θωερτψυιοπασδφγηϕκλζξχϖβνµθωερτ
ψυιοπασδφγηϕκλζξχϖβνµθωερτψυιοπ
ασδφγηϕκλζξχϖβνµθωερτψυιοπασδφγη
ϕκλζξχϖβνµθωερτψυιοπασδφγ...
 
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
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Allocation	
  of	
  	
  
Lifestyle	
  Supporting	
  Services	
  to	
  	
  
Working	
  Diabetes...
Preface
As one can never do an executive MBA without support, I want to take the opportunity to
express my gratitude towar...
Table of contents
	
  

Preface	
  ..........................................................................................
3	
   	
  Qualitative	
  research	
  ........................................................................................
5.1.2	
   Results	
  
.......................................................................................................
“If we could give every individual the right amount of nourishment and exercise,
not too little and not too much,
we would...
Management Summary
In 2011, 3.5 million Dutch inhabitants younger than 65 years suffered one or more
chronic diseases. In ...
Therefore this explorative research focuses on the research question: ‘Is it possible
to divide employees with diabetes me...
Based upon their personal insights and experiences, a majority of interviewed experts
confirmed during the qualitative res...
 	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	...
1

Introduction and background

“One in four kids have either pre-diabetes or diabetes - what I like to call diabesity.
Ho...
1.2

Context of the problem
Of all diabetics in the Netherlands a majority of 90% has diabetes mellitus type 2

(T2DM), wh...
Therefore there seems to be an even bigger need for lifestyle management programs
next to lifestyle intervention programs....
optimize the treatment of their diabetes. The second challenge is to target each type of
working T2DM with specific optima...
1.5

Target group
This research is limited to the Dutch population of working diabetics. Reason for this

is the considera...
1.7

Deliverables for CZ
This paper aims to make an actual contribution towards a (partly) solution for one of

the big ch...
1.8

Structure of the thesis
Chapter 2 sets the theoretical framework for the research with a literature study on

the lat...
2

Theoretical framework
This research has an explorative character and wants to make an initial step in

providing direct...
diet and hypertension (Janssen & Avendonk, 2009). Especially the increase in obesity, aging
and detection are the predomin...
not reversible anymore although the development of the disease can be decelerated. For this
purpose, a growing list of pha...
Dutch employees with diabetes have an additional sick leave of 10.5 days compared to
employees without a chronic disease (...
2.2

Literature Review: Lifestyle medicine

"Medicine is not healthcare. Food is healthcare. Medicine is sick care.
Let's ...
In their aim to banish disease, health care developed a strong focus on conquering
infectious disease and curing infected ...
Egger, Binns and Rossner (2011) state in the second edition of the book Lifestyle
Medicine that “inactivity, poor and over...
Primary prevention aims at preventing a disease from developing by modifying the behavioral
or environmental cause, second...
1996) (Williams, Rodin, Ryan, Grolnick, & Deci, 1998). During 3 years, a program designed
to promote autonomous motivation...
behavior, the current one-size-fits-all approach in supporting services does not appear to be
an all-encompassing solution...
As stated in paragraph 2.1, T2DM is a lifestyle related chronic disease that correlates
strongly with overweight and obesi...
2.3.1.1

WIN-model by TNS NIPO
The WIN-model by TNS NIPO (Figure 4) is a segmentation of the Dutch

population, based upon...
2.3.1.2

Mentality by Motivaction
Mentality by Motivaction (Figure 5) is a values and lifestyle research product that

pro...
2.3.1.3

BSR model by SmartAgent Company
The BSR or Brand Strategy Research Model (by SmartAgent Company) explores the

un...
2.3.1.4

Streetlife by Cendris
The core of Streetlife as shown in Figure 7 consists of more than 300 socio-

demographic a...
 
Figure 8: Mosaic by Experian (Experian Nederland, 2013)

2.3.1.6

Six consumer segments of health care systems by Deloit...
segment may require innovative and tailored products and services, marketing approaches,
business strategies, and new cust...
2.3.2

Empirical based versus scientific supported segmentation model
As stated in paragraph 2.3, this study is looking fo...
However, lately more and more patients want to play a more active role regarding
their own health and treatment, making ex...
Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
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Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
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Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
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Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
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Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
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Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
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Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
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Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients
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Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients

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Is it possible to effectively manage a population of working diabetes type II patients on lifestyle??
This document answers a burning health care issue as the lifestyle related Diabetes Mellitus type II has become the second largest and the fastest growing chronic disease in the Netherlands (and probably in the whole first and second world). It explores the possibilities to segment a population of working Diabetes Mellitus Type 2 patients into different types of people with distinctive characteristics, to plot a course towards a more effective use of lifestyle supporting services around their diabetes.

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Allocation of Lifestyle Supporting Services to Working Diabetes Type II Patients

