Enhanced Invitations Using the Question-Behavior Effect and Financial Incentives to Promote Health Check Uptake in Primary Care

Background

Uptake of health checks for cardiovascular risk assessment in primary care in England is lower than anticipated. The question-behavior effect (QBE) may offer a simple, scalable intervention to increase health check uptake.

Purpose

The present study aimed to evaluate the effectiveness of enhanced invitation methods employing the QBE, with or without a financial incentive to return the questionnaire, at increasing uptake of health checks.

Methods

We conducted a three-arm randomized trial including all patients at 18 general practices in two London boroughs, who were invited for health checks from July 2013 to December 2014. Participants were randomized to three trial arms: (i) Standard health check invitation letter only; (ii) QBE questionnaire followed by standard invitation letter; or (iii) QBE questionnaire with offer of a financial incentive to return the questionnaire, followed by standard invitation letter. In intention to treat analysis, the primary outcome of completion of health check within 6 months of invitation, was evaluated using a p value of .0167 for significance.

Results

12,459 participants were randomized. Health check uptake was evaluated for 12,052 (97%) with outcome data collected. Health check uptake within 6 months of invitation was: standard invitation, 590 / 4,095 (14.41%); QBE questionnaire, 630 / 3,988 (15.80%); QBE questionnaire and financial incentive, 629 / 3,969 (15.85%). Difference following QBE questionnaire, 1.43% (95% confidence interval -0.12 to 2.97%, p = .070); following QBE questionnaire and financial incentive, 1.52% (-0.03 to 3.07%, p = .054).

Conclusions

Uptake of health checks following a standard invitation was low and not significantly increased through enhanced invitation methods using the QBE.

Enhanced invitation methods and uptake of health checks in primary care: randomised controlled trial and cohort study using electronic health records

BACKGROUND

A national programme of health checks to identify risk of cardiovascular disease (CVD) is being rolled out but is encountering difficulties because of low uptake.

OBJECTIVE

To evaluate the effectiveness of an enhanced invitation method using the question-behaviour effect (QBE), with or without the offer of a financial incentive to return the QBE questionnaire, at increasing the uptake of health checks. The research went on to evaluate the reasons for the low uptake of invitations and compare the case mix for invited and opportunistic health checks.

DESIGN

Three-arm randomised trial and cohort study.

PARTICIPANTS

All participants invited for a health check from 18 general practices. Individual participants were randomised.

INTERVENTIONS

(1) Standard health check invitation only; (2) QBE questionnaire followed by a standard invitation; and (3) QBE questionnaire with offer of a financial incentive to return the questionnaire, followed by a standard invitation.

MAIN OUTCOME MEASURES

The primary outcome was completion of the health check within 6 months of invitation. A p-value of 0.0167 was used for significance. In the cohort study of all health checks completed during the study period, the case mix was compared for participants responding to invitations and those receiving 'opportunistic' health checks. Participants were not aware that several types of invitation were in use. The research team were blind to trial arm allocation at outcome data extraction.

RESULTS

In total, 12,459 participants were included in the trial and health check uptake was evaluated for 12,052 participants for whom outcome data were collected. Health check uptake was as follows: standard invitation, 590 out of 4095 (14.41%); QBE questionnaire, 630 out of 3988 (15.80%); QBE questionnaire and financial incentive, 629 out of 3969 (15.85%). The increase in uptake associated with the QBE questionnaire was 1.43% [95% confidence interval (CI) -0.12% to 2.97%; p = 0.070] and the increase in uptake associated with the QBE questionnaire and offer of financial incentive was 1.52% (95% CI -0.03% to 3.07%; p = 0.054). The difference in uptake associated with the offer of an incentive to return the QBE questionnaire was -0.01% (95% CI -1.59% to 1.58%; p = 0.995). During the study period, 58% of health check cardiovascular risk assessments did not follow a trial invitation. People who received an 'opportunistic' health check had greater odds of a ≥ 10% CVD risk than those who received an invited health check (adjusted odds ratio 1.70, 95% CI 1.45 to 1.99; p < 0.001).

