Sophia C Jansen

Adapting the SLIM diabetes prevention intervention to a Dutch real-life setting: joint decision making by science and practice

BackgroundAlthough many evidence-based diabetes prevention interventions exist, they are not easily applicable in real-life settings. Moreover, there is a lack of examples which describe the adaptation process of these interventions to practice. In this paper we present an example of such an adaptation. We adapted the SLIM (Study on Lifestyle intervention and Impaired glucose tolerance Maastricht) diabetes prevention intervention to a Dutch real-life setting, in a joint decision making process of intervention developers and local health care professionals.MethodsWe used 3 adaptation steps in accordance with current adaptation frameworks. In the first step, the elements of the SLIM intervention were identified. In the second step, these elements were judged for their applicability in a real-life setting. In the third step, adaptations were proposed and discussed for those elements which were deemed not applicable. Participants invited for this process included intervention developers and local health care professionals (n=19).ResultsIn the first adaptation step, a total of 22 intervention elements were identified. In the second step, 12 of these 22 intervention elements were judged as inapplicable. In the third step, a consensus was achieved for the adaptations of all 12 elements. The adapted elements were in the following categories: target population, techniques, intensity, delivery mode, materials, organisational structure, and political and financial conditions. The adaptations either lay in changing the SLIM protocol (6 elements) or the real-life working procedures (1 element), or a combination of both (4 elements).ConclusionsThe positive result of this study is that a consensus was achieved within a relatively short time period (nine months) between the developers of the SLIM intervention and local health care professionals on the adaptations needed to make SLIM applicable in a Dutch real-life setting. Our example shows that it is possible to combine the perspectives of scientists and practitioners, and to find a balance between evidence-base and applicability concerns.

Feasibility and potential impact of the adapted SLIM diabetes prevention intervention in a Dutch real-life setting: The SLIMMER pilot study

OBJECTIVE Pilot-testing of the adapted Study on Lifestyle intervention and Impaired glucose tolerance Maastricht (SLIM) and to determine its feasibility and likelihood of achieving desired impact. METHODS Pilot intervention study (a 10-month combined lifestyle intervention) using a one group pre-test post-test design with on-going process measures (i.e. reach, acceptability, implementation integrity, and applicability) and several health outcomes (e.g. body weight). RESULTS In total, 31 subjects participated in the SLIMMER (SLIM iMplementation Experience Region Noord- en Oost-Gelderland) intervention. Participant weight loss was -3.5 kg (p=0.005). Both participants and health care professionals (i.e. practice nurses, dieticians, and physiotherapists) were satisfied with the intervention. The intervention was implemented as planned and appeared to be suitable for application in practice. Refinements have been identified and will be made prior to further implementation and evaluation. CONCLUSION Implementation of the SLIMMER intervention is feasible in a Dutch real-life setting and it is likely to achieve desired impact. Practising and optimising the intervention creates local support for SLIMMER among stakeholders. PRACTICE IMPLICATIONS Performing a pilot study on the basis of a structured approach is a meaningful step in the process of optimising the feasibility and potential impact of an evidence-based intervention in a real-life setting.

Using the intervention mapping protocol to develop a maintenance programme for the SLIMMER diabetes prevention intervention

BackgroundAlthough lifestyle interventions have shown to be effective in reducing the risk for type 2 diabetes mellitus, maintenance of achieved results is difficult, as participants often experience relapse after the intervention has ended. This paper describes the systematic development of a maintenance programme for the extensive SLIMMER intervention, an existing diabetes prevention intervention for high-risk individuals, implemented in a real-life setting in the Netherlands.MethodsThe maintenance programme was developed using the Intervention Mapping protocol. Programme development was informed by a literature study supplemented by various focus group discussions and feedback from implementers of the extensive SLIMMER intervention.ResultsThe maintenance programme was designed to sustain a healthy diet and physical activity pattern by targeting knowledge, attitudes, subjective norms and perceived behavioural control of the SLIMMER participants. Practical applications were clustered into nine programme components, including sports clinics at local sports clubs, a concluding meeting with the physiotherapist and dietician, and a return session with the physiotherapist, dietician and physical activity group. Manuals were developed for the implementers and included a detailed time table and step-by-step instructions on how to implement the maintenance programme.ConclusionsThe Intervention Mapping protocol provided a useful framework to systematically plan a maintenance programme for the extensive SLIMMER intervention. The study showed that planning a maintenance programme can build on existing implementation structures of the extensive programme. Future research is needed to determine to what extent the maintenance programme contributes to sustained effects in participants of lifestyle interventions.

Epidemiology in public health practice

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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.

