Exploring practice and perspectives on shared decision-making about osteoporosis medicines in Fracture Liaison Services: the iFraP development qualitative study.

Interviews and focus groups with patients, FLS clinicians, and GPs identified challenges relating to clinical and shared decision-making about bone health and osteoporosis medicines. Findings will inform the development of the multicomponent iFraP intervention to address identified training needs and barriers to implementation to facilitate SDM about osteoporosis medicines. PURPOSE: The iFraP (improving uptake of Fracture Prevention treatments) study aimed to develop a multicomponent intervention, including an osteoporosis decision support tool (DST), to support shared decision-making (SDM) about osteoporosis medicines. To inform iFraP intervention development, this qualitative study explored current practice in relation to communication about bone health and osteoporosis medicines, anticipated barriers to, and facilitators of, an osteoporosis DST, and perceived training needs. METHODS: Patients attending an FLS consultation (n = 8), FLS clinicians (n = 9), and general practitioners (GPs; n = 7) were purposively sampled to participate in a focus group and/or telephone interview. Data were transcribed, inductively coded, and then mapped to the Theoretical Domains Framework (TDF) as a deductive framework to systematically identify possible barriers to, and facilitators of, implementing a DST. RESULTS: Inductive codes were deductively mapped to 12 TDF domains. FLS clinicians were perceived to have specialist expertise (knowledge). However, clinicians described aspects of clinical decision-making and risk communication as difficult (cognitive skills). Patients reflected on decisional uncertainty about medicines (decision processes). Discussions about current practice and the proposed DST indicated opportunities to facilitate SDM, if identified training needs are met. Potential individual and system-level barriers to implementation were identified, such as differences in FLS configuration and a move to remote consulting (environmental context and resources). CONCLUSIONS: Understanding of current practice revealed unmet training needs, indicating that using a DST in isolation would be unlikely to produce a sustained shift to SDM. Findings will shape iFraP intervention development to address unmet needs.

"They are saying it's high, but I think it's quite low": exploring cardiovascular disease risk communication in NHS health checks through video-stimulated recall interviews with patients - a qualitative study.

BACKGROUND: NHS Health Check (NHSHC) is a national cardiovascular disease (CVD) risk identification and management programme. However, evidence suggests a limited understanding of the most used metric to communicate CVD risk with patients (10-year percentage risk). This study used novel application of video-stimulated recall interviews to understand patient perceptions and understanding of CVD risk following an NHSHC that used one of two different CVD risk calculators. METHODS: Qualitative, semi-structured video-stimulated recall interviews were conducted with patients (n = 40) who had attended an NHSHC using either the QRISK2 10-year risk calculator (n = 19) or JBS3 lifetime CVD risk calculator (n = 21). Interviews were transcribed and analysed using reflexive thematic analysis. RESULTS: Analysis resulted in the development of four themes: variability in understanding, relief about personal risk, perceived changeability of CVD risk, and positive impact of visual displays. The first three themes were evident across the two patient groups, regardless of risk calculator; the latter related to JBS3 only. Patients felt relieved about their CVD risk, yet there were differences in understanding between calculators. Heart age within JBS3 prompted more accessible risk appraisal, yet mixed understanding was evident for both calculators. Event-free survival age also resulted in misunderstanding. QRISK2 patients tended to question the ability for CVD risk to change, while risk manipulation through JBS3 facilitated this understanding. Displaying information visually also appeared to enhance understanding. CONCLUSIONS: Effective communication of CVD risk within NHSHC remains challenging, and lifetime risk metrics still lead to mixed levels of understanding in patients. However, visual presentation of information, alongside risk manipulation during NHSHCs can help to increase understanding and prompt risk-reducing lifestyle changes. TRIAL REGISTRATION: ISRCTN10443908. Registered 7th February 2017.

"We have to change our mindsets": a qualitative study of barriers and facilitators in research collaboration across integrated care system organisations.

