The e-DUCASS Advance study is a randomized study evaluating whether a 24-month digital health education program can improve cardiovascular health among people living in Córdoba, Spain, and representing different socioeconomic backgrounds and areas of the city. Approximately 600 participants aged 12 to 79 years will be enrolled. Participants will be assigned by family so that members of the same family remain in the same study group. All participants will first receive an initial basic health education workshop covering healthy eating, physical activity, sleep, tobacco use, and other health-related behaviors. Families will then be randomly assigned to one of two groups. The control group will receive no additional educational intervention, whereas the digital intervention group will receive weekly educational content through a web-based application or messaging channels. This content will include short videos, infographics, knowledge assessments, motivational activities, and access to support. Cardiovascular health will be assessed at baseline, 12 months, and 24 months using the American Heart Association's Life's Essential 8 score. This score evaluates diet, physical activity, nicotine exposure, sleep, body mass index, blood lipids, blood glucose, and blood pressure. The study will compare changes in cardiovascular health between the two groups and examine whether the effect of the program differs according to the socioeconomic characteristics of the participants' areas of residence. Other assessments will include adherence to a Mediterranean lifestyle, health and nutrition literacy, physical activity and sedentary behavior, chronotype, quality of life, anxiety, and depression.
e-DUCASS Advance is a 24-month, parallel-group, cluster-randomized controlled trial designed to evaluate the effectiveness of an enhanced digital health literacy intervention for improving cardiovascular health among people with different socioeconomic backgrounds in Córdoba, Spain. Participants are recruited from across the city. The household is the unit of randomization, ensuring that all participating members of the same household are assigned to the same trial arm and reducing the risk of contamination between groups. Households are randomized in a 1:1 ratio to the control or digital intervention group using stratified permuted block randomization. Randomization is stratified by socioeconomic status and household composition, resulting in six strata. Household composition is classified into three categories: households with children, households comprising two or more adults without children, and single-person households. Socioeconomic status is categorized as high or low-middle. Households within the upper income quintile of the municipal distribution for Córdoba, based on the 2023 Household Income Distribution Atlas of the Spanish National Statistics Institute, are classified as high income. All remaining households are classified within the low-middle-income category. The randomization sequence was generated by an independent statistical programmer using the blockrand package, version 1.5, in R statistical software, version 4.4.2. Allocation was centralized, and researchers responsible for participant recruitment were unaware of the block sizes and upcoming assignments. Randomization was implemented in three successive waves as recruitment progressed, following a prespecified master randomization log. After the baseline clinical and sociodemographic assessment, all participants receive an initial basic health education workshop addressing healthy eating, physical activity, sleep, tobacco use, and other cardiovascular health-related behaviors. Participants assigned to the control group receive no further structured educational intervention. Participants assigned to the digital intervention group receive weekly educational content through a web-based application or messaging channels for 24 months. The digital intervention is based on three components: education, evaluation, and motivation. Educational materials include short videos and infographics with practical and accessible messages about cardiovascular health and healthy lifestyles. Brief assessments are used to reinforce knowledge and monitor engagement. Motivational activities, participation feedback, and access to support are intended to encourage sustained interaction with the program and the adoption of healthier behaviors. Participants undergo study assessments at baseline, 12 months, and 24 months. These assessments include clinical history, anthropometric measurements, blood pressure, body composition, and biochemical measurements. Cardiovascular health is evaluated using the American Heart Association's Life's Essential 8 score, ranging from 0 to 100 and comprising diet, physical activity, nicotine exposure, sleep health, body mass index, blood lipids, blood glucose, and blood pressure. The primary objective is to compare changes in Life's Essential 8 between the digital intervention and control groups and to examine whether the effect of the intervention differs according to household socioeconomic status. Secondary objectives include evaluating changes in adherence to a Mediterranean lifestyle, health and nutrition literacy, dietary habits, physical activity and sedentary behavior, chronotype, quality of life, anxiety, and depression. Potential differences according to age and sex will also be explored. The target enrollment is approximately 600 participants aged 12 to 79 years. The sample size calculation accounts for household-level clustering and expected losses to follow-up. Longitudinal analyses will account for repeated measurements and the clustering of participants within households.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
PREVENTION
Masking
DOUBLE
Enrollment
600
The intervention is a 24-month enhanced digital health literacy program designed to improve cardiovascular health through sustained education on healthy lifestyles. Participants receive new educational content weekly through a web-based application. Content includes short videos and summary infographics addressing healthy eating, physical activity, sleep health, avoidance of tobacco and nicotine exposure, and other cardiovascular health-related behaviors. The program combines education, evaluation, and motivation. Brief knowledge assessments reinforce learning, while information on content access and views is used to monitor engagement. Motivational activities, participation feedback, and access to support are provided to encourage adherence and sustained behavior change. Content is adapted when appropriate for adolescent participants.