Effectiveness of a Dutch community-based alcohol intervention: Changes in alcohol use of adolescents after 1 and 5 years.

BACKGROUND Underage alcohol drinking is a severe public health problem. The aim of this study was to evaluate the short- and long-term effects of a Dutch community-based alcohol intervention on alcohol use of adolescents in the second and fourth grade of high school. METHODS The community intervention integrated health education, regulation, and enforcement in multiple settings, targeting adolescents as well as their environments. In order to evaluate effectiveness, a quasi-experimental pretest posttest design was used based on three independent cross-sectional surveys in 2003, 2007 and 2011, resulting in an analytical sample of approximately 5700 and 3100 adolescents in the intervention and reference region, respectively. For the main analyses, we compared the change in recent alcohol use and binge drinking in the intervention region with the reference region. Linear regression was used to obtain (adjusted) prevalence of alcohol use. RESULTS During the study period, there was an overall decline in the prevalence of alcohol use. After 1 year of intervention, the decline was 11% (P<0.01) and 6% (P<0.01) stronger in the intervention region as compared to the reference region, for recent alcohol use and binge drinking respectively. This effect was restricted to the second grade and remained after 5 years of intervention. No clear subgroup effects or confounding were observed for ethnicity, gender or educational level. CONCLUSIONS The Dutch community intervention appears to be effective on the short- and long-term in reducing the prevalence of recent alcohol use and binge drinking of (underage) adolescents in the second grade of high school.

Effect and maintenance of the SLIMMER diabetes prevention lifestyle intervention in Dutch primary healthcare: a randomised controlled trial

Background/Objectives: To assess the effectiveness of the SLIMMER combined dietary and physical activity lifestyle intervention on clinical and metabolic risk factors, dietary intake, physical activity, and quality of life after 12 months, and to investigate whether effects sustained six months after the active intervention period ended. Subjects/Methods: SLIMMER was a randomised controlled intervention, implemented in Dutch primary healthcare. In total, 316 subjects aged 40–70 years with increased risk of type 2 diabetes were randomly allocated to the intervention group (10-month dietary and physical activity programme) or the control group (usual healthcare). All subjects underwent an oral glucose tolerance test and physical examination, and filled in questionnaires. Identical examinations were performed at baseline and after 12 and 18 months. Primary outcome was fasting insulin. Results: The intervention group showed significantly greater improvements in anthropometry and glucose metabolism. After 12 and 18 months, differences between intervention and control group were -2.7 kg (95% confidence interval (CI): −3.7; −1.7) and −2.5 kg (95% CI: −3.6; −1.4) for weight, and −12.1 pmol l−1 (95% CI: −19.6; −4.6) and −8.0 pmol l−1 (95% CI: −14.7; −0.53) for fasting insulin. Furthermore, dietary intake, physical activity, and quality of life improved significantly more in the intervention group than in the control group. Conclusions: The Dutch SLIMMER lifestyle intervention is effective in the short and long term in improving clinical and metabolic risk factors, dietary intake, physical activity, and quality of life in subjects at high risk of diabetes.

Process evaluation of a randomised controlled trial of a diabetes prevention intervention in Dutch primary health care: the SLIMMER study

OBJECTIVE To investigate (i) how the SLIMMER intervention was delivered and received in Dutch primary health care and (ii) how this could explain intervention effectiveness. DESIGN A randomised controlled trial was conducted and subjects were randomly allocated to the intervention (10-month combined dietary and physical activity intervention) or the control group. A process evaluation including quantitative and qualitative methods was conducted. Data on process indicators (recruitment, reach, dose received, acceptability, implementation integrity and applicability) were collected via semi-structured interviews with health-care professionals (n 45) and intervention participant questionnaires (n 155). SETTING SLIMMER was implemented in Dutch primary health care in twenty-five general practices, eleven dietitians, nine physiotherapist practices and fifteen sports clubs. SUBJECTS Subjects at increased risk of developing type 2 diabetes were included. RESULTS It was possible to recruit the intended high-risk population (response rate 54 %) and the SLIMMER intervention was very well received by both participants and health-care professionals (mean acceptability rating of 82 and 80, respectively). The intervention programme was to a large extent implemented as planned and was applicable in Dutch primary health care. Higher dose received and participant acceptability were related to improved health outcomes and dietary behaviour, but not to physical activity behaviour. CONCLUSIONS The present study showed that it is feasible to implement a diabetes prevention intervention in Dutch primary health care. Higher dose received and participant acceptability were associated with improved health outcomes and dietary behaviour. Using an extensive process evaluation plan to gain insight into how an intervention is delivered and received is a valuable way of identifying intervention components that contribute to implementation integrity and effective prevention of type 2 diabetes in primary health care.