The introduction of Integrated Care Systems (ICS) in England aimed to increase joint planning and delivery of health and social care, and other services, to better meet the needs of local communities. There is an associated duty to undertake collaborative research across ICS partners to inform this new integrated approach, which might be challenging given that organisations span health, local authority, voluntary and community sector, and research. This study aimed to explore the appetite for collaborative Research and Innovation (R&I) across ICSs, potential barriers and solutions. This qualitative study involved semi-structured interviews with 24 stakeholders who held senior positions within organisations across two ICS areas (Staffordshire and Stoke-on-Trent; Shropshire, Telford and Wrekin). Interview transcripts were analysed using inductive and deductive analysis, first mapping to the Theoretical Domains Framework (TDF), then considering key influences on organisational behaviour in terms of Capability, Opportunity and Motivation from the COM-B Behaviour Change Wheel. There were fundamental limitations on organisational opportunities for collaborative R&I: a historical culture of competition (rather than collaboration), a lack of research culture and prioritisation, compounded by a challenging adverse economic environment. However, organisations were motivated to undertake collaborative R&I. They recognised the potential benefits (e.g., skill-sharing, staff development, attracting large studies and funding), the need for collaborative research that mirrors integrated care, and subsequent benefits for care recipients. Related barriers included negative experiences of collaboration, fear of failing and low confidence. Capability varied across organisations in terms of research skills and confidence, which reflected the range of partners (from local authorities to NHS Trusts, primary care, and academic institutions). These findings indicate a need to shift from a culture of competition to collaboration, and to help organisations across ICS to prioritise research, and share resources and skills to mitigate the limiting effects of a constrained economic environment. This could be further explored using a systems change approach, to develop the collaborative research efforts alongside the overarching move towards integrated care.

Variation in UK fracture liaison service consultation conduct and content before and during the COVID pandemic: results from the iFraP-D UK survey.

We conducted a survey of FLSs' consultation conduct and content which identified marked variation in whether FLS HCPs discussed osteoporosis medicine with patients. A review of service pro formas showed more content related to 'investigating' and 'intervening' than to 'informing'. We propose an expanded FLS typology and model FLS pro forma. PURPOSE: To investigate the nature of direct patient contact in fracture liaison service (FLS) delivery, examine the use and content of pro formas to guide information eliciting and sharing in FLS consultations, and determine service changes which were implemented as a result of the COVID-19 pandemic. METHODS: An electronic survey of UK FLS healthcare practitioners (HCPs) was distributed through clinical networks, social media, and other professional networks. Participants were asked to upload service pro formas used to guide consultation content. Documentary analysis findings were mapped to UK FLS clinical standards. RESULTS: Forty-seven HCPs responded, providing data on 39 UK FLSs, over half of all 74 FLSs reporting to FLS-database. Results showed variation in which HCP made clinical decisions, whether medicines were discussed with patients or not, and in prescribing practice. Services were variably affected by COVID, with most reporting a move to more remote consulting. The documentary analysis of eight service pro formas showed that these contained more content related to 'investigating' and 'intervening', with fewer pro formas prompting the clinician to offer information and support (e.g., about coping with pain). Based on our findings we propose an expanded FLS typology and have developed a model FLS pro forma. CONCLUSION: There is marked variation in the delivery of services and content of consultations in UK FLSs including discussion about osteoporosis medications. Clinical standards for FLSs should clarify the roles of primary and secondary HCPs and the importance of holistic approaches to patient care.

Quantitative content analysis of Freedom of Information requests examining the extent and variations of tools and training for conducting suicide risk assessments in NHS Trusts across England.

OBJECTIVES: Determining the risk for suicide is a difficult endeavour. Clinical guidance in the UK explicitly advises against using risk assessment tools and scales to determine suicide risk. Based on Freedom of Information (FoI) requests made to NHS Trusts in England, this study provides an overview of suicide risk assessment tools in use, training provided in how to use such assessments, and explores implementation of suicide risk assessment guidance in practice in English NHS Trusts. DESIGN: A cross-sectional survey of suicide risk assessment tools and training gathered via FoI requests and subjected to a content analysis. SETTING: FoI requests were submitted to NHS Trusts across England. RESULTS: A wide variety of suicide risk assessments tools were identified as being used in practice, with several trusts reported using more than one tool to determine suicide risk. Forty-one trusts reported using locally developed, unvalidated, tools to assess risk of suicide and 18 stated they do not use a tool. Ten trusts stated they do not train their staff in suicide risk assessment while 13 reported use of specific suicide risk assessment training. Sixty-two trusts stated they do not centrally record the number of assessments conducted or how many individuals are identified as at risk. Content analysis indicated the frequent wider assessment of risk not restricted to suicide risk. CONCLUSIONS: There is wide variation in suicide risk assessment tools being used in practice and some lack of specific training for healthcare staff in determining suicide risk. Few trusts routinely record the number of assessments being conducted or the number of individuals identified at high risk. Implementation of specific training is necessary for the suicide risk assessment process to identify patient needs and develop therapeutic engagement. Routinely recording how many assessments are conducted is a crucial step in improving suicide prevention.

The Contribution of Environmental Science to Mental Health Research: A Scoping Review.

