Chapter 5Results 3: video-stimulated recall interviews – patients

Not concerned by cardiovascular disease risk

For most patients, perceptions were largely focused on a lack of concern, regardless of the way in which CVD risk information was delivered. One patient described how being told her 10-year risk ‘didn’t alarm me . . . I thought 6% wasn’t too bad at all really . . . I thought that was a pretty good, average’ (QRISK2+, 12_131, female, 57). Other patients described how they were ‘quite relaxed about that really’ (JBS3, 7_117, male, 49) after being told their heart age. A small number of patients spoke of their worries after finding out their CVD risk information. For example, on learning that his heart age was 6 years older than his chronological age, one patient explained: ‘that shocked me. No, it concerned me’ (JBS3, 7_105, male, 59).

Receiving CVD risk results also appeared to reassure patients, regardless of the way in which risk was presented. For example, one patient talked about the relief of being given a 10-year risk that she perceived to be low:

So saying to be 6.0 – well under 10, so yeah, yeah, yeah, it is reassuring. Which when she said it was under 10 that’s why I forgot the number, but I was just relieved.

QRISK2, 3_125, female, 56

This was also observed for heart age: ‘I was quite pleased because it came out with my heart age at being my age, so I thought phew [laughter]’ (JBS3, 4_263, female, 61).

It is possible that patients’ lack of concern about their level of CVD risk was related to a widespread perception in the sample of a low level of personal CVD risk (as 70% of the 128 were classified as low risk). However, this perception that personal CVD risk was ‘small’, ‘low’ or ‘quite low’ or ‘wasn’t that high’ was observed among patients with different levels of risk. For example, one patient whose 10-year risk was estimated at just 1% (which was heavily influenced by his relatively young age):

I:

. . . so do you remember what you were told by the practitioner about your level of developing cardiovascular disease, or your risk?

P:

I was very low 1% something like that.

QRISK2+, 12_064, male, 40

And another patient who had a 10-year risk just under the 10% threshold at which intervention might be recommended:

I:

OK so she said that your risk of heart attack or stroke was 8.1%.

P:

Yes so quite low.

JBS3, 8_162, female, 67

However, a patient considered at high risk (≥ 20%) described how they felt when informed of their 10-year risk score, indicating that even those with a high risk of developing CVD did not perceive or understand the severity of this information:

Err, well it didn’t really err, how can I put it, well err, err, well it . . . I thought about it but, 25% that’s yeah I thought well err most people walking round now are at, what is it 25%? . . . You know erm, I, I thought the odds were pretty good myself to be honest with you [laughter].

JBS3, 5_132, male, 74

Patients who were told that they had a low risk of CVD were understandably reassured (see Positive impact of Health Checks). However, there is evidence of false reassurance for those with a high risk of developing CVD who do not recognise the risk severity from the information provided or the related discussion. This can be linked to a lack of understanding (see Mixed levels of understanding), particularly surrounding the notion of percentage risk.

In addition, several patients commented on CVD risk being an estimate or a prediction, and this appeared to influence the perceived severity of threat to their health:

I:

So getting your actual cholesterol result, so rather than having kind of your 10-year risk or your heart age, or your survival age, it would be your cholesterol . . . ?

P:

Yeah very much so because that is the now, you know all those other things are projections.

I:

OK, that’s interesting.

P:

Like a forecast as such. This is the forecast, but that forecast is only determined by the here and now. If there is a lifestyle change tomorrow that information that was given yesterday is null and void to a degree.

JBS3, 4_080, male, 57

This appeared quite prominent in relation to event-free survival age, which this patient considered less credible than heart age:

Cause, yes that [lifetime risk] . . . I think I’d take that as a pinch of salt, to be honest . . . You can’t predict that . . . You know, that’s pretty ridiculous . . . I can listen to myself and think err . . . I’ve got a 51-year heart or you know . . . they’re gonna know that . . . But to predict how long I’m gonna, live really that’s errr . . . science fiction ain’t it really?

QRISK2, 9_087, male, 48

Patients viewing their CVD risk results as a prediction or estimate might facilitate beliefs that CVD risk can be reduced, in turn, enhancing self-efficacy towards positive behaviour change (see Facilitating change). However, for other patients this could be detrimental to the appraisal of their risk and lead to a fatalistic view, rather than considering their CVD risk as being in their control.

