IN CONTROL II

A healthy lifestyle - a healthy diet and adequate exercise - contribute significantly to chronic disease prevention. People with a lower socioeconomic position (SEP) often have an unhealthier lifestyle than people with a higher SEP. However, interventions aimed at promoting a healthy lifestyle reach precisely this lower SEP target group poorly and may increase social inequality. A possible explanation is that interventions traditionally tend to focus on individual determinants of behavior such as knowledge, attitudes and intentions. Moreover, these interventions are often not effective, partly because they do not take into account the - social, physical and political - context in which lifestyle choices are made: unhealthy behavior can be seen as an automatic reaction to the 'obesogenic' environment. Changes in and of the environment in which people live can go a long way in promoting healthy lifestyles and reaching all target groups. Changes in the environment should ensure that the healthy choice becomes the easy choice, the obvious choice or even the only choice, especially also for the hard to reach and change target groups such as people with lower education. However, whether environmental interventions are also effective in improving cardiovascular disease risk factors in the longer term is not known and needs to be investigated. The Research Supermarkets form one of the most important point-of-choice settings with the potential to directly influence purchasing behaviors. ‘Nudges’ (small environmental encouragements) target the quick, automatic choices and do not require conscious decision making, and pricing strategies can seduce consumers to buy healthier alternatives. Such environmental cues can make it easier to initiate and maintain a healthy lifestyle, and as such, to improve cardiometabolic health. In addition, the use of theory-based mobile applications is an effective way to provide tailored and context-specific feedback on physical activity behaviors through the stimulation of ‘goal setting’ and ‘self-management’. Being incorporated in structures and systems, environmental interventions can make the healthy choice an easy choice for everyone. As such, these types of interventions are especially effective in reaching otherwise difficult-to-reach groups such as people with a lower socioeconomic position (SEP). In particular, a combination of ‘nudging’ (targeting automatic behaviors), ‘pricing’ (responding to the price-sensitivity of low income consumers) and tailored physical activity feedback and support (which works better than general education), seems promising for lowering cardiometabolic risk in individuals with low SEP. Yet, the existing evidence is mostly restricted to short-term effects on (proxies of) health behaviors, and little is known about long-term impact of such integrated interventions on cardiometabolic risk factors. With SUPREME NUDGE we expand a previous successful Dutch supermarket pricing strategy intervention, and incorporate promising elements such as nudging and ICT applications to provide real-time and context-specific physical activity feedback. We will investigate the effects of this approach on dietary behaviors, physical activity and established cardiometabolic risk factors in adults with a lower SEP. Using principles from Participatory Action Research and systems thinking, we will consult with the relevant stakeholders to explore options for upscaling and further implementation in society. Outcomes will provide policy- and practice relevant evidence with clear, stepwise and realistic leverage points for helping individuals to maintain healthy behaviors and improve their cardiometabolic health by making the healthy choice the easy choice. SUPREME NUDGE is coordinated by the Amsterdam UMC, location VU University, and includes partners from the VU University, University of Amsterdam, Utrecht University Medical Center, Utrecht University, the Dutch Nutrition Center, Te Velde Research, Nynke van der Laan (ICT developer), Duwtje (creative designers) and supermarket chain Coop. The origin The Heart Foundation aims for more people to make healthy choices, so that they feel vital and run less risk of developing (again) cardiovascular diseases, which was one of the themes of the reserach agenda. With its prevention programs, ZonMw contributes to the improvement of prevention practice, to health gains and to reducing socioeconomic health disparities. Results from research show that healthy behavior cannot be taken for granted, and is strongly influenced by people's social and physical environment and socioeconomic status. Proven effective, innovative and accessible methods to enable people to maintain a healthy lifestyle for a long time are lacking. Therefore, the Dutch Heart Foundation and ZonMw have collaborated to form the program "Gezond leven: goed voor het Hart!". SUPREME NUDGE is one of the projects funded from this program.

Atrial fibrillation and heart failure are two of the major cardiovascular challenges of our time. It is important that these conditions are detected in time and treated according to guidelines. This is far from always the case. It is sometimes not clear that certain symptoms are caused by atrial fibrillation or heart failure, neither to the patient himself nor to health care providers. As a result, it sometimes takes a long time before someone receives the right treatment. The chronic nature of heart diseases such as atrial fibrillation and heart failure also means that patients with these conditions are seen by many healthcare providers. To achieve this in a high-quality and transparent manner, optimal cooperation between the various care domains is necessary. It is important that the principle of right care in the right place (JZOJP) is applied. However, network care is complex and the effective organization of JZOJP by the right healthcare professional is still far from commonplace despite the many initiatives. The origin Better treatment of these conditions was a priority on the cardiovascular disease research agenda. This is why the Dutch Heart Foundation and ZonMw have started the thematic collaboration “Right Heart Care In the Right Place". By combining expertise, we want to detect as many people as possible with atrial fibrillation and heart failure early and treat them optimally. We are doing this in various ways: jointly setting up subsidy rounds to support regional collaborations, supporting a national support structure for the regions and overarching activities that contribute to knowledge development. As part of Right Heart Care In the Right Place, the network program of the Dutch Society of Cardiology, NVVC Connect, together with involved network partners, facilitates an adequate national support structure for affiliated regional collaborations, or Connect regions. The Connect regions are supported and guided in, for example, preparing the subsidy application and they receive support during the implementation of the regional transmural agreements. The research The Right Heart Care In the Right Place consists of two forms of support: the National Impulse: the aim is to set up a sustainable national support structure that stimulates and guides regions in the regional design and implementation of network care in the field of atrial fibrillation and heart failure the Regional Impulse: the aim of the Regio-Impulse Cardiac Care is to support regional alliances, the Connect regions, in implementing regional transmural agreements. By bringing together the various care providers from the 3rd, 2nd and 1st line, these collaborative ventures jointly offer cardiological care for atrial fibrillation or heart failure more integrally and transmurally. In this way, the patient comes into contact with the healthcare provider who can best contribute to the care need at that moment. A maximum of 22 Connect regions can receive funding to implement the transmural agreements or to optimize the implementation in their region.