Mental health is influenced by multiple complex and interacting genetic, psychological, social, and environmental factors. As such, developing state-of-the-art mental health knowledge requires collaboration across academic disciplines, including environmental science. To assess the current contribution of environmental science to this field, a scoping review of the literature on environmental influences on mental health (including conditions of cognitive development and decline) was conducted. The review protocol was developed in consultation with experts working across mental health and environmental science. The scoping review included 202 English-language papers, published between 2010 and 2020 (prior to the COVID-19 pandemic), on environmental themes that had not already been the subject of recent systematic reviews; 26 reviews on climate change, flooding, air pollution, and urban green space were additionally considered. Studies largely focused on populations in the USA, China, or Europe and involved limited environmental science input. Environmental science research methods are primarily focused on quantitative approaches utilising secondary datasets or field data. Mental health measurement was dominated by the use of self-report psychometric scales. Measures of environmental states or exposures were often lacking in specificity (e.g., limited to the presence or absence of an environmental state). Based on the scoping review findings and our synthesis of the recent reviews, a research agenda for environmental science's future contribution to mental health scholarship is set out. This includes recommendations to expand the geographical scope and broaden the representation of different environmental science areas, improve measurement of environmental exposure, prioritise experimental and longitudinal research designs, and giving greater consideration to variation between and within communities and the mediating pathways by which environment influences mental health. There is also considerable opportunity to increase interdisciplinarity within the field via the integration of conceptual models, the inclusion of mixed methods and qualitative approaches, as well as further consideration of the socio-political context and the environmental states that can help support good mental health. The findings were used to propose a conceptual model to parse contributions and connections between environmental science and mental health to inform future studies.

The Impact and Perception of England's Web-Based Heart Age Test of Cardiovascular Disease Risk: Mixed Methods Study.

BACKGROUND: It is well documented that individuals struggle to understand cardiovascular disease (CVD) percentage risk scores, which led to the development of heart age as a means of communicating risk. Developed for clinical use, its application in raising public awareness of heart health as part of a self-directed digital test has not been considered previously. OBJECTIVE: This study aimed to understand who accesses England's heart age test (HAT) and its effect on user perception, knowledge, and understanding of CVD risk; future behavior intentions; and potential engagement with primary care services. METHODS: There were 3 sources of data: routinely gathered data on all individuals accessing the HAT (February 2015 to June 2020); web-based survey, distributed between January 2021 and March 2021; and interviews with a subsample of survey respondents (February 2021 to March 2021). Data were used to describe the test user population and explore knowledge and understanding of CVD risk, confidence in interpreting and controlling CVD risk, and effect on future behavior intentions and potential engagement with primary care. Interviews were analyzed using reflexive thematic analysis. RESULTS: Between February 2015 and June 2020, the HAT was completed approximately 5 million times, with more completions by men (2,682,544/4,898,532, 54.76%), those aged between 50 to 59 years (1,334,195/4,898,532, 27.24%), those from White ethnic background (3,972,293/4,898,532, 81.09%), and those living in the least deprived 20% of areas (707,747/4,898,532, 14.45%). The study concluded with 819 survey responses and 33 semistructured interviews. Participants stated that they understood the meaning of high estimated heart age and self-reported at least some improvement in the understanding and confidence in understanding and controlling CVD risk. Negative emotional responses were provoked among users when estimated heart age did not equate to their previous risk perceptions. The limited information needed to complete it or the production of a result when physiological risk factor information was missing (ie, blood pressure and cholesterol level) led some users to question the credibility of the test. However, most participants who were interviewed mentioned that they would recommend or had already recommended the test to others, would use it again in the future, and would be more likely to take up the offer of a National Health Service Health Check and self-reported that they had made or intended to make changes to their health behavior or felt encouraged to continue to make changes to their health behavior. CONCLUSIONS: England's web-based HAT has engaged large number of people in their heart health. Improvements to England's HAT, noted in this paper, may enhance user satisfaction and prevent confusion. Future studies to understand the long-term benefit of the test on behavioral outcomes are warranted.

Restoration in mental health after visiting urban green spaces, who is most affected? Comparison between good/poor mental health in four European cities.

Several mechanisms have been proposed to explain the association between green space and health, and one of these is the restoration theory, based on the idea that it is possible to increase mental health and decrease stress visiting a natural environment. The aims of the present study were to understand what activities are most related to restoration and if these are the same for people with poorer and better mental health. A questionnaire was administered in four European cities and data about restoration outcomes, type of activity carried out in green spaces and mental health were collected and analyzed. A cross sectional design was used and total of 3134 respondents participated to the questionnaire. The restoration experience was measured with the restoration outcome score, and the mental health was evaluated with a subscale related to mental health of the Medical Outcome Short Form. Participants were divided in two groups according to mental health score. A multiple regression analysis was performed to investigate the association between mental health, type of activity and restoration. The cities showed a similar trend in the association between restoration and type of activity performed in green environment. People with poorer mental health seem to be more sensitive to the positive effect of visiting the green environment and restoration was more evident in these people than in those with better mental health. At the same time, the type of activity was less evident in people with better mental health, and they seemed to be less influenced by the visiting of green space. Green prescription is important for the entire population: people with poorer mental health could have important restorative effects and people with better mental health could continue to protect their well-being using green space.

