"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.

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.

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.

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.

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.

Quantitative examination of video-recorded NHS Health Checks: comparison of the use of QRISK2 versus JBS3 cardiovascular risk calculators.

OBJECTIVES: Quantitatively examine the content of National Health Service Health Check (NHSHC), patient-practitioner communication balance and differences when using QRISK2 versus JBS3 cardiovascular disease (CVD) risk calculators. DESIGN: RIsk COmmunication in NHSHC was a qualitative study with quantitative process evaluation, comparing NHSHC using QRISK2 or JBS3. We present data from the quantitative process evaluation. SETTING AND PARTICIPANTS: Twelve general practices in the West Midlands (England) conducted NHSHC using JBS3 or QRISK2 (6/group). Patients were eligible for NHSHC based on national criteria (aged 40-74, no existing cardiovascular-related diagnoses, not taking statins). Recruitment was stratified by patients' age, gender and ethnicity. METHODS: Video recordings of NHSHC were coded, second-by-second, to quantify who was speaking and what was being discussed. Outcomes included consultation duration, practitioner verbal dominance (ratio of practitioner:patient speaking time (pr:pt ratio)) and proportion of time discussing CVD risk, risk factors and risk management. RESULTS: 173 video-recorded NHSHC were analysed (73 QRISK, 100 JBS3). The sample was 51% women, 83% white British, with approximately equal proportions across age groups. NHSHC duration varied greatly (6.8-38.0 min). Most (60%) lasted less than 20 min. On average, CVD risk was discussed for less than 2 min (9.06%±4.30% of consultation time). There were indications that, compared with NHSHC using JBS3, those with QRISK2 involved less CVD risk discussion (JBS3 M=10.24%, CI: 8.01-12.48 vs QRISK2 M=7.44%, CI: 5.29-9.58) and were more verbally dominated by practitioners (pr:pt ratio JBS3 M=3.21%, CI: 2.44-3.97 vs QRISK2=2.35%, CI: 1.89-2.81). The largest proportion of NHSHC time was spent discussing causal risk factors (M=37.54%, CI: 32.92-42.17). CONCLUSIONS: There was wide variation in NHSHC duration. Many were short and practitioner-dominated, with little time discussing CVD risk. JBS3 appears to extend CVD risk discussion and patient contribution. Qualitative examination of how it is used is necessary to fully understand the potential benefits of these differences. TRIAL REGISTRATION NUMBER: ISRCTN10443908.

Momentary mood response to natural outdoor environments in four European cities.

Exposure to natural outdoor environments (NOE) has been shown in population-level studies to reduce anxiety and psychological distress. This study investigated how exposure to one's everyday natural outdoor environments over one week influenced mood among residents of four European cities including Barcelona (Spain), Stoke-on-Trent (United Kingdom), Doetinchem (The Netherlands) and Kaunas (Lithuania). Participants (n = 368) wore a smartphone equipped with software applications to track location and mood (using mobile ecological momentary assessment (EMA) software), for seven consecutive days. We estimated random-effects ordered logistic regression models to examine the association between mood (positive and negative affect), and exposure to green space, represented by two binary variables indicating exposure versus no exposure to NOE using GPS tracking and satellite and aerial imagery, 10 and 30 min prior to participants' completing the EMA. Models were adjusted for home city, day of the week, hour of the day, EMA survey type, residential NOE exposure, and sex, age, education level, mental health status and neighbourhood socioeconomic status. In addition, we tested for heterogeneity of effect by city, sex, age, residential NOE exposure and mental health status. Within 10 min of NOE exposure, compared to non-exposure, we found that overall there was a positive relationship with positive affect (OR: 1.39, 95% CI: 1.06, 1.81) of EMA surveys, and non-significant negative association with negative affect (OR: 0.80, 95% CI: 0.58, 1.10). When stratifying, associations were consistently found for Stoke-on-Trent inhabitants and men, while findings by age group were inconsistent. Weaker and less consistent associations were found for exposure 30 min prior to EMA. Our findings support increasing evidence of psychological and mental health benefits of exposure to natural outdoor environments, especially among urban populations such as those included in our study.

