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

Race and sex differences in dropout from the STRRIDE trials

Purpose

To determine if race and sex differences exist in determinants and timing of dropout among individuals enrolled in an exercise and/or caloric restriction intervention.

Methods

A total of 947 adults with dyslipidemia (STRRIDE I, STRRIDE AT/RT) or prediabetes (STRRIDE-PD) were randomized to either inactive control or to 1 of 10 exercise interventions, ranging from doses of 8-23 kcal/kg/week, intensities of 50%-75% V ˙ O 2 peak, and durations of 6-8 months. Two groups included resistance training, and one included a dietary intervention (7% weight loss goal). Dropout was defined as an individual withdrawn from the study, with the reasons for dropout aggregated into determinant categories. Timing of dropout was defined as the last session attended and aggregated into phases (i.e., "ramp" period to allow gradual adaptation to exercise prescription). Utilizing descriptive statistics, percentages were generated according to categories of determinants and timing of dropout to describe the proportion of individuals who fell within each category.

Results

Black men and women were more likely to be lost to follow-up (Black men: 31.3% and Black women: 19.6%), or dropout due to work responsibilities (15.6% and 12.5%), "change of mind" (12.5% and 8.9%), transportation issues (6.3% and 3.6%), or reported lack of motivation (6.3% and 3.6%). Women in general noted lack of time more often than men as a reason for dropout (White women: 22.4% and Black women: 22.1%). Regardless of race and sex, most participants dropped out during the ramp period of the exercise intervention; with Black women (50%) and White men (37.1%) having the highest dropout rate during this period.

Conclusion

These findings emphasize the importance of targeted retention strategies when aiming to address race and sex differences that exist in determinants and timing of dropout among individuals enrolled in an exercise and/or caloric restriction intervention.

Enhancing community weight loss groups in a low socioeconomic status area: Application of the COM-B model and Behaviour Change Wheel

Background

Obesity rates are higher among people of lower socioeconomic status. While numerous health behaviour interventions targeting obesity exist, they are more successful at engaging higher socioeconomic status populations, leaving those in less affluent circumstances with poorer outcomes. This highlights a need for more tailored interventions. The aim of this study was to enhance an existing weight loss course for adults living in low socioeconomic communities.

Methods

The Behaviour Change Wheel approach was followed to design an add‐on intervention to an existing local authority‐run weight loss group, informed by mixed‐methods research and stakeholder engagement.

Results

The COM‐B analysis of qualitative data revealed that changes were required to psychological capability, physical and social opportunity and reflective motivation to enable dietary goal‐setting behaviours. The resulting SMART‐C booklet included 6 weeks of dietary goal setting, with weekly behavioural contract and review.

Conclusion

This paper details the development of the theory‐ and evidence‐informed SMART‐C intervention. This is the first report of the Behaviour Change Wheel being used to design an add‐on tool to enhance existing weight loss services. The process benefitted from a further checking stage with stakeholders.

Self-Persuasion Increases Healthy Eating Intention Depending on Cultural Background

Unhealthy eating behavior has become a global health risk and thus needs to be influenced. Previous research has found that self-persuasion is more effective than direct persuasion in changing attitudes and behavioral intentions, but the influence of the cultural backgrounds of those being persuaded remains unclear. We conducted two studies to investigate the effectiveness of self-persuasion and direct persuasion techniques in promoting healthy eating intention among different ethnicities in the Netherlands. Native Dutch, Moroccan–Dutch, and Turkish–Dutch participated both online and offline. Participants saw a poster with either a self-persuasion message (“Why would you choose healthier food?”) or a direct persuasion message (“Choose healthier food!”), and were then asked to report their intention to eat healthily in the upcoming month. Significant cultural differences were found between native Dutch and Moroccan–Dutch in Study 1, and between the native Dutch and Turkish-Dutch who participated offline in Study 2. Accordingly, cultural background was found to moderate the relationship between persuasion and healthy eating intention among these groups. These results provided preliminary evidence for the moderation effect of persuasion on healthy eating intention: Self-persuasion appears to be more effective for people with an individualistic background, and direct persuasion appears to be more effective for people with a collectivistic background.

Physical Activity among Adults with Low Socioeconomic Status Living in Industrialized Countries: A Meta-Ethnographic Approach to Understanding Socioecological Complexities

Method

Using MeSH keywords, we searched major electronic databases including Medline, EMBASE, CINAHL, and PsycINFO in order to identify relevant publications published between January 2000 and October 2018. We included 19 qualitative studies which met inclusion criteria and were focused on physical activity determinants among adults.

Results

Determinants emerging from these studies were grouped into six themes: (i) urban environment, (ii) financial constraints, (iii) work-life integration, (iv) community engagement, (v) social support, and (vi) psychosocial factors. After conceptualising these six themes into a social ecological model, we identified potential research gaps for physical activity among adults with low socioeconomic status living in industrialized countries.

Conclusion

Our major insight was that, in industrialized countries, physical activity overlooks potential strengths to maintain health and well-being of those people with low socioeconomic status. A more complex understanding of contradictions between positive and deficit frames would lead to more critical insights of research gaps of physical activity in adult population with low socioeconomic status.