How is suicide risk assessed in healthcare settings in the UK? A systematic scoping review.

A high proportion of people contact healthcare services in the 12 months prior to death by suicide. Identifying people at high-risk for suicide is therefore a key concern for healthcare services. Whilst there is extensive research on the validity and reliability of suicide risk assessment tools, there remains a lack of understanding of how suicide risk assessments are conducted by healthcare staff in practice. This scoping review examined the literature on how suicide risk assessments are conducted and experienced by healthcare practitioners, patients, carers, relatives, and friends of people who have died by suicide in the UK. Literature searches were conducted on key databases using a pre-defined search strategy pre-registered with the Open Science Framework and following the PRISMA extension for scoping reviews guidelines. Eligible for inclusion were original research, written in English, exploring how suicide risk is assessed in the UK, related to administering or undergoing risk assessment for suicide, key concepts relating to those experiences, or directly exploring the experiences of administering or undergoing assessment. Eighteen studies were included in the final sample. Information was charted including study setting and design, sampling strategy, sample characteristics, and findings. A narrative account of the literature is provided. There was considerable variation regarding how suicide risk assessments are conducted in practice. There was evidence of a lack of risk assessment training, low awareness of suicide prevention guidance, and a lack of evidence relating to patient perspectives of suicide risk assessments. Increased inclusion of patient perspectives of suicide risk assessment is needed to gain understanding of how the process can be improved. Limited time and difficulty in starting an open discussion about suicide with patients were noted as barriers to successful assessment. Implications for practice are discussed.

Using social media for patient and public involvement and engagement in health research: The process and impact of a closed Facebook group.

BACKGROUND: As part of a multifaceted approach to patient and public involvement and engagement (PPIE), alongside traditional methods, a closed Facebook group was established to facilitate PPIE feedback on various aspects of a project that used video-recording to examine risk communication in NHS Health Checks between June 2017 and July 2019. OBJECTIVE: To explore the process and impact of conducting PPIE through a closed Facebook group and to identify the associated benefits and challenges. METHODS: Supported by reflections and information from project meetings used to document how this engagement informed the project, we describe the creation and maintenance of the Facebook Group and how feedback from the group members was obtained. Facebook data were used to investigate levels and types of engagement in the closed Facebook group. We reflect on the challenges of using this method of engaging the public in health research. RESULTS: A total of 289 people joined the 'Risk Communication of Cardiovascular disease in NHS Health Checks' PPIE closed Facebook group. They provided feedback, which was used to inform aspects of the study, including participant-facing documents, recruitment, camera position and how the methodology being used (video-recorded Health Checks and follow-up interviews) would be received by the public. DISCUSSION: Using a closed Facebook group to facilitate PPIE offered a flexible approach for both researchers and participants, enabled a more inclusive method to PPIE (compared with traditional methods) and allowed rapid feedback. Challenges included maintaining the group, which was more labour intensive than anticipated and managing members' expectations. Suggestions for best practice include clear communication about the purpose of the group, assigning a group co-ordinator to be the main point of contact for the group, and a research team who can dedicate the time necessary to maintain the group. CONCLUSION: The use of a closed Facebook group can facilitate effective PPIE. Its flexibility can be beneficial for researchers, patients and public who wish to engage in the research process. Dedicated time for sustained group engagement is important. PATIENT OR PUBLIC CONTRIBUTION: Patient representatives were engaged with the development of the research described in this paper and a patient representative reviewed the manuscript.

Homelessness, hospital discharge and challenges in the context of limited resources: A qualitative study of stakeholders' views on how to improve practice in a deprived setting.

Hospital discharge for people experiencing homelessness is a perennial challenge. The Homeless Reduction Act 2017 (HRA) places new responsibilities on hospitals, but it remains unknown whether this has affected discharge practices. This qualitative study explores stakeholders' views on the challenges around hospital discharge for people experiencing homelessness, in the context of a deprived English city. Semi-structured interviews were conducted with 27 stakeholders. Participants were purposively recruited from local authority, third sector and the National Health Service. Interviews were transcribed and thematic analysis conducted. Analysis generated three main themes. First, a need for better planning and communication with the third sector, particularly around medication, prescriptions and information sharing. Second, the need to improve awareness and 'upskill' hospital staff to work more effectively with people experiencing homelessness, including understanding their needs, the wider support available and HRA requirements. Third, there were calls for (re)investment in a different approach to better support this population, based on outreach and flexibility. The need for improved partnership working and investment was emphasised. Whilst recognising the challenges faced by hospitals, especially within the context of funding cuts, this study highlights the need to recognise the third sector's contribution in supporting people experiencing homelessness in the community. Developing site-specific checklists for practice before discharge (and as early as possible) may help to ensure appropriate measures are in place. Improving legal literacy in the context of what an appropriate discharge is for people experiencing homelessness may help develop staff confidence to challenge the focus on 'quick' discharges.

