Development and implementation of a lifestyle intervention to promote physical activity and healthy diet in the Dutch general practice setting: the BeweegKuur programme

Promotion of Physical Activity by Québec Primary Care Physicians: What Has Changed in the Last Decade?

OBJECTIVE

This study aimed to assess the changes in the frequency of physical activity (PA) counseling and in the predictors of primary care PA promotion in Québec primary care physicians (PCPs) between 2010 and 2020.

METHODS

In 2010, we conducted a survey among Québec PCPs. Questions included: frequency of promoting PA to patients, perceived barriers, needs to improve PA promotion practice, frequency of PCPs' PA practice, and sociodemographic information. In 2020, we took over the 2010 questionnaire to document the evolution of the PA promotion practice.

RESULTS

The proportion of PCPs discussing PA with their patients significantly increased (P < .05) in 2020 for the following health conditions: depression, low back pain, chronic obstructive pulmonary disease, and cancer; it declined (P < .05) for overweight patients, those with metabolic syndrome, and in primary prevention. Collaboration with PA professionals was the major need identified, and it increased in 2020. PCPs' own practice of PA was a predictor of PA promotion in 2010 (odds ratio = 6.679; P < .001) and in 2020 (odds ratio = 6.679; P < .001). In both 2010 and in 2020, older or more experienced PCPs were more likely to discuss PA with their patients without diagnosed diseases than younger ones or those with less experience.

CONCLUSIONS

Over the last 10 years, there has been a significant increase in PCPs promoting PA in Québec; however, it has been mainly oriented toward secondary prevention. It is concerning that PA counseling in primary prevention has declined, notably among younger PCPs. The stronger claim for closer collaboration with kinesiologists suggests that PCPs are in favor of an interprofessional strategy, namely collaboration with PA specialists.

Implementing Falls Prevention in Primary Care: Barriers and Facilitators

Purpose

Limited information is available concerning primary care providers’ encountered barriers and facilitators when implementing falls prevention and providing interventions in a real-life setting. This study aimed to identify barriers and facilitators when i) implementing a falls risk assessment strategy at GP practices and among community nurses and ii) providing evidence-based falls prevention interventions in a real-life setting to independently living, frail older people.

Methods

A researcher’s journal was maintained during the implementation of a falls risk assessment strategy, which entailed notes from informal conversations with GPs, practice nurses and community nurses. After implementation, two online focus groups with GPs, practice and community nurses, physio- and exercise therapists were conducted. Data were thematically analyzed.

Results

Data were collected from 32 GPs, 13 practice nurses, eight community nurses, nine physiotherapists, and two exercise therapists. The GPs and nurses acknowledged that falls prevention is part of their job, meaningful, and that they have sufficient knowledge and skills to offer falls prevention. Collaboration, a previously implemented care program for older people, resources, reimbursement for interventions, and patients’ motivation, awareness and health issues were considered to be important factors for the implementation of falls prevention. Physio- and exercise therapists described collaboration with different disciplines, receiving sufficient referrals, reimbursements, intensity and set-up of the interventions, and patients’ motivation, expectations, goals, self-confidence, awareness, and health issues as important factors when providing falls prevention interventions.

Conclusion

This study identified care provider-, context-, patient-, and innovation (strategy)-related barriers and facilitators when implementing falls prevention and providing interventions in primary care. Development of a more successful implementation strategy should focus on intensifying collaboration, reimbursement for interventions, availability of resources, and patients’ lack of motivation and health issues. Hence, falls prevention may become more structurally applied, reducing a major threat for the quality of life of independently living older people.

A phenomenological study on barriers of adherence to medical advice among type 2 diabetic patients

BACKGROUND

More than three decades of research and study for overcoming the problem of "non-acceptance/non-compliance" of patients has neither resolved nor reduced the severity of this problem. This phenomenological study aimed to identify barriers of adherence to medical advice among type 2 diabetic patients.

METHODS

This study was a qualitative research using phenomenology approach, and the data were analyzed using content analysis approach. Participants were 69 type 2 diabetic patients covered by the diabetes unit of West and East Community Health Centers of Ahvaz, Iran. The views and attitudes of patients about the barriers of adherence to medical advice were elicited by conducting 20-45 min sessions of semi-structured interviews. Data analysis was performed following Colaizzi's seven-step method.

RESULTS

Barriers of adherence to medical advice were classified into systemic and individual barriers. Individual barriers included 11 codes and 5 categories, and systemic barriers contained within 5 codes and 3 categories. Physiologic and physical factors, financial problems, occupational factors, attitudinal problems and lack of knowledge, and social and family problems were identified as individual barriers. Systemic barriers included inadequate publicizing and limited notification, inadequate equipment and facilities, and poor inter-sectional coordination.

CONCLUSIONS

Generally, problems stated by diabetic patients at the individual level can partly be solved by training patients and the people around them. However, as for the systemic problems, it seems that solving the barriers of adherence to medical advice requires coordination with other organizations as well as intersection coordination. Overall, these problems require not only comprehensive health service efforts, but also the support of policymakers to resolve barriers at infrastructure level.

Online and Offline Behavior Change Techniques to Promote a Healthy Lifestyle: A Qualitative Study

Combined lifestyle interventions (CLI) are focused on guiding clients with weight-related health risks into a healthy lifestyle. CLIs are most often delivered through face-to-face sessions with limited use of eHealth technologies. To integrate eHealth into existing CLIs, it is important to identify how behavior change techniques are being used by health professionals in the online and offline treatment of overweight clients. Therefore, we conducted online semi-structured interviews with providers of online and offline lifestyle interventions. Data were analyzed using an inductive thematic approach. Thirty-eight professionals with (n = 23) and without (n = 15) eHealth experience were interviewed. Professionals indicate that goal setting and action planning, providing feedback and monitoring, facilitating social support, and shaping knowledge are of high value to improve physical activity and eating behaviors. These findings suggest that it may be beneficial to use monitoring devices combined with video consultations to provide just-in-time feedback based on the client's actual performance. In addition, it can be useful to incorporate specific social support functions allowing CLI clients to interact with each other. Lastly, our results indicate that online modules can be used to enhance knowledge about health consequences of unhealthy behavior in clients with weight-related health risks.

An Evolving Model of Best Practice in a Community Physical Activity Program: A Case Study of "Active Herts"

BACKGROUND

Community-based physical activity programs typically evolve to respond to local conditions and feedback from stakeholders. Process evaluations are essential for capturing how programs are implemented, yet often fail to capture delivery evolution over time, meaning missed opportunities for capturing lessons learned.

METHODS

This research paper reports on a staged approach to a process evaluation undertaken within a community-based UK 12-month physical activity program that aimed to capture change and adaptation to program implementation. Twenty-five one-to-one interviews and 12 focus groups took place over the 3 years of program delivery. Participants included program participants, management, and service deliverers.

RESULTS

Program adaptations that were captured through the ongoing process evaluation included changes to the design of promotional material, program delivery content, ongoing training in behavior change, and the addition of regular participant community events. The authors address how these strands evolved over program delivery, and how the process evaluation was able to capture them.

CONCLUSION

The pragmatic evaluation approach enabled changes in response to the local context, as well as improvements in the program to be captured in a timely manner, allowing the delivery to be responsive and the evaluation flexible.