  1. 1. θωερτψυιοπασδφγηϕκλζξχϖβνµθωερτ ψυιοπασδφγηϕκλζξχϖβνµθωερτψυιοπ ασδφγηϕκλζξχϖβνµθωερτψυιοπασδφγη ϕκλζξχϖβνµθωερτψυιοπασδφγηϕκλζξχ Allocation  of     ϖβνµθωερτψυιοπασδφγηϕκλζξχϖβνµθ Lifestyle  Supporting  Services  to     ωερτψυιοπασδφγηϕκτψυιοπασδφγηϕκλ Working  Diabetes  Type  II  Patients   ζξχϖβνµθωερτψυιοπασδφγηϕκλζξχϖβ a  meaningful  approach  of  segmentation   νµθωερτψυιοπασδφγηϕκλζξχϖβνµθωε ρτψυιοπασδφγηϕκλζξχϖβνµθωερτψυιο πασδφγηϕκλζξχϖβνµθωερτψυιοπασδφγ ηϕκλζξχϖβνµθωερτψυιοπασδφγηϕκλζ ξχϖβνµθωερτψυιοπασδφγηϕκλζξχϖβν µθωερτψυιοπασδφγηϕκλζξχϖβνµθωερτ ψυιοπασδφγηϕκλζξχϖβνµρτψυιοπασδ φγηϕκλζξχϖβνµθωερτψυιοπασδφγηϕκλ ζξχϖβνµθωερτψυιοπασδφγηϕκλζξχϖβ νµθωερτψυιοπασδφγηϕκλζξχϖβνµθωε ρτψυιοπασδφγηϕκλζξχϖβνµθωερτψυιο πασδφγηϕκλζξχϖβνµθωερτψυιοπασδφγ ηϕκλζξχϖβνµθωερτψυιοπασδφγηϕκλζ ξχϖβνµθωερτψυιοπασδφγηϕκλζξχϖβν µθωερτψυιοπασδφγηϕκλζξχϖβνµθωερτ       Executive  MBA  thesis   Erwin  Spijkers   December  4th,  2013        
  2. 2.                                                                                                        
  3. 3.             Allocation  of     Lifestyle  Supporting  Services  to     Working  Diabetes  Type  II  Patients   a  meaningful  approach  of  segmentation     Executive  MBA  thesis   Erwin  Spijkers   egh.spijkers@gmail.com         Company  supervisor     Joep  de  Groot       Raad  van  bestuur                           CbusineZ     Ringbaan  West  236   5038  KE  Tilburg   The  Netherlands                                                                                                Nyenrode  Business  Universiteit                                Straatweg  25                                3621  BG  Breukelen                                          The  Netherlands   Breukelen   December  4th,  2013                                Faculty  supervisor                                                Prof.  Dr.  Sjaak  Bloem                                Center  for  Marketing  and                            Supply  Chain  Management  
  4. 4. Preface As one can never do an executive MBA without support, I want to take the opportunity to express my gratitude towards the people that have helped me throughout my MBA and in the process of writing this thesis. They gave me the confidence and personal support to go on. I would like to thank Prof. Dr. Sjaak Bloem from the center for marketing and supply chain management for his willingness to guide me through this project. His method of stimulation, criticism and motivation has made it possible to deliver this thesis. He introduced me into the fascinating world of Subjective Experienced Health and together with Dr. Joost Stalpers guided me on my exploration. Their insights and feedback proved invaluable. A warm thanks for my parents, who have supported me unconditionally during my whole life and without whom I never would have been able to travel this road so far. Thank you for your support and everything. Without a doubt, I couldn’t have achieved the level of learning that I did the past 20 months without the love, support and sacrifice from my wife Daniëlle and our three wonderful kids Myrthe, Noah and Liam. On too many occasions I left them to their own devices while I went off to study, prepare assignments or travel to Breukelen. It was only through my wife’s perseverance that we were able to pull through this challenging period in our lives. Thank you for being there.                                                                                                                                              Page  |    iv  
  5. 5. Table of contents   Preface  .........................................................................................................................  iv   Table  of  contents  ..........................................................................................................  v   Management  Summary  ................................................................................................  ix   1    Introduction  and  background  .................................................................................  1   1.1    Introduction  ......................................................................................................................................................  1   1.2    Context  of  the  problem  .................................................................................................................................  2   1.3    Management  problem  ...................................................................................................................................  3   1.4    Research  objective   ..........................................................................................................................................  4   1.5    Target  group  .....................................................................................................................................................  5   1.6    Main  research  question  ................................................................................................................................  5   1.7    Deliverables  for  CZ  .........................................................................................................................................  6   1.8    Structure  of  the  thesis  ...................................................................................................................................  7   2    Theoretical  framework  ...........................................................................................  8   2.1    Literature  Review:  Diabetes  Mellitus  .....................................................................................................  8   2.1.1    Type  2  diabetes  mellitus  ...........................................................................................................................  8   2.1.2    Strongest  modifiable  risk  factor  for  developing  T2DM  ...........................................................  10   2.1.3    Consequences  T2DM  for  the  working  population  ......................................................................  10   2.1.4    Learning  summary  ...................................................................................................................................  11   2.2    Literature  Review:  Lifestyle  medicine  ................................................................................................  12   2.2.1    History  of  healthcare  ..............................................................................................................................  12   2.2.2    Traditional/conventional  medicine  versus  lifestyle  medicine  ..............................................  14   2.2.3    Lifestyle  change  and  motivation  ........................................................................................................  15   2.2.4    Motivation  and  financial  incentives  .................................................................................................  16   2.2.5    Learning  summary  ...................................................................................................................................  17   2.3    Literature  review:  Patient  segmentation  ..........................................................................................  17   2.3.1    Empirical  based  lifestyle  segmentation  models  ..........................................................................  18   2.3.1.1    WIN-­‐model  by  TNS  NIPO  ..........................................................................................................................     19 2.3.1.2    Mentality  by  Motivaction  ..........................................................................................................................     20 2.3.1.3    BSR  model  by  SmartAgent  Company  ...................................................................................................     21 2.3.1.4    Streetlife  by  Cendris  ....................................................................................................................................     22 2.3.1.5    Mosaic  by  Experian   ......................................................................................................................................     22 2.3.1.6    Six  consumer  segments  of  health  care  systems  by  Deloitte  ......................................................     23 2.3.2    Empirical  based  versus  scientific  supported  segmentation  model  .....................................  25   2.3.3    Subjective  Experienced  Health  ...........................................................................................................  25   2.3.3.1    SEH  instrument  .............................................................................................................................................     25 2.3.3.2    SEH  model  .......................................................................................................................................................     26 2.3.3.3    Patient  typology  based  upon  SEH  .........................................................................................................     27 2.3.3.4    SEH  Patient  typology  and  issues  in  health  care  ..............................................................................     29 2.3.3.5    SEH  model  in  practice  ................................................................................................................................     29 2.3.4    Learning  summary  ...................................................................................................................................  30   2.4    Potential  lifestyle  supporting  services  ...............................................................................................  30   2.4.1    Quadrant  I  ...................................................................................................................................................  31   2.4.2    Quadrant  II  ..................................................................................................................................................  32   2.4.3    Quadrant  III  ................................................................................................................................................  33   2.4.4    Quadrant  IV   .................................................................................................................................................  33   2.4.5    High  tech  solutions  for  multiple  quadrants  ..................................................................................  34   2.5    Conceptual  model  ........................................................................................................................................  35   2.5.1    Concepts  used  in  the  conceptual  model  ..........................................................................................  36   2.6    Summary  ..........................................................................................................................................................  37                                                                                                                                        Page  |     v  