I would be more worried if cardiovascular disease risk was higher

Patients dismissed their CVD risk if they perceived it to be low (regardless of risk level). For example, one woman, whose heart age was 5 years older than her chronological age, said:

No I just thinking well it doesn’t bother me ’cos, 5 years OK 5 years, 5 years, but it’s not you know about 20 years, 20 years be thinking ‘Oh my God’, you know . . . horrified, but I think 5 years is not too bad and there’s things that I can work on to try and reduce that really so I wasn’t horrified by it, no.

QRISK2+, 12_131, female, 57

This suggests that this patient, because her heart age was similar to their actual age, regarded the threat as not severe, and perceived that she had self-efficacy over the changes needed to reduce it. Similar thinking was observed in relation to 10-year risk. In the example below, the practitioner had suggested that a 10-year risk of 1.6% was slightly raised:

You tend to look at it and then tend to be kind of, I don’t know, kind of brush it away . . . although she said it was quite high, I think because I think it is such a low percent, it’s kind of not at the front of my mind and I am not concentrating on it.

QRISK2, 9_083, female, 39

Therefore, it appeared that patients’ perceptions of the severity of their CVD risk and vulnerability to it are important in fostering intentions towards risk-reducing behaviour (in line with PMT).

It was common for patients to explain that, if their CVD risk had been higher (whether this was higher 10-year risk, older heart age, or older event-free survival age), they would have been more concerned, and this would have been more likely to prompt change. For example, one patient believed that if he had been given a 10-year risk that was double his current risk (15%), it would have prompted more concern and increased steps to lower it:

P:

You know, I mean if you’d said to me it was 30% . . .

I:

Hm.

P:

. . . a risk . . .

I:

Yeah.

P:

. . . obviously I’d be concerned about it.

I:

Yeah, cos it would have been high . . .

P:

High, it’d be double really, and higher, and obviously I’d have to take erm . . . or listened more, or look at taking steps, to . . .

I:

Hm.

P:

. . . to rectify it or do something about it.

JBS3, 11_028, male, 58

Similarly, patients frequently noted, that if their heart age had been a lot higher than their actual age, it would have been perceived as a more severe threat, prompting behavioural action (in this example, heart age was 51 years vs. chronological age of 55 years):

If it [heart age] had of been a lot higher then I would have thought ‘oh I will definitely go and get a bike and I will go swimming as well’ [laughs].

QRISK2+, 12_083, female, 55

This suggests that an increased understanding surrounding CVD risk level is required for patients to appraise how their individual risk may affect them. If patients do not perceive their CVD risk as a threat, then they are perhaps less likely to make positive behaviour changes and follow practitioner recommendations.

Feedback on cardiovascular disease risk was unexpected

Throughout patient accounts, it became apparent that there were mismatches between expectation and reality of CVD risk. Some patients expected to be told that their overall CVD risk was higher than it was based on known risk factors:

I thought they [10-year risk] were going to be higher, because of saying with my blood pressure and the cholesterol, and so I thought ‘oh I am in trouble here’, yeah and I thought . . . I really did think it was going to be high.

QRISK2, 3_125, female, 56

This was particularly true for 10-year risk. One patient, for example, explains that he was expecting the score to be higher than it was, despite it placing him in a medium–high risk category: ‘I think it was a case of [name] understood that I understood the 17% . . . As I say, I expected it to be higher but thankfully it wasn’t’ (QRISK2 +, 2_084, male, 64).

Many patients had expectations of their heart age that did not match the estimates from the health check and expected a low heart age based on a perception of being in relatively good health:

P:

That is a bit of a surprise really for that, because I don’t feel that you know, and I don’t know I still feel quite energetic and still play you know the sports I do, I am never tired, or feeling like I can’t go on any . . . you know, in fact I do the complete opposite. Yeah, if I feel oh right I am feeling a little bit – like if I am playing badminton for example, I can always push and push and push yeah, to you know go a little bit harder and that so you know I was a bit shocked at that to tell the truth. Not shocked, as in disappointed, but I thought you know . . .