Dog ownership, the natural outdoor environment and health: a cross-sectional study.

OBJECTIVES: Dog owners walking their dog in natural outdoor environments (NOE) may benefit from the physical activity facilitated by dog walking and from time spent in nature. However, it is unclear whether dog owners receive additional health benefits associated with having access to NOE above the physical activity benefit of walking with their dog. We investigated associations between dog ownership, walking, time spent in NOE and health and whether these associations differed among those with good and poor access to NOE and those living in green and less green areas. DESIGN: Cross-sectional study. SETTING: The Positive Health Effects of the Natural Outdoor Environment in Typical Populations in Different Regions in Europe project. PARTICIPANTS: n=3586 adults from Barcelona (Spain), Doetinchem (the Netherlands), Kaunas (Lithuania) and Stoke-on-Trent (UK). DATA COLLECTION AND ANALYSIS: We calculated access to NOE with land maps and residential surrounding greenness with satellite data. Leisure time walking, time spent in NOE and general and mental health status were measured using validated questionnaires. Associations were estimated using multilevel analysis with a random intercept defined at the neighbourhood level. RESULTS: Dog ownership was associated with higher rates of leisure time walking and time spending in NOE (OR 2.17, 95% CI 1.86 to 2.54 and 2.37, 95% CI 2.02 to 2.79, respectively). These associations were stronger in those living within 300 m of a NOE and in greener areas. No consistent associations were found between dog ownership and perceived general or mental health status. CONCLUSIONS: Compared with non-dog owners, dog owners walked more and spent more time in NOE, especially those living within 300 m of a NOE and in greener areas. The health implications of these relationships should be further investigated. In a largely physically inactive society, dog walking in NOE may be a simple way of promoting physical activity and health.

Randomised controlled trial comparing uptake of NHS Health Check in response to standard letters, risk-personalised letters and telephone invitations.

BACKGROUND: NHS Health Check is a primary prevention programme offering cardiovascular disease (CVD) risk assessment to adults in England aged 40-74. Uptake remains a challenge and invitation method is a strong predictor of uptake. There is evidence of low uptake when using invitation letters. Telephone invitations might increase uptake, but are not widely used. We explored the potential to improve uptake through personalising letters to patient's CVD risk, and to compare this with generic letters and telephone invitations. METHODS: HEalth Check TRial (HECTR) was a three-arm randomised controlled trial in nine general practices in Staffordshire (UK). Eligible patients were randomised to be invited to a NHS Health Check using one of three methods: standard letter (control); telephone invitation; letter personalised to the patient's CVD risk. The primary outcome was attendance/non-attendance. Data were collected on a range of patient- and practice-level factors (e.g., patient socio-demographics, CVD risk, practice size, Health Checks outside usual working hours). Multi-level logistic regression estimated the marginal effects to explore whether invitation method predicted attendance. Invitation costs were collated from practices to estimate cost benefit. RESULTS: In total, 4614 patients were included in analysis (mean age 50.2 ± 8.0 yr.; 52.4% female). Compared with patients invited by standard letter (30.9%), uptake was significantly higher in those invited by telephone (47.6%, P < .001), but not personalised letter (31.3%, p = .812). In multi-level analysis, compared with the standard letter arm, likelihood of attendance was 18 percentage points higher in the telephone arm and 4 percentage points higher in the personalised letter arm. The effect of telephone calls appeared strongest in patients who were younger and had lower CVD risk. We estimated per 1000 patients invited, risk-personalised letters could result in 40 additional attended Health Checks (at no extra cost) and telephone invitations could result in 180 additional Health Checks at an additional cost of £240. CONCLUSIONS: Telephone invitations should be advocated to address the substantial deficit between current and required levels of NHS uptake, and could be targeted at younger and lower CVD risk adults. Risk-personalised letters should be explored further in a larger sample of high risk individuals. TRIAL REGISTRATION: Registration number: ISRCTN15840751 date of registration: 24/10/2017.

