Nudging plant-based alternatives to meat and dairy in a real-life online supermarket: A randomized controlled trial.

A shift from predominantly animal-based to plant-based consumption can benefit both planetary and public health. Nudging may help to promote such a shift. This study investigated nudge effects on plant-based alternatives to meat and dairy in an online supermarket. We conducted a two-arm, parallel-group, randomized controlled real-life online supermarket trial. Each customer transaction was randomized to a control arm (regular online supermarket) or an intervention arm (addition of placement, hedonic property and dynamic social norm nudges promoting meat and dairy alternatives). Outcomes were the aggregate of meat and dairy alternative purchases (primary outcome), the number of meat purchases, dairy purchases, meat alternative purchases, and dairy alternative purchases (secondary), and retailer revenue (tertiary). Generalized linear mixed models with a Conway-Maxwell Poisson distribution were used to estimate incidence rate ratios (IRRs). Analyzed data included 8488 transactions by participants (n = 4,266 control arm, n = 4,222 intervention arm), out of which 2,411 (66%) were aged above 45 years, 5,660 (67%) were females, and 1,970 (23%) lived in socially disadvantaged neighborhoods. Intervention arm participants purchased 10% (IRR 1.10 (95% CI 0.99-1.23)) more meat and dairy alternatives and 16% (1.16 (0.99-1.36)) more meat alternatives than control arm participants, although these findings are not statistically significant. There was no difference in dairy alternative purchases (1.00 (0.90-1.10)). Intervention arm participants purchased 3% less meats (0.97 (0.93-1.02)) and 2% less dairy products (0.98 (0.95-1.02)) than control participants. Retailer revenue was not affected (0.98 (0.95-1.01)). Online nudging strategies alone did not lead to a statistically significant higher amount of plant-based purchases, but replication of this work is needed with increased study power. Future studies should also consider nudging strategies as part of a broader set of policies to promote plant-based purchases. TRIAL REGISTRATION: Prospectively registered on 14th of May 2022. ISRCTN16569242 (https://doi.org/10.1186/ISRCTN16569242).

General Mental Health, Loneliness, and Life Satisfaction in the Context of COVID-19 Policies: A 2-Year Cohort Study in the Netherlands, April 2020-January 2022.

OBJECTIVE: Although the COVID-19 pandemic has affected mental health, understanding who has been affected most and why is incomplete. We sought to understand changes in mental health in the context of transmission numbers and pandemic (social) restrictions and whether changes in mental health varied among population groups. METHODS: We analyzed data from 92 062 people (aged ≥16 years and able to read Dutch) who participated in the Corona Behavioral Unit cohort study at the National Institute for Public Health and the Environment, the Netherlands, from April 17, 2020, through January 25, 2022. Participants self-reported mental well-being through multiple rounds of surveys. We used a multivariable linear mixed-effects model to analyze loneliness, general mental health, and life satisfaction. RESULTS: As strictness of pandemic prevention measures and social restrictions increased, people's feelings of loneliness increased and mental health and life satisfaction decreased. As restrictions were relaxed, loneliness decreased and general mental health improved. Younger people (aged 16-24 y) versus older people (aged ≥40 y), people with low (vs high) education levels, and people living alone (vs living together) were more likely to have negative well-being outcomes. We observed that trajectories over time differed considerably only by age, with participants aged 16-24 years affected substantially more than participants aged ≥40 years by pandemic social restrictions. These patterns were consistent across multiple waves of SARS-CoV-2 infection. CONCLUSIONS: Our findings suggest that the social restrictions imposed by the Dutch government during the study period were associated with reduced mental well-being, especially among younger people. However, people appeared resilient as they recovered during periods when restrictions were relaxed. Monitoring and supporting well-being, in particular to reduce loneliness, may help younger people during periods of intense social restrictions.

Lottery incentives for smoking cessation at the workplace: design and protocol of the smoke-free lottery - a cluster randomized trial.

