Effect of an entry-to-care intervention on diabetes distress in individuals with newly diagnosed type 2 diabetes: a study protocol for a cluster-randomized trial.

BACKGROUND: Diabetes distress (DD) affects at least 36% of T2DM patients and is often associated with insufficient support and care. This study examines an intervention that targets DD through enhanced cross-sectoral collaboration and treatment during the first 3 months following diagnosis. The intervention aims to improve care and self-management and to reduce DD. METHODS AND INTERVENTION: The study is designed as a cluster-randomized trial with the intervention focusing on four key elements of diabetes care: effective cross-sectoral communication and information sharing, systematic care, a "one-stop-shop" health screening and start-up conversation at the municipality, and improving patient insights into own care. This study requires 32 clusters (16/arm) to achieve 80% power and a 5% significance cut-off, with 270 patients required. GP recruitment occurred from May to Dec 2022. Patient recruitment is ongoing from May 2022 to Aug 2023. GPs were randomized 1:1 using computer-generated blocks of six. Participating GPs are located in Southern Denmark and are not participating in other trials. Patients must be 18 + years of age, have a T2DM diagnosis, and be fluent in spoken and written Danish. DD is the primary outcome and will be measured at baseline, at four months, and again at a 12-month follow-up. Secondary outcomes include quality of care, self-management, quality of life, and clinical factors. Tertiary outcomes comprise depression, stress, resilience, sleep quality, and social network quality. CONCLUSION: This study is among the first clinical trials exploring the development of DD from diagnosis to 12 months post-diagnosis. Many previous interventions did not directly target DD as the primary outcome. This research provides new insights into DD progression in patients newly diagnosed with T2DM and examines an intervention designed to lower DD in early diabetes stages, contributing to a better understanding of the development of DD and how this intervention affects patient well-being. TRIAL REGISTRATION: ClinicalTrial.gov NCT05571306. Registered on 07 October 2022.

The effectiveness of social-support-based weight-loss interventions-a systematic review and meta-analysis.

OBJECTIVE: This systematic review and meta-analysis examined the effectiveness of social-support-based weight-loss interventions in adult populations with excess weight or obesity. METHODS: We performed a systematic review of randomized controlled trials that reported on the effectiveness of weight-loss interventions which incorporated a social connectedness component. To this end, we conducted a rigorous database search of MEDLINE, Embase, PsycINFO, CINAHL, Cochrane, and PubMed for relevant articles. The quality of eligible trials was evaluated by the Cochrane Risk-of-Bias2 tool. Five meta-analyses on intervention effectiveness in terms of weight loss were executed at 2-4-month assessment, 6-month assessment, end of intervention, and 3- and 6-month follow-up. RESULTS: Twenty-four trials involving couples or peers targeting weight loss in 4 919 adults with BMI ≥ 25 met inclusion criteria. Meta-analyses detected no significant effect of social-support-based weight-loss interventions at either 2-4 month or 6-month assessment. There were, however, significant effects at end of intervention [95% CI 0.39, p = 0.04] and at 3-month [95% CI 0.63, p < 0.01] and 6-month [95% CI 0.34, p = 0.05] follow-up. CONCLUSIONS: There seem to be a significant effect at the end of intervention and 3- and 6-month follow-up. However, further high-quality studies are needed before drawing any clear conclusions. TRIAL REGISTRATION: PROSPERO 2020 CRD42020173696.

Individual differences in empathy in Danish university students: A cross-sectional study.