A remotely-delivered community action project to promote a diabetes lifestyle intervention programme in northwest London: basis, process and outcomes

Background : The prevalence of type 2 diabetes mellitus (T2DM) in London is rising, obesity being a major driver. As part of a primary care placement, the authors (two medical students and a lead general practitioner) directly promoted the Reducing Weight with Intensive Dietary Support (REWIND) programme to patients in Northwest London and collected feedback on the promotion. Methods : The team developed and delivered three remote interventions: a redesigned patient-facing information leaflet, phone calls and text messages, and a live, interactive webinar, to directly engage patients and raise awareness about REWIND. Feedback was collected pre and post-webinar using an anonymised, online survey (essentially functioning as a 'teaching' evaluation). Results : Mean interest in REWIND had increased from 2.7 (pre-promotion) to 4.7 (post-promotion), knowledge about REWIND had increased from 2.1 to 4, and self-reported likelihood of enrolling had increased from 2.6 to 4.2 (P<0.01 in all cases). The reported usefulness of the leaflet and webinar was scored 3.7 and 4.4 respectively. Within two weeks of the webinar, two of these patients had joined REWIND. Conclusion : Feedback from the patients and GP revealed that the project successfully raised awareness, improved knowledge, and increased the likelihood of enrolment in REWIND. Diabetes programmes and organisations are encouraged to adapt the methods of this project to their own contexts, especially in light of COVID-19 where remote interventions will remain essential.

The added value of frequent physical activity group sessions in a combined lifestyle intervention: A cluster randomised trial in primary care

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A combined lifestyle intervention improves lifestyle in overweight and obese subjects.

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Real-world setting study shows that changed lifestyle after a combined lifestyle intervention can be sustained.

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Adding group sessions with a physiotherapist had no added value.

Combined lifestyle interventions (CLIs) that target both physical activity (PA) and diet have been shown to improve PA and health of adults who are overweight; however, optimal amount of guidance remains unclear. This study evaluated the effects of adding PA group sessions to a standard CLI in primary care in the Netherlands. 411 participants (BMI 34.5 ± 4.4 kg/m²) in thirty locations were randomised into a one year CLI or CLI+. CLI comprised individual meetings with lifestyle coach (LSC) and physiotherapist, and group meetings with dietician. PA group sessions were added in CLI+. Primary outcome was minutes of moderate to vigorous PA per week. Secondary outcomes of PA, diet and cardiovascular risk factors (i.e. waist circumference, HbA1c and blood pressure) were evaluated after 12 and 24 months with multilevel analyses. Data were collected from 2010 to 2015. Significant between-group effects were only found for waist circumference, which was significantly lower at twelve months in the CLI+ group (p = 0.011), no other between-group differences were found. Several within-group changes were significant. After participating in the intervention, walking time increased with 83 ± 35 min/week and 100 ± 38 min/week, and BMI decreased with 0.7 ± 0.3 kg/m² and 1.5 ± 0.3 kg/m² in CLI and CLI+ respectively (p < 0.001). Diet, HbA1c and systolic blood pressure changed favourably in both groups. Adding PA group sessions did not elicit added, sustained benefits. A programme with individual meetings with LSC and physiotherapist, and group meetings with dietician can be sufficient to facilitate a healthy lifestyle and reduce cardiovascular risk factors in a population with overweight.

Barrier-belief lifestyle counseling in primary care: A randomized controlled trial of efficacy

OBJECTIVE

Intervening on barrier beliefs (BBs) may inhibit the role of barriers as mediating factors in lifestyle behavior. The aim of this study was to analyze the effects of a barrier-belief counseling intervention (BBCI) on physical activity (PA) and healthy food intake.

METHODS

An RCT was conducted in a primary care setting among adults (aged 18-70), with two interventions: a BBCI (n = 123) and a standardized lifestyle group intervention (SLI) (n = 122). A non-treated hanging control group (n = 36) received no intervention. Outcomes on PA (accelerometer and SQUASH) and fruit and vegetable intake (self-report) were measured with follow-ups at 6, 12 and 18 months, and analyzed using multiple regression.

RESULTS

The BBCI was more effective on PA compared with the SLI (p < .01): in the short term all PA outcomes improved (p < .05), in the long term moderate-to-vigorous PA outcomes improved (p < .05), all with small effect sizes. No differences between interventions were found on fruit and vegetable intake. None of the outcomes in the control group changed over time.

CONCLUSIONS

BBCI in primary care improves PA compared with SLI.

PRACTICE IMPLICATIONS

The customized BB approach seems promising for implementation in healthcare practice to stimulate PA.

Evaluation of a combined lifestyle intervention for overweight and obese patients in primary health care: a quasi-experimental design

BACKGROUND

Combined lifestyle interventions (CLIs) are designed to reduce risk factors for lifestyle-related diseases through increasing physical activity and improvement of dietary behaviour.

OBJECTIVE

To evaluate the effects of a CLI for overweight and obese patients on lifestyle-related risk factors and health care consumption, in comparison to usual care.

METHODS

Data on anthropometric and metabolic measurements, morbidity, drugs prescriptions and general practitioner (GP) consultations were extracted from electronic health records (timeframe: July 2009-August 2013). Using a quasi-experimental design, health outcomes of 127 patients who participated in a 1-year CLI were compared to a group of 254 matched patients that received usual care. Baseline to post-intervention changes in health outcomes between intervention and comparison group were evaluated using mixed model analyses.

RESULTS

Compared to baseline, both groups showed reductions in body mass index (BMI), blood pressure, total cholesterol and low density lipoprotein cholesterol in year post-intervention. For these outcome measures, no significant differences in changes were observed between intervention and comparison group. A significant improvement of 0.08 mmol/l in high density lipoprotein (HDL) cholesterol was observed for the intervention group above the comparison group (P < 0.01). No significant intergroup differences were shown in drugs prescriptions and number of GP consultations.

CONCLUSION

A CLI for overweight and obese patients in primary health care resulted in similar effects on health outcomes compared to usual care. Only an improvement on HDL cholesterol was shown. This study indicates that implementation and evaluation of a lifestyle intervention in primary health care is challenging due to political and financial barriers.

Physical and social environmental changes to promote walking among Dutch older adults in deprived neighbourhoods: the NEW.ROADS study

BACKGROUND

Physical activity is important for healthy ageing, and daily walking is seen as a feasible way to be active at older ages. Yet, many older persons, particularly in lower socioeconomic groups and residing in deprived neighbourhoods, are insufficiently active. Creating a physical and social neighbourhood environment that is more supportive for walking has the potential to improve walking behaviour. Current evidence of the impact of changes to the physical and/or social environmental on walking behaviour is scarce. The aim of the NEW.ROADS study is to design, implement and evaluate changes to the physical and social environment for the purpose of increasing walking behaviour among older residents of deprived neighbourhoods.

METHODS

Physical and social environmental interventions were developed by matching scientific evidence on environmental determinants of walking, with input from the target population and stakeholders, and ongoing neighbourhood activities. Specifically, a neighbourhood walking route was designed and marked, and neighbourhood walking groups were organised. These environmental interventions were evaluated in a four-armed experimental study. In addition, the design of the study to evaluate the effect of these environmental changes on walking behaviour is described.