BACKGROUND: Smoking is the leading behavioral risk factor for the loss of healthy life years. Many smokers want to quit, but have trouble doing so. Financial incentives in workplace settings have shown promising results in supporting smokers and their design influences their impact. Lotteries that leverage behavioral economic insights might improve the effectiveness of workplace cessation support. METHODS AND DESIGN: We examine in a cluster randomized trial if a workplace cessation group training paired with lottery deadlines will increase continuous abstinence rates over and above the cessation training alone. Organizations are randomized to either the control arm or lottery arm. The lotteries capitalize regret aversion by always informing winners at the deadline, but withholding prizes if they smoked. In the lottery-arm, winners are drawn out of all participants within a training group, regardless of their smoking status. In weeks 1-13 there are weekly lotteries. Winners are informed about their prize (€50), but can only claim it if they did not smoke that week, validated biochemically. After 26 weeks, there is a long-term lottery where the winners are informed about their prize (vacation voucher worth €400), but can only claim it if they were abstinent between weeks 13 and 26. The primary outcome is continuous abstinence 52 weeks after the quit date. DISCUSSION: There is a quest for incentives to support smoking cessation that are considered fair, affordable and effective across different socioeconomic groups. Previous use of behavioral economics in the design of lotteries have shown promising results in changing health behavior. This cluster randomized trial aims to demonstrate if these lotteries are also effective for supporting smoking cessation. Therefore the study design and protocol are described in detail in this paper. Findings might contribute to the application and development of effective cessation support at the workplace. TRIAL REGISTRATION: Netherlands Trial Register Identifier: NL8463 . Date of registration: 17-03-2020.

The longitudinal association between chronic stress and (visceral) obesity over seven years in the general population: The Hoorn Studies.

BACKGROUND: We aimed to study the mediating role of diet quality, physical activity, smoking, and alcohol intake in the association of stressful life events with visceral obesity over a seven-year period and assessed effect modification by sex and SES. METHODS: In total, 2416 participants with a mean age of 56.1 (±7.3) years, of which 51.4% were women, and 12.5% had a lower educational level from the Hoorn studies were followed for seven years. Stress was measured with a 'Serious Life Events' questionnaire, which was summed into a total score (range zero to ten events) and stratified to account for nonlinearity. Changes in visceral obesity were assessed by changes in BMI (kg/m2) and waist circumference (cm) in seven years. We used the product of coefficient approach to assess mediation of the following lifestyle factors: diet, physical activity, smoking, and alcohol intake. We analyzed associations between stressful life events and change in BMI and waist circumference with linear regression models. RESULTS: Within the low education group, we observed a significant association between ≥3 stressful life events and a change in BMI (0.60 kg/m2 (CI: 0.05, 1.14)) and waist circumference (2.23 cm (CI: 0.19, 4.48)), compared to experiencing no events. For both BMI and waist circumference, no significant associations were observed when experiencing 1 or 2 events. In the moderate to high education group, we observed only statistically significant associations for waist circumference when experiencing ≥3 stressful life events (0.86 cm (CI: 0.05, 1.41)) and not for the other event groups. Our mediation analyses showed that the proportion mediated by smoking was 13.2%, while the other lifestyle factors showed no mediating effect. CONCLUSIONS: Multiple stressful life events are associated with an increase in waist circumference and BMI in those with lower education. Smoking might play a mediating role in this association.

Facilitators and barriers of intersectoral co-operation to promote healthier and more environmentally friendly behaviour: a qualitative evaluation through focus groups for the INHERIT project.

BACKGROUND: Tackling challenges related to health, environmental sustainability and equity requires many sectors to work together. This "intersectoral co-operation" can pose a challenge on its own. Research commonly focuses on one field or is conducted within one region or country. The aim of this study was to investigate facilitators and barriers regarding intersectoral co-operative behaviour as experienced in twelve distinct case studies in ten European countries. The COM-B behavioural system was applied to investigate which capabilities, opportunities and motivational elements appear necessary for co-operative behaviour. METHOD: Twelve focus groups were conducted between October 2018 and March 2019, with a total of 76 participants (policymakers, case study coordinators, governmental institutes and/or non-governmental organisations representing citizens or citizens). Focus groups were organised locally and held in the native language using a common protocol and handbook. One central organisation coordinated the focus groups and analysed the results. Translated data were analysed using deductive thematic analysis, applying previous intersectoral co-operation frameworks and the COM-B behavioural system. RESULTS: Amongst the main facilitators experienced were having highly motivated partners who find common goals and see mutual benefits, with good personal relationships and trust (Motivation). In addition, having supportive environments that provide opportunities to co-operate in terms of support and resources facilitated co-operation (Opportunity), along with motivated co-operation partners who have long-term visions, create good external visibility and who have clear agreements and clarity on roles from early on (Capability). Barriers included not having necessary and/or structural resources or enough time, and negative attitudes from specific stakeholders. CONCLUSIONS: This study on facilitators and barriers to intersectoral co-operation in ten European countries confirms findings of earlier studies. This study also demonstrates that the COM-B model can serve as a relatively simple tool to understand co-operative behaviour in terms of the capability, opportunity and motivation required amongst co-operation partners from different sectors. Results can support co-operators' and policymakers' understanding of necessary elements of intersectoral co-operation. It can help them in developing more successful intersectoral co-operation when dealing with challenges of health, environmental sustainability and equity.