I:

You thought it would be lower rather than higher.

P:

Lower than that yeah, because I don’t feel like I physically can’t do anything.

JBS3, 4_311, male, 57

This suggests that patient awareness or perceptions of their own health status are important. If a patient perceives themselves to be physically fit, they may underestimate their personal level of CVD risk, which might be elevated. This could stem from a lack of understanding of the CVD risk score itself and the information on which it is based, which is important if patients are to understand how lifestyle changes can be used to manage and reduce their risk.

Theme summary

It is likely to be insufficient to provide patients with their 10-year risk, or a heart age, in the absence of supporting information. Putting these results into context or presenting them in a different way to ensure that the severity of patient’s risk is understood is important to engage patients in discussion to address misunderstandings or misperceptions about what the score means, why it might be higher/lower than expected and the implications for their health.

Understanding versus lack of understanding

Throughout patient accounts, there was a distinct division between patients who seemed to understand the CVD risk information provided and those who did not. This was particularly true for 10-year risk and event-free survival age and, to a lesser extent, heart age. Some patients demonstrated a level of understanding of percentage 10-year risk (albeit with some confusion):

I:

Yeah, OK, and do you know erm . . . kind of do you understand what [practitioner] meant when she gave you that percentage score?

P:

Yeah that you’ve got 6% risk of, of getting heart disease in life really yeah, out of 100 people you know 1 in 6.

QRISK2+, 12_131, female, 57

For other patients, gaps in knowledge and understanding of the score were observed. Some could not recall what their score meant. For example, one patient struggled to ‘remember what the significance of 9.5 was’ (JBS3, 4_233, female, 69), when talking about her 10-year risk. Other patients found it difficult to put the percentage score into context in terms of a ‘good’ and ‘bad’ outcome. This was evident across all risk categories (low, medium and high). For example, a patient with a relatively low percentage demonstrated confusion about her 3% 10-year risk:

It depends, like I said, what it actually means. If 3% is not good, then obviously that information wasn’t useful to me, because I have gone away thinking that’s fantastic. Even though I am a bit sceptical, erm but if you are saying 3% actually is good, then yeah it was accurate what she was saying to me. But it almost seems as if, because she did say like slightly higher, I think if 3% is a high risk of you know heart disease, then 3% is not good, because 3% makes you think it’s good, because 3 out of 100 is good.

QRISK2, 9_295, female, 51

This lack of clarity was also observed where risk was higher:

I can’t quite understand what like 25% is, what’s, what’s good and what’s bad with 25%?

JBS3, 5_132, male, 74

This suggests that, regardless of the actual score, patients may find it difficult to understand the implications and severity of a 10-year risk. Despite misunderstanding, some described their experience of being told 10-year risk positively: ‘I thought that bit of it was very good indeed, obviously I didn’t recall it, but I did think that was good how that was explained and showed’ (JBS3, 4_080, male, 57). Yet the potential benefit of such positive perceptions is likely to be undermined by the lack of recall or understanding of CVD risk information.

Lack of understanding was also common for JBS3 event-free survival age. Instead of viewing lifetime risk as the expected age of survival free from CVD events, some patients interpreted this as predicted age of survival. This appeared to be the case not only for patients who were given this lifetime risk estimate during the health check, but also for QRISK2 patients when asked their opinion on this alternative way of presenting CVD risk:

I:

So this would be your age to expect to live to without a heart attack, or a stroke . . .

P:

Hm.

I:

. . . and then after that age, your risk would increase significantly.

P:

Hm hm.

I:

So it is not necessarily kind of when you are dying.

P:

When you are expected to live to? Hm. Hm. Well you see now, what’s interesting about that, because now that I have read that, I have realised what it says . . .

I:

Hm.

P:

. . . but initially, what I thought, and I think that’s probably what a lot of people would think. Initially you read it quickly and it looks like it is saying that we expect you to live until this age.

I:

OK, so life expectancy.

P:

And when you see that, then you cut off from what that’s saying . . .

I:

Right OK.

P:

. . . so I think that’s . . . because that is exactly what I have just done.

I:

Yeah

P:

I have just dismissed that bit there, and only read to there, on average expect to survive to 73.