DISCUSSION

Designing and implementing environmental interventions is a complex endeavour, challenged by limited available theory and evidence. Input from the target population and professional stakeholders is essential, but may also put constraints on the evaluation.

TRIAL REGISTRATION

NTR3800 (registered 9/1/2013).

Factors influencing the introduction of physical activity interventions in primary health care: a qualitative study

BACKGROUND

The introduction of efficacious physical activity (PA) interventions in routine primary health care (PHC) is a complex process. Understanding factors influencing the process can enhance the development of successful introduction strategies.

PURPOSE

The aim of this qualitative study was to explore stakeholders' perceptions on factors influencing the introduction, i.e., adoption, implementation, and continuation, of PA interventions in PHC.

METHOD

Twenty-eight semistructured interviews were held with intervention managers, PHC advisors, intervention providers, and referring general practitioners of five PA interventions delivered in PHC. A theoretical framework on the introduction of innovations in health care was used to guide the data collection. Influencing factors were identified using thematic analysis.

RESULTS

Stakeholders reported preconditions for the introduction of PA interventions in PHC (e.g., support, resources, and networks and collaborations), in addition to characteristics of PA interventions (e.g., compatibility, flexibility, and intervention materials) and characteristics of PHC professionals (e.g., knowledge, positive attitudes, and beliefs about capabilities) perceived to enhance the introduction process. Furthermore, they proposed strategies for the development of PA interventions (e.g., involvement of future stakeholders, full development, and refinement) and strategies to introduce PA interventions in PHC (e.g., training, assistance, and reinforcement). The majority of the influencing factors were discussed specifically in relation to one or two stages.

CONCLUSION

This study presents an overview of factors that are perceived to influence the introduction of PA interventions in PHC. It underscores the importance of taking these factors into account when designing introduction strategies and of giving special attention to the distinct stages of the process.

Facilitators and barriers in the collaboration between the primary care and the sport sector in order to promote physical activity: A systematic literature review

INTRODUCTION

The aim of this review was to identify collaborative initiatives between the primary care and the sport sector in order to promote physical activity (PA), and barriers and facilitators in these initiatives.

METHOD

Pubmed, SportDiscus, Web of Science, and SOCindex were systematically searched for publications published between 2000 and June 2014. Publications reporting on collaboration between the primary care and the sport sector to promote PA were included. Publications reporting on non-empirical data were excluded, except for study protocols.

RESULTS

The search process yielded 1352 publications. After selection, 40 publications were included. Twenty-eight different initiatives were divided into four forms of collaboration, and two approaches to promote PA were distinguished with different kinds of facilitators and barriers. In the referral of patients, sport professionals' lack of medical knowledge, and health professionals' lack of time, were seen as barriers. In networks to organize activities to promote PA among the community, different shared interests and different cultures were seen as barriers.

CONCLUSION

This review showed that performance of intersectoral collaboration and the collaboration between both sectors are still unexplored. This review provides a first step towards an insight into collaboration and factors that facilitate or hinder collaboration between these sectors.

One-Year Results of the BeweegKuur Lifestyle Intervention Implemented in Dutch Primary Healthcare Settings

Background. Lifestyle interventions focusing on healthy diet and physical activity (PA) are effective in reducing health risks in controlled research settings. The aim of this study was to investigate the one-year results of the BeweegKuur lifestyle intervention implemented nationwide in Netherlands for people with a weight-related health risk. Materials and Methods. Data were requested from all 160 locations participating in the BeweegKuur. In a one group pretest/posttest study, one-year changes in health outcome variables and time spent on physical activity were tested with dependent t-tests. Associations between one-year changes in weight and waist circumference and sociodemographic factors and uptake of the program were analysed with ANOVA. Results. Data for 517 participants from 47 locations were available for analysis. One year after the intervention, weight reduced by 2.9 kg (95% CI -3.3;, -2.5), waist circumference by 4.3 cm (-4.9; -3.7), and blood glucose by 0.5 mmol/L (-0.8; -0.3). Physical activity increased significantly. Higher uptake of the program was associated with a larger decrease in waist circumference. Conclusion. The results of the study suggest that lifestyle interventions implemented in real-life primary healthcare settings with tailor-made supervision can contribute meaningfully to primary prevention.

Collaboration of general practitioners and exercise providers in promotion of physical activity a written survey among general practitioners

BACKGROUND

General practitioners have an ideal position to motivate inactive patients to increase their physical activity. Most patients are able to exercise in regular local facilities outside the health care setting. The purpose of this study was to get insight into general practitioners perceptions and current practices regarding referral of patients to local exercise facilities. Furthermore, collaboration with exercise providers in the community was investigated, and motivators and barriers for referral.

METHODS

A written questionnaire sent to a representative random sample of 800 Dutch general practitioners. Descriptive statistics and Chi(2) tests were used.

RESULTS

All responding general practitioners (340) recommend their patients to take more exercise when necessary and 87 % say to refer patients sometimes. Limited motivation of the patient (44 %) and reduced health status (34 %) are the most mentioned barriers for advising patients to increase physical activity. When referred, most patients are send to a physical therapist (69 %) but also local exercise facilities were mentioned (54 %). The most important barrier for referring patients to local exercise activities are patients limited financial possibilities (46 %). Restricted knowledge of local exercise- or sport facilities was an additional barrier (19 %). There is little structural collaboration between general practitioners and exercise providers, but when collaboration exists general practitioners refer more often. Positive experiences of patients (67 %), affordable offers (59 %) and information of local exercise facilities (46 %) are seen as important promoting factors for referral. Although 32 % of the general practitioners think that good collaboration would be stimulating, regular meetings with sports and exercise providers were considered the least important for increasing referral (3 %).

CONCLUSIONS

Dutch physicians have a positive attitude towards stimulating physical activity but referral to local exercise facilities is low. Referral is partly hindered by restricted knowledge of local exercise facilities. Although general practitioners think that collaboration is important for physical activity promotion, it should not cost them much extra time. A coordinator with knowledge of the local situation can facilitate contacts between GP practices and sports providers.

Making the connection-factors influencing implementation of evidence supported and non-evaluated lifestyle interventions in healthcare: a multiple case study

Many implementation barriers relate to lifestyle interventions (LIs) being developed by scientists. Exploring whether implementation of non-evaluated LIs is less complicated, might offer insight how to improve the use of effective interventions. This study aimed to identify influencing factors for implementation and compare factors between evidence supported and non-evaluated LIs. Evidence-supported (n = 7) and non-evaluated LIs (n = 7) in hospitals, general practices and community care organizations were included as cases. Semi-structured interviews (n = 46) were conducted. Additionally, documents (n = 207) were collected describing intervention, implementation process, and policy. We used a stepwise approach to inductively identify factors, organize them by diffusion phase, and an existing framework. A total of 37 factors were identified. 'Dissemination' factors were mainly observed in evidence-supported LIs. 'Compatibility to existing structures' ('adoption'), 'funding' and 'connection to existing care processes' ('implementation') was factors identified in all cases. 'Quality control' and 'ongoing innovation' ('maintenance') were reported in evidence-supported interventions. In all domains of the framework factors were observed. Factors identified in this study are in line with the literature. The findings do not support the assumption that implementation of non-evaluated LIs is perceived as less complex.

