Risk factors for gastroenteritis associated with canal swimming in two cities in the Netherlands during the summer of 2015: A prospective study.

Urban canal swimming events are popular in the Netherlands. In 2015, two city canal swimming events took place, in Utrecht (Utrecht Singel Swim, USS) and in Amsterdam (Amsterdam City Swim, ACS). This prospective study characterizes the health risks associated with swimming in urban waters. Online questionnaires were sent to 160 (USS) and 2,692 (ACS) participants, with relatives of participants who did not swim completing the questionnaire as a control. Swimming water specimens and stool specimens of diarrheic participants in the ACS group were analysed. A total of 49% of USS and 51% of ACS swimmers returned their questionnaires. Nine percent of USS swimmers and 4% of non-swimmers reported gastrointestinal complaints (aRR 2.1; 95% CI: 0.3-16), while a total of 31% of ACS swimmers and 5% of non-swimmers reported gastrointestinal complaints (aRR 6.3; 95% CI: 4.1-9.5). AGI risk among ACS participants was directly related to increasing number of mouthfuls of water swallowed. Various norovirus genotypes were detected in five out of seven stool specimens taken from ACS participants and in all three tested ACS water samples. We conclude that the AGI risk among open-water swimmers in urban areas depends on the circumstances around the event. The epidemiological curve, the statistical association between swimming and AGI, and the microbiological evidence for norovirus in stool and water specimens suggest that AGI outbreak after the ACS event was due to water contamination by multiple norovirus strains, which is possibly linked to sewage overflow due to prior heavy rainfall. There is need for more targeted preventive measurements and recommendations for organizers, municipal authorities and participants to prevent this reoccurring in the future.

Effects of a brief cardiovascular prevention program by a health advisor in primary care; the 'Hartslag Limburg' project, a cluster randomized trial.

OBJECTIVE: To determine in primary care patients at high risk for a cardiovascular event, the effects on biomedical risk factors for and incidence of cardiovascular events, of a brief cardiovascular prevention program executed by a health advisor. DESIGN: cluster randomized controlled trial with 1275 patients (24 general practices) in and around Maastricht, the Netherlands (1999-2004). INTERVENTION: health advisors were to complete computerized cardiovascular risk profiles, provide multi-factorial tailored health education and advice, and communicate with GP's to optimize treatment. OUTCOME: differences in changes in risk factors between baseline and follow up at 6, 18, and 36 months and incidence of cardiovascular events at 36 months. PROCESS: Because of logistic reasons risk profiles were put on paper instead of in the computerized patient files. On average patients attended 2.3 counseling sessions. Interaction with GPs was less productive than expected. OUTCOME: Effect after six months on BMI (-0.20 kg/m(2) (95% CI -0.38 to -0.01, p=0.039), Cohen's d: -0.18), and after 18 months on HDL-cholesterol (+0.05 mmol/l (95% CI +0.01 to +0.09, p=0.014), Cohen's d: 0.14). No other (subgroup) effects were found. CONCLUSION: Given the lack of clinically meaningful effects, implementation of this intervention in its present form is not justified.

Lifestyle factors of a five-year community-intervention program: the Hartslag Limburg intervention.

BACKGROUND: Community-based health promotion is a widely advocated strategy in public health to favorably alter lifestyle. The aim of this study was to investigate the net effect of a cardiovascular disease-prevention program (Hartslag Limburg) on lifestyle factors after 5 years of intervention (1998-2003). METHODS: In a cohort study, 5-year mean changes in lifestyle factors (energy intake; fat intake; time spent on leisure-time physical activity; walking, bicycling, and sports; and smoking behavior) between subjects from the intervention area (n=2356) and the control area (n=758) were compared for men and women and for those with a low (less than intermediate secondary education) and a moderate (intermediate vocational or higher secondary education) or high (higher vocational education or university) educational level. Adjustments were made for age and the mean of the individual pre- and post-intervention measurement of the variable under study. When stratifying for gender, adjustments were made for educational level, and vice versa. RESULTS: In general, lifestyle factors changed unfavorably in the control group, whereas changes were less pronounced or absent in the intervention group. The adjusted difference in mean change in lifestyle factors between the intervention group and the control group was significant (p

Cardiovascular prevention in the Hartslag Limburg project: effects of a high-risk approach on behavioral risk factors in a general practice population.