Geographic Disparities in Previously Diagnosed Health Conditions in Colorectal Cancer Patients Are Largely Explained by Age and Area Level Disadvantage

Background: Geographical disparity in colorectal cancer (CRC) survival rates may be partly due to aging populations and disadvantage in more remote locations; factors that also impact the incidence and outcomes of other chronic health conditions. The current study investigates whether geographic disparity exists amongst previously diagnosed health conditions in CRC patients above and beyond age and area-level disadvantage and whether this disparity is linked to geographic disparity in CRC survival.

Methods: Data regarding previously diagnosed health conditions were collected via computer-assisted telephone interviews with a cross-sectional sample of n = 1,966 Australian CRC patients between 2003 and 2004. Ten-year survival outcomes were acquired in December 2014 from cancer registry data. Multivariate logistic regressions were applied to test associations between previously diagnosed health conditions and survival rates in rural, regional, and metropolitan areas.

Results: Results suggest that only few geographical disparities exist in previously diagnosed health conditions for CRC patients and these were largely explained by socio-economic status and age. Living in an inner regional area was associated with cardio-vascular conditions, one or more respiratory diseases, and multiple respiratory diagnoses. Higher occurrences of these conditions did not explain lower CRC-specific 10 years survival rates in inner regional Australia.

Conclusion: It is unlikely that health disparities in terms of previously diagnosed conditions account for poorer CRC survival in regional and remote areas. Interventions to improve the health of regional CRC patients may need to target issues unique to socio-economic disadvantage and older age.

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

Background

Evaluation of the implementation process of trials is important, because the way a study is implemented modifies its outcomes. Furthermore, lessons learned during implementation can inform other researchers on factors that play a role when implementing interventions described in research. This study evaluates the implementation of the MetSLIM study, targeting individuals with low socioeconomic status of different ethnic origins. The MetSLIM study was set up to evaluate the effectiveness of a lifestyle programme on waist circumference and other cardio-metabolic risk factors. The objective of this evaluation was to identify components that were essential for the implementation of the MetSLIM study and to inform other researchers on methodological aspects when working with inadequately reached populations in health research.

Methods

In this evaluation study the experiences of health professionals, study assistants, a community worker and regional research coordinators involved in the MetSLIM study were explored using semi-structured interviews. Questionnaires were used to evaluate participants’ satisfaction with the lifestyle intervention.

Results

Our analyses show that a flexible recruitment protocol eventually leads to recruitment of sufficient participants; that trust in the recruiter is an important factor in the recruitment of individuals with low socioeconomic status of different ethnic origins; and that health professionals will unavoidably shape the form of intervention activities. Furthermore, our evaluation shows that daily practice and research mutually influence each other and that the results of an intervention are a product of this interaction.

Conclusions

Health promotion research would benefit from a perspective that sees intervention activities not as fixed entities but rather as social interaction that can take on numerous forms. Analysing and reporting the implementation process of studies, like in this evaluation, will allow readers to get a detailed view on the appropriateness of the (intended) study design and intervention for the targeted population. Evaluation studies that shed light on the reasons for adaptations, rather than describing them as deviation from the original plan, would point out methodological aspects important for a study’s replication. Furthermore, they would show how various factors can influence the implementation, and therewith initiate a learning cycle for the development of future intervention studies.

Trial registration

Netherlands Trial Register NTR3721 (since November 27, 2012).

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

Objective

To evaluate whether the lifestyle intervention MetSLIM targeting individuals of low socio-economic status of Turkish, Moroccan and Dutch origin was successful in improving waist circumference and other cardiometabolic risk factors, lifestyle behaviour and quality of life.

Design

A quasi-experimental intervention study (Netherlands Trial Register NTR3721). The intervention group participated in a 12-month combined dietary and physical activity programme. Examinations were performed at baseline and after 12 months. Participants underwent anthropometric measurements and blood withdrawal, and completed questionnaires on dietary intake, physical activity and quality of life.

Setting

Socio-economically deprived neighbourhoods in two Dutch cities, involving non-blinded ethnicity-matched and gender-matched research assistants, dietitians and sports instructors.

Subjects

Mainly Turkish (49 %) and Dutch (36 %) subjects, aged 30–70 years, with a waist-to-height ratio of >0·5 (intervention,n117; control,n103). Dropout was 31 %.

Results

At 12 months, the intervention group showed greater improvements than the control group in waist circumference (β=−3·3 cm, 95 % CI −4·7, −1·8,P<0·001) and other obesity measures. Additionally, greater reductions were observed for total cholesterol (β=−0·33 mmol/l, 95 % CI −0·56, −0·10,P=0·005) and LDL cholesterol (β=−0·35 mmol/l, 95 % CI −0·56, −0·14,P=0·001). Dietary changes were significant for fibre intake (β=1·5 g/4184 kJ (1000 kcal), 95 % CI 0·3, 2·7,P=0·016). Compared with the control group, the intervention group reported a decrease in total minutes of physical activity (β=−573 min/week, 95 % CI −1126, −21,P=0·042) and showed improvements in the quality-of-life domains ‘health transition’ and ‘general health’.

Conclusions

MetSLIM was shown to be effective in improving waist circumference, total and LDL cholesterol, and quality of life among Dutch and Turkish individuals living in deprived neighbourhoods.