Supplementary Figure shows the study flowchart. As per recruitment goal, 200 eligible individuals were identified and invited to participate in the selective prevention intervention in each country (total N=1,000). In total, less than half of invited individuals (47.4%, n=474) accepted the invitation. Acceptance rates ranged from 19.5% (n=39) in Sweden to 100% (n=200) in the Czech Republic. Sweden had the highest risk-assessment completion rate (100%, n=39) among all countries, while Greece had the lowest (65.4%, n=70). Across all sites, there was an 84.2% (n=399) risk-assessment completion rate.
Participants’ demographics are summarized in Table 1. Women were over-represented in all countries [Czech Republic: 60.5% (n=121), Greece: 59.8% (n=34), Netherlands: 54.5% (n=36), Sweden: 69.2% (n=27)], apart from Denmark (46.8%, n=29). Mean age of participants ranged from 50 (± 8.8) years in the Czech Republic to 55.5 (± 6.3) years in Denmark.
In all countries, except for Greece, most participants had university education [Czech Republic: 82.3% (n=63), Denmark: 83.4% (n=45), Netherlands: 80.3% (n=53), Sweden: 100% (n=39)], while in Greece the majority of participants had completed secondary education (48.6%, n=52). Most participants were working full-time and were covered by health insurance. In the Czech Republic and Sweden most participants reported an income above the country average [42.2% (n=84) and 61.5% (n=24), respectively]. In the Netherlands, most participants had an income equal to the national average (53.8%, n=35), while in Greece the reported income was lower than the average (62.6%, n=67).
[Table 1 approximately here]
CMD-risk factors related to participant lifestyles are presented in Table 2. Daily smoking ranged from 43% (n=46) in Greece to 3.1% (n=2) in the Netherlands. Long-term ex-smokers (quit over 6 months ago) accounted for 34.4% (n=22) in the Netherlands, 33.3% in Denmark (n=20), 20.5% in Sweden (n=8), 17% (n=34) in the Czech Republic and 15% in Greece (n=16). Rates of never-smoking ranged from 32.7% (n=35) in Greece to 71.8% (n=28) in Sweden.
The median (IQR) number of standard alcoholic beverages consumed weekly reached [7(9)] in Greece, followed by Denmark [4(8)], Sweden [3(5)], Netherlands [2(7)], and the Czech Republic [2(6)]. Additionally, more than 10% of participants in all countries stated that they drink four (for women) or five (for men) standard drinks on a single occasion at least once weekly.
Rates of sedentary lifestyle ranged from 8.1% (n=5) in Denmark to 19.6% (n=21) in Greece. Roughly one out of four participants were classified as under-active (light or moderate exercise, not weekly) in the Czech Republic (31.6%, n=62), Denmark (25%, n=12), the Netherlands (20%, n=13) and in Sweden (25.6%, n=10), while in Greece the rate was almost double (48.1%, n=51).
Daily vegetable consumption was reported by most participants in Sweden (82%, n=32), the Netherlands (80%, n=52), Denmark (61.3%, n=38), but not in the Czech Republic (44.2%, n=88) and Greece (12.1%, n=13). In all countries, daily fruit consumption was reported by half or more of participants, apart from Greece where the rate was 21.5% (n=23). In the Czech Republic, Denmark, and Greece, most participants reported fish consumption a few times per month [62.1% (n=123), 50% (n=31) and 67.3% (n=72) respectively].
[Table 2 approximately here]
Table 3 presents CVD-risk scores for participants who completed the risk assessment tool used in each country. The median (25%-75% quartiles) of the country-adjusted European Heart SCORE was 1 (0-3) in Greece and 1 (0-2) in the Czech Republic. The median of Svenska score in Sweden was, remarkably, zero [0 (0-1)]. In Greece, 11.4% (n=8) of participants were found with increased CVD-risk (SCORE≥5%). Respective rates for Czech Republic and Sweden were 6.9% (n=21) and zero. In Greece and the Czech Republic, 4.3% (n=3) and 2.3% (n=4) of participants respectively were classified in the highest CVD-risk category (SOCRE≥10%). In Denmark, the median (25%-75%) of the modified Heartscore BMI score was 2 (1-3), with 8.6% (n=5) of participants classified at high CVD-risk. In the Netherlands, the median (25%-75%) PC CMR score was 22 (13.5-39.5), with 21 (36.8%) participants found to be at high risk.
[Table 3approximately here]
Participant evaluation of the intervention
Figure 1 shows participants’ evaluation of the selective prevention process assessed on a ten-point scale. In Sweden, intervention feasibility was assessed with the highest scores [median (25%-75% quartile): 9.2 (8.2 – 9.9)], while usefulness received the lowest scores [median (25%-75%): 6.1 (5 – 7.4)]. Greek participants assessed intervention’s ability to encourage a healthier lifestyle with the highest scores [7.6 (7.1-7.9)] and its relevance the lowest [5.9 (5.5-7.7)]. In the Czech Republic all process evaluation dimensions received similar assessments, with median scores (25% - 75%) ranging from 7.2 (5.1 - 8.6) for relevance to 7.5 (6.2 – 9.2) for usefulness. Participants in Denmark and the Netherlands did not evaluate the risk assessment intervention, despite their invitation to do so.
[Figure 1 approximately here]
Perception and barriers towards lifestyle modification
In response to the risk assessment, the vast majority of participants in the Czech Republic (84.5%, n=147), Greece (92.8%, n=64) and Sweden (82.1%, n=32) reported they were willing to change their lifestyle in order to reduce their CMD-risk (Figure 2A). The main motivation behind this willingness was related to their desire for better health [Czech Republic: 71.3% (n=124), Greece: 61.4% (n=43), Sweden: 61.5% (n=24)]. A secondary reason for behavioral change specific to the Czech Republic was the possibility of having an increased CMD-risk (31%, n=51), while in Greece it was the doctor’s motivation to do so (21.4%, n=15). In Sweden, the possibility of having an increased CMD-risk was the only secondary reason for behavioral change (61.5%, n=24). Participants in Denmark and the Netherlands did not respond to the above questions.
About one out of three Czech participants (34.5%, n=59) stated that they had encountered barriers in their attempt to change their lifestyle (Figure 2B). The equivalent rates were 12.8% (n=9) in Greece and 15.4% (n=6) in Sweden. Lack of time (37.3%, n=22) and motivation (35.6%, n=21) were identified as main barriers among the 59 Czech participants who had encountered barriers in their lifestyle-change attempt. In Greece, all nine (100%) participants stated that they had tried but found it too difficult to start a healthier lifestyle. Other barriers reported by Greek participants included lack of budget (66.6%, n=6), time (44.4%, n=4), and knowledge about where to start (33.3%, n=3). In Sweden four out of six (66.7%) participants who reported barriers to lifestyle change, gave other reasons for not changing lifestyle, followed by having tried but finding it too difficult (50%, n=3 ) and lack of motivation (33.3%, n=2).
[Figure 2 approximately here]