BACKGROUND: Empathy is widely recognized as a multi-dimensional construct, involving emotional and cognitive components. These may cause distinct experiences and behaviors that can be both beneficial and deleterious to individuals' well-being and mental health. AIM: We wished to examine the association between emotional and cognitive empathy of Danish university students as measured by the multidimensional Interpersonal Reactivity Index (IRI) and study major, sex, age, and parental status. Additionally, we aimed to gauge the validity of the Jefferson Scale of Empathy - Student version (JSE-S) as a measure of primarily cognitive empathy in the context of medical majors by comparing JSE-S scores with IRI cognitive scores. METHODS: In our national, cross-sectional study, conducted in October 2020, we used survey data from students in their first, third, and final study year. All students from University of Southern Denmark were invited to fill out IRI, and all medical students at Denmark's four medical educations were additionally invited to fill out the JSE-S. Associations were estimated by linear regression models. RESULTS: Of 14,072 invited, 2,595 students completed the questionnaire. Health majors scored statistically significantly higher on cognitive empathy than students from other study majors. The JSE-S correlated significantly with the cognitive empathy subscales of the IRI. Furthermore, the effects found in relation to sex, age-, and parental status were significant. CONCLUSION: Our study results show that large differences in empathy exist between university students and study majors. Overall, our results highlight (1) the relevance of investigating empathy as a multidimensional versus a global construct in young adult populations (including university students) and (2) the importance of focusing on differences in empathy across different student characteristics.

Structural racism and health: Assessing the mediating role of community mental distress and health care access in the association between mass incarceration and adverse birth outcomes.

Research has linked spatial concentrations of incarceration with racial disparities in adverse birth outcomes. However, little is known about the specific mechanisms of this association. This represents an important knowledge gap in terms of intervention. We theorize two pathways that may account for the association between county-level prison rates and adverse birth outcomes: (1) community-level mental distress and (2) reduced health care access. Examining these mechanisms, we conducted a cross-sectional study of county-level prison rates, community-level mental distress, health insurance, availability of primary care physicians (PCP) and mental health providers (MHP), and adverse birth outcomes (preterm birth, low birth weight, infant mortality). Our data set included 475 counties and represented 2,677,840 live U.S. births in 2016. Main analyses involved between 170 and 326 counties. All data came from publicly available sources, including the U.S. Census and the Centers for Disease Control and Prevention. Descriptive and regression results confirmed the link between prison rates and adverse birth outcomes and highlighted Black-White inequities in this association. Further, bootstrap mediation analyses indicated that the impact of spatially concentrated prison rates on preterm birth was mediated by PCP, MHP, community-level mental distress, and health insurance in both crude and adjusted models. Community-level mental distress and health insurance (but not PCP or MHP) similarly mediated low birthweight in both models. Mediators were less stable in the effect on infant mortality with only MHP mediating consistently across models. We conclude that mass incarceration, health care access, and community mental distress represent actionable and urgent targets for structural-, community-, and individual-level interventions targeting population inequities in birth outcomes.

The effect of psychological interventions targeting overweight and obesity in school-aged children: a systematic review and meta-analysis.

BACKGROUND: Multi-component psychological interventions may mitigate overweight and obesity in children and adolescents. Evidence is, however, scattered on the effectiveness of such interventions. This study aims to review the available evidence on the effectiveness of multi-component psychological interventions on anthropometric measures of school-aged children with overweight or obesity. METHODS: We systematically searched international databases/search engines including PubMed and NLM Gateway (for MEDLINE), Web of Science, SCOPUS, and Google Scholar up to November 2022 for relevant articles pertaining to psychological weight-loss interventions targeting school-aged children. Two reviewers screened and extracted pertinent data. The quality of included studies was assessed using the Cochrane Risk of Bias Tool for Randomized Trials. Random effect meta-analysis was used to calculate, and pool standardized mean differences (SMD). We distinguished between intervention and maintenance effects. Intervention effects were defined as the mean change in outcome measurement detected between baseline and post-treatment. Maintenance effects were defined as the mean change in outcome measurement between post-treatment and last follow-up. RESULTS: Of 3,196 studies initially identified, 54 and 30 studies were included in the qualitative and quantitative syntheses, respectively. Most studies reported on group-based interventions. The significant effects of intervention on BMI z-score (SMD -0.66, 95% CI: -1.15, -0.17) and WC (SMD -0.53, 95% CI: -1.03, -0.04) were observed for interventions that centered on motivational interviewing and cognitive behavioral therapy, respectively. Mean BMI and WC did not differ significantly between post-treatment and last follow-up measurement (maintenance effect), indicating that an initial weight loss obtained through the intervention period could be maintained over time. CONCLUSIONS: Findings indicate that motivational interviewing and cognitive behavioral therapy as interventions to reduce BMI z-score (generalized obesity) and waist circumference (abdominal obesity) are effective and durable. However, detailed analyses on individual components of the interventions are recommended in future effectiveness studies.