CONCLUSIONS

Uptake of a health check following an invitation letter is low and is not increased through an enhanced invitation method using the QBE. The offer of a £5 incentive did not increase the rate of return of the QBE questionnaire. A high proportion of all health checks are performed opportunistically and not in response to a standard invitation letter. Participants receiving opportunistic checks are at higher risk of CVD than those responding to standard invitations. Future research should aim to increase the accessibility of preventative medical interventions to increase uptake. Research should also explore the wider use of electronic health records in delivering efficient trials.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN42856343.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 84. See the NIHR Journals Library website for further project information.

Is there a role for patients and their relatives in escalating clinical deterioration in hospital? A systematic review

BACKGROUND

Measures exist to improve early recognition of, and response to, deteriorating patients in hospital. However, deteriorating patients continue to go unrecognized. To address this, interventions have been developed that invite patients and relatives to escalate patient deterioration to a rapid response team (RRT).

OBJECTIVE

To systematically review articles that describe these interventions and investigate their effectiveness at reducing preventable deterioration.

SEARCH STRATEGY

Following PRISMA guidelines, four electronic databases and two web search engines were searched to identify literature investigating patient and relative led escalation.

INCLUSION CRITERIA

Articles investigating the implementation or use of systems involving patients and relatives in the detection of clinical patient deterioration and escalation of patient care to address any clinical or non-clinical outcomes were included. Articles' eligibility was validated by a second reviewer (20%).

DATA EXTRACTION

Data were extracted according to pre-defined criteria.

DATA SYNTHESIS

Narrative synthesis was applied to included studies.

MAIN RESULTS

Nine empirical studies and 36 grey literature articles were included in the review. Limited studies were conducted to establish the clinical effectiveness of patient and relative led escalation. Instead, studies investigated the impact of this intervention on health-care staff and available resources. Although appropriate, this reflects the infancy of research in this area. Patients and relatives did not overwhelm resources by activating the RRT. However, they did activate it to address concerns unrelated to patient deterioration.

CONCLUSIONS

Activating a RRT may not be the most appropriate or cost-effective method of resolving non-life-threatening concerns.

A Web-Based and Mobile Health Social Support Intervention to Promote Adherence to Inhaled Asthma Medications: Randomized Controlled Trial

BACKGROUND

Online communities hold great potential as interventions for health, particularly for the management of chronic illness. The social support that online communities can provide has been associated with positive treatment outcomes, including medication adherence. There are few studies that have attempted to assess whether membership of an online community improves health outcomes using rigorous designs.

OBJECTIVE

Our objective was to conduct a rigorous proof-of-concept randomized controlled trial of an online community intervention for improving adherence to asthma medicine.

METHODS

This 9-week intervention included a sample of asthmatic adults from the United Kingdom who were prescribed an inhaled corticosteroid preventer. Participants were recruited via email and randomized to either an "online community" or "no online community" (diary) condition. After each instance of preventer use, participants (N=216) were required to report the number of doses of medication taken in a short post. Those randomized to the online community condition (n=99) could read the posts of other community members, reply, and create their own posts. Participants randomized to the no online community condition (n=117) also posted their medication use, but could not read others' posts. The main outcome measures were self-reported medication adherence at baseline and follow-up (9 weeks postbaseline) and an objective measure of adherence to the intervention (visits to site).

RESULTS

In all, 103 participants completed the study (intervention: 37.8%, 39/99; control: 62.2%, 64/117). MANCOVA of self-reported adherence to asthma preventer medicine at follow-up was not significantly different between conditions in either intention-to-treat (P=.92) or per-protocol (P=.68) analysis. Site use was generally higher in the control compared to intervention conditions.

CONCLUSIONS

Joining an online community did not improve adherence to preventer medication for asthma patients. Without the encouragement of greater community support or more components to sustain engagement over time, the current findings do not support the use of an online community to improve adherence.

CLINICALTRIAL

International Standard Randomized Controlled Trial Number (ISRCTN): 29399269; http://www.isrctn.com/ISRCTN29399269/29399269 (Archived by WebCite at http://www.webcitation.org/6fUbEuVoT).

Partner- and planning-based interventions to reduce fat consumption: randomized controlled trial

OBJECTIVE

The research tested the efficacy of partner- and planning-based interventions to reduce dietary fat intake over a 6-month period.