SLIMMER diabetes voorkomen in de eerste lijn

SamenvattingDuijzer G, Haveman-Nies A, Jansen SC, Ter Beek J, Van Bruggen R, Willink MGJ et al. SLIMMER diabetes voorkomen in de eerste lijn. Huisarts Wet 2017;60(4):160-3. De prevalentie van diabetes is de afgelopen jaren flink gestegen. Onderzoek toont aan dat leefstijlverandering diabetes mellitus type 2 bij hoogrisicopatiënten kan uitstellen of voorkomen. De implementatie en effectiviteit van preventieprogramma’s in de praktijk blijft echter een uitdaging vanwege de noodzakelijke aanpassing aan de lokale context en beperkte (financiële) middelen. Omdat in Nederland nog geen effectief diabetespreventieprogramma voor de eerste lijn bestond, is het SLIMMER-programma ontwikkeld. SLIMMER is een gecombineerde leefstijlinterventie waarbij mensen gedurende tien maanden begeleid worden om gezonder te gaan eten en meer te bewegen. In deze beschouwing bespreken we de effectiviteit van het SLIMMER-programma in de eerste lijn en vergelijken we die met de bevindingen van andere implementatieonderzoeken op dit terrein. We hebben de effectiviteit van het SLIMMER-programma onderzocht door middel van een gerandomiseerd gecontroleerd onderzoek. SLIMMER blijkt te leiden tot verbeteringen in klinische en metabole risicofactoren, voedinginname, beweging en kwaliteit van leven. Daarbij waren klinische effecten van ons programma groter dan die van de meeste andere preventieprogramma’s. Dit kan komen door de gedegen voorbereiding, het intensieve programma, het onderhoudsprogramma en aansluiting bij de reguliere werkwijze van eerstelijnszorgverleners. De resultaten van dit onderzoek bieden waardevolle inzichten die kunnen bijdragen aan structurele verankering en financiering van effectieve diabetespreventieprogramma’s in de Nederlandse eerste lijn.

Wanneer welke evaluatie-opzet: Kieswijzer voor interventies in de publieke gezondheid

SamenvattingDe evaluatie van interventies heeft een belangrijke plaats in de publieke gezondheid. Zowel praktijk, beleid als wetenschap zijn gebaat bij een antwoord op de vraag: werkt de interventie? Welke evaluatie-opzet gebruikt moet worden om deze vraag te beantwoorden, hangt af van het type interventie en de resultaten die men wil bereiken. Wij zijn ervan overtuigd dat zowel de evaluatie-opzet zonder controlegroep, de evaluatie-opzet met controlegroep en de randomised controlled trial (rct) bestaansrecht hebben in de publieke gezondheid. Om de juiste evaluatie-opzet te kunnen kiezen, zijn twee zaken van doorslaggevend belang. Ten eerste het niveau van resultaten dat men wil gaan meten: dichtbij of veraf van de interventie in tijd en causale keten. Voor resultaten dichtbij de interventie volstaat de evaluatie-opzet zonder controlegroep, voor resultaten verder weg is een controlegroep noodzakelijk. De tweede doorslaggevende factor is de zekerheid waarmee men de vraag: zijn de resultaten toe te schrijven aan de interventie? beantwoord wil zien. De gewenste zekerheid van conclusies bepaalt de keuze tussen de evaluatie-opzet met controlegroep en de rct. Op basis van deze principes hebben wij de Kieswijzer ontwikkeld. Deze Kieswijzer faciliteert de keuze van de evaluatie-opzet voor interventies in de publieke gezondheid.AbstractWhen to use which design: ‘Roadmap’ for the evaluation of public health interventionsThe evaluation of interventions becomes more and more important in public health. Public health practice, policy and science all benefit from an answer to the question: does the intervention work? The evaluation design that should be used to answer this question, depends on the type of intervention and the results aimed at. We are convinced that the evaluation design without control group, the evaluation design with control group and the randomised controlled trial (rct) all have the right to exist in public health. To ensure the choice of the right evaluation design, two things are of major importance. First, the outcome level one wants to measure: closeby or distant from the intervention in time and causal chain. For outcome levels closeby, the evaluation design without control group is sufficient; for outcome levels further away, a control group is necessary. The second crucial factor is how sure one wants to be about attributing the results to the intervention. The desired certainty of conclusions determines the choice between the evaluation design with control group and the rct. Based on these principles, we developed the ‘Roadmap’. This ‘Roadmap’ facilitates the choice of the evaluation design for public health interventions.Key words: evaluation, design, internal validity, interventions, public health, health promotion.