A comprehensive framework for operationalizing structural racism in health research: The association between mass incarceration of Black people in the U.S. and adverse birth outcomes.

Structural racism represents a key determinant of the racial health disparities that has characterized the U.S. population throughout its existence. While this reality has recently begun to gain increasing acknowledgment and acceptance within the health sciences, there are still considerable challenges related to defining the concept of structural racism and operationalizing it in empirical study. In this paper, building on the existing evidence base, we propose a comprehensive framework that centers structural racism in terms of its historical roots and continued manifestation in most domains of society, and offer solutions for the study of this phenomenon and the pathways that connect it to population-level health disparities. We showcase our framework by applying it to the known link between spatial and racialized clustering of incarceration - a previously cited representation of structural racism - and disparities in adverse birth outcomes. Through this process we hypothesize pathways that focus on social cohesion and community-level chronic stress, community crime and police victimization, as well as infrastructural community disinvestment. First, we contextualize these mechanisms within the relevant extant literature. Then, we make recommendations for future empirical pathway analyses. Finally, we identify key areas for policy, community, and individual-level interventions that target the impact of concentrated incarceration on birth outcomes among Black people in the U.S.

The Association Between Individualised Religiosity and Health Behaviour in Denmark: Are Social Networks a Mediating Factor?

The present study investigates whether social networks mediate the well-established positive association between religiosity and health behaviour. Most research has focused on traditional public religiosity (e.g. regular church attendance). This study, however, focuses on the Danish population in which non-traditional and private religiosity is common. We utilise data from the Danish population-based project, Early Detection and Prevention. Our results suggest that religiosity is linked to health behaviour; however, this association is not mediated by social network.

Non-participation in a targeted prevention program aimed at lifestyle-related diseases: a questionnaire-based assessment of patient-reported reasons.

BACKGROUND: Having an unhealthy lifestyle is associated with a higher risk of developing lifestyle-related diseases. Current evidence suggests that interventions targeting health-risk behaviors can help people improve their lifestyles and prevent lifestyle-related diseases. However, preventive programs are often challenged by low participation rates. Reasons for non-participation include lack of time and/or interest, and/or no perceived need for lifestyle intervention. This study explores causes for non-participation in a sample of people who chose not to take up a targeted preventive program (TOF pilot2 study). Patient-reported reasons as well as sociodemographic characteristics and lifestyle factors are in focus. METHODS: A total of 4633 patients from four Danish GP clinics received an invitation to take part in the TOF pilot2 study. Patients who chose not to participate in the TOF pilot2 study were asked to fill in a questionnaire concerning reasons for non-participation, lifestyle, BMI and self-rated health. Descriptive analyses were used to summarize the results. RESULTS: A total of 2462 patients (53.1%) chose not to participate in the TOF pilot2 study. Among these, 84 (3.4%) answered the full questionnaire on reasons for not participating, lifestyle, BMI and self-rated health. The most common reasons for non-participation were lack of time, having an already healthy lifestyle, and feeling healthy. Based on their self-reported lifestyle 45 (53.6%) of the non-participants had one or more health-risk behaviors including smoking, unhealthy diet, BMI ≥ 35 and/or sedentary lifestyle and were therefore eligible to receive the targeted intervention at the GP or the MHC in the original TOF pilot2 study. CONCLUSION: When planning future preventive programs it is important to know the main reasons for patients to not participate. This study provides rare insight into why people opt out of health interventions and advances the evidence base in this area. Our results may inform efforts to better involve these patients in preventive health programs. TRIAL REGISTRATION: Trial registration number: NCT02797392 .

Racialized economic segregation and health outcomes: A systematic review of studies that use the Index of Concentration at the Extremes for race, income, and their interaction.