  6. 6. 3    Qualitative  research  .............................................................................................  38   3.1    Methodology  ...................................................................................................................................................     38 3.1.1    Goal  and  justification  ..............................................................................................................................  38   3.1.2    Respondents  ................................................................................................................................................  39   3.1.3    Design  ............................................................................................................................................................  39   3.1.4    Checklist  ........................................................................................................................................................  40   3.1.5    Procedure  .....................................................................................................................................................  40   3.2    Results  ...............................................................................................................................................................     41 3.2.1    Preface  ...........................................................................................................................................................  41   3.2.2    Data  analysis  ..............................................................................................................................................  41   3.3    Results:  general  observations  .................................................................................................................     41 3.3.1    Consequence  of  having  T2DM  for  employees  ...............................................................................  42   3.3.2    Existing  supporting  services  for  T2DM  treatment  .....................................................................  43   3.3.3    SEH  and  segmentation  of  working  T2DM  patients   ....................................................................  44   3.3.4    Allocation  of  services  to  different  types  of  working  T2DM  patients   ...................................  45   3.4    Conclusions  qualitative  research  ...........................................................................................................     46 3.4.1     Input  from  the  quantitative  research  towards  the  qualitative  research  .........................  47   4    Quantitative  research  ..........................................................................................  49   4.1    Method  ..............................................................................................................................................................     49 4.1.1.    Goal  and  justification  .............................................................................................................................  49   4.1.2    Respondents  ................................................................................................................................................  49   4.1.3    Design  ............................................................................................................................................................  50   4.1.4    Questionnaire  .............................................................................................................................................  50   4.1.5    Procedure  .....................................................................................................................................................  51   4.2    Data  analysis  and  scales  ............................................................................................................................     51 4.3    Results:  general  observations  .................................................................................................................     52 4.3.1    Segmentation  .............................................................................................................................................  53   4.3.2    SEH  per  quadrant  .....................................................................................................................................  53   4.3.3    The  SEH  model  in  a  population  working  T2DM  patients  ........................................................  54   4.3.4    Attitude  towards  lifestyle  supporting  services   .............................................................................  55   4.3.4.1    My  diabetes  will  improve  most…  ..........................................................................................................  55   4.3.4.2    Practical  things  around  my  diabetes,  I  prefer  to…  ........................................................................  57   4.3.4.3    I  will  be  served  best  with…  ......................................................................................................................  59   4.3.4.4    My  biggest  issue  around  diabetes  is…  ................................................................................................  60   4.3.4.5    Problems,  questions  and  advice  concerning  my  diabetes,  I  prefer  to…  ...............................  62   4.3.4.6    Relevant  information  concerning  my  diabetes,  I  prefer  to…  ....................................................  63   4.3.5    Current  lifestyle  .........................................................................................................................................  65   4.3.5.1    Sufficient  night  rest  .....................................................................................................................................  65   4.3.5.2    Daily  breakfast  ..............................................................................................................................................  65   4.3.5.3    Physical  exercise  ..........................................................................................................................................  66   4.3.5.4    Candy  and  snacks  in  between  meals  ...................................................................................................  66   4.3.5.5    Body  weight  ...................................................................................................................................................  67   4.3.5.6    Relaxation  .......................................................................................................................................................  67   4.3.5.7    Healthy  and  varied  food   ............................................................................................................................  67   4.4    Social,  economic  and  demographic  variables   ...................................................................................     68 4.4.1   Rating  of  own  body  weight  ....................................................................................................................  68   4.4.2   Comorbidity  ..................................................................................................................................................  69   4.4.3   Highest  level  of  education  ......................................................................................................................  69   4.5    Conclusions  quantitative  research  ........................................................................................................     70 4.5.1   Applicability  of  SEH  model  in  population  of  working  T2DM  patients  ................................  70   4.5.2   Attitude  towards  lifestyle  supporting  services  ..............................................................................  70   4.5.3   Current  lifestyle  ..........................................................................................................................................  73   4.5.4   Social,  Economic  and  Demographic  variables  ..............................................................................  73   5    Conclusions  &  discussion   ......................................................................................  75   5.1   Qualitative  research  .....................................................................................................................................     75 5.1.1   Process  ............................................................................................................................................................  76                                                                                                                                        Page  |    vi  
  7. 7. 5.1.2   Results   .............................................................................................................................................................  76   5.2   Quantitative  research  ..................................................................................................................................  78   5.2.1   Process  ............................................................................................................................................................  78   5.2.2   Results   .............................................................................................................................................................  79   5.3   Résumé  ..............................................................................................................................................................  80   6    Recommendations  ................................................................................................  81   6.1   Shortlist  next  first  steps  .............................................................................................................................  83   7     Epilogue:  SEH  and  the  broader  picture  ..................................................................  84   7.1   Why  capitation?  .............................................................................................................................................  84   7.2     What  is  capitation?  ......................................................................................................................................  85   7.3   Capitation  and  contracting  results  ........................................................................................................  86   Bibliography  ................................................................................................................  87   Glossary  ......................................................................................................................  93   Appendix  A  Checklist  expert  interview  ......................................................................  A-­‐1   Appendix  B  Example  trial  questionnaire  ....................................................................  B-­‐1   Appendix  C  Global  results  of  trial  questionnaire  .........................................................   C-­‐1   Appendix  D  Feedback  on  trial  questionnaire  .............................................................  D-­‐1   Appendix  E  Questionnaire  ..........................................................................................  E-­‐1   Appendix  F  Data  analysis  questionnaire  CZ  panel  .......................................................  F-­‐1   Appendix  G  Lifestyle  supporting  services   ...................................................................  G-­‐1   Appendix  H  PAM-­‐13  NL  .............................................................................................  H-­‐1   Appendix  I  PAM-­‐13  NL  ................................................................................................   I-­‐1                                                                                                                                                Page  |    vii  
  8. 8. “If we could give every individual the right amount of nourishment and exercise, not too little and not too much, we would have found the safest way to health.” -­‐  Hippocrates                                                                                                                                    Page  |    viii  