Factors influencing primary health care professionals' physical activity promotion behaviors: a systematic review

BACKGROUND

Despite the promising findings related to the efficacy of interventions aimed at promoting physical activity (PA) in primary health care (PHC), the translation of these interventions to PHC practice does not always happen as desired.

PURPOSE

To help understand why efficacious PHC-based PA interventions are not effectively translated to practice, this study systematically reviewed the literature on factors influencing PHC professionals' PA promotion practices.

METHOD

Literature searches were conducted in Web of Science, PubMed, and PsycINFO for peer-reviewed articles published in English from 1990 onwards. Studies were included that met the following criteria: (1) involving PHC-based PA interventions, and (2) reporting factors influencing PHC professionals' PA promotion behaviors. Two researchers independently screened studies and extracted data. A narrative synthesis using thematic analysis was conducted to identify factors.

RESULTS

Of the 4,469 identified articles, 59 were included in the review. Factors were identified by qualitative methods, barrier/facilitator ratings, and the examination of the relationship between factors and PA promotion, and the effectiveness of introduction strategies. Many factors related to the development, delivery, and effects of the innovation, the sociopolitical and organizational culture, resources, and support, patient and PHC professional characteristics, and innovation strategies were identified as potential influences on PHC professionals' PA promotion practices. However, the lack of evidence on the relationship between factors and PA promotion indicated insufficient evidence on PA promotion determinants.

CONCLUSION

This extensive overview of potential factors can inform intervention developers and implementers on which factors may play a role when introducing PA interventions in PHC. Future research should further investigate relationships between factors and PA promotion, which should be guided by qualitative in-depth knowledge on influencing factors.

Factors associated with physical therapists' implementation of physical activity interventions in The Netherlands

BACKGROUND

Physical therapists play an important role in the promotion of physical activity (PA) and the effectiveness of PA interventions. However, little is known about the extent to which they implement PA interventions following the intervention protocol and about the factors influencing their implementation behaviors.

OBJECTIVE

The study objective was to investigate physical therapists' implementation fidelity regarding PA interventions, including completeness and quality of delivery, and influencing factors with a Theoretical Domains Framework-based questionnaire.

DESIGN

The study was based on a cross-sectional design.

METHODS

A total of 268 physical therapists completed the Determinants of Implementation Behavior Questionnaire. Questions about completeness and quality of delivery were based on components and tasks of PA interventions as described by the Royal Dutch Society for Physical Therapy. Multilevel regression analyses were used to identify factors associated with completeness and quality of delivery.

RESULTS

High implementation fidelity was found for the physical therapists, with higher scores for completeness of delivery than for quality of delivery. Physical therapists' knowledge, skills, beliefs about capabilities and consequences, positive emotions, behavioral regulation, and the automaticity of PA intervention delivery were the most important predictors of implementation fidelity. Together, the Theoretical Domains Framework accounted for 23% of the variance in both total completeness and total quality scores.

LIMITATIONS

The cross-sectional design precluded the determination of causal relationships. Also, the use of a self-report measure to assess implementation fidelity could have led to socially desirable responses, possibly resulting in more favorable ratings for completeness and quality.

CONCLUSIONS

This study enhances the understanding of how physical therapists implement PA interventions and which factors influence their behaviors. Knowledge about these factors may assist in the development of strategies to improve physical therapists' implementation behaviors.

The implementation and sustainability of a combined lifestyle intervention in primary care: mixed method process evaluation

BACKGROUND

The impact of physical inactivity and unhealthy diet on health is increasingly profound. Lifestyle interventions targeting both behaviors simultaneously might decrease the prevalence of overweight and comorbidities. The Dutch 'BeweegKuur' is a combined lifestyle intervention (CLI) in primary care, to improve physical activity and dietary behavior in overweight people. In a cluster randomized controlled trial, the (cost-) effectiveness of an intensively guided program has been compared to a less intensively guided program. This process evaluation aimed to assess protocol adherence and potential differences between clusters. In addition, sustainability (i.e. continuation of the CLI in practice after study termination) was evaluated.

METHODS

Existing frameworks were combined to design the process evaluation for our intervention and setting specifically. We assessed reach, fidelity, dose delivered and received, context and implementation strategy. Both qualitative and quantitative data were used for a comprehensive evaluation. Data were collected in semi-structured interviews with health care providers (HCPs, n = 25), drop-out registration by HCPs, regular questionnaires among participants (n = 411) and logbooks kept by researchers during the trial.

RESULTS

Protocol adherence by professionals and participants varied between the programs and clusters. In both programs the number of meetings with all HCPs was lower than planned in the protocol. Participants of the supervised program attended, compared to participants of the start-up program, more meetings with physiotherapists, but fewer with lifestyle advisors and dieticians. The 'BeweegKuur' was not sustained, but intervention aspects, networks and experiences were still utilized after finalization of the project. Whether clusters continued to offer a CLI seemed dependent on funding opportunities and collaborations.

CONCLUSIONS

Protocol adherence in a CLI was problematic in both HCPs and participants. Mainly the amount of dietary guidance was lower than planned, and decreased with increasing guidance by PT. Thus, feasibility of changing physical activity and dietary habits simultaneously by one intervention in one year was not as high as expected. Also the sustainability of CLI was poor. When a CLI program is started, re-invention should be allowed and maximum effort should be taken to guarantee long term continuation, by planning both implementation and sustainability carefully.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN46574304 . Registered 23 December 2010.

To what extent do primary care practice nurses act as case managers lifestyle counselling regarding weight management? A systematic review

BACKGROUND

In this review study, we are the first to explore whether the practice nurse (PN) can act as case manager lifestyle counselling regarding weight management in primary care.

METHODS

Multiple electronic databases (MEDLINE, PsycINFO) were searched to identify relevant literature after 1995. Forty-five studies fulfilled the inclusion criteria. In addition, all studies were judged on ten quality criteria by two independent reviewers.

RESULTS

Especially in the last three years, many studies have been published. The majority of the studies were positive about PNs' actual role in primary care. However, several studies dealt with competency issues, including disagreement on respective roles. Thirteen studies were perceived as high quality. Only few studies had a representative sample. PNs' role in chronic disease management is spreading increasingly into lifestyle counselling. Although PNs have more time to provide lifestyle counselling than general practitioners (GPs), lack of time still remains a barrier. In some countries, PNs were rather ambiguous about their role, and they did not agree with GPs on this.

CONCLUSION

The PN can play the role of case manager lifestyle counselling regarding weight management in primary care in the UK, and wherever PNs are working under supervision of a GP and a primary health care team is already developed with agreement on roles. In countries in which a primary health care team is still in development and there is no agreement on respective roles, such as the USA, it is still the question whether the PN can play the case manager role.

