Title: Qualitative video-stimulated recall study to explore cardiovascular disease risk communication in NHS Health checks using QRISK2 10-year risk and JBS3 lifetime risk calculators
Funder: Department of Health and Social Care

Abstract: DESIGN Qualitative study using Video Stimulated Recall (VSR) for in-depth analysis of risk communication in NHS Health Checks SETTING General practice (West Mids) TARGET POPULATION Patients - adults (40-74 yr), eligible for NHS Health Check Clinicians - staff delivering NHS Health Checks (e.g., practice nurse) INCLUSION CRITERIA Practices - run NHS Health Checks using QRISK2 in the consultation; already or willing to deliver Health Checks in specific clinics to facilitate data collection Patients - NHS Health Check criteria (1) HEALTH TECHNOLOGY QRISK2 and JBS3 risk calculators SAMPLE SIZE • 12 practices sampled for diversity in terms of area socio-demographics, size and ethnic profile of the practice population, to ensure generalisability through studying a range of practices. Assigned randomly to QRISK2 or JBS3 • 240 consultations video-recorded to obtain 144 (72 per group) for qualitative analysis (all 240 for quantitative analysis) • 48 patient VSR interviews, 24 per group (sampled across CVD risk groups) • 18-24 clinician VSR interviews (1-2 per practice) Comparable size to studies of recorded consultations (2) and VSR (3); will provide range of patients; allows for dropout (~50%) and exclusions where CVD risk is not discussed CVD risk (4). PATHWAYS Current: Usual NHS Health Check pathway Study: Current pathway with half of practices using JBS3 following brief training OUTCOMES Detailed insight into: 1. How CVD risk is discussed 2. Patient/clinician perceptions and understanding of CVD risk 3. Advice/treatment discussed in consultations, and patient intentions 4. 1-3 when using QRISK2 or JBS3 5. Underlying mechanisms. PILOT STUDY VSR processes will be developed and tested (e.g., camera position, interview questions/prompts) through PPI. ANALYSIS Video-recorded consultations and audio-recorded VSR interviews will be analysed using thematic analysis (TA (5)) using constant comparison: • deductive for analysis of Health check consultations • inductive for analysis of VSR interviews (codes/themes generated from data). All Health Check consultations will also be quantitatively analysed (e.g., number of CVD risk mentions; time discussing risk) Most analysis will be between groups (to compare QRISK2 and JBS3). Case study analysis will be used in a subsample, where a case is a matched consultation, patient interview, and clinician interview (and quantitative data), to further explore mechanisms by which intentions for health-protective behaviour are elicited. PROJECT TIMETABLE • Practice recruitment/training (month 1-3) • Ethics (month 1-6) • Qualitative data collection (month 6-20) • Patient record review (month 6-22) • Qualitative and quantitative data analysis, data triangulation (month 11-25) • Reporting, dissemination (month 26-30). EXPERTISE • Associate Professor, PI of qualitative/quantitative Health Check research and ongoing RCT (CG) • Senior qualitative researchers in primary care health promotion (DC, NE) • GPs with clinical and behavioural expertise (RC, EC) • Health psychology and qualitative research methods (SG) • Statistical expertise (DCC) • Expert advisors in VSR (ZP) and national/policy implications (MK). A Project Advisory Board (or Steering Group) will be chaired by a senior academic with relevant expertise, with academic, clinical and lay members. We will not involve a CTU as this is not a clinical trial.

Lay abstract: Cardiovascular disease (CVD) is a general term for conditions of the heart and blood vessels, including heart disease and stroke. CVD accounts for over a quarter of all UK deaths. Yet the risk of developing CVD can be reduced through, for example, being more active, stopping smoking or some medications. In 2009 the NHS Health Check programme was launched to reduce CVD in England. This national programme invites people to have their CVD risk measured in general practice, usually by a practice nurse or health care worker. The clinician should then discuss the patients’ CVD risk with them and, if required, advise them how to reduce it. Much of the value of Health Checks is likely to depend on how well clinicians understand CVD risk and if they are able explain it to patients in a way that encourages them to follow advice to reduce risk. This research will explore how clinicians use two different ways of measuring CVD risk in Health Checks: • QRISK2 is a percentage risk of developing CVD in the next 10 years, which is currently used in most general practices. There is evidence that clinicians and patients often do not understand this kind of percentage score and have unanswered questions about their own CVD risk after a Health Check. • JBS3 Risk Calculator is a new tool that measures ‘lifetime’ risk. It has different displays and functions to make it easier for clinicians to understand and explain why and how patients should reduce CVD risk. We aim to use video-recording and interviews to get an in-depth understanding of discussions around CVD risk during Health Checks when using each risk scoring method, how patients respond, and how this might result in patient behaviour change. We will do this in 12 general practices in the West Midlands, half using QRISK2 and half using JBS3. We will video-record Health Checks consultations in each practice to give an accurate record and then use videos in follow-up interviews. To reach conclusions about use of QRISK2 and JBS3 in Health Checks we will carry out: • Analysis of video-recorded Health Checks, looking for sections that relate to CVD risk, such as how often CVD risk was mentioned, if risk scores were used, time spent discussing risk • More detailed analysis of clinician-patient interactions and responses during Health Checks, considering both verbal and non-verbal (i.e., body language) communication • Interviews with patients and clinicians after Health Checks, using video clips to help them to reflect on their thoughts and feelings • A review of patient records to see what (if any) actions took place after the Health Check (e.g., referrals, medication). Patient and public involvement is central to projects like this. We have discussed this project at two Patient Participation Group meetings to ensure it is considered important and acceptable by those we hope will benefit from the work. Putting patients at the core of this project, we will continue to consult with patients groups, have a patient working with us directly, and include 2 more on the steering group. At the end of the project we will write a full report of findings, publish the results in academic health journals, present at conferences and present findings to Public Health England, who commission the Health Check programme. All patients and clinicians who take part will receive information on findings. The project lay member will help to communicate findings so results are shared as widely as possible.

Research activity codes: 7.3 MANAGEMENT AND DECISION MAKING
Health categories: CARDIOVASCULAR