Evaluation of community provision of a preventive cardiovascular programme - the National Health Service Health Check in reaching the under-served groups by primary care in England: cross sectional observational study

Effect of GP visits in the compliance of preventive services: a cross-sectional study in Europe

BACKGROUND

Performing cardiovascular and cancer screenings in target populations can reduce mortality. Visiting a General Practitioner (GP) once a year is related to an increased likelihood of preventive care. The aim of this study was to analyse the influence of visiting a GP in the last year on the delivery of preventive services based on sex and household income.

METHODS

Cross-sectional study using data collected from the European Health Interview Survey 2013-2015 of individuals aged 40-74 years from 29 European countries. The variables included: sociodemographic factors (age, sex, and household income (HHI) quintiles [HHI 1: lowest income, HHI 5: more affluent]), lifestyle factors, comorbidities, and preventive care services (cardiometabolic, influenza vaccination, and cancer screening). Descriptive statistics, bivariate analyses and multilevel models (level 1: citizen, level 2: country) were performed.

RESULTS

242,212 subjects were included, 53.7% were female. The proportion of subjects who received any cardiometabolic screening (92.4%) was greater than cancer screening (colorectal cancer: 44.1%, gynaecologic cancer: 40.0%) and influenza vaccination. Individuals who visited a GP in the last year were more prone to receive preventive care services (cardiometabolic screening: adjusted OR (aOR): 7.78, 95% CI: 7.43-8.15; colorectal screening aOR: 1.87, 95% CI: 1.80-1.95; mammography aOR: 1.76, 95% CI: 1.69-1.83 and Pap smear test: aOR: 1.89, 95% CI:1.85-1.94). Among those who visited a GP in the last year, the highest ratios of cardiometabolic screening and cancer screening benefited those who were more affluent. Women underwent more blood pressure measurements than men regardless of the HHI. Men were more likely to undergo influenza vaccination than women regardless of the HHI. The highest differences between countries were observed for influenza vaccination, with a median odds ratio (MOR) of 6.36 (under 65 years with comorbidities) and 4.30 (over 65 years with comorbidities), followed by colorectal cancer screening with an MOR of 2.26.

CONCLUSIONS

Greater adherence to preventive services was linked to individuals who had visited a GP at least once in the past year. Disparities were evident among those with lower household incomes who visited a GP. The most significant variability among countries was observed in influenza vaccination and colorectal cancer screening.

Understanding factors affecting implementation success and sustainability of a comprehensive prevention program for cardiovascular disease in primary health care: a qualitative process evaluation study combining RE-AIM and CFIR

AIM

Our aim was to evaluate the implementation process of a comprehensive cardiovascular disease prevention program in general practice, to enhance understanding of influencing factors to implementation success and sustainability, and to learn how to overcome barriers.

BACKGROUND

Cardiovascular disease and its risk factors are the world's leading cause of mortality, yet can be prevented by addressing unhealthy lifestyle behavior. Nevertheless, the transition toward a prevention-oriented primary health care remains limited. A better understanding of factors facilitating or hindering implementation success and sustainability of prevention programs, and how barriers may be addressed, is needed. This work is part of Horizon 2020 project 'SPICES', which aims to implement validated preventive interventions in vulnerable populations.

METHODS

We conducted a qualitative process evaluation with participatory action research approach of implementation in five general practices. Data were collected through 38 semi-structured individual and small group interviews with seven physicians, 11 nurses, one manager and one nursing assistant, conducted before, during, and after the implementation period. We applied adaptive framework analysis guided by RE-AIM Qualitative Evaluation for Systematic Translation (RE-AIM QuEST) and Consolidated Framework for Implementation Research (CFIR).

FINDINGS

Multiple facilitators and barriers affected reach of vulnerable target populations: adoption by primary health care providers, implementation and fidelity and intention to maintain the program into routine practice. In addition, our study revealed concrete actions, linked to implementation strategies, that can be undertaken to address identified barriers. Prioritization of prevention in general practice vision, ownership, and shared responsibility of all team members, compatibility with existing work processes and systems, expanding nurse's roles and upskilling competence profiles, supportive financial and regulatory frameworks, and a strong community - health care link are crucial to increase implementation success and long-term maintenance of prevention programs. COVID-19 was a major barrier to the implementation. RE-AIM QuEST, CFIR, and participatory strategies are useful to guide implementation of prevention programs in primary health care.