  9. 9. Management Summary In 2011, 3.5 million Dutch inhabitants younger than 65 years suffered one or more chronic diseases. In that same year diabetes mellitus was the second most prevalent chronic disease amongst the potential labor force as well as the fastest growing chronic disease. On average, employees with diabetes have 10.5 days of additional sick leave per year compared to employees without chronic disease. This results in a significant financial interest for the employers as well as for the sickness insurance companies. TNO estimates the yearly additional gross cost of diabetes related absence at € 398 million for employers. Of all diabetics, 90% suffers the lifestyle related diabetes mellitus type II (T2DM). T2DM progresses through several phases and once a person is fully diagnosed for having diabetes with complications, this is not reversible anymore although the development of the disease can be decelerated. For this purpose a growing list of pharmaceutical medications is available. Yet, trying to cure a lifestyle related chronic disease with pharmaceutical medicine is like fighting a running battle. When lifestyle is the cause, a change in lifestyle obviously is the cure. Therefore ‘Lifestyle Medicine’ is more sustainable and to be preferred. Conventional (pharmaceutical) medicine treats the (consequences of the) disease where lifestyle medicine aims at changing an individual’s lifestyle and/or behavior to treat the cause of the disease or even prevent the cause from happening. Lifestyle medicine implies that the individual concerned is an active partner in the process, instead of being a passive receiver of medical care. The principal patient requirement in lifestyle medicine is ‘change’. Yet, regarding lifestyle change motivation is often the missing link between a clinician’s prescription and a patient’s cure. Therefore the ultimate goal of lifestyle medicine is to motivate individuals intrinsically to change their lifestyle in a positive and durable way. Currently all employees with diabetes are being treated in the same way, when being sick. Supporting services to optimize the treatment of their disease are not being offered in a differentiated way but in a one-size-fits-all approach. Services that suit the specific needs of individual people lead to greater health improvements than services that do not so. The current non-differentiated approach in supporting services does not appear to be an allencompassing solution as different people get mobilized by different motivators and most likely will have a different readiness, willingness and ability to act regarding their health care behavior. To treat each T2DM patient with the most appropriate lifestyle medicine, a meaningful approach of segmentation based upon lifestyle is required.                                                                                                                                    Page  |     ix  
  10. 10. Therefore this explorative research focuses on the research question: ‘Is it possible to divide employees with diabetes mellitus type II into different types of people with distinctive characteristics, as a starting point towards a more effectively use of lifestyle supporting services around their diabetes (more effectively meaning improved experienced health)?’ Currently there is not one standardized lifestyle segmentation model, although market research firms and consultants are constantly devising new models and categories to segment the Dutch population based upon lifestyle. All these models are empirical based and not scientifically supported by a falsifiable theory. As such they only appoint different lifestyle behaviors but do not offer insight how to influence or change these behaviors. In multiple studies, Bloem & Stalpers identified Subjective Experienced Health (SEH) as the biggest driver of health care behavior (the part of lifestyle behavior this study focuses on). In his dissertation, Bloem (2008) developed the SEH-ladder model, a PROM (patient reported outcome measures) that enables caregivers and patients to objectively measure and discuss something as subjective as a patient’s experienced health. In 2009, Stalpers identified two key psychological determinants of subjective health that are related to the patient’s coping style and coping strategy. Based on these findings, Stalpers developed the SEH population model that enables the segmentation of health care patients into four different types of people. This segmentation model could be very useful to allocate existing and new services to specific types of patients, to influence therapy non-adherence and to better support self-management of patients. In short: personalized care. To examine the applicability of the SEH model amongst T2DM patients, this explorative study started with a qualitative research by interviewing experts in the field of diabetes. The interviews focused on gaining insights and knowledge from the experts around 4 topics: • The consequences of having diabetes type II as an employee (related to the services preferred and needed); • Any existing services to support the treatment of (working) diabetics; • A meaningful segmentation of (working) diabetics and the SEH model; • The possibility of allocating existing supporting services to different segments of working T2DM patients.                                                                                                                                    Page  |     x  
  11. 11. Based upon their personal insights and experiences, a majority of interviewed experts confirmed during the qualitative research the usability of the SEH model in segmenting (working) T2DM patients. Additionally they made an initial step in allocating several lifestyle supporting services to different types of T2DM employees. The results of the qualitative research were a starting point for the questionnaire that was used in the subsequent quantitative research. This questionnaire was sent to 1046 known diabetics of the CZ member panel. After selecting the completed questionnaires filled in by working T2DM patients, it resulted in a population of 121 valid cases. Main goal of the quantitative research was to seek empirical support, on one hand for the applicability of the SEH model in a population of working T2DM patients and on the other hand for the allocation of different lifestyle supporting services towards the four quadrants of the SEH model by the experts. This study confirmed the applicability of the SEH model in a population of working T2DM by conducting two multiple regressions between the variable SEH score and the two predictors (acceptance and perceived control). The results of the questionnaire regarding the attitude of the different types of T2DM patients towards several lifestyle supporting services to improve their treatment showed a pattern that generally was in line with the expectations of the experts. The main conclusion of this research is positive: yes, it is possible to segment T2DM employees in a meaningful way into different types of people with distinctive characteristics, as a starting point towards a more effectively use of lifestyle supporting services around their diabetes (more effectively meaning improved experienced health). The conclusions and discussion can be read in full detail in chapter 5. The recommendations as well as a ‘shortlist of next first steps’ are stated in chapter 6. Finally, chapter 7 settles this paper with an epilogue about the possibilities of capitation and the SEH model.                                                                                                                                    Page  |     xi  
  12. 12.                                                                                                                                      
  13. 13. 1 Introduction and background “One in four kids have either pre-diabetes or diabetes - what I like to call diabesity. How did this happen?” Mark Hyman M.D., practicing physician and internationally recognized authority in the field of Functional Medicine 1.1 Introduction The potential labor force of the Netherlands (people aged between 15 and 64) counts many people with a chronic disease. In 2011 more than 10% of people aged younger than 24 had a chronic disease, this was 27% amongst all people aged between 25 and 54 and even 48% of all people aged between 55 and 64 (Gijsen, Oostrum, & Schellevis, 2013). This means 3.5 million Dutch inhabitants younger than 64 suffered at least one chronic disease in 2011. The RIVM (National Institute for Public Health and the Environment) of the Dutch Ministry of health, Welfare and Sport regularly explores the future of public health in the Netherlands. In its NKV 2013 (National Compass Public Health), the RIVM concluded that diabetes was the second most prevalent disease in 2011 amongst inhabitants aged between 15 and 65 (potential labor force) with 363,800 diabetics in this age (Gommer & Poos, 2013). In 2011 about 801,000 inhabitants of the Netherlands were diagnosed for diabetes according this same RIVM and it was estimated there were another 200,000 people with diabetes that had not been diagnosed yet (Baan & Spijkerman, 2013). Every year 87,000 more people are being diagnosed for diabetes, which accounts almost 200 a day. The RIVM predicts that the Netherlands will have 1,300,000 people with diabetes in the year 2025, if policies remain unchanged. Of the whole Dutch labor force, currently 2.1-2.5% has diabetes (Nederlandse Diabetes Vereniging, 2012). On a labor force of 7.4 million people this counts for 162,000 diabetics. On an average, employees with diabetes have an additional 10.5 days of sick leave per year when compared to people without a chronic disease (15.6 compared to 4.9). This results yearly in 1.7 million diabetes related sick days amongst the working population of The Netherlands. TNO (Applied Scientific Research) estimates the yearly additional gross costs of diabetes related absence at € 398 million (s.n., 2013c). A specialized consultancy firm estimates the total cost associated with lost annual productivity because of diabetes in the Netherlands at 5-6 billion euro and the total medical costs of diabetes patients at 4-5 billion euro (Booz & Company, 2011).                                                                                                                                    Page  |     1  
  14. 14. 1.2 Context of the problem Of all diabetics in the Netherlands a majority of 90% has diabetes mellitus type 2 (T2DM), which is a chronic metabolic disease that develops when the body does not respond properly to insulin anymore, a hormone made by the pancreas (Harris & Zimmet, 1997). Notwithstanding the complex and multifactorial nature of T2DM, its single most important predictor is excessive body weight (Chen, Magliano, & Zimmet, 2012) as the proximal cause of insulin resistance in the modern age is lifestyle and, more specifically, obesity and inactivity (Colqhoun & Egger, 2011). The high prevalence of diabetes in the Netherlands today (Baan & Poos, 2013a), the expected further increasing number of diabetics and the potential success of lifestyle interventions make this an interesting market for many profit and non-profit initiatives. So far, almost 2000 lifestyle interventions have been developed in the Netherlands by various, often local, providers and at least 70 of them are focusing specifically on diabetics (s.n., 2013f). Yet, most of these lifestyle interventions are being implemented with various degrees of success, and eventual positive effects do not seem to last for the majority of participants, as self-management is a problem for many people in the modern ‘obesogenic’ environment. The Booz & Company report of professor Ab Klink concluded that regarding the treatment of diabetes, non-compliance is a challenge of distant benefits and large required behavioral change (Booz & Company, 2011). Significant in this report is Figure 1 that shows that diabetes and obese have a lot in common with addictions like smoking and alcohol when it comes to the degree to which behavior change is required and the motivation to comply with best known therapies.   Figure 1: Chronic quadrangle (Booz & Company, 2011)                                                                                                                                    Page  |     2  
