It is a cluster-randomised, sort 2 hybrid medical trial managed with two parallel teams. The protocol of the medical trial [13] was written and revealed in compliance with the Suggestions for Interventional Trials (SPIRIT) [16] and the Requirements for Reporting Implementation Research (StaRI) [17].

Research setting

The research was carried out in major healthcare centres of seven Autonomous Communities of Spain from January 2017 to December 2018. Healthcare on this scope is offered in healthcare centres, that are manned by multidisciplinary groups of physicians, nurses, pediatricians, midwives, social employees and dentists, who perform actions of well being care, well being schooling, well being promotion and prevention and actions for the group [18].


The contributors had been recruited from the well being centres by a number of strategies: 1) on the time of the go to as a part of traditional care; 2) ready room or admission desk of the healthcare centre; 3) by an individual in control of recruiting contributors; 4) posters within the well being centres; 5) telephone calls to sufferers who met the choice standards.


The EIRA research consists of the participation of 26 healthcare centres. The factors for the number of the centres had been the next: 1) accessing the Web; 2) having the potential for finishing up group actions; 3) being situated in areas with out nice cultural and linguistic variety; and 4) having an lively and extremely dedicated skilled workforce. The professionals of the chosen healthcare centres participated voluntarily and signed a collaboration dedication to the research.

The research included folks between 45 and 75 years of age who introduced not less than two of the next standards associated to their existence on the time of the screening: 1) smoker; 2) low adherence to the MD (evaluated by two validated questions in regards to the each day consumption of vegetables and fruit [19]); and three) inadequate degree of bodily exercise (evaluated by the Temporary Bodily Exercise Evaluation Instrument [20]). The exclusion standards had been as follows: superior critical diseases, cognitive impairment, dependence in primary on a regular basis actions, extreme psychological sickness, being included in a long-term house well being care program, being below therapy for most cancers or in end-of-life care, or not planning to reside within the space in the course of the time that the intervention lasted. The chosen contributors signed an knowledgeable consent earlier than any examination or process of the research and carried out two evaluations, i.e., at baseline and at 12 months.

Information assortment and administration

Recruitment, screening go to and intervention visits, together with group classes, had been carried out by the healthcare professionals of the collaborating healthcare centres. The analysis visits (baseline and 12 months) had been carried out by an exterior unit of healthcare professionals educated in every centre since these actions weren’t thought of to be associated to the standard care. An digital data-collection pocket book was designed. The research was managed by coordinators on the central, regional and native ranges inside every of the collaborating healthcare centres. Totally different communication strategies, comparable to conferences and newsletters, had been used among the many coordinators and managers of the research.

Major and secondary outcomes of this manuscript

This hybrid trial has the next major aims: to judge the effectiveness and cost-effectiveness of a fancy a number of danger intervention on lowering tobacco use, enhancing adherence to Mediterranean dietary sample and growing bodily exercise degree in 12 months to baseline in contrast with traditional care; to evaluate the effectiveness of an implementation technique by way of acceptability, adoption, appropriateness, feasibility, constancy, implementation value and penetration.

The first consequence of this manuscript was the change, after 12 months, within the variety of contributors in every group with a rating equal to or higher than 9 factors on the MEDAS, which might point out good adherence to the MD sample. Secondary outcomes had been the change within the world rating of adherence to the MD, the change within the proportion of people who positively complied with every of the gadgets of the questionnaire, and the change in weight, blood stress and laboratory variables included in cardiovascular danger estimation calculators.

Measurement variables and instrument

Adherence to the Mediterranean Eating regimen

This questionnaire was developed and validated by the PREDIMED group [11], and consists of 14 questions with two potential solutions. Every merchandise was scored with both zero or one level relying on whether or not the person met the established suggestions concerning the MD. These suggestions are the next: 1) use of olive oil as the primary fats for cooking; 2) each day consumption of not less than 4 tablespoons of olive oil; 3) each day consumption of not less than 2 servings (1 serving = 200 g) of greens (not less than one in every of them in a salad or uncooked); 4) each day consumption of three or extra fruit items (together with pure juice); 5) consumption of lower than one carbonated and/or sugary beverage per day; 6) consumption of lower than one serving (100–150 g) of pink meat, hamburgers, sausages or processed meat per day; 7) weekly consumption of not less than 3 servings (1 serving = 150 g) of legumes; 8) consumption of not less than 3 servings of fish or shellfish per week (1 piece or portion dish: 100—150 fish or 4–5 items or 200 g of seafood); 9) consumption of lower than one serving (12 g) of cream, butter or margarine per day; 10) consumption of seven or extra glasses of wine in the entire earlier week; 11) consumption of nuts 3 or extra instances per week (1 serving = 30 g); 12) consumption of business (non-home-made) pastries lower than twice per week; 13) choice for the consumption of hen, turkey or rabbit meat as an alternative of beef, pork, hamburgers or sausages; and 14) consumption of “sofrito” (sauce made with tomato, garlic, onion and different greens to decorate rice, pasta, meat and different dishes) 2 or extra instances per week. The ultimate rating vary was 0 to 14 factors. Though the MEDAS questionnaire doesn’t have a longtime cut-off level to discern good adherence to the MD, the cut-off level of 9 factors or extra has ceaselessly been used to point good adherence to this dietary sample [6, 21].

