Comparison of coronary heart disease genetic assessment with conventional cardiovascular risk assessment in primary care: reflections on a feasibility study.

AIM: This study assesses the feasibility of collecting genetic samples and self-reported outcome measures after cardiovascular risk assessment, and presenting the genetic test results to participants. BACKGROUND: Coronary heart disease (CHD) genetic tests are increasingly available through direct-to-consumer marketing, but their potential clinical impact on cardiovascular risk assessment is unclear. METHODS: Observational study in 10 British general practices in Central England. A total of 320 individuals, who had completed conventional cardiovascular risk assessment, were offered CHD genetic test, with follow-up outcome questionnaire at eight months for lifestyle change and State-Trait Anxiety. FINDINGS: A total of 119 (37%) participants returned genetic test specimens, with over a third reporting family history of CHD in a specified relative; 79 (66.4%) were categorized above-average risk on conventional cardiovascular risk assessment, 65 of whom (82.3%) were only average risk on genetic assessment. The dietary fat questionnaire was poorly completed while study participation was not associated with increased anxiety (mean increase in anxiety score=2.1; 95% CI -0.1-4.3; P=0.06). CONCLUSION: As a feasibility study, over a third of individuals offered genetic testing in primary care, as part of CVD risk assessment, took up the offer. Although intervention did not appear to increase anxiety, this needs further evaluation. To improve generalizability and effect size, future studies should actively engage individuals from wider socio-economic backgrounds who may not have already contemplated lifestyle change. The current research suggests general practitioners will face the clinical challenge of patients presenting with direct-to-consumer genetic results that are inconsistent with conventional cardiovascular risk assessment.

Perspectives on enhancing physical activity and diet for health promotion among at-risk urban UK South Asian communities: a qualitative study.

OBJECTIVES: To explore perspectives on enhancing physical activity and diet among South Asians in urban deprived communities at high risk of chronic disease and to inform development of culturally appropriate health promotion intervention. DESIGN: Qualitative study using semistructured one-to-one and family group interviews with thematic analysis of data. SETTING: Urban disadvantaged communities in the East Midlands of the UK. PARTICIPANTS: 45 respondents, including 34 people of South Asian origin (16 at-risk individuals, six family groups involving 18 relatives), of mainly Pakistani and Indian origin, including 16 non-English speakers; and 11 health professionals working locally with communities of concern. RESULTS: South Asian participants underlined the challenges of requiring family members across generations to engage in modifying dietary behaviours, and the central role of communal eating of traditional 'Asian' food in their cultural lives. Barriers to increasing physical activity included cost, personal safety and lack of time outside of long working hours and carer commitments. However, increasing walking activity was regarded as feasible by both community and health professional participants. Respondents emphasised using a social approach for potential interventions, undertaking activity with family or friends and with bilingual community peers to facilitate engagement, motivation and support. Spoken content and delivery of interventions was favoured, including personal stories and multilingual audio-visual information; within local informal rather than provider settings, including the home; and aided by pedometers for self-monitoring. CONCLUSIONS: Focusing on physical activity by increasing walking may hold promise as health promotion in this deprived South Asian community context. Further intervention development, with exploration of feasibility and acceptability of the social approach and elements suggested, is merited.

Opportunities and challenges for enhancing preconception health in primary care: qualitative study with women from ethnically diverse communities.

OBJECTIVE:  There is a growing interest in developing and offering more systematic preconception healthcare. However, it is unclear how this might be regarded by ethnically diverse communities at higher risk of poor maternal and child health outcomes. We sought to explore perceptions about preconception health and care among women from these communities to identify opportunities and challenges for intervention development in primary care. DESIGN: Qualitative study using focus groups and semistructured interviews. SETTING: Ethnically diverse and socially disadvantaged community settings of the UK. PARTICIPANTS: 41 women aged 18-45 years, of Pakistani, Indian, Caribbean, African, White and mixed ethnic origin, participating in nine focus groups, half of whom (n=19) had one-to-one follow-up telephone interviews. RESULTS: Women had modest or poor awareness of preconception health issues. They perceived these could be addressed in primary care, particularly if raised within a range of clinically 'relevant' consultations, such as for contraception, or when opportune for individuals in their social context. However, challenges for engaging women in preconception care more routinely were underlined. These included little prevailing culture of preparing for pregnancy and the realities of their pregnancies often being unplanned; and, for those planning pregnancy, sensitivity and maintaining secrecy when trying to conceive. A preference for female professionals, engaging men, and enhancing access for younger people or women less disposed to general practice, in educational and other settings were highlighted. CONCLUSIONS: Raising preconception health when this has heightened clinical or social resonance for women may hold promise for initiating more systematic intervention. In primary care this could offer greater potential to directly engage those with low awareness or not considering pregnancy, while enlarging opportunity for others who may be seeking to conceive. Promoting 'preparation for pregnancy' more widely might form part of healthcare and education over the life course. Further intervention development research exploring these possibilities, including their feasibility and acceptability is needed.

How does a simple enquiry compare to a detailed family history questionnaire to identify coronary heart disease or diabetic familial risk?

PURPOSE: To examine whether a simple enquiry can provide similar family history information compared with a detailed questionnaire for coronary heart disease or diabetes. METHODS: Data from two randomized controlled trials were extracted that assess the clinical value of using family history information for either coronary heart disease (ISRCTNI17943542) or diabetes risk assessment (NTR1938) in a community-based population. Outcome measures were percentage agreement, sensitivity, and specificity of self-reported family history for coronary heart disease and diabetes by means of a simple enquiry, when compared with a detailed questionnaire. RESULTS: Agreement between both family history tools was 76.8% for first-degree relatives with coronary heart disease, and 89.2% and 87.6% for first- and second-degree relatives with diabetes, respectively. The sensitivity was 44.2% for first-degree relatives with coronary heart disease, 81.9% for first-degree relatives with diabetes, and 35.4% for second-degree relatives with diabetes. Specificity was 89.3%, 97.0%, and 94.5%, respectively. CONCLUSION: Compared with a detailed questionnaire, the simple enquiry correctly identified the majority of individuals classified as having no significant family history but missed a significant proportion of individuals with positive family history. Incorrect classification of family history, in particular the high false-negative rate, has implications on the utility of a simple enquiry in identifying familial risk in clinical practice.