DESIGN

Randomized controlled, blinded, parallel trial.

METHODS

A computer randomization feature was used to allocate council employees (N = 427, of which 393 completed baseline measures) to one of four conditions (partner + implementation intentions, partner-only, implementation intentions, and control group) before they completed measures at baseline and follow-ups at 1, 3, and 6 months post-baseline. Outcome measures were comprised of validated self-report measures of dietary fat intake (saturated fat intake, fat intake, ratio of 'good' fats to 'bad' fats); psychosocial mediators (enjoyment, intention, self-efficacy, social influence, partner support); weight and waist size (baseline and 6 months only).

RESULTS

Data from 393 participants were analysed in accordance with intention-to-treat analyses. All intervention groups reported greater reductions in fat intake than the control group at 3 months. The partner-based groups increased the ratio of 'good' fats to 'bad' fats at 3 and 6 months and lost more inches on their waist, versus the non-partner groups. The impacts of the partner-based manipulations on outcomes were partially mediated by greater perceived social influences, partner support, and enjoyment of avoiding high-fat foods. The partner-based interventions also increased intention and self-efficacy. However, the effects in this study were typically small and generally marginally significant.

CONCLUSIONS

Partner-based interventions had some positive benefits on dietary-related outcomes at 3 and 6 months. Support for implementation intentions was more limited.

Lifting the lid on GPCRs: the role of extracellular loops

GPCRs exhibit a common architecture of seven transmembrane helices (TMs) linked by intracellular loops and extracellular loops (ECLs). Given their peripheral location to the site of G-protein interaction, it might be assumed that ECL segments merely link the important TMs within the helical bundle of the receptor. However, compelling evidence has emerged in recent years revealing a critical role for ECLs in many fundamental aspects of GPCR function, which supported by recent GPCR crystal structures has provided mechanistic insights. This review will present current understanding of the key roles of ECLs in ligand binding, activation and regulation of both family A and family B GPCRs.

Insight into sight, touch, taste and smell by multiple discriminations from norm

The paper presents an innovative theory of perception of multiple features across and within modalities. Each step is illustrated by an aspect of data from diverse experiments. The theory is that a template or norm of previously configurated features is used to perceive an object in a situation, such as consuming an item of food or drink. A mouthful usually stimulates sight first and then touch, taste and smell, with thermal, irritative, kinaesthetic and auditory patterns often also involved. The visual information also typically includes meanings of words, numbers and pictures. Attended sensory and symbolic features of the situation are integrated by the individual into a multidimensional distance from the norm. Dimensions are calibrated in units of the response's discrimination between levels of each stimulus feature. This approach to perceptual performance is expounded for sensed and/or conceived visual features of drinks and foods, and their tasted or smelt constituents, or felt and heard cracking during a bite. In addition, the conceptual process that informs an analytical judgment can influence another judgment. Applying the concept to a stimulus forms a descriptive process. A concept may also be applied to another concept or to a description, giving greater depth of meaning to an integrative judgment. Furthermore, a description can be applied to an environmental source of stimulation, creating a percept that presumably is conscious, whereas unconceptualised stimulation may be subconscious.

A network-individual-resource model for HIV prevention

HIV is transmitted through dyadic exchanges of individuals linked in transitory or permanent networks of varying sizes. A theoretical perspective that bridges key individual level elements with important network elements can be a complementary foundation for developing and implementing HIV interventions with outcomes that are more sustainable over time and have greater dissemination potential. Toward that end, we introduce a Network-Individual-Resource (NIR) model for HIV prevention that recognizes how exchanges of resources between individuals and their networks underlies and sustains HIV-risk behaviors. Individual behavior change for HIV prevention, then, may be dependent on increasing the supportiveness of that individual's relevant networks for such change. Among other implications, an NIR model predicts that the success of prevention efforts depends on whether the prevention efforts (1) prompt behavior changes that can be sustained by the resources the individual or their networks possess; (2) meet individual and network needs and are consistent with the individual's current situation/developmental stage; (3) are trusted and valued; and (4) target high HIV-prevalence networks.