  15. 15. Therefore there seems to be an even bigger need for lifestyle management programs next to lifestyle intervention programs. However a challenging obstacle towards lifestyle management programs is the funding of costs. Where lifestyle intervention programs have a temporarily nature and last a few weeks to a few months, lifestyle management programs have a prolonged nature of several months to years. Because of this reason it looks preferable to put an initial focus on lifestyle management programs involving as many stakeholders as possible. Given the financial interest of employers in reducing the diabetes related sick leave as mentioned in paragraph 1.1, the population of working diabetics in the Netherlands appears to be a logic first group to target with lifestyle management programs. 1.3 Management problem CZ is one of the four big health insurance companies in the Netherlands with a market share of approximately 20% (NZa, 2013). As such, CZ has a major interest in effective answers to the big diabetes related issues in the Netherlands, but finding and inventing these answers/products is not CZ’s core business. Yet, CZ is taking its social responsibility and stimulates promising and innovative concepts via its venture for participation and innovation: ‘CbusineZ’. Through CbusineZ, CZ is exploring possibilities of a new business model in which a capable third party manages CZ’s population of working T2DM clients effectively on lifestyle. This results in the question: “Is it possible within the Dutch healthcare system, for a fixed price per person, to effectively and efficiently manage a population of working diabetics regarding lifestyle, as an addition to existing healthcare insurance?” But to answer this question, there are some challenges to overcome. The long-term benefits of most lifestyle interventions are being influenced by many personal factors, amongst others on the bio-medical and psychological level. At the moment supporting services to optimize the treatment of people with diabetes are not being offered in a differentiated way but in a one-size-fits-all approach. Services that suit the specific needs of individual people lead to greater health improvements than services that do not so, because of the already mentioned personal motivation. The opposite approach to manage every diabetic individually on lifestyle would cause extensive technical and financial challenges. Combining the advantages of both approaches into one would lead to segmentation. The first challenge for CZ is to segment its population of working T2DM into several types of people that, as a group, have specific preferences regarding the supporting services to                                                                                                                                    Page  |     3  
  16. 16. optimize the treatment of their diabetes. The second challenge is to target each type of working T2DM with specific optimal supporting services, leading to better and longer lasting results per type of working T2DM. Finally, to further refine and optimize the match between every type of T2DM and the offered supporting services, it will be essential to regularly monitor the results and the patients’ feedback. Regarding the development of a business model, CZ and its partner to be face more challenges to overcome. For example the question which method to use for financing this business model, how to get employers involved and willing to pay, etcetera. In the process described above that eventually should result in a business model to effectively and efficiently manage working T2DM on lifestyle, the study focuses in this explorative research on the initial step: segmentation. This rises the question: ‘Can employees with diabetes mellitus type 2 be divided into different types of people with distinctive characteristics, as a starting point to plot a course towards a more effectively use of services around diabetes mellitus type 2 (T2DM), more effectively meaning improved experienced health?” At the moment CZ lacks the insights in this. 1.4 Research objective There are many ways of segmenting patients, which in many cases are empirical- driven and usually not based on theory. Bloem & Stalpers (2012) have developed a patient typology based on subjective experienced health (SEH) because this experienced health is one of the biggest drivers of health care behavior. Based on the patients scores on two variants of experienced health (Stalpers, 2009), the SEH model enables us to divide patients into four quadrants, each with its own specific needs. These specific needs per quadrant make it possible to decide what initiatives and actions will serve best the improvement of health consumers’ experienced health (Bloem, 2012). The objective of this explorative research is to gain insights and knowledge concerning the possibilities to divide all working diabetics in the Netherlands according the SEH model into different types of people with distinctive characteristics as starting point to plot a course towards better serving them with lifestyle supporting services. Eventually this should result in an improvement of the experienced health of working diabetics, a decrease of T2DM related sick days and thus a financial profit for the employer as well as for the health insurer and even for Dutch society.                                                                                                                                    Page  |     4  
  17. 17. 1.5 Target group This research is limited to the Dutch population of working diabetics. Reason for this is the consideration to put the initial focus on a population that holds the biggest chance on success and the promise of substantial results. Big advantage of this population is the fact that an extra stakeholder is involved: the employer. It is expected that this extra stakeholder will have a positive influence on the population’s adherence towards lifestyle management and that this extra stakeholder will be willing to invest in the potential lifestyle management program. This brings advantages to all parties involved: • Improvement in quality of life of employees with diabetes and who are motivated to change their lifestyle; • Decrease of employers’ cost related to diabetic employees; • Decrease of health insurer’s cost related to working diabetics; • Because of the previous bullet point, the health insurer eventually will have an increased budget available that can be spend on non-working diabetics. 1.6 Main research question The main research question of this explorative research is formulated as follows: ‘Is it possible to divide employees with diabetes mellitus type 2 into different types of people with distinctive characteristics, as a starting point towards a more effective use of lifestyle supporting services around their diabetes (more effectively meaning improved experienced health)?’ To answer the main research question, the following sub-questions will be answered: • Is the SEH segmentation model for health care patients applicable to a population of working T2DM patients? • Is it possible to make an initial step as a guideline towards plotting different lifestyle supporting services to each of the four types of people arising from the SEH model? • Do the four types of people from the SEH model favor the kind of lifestyle supporting services that were plotted to them as an initial step?                                                                                                                                    Page  |     5  
  18. 18. 1.7 Deliverables for CZ This paper aims to make an actual contribution towards a (partly) solution for one of the big challenges of Dutch healthcare and in fact Dutch society: the T2DM epidemic. Therefore a pragmatic approach is chosen, in line with the vision of CbusineZ: “The chances that healthcare immediately adopts new solutions are very small. That is why CbusineZ does not want to wait with new initiatives until there is wide support, we just start” (s.n., 2013e). Instead of prolonged theoretical considerations while attempting to find the perfect and comprehensive solution to all the problems, this exploratory paper intends to partly work towards a feasible business model with a win-win result for working people with diabetes as well as their employers, health insurer CZ and the implementing party. As such, this research aims to contribute to the further refining of the SEH model of segmenting healthcare patients and more specifically to test its usability in a population of working T2DM patients and their subjective experienced health. Proven usability of this model will open the door for better targeting lifestyle supporting services that in return will lead to several healthcare gains. Gains on a personal level when referring to health improvements of diabetics (better alignment leads to higher motivation to accept and adhere a service, most probably resulting in better personal health) as well as on a financial level when referring to less waste of care. Deliverables of this exploratory research are: • Gaining insight in the applicability of the SEH model to divide a population of working T2DM patients into different types of people; • Gaining insight in the current lifestyle of the different types of T2DM patients arising from the SEH model; • Making an initial step as a guideline towards plotting different lifestyle supporting services to each of the four types of T2DM patients arising from the SEH model; • Fit of the preference of the different types of T2DM patients according the SEH model towards the preliminary plotted lifestyle supporting services per quadrant. Furthermore this paper will integrate all useful input that comes across during this research in its recommendations regarding the development of a business model.                                                                                                                                    Page  |     6  
  19. 19. 1.8 Structure of the thesis Chapter 2 sets the theoretical framework for the research with a literature study on the latest insights of diabetes mellitus type 2, lifestyle medicine and patient segmentation that lead to the conceptual model as well as an overview of potential lifestyle supporting services. Chapter 3 presents a qualitative and explorative research in the form of expert interviews. As the majority of interviewed experts confirms the possible usability of the SEH model in segmenting working T2DM patients, the output of the qualitative research serves as input for the subsequent quantitative research in chapter 4 that was held amongst 1046 T2DM patients. The quantitative research provides empirical support for the allocation of different lifestyle supporting services towards specific types of patients. In chapter 5, the study offers the conclusions of both researches and a discussion. In chapter 6 the recommendations are presented and finally chapter 7 settles this paper with an epilogue.                                                                                                                                    Page  |     7  
  20. 20. 2 Theoretical framework This research has an explorative character and wants to make an initial step in providing direction towards a better allocation of various lifestyle supporting services to different types of T2DM patients with the aim to improve the patient’s experienced health. As such, it is important the reader has a clear understanding of the topics Diabetes Mellitus, Lifestyle Medicine, Patients Segmentation and how they are related to each other. Therefore this chapter starts with a literature study to every one of these topics before presenting the conceptual model and the hypotheses. 2.1 Literature Review: Diabetes Mellitus “I am a type-2 diabetic, and they took me off medication simply because I ate right and exercised. Diabetes is not like a cancer, where you go in for chemo and radiation. You can change a lot through a basic change of habits.” Sherri Shepherd, American comedienne, actress and television personality Diabetes mellitus is a chronic metabolic condition characterized by high levels of blood glucose due to impaired insulin production or action, or both (American Diabetes Association, 2010). Diabetes can be divided into two groups: diabetes type 1 en diabetes type 2. Of all diabetics, 10% suffers diabetes type 1 and 90% diabetes type 2. The pancreas of a patient suffering diabetes type 1 does not produce insulin while the pancreas of a type 2 patient produces insulin but the body will not respond (enough) anymore tot this insulin. In both cases the high levels of glucose effects blood vessels and nerves and therefore can affect any part of the body. 2.1.1 Type 2 diabetes mellitus Type 2 diabetes mellitus (T2DM) appears to develop through multiple physiological mechanisms and numerous risk factors. Known risk factors to develop T2DM are a family history of diabetes, non-white race/ethnicity, obesity, age, smoking, physical inactivity, poor                                                                                                                                    Page  |     8  