Alcohol and physical activity screening in the National Health Service Health Check programme: Comparison of medical records and actual practice.

Objectives: National data for the National Health Service (NHS) Health Check programme (in England), collected by University College London, Public Health England and NHS Digital, found that physical activity and alcohol was recorded in just 64.5% and 38.3% of patient records, respectively. We examined video recorded NHS Health Checks from the RIsk COmmunication in NHS Health Check study (collected 2018-19) to explore alcohol and physical activity measurement, comparing recorded and actual activity. Study design: Observational study. Methods: Anonymised medical records and transcripts of 130 video-recorded NHS Health Checks from 12 general practices were compared to understand use of alcohol (Alcohol Use Disorders Identification Test, Alcohol Use Disorders Identification Test-Concise, Fast Alcohol Screening Test) and physical activity (General Practitioner Physical Activity Questionnaire) measures. Results: Findings showed considerable discrepancies between how alcohol measurement was recorded in the patient's medical record and how it was assessed in practice. Equally, practitioners completed or partially completed AUDIT in fewer than half of patients who were perceived to be eligible for further screening. There was more consistency in physical activity assessment. Omitted questions, related to physical activity, were largely around work-related physical activity. Conclusions: Overall, inconsistent use of recommended tools for screening alcohol and physical activity in NHS Health Check suggests that some practitioners do not follow recommended national guidance. Omission of certain questions led to missed opportunities for practitioners to discuss alcohol consumption, particularly with those who reported apparently excessive alcohol consumption (>14 units per week). Interviews with NHS Health Check practitioners may help to understand barriers to following recommended practice and identify areas for improvement. Classification: Restricted.

Understanding the Role of Nature Engagement in Supporting Health and Wellbeing during COVID-19.

The importance of natural environments in supporting health and wellbeing has been well evidenced in supporting positive mental and physical health outcomes, including during periods of crisis and stress. Given the disproportionate impacts of the COVID-19 pandemic have been greatest for those who are most vulnerable, understanding the role of natural environment and alternative forms of nature engagement in supporting health and wellbeing for vulnerable groups is important. This study explored how nature engagement supported health and wellbeing in those with a pre-existing health condition during the first UK lockdown. Semi-structured interviews were conducted with 17 adults with a pre-existing health condition and analysed using Interpretative Phenomenological Analysis (IPA). Four themes were identified: COVID-19 versus nature; Nature as an extension and replacement; Nature connectedness; and Therapeutic nature. The findings show the importance of nature in supporting health and wellbeing in those with a pre-existing health condition through engagement with private and public natural environments, micro-restorative opportunities, nature connection as an important pathway, and the therapeutic benefits of nature engagement. The present research extends the evidence-base beyond patterns of nature engagement to a deeper understanding of how those with existing health conditions perceived and interacted with nature in relation to their health and wellbeing during the first UK lockdown. Findings are discussed in relation to health supporting environments, micro-restorative opportunities, and policy implications.

Use of the Natural Outdoor Environment in Different Populations in Europe in Relation to Access: Implications for Policy.

This cross-cultural study explores the relationship of natural outdoor environment (NOE) use with NOE access. Most urban planning recommendations suggest optimal accessibility to be 300 m-500 m straight distance to spaces with vegetation of at least 1 hectare. Exploring this recommendation, we used data (n = 3947) from four European cities collected in the framework of the PHENOTYPE study: Barcelona (Spain), Doetinchem (The Netherlands), Kaunas (Lithuania) and Stoke-on-Trent (United Kingdom) to obtain residential access to NOE (straight or network distances, using 300 m and 150 m buffers, to NOE larger than 1 hectare or 0.5 hectare) and use of NOE (i.e., self-reported time spent in NOE). Poisson regression models were used to examine the associations between residential access and use of NOE. The models with the strongest association with time spent in NOE in the combined sample were for those living within 300 m straight line distance to either 0.5 ha or 1 ha NOE. Noting that the only indicator that was consistent across all individual cities was living with 150 m network buffer of NOE (of at least 1 ha), this warrants further exploration in reducing recommendations of 300 m straight-line distance to 150 m network distance to 1 ha of NOE for a general indicator for cities within Europe.

Influences of decisions to attend a national diabetes prevention programme from people living in a socioeconomically deprived area.