Extensive research shows that residential segregation has severe health consequences for racial and ethnic minorities. Most research to date has operationalized segregation in terms of either poverty or race/ethnicity rather than a synergy of these factors. A novel version of the Index of Concentration at the Extremes (ICERace-Income) specifically assesses racialized economic segregation in terms of spatial concentrations of racial and economic privilege (e.g., wealthy white people) versus disadvantage (e.g., poor Black people) within a given area. This multidimensional measure advances a more comprehensive understanding of residential segregation and its consequences for racial and ethnic minorities. The aim of this paper is to critically review the evidence on the association between ICERace-Income and health outcomes. We implemented the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to conduct a rigorous search of academic databases for papers linking ICERace-Income with health. Twenty articles were included in the review. Studies focused on the association of ICERace-Income with adverse birth outcomes, cancer, premature and all-cause mortality, and communicable diseases. Most of the evidence indicates a strong association between ICERace-Income and each health outcome, underscoring income as a key mechanism by which segregation produces health inequality along racial and ethnic lines. Two of the reviewed studies examined racial disparities in comorbidities and health care access as potential explanatory factors underlying this relationship. We discuss our findings in the context of the extant literature on segregation and health and propose new directions for future research and applications of the ICERace-Income measure.

Effects of a Co-Design-Based Invitation Strategy on Participation in a Preventive Health Check Program: Randomized Controlled Trial.

BACKGROUND: Preventive primary care programs that aim to reduce morbidity and mortality from lifestyle-related diseases are often affected by low-to-moderate participation rates. Improving participation rates is essential for clinical effectiveness and cost-effectiveness. In 2016-2017, we conducted a pilot study (TOF pilot1) for a preventive primary care intervention (TOF is the Danish abbreviation for "Early Detection and Prevention"). Among 8814 invited patients, 3545 (40.22%) consented to participate, with the highest participation rates among women and patients with higher income, education, and employment. OBJECTIVE: The aim of this study was to evaluate the effects of a revised invitation strategy on invitation comprehensibility, the overall participation rate, and participant demography. The new strategy specifically targeted men and patients of low educational attainment. METHODS: This study was embedded in the second TOF pilot study (TOF pilot2, initiated in October 2018) that tested an adjusted intervention. The revised invitation strategy comprised a prenotification postcard and a new invitation that specifically targeted men and patients of low educational attainment. The new invitation was developed in a co-design process that included communication professionals and target-group representatives. The study sample consisted of 4633 patients aged between 29 and 59 years, who resided in one of two municipalities in the Region of Southern Denmark. Eligible patients were randomly assigned to one of four invitation groups. The control group (Group 1) received the original invitation used in TOF pilot1. The intervention groups received the original invitation and the prenotification postcard (Group 2), the new revised invitation and the prenotification postcard (Group 3), or the new invitation but no prenotification postcard (Group 4). RESULTS: Overall, 2171 (46.86%) patients consented to participate. Compared to the control group, participation rates increased significantly in all three intervention groups (all P<.001). Participation across the three intervention groups increased for women and men, as well as for patients with high and low educational attainment and high and low family income. The largest relative increase in participation rates occurred among men, patients with low educational attainment, and patients with low family income. No increase in participation was detected for unemployed patients or patients of non-Danish origin. Most participants found the original (813/987, 82.37%) and new (965/1133, 85.17%) invitations easy to understand with no significant difference (P=.08) in comprehensibility between invitations. CONCLUSIONS: The results suggest that participation in preventive primary care interventions can be greatly increased by implementing a co-design-based invitation strategy that includes prenotification postcards and targeted invitations. Although firm conclusions cannot be made from this study, the observed increased participation rates for men and patients of low socioeconomic status may be relevant in programs that aim to reduce social inequality in health. TRIAL REGISTRATION: ClinicalTrials.gov NCT03913585; https://clinicaltrials.gov/ct2/show/NCT03913585.

The Association between Maternal Experiences of Interpersonal Discrimination and Adverse Birth Outcomes: A Systematic Review of the Evidence.