BACKGROUND: This study describes a general-practice-based high-risk cardiovascular prevention approach in Maastricht, The Netherlands (1999-2003). The intervention consisted of a complete registration of risk factors, optimization of medical treatment and health counseling on high fat consumption, smoking and physical inactivity. METHODS: Behavioral effects were assessed in a trial, randomization by practice and usual care as control. Validated questionnaires were completed by 1300 patients at baseline, 1174 after 4 months (90.3%) and 1046 (80.5%) after 18 months. RESULTS: After 4 months, intention-to-treat analyses revealed a decrease in saturated fat intake of 1.3 points (scale ranging from 7 to 30 points, p=0.000). This was partly sustained after 18 months (-0.5 points, p=0.014). After 18 months, obese intervention patients were more likely to be sufficiently physically active than their control counterparts (OR=1.90, p=0.023). No intervention effects were found for smoking. CONCLUSION: Given the multiple factor and multiple component high-risk approach, the intervention had modest effects on only some of the behavioral risk factors addressed. Process data showed that the registration of risk factors and the optimization of medical treatment were only partly implemented, that the health counseling component could be further improved and that the intervention could benefit from additional health promoting strategies.

Effects of health counseling on behavioural risk factors in a high-risk cardiology outpatient population: a randomized clinical trial.

BACKGROUND: An evaluation study of an individual lifestyle advice intervention to reduce cardiovascular risk behaviours (high fat consumption, smoking, physical inactivity). METHODS: A randomized, controlled trial at the cardiology outpatient clinic of the University Hospital Maastricht. Participants were at high risk of incurring a cardiovascular event. Changes in risk behaviours and behavioural determinants were assessed with self-administered validated questionnaires. RESULTS: Questionnaires were completed by 1270 patients at baseline, 1169 after 4 months (92%), and 1032 after 18 months (81.3%). After 4 months, intention-to-treat analyses revealed a decrease in fat consumption (-5.6%, P = 0.000), a reduction in the percentage of smokers [odds ratio (OR) 0.57, 95% confidence intervals (CI) 0.33-0.97] and a trend towards a maintained physical activity level (OR 1.28, 95% CI 0.97-1.70). No long-term effects were found. CONCLUSION: The lifestyle advice intervention was potentially effective in changing cardiovascular risk behaviours, but should be further improved to be effective in secondary cardiovascular prevention. The main limitations of the study were related to the randomization procedure and the self-selection of patients and cardiologists.

Costs of the 'Hartslag Limburg' community heart health intervention.

BACKGROUND: Little is known about the costs of community programmes to prevent cardiovascular diseases. The present study calculated the economic costs of all interventions within a Dutch community programme called Hartslag Limburg, in such a way as to facilitate generalisation to other countries. It also calculated the difference between the economic costs and the costs incurred by the coordinating institution. METHODS: Hartslag Limburg was a large-scale community programme that consisted of many interventions to prevent cardiovascular diseases. The target population consisted of all inhabitants of the region (n = 180.000). Special attention was paid to reach persons with a low socio-economic status. Costs were calculated using the guidelines for economic evaluation in health care. An overview of the material and staffing input involved was drawn up for every single intervention, and volume components were attached to each intervention component. These data were gathered during to the implementation of the intervention. Finally, the input was valued, using Dutch price levels for 2004. RESULTS: The economic costs of the interventions that were implemented within the five-year community programme (n = 180,000) were calculated to be about euro900,000. euro555,000 was spent on interventions to change people's exercise patterns, euro250,000 on improving nutrition, euro50,000 on smoking cessation, and euro45,000 on lifestyle in general. The coordinating agency contributed about 10% to the costs of the interventions. Other institutions that were part of the programme's network and external subsidy providers contributed the other 90% of the costs. CONCLUSION: The current study calculated the costs of a community programme in a detailed and systematic way, allowing the costs to be easily adapted to other countries and regions. The study further showed that the difference between economic costs and the costs incurred by the coordinating agency can be very large. Cost sharing was facilitated by the unique approach used in the Hartslag Limburg programme.

Effect of 5-year community intervention Hartslag Limburg on cardiovascular risk factors.