A qualitative study of cardiovascular disease risk communication in NHS Health Check using different risk calculators: protocol for the RIsk COmmunication in NHS Health Check (RICO) study.

BACKGROUND: NHS Health Check is a national cardiovascular disease (CVD) risk assessment programme for 40-74 year olds in England, in which practitioners should assess and communicate CVD risk, supported by appropriate risk-management advice and goal-setting. This requires effective communication, to equip patients with knowledge and intention to act. Currently, the QRISK®2 10-year CVD risk score is most common way in which CVD risk is estimated. Newer tools, such as JBS3, allow manipulation of risk factors and can demonstrate the impact of positive actions. However, the use, and relative value, of these tools within CVD risk communication is unknown. We will explore practitioner and patient CVD risk perceptions when using QRISK®2 or JBS3, the associated advice or treatment offered by the practitioner, and patients' responses. METHODS: RIsk COmmunication in NHS Health Check (RICO) is a qualitative study with quantitative process evaluation. Twelve general practices in the West Midlands of England will be randomised to one of two groups: usual practice, in which practitioners use QRISK®2 to assess and communicate CVD risk; intervention, in which practitioners use JBS3. Twenty Health Checks per practice will be video-recorded (n = 240, 120 per group), with patients stratified by age, gender and ethnicity. Post-Health Check, video-stimulated recall (VSR) interviews will be conducted with 48 patients (n = 24 per group) and all practitioners (n = 12-18), using video excerpts to enhance participant recall/reflection. Patient medical record reviews will detect health-protective actions in the first 12-weeks following a Health Check (e.g., lifestyle referrals, statin prescription). Risk communication, patient response and intentions for health-protective behaviours in each group will be explored through thematic analysis of video-recorded Health Checks (using Protection Motivation Theory as a framework) and VSR interviews. Process evaluation will include between-group comparisons of quantitatively coded Health Check content and post-Health Check patient outcomes. Finally, 10 patients with the most positive intentions or behaviours will be selected for case study analysis (using all data sources). DISCUSSION: This study will produce novel insights about the utility of QRISK®2 and JBS3 to promote patient and practitioner understanding and perception of CVD risk and associated implications for patient intentions with respect to health-protective behaviours (and underlying mechanisms). Recommendations for practice will be developed. TRIAL REGISTRATION: ISRCTN ISRCTN10443908 . Registered 7th February 2017.

Availability, use of, and satisfaction with green space, and children's mental wellbeing at age 4 years in a multicultural, deprived, urban area: results from the Born in Bradford cohort study.