Study protocol: a cluster randomised controlled trial of a school based fruit and vegetable intervention - Project Tomato

Background

The School Fruit and Vegetable Scheme (SFVS) is an important public health intervention. The aim of this scheme is to provide a free piece of fruit and/or vegetable every day for children in Reception to Year 2. When children are no longer eligible for the scheme (from Year 3) their overall fruit and vegetable consumption decreases back to baseline levels. This proposed study aims to design a flexible multi-component intervention for schools to support the maintenance of fruit and vegetable consumption for Year 3 children who are no longer eligible for the scheme.

Method

This study is a cluster randomised controlled trial of Year 2 classes from 54 primary schools across England. The schools will be randomly allocated into two groups to receive either an active intervention called Project Tomato, to support maintenance of fruit intake in Year 3 children, or a less active intervention (control group), consisting of a 5 A DAY booklet. Children's diets will be analysed using the Child And Diet Evaluation Tool (CADET), and height and weight measurements collected, at baseline (Year 2) and 18 month follow-up (Year 4). The primary outcome will be the ability of the intervention (Project Tomato) to maintain consumption of fruit and vegetable portions compared to the control group.

Discussion

A positive result will identify how fruit and vegetable consumption can be maintained in young children, and will be useful for policies supporting the SFVS. A negative result would be used to inform the research agenda and contribute to redefining future strategies for increasing children's fruit and vegetable consumption.

Trial registration

Medical Research Council Registry code G0501297

Relations between implicit and explicit measures of attitudes and measures of behavior: evidence of moderation by individual difference variables

The moderating role of individual difference variables (Self-Reported Habit Index [SRHI], Need for Cognition [NFC]) on relationships between implicit (Implicit Association Test [IAT], Extrinsic Affective Simon Test [EAST]) or explicit measures of attitude and behavior is assessed in two studies. A dissociation pattern is found on self-report diary measures of behavior. In Study 1, the EAST-behavior relationship is moderated by SRHI; explicit measures of the attitude-behavior relationship are moderated by NFC. In Study 2, the IAT-behavior relationship is moderated by SRHI; explicit measures of the attitude-behavior relationship are moderated by NFC. Higher levels of SRHI and NFC are associated with stronger relationships between the implicit or explicit measures of attitude and the measure of behavior. In Study 2, the SRHI x IAT interaction is replicated for an objective behavior measure. Implications for understanding the relationship between implicit and explicit measures of attitudes and measures of behavior are discussed.

Promoting adherence to antibiotics: a test of implementation intentions

OBJECTIVE

This prospective study tested whether implementation intentions increased adherence to short-term antibiotics in a patient sample. Implementation intentions specify exactly when and where an individual will undertake an activity. They may help people achieve health behaviours, such as taking medicines.

METHODS

A total of 220 patients with an antibiotics prescription were randomly assigned to four groups (control, Theory of Planned Behaviour (TPB) questionnaire, TPB questionnaire+formed own implementation intention for taking the medicine, TPB questionnaire+researcher formed implementation intention). Participants were telephoned at the end of the course to record adherence. Two hundred and seven participants completed the study.

RESULTS

At follow-up, adherence was high (75.8% reported no tablets left). Analysis revealed no significant difference in adherence between groups.

CONCLUSION

High adherence to antibiotics was achieved, but not improved by implementation intentions.

PRACTICE IMPLICATIONS

Providing information and telephone follow-up may have been the unintended effective intervention in this study.

Barriers to healthy eating amongst men: A qualitative analysis

Currently, little is known about the meanings men attach to food or to the links between food and health. The burgeoning literature on men's health highlights forms of masculinity (e.g. risk-taking, invulnerability) as a factor (negatively) influencing men's health practices. The aim of this study was to provide an analysis of men's accounts of food and health using concepts pertaining to masculinity. We report on a qualitative analysis of a dataset comprising 24 interviews with UK men from a range of age and social class groups. Our findings suggest two principal barriers to healthy eating in men: cynicism about government health messages and a rejection of healthy food on grounds of poor taste and inability to satisfy. These findings are discussed in relation to masculine ideals such as rationality, autonomy and strength. The implications of our analysis for future research and men's health promotion policy are discussed.