In the present systematic review, we argue that maternal experiences of interpersonal discrimination at least partially account for the disproportionate rates of adverse birth outcomes in minority populations. Since the 1990s, research in this area has slowly, but steadily increased, shedding more light on the insidious nature of interpersonal discrimination and its toxic health effects. With the aim of bringing this topic to the fore in academic as well as clinical settings, this paper provides a state-of-the-art review of the empirical knowledge on the relationship between maternal experiences of discrimination and birth outcomes. Of 5901 articles retained in the literature search, 28 met the predefined inclusion criteria. Accounting for a range of health and behavioral factors, the vast majority of these studies support the notion that maternal experiences of interpersonal discrimination predict a range of adverse birth outcomes, including preterm birth, low birth weight, and various physiological markers of stress (allostatic load) in both mother and child pre- and postpartum. Several moderators and mediators of this relationship were also identified. These related primarily to the type (first-hand and vicarious), timing (childhood, adolescence, and adulthood), frequency, and pervasiveness of discrimination experienced, as well as to maternal mental health and coping. More research into these factors, however, is required to definitively determine their significance. We discuss these findings as they relate to the general health repercussions of interpersonal discrimination, as well as in terms of applied prenatal care and interventions. Ultimately, we argue that assessing maternal experiences of interpersonal discrimination in prenatal care may represent a considerable asset for mitigating existing majority-minority disparities in adverse birth outcomes.

High Variability in Implementation of Selective-Prevention Services for Cardiometabolic Diseases in Five European Primary Care Settings.

(1) Background: Cardiometabolic diseases are the most common cause of death worldwide. As part of a collaborative European study, this paper aims to explore the implementation of primary care selective-prevention services in five European countries. We assessed the implementation process of the selective-prevention services, participants' cardiometabolic profile and risk and participants' evaluation of the services, in terms of feasibility and impact in promoting a healthy lifestyle. (2) Methods: Eligible participants were primary care patients, 40-65 years of age, without any diagnosis of cardiometabolic disease. Two hundred patients were invited to participate per country. The extent to which participants adopted and completed the implementation of selective-prevention services was recorded. Patient demographics, lifestyle-related cardiometabolic risk factors and opinions on the implementation's feasibility were also collected. (3) Results: Acceptance rates varied from 19.5% (n = 39/200) in Sweden to 100% (n = 200/200) in the Czech Republic. Risk assessment completion rates ranged from 65.4% (n = 70/107) in Greece to 100% (n = 39/39) in Sweden. On a ten-point scale, the median (25-75% quartile) of participant-reported implementation feasibility ranged from 7.4 (6.9-7.8) in Greece to 9.2 (8.2-9.9) in Sweden. Willingness to change lifestyle exceeded 80% in all countries. (4) Conclusions: A substantial variation in the implementation of selective-prevention receptiveness and patient risk profile was observed among countries. Our findings suggest that the design and implementation of behavior change cardiometabolic programmes in each country should be informed by the local context and provide some background evidence towards this direction, which can be even more relevant during the current pandemic period.

Changes in Health-Risk Behavior, Body Mass Index, Mental Well-Being, and Risk Status Following Participation in a Stepwise Web-Based and Face-to-Face Intervention for Prevention of Lifestyle-Related Diseases: Nonrandomized Follow-Up Cohort Study.