AIMS: To explore key influences of decisions in participants from a socioeconomically deprived area to attend the Healthier You: NHS Diabetes Prevention Programme (NHSDPP). The NHSDPP is a lifestyle behaviour change programme for adults with prediabetes living in England. METHODS: Semi-structured interviews were conducted with 35 participants who had attended the initial assessment, but not yet started the NHSDPP; 23 were classified as "attenders," 12 as "non-attenders" after they were interviewed based on whether they had attended the first NHSDPP session or not. Transcribed interviews were analysed using inductive thematic analysis. RESULTS: Seven themes were derived from the data. The results demonstrate how understanding type 2 diabetes, making lifestyle changes, comparing themselves with others, having support and certain self-perceptions can all affect individuals' motivation to attend a diabetes prevention programme. Accessibility and practicalities also influenced both motivation and attendance. CONCLUSIONS: This study identified a range of different influences on decisions to attend a diabetes prevention programme, which programme organisers and healthcare professionals should consider to maximise attendance. Initial communication from general practitioners (GPs) and initial assessments are key points where people's beliefs and understanding could be explored.

Cardiovascular disease risk communication in NHS Health Checks using QRISK®2 and JBS3 risk calculators: the RICO qualitative and quantitative study.

BACKGROUND: The NHS Health Check is a national cardiovascular disease prevention programme. There is a lack of evidence on how health checks are conducted, how cardiovascular disease risk is communicated to foster risk-reducing intentions or behaviour, and the impact on communication of using different cardiovascular disease risk calculators. OBJECTIVES: RIsk COmmunication in Health Check (RICO) study aimed to explore practitioner and patient understanding of cardiovascular disease risk, the associated advice or treatment offered by the practitioner, and the response of the patients in health checks supported by either the QRISK®2 or the JBS3 lifetime risk calculator. DESIGN: This was a qualitative study with quantitative process evaluation. SETTING: Twelve general practices in the West Midlands of England, stratified on deprivation of the local area (bottom 50% vs. top 50%), and with matched pairs randomly allocated to use QRISK2 or JBS3 during health checks. PARTICIPANTS: A total of 173 patients eligible for NHS Health Check and 15 practitioners. INTERVENTIONS: The health check was delivered using either the QRISK2 10-year risk calculator (usual practice) or the JBS3 lifetime risk calculator, with heart age, event-free survival age and risk score manipulation (intervention). RESULTS: Video-recorded health checks were analysed quantitatively (n = 173; JBS3, n = 100; QRISK2, n = 73) and qualitatively (n = 128; n = 64 per group), and video-stimulated recall interviews were undertaken with 40 patients and 15 practitioners, with 10 in-depth case studies. The duration of the health check varied (6.8-38 minutes), but most health checks were short (60% lasting < 20 minutes), with little cardiovascular disease risk discussion (average < 2 minutes). The use of JBS3 was associated with more cardiovascular disease risk discussion and fewer practitioner-dominated consultations than the use of QRISK2. Heart age and visual representations of risk, as used in JBS3, appeared to be better understood by patients than 10-year risk (QRISK2) and, as a result, the use of JBS3 was more likely to lead to discussion of risk factors and their management. Event-free survival age was not well understood by practitioners or patients. However, a lack of effective cardiovascular disease risk discussion in both groups increased the likelihood of a maladaptive coping response (i.e. no risk-reducing behaviour change). In both groups, practitioners often missed opportunities to check patient understanding and to tailor information on cardiovascular disease risk and its management during health checks, confirming apparent practitioner verbal dominance. LIMITATIONS: The main limitations were under-recruitment in some general practices and the resulting imbalance between groups. CONCLUSIONS: Communication of cardiovascular disease risk during health checks was brief, particularly when using QRISK2. Patient understanding of and responses to cardiovascular disease risk information were limited. Practitioners need to better engage patients in discussion of and action-planning for their cardiovascular disease risk to reduce misunderstandings. The use of heart age, visual representation of risk and risk score manipulation was generally seen to be a useful way of doing this. Future work could focus on more fundamental issues of practitioner training and time allocation within health check consultations. TRIAL REGISTRATION: Current Controlled Trials ISRCTN10443908. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 50. See the NIHR Journals Library website for further project information.