BACKGROUND: A widely advocated strategy in public health is community-based health promotion. The aim of this study was to investigate the net effect of a cardiovascular disease prevention program (Hartslag Limburg) on cardiovascular risk factors after 5 years of intervention. DESIGN: Cohort study comparing 5-year mean change in risk factors between the intervention and reference area. The statistical analyses for the study were performed in 2005. SETTING/PARTICIPANTS: In 1998, 3000 subjects (aged 25 to 70) from the intervention area and 895 subjects from a reference area participated in the baseline measurement. Of these, 2414 intervention subjects and 758 reference subjects completed the follow-up measurement in 2003. INTERVENTION: Hartslag Limburg is an integrative community-based cardiovascular disease prevention program promoting a healthy lifestyle. MAIN OUTCOME MEASURES: Body mass index (BMI), waist circumference, blood pressure, serum glucose (nonfasting), and serum total and high-density lipoprotein (HDL) cholesterol. RESULTS: During the 5-year follow-up, risk factors changed unfavorably in the reference group, whereas changes were less pronounced or absent in the intervention group. The adjusted difference in mean change in risk factors between intervention and reference group was significant (p<0.05) for BMI: -0.36 kg/m(2) in men and -0.25 kg/m(2) in women; waist circumference -2.9 cm in men and -2.1 cm in women; systolic blood pressure: -7.8 mmHg in men and -5.5 mmHg in women; total cholesterol 0.11 mmol/L in women and finally serum glucose -0.23 mmol/L in women. CONCLUSIONS: Hartslag Limburg succeeded in reducing-and in some cases, preventing-age- and time-related increase in BMI, waist circumference, blood pressure, and, in women, nonfasting glucose concentration.

Implementation of an innovative health service a "real-world" diffusion study.

BACKGROUND: Although reporting on the healthcare-setting level of continuance or discontinuance of an intervention once a trial is completed has been recommended, such "real-world" diffusion studies are rare. The present example was made possible by funding to explore opportunities for post-trial implementation of an innovative health counseling intervention for cardiovascular prevention in The Netherlands. METHODS: Between 2001 and 2004, in a longitudinal case study, we compared two healthcare settings: a cardiology outpatient clinic and general practices. Rogers' diffusion of innovations theory served as the theoretical background. Information was extracted from minutes of meetings and informal conversations with health counselors, and checked by the project manager. Additional data were collected from physicians with a short questionnaire. RESULTS: Implementation of the health counseling intervention was successful in the cardiology outpatient clinic, but was unsuccessful in the general practices. Success was related to a centralized diffusion system, stronger "change agent" efforts, avoidance of post-trial interruption of service delivery, easily achievable "reinventions," and positive physician perceptions of the service (i.e., not complex and compatible with current practice routines). Support came from changes in the organization of care that created opportunities for, instead of competition with, the innovative service. However, coincidental events may also have played a part. CONCLUSIONS: Our findings confirm the importance of most theoretically predicted individual and organizational diffusion variables. This implies that the implementation of innovative healthcare services requires attention at both levels.

The Dutch Heart Health Community Intervention 'Hartslag Limburg': effects on smoking behaviour.

BACKGROUND AND METHODS: A pretest-posttest control group design with two posttests was used to evaluate the effects of a regional Dutch Heart Health Community Intervention on smoking behaviour and its determinants. At baseline, a cohort research population of 1,200 smokers was recruited in the intervention region and in a control region. Data was gathered by means of short structured telephone interviews. RESULTS: No significant differences were found between the intervention region and the control region on smoking behaviour and its determinants. CONCLUSION: It is concluded that the regional intervention was unable to exceed secular trends in smoking cessation.

The Dutch Heart Health Community Intervention 'Hartslag Limburg': design and results of a process study.

In 1998, a regional cardiovascular diseases prevention program was started in The Netherlands. This paper presents the design and results of a process study on the community intervention. The main purpose of the study was to gain insight into the reasons why expected effects were or were not achieved. Data was collected using multiple data sources and/or methods to measure indicators of intervention implementation. The results indicate that the community analysis and the subsequent organization of nine local Health Committees had been satisfactory. However, some factors that might influence the actual functioning of the Health Committees could be improved. Furthermore, the expert training for the members of these Committees had not yet been carried out as planned and there were doubts about the added value of collaboration with experts thus far. Environmental strategies were felt to need more attention and ensuring long-term continuation requires continuous effort. Most of the 293 intervention activities had focused on nutrition, while smoking cessation activities had been given lowest priority. It is concluded that the process evaluation has provided information about successful and less successful elements of the community intervention.

The Dutch Heart Health community intervention 'Hartslag Limburg': results of an effect study at individual level.

'Hartslag Limburg' (Dutch for Heartbeat Limburg), a regional cardiovascular diseases (CVD) prevention program, integrates a community strategy and a high-risk strategy to reduce CVD risk behaviors. The present paper focuses on the effects of the community intervention on fat intake and physical activity. The project was based on community organization principles and health education theories and methods. In order to implement the intervention, nine local Health Committees were set up, each organizing activities that facilitate and encourage people to adopt a healthier lifestyle. A pre-test-post-test control group design with two post-tests was used to evaluate the intervention. At baseline, representative random cohort research samples were selected in the Maastricht region and in a control region. Data on fat intake and physical activity, and on the psychosocial determinants of these behaviors, were gathered by means of mail surveys. The present study indicates that the intervention had a significant effect on fat reduction, especially among respondents aged