Finding common ground in implementation: towards a theory of gradual commonality

This article reports on an empirical study that aimed to design a practice-based theory about collaboration on the local implementation of a nationally developed health-promoting intervention. The study's objective is to better understand the dynamic process of complex collaboration. The research is based on a Delphi study among some 100 individuals in local and regional networks, in which various professionals work together to implement the BeweegKuur, which translates as 'course of exercise'. The BeweegKuur is a combined lifestyle intervention aimed at promoting sufficient physical exercise and a healthy diet among people in the Netherlands who are overweight and at risk of diabetes. The Delphi study in three rounds systematically and interactively constructs a common perspective on implementation, reflecting stakeholders' ideas about the collaboration and providing an insight into how these ideas are influenced by the context of the implementation. The statistical and qualitative analyses of the responses to the feedback in the Delphi study form the basis for this practice-based theory on complex collaboration, called the theory of gradual commonality. During interaction, consensus gradually emerges about co-creation as a collaboration strategy. Co-creation leaves room for various ways of achieving the ambitions of the BeweegKuur. This article discusses the importance of this practice-based theory and the value of the Delphi research strategy for promoting health.

The contribution of lifestyle coaching of overweight patients in primary care to more autonomous motivation for physical activity and healthy dietary behaviour: results of a longitudinal study

Background

Combined lifestyle interventions (CLIs) have been advocated as an effective instrument in efforts to reduce overweight and obesity. The odds of maintaining higher levels of physical activity (PA) and healthier dietary behaviour improve when people are more intrinsically motivated to change their behaviour. To promote the shift towards more autonomous types of motivation, facilitator led CLIs have been developed including lifestyle coaching as key element. The present study examined the shift in types of motivation to increase PA and healthy dieting among participants of a primary care CLI, and the contribution of lifestyle coaching to potential changes in motivational quality.

Methods

This prospective cohort study included participants of 29 general practices in the Netherlands that implemented a CLI named ‘BeweegKuur’. Questionnaires including items on demographics, lifestyle coaching and motivation were sent at baseline and after 4 months. Aspects of motivation were assessed with the Behavioural Regulation and Exercise Questionnaire (BREQ-2) and the Regulation of Eating Behaviour Questionnaire (REBS). We performed a drop out analysis to identify selective drop-out. Changes in motivation were analysed with t-tests and effect size interpretations (Cohen’s d), and multivariate regression analysis was used to identify predictors of motivational change.

Results

For physical activity, changes in motivational regulation were fully in line with the tenets of Self Determination Theory and Motivational Interviewing: participants made a shift towards a more autonomous type of motivation (i.e. controlled types of motivation decreased and autonomous types increased). Moreover, an autonomy supportive coaching style was generally found to predict a larger shift in autonomous types of motivation. For healthy dietary behaviour, however, except for a small decrease in external motivation, no favourable changes in different types of motivation were observed. The relation between coaching and motivation appeared to be influenced by the presence of physical activity guidance in the programme.

Conclusions

Motivation of participants of a real life primary care CLI had changed towards a more autonomous motivation after 4 months of intervention. Autonomy-supportive lifestyle coaching contributed to this change with respect to physical activity. Lifestyle coaching for healthy diet requires thorough knowledge about the problem of unhealthy dieting and solid coaching skills.

Quality of weight-loss counseling by Dutch practice nurses in primary care: an observational study

BACKGROUND/OBJECTIVE

To assess the quality of weight-loss counseling provided by Dutch primary care practice nurses (PNs) to overweight and obese patients including both PNs' compliance with the Five A's Model for behavioral counseling in primary care, and the use of different communication styles. In addition, relationships between PN/patient characteristics (including Five A's) and communication styles will be examined.

SUBJECTS/METHODS

In this observational study, 100 videotaped real-life consultations, collected in 2010/2011, were viewed using an observational checklist. Selection of consultations was based on PNs' registration of patient's complaint. The quality of weight-loss counseling was assessed by the Five A's Model (sequence of evidence-based practice behaviors that are effective for helping patients to change health behaviors) and by PNs' communication styles. Moreover, several PN and patient characteristics were registered. Descriptive statistics and logistic regression analysis were conducted with significance set at P<0.05.

RESULTS

PNs most frequently arranged follow-up, assessed the risk and current behavior and advised. However, they rarely assisted in addressing barriers and securing support. For weight or physical activity, most PNs used a motivational communication style. In discussions of nutrition, they mostly used an informational communication style. Moreover, PNs used a combination of communication styles. PN characteristics, including their behavior concerning the Five A's, were stronger related to communication styles than patient characteristics.

CONCLUSIONS

PNs reasonably complied with the Five A's Model. The quality of PNs' weight-loss counseling might be increased by routinely providing assistance in addressing barriers and securing support, and routinely reaching agreement with collaboratively set goals.

Discriminant content validity of a theoretical domains framework questionnaire for use in implementation research

BACKGROUND

To improve the implementation of innovations in healthcare settings, it is important to understand factors influencing healthcare professionals' behaviors. We aimed to develop a generic questionnaire in English and in Dutch assessing the 14 domains of behavioral determinants from the revised TDF (Cane et al., 2012) that can be tailored to suit different targets, actions, contexts, and times of interest, and to investigate questionnaire items' discriminant content validity.

METHODS

We identified existing questionnaires including items assessing constructs within TDF domains and developed new items where needed. Nineteen judges allocated 79 items to one or more TDF domains. One-sample t-tests were used to examine the discriminant content validity of each item, i.e., whether items measured intended domains or whether items measured a combination of domains.

RESULTS

We identified items judged to discriminately measure 11 out of 14 domains. Items measuring the domains Reinforcement, Goals, and Behavioral regulation were judged to measure a combination of domains.

CONCLUSIONS

We have developed a questionnaire in English and in Dutch able to discriminately assess the majority of TDF domains. The results partly support Cane et al.'s (2012) 14-domain validation of the TDF and suggest that Michie et al.'s (2005) 12-domain original version might be more applicable in developing a TDF-based questionnaire. The identified items provide a robust basis for developing a questionnaire to measure TDF-based determinants of healthcare professionals' implementation behaviors to suit different targets, actions, contexts, and times. Future research should investigate the concurrent and predictive validity and reliability of such a questionnaire in practice.

A qualitative assessment of COPD patients' experiences of pulmonary rehabilitation and guidance by healthcare professionals

BACKGROUND

The present study aimed to assess COPD patients' experiences during an in-patient pulmonary rehabilitation program and the guidance provided by healthcare professionals. A third aim regarded examining ways to anticipate the transfer to the home environment after completion of the program.

METHODS

Focus groups and semi-structured interviews were used to collect data from seven COPD patients at the beginning and six other COPD patients at the end of an in-patient pulmonary rehabilitation program, supplemented by a focus group and semi-structured interviews with 14 healthcare professionals of the involved disciplines. Data were analyzed using a phenomenological approach.

RESULTS

Starting out, patients displayed trouble with acceptance of their disease, they had insufficient knowledge, and showed difficulties in setting specific realistic goals. Seeing fellow patients struggle with similar problems and tailored counseling by healthcare professionals helped them to overcome these barriers. During rehabilitation, patients became more confident in exercising and managing their daily life activities. Many patients evolved a desire to self-regulate their lives. Incorporating health-enhancing behaviors after returning home into their usual daily routines was anticipated to be tough.