Instituto Maimónides de Investigación Biomédica de Córdoba
Córdoba, Spain
RECRUITINGMean Change From Baseline in Life's Essential 8 Score at 24 Months
Cardiovascular health will be assessed using the American Heart Association's Life's Essential 8 score. The overall score is calculated as the mean of eight component scores: diet, physical activity, nicotine exposure, sleep health, body mass index, blood lipids, blood glucose, and blood pressure. Each component and the overall score range from 0 to 100 points, with higher scores indicating better cardiovascular health.
Time frame: Baseline and 24 months
Mean Change From Baseline in Life's Essential 8 Score at 12 Months
Cardiovascular health will be assessed using the American Heart Association's Life's Essential 8 score. The overall score is calculated as the mean of eight component scores: diet, physical activity, nicotine exposure, sleep health, body mass index, blood lipids, blood glucose, and blood pressure. Each component and the overall score range from 0 to 100 points, with higher scores indicating better cardiovascular health.
Time frame: Baseline and 12 months
Mean Change From Baseline in Mediterranean Lifestyle Index Score at 24 Months
Adherence to the Mediterranean lifestyle will be assessed using the 28-item Mediterranean Lifestyle Index (MEDLIFE), which evaluates Mediterranean food consumption, Mediterranean dietary habits, physical activity, rest, and social interaction. Each item is scored as 0 or 1, producing an overall score ranging from 0 to 28 points. Higher scores indicate greater adherence to a Mediterranean lifestyle.
Time frame: Baseline and 24 months
Mean Change From Baseline in Mediterranean Diet Adherence Screener Score at 24 Months
Adherence to the Mediterranean diet will be assessed using the 14-item Mediterranean Diet Adherence Screener (MEDAS). Each item contributes 0 or 1 point, resulting in a total score ranging from 0 to 14 points. Higher scores indicate greater adherence to the Mediterranean dietary pattern.
Time frame: Baseline and 24 months
Mean Change From Baseline in Physical Activity at 24 Months
Physical activity will be assessed using the International Physical Activity Questionnaire (IPAQ), a validated self-reported instrument evaluating physical activity performed during the previous seven days. A physical activity score will be derived according to the standardized IPAQ scoring procedure, with higher values indicating a greater level of physical activity.
Time frame: Baseline and 24 months
Mean Change From Baseline in Patient Health Questionnaire-9 Score at 24 Months
Depressive symptoms will be assessed using the 9-item Patient Health Questionnaire (PHQ-9). Each item is scored from 0 to 3, producing a total score ranging from 0 to 27 points. Higher scores indicate greater severity of depressive symptoms. For each participant, change will be calculated as the 24-month score minus the baseline score.
Time frame: Baseline and 24 months
Mean Change From Baseline in Generalized Anxiety Disorder-7 Score at 24 Months
Anxiety symptoms will be assessed using the 7-item Generalized Anxiety Disorder scale (GAD-7). Each item is scored from 0 to 3, producing a total score ranging from 0 to 21 points. Higher scores indicate greater severity of anxiety symptoms. For each participant, change will be calculated as the 24-month score minus the baseline score.
Time frame: Baseline and 24 months
Mean Change From Baseline in EQ-5D-5L Index Score at 24 Months
Health-related quality of life will be assessed using the EQ-5D-5L questionnaire, which evaluates mobility, self-care, usual activities, pain or discomfort, and anxiety or depression. Each dimension has five levels of severity. Responses will be converted into a health utility index using the Spanish EQ-5D-5L value set. The index has a maximum value of 1, representing full health, and may include values below 0 for health states considered worse than death. Higher values indicate better health-related quality of life. Change will be calculated as the 24-month index value minus the baseline value.
Time frame: Baseline and 24 months
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