Relation between breakfast food choices and knowledge of dietary fat and fiber among Swedish schoolchildren

PURPOSE

To investigate dietary knowledge and beliefs of schoolchildren, in relationship to breakfast choices, with specific attention to fat and fiber content.

METHODS

Food choice and perceptions were studied by interviews using the "stacking box methodology". Youth (n = 181) aged 11-15 years were instructed to select food items among photographs of breakfast foods. In addition to choosing their own typical breakfasts, they were asked to exchange foods in hypothetical breakfasts to create meals with less fat and more fiber. The interview also dealt with recent changes in breakfast habits, and perceptions of healthy breakfasts, dietary fat, and foods rich in fiber. Data were analyzed by logistic regression.

RESULTS

Knowledge concerning sources and health attributes of dietary fiber was associated with usual consumption of bread and breakfast cereals rich in fiber. In a similar way, a positive attitude toward limited fat intake predicted consumption of reduced-fat milk products. However, no association was observed between food choices and knowledge of a food-packaging symbol indicating low-fat and fiber-enriched foods.

CONCLUSION

Lack of awareness of, and knowledge about, healthy eating may be important barriers to the development of health promoting food habits by schoolchildren.

Body weight, body-weight concerns and eating styles in habitual heavy users and non-users of artificially sweetened beverages

This study investigated reported body weight, concerns about body weight and eating styles in habitual heavy users (consume>825 ml/day) and habitual non-users of artificially sweetened beverages (ASBs). Groups of habitual heavy users (N=51) and non-users (N=69) were compared on measures of weight using self-reported body mass index (BMI), and measures of weight concern and eating style using the Dutch Eating Behaviors Questionnaire (DEBQ), the Yale Eating Patterns Questionnaire (YEPQ), and the Eating Disorder Inventory (EDI). Habitual heavy users reported higher body weights (BMI), greater concerns about weight and greater tendencies toward certain eating styles, when compared to non-users. Using logistic regression, 82% of respondents were correctly classified as heavy or non-users of ASBs using body mass index and body-weight concerns. Associations between a heavy use of ASBs and certain eating styles can be explained by association with high body weights and concerns about body weight.

Sources of bias in a dietary survey of children

OBJECTIVE

To compare non-responders and responders to a dietary survey with respect to demographic variables and intention to choose selected breakfast foods, and to examine if there was any systematic change in number of food items reported during a 7 d recording period.

DESIGN

Cross-sectional survey.

SETTING

Mölndal, Sweden.

SUBJECTS

All pupils in 5th, 7th and 9th grades in the municipality were asked to complete a questionnaire during school hours. All those present (n = 1584, 92% of total) answered questions about lifestyle factors and about intentions, attitudes and beliefs concerning high-fibre bread and milk with varying fat content. All subjects in the initial sample were asked to fill in a 7 d record of food consumed. Acceptable food records were completed by 69% of the initial participants.

RESULTS

Subjects not completing the food record differed significantly from participants with respect to demographic, lifestyle and dietary factors. Dropout was more common among those who reported not usually eating breakfast and among those intending to drink whole milk for breakfast. A decline in reported food items during the recording period was also observed.

CONCLUSIONS

Two sources of bias were observed here, one indicating significant differences between non-participants and participants, the other suggesting the presence of a time-dependent trend in number of recorded foods. It is likely such biases are present in other dietary surveys involving schoolchildren, and should be taken into consideration in the design, analysis and interpretation of such studies.

Exceeding the speed limit: an evaluation of the effectiveness of a police intervention

Driving too fast is probably one of the main contributors to the occurrence and severity of road accidents, and intention to speed is an important predictor of exceeding speed limits. This study examined the effect of a police intervention on exceeding the posted speed limit (speed of vehicles on the target road) and on intentions to speed (attitude questionnaire). The intervention consisted of a week in which 'police speed check area' warning signs were put up on the target 40 mph limit road, followed by a week of active police presence, followed by a further week in which the signs remained. The speed of vehicles was measured using police data collection equipment for a total of 7 weeks. The effect on the intentions of drivers using the road to exceed speed limits was assessed across age, sex and pre-intervention speeding behaviour using questionnaire measures. Fewer people broke the speed limit during the intervention than before, this effect lasting to a limited extent up to 9 weeks after police activity ceased and 8 weeks after signs were removed. The effect on drivers breaking the speed limit by large amounts was more transient. The intervention reduced intention to speed for subject groupings with high pre-intervention intention. Traffic flow contributed significantly to the variance in vehicle speed, but was not responsible for differences between the weeks, which may therefore be attributed to the intervention. Traffic flow also did not account for differences in speed between the two directions of traffic, which may therefore be attributed to the fact that the road areas preceding the target area in each direction differed in their speed limits (70 vs 30 mph). Intentions to speed, as well as speed adaptation difficulties are though to contribute to these differences.