In England, NHS Health Checks aim to prevent cardiovascular diseases, such as heart attack and stroke. Health checks are conducted in primary care by a health-care assistant or practice nurse, who should measure the patient's risk of cardiovascular disease before advising them on how to reduce their risk. Cardiovascular disease risk is measured using a cardiovascular disease risk calculator. These calculators use various patient characteristics (e.g. age, sex, blood pressure and cholesterol) to predict how likely patients are to have a heart attack or stroke in the future. The aim of this study was to compare how practitioners explain cardiovascular disease risk to patients during health checks when using two risk calculators: QRISK^®2, which measures the risk of heart attack or stroke over the next 10 years (current usual practice), and JBS3 (a newer risk calculator), which gives this risk across the lifetime, is more interactive and has various visual displays of risk. We were interested to see if using JBS3 in health checks would lead to better practitioner and patient understanding of cardiovascular disease risk and result in patients intending to change, or actually changing, their behaviour to reduce their cardiovascular disease risk (compared with QRISK2). Health checks were video-recorded: 73 using QRISK2 and 100 using JBS3. Patients and members of the public advised on the study design, methods and management. Most consultations lasted < 20 minutes, with most time spent discussing the causes of cardiovascular disease. There was evidence that, compared with health checks using JBS3, those using QRISK2 led to less discussion of risk and practitioners speaking far more than patients. Sixty-four health checks from each risk calculator group were examined in depth. Opportunities to check whether or not patients understood the cardiovascular disease risk information and to encourage ways to lower risk were missed, making it less likely that patients would change their behaviour. The way that risk is presented by JBS3 seems to be more easily understood by patients than that presented by QRISK2. Nineteen patients in the QRISK2 group and 21 patients in the JBS3 group were interviewed 4 weeks after the consultation, and the practitioners were interviewed after they had completed all of their health checks. Patients found it difficult to understand and remember what they had been told about their cardiovascular disease risk during their health check. Their understanding and motivation to change behaviour appeared to be higher when they were visually shown how behaviour changes could lower their risk. Practitioners sometimes misunderstood risk and used patients' reactions to judge whether or not they understood, rather than asking them. Our findings should help to improve how cardiovascular disease risk is communicated during health checks in future, through simple changes to the consultations (e.g. using aspects of JBS3) and by highlighting a gap in practitioners' training.

Improving uptake of Fracture Prevention drug treatments: a protocol for Development of a consultation intervention (iFraP-D).

INTRODUCTION: Prevention of fragility fractures, a source of significant economic and personal burden, is hindered by poor uptake of fracture prevention medicines. Enhancing communication of scientific evidence and elicitation of patient medication-related beliefs has the potential to increase patient commitment to treatment. The Improving uptake of Fracture Prevention drug treatments (iFraP) programme aims to develop and evaluate a theoretically informed, complex intervention consisting of a computerised web-based decision support tool, training package and information resources, to facilitate informed decision-making about fracture prevention treatment, with a long-term aim of improving informed treatment adherence. This protocol focuses on the iFraP Development (iFraP-D) work. METHODS AND ANALYSIS: The approach to iFraP-D is informed by the Medical Research Council complex intervention development and evaluation framework and the three-step implementation of change model. The context for the study is UK fracture liaison services (FLS), which enact secondary fracture prevention. An evidence synthesis of clinical guidelines and Delphi exercise will be conducted to identify content for the intervention. Focus groups with patients, FLS clinicians and general practitioners and a usual care survey will facilitate understanding of current practice, and investigate barriers and facilitators to change. Design of the iFraP intervention will be informed by decision aid development standards and theories of implementation, behaviour change, acceptability and medicines adherence. The principles of co-design will underpin all elements of the study through a dedicated iFraP community of practice including key stakeholders and patient advisory groups. In-practice testing of the prototype intervention will inform revisions ready for further testing in a subsequent pilot and feasibility randomised trial. ETHICS AND DISSEMINATION: Ethical approval was obtained from North West-Greater Manchester West Research Ethics Committee (19/NW/0559). Dissemination and knowledge mobilisation will be facilitated through national bodies and networks, publications and presentations. TRIAL REGISTRATION NUMBER: researchregistry5041.

Cardiovascular disease risk communication in NHS Health Checks: a qualitative video-stimulated recall interview study with practitioners.

BACKGROUND: NHS Health Check (NHSHC) is a national programme to identify and manage cardiovascular disease (CVD) risk. Practitioners delivering the programme should be competent in discussing CVD risk, but there is evidence of limited understanding of the recommended 10-year percentage CVD risk scores. Lifetime CVD risk calculators might improve understanding and communication of risk. AIM: To explore practitioner understanding, perceptions, and experiences of CVD risk communication in NHSHCs when using two different CVD risk calculators. DESIGN & SETTING: Qualitative video-stimulated recall (VSR) study with NHSHC practitioners in the West Midlands. METHOD: VSR interviews were conducted with practitioners who delivered NHSHCs using either the QRISK2 10-year risk calculator (n = 7) or JBS3 lifetime CVD risk calculator (n = 8). Data were analysed using reflexive thematic analysis. RESULTS: In total, nine healthcare assistants (HCAs) and six general practice nurses (GPNs) were interviewed. There was limited understanding and confidence of 10-year risk, which was used to guide clinical decisions through determining low-, medium-, or high-risk thresholds, rather than as a risk communication tool. Potential benefits of some JBS3 functions were evident, particularly heart age, risk manipulation, and visual presentation of risk. CONCLUSION: There is a gap between the expectation and reality of practitioners' understanding, competencies, and training in CVD risk communication for NHSHCs. Practitioners would welcome heart age and risk manipulation functions of JBS3 to promote patient understanding of CVD risk, but there is a more fundamental need for practitioner training in CVD risk communication.