Prevention of Cardiovascular Diseases in Community Settings and Primary Health Care: A Pre-Implementation Contextual Analysis Using the Consolidated Framework for Implementation Research

Cardiovascular diseases are the world’s leading cause of mortality, with a high burden especially among vulnerable populations. Interventions for primary prevention need to be further implemented in community and primary health care settings. Context is critically important to understand potential implementation determinants. Therefore, we explored stakeholders’ views on the evidence-based SPICES program (EBSP); a multicomponent intervention for the primary prevention of cardiovascular disease, to inform its implementation. In this qualitative study, we conducted interviews and focus groups with 24 key stakeholders, 10 general practitioners, 9 practice nurses, and 13 lay community partners. We used adaptive framework analysis. The Consolidated Framework for Implementation Research guided our data collection, analysis, and reporting. The EBSP was valued as an opportunity to improve risk awareness and health behavior, especially in vulnerable populations. Its relative advantage, evidence-based design, adaptability to the needs and resources of target communities, and the alignment with policy evolutions and local mission and vision, were seen as important facilitators for its implementation. Concerns remain around legal and structural characteristics and intervention complexity. Our results highlight context dimensions that need to be considered and tailored to primary care and community needs and capacities when planning EBSP implementation in real life settings.

A realist synthesis of staff-based primary health care interventions addressing universal health coverage

Background

Methods

Results

Conclusions

Introducing multi-component cardiovascular health screening into existing Abdominal Aortic Aneurysm (AAA) screening programmes in the UK: a qualitative study of programme staff views

BACKGROUND

Cardiovascular disease is a major contributor to poor health in the UK and the leading cause of death in England. Peripheral arterial disease and high blood pressure are conditions that identify individuals at high cardiovascular disease risk, likely to benefit from cardiovascular risk management. Both conditions remain considerably underdiagnosed and untreated. The National Health Service abdominal aortic aneurysm (AAA) screening programmes represent an opportunity to screen for these conditions with potentially minimal additional effort or cost. We explored AAA screening programme staff views on the proposed introduction of such additional screening within AAA screening.

METHODS

Nine focus groups and seven follow-on interviews were undertaken with 38 AAA screening staff. Our study methods were oriented broadly towards a grounded theory methodology, and data were analysed using thematic analysis.

RESULTS

Three themes were identified: (i) 'Perceptions of patient experience and health-related outcomes', (ii) 'Opportunities and challenges for programme staff', and (iii) 'Maintaining and improving programme standards'. Staff talked about the high uptake of AAA screening, staff experience and skills in their role, and the programme's high quality standards as both opportunities and potential challenges linked to the proposed additions to AAA screening. While positive about the potential to improve patients' health outcomes, participants had questions about the practicalities of incorporating additional procedures within their time- and resource-constrained context, and how this may reconfigure work processes, roles and relationships.

CONCLUSIONS

The proposed additions to the programme require taking staff's views into account. Key areas that need to be addressed relate to ensuring follow-up support for patients, clarity around staff responsibilities, and availability of sufficient resources for the programme.

NHS Health Check programme: a rapid review update

OBJECTIVE

To update a rapid review published in 2017, which evaluated the NHS Health Check programme.

METHODS

An enlarged body of evidence was used to readdress six research objectives from a rapid review published in 2017, relating to the uptake, patient experiences and effectiveness of the NHS Health Check programme. Data sources included MEDLINE, PubMed, Embase, Health Management Information Consortium (HMIC), Cumulative Index of Nursing and Allied Health Literature (CINAHL), Global Health, PsycINFO, the Cochrane Library, NHS Evidence, Google Scholar, Google, ClinicalTrials.gov and the ISRCTN registry, Web of Science, Science Citation Index, The Cochrane Library, NHS Evidence, OpenGrey and hand searching article reference lists. These searches identified records from between January 1996 and December 2019. Screening, data extraction and quality appraisal using the Critical Appraisals Skills Programme checklists were performed in duplicate. Grading of Recommendations Assessment, Development and Evaluations was implemented. Data were synthesised narratively.