BACKGROUND: It is unknown whether the quantity or quality of green space is more important for mental wellbeing. We aimed to explore associations between availability of, satisfaction with, and use of green space and mental wellbeing among children aged 4 years in a multi-ethnic sample. METHODS: We did a 4-year follow-up assessment of participants in the Born in Bradford longitudinal cohort study, which recruited children and mothers at the city's main maternity unit from 2007 to 2011. The primary outcome was parent-reported mental wellbeing for children aged 4 years, assessed with the standardised Strengths and Difficulties Questionnaire. Total, internalising, and externalising behavioural difficulties and prosocial behaviour scales were computed (with higher scores indicating greater difficulties or more prosocial behaviour). Residential green space around participants' home addresses and distance to major green spaces were computed with the normalised difference vegetation index (NDVI). A subsample of participants completed additional questionnaires on measures of satisfaction with, and use of, local green spaces. Multiple regressions examined associations between green space and children's mental wellbeing and explored moderation by ethnicity (white British vs south Asian) and socioeconomic status. FINDINGS: Between Oct 1, 2012, and June 30, 2015, 2594 mothers attended a follow-up appointment during which they completed a detailed questionnaire assessing the health of their child. 1519 (58%) participants were of south Asian origin, 740 (29%) of white British origin, and 333 (13%) of another ethnicity. Data on ethnicity were missing for two participants. 832 (32%) of 2594 participants completed additional questionnaires. Ethnicity moderated associations between residential green space and mental wellbeing (p<0·05 for total and internalising difficulties). After adjusting for all relevant variables, more green space was associated with fewer internalising behavioural difficulties (mean NDVI 100 m: ß -2·35 [95% CI -4·20 to -0·50]; 300 m: -3·15 [-5·18 to -1·13]; 500 m: -2·85 [-4·91 to -0·80]) and with fewer total behavioural difficulties (100 m: -4·27 [-7·65 to -0·90]; 300 m: -5·22 [-8·91 to -1·54]; 500 m: -4·82 [-8·57 to -1·07]) only for south Asian children across all three buffer zones. In the subsample of participants, the effect of NDVI on wellbeing was rendered non-significant after controlling for satisfaction with, and use of, green space. Among south Asian children, satisfaction with green space was significantly associated with fewer total behavioural difficulties across all three buffer zones (ß -0·59 [95% CI -1·11 to -0·07]), fewer internalising behavioural difficulties within 100 m (-0·28 [95% CI -0·56 to -0·003]) and 300 m buffer zones (-0·28 [-0·56 to -0·002]), and greater prosocial behaviour across all three buffer zones (0·20 [0·02 to 0·38]); no such associations were observed among white British children. INTERPRETATION: Positive effects of green space on wellbeing differ by ethnicity. Satisfaction with the quality of green space appears to be a more important predictor of wellbeing than does quantity of green space. Public health professionals and urban planners need to focus on both quality and quantity of urban green spaces to promote health, particularly among ethnic minority groups. FUNDING: European Community's Seventh Framework Programme.

Living Close to Natural Outdoor Environments in Four European Cities: Adults' Contact with the Environments and Physical Activity.

This study investigated whether residential availability of natural outdoor environments (NOE) was associated with contact with NOE, overall physical activity and physical activity in NOE, in four different European cities using objective measures. A nested cross-sectional study was conducted in Barcelona (Spain); Stoke-on-Trent (United Kingdom); Doetinchem (The Netherlands); and Kaunas (Lithuania). Smartphones were used to collect information on the location and physical activity (overall and NOE) of around 100 residents of each city over seven days. We used Geographic Information Systems (GIS) to determine residential NOE availability (presence/absence of NOE within 300 m buffer from residence), contact with NOE (time spent in NOE), overall PA (total physical activity), NOE PA (total physical activity in NOE). Potential effect modifiers were investigated. Participants spent around 40 min in NOE and 80 min doing overall PA daily, of which 11% was in NOE. Having residential NOE availability was consistently linked with higher NOE contact during weekdays, but not to overall PA. Having residential NOE availability was related to NOE PA, especially for our Barcelona participants, people that lived in a city with low NOE availability.

Natural outdoor environments and mental health: Stress as a possible mechanism.

INTRODUCTION: Better mental health has been associated with exposure to natural outdoor environments (NOE). However, comprehensive studies including several indicators of exposure and outcomes, potential effect modifiers and mediators are scarce. OBJECTIVES: We used novel, objective measures to explore the relationships between exposure to NOE (i.e. residential availability and contact) and different indicators of mental health, and possible modifiers and mediators. METHODS: A nested cross-sectional study was conducted in: Barcelona, Spain; Stoke-on-Trent, United Kingdom; Doetinchem, Netherlands; Kaunas, Lithuania. Participants' exposure to NOE (including both surrounding greenness and green and/or blue spaces) was measured in terms of (a) amount in their residential environment (using Geographical Information Systems) and (b) their contact with NOE (using smartphone data collected over seven days). Self-reported information was collected for mental health (psychological wellbeing, sleep quality, vitality, and somatisation), and potential effect modifiers (gender, age, education level, and city) and mediators (perceived stress and social contacts), with additional objective NOE physical activity (potential mediator) derived from smartphone accelerometers. RESULTS: Analysis of data from 406 participants showed no statistically significant associations linking mental health and residential NOE exposure. However, NOE contact, especially surrounding greenness, was statistically significantly tied to better mental health. There were indications that these relationships were stronger for males, younger people, low-medium educated, and Doetinchem residents. Perceived stress was a mediator of most associations, and physical activity and social contacts were not. CONCLUSIONS: Our findings indicate that contact with NOE benefits mental health. Our results also suggest that having contact with NOE that can facilitate stress reduction could be particularly beneficial.