BACKGROUND: Recent evidence suggests the effectiveness of stepwise, targeted approaches for the prevention of lifestyle-related diseases with combinations of web-based and face-to-face interventions showing promising results. OBJECTIVE: This paper reports on 1-year changes in health-risk behaviors, BMI, self-rated health, mental well-being, and risk of disease at 1-year follow-up after participation in a stepwise intervention that targeted persons at high risk of disease and persons with health-risk behavior. To this end, we distinguish between participants who took up the full intervention (web-based plus face-to-face) and those who received only the web-based intervention. METHODS: The Early Detection and Prevention (Danish acronym: TOF) pilot study was conducted as a nonrandomized, 1-year follow-up intervention study in two municipalities in the Region of Southern Denmark. A total of 9400 citizens born between 1957 and 1986 (aged 29 to 60 years) were randomly sampled from participating general practitioner (GP) patient-list systems and were invited to take part in the study. Participants were subsequently stratified into risk groups based on their responses to a questionnaire on health-risk behavior and data from their GP's electronic patient record (EPR) system. All participants received a digital personal health profile with individualized information on current health-risk behavior and targeted advice on relevant health-risk behavior changes. In addition, patients at high risk of disease, as indicated by their digital health profile, were offered a targeted intervention at their GP. Patients who were not deemed at high risk of disease but who exhibited health-risk behaviors were offered a targeted intervention at their municipal health center (MHC). At 1-year follow-up, health-risk behaviors, self-rated health, BMI, and mental well-being were reassessed by questionnaire, and current information on diagnoses and medical treatment was retrieved from the EPRs. RESULTS: Of 598 patients at high risk of disease or with health-risk behavior, 135 took up the targeted intervention at their GP or MHC and 463 received the personal health profile only. From baseline to 1-year follow-up, the number of patients with unhealthy eating habits decreased, mean mental well-being increased, and smoking prevalence decreased in patients who had received the digital personal health profile alone. Among patients who took up the targeted intervention, unhealthy eating habits and sedentary lifestyles decreased and significant reductions in mean BMI were observed. At 1-year follow up, no health-risk behaviors were detected among 17.4% of patients who at baseline had exhibited health-risk behaviors or high risk of disease. CONCLUSIONS: A stepwise targeted preventive approach using web-based and face-to-face elements may lead to favorable lifestyle changes. Specifically, a web-based approach may improve smoking and eating habits and mental well-being, whereas supplementary face-to-face interventions may be necessary to improve exercise habits and BMI. TRIAL REGISTRATION: ClinicalTrials.gov NCT02797392; https://clinicaltrials.gov/ct2/show/NCT02797392. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s12875-018-0820-8.

Should social disconnectedness be included in primary-care screening for cardiometabolic disease? A systematic review of the relationship between everyday stress, social connectedness, and allostatic load.

In the present review, we argue that social disconnectedness could and should be included in primary-care screening protocols for the detection of cardiometabolic disease. Empirical evidence indicates that weak social connectedness represents a serious risk factor for chronic diseases, including cardiovascular disease, diabetes, and various cancers. Weak social connectedness, however, is largely regarded as a second-tier health-risk factor in clinical and research settings. This may be because the mechanisms by which this factor impacts on physical health are poorly understood. Budding research, however, advances the idea that social connectedness buffers against stress-related allostatic load-a known precursor for cardiovascular disease and cancer. The present paper reviews the empirical knowledge on the relationship between everyday stress, social connectedness, and allostatic load. Of 6022 articles retained in the literature search, 20 met predefined inclusion criteria. These studies overwhelmingly support the notion that social connectedness correlates negatively with allostatic load. Several moderators of this relationship were also identified, including gender, social status, and quality of social ties. More research into these factors, however, is warranted to conclusively determine their significance. The current evidence strongly indicates that the more socially connected individuals are, the less likely they are to experience chronic stress and associated allostatic load. The negative association between social connectedness and various chronic diseases can thus, at least partially, be explained by the buffering qualities of social connectedness against allostatic load. We argue that assessing social connectedness in clinical and epidemiological settings may therefore represent a considerable asset in terms of prevention and intervention.

An evidence-based toolbox for the design and implementation of selective-prevention primary-care initiatives targeting cardio-metabolic disease.