Encouraging and Enabling Lifestyles and Behaviours to Simultaneously Promote Environmental Sustainability, Health and Equity: Key Policy Messages from INHERIT.

Human consumption and activity are damaging the global ecosystem and the resources on which we rely for health, well-being and survival. The COVID-19 crisis is yet another manifestation of the urgent need to transition to more sustainable societies, further exposing the weaknesses in health systems and the injustice in our societies. It also underlines that many of the factors leading to environmental degradation, ill health and social and health inequities are interlinked. The current situation provides an unprecedented opportunity to invest in initiatives that address these common factors and encourage people to live more healthily and sustainably. Such initiatives can generate the positive feedback loops needed to change the systems and structures that shape our lives. INHERIT (January 2016-December 2019), an ambitious, multisectoral and transnational research project that involved 18 organisations across Europe, funded by the European Commission, explored such solutions. It identified, defined and analysed promising inter-sectoral policies, practices and approaches to simultaneously promote environmental sustainability, protect and promote health and contribute to health equity (the INHERIT "triple-win") and that can encourage and enable people to live, move and consume more healthfully and sustainably. It also explored the facilitators and barriers to working across sectors and in public private cooperation. The insights were brought together in guidelines setting out how policy makers can help instigate and support local "triple-win" initiatives that influence behaviours as an approach to contributing to the change that is so urgently needed to stem environmental degradation and the interlinked threats to health and wellbeing. This article sets out this guidance, providing timely insights on how to "build back better" in the post pandemic era.

Intersectoral Cooperation in 12 European Case Studies Aiming for Better Health, Environmental Sustainability, and Health Equity: Protocol for a Qualitative Evaluation.

BACKGROUND: The INHERIT (INtersectoral Health and Environment Research for InnovaTion) project has evaluated intersectoral cooperation (IC) in 12 European case studies attempting to promote health, environmental sustainability, and equity through behavior and lifestyle changes. These factors are the concerns of multiple sectors of government and society. Cooperation of health and environmental sectors with other sectors is needed to enable effective action. IC is thus essential to promote a triple win of health, sustainability, and equity. OBJECTIVE: This paper describes the design of a qualitative study to gain insights into successful organization of IC, facilitators and barriers, and how future steps can be taken to improve IC in the evaluated case studies. METHODS: Each case study was assessed qualitatively through a focus group. A total of 12 focus groups in 10 different European countries with stakeholders, implementers, policymakers, and/or citizens were held between October 2018 and March 2019. Five to eight participants attended each focus group. The focus group method was based on appreciative inquiry, which is an asset-based approach focusing on what works well, why it is working well, and how to strengthen assets in the future. A stepped approach was used, with central coordination and analysis, and local implementation and reporting. Local teams were trained to apply a common protocol using a webinar and handbook on organizing, conducting, and reporting focus groups. Data were gathered in each country in the local language. Translated data were analyzed centrally using deductive thematic analysis, with consideration of further emerging themes. Analyses involved the capability, opportunity, motivation-behavior (COM-b) system to categorize facilitators and barriers into capability, motivation, or opportunity-related themes, as these factors influence the behaviors of individuals and groups. Web-based review sessions with representatives from all local research teams were held to check data analysis results and evaluate the stepped approach. RESULTS: Data collection has been completed. A total of 76 individuals participated in 12 focus groups. In December 2019, data analysis was nearly complete, and the results are expected to be published in fall 2020. CONCLUSIONS: This study proposes a stepped approach that allows cross-country focus group research using a strict protocol while dealing with language and cultural differences. The study generates insights into IC processes and facilitators in different countries and case studies to filter out which facilitators are essential to include. Simultaneously, the approach can strengthen cooperation among stakeholders by looking at future cooperation possibilities. By providing knowledge on how to plan for, improve, and sustain IC successfully to deal with today's multisectoral challenges, this study can contribute to better intersectoral action for the triple win of better health, sustainability, and equity. This protocol can serve as a tool for other researchers who plan to conduct cross-country qualitative research. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/17323.