  21. 21. diet and hypertension (Janssen & Avendonk, 2009). Especially the increase in obesity, aging and detection are the predominant factors in the ongoing increase in diabetes incidence (Baan & Poos, 2013b). Diabetes Mellitus type 2 progresses through the following phases (Colqhoun & Egger, 2011): • Metabolic syndrome, often first physically indicated by an increase in subcutaneous abdominal fat; • Pre-diabetes, a phase of increasing insulin resistance (Krentz, 1996) and/or a rise in impaired fasting glucose or impaired glucose tolerance (Twigg, Kamp, Davis, Neylon, & Flack, 2007); • Fully diagnosed diabetes; • End-point disease. Poortvliet, Schrijvers and Baan (2007) identify almost identical stages and also mention the transition probabilities between the different stages. Transition probabilities that can be influenced by activities of prevention or healthcare, as shown in Figure 2. Figure 2: Five stages in the development of diabetes (Poortvliet et al., 2007)   Progression from the first signs of pre-diabetes to fully diagnosed diabetes may take several years but this can also occur more rapidly as this process can be decelerated or even prevented. Especially in the early stages of pre-diabetes there is a window of opportunity for reversing the problem by changes in lifestyle (Tuomilehto et al., 2001). But once a person is fully diagnosed for having diabetes with complications, this is                                                                                                                                    Page  |     9  
  22. 22. not reversible anymore although the development of the disease can be decelerated. For this purpose, a growing list of pharmaceutical medications is available (s.n., 2013b). Yet, it is well recognized that “different patients respond in different ways to the same medication and that these differences are often greater among members of a population than they are within the same person at different times” (Evans & McLeod, 2003). Trying to cure lifestyle related chronic diseases with pharmaceutical medicine is like fighting a running battle, or like the Dutch say: “trying to dry out a flooded room without turning off the taps”. Therefore lifestyle change might be a more sustainable and preferable alternative to pharmaceutical medications not only to prevent the development of T2DM but also to decelerate the development of T2DM, as a number of prospective studies has shown (Tuomilehto, 2007). 2.1.2 Strongest modifiable risk factor for developing T2DM Certain factors like ethnicity and aging are a given fact but consistent with its role in the pathogenesis of T2DM, obesity is the strongest modifiable risk factor for type 2 diabetes (Gregg, 2013). High intake of sugar-sweetened beverages including soft drinks, fruit drinks and sweetened carbonated beverages has been implicated as an important risk factor for obesity, insulin resistance and T2DM (Malik et al., 2010) (Hu & Malik, 2010). Approximately 80% of the people with T2DM in the Netherlands are overweight or even obese (Janssen & Avendonk, 2009). The risk of developing T2DM decreases with 50% when people with overweight perform physical exercise for half an hour daily and loose a couple of kilograms (Janssen & Avendonk, 2009). Consuming healthy food in moderate portions, daily exercise and taking care of a good body weight will enable the small quantity of insulin still being produced to ensure correct values of blood glucose. 2.1.3 Consequences T2DM for the working population T2DM is a serious chronic disease. At minimum 40 to 56 percent of the people with diabetes suffer at least one chronic complication, such as cardiovascular diseases, eyeanomalies and kidney disease (Poortvliet, Schrijvers, & Baan, 2007). Of all diabetics between 15 and 65 years in the Netherlands, only 40% had a paid job in 2005, compared to 63% of the people within the same age without a chronic disease. In the same year, 27% of all diabetics in the Netherlands were partly or fully incapacitated compared to 8% of people without a chronic disease (Brink-Muinen, Spreeuwenberg, & Rijken, 2007). On average,                                                                                                                                    Page  |     10  
  23. 23. Dutch employees with diabetes have an additional sick leave of 10.5 days compared to employees without a chronic disease (s.n., 2013c). Because of the influence of diabetes on morbidity and mortality, diabetes patients of all ages run a higher risk of dying than people without diabetes. Franco, Steyerberg, Hu, Mackenbach & Nusselder (2007) state that “having diabetes significantly increased the risk of developing cardiovascular disease (hazard ratio, 2.5 for woman and 2.4 for men) and of dying when CVD (cardiovascular disease) was present (hazard ratio, 2.2 for women and 1.7 for men). Diabetic men and women of 50 years and older lived an average 7.5 (95% confidence interval, 5.5-9.5) and 8.2 (95% confidence interval, 6.1-10.4) years less than their non-diabetic equivalents.” A Canadian study in 1997 showed that the average life expectancy for diabetes patients was 12 years less than the average life expectancy of people without diabetes (Manuel & Schultz, 2004). The level of risk depends on the period of time of having diabetes, because the younger a person is when diabetes occurs the higher the risk of premature death. A Dutch study in 1999 estimated that 45 years old diabetes patients would live on average 5 to 10 years shorter than people of similar age without a chronic disease. The decrease in life expectancy reduces when people grow older, until the difference is 0 years at the age of 95 (Baan et al., 1999). The RIVM developed the empirical based Chronic Disease Model (CDM) that indicates diabetic males of 45 years old have a 9 years shorter life expectancy than men of similar age without a chronic disease. For diabetic females of 45 years old the difference is 11 years. 2.1.4 Learning summary T2DM is a lifestyle related disease that has a strong correlation to overweight and obesity. A healthy lifestyle will decrease the chances of developing T2DM considerably, even when a person already has the signs of pre-diabetes. Once a person is fully diagnosed for having T2DM, this is not reversible anymore although the process can be decelerated. And although pharmaceutical medications are widely available, lifestyle change would be the preferred and more sustainable alternative. Most T2DM patients and people with a high risk to develop T2DM would benefit from consuming healthy food in moderate portions, exercising regularly and taking care of a good bodyweight. Having diabetes results in an additional sick leave of 10.5 days and a significant shorter life expectancy. Furthermore at least half of all diabetics suffer one or more chronic complication.                                                                                                                                    Page  |     11  
  24. 24. 2.2 Literature Review: Lifestyle medicine "Medicine is not healthcare. Food is healthcare. Medicine is sick care. Let's all get this straight for a change." Sidney R Garfield (1906-1984), Kaiser Permanente’s founding physician. "Let food be thy medicine and medicine be thy food." Hippocrates (460-370 BC), Greek philosopher and physician, considered to be the father of Western medicine. Around 400 BC, Hippocrates hinted at the importance of lifestyle in relation to health by suggesting that in order to keep well one should simply ‘avoid too much food, too little toil’. Until a few decades ago, the big majority of people had little difficulty conforming to this recommendation. In fact, for most people the problem was getting enough food and having to toil too much in their struggle to survive. The industrial revolution changed the environment in which humans live, both macro and micro, resulting in a changed lifestyle and behavior. Machines began to replace people in physically demanding work and the availability and quality of food started to improve. These developments eventually led to the present situation where the worldwide rise in obesity has focused attention on lifestyle as a prominent cause of disease in modern times. According the Australian Institute of Health and Welfare (AIHW), up to 70% of all visits to a doctor are now thought to have a predominantly lifestyle-based cause (Cooper-Stanbury & et al., 2006). 2.2.1 History of healthcare On some point in the evolution of life, mammals appeared and they developed the genetic capacity of storing fat as a means of getting through the inevitable lean times, provoked by the harsh environment and strong competition for scarce resources. Out of these mammals, the Homo sapiens and it successors evolved until modern man. And until the industrial revolution, the biggest concerns were getting enough to eat, not being eaten or killed in warfare and battling the countless co-evolving disease microorganisms. Scientific progress changed the arena, or to put it in the words of De Courter and Egger (2011): “Changes in public health and hygiene around the time of the industrial revolution of the late nineteenth century and the development of medical marvels, such as vaccinations and antibiotics, resulted in a massive blow to infectious diseases”.                                                                                                                                    Page  |     12  
  25. 25. In their aim to banish disease, health care developed a strong focus on conquering infectious disease and curing infected people. In fact, a big part of western health care was and still is directed to this: providing proper treatment and/or medication to sick people to cure them as soon as possible. The process (note: not the treatment) is pretty simple and performance was relatively easy to measure by: • The number of sick people that got treatment/medication; • The number of people that recovered; • The time it took before a patient was recovered; • The financial cost of the treatment/medication. Great medical and technological advances led to the euphoria of the 1960s, when it appeared that the battle against disease had been all but won. Incentives, measurements and the general way of funding health care in western world were mainly focused on process optimization: increasing the efficiency of the process (increase the capacity to treat more sick people) and effectiveness of the process (increase the positive output of the process). However, around the same time a new sort of disease arose and it became apparent that western world health care with its focus on pharmaceutical medicine and curing infections was not well prepared to respond to these lifestyle related (chronic) diseases. Paragraph 2.1.1 stated that trying to fight lifestyle-based chronic diseases with pharmaceutical medicine is like fighting a running battle. When lifestyle is the cause, a change in lifestyle obviously is the cure. Figure 3 shows the scope of lifestyle medicine and its place versus traditional/conventional medicine.                   Figure 3: The place of lifestyle medicine (Egger, Binns, & Rossner, 2011)                                                                                                                                      Page  |     13  