Cardio-metabolic diseases (CMD; cardiovascular disease, type 2 diabetes, chronic kidney disease) represent a global public health problem. Worldwide, nearly half a billion people are currently diagnosed with diabetes, and cardiovascular disease is the leading cause of death. Most of these diseases can be assuaged/prevented through behavior change. However, the best way to implement preventive interventions is unclear. We aim to fill this knowledge gap by creating an evidence-based and adaptable "toolbox" for the design and implementation of selective prevention initiatives (SPI) targeting CMD. We built our toolbox based on evidence from a pan-European research project on primary-care SPIs targeting CMD. The evidence includes (1) two systematic reviews and two surveys of patient and general practitioner barriers and facilitators of engaging with SPIs, (2) a consensus meeting with leading experts to establish optimal SPI design, and (3) a feasibility study of a generic, evidence-based primary-care SPI protocol in five European countries. Our results related primarily to the five different national health-care contexts from which we derived our data. On this basis, we generated 12 general recommendations for how best to design and implement CMD-SPIs in primary care. We supplement our recommendations with practical, evidence-based suggestions for how each recommendation might best be heeded. The toolbox is generic and adaptable to various national and systemic settings by clinicians and policy makers alike. However, our product needs to be kept up-to-date to be effective and we implore future research to add relevant tools as they are developed.

What should selective cardiometabolic prevention programmes in European primary care look like? A consensus-based design by the SPIMEU group.

Background: Selective prevention of cardiometabolic diseases (CMD)-that is, preventive measures specifically targeting the high-risk population-may represent the most effective approach for mitigating rising CMD rates. Objectives: To develop a universal concept of selective CMD prevention that can guide implementation within European primary care. Methods: Initially, 32 statements covering different aspects of selective CMD prevention programmes were identified based on a synthesis of evidence from two systematic literature reviews and surveys conducted within the SPIMEU project. The Rand/UCLA appropriateness method (RAM) was used to find consensus on these statements among an international panel consisting of 14 experts. Before the consensus meeting, statements were rated by the experts in a first round. In the next step, during a face-to-face meeting, experts were provided with the results of the first rating and were then invited to discuss and rescore the statements in a second round. Results: In the outcome of the RAM procedure, 28 of 31 statements were considered appropriate and three were rated uncertain. The panel deleted one statement. Selective CMD prevention was considered an effective approach for preventing CMD and a proactive approach was regarded as more effective compared to case-finding alone. The most efficient method to implement selective CMD prevention systematically in primary care relies on a stepwise approach: initial risk assessment followed by interventions if indicated. Conclusion: The final set of statements represents the key characteristics of selective CMD prevention and can serve as a guide for implementing selective prevention actions in European primary care.

Step-wise approach to prevention of chronic diseases in the Danish primary care sector with the use of a personal digital health profile and targeted follow-up - an assessment of attendance.

BACKGROUND: Current evidence on chronic disease prevention suggests that interventions targeted at high-risk individuals represents the best way forward. We implemented a step-wise approach in the Danish primary care sector, designed for the systematic and targeted prevention of chronic disease. The intervention centered on a personal digital health profile for all participants, followed by targeted preventive programs for high-risk patients. The present paper examines individual characteristics and health-care usage of patients who took up the targeted preventive programs in response to their personal digital health profile. METHODS: A sample of patients born between 1957 and 1986 was randomly selected from the patient-list system of participating general practitioners in two Danish municipalities. The selected patients received a digital invitation to participate. Consenting patients received a second digital invitation for a personal digital health profile based on questionnaire and electronic patient record data. The personal digital health profile contained individualized information on risk profile and personalized recommendations on further actions. If at-risk or presenting with health-risk behaviour a patient would be advised to contact either their general practitioner or municipal health centre for targeted preventive programs. Attendance at the targeted preventive programs was examined using Poisson regression and chi-squared automatic interaction detection methods. RESULTS: A total of 9400 patients were invited. Of those who participated (30%), 22% were advised to get a health check at their general practitioner. Of these, 19% did so. Another 23% were advised to schedule an appointment for behaviour-change counselling at their municipal health centre. A total of 21% took the advice. Patients who had fair or poor self-rated health, a body mass index above 30, low self-efficacy, were female, non-smokers, or lead a sedentary lifestyle, were most likely to attend the targeted preventive programs. CONCLUSIONS: A personal digital health profile shows some promise in a step-wise approach to prevention in the Danish primary care sector and seems to motivate people with low self-efficacy to attend targeted preventive programs. TRIAL REGISTRATION: Registered at Clinical Trial Gov (Unique Protocol ID: TOFpilot2016 ). Prospectively registered on the 29th of April 2016.