CONCLUSION

Patients undergoing pulmonary rehabilitation experience a complex health behavior change process, in which healthcare professionals fulfill a major contributing role. Therefore, guiding patients through this health behavior change process is a vital component of healthcare professionals' work, regarding which the present study made practical implications such as applying a personalized approach by giving tailored advices, applying an autonomy-supportive counseling style, teaching self-management skills, and referring patients to local exercise facilities.

Perceptions of Dutch health care professionals regarding the Care Standard for diabetes

Background

The Netherlands can be regarded as unique in the use of the Netherlands Diabetes Federation (NDF) Care Standard (CS) for diabetes. The need to understand the barriers obstructing optimal health care, the dissemination and implementation of health care innovations into daily practice and the extent to which health care professionals actually adhere to guidelines has been emphasized repeatedly. Therefore, the aim of the present study was to suggest ways to optimize the implementation of the CS by examining the perceptions of Dutch health care professionals regarding the CS and the barriers to using it.

Methods

A cross-sectional questionnaire survey was conducted among health care professionals (N = 1547) in 2010.

Results

A total of 39.6% (N = 1323) of the participating health care professionals possessed the CS. Only 15.5% of the professionals who were to some extent familiar with the CS (N = 1100) described themselves as working in complete accordance with the CS. The majority (83.9%) thought the CS contributed greatly to ensuring the quality of care; the judgment on the feasibility of working in accordance with the CS was positive (mean = 3.9 on a 5-point Likert scale). However, professionals tended to perceive the guidelines issued by the own professional association as the norm for high quality diabetes care, rather than the CS. The main barrier to using the CS was the lack of effective lifestyle interventions (or access to them) to provide care for people with diabetes or those at increased risk for the disorder.

Conclusions

A limited percentage of health care professionals were found to posses the CS. It is questionable whether possession of the CS is a prerequisite for delivering high quality care. Overall, professionals were largely positive about the CS, although only a minority indicated they were working in complete accordance with it. Professionals and professional organizations should be further educated about the content of the CS and especially its added value with respect to the guidelines for their own professional group, in terms of the multidisciplinary approach to diabetes care. Furthermore, attention should be given to the most important perceived barriers, to facilitate adherence to the CS.

Factors influencing the adoption, implementation, and continuation of physical activity interventions in primary health care: a Delphi study

BACKGROUND

The introduction of efficacious physical activity interventions in primary health care is a complex process. Understanding factors influencing the process can enhance the development of effective introduction strategies. This Delphi study aimed to identify factors most relevant for the adoption, implementation, and continuation of physical activity interventions in primary health care by examining experts' opinions on the importance and changeability of factors previously identified as potentially relevant for the process.

METHODS

In the first round, 44 experts scored factors on their importance for each stage of the introduction process, as well as on their changeability. In the second round, the same experts received a questionnaire containing a reduced list of factors, based on the first-round results. They were asked to indicate their top-10 most important factors for each stage, and to re-rate factors' changeability. Thirty-seven experts completed this round.

RESULTS

Most important factors could be identified for each stage. Some factors were found important for a specific stage, e.g., the presence of intervention champions within the organization (adoption), provider knowledge (implementation), and the intervention's sustainability (continuation), while others were perceived important for all stages, i.e., the intervention's financial feasibility, the intervention's accessibility to the target group, and time to deliver the intervention. The majority of most important factors was perceived changeable. However, for some factors no consensus could be reached regarding their changeability.

CONCLUSIONS

This study identified general and stage-specific factors relevant for the introduction of physical activity interventions in primary health care. It emphasizes the importance of taking these factors into account when designing introduction strategies, and of giving special attention to the distinct stages of the process. Due to lack of consensus on the changeability of most important factors, the extent to which these factors can be influenced by introduction strategies remains unclear.

Perceived facilitators and barriers in diabetes care: a qualitative study among health care professionals in the Netherlands

Background

The need to understand barriers to the implementation of health care innovations in daily practice has been widely documented, but perceived facilitators and barriers in diabetes care by Dutch health care professionals remain unknown. The aim of this study was to investigate these factors among health care professionals (HCPs) using a qualitative research design.

Methods

Data were collected from 18 semi-structured interviews with HCPs from all professions relevant to diabetes care. The interviews were recorded and transcribed verbatim and the data were analyzed using NVivo 8.0.

Results

Major facilitators were the more prominent role of the practice nurses and diabetes nurses in diabetes care, benchmarking, the Care Standard (CS) of the Netherlands Diabetes federation and multidisciplinary collaboration, although collaboration with certain professional groups (i.e. dieticians, physical therapists and pharmacists), as well as the collaboration between primary and secondary care, could still be improved. The bundled payment system for the funding of diabetes care and the role of the health insurers were perceived as major barriers within the health care system. Other important barriers were reported to be the lack of motivation among patients and the lack of awareness of lifestyle programs and prevention initiatives for diabetes patients among professionals.

Conclusions

Organizational changes in diabetes care, as a result of the increased attention given to management continuity of care, have led to an increased need for multidisciplinary collaboration within and between health care sectors (e.g. public health, primary care and secondary care). To date, daily routines for shared care are still sub-optimal and improvements in facilities, such as registration systems, should be implemented to further optimize communication and exchange of information.

Baseline predictors of maintenance of intervention-induced changes in physical activity and sitting time among diabetic and pre-diabetic patients: a descriptive case series

Background

The aim of this study was to explore the predictive value of baseline characteristics in relation to changes in physical activity (PA) and sedentary behaviour among diabetic and pre-diabetic patients participating in a primary care based exercise intervention. We used a descriptive case series among diabetic and pre-diabetic patients (n = 119, 50.8% male, mean age 65.5 (SD = 7.8)). Measurements took place with questionnaires at baseline and two years after the start of the intervention. Predictor variables included demographic factors, Body Mass Index, baseline PA and sitting time, and baseline socio-cognitive profile.

Results

At follow-up, respondents spent more time being physically active than at baseline. For the total group, the average sitting time remained almost unchanged between the two measurements. Further exploration showed that respondents who had relatively high levels of PA at the start of the intervention, increased their total sitting time, while respondents with relatively low levels of PA at the start decreased their sitting time. The socio-cognitive profile did not predict behaviour change. The intervention appeared to be suitable for people with a low-education level, but the results should be interpreted in view of the limitations of the study such as the non-controlled design, self-reported outcomes and selective drop-out of participants.

Conclusions

Interventions for this specific target group may need to put more emphasis on the prevention of increased sitting time. The finding that the socio-cognitive profile did not predict behaviour change may underline the proposition that decisions to initiate and maintain PA behaviour change are to a large extend non-linear events. Acknowledging the possible non-linearity of the relationship between socio-cognitive determinants and behaviour change will help our understanding of this complex and dynamic process.

Implementation of a lifestyle intervention for type 2 diabetes prevention in Dutch primary care: opportunities for intervention delivery

Background

As in clinical practice resources may be limited compared to experimental settings, translation of evidence-based lifestyle interventions into daily life settings is challenging. In this study we therefore evaluated the implementation of the APHRODITE lifestyle intervention for the prevention of type 2 diabetes in Dutch primary care. Based on this evaluation we discuss opportunities for refining intervention delivery.