Clinically related measures

Different variables had been measured, together with remedy use obtained from medical notes, blood stress, glucose, weight, top, and laboratory parameters (complete serum ldl cholesterol, LDL-cholesterol, HDL-cholesterol, triglycerides). Weight was measured twice at every go to utilizing validated scales with an error of ± 0.1 kg. Blood stress was measured 3 instances in every arm utilizing validated gadgets (OMRON M10-IT) following the measurement protocol of the European Society of Hypertension [22]. Laboratory checks had been carried out on fasting for 10–12 h and samples had been despatched to a central laboratory to be analyzed. The central laboratories all belonged to hospitals of the Spanish Well being System and met all of the required high quality necessities. Ldl cholesterol and triglyceride values had been expressed in mg/dL and glycosylated hemoglobin in proportion. An in depth description of the best way by which these variables had been measured was revealed with the research protocol [13].

On the primary go to, a researcher requested every particular person questions to find out the stage of change for every way of life studied following the constructs of the Transtheoretical Mannequin by Prochaska et al. [23] that classifies people into numerous levels of well being habits change: Precontemplation: No intention to take motion inside the subsequent 6 months, Contemplation: Intends to take motion inside the subsequent 6 months, Preparation: Intends to take motion inside the subsequent 30 days and has taken some behavioural steps on this route, Motion: Modified overt behaviour for lower than 6 months, Upkeep: Modified overt behaviour for greater than 6 months, and Termination: No temptation to relapse and 100% confidence.

Task of intervention

The task of the intervention was carried out by healthcare centre and was computer-generated at a central location (IDIAP Jordi Gol, Barcelona, Spain). For every of the seven Autonomous Communities, half of their collaborating healthcare centres (N = 13) had been randomised to the intervention group and the opposite half (N = 13) had been randomised to the management group. Each the investigators conducting the assessments (baseline and 12 months) and the investigators conducting the statistical analyzes had been blinded to the intervention. As a result of very traits of the intervention, each the contributors and the researchers who carried out the interventions couldn’t be blinded to the intervention.

Intervention (solely healthcare centres of the intervention group)

The intervention was grounded within the transtheoretical mannequin of behaviour change [24] and was carried out by physicians and nurses of the healthcare centres inside their routine of traditional care, in line with the conceptual framework of the “5 A’s”: Assess, Advise, Agree, Help, and Organize follow-up [25]. The intervention was based mostly on the outcomes of the earlier phases of the research (pre-clinical, part I and part II) [8, 26,27,28,29,30,31,32]. It had three totally different motion ranges: particular person, group and group. In all these ranges, the intention was to behave on the behaviours associated to smoking, food regimen and bodily exercise on the similar time, though, relying on the participant, actions had been prioritised for a number of of those behaviours.

Particular person intervention: the person intervention degree included 2–3 visits of 25–30 min every, with the potential for conducting another go to as a reinforcement of the intervention. Relying on the stage of change by which every participant was for every of the behaviours, both very transient (3 min) intervention (contributors in pre-contemplation, contemplation and upkeep part) or particular intervention (contributors in preparation and motion part) was offered. The intention of the very transient intervention was to boost consciousness of the necessity for a behavioural change and help the change or assist to forestall potential relapses, whereas the precise intervention was aimed toward establishing an agreed particular plan for the behavioural change. To ensure an enough and standardized measurement of the contributors’ stage of change in relation to their existence, all of the professionals undertook a 20-h on-line course on motivational interview [33]. Some research counsel the effectiveness of the Quick Message Service-SMS in well being promotion interventions, particularly in relation to the cessation of tobacco consumption and growing bodily exercise, though sure gaps persist and additional analysis on the topic is advisable [34, 35]. The intervention employed info and communication applied sciences (ICTs), comparable to web sites for the contributors, textual content messaging (in all of the levels of change), smartphone functions (solely within the preparation and motion phases) [7] and different assistive gadgets like smartwatches and pedometers. The number of the ICTs was carried out by earlier pilot research and the effectiveness of those in earlier research [7]. Its relationship with the idea of change is described in Desk 1.

Desk 1 Traits of dietary element of the intervention in line with the dietary habits stage of change

Group intervention: Two well being schooling workshops targeted on nutritious diet and bodily exercise had been carried out. These workshops had been carried out after the person intervention and had been directed by professionals of the concerned centres. That they had a length of 90–120 min and had been aimed toward strengthening the suggestions given within the particular person classes and offering pointers to facilitate the apply of bodily exercise and the adoption of wholesome consuming behaviours. The group classes had been tailored to the context of every healthcare centre of the collaborating intervention group. Some examples of workshops had been: bodily train classes, cooking workshops or getting ready seasonal menus.