RESULTS

697 studies were identified, and 29 new studies included in the review update. The number of published studies on the uptake, patient experiences and effectiveness of the NHS Health Check programme has increased by 43% since the rapid review published in 2017. However, findings from the original review remain largely unchanged. NHS Health Checks led to an overall increase in the detection of raised risk factors and morbidities including diabetes mellitus, hypertension, raised blood pressure, cholesterol and chronic kidney disease. Individuals most likely to attend the NHS Health Check programme included women, persons aged ≥60 years and those from more socioeconomically advantaged backgrounds. Opportunistic invitations increased uptake among men, younger persons and those with a higher deprivation level.

CONCLUSIONS

Although results are inconsistent between studies, the NHS Health Check programme is associated with increased detection of heightened cardiovascular disease risk factors and diagnoses. Uptake varied between population subgroups. Opportunistic invitations may increase uptake.

Experiences of cervical screening participation and non-participation in women from minority ethnic populations in Scotland

Background

The introduction of screening in the UK and other high‐income countries led to a significant decrease in the incidence of cervical cancer and increase in survival rates. Minority ethnic groups are often underrepresented in screening participation for reasons that are poorly understood.

Objective

To explore experiences of cervical screening participation and non‐participation of women from minority ethnic populations in Scotland and gain insights to support the development of interventions that could potentially support screening participation and thereby reduce inequalities.

Design

Qualitative comparison group study using in‐depth, semi‐structured individual interviews that were thematically analysed.

Setting and participants

This study took place in Scotland. Fifty women were purposively sampled from four ethnic minority groups: South Asian; East European; Chinese; and Black African or Caribbean. White Scottish women were also interviewed.

Results

Many experiences described were common regardless of ethnicity, such as difficulties managing competing priorities, including work and care responsibilities. However, important differences existed across the groups. These included going abroad for more frequent screening, delayed introduction to screening and not accessing primary care services, language difficulties in health‐care settings despite proficiency in English and not being sexually active at screening commencement. Experiences of racism, ignorance and feeling shamed were also reported.

Conclusions

Key differences exist in the experience of minority ethnic groups in Scotland. These offer potential opportunities to reduce disparity and support screening participation including maximizing co‐incidental interactions and developing outreach work.

An Investigation of the Association between Health Screening and Dental Scaling in Korea

Dental disease is one of the most prevalent chronic diseases worldwide, and its expenditure is continuously increasing. Periodontal disease is increasing as a chronic non-communicable disease in adults and older people. Health screening has been shown to be cost-effective and improves the quality of life through the early detection of diseases. This study aimed to analyze the relationship between national health screening and dental scaling as a preventive service for periodontal disease. The study used sample cohort data from 2002 to 2015 provided by the National Health Insurance Sharing Service in South Korea. A logistic regression analysis of the utilization of dental scaling was performed to identify the independent effects of national health screening. People who underwent health screening showed a higher tendency to undergo dental scaling. Additionally, disparities in utilization according to socioeconomic status were reduced among those who underwent screening. The intervention to extend dental coverage could be more beneficial when combined with health screening, encouraging more people to participate and reducing inequalities in utilization.

NHS Health Check programme: a protocol for a realist review

INTRODUCTION

The NHS Health Check aims to identify individuals at increased risk of cardiovascular diseases (CVDs) among the adult population in England. The Health Check includes calculation of CVD risk and discussion of pharmacological and lifestyle approaches to manage risk, including referral to lifestyle support services. The programme is commissioned by Local Authorities (LAs) and is delivered by a range of different providers in different settings. There is significant variation in activity, with uptake ranging from 25% to 85% in different areas, and clear evidence of variation in implementation and delivery practice.