Does the Health Impact of Exposure to Neighbourhood Green Space Differ between Population Groups? An Explorative Study in Four European Cities.

It has been suggested that certain residents, such as those with a low socioeconomic status, the elderly, and women, may benefit more from the presence of neighbourhood green space than others. We tested this hypothesis for age, gender, educational level, and employment status in four European cities. Data were collected in Barcelona (Spain; n = 1002), Kaunas (Lithuania; n = 989), Doetinchem (The Netherlands; n = 847), and Stoke-on-Trent (UK; n = 933) as part of the EU-funded PHENOTYPE project. Surveys were used to measure mental and general health, individual characteristics, and perceived neighbourhood green space. Additionally, we used audit data about neighbourhood green space. In Barcelona, there were positive associations between neighbourhood green space and general health among low-educated residents. In the other cities and for the other population groups, there was little evidence that the association between health and neighbourhood green space differed between population groups. Overall, our study does not support the assumption that the elderly, women, and residents who are not employed full-time benefit more from neighbourhood green space than others. Only in the highly urbanised city of Barcelona did the low-educated group benefit from neighbourhood green spaces. Perhaps neighbourhood green spaces are more important for the health of low-educated residents in particularly highly urbanised areas.

The effect of randomised exposure to different types of natural outdoor environments compared to exposure to an urban environment on people with indications of psychological distress in Catalonia.

INTRODUCTION: Experimental studies have reported associations between short-term exposure to natural outdoor environments (NOE) and health benefits. However, they lack insight into mechanisms, often have low external and ecological validity, and have rarely focused on people with some psycho-physiological affection. The aim of this study was to use a randomized, case-crossover design to investigate: (i) the effects of unconstrained exposure to real natural and urban environments on psycho-physiological indicators of people with indications of psychological distress, (ii) the possible differential effects of 30 and 30+180 minutes exposures, and (iii) the possible mechanisms explaining these effects. MATERIAL AND METHODS: People (n = 26) with indications of psychological distress were exposed to green (Collserola Natural Park), blue (Castelldefels beach) and urban (Eixample neighbourhood) environments in Catalonia. They were exposed to all environments in groups for a period of 30+180 minutes between October 2013 and January 2014. During the exposure period, participants were instructed to do what they would usually do in that environment. Before, during (at 30 and 30+180 minutes) and after each exposure, several psycho-physiological measures were taken: mood (measured as Total Mood Disturbance, TMD), attention capacity (measured as backwards digit-span task), stress levels (measures as salivary cortisol), systolic and diastolic blood pressure, heart rate, autonomous nervous system (assessed as heart rate variability and the indicators: low frequency power (LF), high frequency power (HF), ratio between LF and HF (LF:HF), and coefficients of component variance of LF, HF, and LF:HF). We also measured several potential mediators: air pollution, noise, physical activity, social interactions, and self-perceived restoration experience. RESULTS: When compared with responses to urban environment, we found statistically significantly lower TMD [-4.78 (-7.77, -1.79) points difference], and salivary cortisol [-0.21 (-0.34, -0.08) log nmol/L] in the green exposure environment, and statistically significantly lower TMD [-4.53 (-7.57, -1.49) points difference], and statistically significant favourable changes in heart rate variability indicators (specifically LF:HF and CCV-LF:HF with around -0.20 points of difference of the indicators) in the blue exposure environment. Physical activity and self-perceived restoration experience partially mediated the associations between NOE and TMD. Physical activity and air pollution partially mediated the associations between NOE and heart rate variability. DISCUSSION AND CONCLUSIONS: This study extends the existing evidence on the benefits of NOE for people's health. It also suggests NOE potential as a preventive medicine, specifically focusing on people with indications of psychological distress. TRIAL REGISTRATION: Clinicaltrials.gov NCT02624921.