QRISK2, 9_295, female, 51

This was also the case for one patient on being informed of his event-free survival age in the health check, which was relatively close to his actual age. The confusion understandably caused a great deal of concern (until this was identified and resolved):

I:

So did you, did it make you feel sort of what emotions was it sparking was it . . . ?

P:

Erm deflated me a little bit.

I:

Yeah.

P:

Erm, because I’ve never, ever thought about it and err it was my fault, that, that was the bit I felt where it let itself down a little bit.

I:

Yeah.

P:

Erm, if she’d have said yeah, yeah we can guarantee, well not guarantee, but we can see you’ve got reasonable amount of having good health until you’re 80 you know 82.

I:

Yeah.

P:

And then things might deteriorate a little bit.

I:

Yeah.

P:

That would have been perfect I’d have . . .

I:

Yeah.

P:

But then as I say 82.7 mentioned and I thought to myself and I never, that was it, the end of the interview really, I think.

I:

Yeah.

P:

As I thought, then, then it gets in your, gets in your head then.

JBS3, 5_132, male, 74

Understanding of heart age was also mixed, but patients seemed to have a better understanding of this than on other risk scores, and the comparison with chronological age allowed patients to quickly appraise their individual risk as ‘good’ or ‘bad’:

Where it says ‘your heart age is’ and gives you a heart age, straight away you know whether that is good, or bad, because if your [chronological] heart age is lower than the reading [heart age estimate], then you know straight away that is not so good. Whereas if it is higher you know. So I think that one is a bit more clearer.

QRISK2, 9_295, female, 51

However, some patients found the concept of heart age challenging, and failed to understand the context or implications of a heart age different to their actual age:

. . . again it, it’s there was this lack of information you know, what do these numbers mean? . . . I can’t remember ever being told what the numbers actually mean . . . You know what is the, you’ve got a heart of a 72-year-old, or 73-year-old and you’re, you’re 62. What does that actually mean?

JBS3, 4_143, male, 62

Overall, lack of understanding was evident across all methods, especially QRISK2 and event-free survival age. This highlights the need for practitioners to check patient understanding during the consultation and, where necessary, tailor the information to the patient.

Importance of context

One way to improve understanding of CVD risk relates to the context in which the different risks are presented [i.e. the extent to which practitioners demonstrate the relevance to patients (its severity or their vulnerability to it)]. This was highlighted by some patients, who believed that the CVD risk information lacked context, making it difficult to understand or appreciate the severity:

P:

. . . walked off and probably thought afterwards, I could have done with actually understanding is the heart age kind of thing, normal . . .

I:

Hm.

P:

. . . I was kind of thinking come out probably late 30s mid to late 30s something like that . . .

I:

Yeah.

P:

. . . but that’s without knowing anything about it . . .

I:

Hm and was it useful to be told a heart age?

P:

It’ it needs more context think . . .

I:

Hm.

P:

. . . on reflection as I walked away I don’t, didn’t really ask what that meant, it’s just stuck in me that it’s like hm . . . it’s not younger than me which, I imagined it should be.

QRISK2+, 12_064, male, 40

This idea was also discussed in relation to 10-year risk, in which additional context helped the patient to understand (in this example, as noted in Chapter 7, this quotation also reflected understanding conferred through a follow-up telephone call in which a specialised nurse practitioner provided further explanation):

I:

Erm, and did you understand what she meant when she said a risk of 17%?

P:

Erm, yes, I think . . . We did do kind of an analogy of you know like 100 people in a room – 17 can be expected . . . but you don’t know which of the 17 . . . which I thought was quite a nice graphic analogy to give you a visual picture.

I:

Yes. Was that something that she showed you on a screen or was it . . . ?

P:

No we just discussed it.

I:

It was conversation?

P:

Conversation, yes.

I:

Brilliant. So that kind of helped you to put it into context a little bit about sort of the 17%?

P:

Yes.

QRISK2+, 2_084, male, 64

Patients who were not given as much detail on the 10-year risk to put it into context appeared to have less understanding of the implications:

I think with the percentage unless you have been given the range it should be in for your age and for your, you know, capabilities, then it’s kind of a mismatch of information. I don’t know which to kind of . . . they are saying it’s high, but I think it’s quite low, but I don’t know what high is because I haven’t been given anything to compare it against.