METHODS AND ANALYSIS

We aim to understand how the NHS Health Check programme works in different settings, for different groups, so that we can recommend improvements to maximise intended outcomes. To do so, we will undertake a realist review and a survey of LA public health teams. Our review will follow Pawson's five iterative stages: (1) locate existing theories, (2) search for evidence, (3) article selection, (4) extract and organise data and (5) synthesise evidence and draw conclusions. Our review will include documents describing local implementation alongside published research studies. We will recruit a stakeholder group (including Public Health England, commissioners and providers of Health Checks, plus members of the public and patients) to advise us throughout. Our survey will be sent to all 152 LAs in England to gather detailed information on programme delivery (including COVID-19-related changes) and available referral services. This will enable us to map delivery across England and relate these data to programme outcomes.

ETHICS AND DISSEMINATION

Ethical approval is not required for this review. For the survey, we have received approval from the University of Kent Research Ethics Committee. Our findings will be used to develop recommendations on tailoring, implementation and design strategies to improve delivery of the NHS Health Check in different settings, for different groups.

PROSPERO REGISTRATION NUMBER

CRD42020163822.

Cardiovascular risk profiles and the uptake of the NHS Healthcheck programme in male prisoners in six UK prisons: an observational cross-sectional survey

INTRODUCTION

Half of all deaths in custody are due to natural causes, the most common being cardiovascular disease (CVD). National Health Service Healthchecks should be available to all eligible prisoners; it is not clear who receives them. Mental health issues are common in prisoners and may affect how healthcare interventions should be delivered. Current policy is to offer Healthchecks to those serving over 2 years in prison.

OBJECTIVES, METHODS, SETTING AND DESIGN

An observational cross-sectional survey in six male prisons in England between September 2017 and January 2019 in prisoners aged 35-74 to identify who was eligible for a Healthcheck and compare CVD risk data with those that were not, and factors associated with uptake.

OUTCOME MEASURES

Characteristics of those accepting a Healthcheck were compared with those declining. Assessments of anxiety and depression were compared with CVD risk factors.

RESULTS

1207 prisoners completed a Healthcheck. 21.8% of prisoners were ineligible due to existing comorbidities. 76.4% of those invited took up a Healthcheck, and of those, 12.1% were found to have new significant CVD comorbidity. CVD risk was similar to community levels but this population was 10 years younger. Definite case-level depression or anxiety was present in 20.7% and 18.0%, respectively, of participants. An association was found between ethnicity and those invited (p=0.023, φ=0.1) and accepting (p=0.008, φ=0.1) a Healthcheck. 9.7% of prisoners serving less than 2 years had CVD risk scores of 10% or more, and had similar CVD risk profiles but much higher levels of anxiety (p<0.001, φ=0.2) or depression (p=0.009, φ=0.2) than those serving 2 years or more.

CONCLUSION

Cardiovascular risk was comparable with community rates and in some prisons, much higher. Rates of anxiety and depression were high. The national policy for selecting prisoners for Healthchecks may leave many high-risk prisoners without appropriate cardiovascular preventative assessments.

Concept analysis of community health outreach

Background

The definition of community health outreach to promote the health of vulnerable populations depends heavily on the particulars of the given health project and community. There is no consistency in the definitions attached to the concept itself. Our study aimed to clarify the general definition of community health outreach to facilitate its understanding and use.

Methods

Walker and Avant’s (2010) method of concept analysis was used to understand community health outreach. A total of 45 articles were included in the analysis after having searched for text on database portals like PubMed, Scopus, CINAHL complete and EMBASE published between 2010 and 2018.

Results

The defining attributes of the concept of community health outreach were purposive, temporary, mobile and collaboration with community. The antecedents were population facing health risks and awareness of health risks. The consequences were increased accessibility and health promotion.

Conclusion

This study proposed the definition of community health outreach as a temporary, mobile project that involves the collaboration of a community to undertake its purposeful health intervention of reaching a population facing health risks. This definition provides a general understanding of the outreach undertaken by health workers and enables the strong connection between health professionals and community residents.

Evaluating the effectiveness of the NHS Health Check programme in South England: a quasi-randomised controlled trial

OBJECTIVE

To evaluate uptake, risk factor detection and management from the National Health Service (NHS) Health Check (HC).

DESIGN

This is a quasi-randomised controlled trial where participants were allocated to five cohorts based on birth year. Four cohorts were invited for an NHS HC between April 2011 and March 2015.

SETTING

151 general practices in Hampshire, England, UK.

