Yes / This study aimed to explore the challenges and barriers faced by staff involved in the delivery of the National Health Service (NHS) Health Check, a systematic cardiovascular disease (CVD) risk assessment and management program in primary care. Data have been derived from three qualitative evaluations that were conducted in 25 General Practices and involved in depth interviews with 58 staff involved all levels of the delivery of the Health Checks. Analysis of the data was undertaken using the framework approach and findings are reported within the context of research and practice considerations. Findings indicated that there is no ‘one size fits all’ blueprint for maximising uptake although success factors were identified: evolution of the programme over time in response to local needs to suit the particular characteristics of the patient population; individual staff characteristics such as being proactive, enthusiastic and having specific responsibility; a supportive team. Training was clearly identified as an area that needed addressing and practitioners would benefit from CVD specific baseline training and refresher courses to keep them up to date with recent developments in the area. However there were other external factors that impinged on an individual’s ability to provide an effective service, some of these were outside the control of individuals and included cutbacks in referral services, insufficient space to run clinics or general awareness of the Health Checks amongst patients. The everyday experiences of practitioners who participated in this study suggest that overall, Health Check is perceived as a worthwhile exercise. But, organisational and structural barriers need to be addressed. We also recommend that clear referral pathways be in place so staff can refer patients to appropriate services (healthy eating sessions, smoking cessation, and exercise referrals). Local authorities need to support initiatives that enable data sharing and linkage so that GP Practices are informed when patients take up services such as smoking cessation or alcohol harm reduction programmes run by social services.

BackgroundIndividuals from low socio-economic backgrounds have higher rates of morbidity and premature mortality from cardiovascular risk factors compared to those from more affluent backgrounds.Hearty Lives Dundee is a complex intervention which aims to address this health inequality. The intervention targets cardiovascular health checks at population groups who are likely to be at high risk, but tend not to engage with traditional services. Practitioners have tried to increase engagement with the target groups through a number of strategies. These included community and workplace-based assessments, and General Practice-run health checks supported by an outreach facility. The aim of this thesis was to explore what works at increasing patient uptake of cardiovascular health checks, for what groups, in what circumstances, and why?MethodsA Realistic Evaluation was undertaken using a mixed methods approach. Routine data was extracted from the Hearty Lives database and descriptive statistics reported on patients attending the community-based opportunistic service and the GP-based service. A total of thirty semi-structured interviews and one focus group (n=5) were conducted with patient attenders and non-attenders of community and General Practice-based health checks. Seven staff from the Hearty Lives programme were also interviewed. Thematic analysis was undertaken using Ritchie and Spencer’s Framework approach.ResultsAttenders at health checks were more likely to be female and older, regardless of the setting. Uptake varied by the number and type of invitation method. Cardiovascular risk was greater in the target population presenting opportunistically but was confounded by the older age of this group.Patient engagement relied on the interaction of a number of factors which varied according to setting; accessibility, invitation method, personal circumstances, cues to action and barriers. A continuum existed from barriers to motivators to attendance depending on the presence or absence of a cue to action, e.g. family history or symptoms. The concept of preventive health checks for cardiovascular disease was not well understood as some patients did not perceive a need to attend without symptoms. Additionally, the health check was viewed as optional by many and not treated with the same seriousness as perceived ‘compulsory’ cancer screenings.DiscussionThe complex lives of the intended target population merit a range of accessible services to reduce barriers to preventive health care. The Realistic Evaluation approach provided transferable knowledge of how to effectively engage with people from different backgrounds and care utilisation preferences, which could easily inform similar NHS services.

Background: Increasing attention has been paid to preventative health over the past few decades. However because of constraints on consultation time and medical funds general practitioners (GPs) are often unsure which measures are appropriate and when to carry them out. They need to be well informed about the cost-effectiveness and evidence regarding each preventative measure to help their patients make informed choices about what needs to be done. Due to the large number of recommended screening measures general practitioners are often unsure which to prioritise and also forget to carry out all recommended measures. Recommendations for screening in South Africa and research into preventive strategies used by general practitioners are lacking. This research attempts to find out whether the prevention strategies used by general practitioners in private practice in Grahamstown follow recommended guidelines. Methods: To obtain a broad understanding of prevention strategies used by general practitioners in Grahamstown, the following tracer conditions were selected for the study: screening for smoking, breast cancer, cervical cancer, colorectal cancer, hyperlipidaemia, prostate cancer and human immunodeficiency virus (HIV) infection. Research on routine annual health checks was included as these are used by many GPs to screen for tracer conditions. The research was done in 2 parts: 1. Review of the literature to obtain evidence on the recommended prevention strategy for each of the selected tracer conditions and 2. Interviews with GPs to evaluate the prevention strategy they used for each tracer condition. The literature was reviewed for evidence on the following parameters for each tracer condition: burden of the disease prevented; cost-effectiveness of the screening measures; sensitivity and specificity of screening tests; whether the screening measure for and treatment of the tracer condition is acceptable to patients; appropriate duration between repeated screening tests and whether there is effective treatment for the tracer condition. Eleven general practitioners were interviewed on the prevention strategies they use for each of the selected tracer conditions. Transcriptions of the interviews were analysed qualitatively and qualitatively. The prevention strategies used by the general practitioners was then compared to recommended guidelines. Results: Evidence from the literature regarding the burden of and optimal prevention strategy for each tracer condition is reported. Using this evidence an appropriate prevention strategy for each tracer condition is outlined. The prevention strategies used by the GPs for each tracer condition and the routine annual health check is reported from the analysis of the interviews. The results show a wide range of differing strategies used by the GPs, often not following recommendations from research. Discussion: The prevention strategies used by general practitioners for each tracer condition is compared with the recommendations from the literature. Important differences between what are recommended and what general practitioners are doing is discussed. Some general practitioners are practicing largely curative medicine and are not adequately screening their patients. Others are over screening with too many unnecessary tests being done annually as a routine. The interviews reveal that generally GPs do not discuss the potential harms and limitations of screening tests with their patients; do not keep check lists for each patient and do not use registers or recall systems to ensure all screening is done. Conclusion: General practitioners need to ensure their prevention strategies follow recommended guidelines. To do so they can use the routine annual health check or opportunistic case finding and prevention. They need to ensure that routine health checks are targeted to the individual patients’ health risks and avoid doing unnecessary tests. Check lists can help to ensure all screening is done on every patient. While registers and recall systems improve screening rates they are not always possible in busy general practices. Recommended prevention strategies for each of the tracer conditions are made.