health advice. On request, a health counseling session with the program physician was available. Follow-up data on CVD risk were collected 1 year after initial participation. The primary outcome was a change in Framingham CVD risk at 6 months relative to baseline. We checked for a possible background effect of an increased health consciousness as a consequence of program introduction at the worksite by comparing baseline measurements of early program participants with baseline measurements of participants who completed the program 6 months later. RESULTS: A total of 176 employees completed follow-up measurements after a mean of 7 months. There was a graded relation between CVD risk changes and baseline risk, with a relative reduction of 17.9% (P = 0.001) in the high-risk category (baseline CVD risk ≥ 20%). Changes were not explained by additional health counseling, medication, or an increase in health consciousness within the company. CONCLUSIONS: Voluntary participation in a Web-based HRA with tailored feedback at the worksite reduced CVD risk by nearly 18% among participants at high CVD risk and by nearly 5% among all participants. Web-based HRA could improve CVD risk in similar populations. Future research should focus on the persistence of the effects underlying the CVD risk reduction.

Cardiovascular risk assessment in haemophilia patients.

Haemophilia patients have a reduced cardiovascular mortality, which may be the result of a lifelong deficiency of factor VIII or IX. On the other hand, the prevalence of risk factors may differ in these chronically ill patients compared to the general population. The prevalence of risk factors and expected risk of cardiovascular disease was compared in haemophilia patients and healthy controls. In adult haemophilia A and B patients, body mass index, blood pressure, cholesterol levels and fasting glucose levels were measured and compared to healthy age-matched males. The expected risk of mortality due to cardiovascular disease was calculated using a European risk prediction algorithm (SCORE). A total of 100 haemophilia A and B patients and 200 healthy controls were analysed. The mean age of the patients was 47 years (range 18-83). The number of haemophiliacs with hyperglycaemia (24%) and hypertension (51%) was higher than in the controls (p-values 0.001 and 0.03, respectively). The mean low-density lipoprotein (LDL) cholesterol level in cases was lower than the controls (3.02 mM (0.69-6.57) and 3.60 mM (1.68-5.95), respectively, p < 0.001). Fewer cases had increased LDL levels (p=0.045). No difference was found in the 10-year cardiovascular mortality risk >10% between cases and controls (12% and 7%, respectively, p = 0.18). The prevalence of risk factors and expected risk of cardiovascular disease in haemophilia patients is comparable to the general population. This strengthens the hypothesis that hypocoagulability may reduce cardiovascular mortality in haemophilia patients.

Systematic review of guidelines on cardiovascular risk assessment: Which recommendations should clinicians follow for a cardiovascular health check?

OBJECTIVE: To appraise guidelines on cardiovascular risk assessment to guide selection of screening interventions for a health check. DATA SOURCES: Guidelines in the English language published between January 1, 2003, and May 2, 2009, were retrieved using MEDLINE and CINAHL. This was supplemented by searching the National Guideline Clearinghouse, National Library for Health, Canadian Medical Association Infobase, and G-I-N International Guideline Library. STUDY SELECTION: We included guidelines developed on behalf of professional organizations from Western countries, containing recommendations on cardiovascular risk assessment for the apparently healthy population. Titles and abstracts were assessed by 2 independent reviewers. Of 1984 titles identified, 27 guidelines met our criteria. DATA EXTRACTION: Rigor of guideline development was assessed by 2 independent reviewers. One reviewer extracted information on conflicts of interest and recommendations. RESULTS: Sixteen of 27 guidelines reported conflicts of interest and 17 showed considerable rigor. These included recommendations on assessment of total cardiovascular risk (7 guidelines), dyslipidemia (2), hypertension (2), and dysglycemia (7). Recommendations on total cardiovascular risk and dyslipidemia included prediction models integrating multiple risk factors, whereas remaining recommendations were focused on single risk factors. No consensus was found on recommended target populations, treatment thresholds, and screening tests. CONCLUSIONS: Differences among the guidelines imply important variation in allocation of preventive interventions. To make informed decisions, physicians should use only the recommendations from rigorously developed guidelines.

Preliminary validation of clinical assessment for deep vein thrombosis in orthopaedic outpatients.

The purpose of our study was to determine if a previously published clinical decision rule designed to estimate the probability of proximal deep vein thrombosis in outpatients is valid when applied exclusively to outpatients with musculoskeletal disorders. We also sought to determine whether probability estimates differed for patients with or without trauma, fracture, or recent orthopaedic surgery. Data collected from outpatients with surgical and nonsurgical musculoskeletal disorders (n = 464) were extracted from the datasets of three previously published studies done on heterogeneous groups of patients (n = 3424). Followup for all patients was 3 months. Testing of all patients for thromboembolic disease was done using validated diagnostic procedures. Probability estimates for orthopaedic outpatients were consistent with estimates from published studies. The proportion of patients who had venous thromboembolism was 5.6% (95% confidence interval, 3.5-8.7%) for the low probability group, 14.1% (95% confidence interval, 8.6-22.4%) for the moderate probability group, and 47.4% (95% confidence interval, 35.3-60%) for the high probability group. Validity estimates for patients with and without recent trauma, surgery, or fracture differed, but not dramatically. The validity of the clinical decision rule as applied to outpatients with musculoskeletal disorders was supported.