PARTICIPANTS

366 005 participants born 1 April 1940-31 March 1976 eligible for an NHS HC.

INTERVENTION

NHS HC invitation.

MAIN OUTCOME MEASURES

HC attendance and absolute percentage changes and ORs of (1) detecting cardiovascular disease (CVD) 10-year risk >10% and >20%, smokers, and total cholesterol (TC) >5.5 mmol/L and >7.5 mmol/L; (2) diagnosing hypertension, type 2 diabetes mellitus, chronic kidney disease (CKD) and atrial fibrillation (AF); and (3) new interventions with statins, antihypertensives, antiglycaemics and nicotine replacement therapy (NRT).

RESULTS

HC attendance rose from 12% to 30% between 2011/2012 and 2014/2015 (p<0.001). HC invitation increased detection of CVD risk >10% (2.0%-3.6, p<0.001) and >20% (0.1%-0.6%, p<0.001-0.392), TC >5.5 mmol/L (4.1%-7.0%, p<0.001) and >7.5 mmol/L (0.3%-0.4% p<0.001), hypertension (0.3%-0.6%, p<0.001-0.003), and interventions with statins (0.2%-0.9%, p<0.001-0.017) and antihypertensives (0.1%-0.6%, p<0.001-0.205). There were no consistent differences in detection of smokers, NRT, or diabetes, AF or CKD. Multivariate analyses showed associations between HC invitation and detecting CVD risk >10% (OR 8.01, 95% CI 7.34 to 8.73) and >20% (5.86, 4.83 to 7.10), TC >5.5 mmol/L (3.72, 3.57 to 3.89) and >7.5 mmol/L (2.89, 2.46 to 3.38), and diagnoses of hypertension (1.33, 1.20 to 1.47) and diabetes (1.34, 1.12 to 1.61). OR of CVD risk >10% plus statin and >20% plus statin, respectively, was 2.90 (2.36 to 3.57) and 2.60 (1.92 to 3.52), and for hypertension plus antihypertensive was 1.33 (1.18 to 1.50). There were no associations with AF, CKD, antiglycaemics or NRT. Detection of several risk factors varied inversely by deprivation.

CONCLUSIONS

HC invitation increased detection of cardiovascular risk factors, but corresponding increases in evidence-based interventions were modest.

NHS Health Check and healthy lifestyle in Leicester, England: analysis of a survey dataset

AIMS

A major component of the National Health Service (NHS) Health Check in England is to provide lifestyle advice to eligible participants. The aims of the study were to explore the variations (in terms of uptake) in the NHS Health Check in Leicester and to determine its association with a healthy lifestyle.

METHODS

This cross-sectional study used data from the Leicester Health and Wellbeing Survey (2015).

RESULTS

The odds of having an NHS Health Check were found to be higher in Black and minority ethnic groups and in people of other religions. The odds were lower in people without a religion, residing in the fourth index of multiple deprivation quintile and in ex-smokers. No associations were found between having an NHS Health Check and describing a healthy lifestyle, following a healthy lifestyle, thinking of making lifestyle changes in the next 6 months, cutting down on/stopping smoking among current smokers, or amount of alcohol current drinkers would like to drink.

CONCLUSIONS

In Leicester, a few variations in having an NHS Health Check were found among different socio-economic, demographic and behavioural groups. No association was found between the NHS Health Check and a healthy lifestyle. Thus, the improvement work should focus on reducing these variations in having the NHS Health Check and bringing its benefits on promoting a healthy lifestyle.

Digital Recruitment and Acceptance of a Stepwise Model to Prevent Chronic Disease in the Danish Primary Care Sector: Cross-Sectional Study

Background

During recent years, stepwise approaches to health checks have been advanced as an alternative to general health checks. In 2013, we set up the Early Detection and Prevention project (Tidlig Opsporing og Forebyggelse, TOF) to develop a stepwise approach aimed at patients at high or moderate risk of a chronic disease. A novel feature was the use of a personal digital mailbox for recruiting participants. A personal digital mailbox is a secure digital mailbox provided by the Danish public authorities. Apart from being both safe and secure, it is a low-cost, quick, and easy way to reach Danish residents.