Group intervention: This intervention was targeted on the social prescription [36] of sources and actions carried out within the surroundings of the group of every healthcare centre. Social prescription, additionally typically often known as group referral, is a technique of enabling well being professionals to refer folks to a spread of native, non-clinical companies. The referrals typically, however not solely, come from professionals working in major care settings, for instance, basic practitioners or apply nurses. Within the EIRA research, beforehand, every centre recognized the accessible sources, in addition to the actions with their schedule, length and frequency. Relying on the probabilities of every participant and different conditioning elements just like the work surroundings and time availability, the actions that greatest suited every participant had been chosen. Some examples of those actions had been: cooking programs, heart-healthy walks, sport actions, dancing programs and actions, and inexperienced bodily exercise programmes. Its relationship with the idea of change is described in Desk 1.

Dietary element of the intervention: The dietary intervention was carried out by an individual included as employees of every Major Care Staff collaborating within the research. A selected coaching in dietary recommendation and on the Mediterranean food regimen was offered to the professionals who had been in control of finishing up this intervention in every middle. The coaching lasted 8 h and was imparted by a dietician-nutritionist. Throughout the particular person intervention, the precise part about MD included the next contents: 1) rationalization of the idea of MD; 2) causes for adopting a MD; 3) personalised suggestions in regards to the modifications that have to be launched and settlement on the aims to achieve; 4) supply of informative materials summarizing the intervention (leaflets); 5) the potential for finishing up group workshops; 6) the potential for conducting group actions; 7) the potential for becoming a member of the SMS messaging programme; 8) the potential for utilizing ICTs (web sites, smartphone functions, and so on.). Throughout the group intervention, the precise part in regards to the MD included well being schooling workshops, cooking workshops and getting ready seasonal menus. Group intervention was based mostly on social prescription that included the actions recognized in every intervention middle. Some examples of those actions had been cooking programs or diet schooling classes to the group. Desk 1 consists of info on the kind of intervention based mostly on the stage of change in dietary habits.

The particular intervention to deal with smoking adopted the rules of motivational interview and included the institution of a D-day to stop smoking and the submission of written materials with follow-up visits at 15 days and 1 month after the D-day. Then again, the precise intervention to deal with bodily exercise was based mostly on consensus with the participant on a personalised bodily exercise plan that ideally included group sources or programmes within the healthcare centre itself.

Common care (healthcare centres of the management group)

The professionals of the management group healthcare centres had been requested to combine the approach to life suggestions of the Programme of Preventive Actions and Well being Promotion [37] into their traditional apply. This programme consists of protocols about way of life suggestions (food regimen suggestions specializing in the adoption of the MD, bodily exercise and smoking cessation) and a set of preventive actions for particular teams of sufferers (i.e., age, intercourse and danger) based mostly on transient recommendation for the prevention of cardiovascular illnesses, psychological illnesses and most cancers, in addition to for the follow-up of basic and particular vaccination campaigns. This intervention within the management group differs from the EIRA intervention, since it’s a transient, non-intensive and distinctive intervention.

Ethics approval

The template knowledgeable consent kinds had been reviewed and authorized by the Analysis Ethics Committee of the IDIAP Jordi Gol (approval quantity P16/025). The research complied with all relevant legal guidelines on the safety of non-public information. All information assortment kinds had been recognized by a coded identification quantity solely to take care of participant confidentiality.

Pattern measurement

A pattern measurement of 3640 contributors (1820 for every group), permitting for 30% loss to follow-up, was estimated to have 80% energy (at 5% significance degree, two-tailed and with an intracluster correlation of 0.01), to detect an absolute distinction in a optimistic change in a number of of the three behaviours of 8% between teams (EIRA intervention and traditional care).

Statistical energy was estimated for the primary consequence variable of this manuscript (proportion of people with good adherence to the MD on the finish of the research). Accepting an alpha danger of 0.05 and an influence of 80% in a bilateral take a look at, a pattern of 1481 topics within the first group (EIRA intervention) and 1581 within the management group was sufficient to acknowledge as statistically vital the distinction from 42% within the first group to 34% within the second group (statistical energy 100%).

Statistical analyses

The statistical analyses had been carried out by intention-to-treat. The normality of the variables was assessed utilizing the Kolmogorov–Smirnov take a look at. To handle potential biases on account of incomplete follow-up and non-response within the surveys, a number of imputation by chained equations (mice perform in R software program) with 50 imputed datasets was utilized to outcomes and covariates [38, 39]. Estimates from every imputed dataset had been mixed following the foundations outlined by Rubin [40]. The specific variables are expressed as n and percentages, whereas the quantitative variables are expressed as imply and normal deviation. The imply variations between the research teams had been evaluated with Pupil’s t-test, whereas the intragroup variations had been assessed by Pupil’s t-test for paired information. The connection between two categorical variables was analysed utilizing the chi-squared take a look at. Evaluation of covariance (ANCOVA), with age, intercourse, middle and dietary habits stage of change as covariates, was used to check the modifications between the 2 teams. For secondary outcomes, modifications in bodily exercise and smoking cessation as covariates had been moreover included within the evaluation mannequin. For the bilateral distinction of hypotheses, an alpha danger of 0.05 was set because the restrict of statistical significance. The information had been analysed utilizing the statistical software program SPSS for Home windows model 25.0. (IBM Corp, Armonk, NY, USA).

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