  26. 26. Egger, Binns and Rossner (2011) state in the second edition of the book Lifestyle Medicine that “inactivity, poor and over-nutrition, smoking, drug and alcohol abuse, inappropriate medication use, stress, sexual behavior, inadequate sleep, risk taking and environmental exposure (sun, chemical, the built environment) are significant new and different causes of disease that call for a modified approach to health management. Lifestyle medicine is a relatively new and different approach of doing this”. In the same book lifestyle medicine is defined as “the application of environmental, behavioral, medical and motivational principles to the management of lifestyle-related health problems in a clinical setting, including self-care and self-management” (Egger, Binns, et al., 2011).     Comprehensive programs have been and are being conducted to better understand the causes, predictors and possible treatments of lifestyle related chronic diseases like T2DM and their risk factors. Two of the more extensive programs currently running in the Netherlands are: • ‘The Maastricht Study’, a 5-year lasting research amongst 10,000 people (half of them T2DM patients and half of them without T2DM) that studies the pathophysiology of obesity, the metabolic syndrome and type 2 diabetes in general and its relation to cardiovascular disease and associated co-morbidities in particular (s.n., 2013d); • ‘JOGG’ (Youth On Healthy Weight), based upon the successful French program ‘Epode’, a local sustainable and intersectoral approach to transform the increasing overweight among young people (0-19 years) into a decrease. Public and private parties cooperate in this initiative that has a pivotal role for municipalities (s.n., 2013a). 2.2.2 Traditional/conventional medicine versus lifestyle medicine Lifestyle medicine, although it is a clinical discipline, forms a bridge with public health and health promotion. Health promotion is defined as “the combination of educational and environmental supports for actions and conditions of living conducive to health” (Greene & Kreuter, 2005). Lifestyle medicine differs from traditional/conventional medicine in that it aims at changing an individual’s lifestyle and/or behavior that results in disease, as opposed to simply treat the (consequences of) the disease (Egger, Binns, et al., 2011). This implies that the individual concerned is an active partner in the process instead of being a passive receiver of medical care. As such lifestyle medicine includes three consecutive phases of prevention.                                                                                                                                    Page  |     14  
  27. 27. Primary prevention aims at preventing a disease from developing by modifying the behavioral or environmental cause, secondary prevention focuses on modifying existing risk factors to avoid the disease and tertiary prevention aims to rehabilitate a patient from a disease state and preventing recurrence. Table 1 shows some of the other main differences between traditional/conventional and lifestyle medicine approach. Table 1: Differences between conventional and lifestyle medicine approaches (Egger, Binns, et al., 2011) Lifestyle medicine also differs from non-medical clinical practice in the fact that lifestyle medicine may include medication (e.g. for quitting smoking) and even surgery when this is appropriate (e.g. for weight control). 2.2.3 Lifestyle change and motivation “Patients with chronic conditions make day-to-day decisions about —self-manage— their illnesses” (Bodenheimer, 2002). “The principal patient requirement in lifestyle medicine is change” (Egger, Coutts, & Litt, 2011). “Regarding lifestyle change, motivation is often the missing link between a clinician’s prescription and a patient’s cure” (Colqhoun & Egger, 2011). A possible explanation for this might be provided by the self-determination theory (SDT) of motivation (Deci & Ryan, 1985). This theory is all about the concept of autonomous motivation, defined as feeling free and acting for the sake of rewards that are inherent to the activity itself. SDT proposes that healthy lifestyle change will occur and persist if it is autonomously motivated. Indeed several studies showed that self-reported autonomous motivation has a positive impact on persistence and maintenance of lifestyle change related behavior like physical activity and weight loss (Williams, Grow, Freedman, Ryan, & Deci,                                                                                                                                    Page  |     15  
  28. 28. 1996) (Williams, Rodin, Ryan, Grolnick, & Deci, 1998). During 3 years, a program designed to promote autonomous motivation for exercise and weight management was being compared to a general program health education control program. After 3-years, the results on exercise and weight loss were significantly better for the program designed to promote autonomous motivation (Moller, McFadden, Hedeker, & Spring, 2012). 2.2.4 Motivation and financial incentives Financial incentives are regularly being used in health behavior interventions to raise the patient’s motivation. However recent research raised the presumption that emphasizing financial incentives can have negative consequences if the incentives are being experienced as controlling (Moller et al., 2012). A systematic review of overweight/obesity treatments including 9 programs with follow-up of one year or more in which financial incentives were used, showed no improvement in weight loss maintenance at 12 or 18 months after the incentives had been stopped. In fact, at a 30 month follow-up there even was a trend towards weight gain above baseline (Paul-Ebhohimhen, Avenell, 2008). SDT makes a distinction between intrinsic motivation on one hand and extrinsic motivation on the other, were intrinsic motivation is linked to positive emotions (like enjoyment or interest) and extrinsic motivation to the satisfaction associated with action that is personally meaningful (for example because of receiving extrinsic rewards like positive appreciation by relatives or financial incentives). Many studies have shown that tangible, performance contingent reward like financial incentives tend to weaken the intrinsic motivation and the longer such an extrinsic reward a is in play, the weaker the intrinsic motivation will become (Deci, Ryan, & Koestner, 1999). This is often referred to as “the undermining effect” (Moller et al., 2012). Therefor the use of financial, performance related incentives in this process should be considered well on forehand. The ultimate goal of lifestyle medicine is to move individuals that are not intrinsic motivated from requiring extrinsic motivators through incentives to intrinsic motivation as soon as possible. This is done best by motivational interviewing techniques (Rubak, Sandbaek, Lauritzen, & Christensen, 2005), which means “assessing patients’ readiness, willingness and ability to act and helping them see the gap between where they are and where they would prefer to be. Reducing the barriers and increasing the triggers to action will assist in shifting the patient toward the desired goal” (Egger, Coutts, et al., 2011). Because of the abovementioned differences in peoples’ motivators and conditions to act regarding their health care                                                                                                                                    Page  |     16  
  29. 29. behavior, the current one-size-fits-all approach in supporting services does not appear to be an all-encompassing solution. 2.2.5 Learning summary Conventional (pharmaceutical) medicine simply treats the (consequences of the) disease where lifestyle medicine aims at changing an individual’s lifestyle and/or behavior to treat the cause of the disease or even prevent the cause from happening. This implies that the patient is an active partner in the process instead of being a passive receiver of medical care, because the principal patient requirement in lifestyle medicine is ‘change’. Changing a person’s lifestyle sustainable requires this person to be autonomously motivated to change his lifestyle. Autonomous motivation is the sum of intrinsic and extrinsic motivation, which can be stimulated by extrinsic rewards. But extrinsic rewards and especially tangible, performance contingent rewards tend to undermine the intrinsic motivation. Therefor the ultimate goal of lifestyle medicine is to move individuals that are not intrinsic motivated from requiring extrinsic motivators through incentives to intrinsic motivation as soon as possible. As different people get mobilized by different motivators (extrinsic or intrinsic) and most likely will have a different readiness, willingness and ability to act regarding their health care behavior, the current one-size-fits-all approach in supporting services does not appear to be an all-encompassing solution. 2.3 Literature review: Patient segmentation “The goal of patient segmentation is to identify groups of patients that maximize both the similarities between individuals within a group (homogeneity) and the differences between groups (heterogeneity) as large as possible.” Anonymous According a report of Nivel, people with a chronic disease (25% of the Dutch population) often feel very involved in their treatment, but around forty percent of them lack the skills to perform 'self-management'. They need ‘tailored’ support that better meets their capabilities, wishes and demand (Rademakers, 2013).                                                                                                                                    Page  |     17  
  30. 30. As stated in paragraph 2.1, T2DM is a lifestyle related chronic disease that correlates strongly with overweight and obesity. Most T2DM patients and people with a high risk to develop T2DM would benefit from lifestyle change. Paragraph 2.2.3 made clear that changing a person’s lifestyle in a sustainable way requires this person to be autonomously motivated to change his lifestyle. However, paragraph 2.2.4 pointed out that different people get mobilized by different motivators. This could be a cause for the low success rate of the current onesize-fits-all approach amongst T2DM patients. The opposite approach to manage every diabetic individually on lifestyle would cause extensive technical and financial challenges. A possible third way would be to combine the advantages of both approaches into one, leading to segmentation. There are many ways of segmenting healthcare patients and traditionally healthcare organizations segment their market based upon health measures and demographics. To some extent this segmentation makes sense, because firstly people have to be diagnosed for diabetes or one of its precursors (metabolic-syndrome and pre-diabetes). Afterwards also demographic facts have to be considered, as paragraph 2.1.3 indicated it makes a big difference if a person is being diagnosed for having diabetes while being 45 or 90 years old. But segmentation only based upon health measures and demographics surely is not sufficient as people with identical biological-physiological parameters may differ in lifestyle behavior, self-management capabilities, wishes and demands. Therefor this research is specifically interested in finding a meaningful segmentation based upon lifestyle behavior as a add-on to the traditional segmentations based upon health measures and demographics. The rationale for this choice is the fact that this research is looking for ways to influence the lifestyle behavior of T2DM patients in a sustainable way. 2.3.1 Empirical based lifestyle segmentation models There is not one standardized lifestyle segmentation model, instead market research firms and advertising agencies are constantly devising new categories, which will best help target possible consumers of their clients products amongst Dutch population. Most lifestyle segmentation models try to classify people according to their values, beliefs, opinions and interests. In this paragraph a few of these models will be discussed that are (partial) based upon lifestyle. The majority of those models are empirical based.                                                                                                                                    Page  |     18  