Objective

In this study we analyze the association between the rates of acceptance of 2 digital invitations sent to a personal digital mailbox and the sociodemographic determinants, medical treatment, and health care usage in a stepwise primary care model for the prevention of chronic diseases.

Methods

We conducted a cross-sectional analysis of the rates of acceptance of 2 digital invitations sent to randomly selected residents born between 1957 and 1986 and residing in 2 Danish municipalities. The outcome was acceptance of the 2 digital invitations. Statistical associations were determined by Poisson regression. Data-driven chi-square automatic interaction detection method was used to generate a decision tree analysis, predicting acceptance of the digital invitations.

Results

A total of 8814 patients received an invitation in their digital mailbox from 47 general practitioners. A total of 40.22% (3545/8814) accepted the first digital invitation, and 30.19 % (2661/8814) accepted both digital invitations. The rates of acceptance of both digital invitations were higher among women, older patients, patients of higher socioeconomic status, and patients not diagnosed with or being treated for diabetes mellitus, chronic obstructive pulmonary disease, or cardiovascular disease.

Conclusions

To our knowledge, this is the first study to report on the rates of acceptance of digital invitations to participate in a stepwise model for prevention of chronic diseases. More studies of digital invitations are needed to determine if the acceptance rates seen in this study should be expected from future studies as well. Similarly, more research is needed to determine whether a multimodal recruitment approach, including digital invitations to personal digital mailboxes will reach hard-to-reach subpopulations more effectively than digital invitations only.

Patient experiences of telephone outreach to enhance uptake of NHS Health Checks in more deprived communities and minority ethnic groups: A qualitative interview study

Background

The NHS Health Checks preventative programme aims to reduce cardiovascular morbidity across England. To improve equity in uptake, telephone outreach was developed in Bristol, involving community workers telephoning patients amongst communities potentially at higher risk of cardiovascular disease and/or less likely to take up a written invitation, to engage them with NHS Health Checks. Where possible, caller cultural background/main language is matched with that of the patient called. The call includes an invitation to book an NHS Health Check appointment, lifestyle questions from the Health Check, and signposting to lifestyle services.

Objective

To explore the experiences of patients who received an outreach call.

Design/Setting/Participants

Thematic analysis of semi‐structured interviews with 24 patients (15 female), from seven primary care practices, who had received an outreach call.

Results

The call increased participants’ understanding of NHS Health Checks and overcame anticipated difficulties with making an appointment. Half reported that they would not have booked if only invited by letter. The cultural identity/language skills of the caller were important in facilitating the interaction for some who might otherwise encounter language or cultural barriers. The inclusion of lifestyle questions and signposting prompted a minority to make lifestyle changes.

Conclusions

Participants valued easily generalizable aspects of the intervention—a telephone invitation with ability to book during the call—and reported that it prompted acceptance of an NHS Health Check. A caller who shared their main language/cultural background was important for a minority of participants, and improved targeting of this would be beneficial.

Cardiovascular disease in racial/ethnic minority populations: illness burden and overview of community-based interventions

Cardiovascular disease, the leading cause of death in the USA, poses a unique and multilateral burden to racial/ethnic minorities. The admixture of comorbid conditions, structural barriers, and psychosocial standing complicates the prevention, diagnosis, and management of cardiovascular disease in racial/ethnic minority populations and requires newer approaches to reduce existing disparities. A discussion of the cardiovascular disease risk burden is presented, along with an overview of multi-stratified considerations for improving racial/ethnic minority cardiovascular health via community engagement.

Risk biomarkers enable precision in public health

Precision medicine uses biomarkers to diagnose disease. However, they can also be used to measure risk of disease. Thus, biomarkers herald a new addition to public health - Precision Public Health. We examine the implications. Risk biomarkers are identified by analyzing population cohorts. They constitute risk factors in mathematical 'Disease Risk Models'. The risk may be fixed as in a genetic biomarker or variable as in some protein biomarkers. They help monitor current risk of disease in an individual, thereby aiding efforts to reduce risk. In the UK, the NHS Health Check system is a universal system for assessing risk and for risk reduction. The system can now make use of modern biomarkers once appropriate infrastructure and governance are in place.