Digital Recruitment and Acceptance of a Stepwise Model to Prevent Chronic Disease in the Danish Primary Care Sector: Cross-Sectional Study.

BACKGROUND: During recent years, stepwise approaches to health checks have been advanced as an alternative to general health checks. In 2013, we set up the Early Detection and Prevention project (Tidlig Opsporing og Forebyggelse, TOF) to develop a stepwise approach aimed at patients at high or moderate risk of a chronic disease. A novel feature was the use of a personal digital mailbox for recruiting participants. A personal digital mailbox is a secure digital mailbox provided by the Danish public authorities. Apart from being both safe and secure, it is a low-cost, quick, and easy way to reach Danish residents. OBJECTIVE: In this study we analyze the association between the rates of acceptance of 2 digital invitations sent to a personal digital mailbox and the sociodemographic determinants, medical treatment, and health care usage in a stepwise primary care model for the prevention of chronic diseases. METHODS: We conducted a cross-sectional analysis of the rates of acceptance of 2 digital invitations sent to randomly selected residents born between 1957 and 1986 and residing in 2 Danish municipalities. The outcome was acceptance of the 2 digital invitations. Statistical associations were determined by Poisson regression. Data-driven chi-square automatic interaction detection method was used to generate a decision tree analysis, predicting acceptance of the digital invitations. RESULTS: A total of 8814 patients received an invitation in their digital mailbox from 47 general practitioners. A total of 40.22% (3545/8814) accepted the first digital invitation, and 30.19 % (2661/8814) accepted both digital invitations. The rates of acceptance of both digital invitations were higher among women, older patients, patients of higher socioeconomic status, and patients not diagnosed with or being treated for diabetes mellitus, chronic obstructive pulmonary disease, or cardiovascular disease. CONCLUSIONS: To our knowledge, this is the first study to report on the rates of acceptance of digital invitations to participate in a stepwise model for prevention of chronic diseases. More studies of digital invitations are needed to determine if the acceptance rates seen in this study should be expected from future studies as well. Similarly, more research is needed to determine whether a multimodal recruitment approach, including digital invitations to personal digital mailboxes will reach hard-to-reach subpopulations more effectively than digital invitations only.

Targeted prevention in primary care aimed at lifestyle-related diseases: a study protocol for a non-randomised pilot study.

BACKGROUND: The consequences of lifestyle-related disease represent a major burden for the individual as well as for society at large. Individual preventive health checks to the general population have been suggested as a mean to reduce the burden of lifestyle-related diseases, though with mixed evidence on effectiveness. Several systematic reviews, on the other hand, suggest that health checks targeting people at high risk of chronic lifestyle-related diseases may be more effective. The evidence is however very limited. To effectively target people at high risk of lifestyle-related disease, there is a substantial need to advance and implement evidence-based health strategies and interventions that facilitate the identification and management of people at high risk. This paper reports on a non-randomized pilot study carried out to test the acceptability, feasibility and short-term effects of a healthcare intervention in primary care designed to systematically identify persons at risk of developing lifestyle-related disease or who engage in health-risk behavior, and provide targeted and coherent preventive services to these individuals. METHODS: The intervention took place over a three-month period from September 2016 to December 2016. Taking a two-pronged approach, the design included both a joint and a targeted intervention. The former was directed at the entire population, while the latter specifically focused on patients at high risk of a lifestyle-related disease and/or who engage in health-risk behavior. The intervention was facilitated by a digital support system. The evaluation of the pilot will comprise both quantitative and qualitative research methods. All outcome measures are based on validated instruments and aim to provide results pertaining to intervention acceptability, feasibility, and short-term effects. DISCUSSION: This pilot study will provide a solid empirical base from which to plan and implement a full-scale randomized study with the central aim of determining the efficacy of a preventive health intervention. TRIAL REGISTRATION: Registered at Clinical Trial Gov (Unique Protocol ID: TOFpilot2016 ). Registered 29 April 2016. The study adheres to the SPIRIT guidelines.