Methods

A 2.5-year intervention was performed in 14 general practices in the Netherlands among individuals at high risk for type 2 diabetes (FINDRISC-score ≥ 13) (n = 479) and was compared to usual care (n = 446). Intervention consisted of individual lifestyle counselling by nurse practitioners (n = 24) and GPs (n = 48) and group-consultations. Drop-out and attendance were registered during the programme. After the intervention, satisfaction with the programme and perceived implementation barriers were assessed with questionnaires.

Results

Drop-out was modest (intervention: 14.6 %; usual care: 13.2 %) and attendance at individual consultations was high (intervention: 80-97 %; usual care: 86-94 %). Providers were confident about diabetes prevention by lifestyle intervention in primary care. Participants were more satisfied with counselling from nurse practitioners than from GPs. A major part of the GPs reported low self-efficacy regarding dietary guidance. Lack of counselling time (60 %), participant motivation (12 %), and financial reimbursement (11 %) were regarded by providers as important barriers for intervention implementation.

Conclusions

High participant compliance and a positive attitude of providers make primary care a suitable setting for diabetes prevention by lifestyle counselling. Results support a role for the nurse practitioner as the key player in guiding lifestyle modification. Further research is needed on strategies that could increase cost-effectiveness, such as more stringent criteria for participant inclusion, group-counselling, more tailor-made counselling and integration of screening and / or interventions for different disorders.

Determinants of Dutch general practitioners' nutrition and physical activity guidance practices

OBJECTIVE

General practitioners (GP) are uniquely placed to guide their patients on nutrition and physical activity. The aims of the present study were to assess: (i) the extent to which GP guide on nutrition and physical activity; (ii) the determinants that cause GP to give guidance on nutrition and physical activity; and (iii) the extent to which these guidance practices have the same determinants.

DESIGN

Cross-sectional study, mail questionnaire.

SETTING

Dutch general practice.

SUBJECTS

Four hundred and seventy-two GP in practice for 5–30 years.

RESULTS

Our study showed that the majority of GP had similar practices for both nutrition and physical activity guidance. Fair associations were found between nutrition and physical activity guidance practices. More than half of the explained variance in the models of physical activity guidance practices was improved by the inclusion of nutrition guidance practices in the models. Moreover, GP reported higher frequencies of physical activity guidance practices than nutrition guidance practices. Nutrition guidance practices predicted the same physical activity guidance practices.

CONCLUSIONS

The majority of GP had similar practices for nutrition and physical activity guidance. GP were more inclined to guide their patients on physical activity than on nutrition. Self-efficacy was found to be a determinant in most models for guidance practices. Guidance practices proved to be a mix of prevention and treatment components. Consequently, we advise raising the selfefficacy of GP by training in medical school and in continuing medical education. We also recommend the combination of both nutrition and physical activity guidance in general practice.

Factors determining the motivation of primary health care professionals to implement and continue the 'Beweegkuur' lifestyle intervention programme

AIM

To examine factors explaining motivation among health care professionals to implement and continue a multidisciplinary primary care-based lifestyle intervention, called BeweegKuur, to support prevention and treatment of type 2 diabetes mellitus.

METHODS

Questionnaire research with two measurements among Dutch general practitioners, practice nurses and physiotherapists participating in a pilot study. At baseline, professionals were generally preparing to start the implementation. At second measurement, all practices were implementing BeweegKuur.

RESULTS

The results reveal a positive motivation among professionals to implement and continue the intervention. The motivation of practice nurses to continue implementation was lower compared with other professionals. Social support by colleagues, compatibility and perceived relative advantage of the intervention for the professionals were associates of the baseline motivation to implement it. High-baseline self-efficacy and profession (i.e. not being practice nurse) positively predicted the motivation to continue the intervention at second measurement.

CONCLUSIONS

Professionals in our study can be characterized as innovators or early adopters, and inclusion of BeweegKuur in the basic health insurance package may persuade other adoption categories to implement the intervention. An intensified focus on skills building (e.g. motivational interviewing skills, general lifestyle counselling skills) is expected to contribute to sustained high-quality implementation of the intervention.

Pre-exercise screening and health coaching in CHD secondary prevention: a qualitative study of the patient experience

Secondary prevention programmes can be effective in reducing morbidity and mortality from coronary heart disease (CHD). In particular, UK guidelines, including those from the Department of Health, emphasize physical activity. However, the effects of secondary prevention programmes with an exercise component are moderate and uptake is highly variable. In order to explore patients' experiences of a pre-exercise screening and health coaching programme (involving one-to-one consultations to support exercise behaviour change), semi-structured telephone interviews were undertaken with 84 CHD patients recruited from primary care. The interviews focused on patients' experiences of the intervention including referral and any recommendations for improvement. A thematic analysis of transcribed interviews showed that the majority of patients were positive about referral. However, patients also identified a number of barriers to attending and completing the programme, including a belief they were sufficiently active already, the existence of other health problems, feeling unsupported in community-based exercise classes and competing demands. Our findings highlight important issues around the choice of an appropriate point of intervention for programmes of this kind as well as the importance of appropriate patient selection, suggesting that the effectiveness of health coaching may be under-reported as a result of including patients who are not yet ready to change their behaviours.

Using electronic medical records analysis to investigate the effectiveness of lifestyle programs in real-world primary care is challenging: a case study in diabetes mellitus

OBJECTIVE

The increasing prevalence of diabetes suggests a gap between real world and controlled trial effectiveness of lifestyle interventions, but real-world investigations are rare. Electronic medical registration facilitates research on real-world effectiveness, although such investigations may require specific methodology and statistics. We investigated the effects of real-world primary care for patients with type 2 diabetes mellitus (T2DM).

STUDY DESIGN AND SETTING

We used medical records of patients (n=2,549) with T2DM from 10 primary health care centers. A mixed-effects regression model for repeated measurements was used to evaluate the changes in weight and Hemoglobin A1c (HbA1c) over time.

RESULTS

There was no statistically significant change in weight (+0.07 kg, P=0.832) and HbA1c (+0.03%, P=0.657) during the observation period of 972 days. Most patients maintained their physical activity level (70%), and 54 % had an insufficient activity level. The variability in the course of weight and HbA1c was because of differences between patients and not between health care providers.

CONCLUSION

Despite effective lifestyle interventions in controlled trial settings, we found that real-world primary care is only able to stabilize weight and HbA1c in patients with T2DM over time. Medical registration can be used to monitor the actual effectiveness of interventions in primary care.

Translating the SLIM diabetes prevention intervention into SLIMMER: implications for the Dutch primary health care

All over the world, prevalence and incidence rates of type 2 diabetes mellitus are rising rapidly. Several trials have demonstrated that prevention by lifestyle intervention is (cost-) effective. This calls for translation of these trials to primary health care. This article gives an overview of the translation of the SLIM diabetes prevention intervention to a Dutch real-life setting and discusses the role of primary health care in implementing lifestyle intervention programmes. Currently, a 1-year pilot study, consisting of a dietary and physical activity part, performed by three GPs, three practice nurses, three dieticians and four physiotherapists is being conducted. The process of translating the SLIM lifestyle intervention to regular primary health care is measured by means of the process indicators: reach, acceptability, implementation integrity, applicability and key factors for success and failure of the intervention. Data will be derived from programme records, observations, focus groups and interviews. Based on these results, our programme will be adjusted to fit the role conception of the professionals and the organization structure in which they work.