Ranking Preventive Interventions from Different Policy Domains: What Are the Most Cost-Effective Ways to Improve Public Health?

It is widely acknowledged that in order to promote public health and prevent diseases, a wide range of scientific disciplines and sectors beyond the health sector need to be involved. Evidence-based interventions, beyond preventive health interventions targeting disease risk factors and interventions from other sectors, should be developed and implemented. Investing in these preventive health policies is challenging as budgets have to compete with other governmental expenditures. The current study aimed to identify, compare and rank cost-effective preventive interventions targeting metabolic, environmental, occupational and behavioral risk factors. To identify these interventions, a literature search was performed including original full economic evaluations of Western country interventions that had not yet been implemented in the Netherlands. Several workshops were held with experts from different disciplines. In total, 51 different interventions (including 13 cost saving interventions) were identified and ranked based on their incremental cost-effectiveness ratio (ICER) and potential averted disability-adjusted life years (DALYs), resulting in two rankings of the most cost-effective interventions and one ranking of the 13 cost saving interventions. This approach, resulting in an intersectoral ranking, can assist policy makers in implementing cost-effective preventive action that considers not only the health sector, but also other sectors.

Urban Green Space: Creating a Triple Win for Environmental Sustainability, Health, and Health Equity through Behavior Change.

Urbanization, costs of green space maintenance, and diminishing connection between people and nature all exert pressures on urban green space. This is regrettable as green space has the potential to create wins for environmental sustainability, health, and health equity. This paper explores this potential triple win and investigates how to increase the use of urban green space through behavior change. A narrative literature review was conducted and was supplemented with literature suggested by experts. Results show that creating well-designed green spaces and stimulating people to use them can indeed deliver this triple win. Providing accessible, attractive, well-maintained green space with room for socialization, and where people feel safe, may increase the opportunity and motivation of people to use it more often. Informing and educating people and organizing activities may increase capability (and motivation) to use green space. Since the use of green space depends on life stage, lifestyle factors and individual values, it is important to involve potential users in its design. We recommend a specific focus on those groups who may benefit most from the use of green space. More evaluation is needed to inform effective green space interventions and to assess related economic, social, and environmental benefits.

Ten Lessons for Good Practice for the INHERIT Triple Win: Health, Equity, and Environmental Sustainability.

The world's challenges of climate change, damage to ecosystems, and social and health inequalities require changes in human behaviours at every level of organisation, among governments, business, communities, and individuals. An important question is how behaviour change can be enabled and supported at the scale and speed required. The research reported in this paper describes important lessons for good practice in changing contexts to modify behaviours for a triple win for health, equity and environmental sustainability. Authors synthesised learning from qualitative, quantitative and cost benefit evaluations of 15 case studies conducted in 12 countries in Europe. The case studies address ways of living (green spaces and energy efficient housing), moving (active transport) and consuming (healthy and sustainable diets) that support the triple win. Ten lessons for good practice were identified. These include bringing a triple win mindset to policy and practice in planning interventions, with potential to improve environmental sustainability, health and equity at the same time. The lessons for good practice are intended to support governmental and non-governmental actors, practitioners and researchers planning to work across sectors to achieve mutual benefits for health and environmental sustainability and in particular to benefit poorer and more socio-economically disadvantaged groups.

The INHERIT Model: A Tool to Jointly Improve Health, Environmental Sustainability and Health Equity through Behavior and Lifestyle Change.

The need for analysis and action across the interrelated domains of human behaviors and lifestyles, environmental sustainability, health and inequality is increasingly apparent. Currently, these areas are often not considered in conjunction when developing policies or interventions, introducing the potential for suboptimal or conflicting outcomes. The INHERIT model has been developed within the EU-funded project INHERIT as a tool to guide thinking and intersectoral action towards changing the behaviors and lifestyles that play such an important role in today’s multidisciplinary challenges. The model integrates ecological public health and behavioral change models, emphasizing inequalities and those parts of the causal process that are influenced by human behaviors and lifestyles. The model was developed through web-based and live discussions with experts and policy stakeholders. To test the model’s usability, the model was applied to aspects of food consumption. This paper shows that the INHERIT model can serve as a tool to identify opportunities for change in important −food-related behaviors and lifestyles and to examine how they impact on health, health inequalities, and the environment in Europe and beyond. The INHERIT model helps clarify these interrelated domains, creating new opportunities to improve environmental health and health inequality, while taking our planetary boundaries into consideration.