QRISK2, 9_083, female, 39

Therefore, the context in which CVD risk information is communicated is important to aid understanding. Providing patients with more explanation on how to position their score relative to the population might facilitate understanding of the severity of their personal risk. One method of doing this is to provide some more information (e.g. use of analogies, relative risk) during the CVD risk discussion. Another method relates to the presentation of information, particularly given the positive perceptions of the ability to manipulate a patient’s CVD risk using JBS3 (see Importance of presentation).

Perceived changeability of cardiovascular disease risk

In addition to varied understanding of CVD risk in general, there were apparent differences in understanding of whether or not it could be changed by lifestyle factors. A small number of patients thought that it was fixed:

Yeah, you know, so err and having known the fact that my dad had a heart attack has increased my score . . . and she said herself on the video you can’t do anything about that. That’s just there you are there’s 10 points on the score.

QRISK2, 6_044, male, 61

In contrast, other patients talked about CVD risk as changeable: ‘Yeah, yeah, I remember thinking so I could do something about it’ (JBS3, 4_233, female, 69), or even acknowledged their own role in lowering the score: ‘But obviously it could come down, it could be better I guess if I change . . .’ (QRISK2 +, 2_001, female, 66). There was also an awareness that CVD risk could also increase over time, an important point for patients to understand from a prevention perspective:

. . . so, but again she did say that it wouldn’t stay the same it would change, so I do know that I, I do need to start looking after me self . . . a bit better.

QRISK2, 10_539, male, 51

The idea of CVD risk being a prediction or a ‘lottery’ was also evident in relation to discussion about the patient’s ability to make changes. This highlights an important separation between patient’s lifestyle or risk-reducing behaviours and what they see as a prediction of future disease risk, which might lack credibility:

I:

Yeah, so was that information in particular helpful, or unhelpful, the 9%?

P:

Oh!

I:

To you?

P:

To me it didn’t mean anything, because to me you know I can change my lifestyle and all that sort of thing, but at the end of the day it is a bit of a sort of like lottery really isn’t it? [Laughs].

I:

Yeah, yeah, I think it is isn’t it really?

P:

I would be quite happy if I had 9% chance of winning the lottery! [Laughing].

QRISK2+, 2_001, female, 66

This could be positive because of associations with change and adaptability, but negative in terms of fatalistic attitudes and not recognising CVD risk as the context or reason for making health-promoting changes.

Finally, despite the predominant belief that CVD risk (or risk factors) was modifiable, some patients lacked understanding about how to implement positive changes, for example to reduce cholesterol:

So it then led me to think ‘Well, where am I with it, can I do something about it?’. I don’t think I can do much more with my standard of living and exercise to be honest. So I think ‘well if there is an issue it might be genetic’, but I am now in the process of thinking ‘well you know what let’s get this tested again and see where we are’.

JBS3, 4_080, male, 57

Or in terms of lowering CVD risk itself:

But that part wasn’t . . . I am not clear about, erm I think at that point you are just . . . I am not sure actually, I am not sure how . . . right now so it’s 4.8% over the next 10 years, but I don’t know how you would lessen that.

JBS3, 4_263, female, 61

This makes clear the important link between clarity and understanding of CVD risk information, and patients’ perceptions (and subsequent intentions) regarding their ability to reduce risk through lifestyle changes.

Theme summary

Patients often do not understand CVD risk information (particularly 10-year risk and event-free survival age) and the implications of the scores. They are often unable to determine if their CVD risk is higher than that of others of the same age and, therefore, they may not be sufficiently motivated to change their behaviour. Patients would benefit from practitioners providing further information to make clear the relevance of their CVD risk. Visual presentation and risk score manipulation offer tools that can accommodate the range of patients, and also to make the important link between lifestyle change and overall CVD risk.