Does surrounding greenness moderate the relationship between apparent temperature and physical activity? Findings from the PHENOTYPE project.

BACKGROUND: Physical activity can be affected by both meteorological conditions and surrounding greenness, but few studies have evaluated the effects of these environmental factors on physical activity simultaneously. This multi-city comparative study aimed to assess the synergetic effects of apparent temperature and surrounding greenness on physical activity in four European cities. Specifically, we aimed to identify an interaction between surrounding greenness and apparent temperature in the effects on physical activity. METHODS: Data were collected from 352 adult residents of Barcelona (Spain), Stoke-on-Trent (United Kingdom), Doetinchem (The Netherlands), and Kaunas (Lithuania) as part of the PHENOTYPE study. Participants wore a smartphone for seven consecutive days between May-December 2013 and provided additional sociodemographic survey data. Hourly average physical activity (Metabolic Equivalent of Task (MET)) and surrounding greenness (NDVI) were derived from the Calfit mobile application collecting accelerometer and location data. Hourly apparent temperature was calculated from temperature and relative humidity, which were obtained from local meteorological stations along with other meteorological covariates (rainfall, windspeed, and sky darkness). We assessed the interaction effects of apparent temperature and surrounding greenness on hourly physical activity for each city using linear mixed models, while adjusting for meteorological, demographic, and time-related variables. RESULTS: We found significant interactions between apparent temperature and surrounding greenness on hourly physical activity in three of four cities, aside from the coastal city of Barcelona. Significant quadratic effects of apparent temperature were found in the highest level of surrounding greenness for Stoke-on-Trent and Doetinchem, with 4% decrease in median MET observed for a 10°C departure from optimal temperature (15.2°C and 14.6°C, respectively). Significant linear effects were found for higher levels of surrounding greenness in Kaunas, whereby an increase of 10°C was associated with ∼4% increase in median MET. CONCLUSION: Apparent temperature and surrounding greenness interacted in the effect on hourly physical activity across three of four European cities, with varying effect between cities. While quadratic effects of temperature suggest diminishing levels of physical activity in the highest greenness levels in cities of temperate climates, the variation in surrounding greenness between cities could be further explored, particularly by looking at indoor-outdoor locations. The study findings support the need for evidence-based physical activity promotion and urban design.

Developing a model Fracture Liaison Service consultation with patients, carers and clinicians: a Delphi survey to inform content of the iFraP complex consultation intervention.

Fracture Liaison Services are recommended to deliver best practice in secondary fracture prevention. This modified Delphi survey, as part of the iFraP (Improving uptake of Fracture Prevention drug Treatments) study, provides consensus regarding tasks for clinicians in a model Fracture Liaison Service consultation. PURPOSE: The clinical consultation is of pivotal importance in addressing barriers to treatment adherence. The aim of this study was to agree to the content of the 'model Fracture Liaison Service (FLS) consultation' within the iFraP (Improving uptake of Fracture Prevention drug Treatments) study. METHODS: A Delphi survey was co-designed with patients and clinical stakeholders using an evidence synthesis of current guidelines and content from frameworks and theories of shared decision-making, communication and medicine adherence. Patients with osteoporosis and/or fragility fractures, their carers, FLS clinicians and osteoporosis specialists were sent three rounds of the Delphi survey. Participants were presented with potential consultation content and asked to rate their perception of the importance of each statement on a 5-point Likert scale and to suggest new statements (Round 1). Lowest rated statements were removed or amended after Rounds 1 and 2. In Round 3, participants were asked whether each statement was 'essential' and percentage agreement calculated; the study team subsequently determined the threshold for essential content. RESULTS: Seventy-two, 49 and 52 patients, carers and clinicians responded to Rounds 1, 2 and 3 respectively. One hundred twenty-two statements were considered. By Round 3, consensus was reached, with 81 statements deemed essential within FLS consultations, relating to greeting/introductions; gathering information; considering therapeutic options; eliciting patient perceptions; establishing shared decision-making preferences; sharing information about osteoporosis and treatments; checking understanding/summarising; and signposting next steps. CONCLUSIONS: This Delphi consensus exercise has summarised for the first time patient/carer and clinician consensus regarding clearly defined tasks for clinicians in a model FLS consultation.