The BeweegKuur programme: a qualitative study of promoting and impeding factors for successful implementation of a primary health care lifestyle intervention for overweight and obese people

BACKGROUND

The aim of the study was to identify promoting and impeding factors for successful implementation of a Dutch primary health care-based lifestyle programme called 'BeweegKuur'. BeweegKuur aims to increase the physical activity and change the diet of people at increased health risk due to overweight or obesity.

OBJECTIVE

To determine perceived promoting and impeding factors in the implementation of the BeweegKuur programme for overweight and obese people.

METHODS

This study consisted of 3 focus group meetings with intervention participants, 15 interviews with health care professionals (HCPs) and 1 focus group session with dieticians. The interviews and focus groups were recorded and transcribed verbatim. The data were analysed with the Nvivo qualitative research software package.

RESULTS

For some intervention participants, the invitation to participate in BeweegKuur came unexpectedly, as they had not been diagnosed with an illness. HCPs were aware of this and took time to explain to participants that the programme was appropriate and safe for them. Participants as well as professionals were generally positive about the feasibility of the programme for overweight and obese people.

CONCLUSIONS

HCPs as well as intervention participants were motivated to participate in the programme, and generally indicated that the intervention was in accordance with their needs. The multidisciplinary approach and the combination of physical activity and dietary behaviour change can make the BeweegKuur programme a success if potential impeding factors like those identified in the present study are overcome.

Designing feasible interventions for healthy pregnancies in low-resource settings

In low-resource settings there is a need for effective interventions targeting women before and during pregnancy to improve their health outcomes and provide the best start to life for their infants. The aim of this paper is to provide an overview for designing, implementing, and evaluating such interventions. Drawing upon published literature and case studies, several key steps in the process of intervention design, implementation, and evaluation are identified. Pregnancy intervention studies in low-resource settings are challenging. Essential intervention process steps include: (1) selecting the optimal setting to pilot the intervention; (2) forming strong stakeholder collaborations; (3) identifying, understanding, and prioritizing community health problems; (4) facilitating the demand for intervention research and evidence utilization; (5) effectively implementing and evaluating the prototype intervention to provide evidence of effectiveness; and (6) planning with stakeholders for sustainability. Fundamental to any intervention for healthy pregnancies is the understanding that the process does not end with an evaluation study, but rather the end goal is to ensure successful interventions are sustainable, scalable, and integrated into health services.

Effectiveness and cost-effectiveness of 'BeweegKuur', a combined lifestyle intervention in the Netherlands: rationale, design and methods of a randomized controlled trial

Background

Improving the lifestyle of overweight and obese adults is of increasing interest in view of its role in several chronic diseases. Interventions aiming at overweight or weight-related chronic diseases suffer from high drop-out rates. It has been suggested that Motivational Interviewing and more frequent and more patient-specific coaching could decrease the drop-out rate. 'BeweegKuur' is a multidisciplinary lifestyle intervention which offers three programmes for overweight persons. The effectiveness and the cost-effectiveness of intensively guided programmes, such as the 'supervised exercise programme' of 'BeweegKuur', for patients with high weight-related health risk, remain to be assessed. Our randomized controlled trial compares the expenses and effects of the 'supervised exercise programme' with those of the less intensively supervised 'start-up exercise programme'.

Methods/Design

The one-year intervention period involves coaching by a lifestyle advisor, a physiotherapist and a dietician, coordinated by general practitioners (GPs). The participating GP practices have been allocated to the interventions, which differ only in terms of the amount of coaching offered by the physiotherapist. Whereas the 'start-up exercise programme' includes several consultations with physiotherapists to identify barriers hampering independent exercising, the 'supervised exercise programme' includes more sessions with a physiotherapist, involving exercise under supervision. The main goal is transfer to local exercise facilities. The main outcome of the study will be the participants' physical activity at the end of the one-year intervention period and after one year of follow-up. Secondary outcomes are dietary habits, health risk, physical fitness and functional capacity. The economic evaluation will consist of a cost-effectiveness analysis and a cost-utility analysis. The primary outcome measures for the economic evaluation will be the physical activity and the number of quality-adjusted life years. Costs will be assessed from a societal perspective with a time horizon of two years. Additionally, a process evaluation will be used to evaluate the performance of the intervention and the participants' evaluation of the intervention.

Discussion

This study is expected to provide information regarding the additional costs and effects of the 'supervised exercise programme' in adults with very high weight-related health risk.

Trial registration number

ISRCTN: ISRCTN46574304

Sitting time and Body Mass Index in diabetics and pre-diabetics willing to participate in a lifestyle intervention

This cross-sectional study examined the relationship between Body Mass Index (BMI), total sitting time and total physical activity time in a generally overweight or obese population of type 2 diabetics or pre-diabetics willing to participate in a lifestyle intervention [n = 221, 55.1% male, mean age (SD) 62.0 (9.9), mean BMI (SD) 31.4 (5.0)]. In addition, we aimed to identify demographic and psychosocial associates of the motivation to become more physically active. The measurement instrument was a self-report questionnaire. Results showed that total sitting time was more closely related to BMI than total physical activity time. Subjects with a higher weight status were more sedentary, but they were also more motivated to be physically active. On the other hand, their self-efficacy to be physically active was lower than subjects with a lower weight status. Lifestyle interventions to decrease the risk of obesity and type 2 diabetes should aim not only at increasing total physical activity time, but also at reducing the total sitting time. Despite generally high levels of motivation among these obese participants, intervention designers and intermediaries should be aware of their low level of self-efficacy towards being physically active.

Effect of lifestyle intervention for people with diabetes or prediabetes in real-world primary care: propensity score analysis

BACKGROUND

Many lifestyle interventions for patients with prediabetes or type 2 diabetes mellitus (T2DM) have been investigated in randomised clinical trial settings. However, the translation of these programmes into primary care seems challenging and the prevalence of T2DM is increasing. Therefore, there is an urgent need for lifestyle programmes, developed and shown to be effective in real-world primary care. We evaluated a lifestyle programme, commissioned by the Dutch government, for patients with prediabetes or type 2 diabetes in primary care.

METHODS

We performed a retrospective comparative medical records analysis using propensity score matching. Patients with prediabetes or T2DM were selected from ten primary healthcare centres. Patients who received the lifestyle intervention (n = 186) were compared with a matched group of patients who received usual care (n = 2632). Data were extracted from the electronic primary care records. Propensity score matching was used to control for confounding by indication. Outcome measures were exercise level, BMI, HbA1c, fasting glucose, systolic and diastolic blood pressure, total cholesterol, HDL and LDL cholesterol and triglycerides and the follow-up period was one year.

RESULTS

There was no significant difference at follow-up in any outcome measure between either group. The reduction at one year follow-up of HbA1c and fasting glucose was positive in the intervention group compared with controls, although not statistically significant (-0.12%, P = 0.07 and -0.17 mmol/l, P = 0.08 respectively).

CONCLUSIONS

The effects of the lifestyle programme in real-world primary care for patients with prediabetes or T2DM were small and not statistically significant. The attention of governments for lifestyle interventions is important, but from the available literature and the results of this study, it must be concluded that improving lifestyle in real-world primary care is still challenging.