Facilitating change (risk management)

The extent to which patients reported to have altered their intentions or behaviours as result of the health check varied. For some, the health check prompted them to contemplate behaviour change: ‘did make me think a bit more . . .’ (JBS3, 7_136, female, 53); ‘put it [CVD risk] on my mind’ (QRISK2 +, 12_083, female, 55). For some, it resulted in a positive change in attitude towards health: ‘Overall . . . I came out with the attitude I’ve got to be more health focused’ (JBS3, 7_105, male, 59). For others, it appeared to increase their awareness of lifestyle aspects that might need to be changed, and promoted contemplation to engage with this:

Erm . . . no, the good thing was like you know get your cholesterol checked I had that, had previously checked it was still little bit high, but I’d gone up again erm . . . so it’s made me think about changing my diet and . . . and erm . . . tweaking it a little bit here and there . . .

QRISK2+, 12_131, female, 57

Consequently, a number of patients had not made any changes based on the recommendations provided, but were considering change. Others had made positive changes to lifestyle and behaviour. Overall, the health check seemed to facilitate patients to ‘work on that [behaviour] a bit harder’ (JBS3, 4_311, male, 57). Positive changes in several health behaviours were seen, mostly those most discussed by practitioners (see Chapter 4), such as physical activity, healthy eating and blood pressure monitoring.

Many patients talked about increasing their levels of physical activity following the health check. Typical examples involved increasing walking ‘I’ve started to go out a few minutes earlier and walking up the hill [laughs] . . . it’s just a few minutes a day . . . might make a difference’ (QRISK2 +, 12_055, female, 65), or other home-based exercise:

P:

I have, I mean like I have got my step machine . . . I have got a step machine that was in the garage, I have brought that inside, so I can do that while I am watching television.

I:

How brilliant!

P:

So like it does get me out of breath.

QRISK2, 9_202, female, 46

There were also several instances of dietary change. This could involve reducing intake of certain foods:

I’ve cut sugar down no end.

JBS3, 5_132, Male, 74

I:

Brilliant. So has being told your level of cardiovascular risk, so either the percentage, the heart age, the survival age, has that affected you in any way at all, sort of you know how you are approaching kind of lifestyle and things like that?

P:

Well, certainly, over diet really, over the cheese, because I was . . . she actually suggested cutting it down to a couple of times a week, which I have done already, so that definitely has had an impact.

JBS3, 4_263, female, 61

Others had substituted foods:

I:

Do you mind me asking what change you made?

P:

. . . erm . . . cut out some dairy . . . so I stopped using milk in porridge, and things like that and using water . . . got coconut milk as well, erm . . . and cut out bread . . . and erm . . . I’ve actually got a bit more, I’m not gonna go vegetarian, but I’ve gone a bit more vegetarian . . . I’m eating probably slightly less, but I’ve cut the crap out . . .

QRISK2+, 12_064, male, 40

When blood pressure was highlighted as a particular issue during the health check, some participants engaged in positive behaviour change related to further monitoring, either at the general practice or at home:

But the fact that I went out and ordered a small blood pressure monitor and one thing and another erm and presented my wife with those sheets and whatever. I’ve never done anything like that before.

JBS3, 7_105, male, 59

Despite the positive contemplation and actual behaviour change taking place, the changes made by patients were small: ‘I have not made any massive changes’ (JBS3, 7_105, male, 59). This could be explained by a number of the preceding themes, such as feeling reassured by their CVD risk, thinking CVD risk was low, considering behaviour change only if CVD risk is perceived to be high, believing that they were already doing the right thing, and perceived ability to change. For example, one patient talked about taking a ‘small step’ as a result of attending the health check:

And then erm, I forgot about the heart age, when she said about the heart age yeah. I just went back with the erm the life expectancy age. Erm, yeah so it has it, it gave me the momentum to do something, I know it’s only a small step but it’s a step.

JBS3, 5_185, male, 47

Overall, evidence related to contemplation of change and also the relatively modest changes made by many patients suggests that something else, in addition to what was included in the health check, may be needed to facilitate intentions for, and implementation of, more consistent and substantive behaviour change.

Impact of heart age

When asked about the CVD risk information they could remember, numerous patients could recall their heart age, more so than 10-year or event-free survival age. As a result, heart age seemed to stand out to patients as being more impactful:

P:

I think, I think the thing that registered with me and that sort of really grabbed my attention, and I know I said this earlier, all I could see was that 65 on that screen.