Measurement of food perception, food preference, and nutrient selection

Perception, preference, and selection are all objectively measurable performances that discriminate between different levels of entities such as the sugar, thickener, or protein in a food. A rating or an intake may not be controlled by the word that the experimenter or the subject uses to describe it: "protein"-oriented food selection, "thickness" preference, or "sweetness" perception is proved only when the named objective influence, isolated from any other influence, accounts for the observed variations in choice response. Difference-measuring designs can be extended from merely two levels of an influence to a continuum over the natural range of levels, thus evoking linear psychophysical (dose-response) performance from which the strength of that influence can be estimated. Usually, at least a few influences are operative at once on a choice. Because the interactions may vary among people, the only valid causal analysis is at the individual level. Examples are given of food taste tolerance in the elderly, integration of sensory and attitudinal influences, and dietary choices misattributed to carbohydrate craving.

Do comparisons of a food characteristic with ideal necessarily involve learning?

Untrained assessors graphically rated the saltiness of plain slices of white bread relative to a personally ideal level of saltiness, with each test session designed to minimize known contextual effects on ratings. Judgements were highly reliable from the first session. However, the mean of the residual variances of individuals' psychophysical functions was approximately halved by the fifth session. To test whether this was an accommodation to the method or to the product, assessors rated the same product by a different procedure in one further session and a different food by the same procedure in a final session. The mean residuals lay in the direction of an accommodation to the method, but this difference proved not to be significant. The initial fall in residuals might indicate some learning about the product which was not adequately tested in the experimental manipulation. Nevertheless, it is clear that the method can be immediately used with high precision by unpractised volunteers.

Preferred sweetness of a lime drink and preference for sweet over non-sweet foods, related to sex and reported age and body weight

The ideal sugar concentration in a lime drink, the tolerance of deviations from that ideal, the choices between sweet and non-sweet foods, and tea and coffee sugaring habits, were assessed for each individual in an unstratified sample of 344 children and adults of both sexes, and body mass index (BMI) for 241 of them. Lime drink ideal point, hot-drink sugaring habits and the preferences for cake trolley over cheeseboard, flavoured milk shake over ice-cold milk, lemonade or tonic water over soda water and bread and margarine with honey or chocolate spread over plain bread and margarine, were all reliably associated positively with each other. This confirms the reality of the "sweet tooth", but not its extension to all sweet foods, because preferences for carrot over celery and for orange juice over tomato juice were not reliably associated with the other preferences. On average, the men showed a greater sweetness preference than the women. Women and younger subjects showed on average greater preferences for carrot and orange juice over the alternatives. When BMI was disconfounded from age and sex, it did not relate either to the preference for foods and drinks generally regarded as sweet or to the preference for a sweet alternative to a non-sweet vegetable food or drink.

Effect of stimulus range on judgements of sweetness intensity in a lime drink

The effect of the range of levels of the test stimuli on ratings of sweetness intensity is demonstrated for a lime drink. The results are consistent with Poulton's (1979) suggestion that range effects can be predicted from the deviation of the mean response in a session from the mid-point of the response dimension. It is demonstrated that this range bias can be avoided by adding a readily anchored mid-point (ideal) to the response dimension and selecting stimuli so that the mean response is close to this mid-point. This bias-reducing, relative-to-mid-point procedure also produces a stronger linear relationship between ratings and concentration ratios than does the conventional end-point-anchored intensity rating procedure. The similarity of the linear semi-log functions of response relative to extremely sweet and relative to ideally sweet is taken as evidence that the two types of responses are not independent.