  31. 31. 2.3.1.1 WIN-model by TNS NIPO The WIN-model by TNS NIPO (Figure 4) is a segmentation of the Dutch population, based upon values and socio-demographic characteristics. WIN is an abbreviation for ‘Waardensegmenten in Nederland’ (value segments in the Netherlands). It encompasses a value research method derived from earlier studies (Schwartz, 1990)(Schwartz, 1992) including leisure activities like museum visits, television program preferences and favorable newspaper brands. This model distinguishes seven groups in Dutch society, which differ greatly from one another in terms of lifestyle, attitudes, motivations and behaviors. An eighth category (‘balanced’) exists of people who have characteristics of all other 7 typologies. The WIN-model is based on the values that people think are important in their lives. These various values appear to be correlated with different ways of living, housing, dressing, thinking, voting and consuming. TNS NIPO claims that the WIN variable together with the socio-demographic background characteristics provides a rich colored image of the consumer, making it possible to determine how to approach each consumer in the most optimum way. Figure 4: WIN-model by TNS NIPO (TNS NIPO, 2012)                                                                                                                                        Page  |     19  
  32. 32. 2.3.1.2 Mentality by Motivaction Mentality by Motivaction (Figure 5) is a values and lifestyle research product that provides a look at target group classification and approach. By conducting research into people’s perceptions, it tries to explain what motivates target groups, how trends come about, and the broader context in which they operate. Using the Mentality model, Motivaction groups people according to their attitudes towards life. Eight social environments have been identified in the Netherlands. These social environments are defined on the basis of personal views and values that lie at the heart of people’s lifestyles. People from the same social environment share values with regard to work, leisure time and politics, and demonstrate similar ambitions and aspirations. Every environment has its own lifestyle and consumption patterns, which are expressed in concrete behavior. Based upon more than a decade of empirical research, Motivaction claims that these social environments represent a stable, consistent, practical and useful segmentation. Appendix I shows a special Mentality model, aiming at Dutch health consumers. Figure 5: Mentality by Motivaction (Lampert, 2012)                                                                                                                                      Page  |     20  
  33. 33. 2.3.1.3 BSR model by SmartAgent Company The BSR or Brand Strategy Research Model (by SmartAgent Company) explores the underlying structures and values, needs and motives of people within a particular domain. As a citizen in society and consumer of public services like education, health and care, as an inhabitant and user of the facilities of a town or village, as a laborer and participant to the production of goods and services, but also as a consumer of products and services for recreation and entertainment. The model is visualized in Figure 6 through two dimensions from social science; horizontally is the sociological dimension (on the left ‘ego’ versus ‘group’ on the right) and vertically the psychological dimension (the lower quadrants representing ‘introvert’ versus ‘extrovert’ in the upper quadrants). In this way four different quadrants, or four worlds of experience, emerge from which people think and act. According SmartAgent Company, the BSR-model is dynamic and domain-specific as they look for a meaningful, unique segmentation within each domain, leading to a solution that contains four, five, six, or perhaps as many as seven segments. Each segment has a clear distinctive psychographic profile and in combination with traditional features such as age, gender and education should form a useful basis for consumer-oriented product development and communication. Figure 6: BSR model by SmartAgent Company (SmartAgent Company, 2013)                                                                                                                                      Page  |     21  
  34. 34. 2.3.1.4 Streetlife by Cendris The core of Streetlife as shown in Figure 7 consists of more than 300 socio- demographic and lifestyle characteristics grouped on postcode. The dataset Streetlife is made up of different sources. In addition to a number of nationwide sources, such as CBS and Kadaster, use was made of the detailed information from the file of the Stichting Selectieve Post (SSP), CCI lifestyle data of Acxiom, Sanoma, CBS, Dataland and PostNL. The Streetlife model identifies eleven different types of consumers. Figure 7: Streetlife model by Cendris (Cendris, 2013)   2.3.1.5 Mosaic by Experian The MOSAIC database (by Experian) has seven million Dutch consumer households classified into 11 main groups with 44 subtypes. These types are formed on the basis of knowledge about socio-demographics, lifestyle, culture and (buying) behavior. The database of "MOSAIC Household' is linked to a database with a large amount of data of all Dutch households, such as age, family composition, social class, lifestyle and other sociodemographic and psychographic data. This MOSAIC data is linked to a zip code to determine the locals profile at a certain zip code. Visually, Mosaic looks like Figure 8.                                                                                                                                    Page  |     22  
  35. 35.   Figure 8: Mosaic by Experian (Experian Nederland, 2013) 2.3.1.6 Six consumer segments of health care systems by Deloitte Since 2008, Deloitte has surveyed consumers in the U.S. to assess their views about their own health and how they navigate their systems of care. From the results, Deloitte derived six distinctive segments of health care systems consumers based upon the consumers’ behaviors and attitudes. According to Deloitte “a health care organization – pharmaceutical company, medical device manufacturer, health insurance plan, hospital, medical practice, retail pharmacy – is likely to interact with each of the six health care consumer segments in its customer/user/member/patient base. Meeting the preferences, needs, and demands of each                                                                                                                                    Page  |     23  
  36. 36. segment may require innovative and tailored products and services, marketing approaches, business strategies, and new customer service models. To achieve the expected benefits of consumerism (i.e., more satisfied consumers, greater adherence to treatment choices, improved health outcomes, and reduced overall health care spending) stakeholders will need to develop highly-targeted, consumer-oriented products, service offerings, and online supports to reach each type of consumer and propel him forward into greater engagement and self-management” (Deloitte, 2013). Knowing the six consumer segments as shown in Figure 9 should be useful in this. Six health care consumer segments Shop & Save active; seeks options and switches for value; saves for future health costs Out & About independent; prefers alternatives; wants to customize services 4% 9% Sick & Savvy Casual & Cautious 6 14% consumes considerable health care services & products; partners with physician to make treatment decisions 17% 34% not engaged; no current need; cost-conscious health care consumer segments 22% Online & Onboard Content & Compliant online learner; happy with care but interested in alternatives & technologies happy with physician, hospital and health plan; trusting and follows care plans Attitudes & behaviors matter most – every demographic cohort includes a mix of the 6 segments Seniors 1900-1945 Boomers 1946-1964 Gen X 1965-1981 Millennials 1982-1994 15% 40% 30% 14% 24% 39% 46% 24% 15% 17% 18% 19% 16% 11% 18% 5% 6% 10% 10% 8% Figure 9: Six segments of health care consumer segments (Deloitte, 2013)                                                                                                                                    Page  |     24   1% 3% 4% 7%  
  37. 37. 2.3.2 Empirical based versus scientific supported segmentation model As stated in paragraph 2.3, this study is looking for ways to influence the lifestyle behavior of T2DM patients in a sustainable way. All the lifestyle segmentation models in paragraphs 2.3.1.1 to 2.3.1.6 might be useful in dividing the Dutch health care consumers into distinctive segments with different capabilities, wishes and demands. However, all these models are empirical based and not scientifically supported by a falsifiable theory. As such they only appoint different lifestyle behaviors but do not offer insight how to influence or change these behaviors. To gain insight how the lifestyle behavior of T2DM patients might be influenced, this study is looking for a scientific based lifestyle behavior segmentation model for health care patients. 2.3.3 Subjective Experienced Health In line with basic psychological insights, Bloem & Stalpers (2012) identified subjective experienced health (SEH) as the biggest driver of health care behavior. They define health care behavior to “not only encompass health care as provided by medical professionals, but to include all behaviors undertaken by an individual in relation to his health”. Furthermore they describe SEH as “an individual’s experience of physical and mental functioning while living his life the way he wants to, within the actual constraints and limitations of individual existence”. 2.3.3.1 SEH instrument In his dissertation, Bloem (2008) developed a PROM (Patient Reported Outcome Measures) to measure an individual’s experienced health. Insight in individuals’ experienced health is important for caregivers because such insights –in combination with biomedical insights- lead to better diagnoses, treatments and healings of patients, as shown by research. The subjective experienced health (SEH) instrument enables caregivers and patients to objectively discuss something as subjective as the patient’s experienced health. Beforehand there was hardly any attention for the patient’s health experience during meetings between caregivers and patients as during those meetings the bio-medical (with or without the biopsychosocial) perspective and the World Health Organization (WHO) were leading (Bloem, 2008).                                                                                                                                    Page  |     25  
  38. 38. However, lately more and more patients want to play a more active role regarding their own health and treatment, making experienced health an important topic during caregiver-patient meetings, next to the bio-medical knowledge. Experienced health also plays a major role in the current development of encouraging self-management and patientempowerment, especially within chronic health care. That is why Dutch care facilities are now following the example of their fellow institutions in the UK and the U.S. and orient themselves on the usability of PROMs (Patient Reported Outcome Measures) to integrate experienced health into (the evaluation of) care (TNO, 2012). Bloem developed the SEH instrument that towards patients is represented as a ladder model with nine steps (Figure 10). First patients are asked to describe their best day of the last period -three months to one year- and to think of that day as the highest step of the ladder. Secondly patients are asked to describe their worst day during the same period and to think of that day as the lowest step of the ladder. Subsequently patients are asked to point at what step of the ladder they were on average during the last month and finally the same question for their position on the ladder today. This ladder model enables caregivers and patients to quantify, measure and discuss something as subjective as experienced health. Especially when it is used on a regular basis. Figure 10: SEH instrument   2.3.3.2 SEH model Bloem & Stalpers acknowledge the fact that a person’s subjective experience of health is very much related to the biological-physiological state of this person, especially age and the                                                                                                                                    Page  |     26  

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