I:

Yeah.

P:

And I couldn’t . . .

I:

Yeah so the heart age really kind of . . .

P:

. . . that was wallop.

I:

Yeah.

P:

Yeah. That heart age and I think perhaps I missed some of the, shall we say, the finer detail because I was focused on that.

I:

Yeah.

P:

I could see that 65 and I was thinking, bloody hell, I ain’t 65!

JBS3, 7_105, male, 59

Clearly, it would be problematic if patients, in trying to process heart age information, ‘switch off’ and are unable to engage with subsequent recommendations from the practitioner. However, given the lack of retention of 10-year risk (and confusion over event-free survival age), understanding the implications and retaining one of the metrics can be interpreted as a positive, as it could provide the context for a meaningful discussion of risk management.

The concept of heart age was also well received by patients in the QRISK2 group who were interviewed, who were shown alternative ways of presenting CVD risk information during their VSR interview:

Err I think that one has got the most positive impact really. Even if it wasn’t positive from point of view of your heart age, if it was higher than what your [chronological] heart age is. I think you would still straight away understand that more and know what you have got to do.

QRISK2, 9_295, female, 51

Heart age was perceived to increase understanding of CVD risk among patients in both the JBS3 group and the QRISK2 group:

But when it was very clearly written, you know so the model brings it up as your heart age, given the information that it has got, is 61 years and I thought ‘well that is so clear and understandable’, so I found that very helpful, because if it had been much higher, then that would have also been very understandable.

JBS3, 4_263, female, 61

In addition, heart age appeared more relatable and, perhaps, more credible. As reported earlier, one patient described event-free survival age as ‘science fiction’, but could believe the idea of heart age:

I can, I can listen to myself and think err . . . I’ve got a 51 year heart, or you know . . . they’re gonna know that . . .

QRISK2, 9_087, male, 48

This links in with the earlier idea that CVD risk is only a prediction. If heart age is perceived as more relatable and credible, patients may have an increased understanding of how their risk of developing CVD, be able to appraise its severity and their vulnerability to it and, therefore, be more likely to make behaviour changes to mitigate the risk. This was illustrated in the patients accounts around heart age prompting change as ‘it is that swift kick to say: “get out there and do something” ’ (QRISK2 +, 2_084, male, 64):

Don’t get me wrong, it was enough to make me say to my wife ‘I’ve got to do something about what I eat, and I’ve got to get more exercise and I’ve got to do this, and I’ve got to get that’, and I ordered a blood pressure monitor and all the other things. I even checked that the bathroom scales worked properly.

JBS3, 7_105, male, 59

The other methods of presenting CVD risk information (10-year risk, event-free survival age) were also commented on by patients in terms of their strengths, limitations, ability to increase understanding and also impact on behaviour change. However, conversations around heart age were much more common, and rarely in a negative context. Some patients were alarmed or even shocked to learn that their heart age was higher than their actual age and clearly did not expect to receive such information:

Well it made me, what she said is that this is the age group I would be . . . so obviously that’s alarming, because . . . it’s like adding another 10 years to your life. You know which you don’t want . . . you know you don’t mind erm . . . being at the level where you are at your age . . .

JBS3, 11_028, male, 58

Clearly, a CVD risk metric, such as heart age, that is understandable and impactful has the benefit of giving patients a better appreciation of their risk than does 10-year or event-free survival age.

Theme summary

There was evidence that attending a health check had a positive impact on many patients, but these often related to contemplating change or making relatively small changes to lifestyle. Heart age appeared to be preferred by patients, and beneficial for facilitating patients’ understanding and appraisal of CVD risk (compared with 10-year or event-free survival age).

Difficult to absorb information

Patients frequently highlighted the difficulties in absorbing information presented in the health check and commented that they ‘Didn’t really sort of take in you know what the numbers were’ (QRISK2, 3_125, female, 56). They felt that the volume of information provided to them in a short space of time limited their capacity to retain and accurately recall it:

As I say, when you are in somewhere like that you can’t take on too much either can you really? Because it all becomes a bit muddled together.

JBS3, 4_263, female, 61

This appeared particularly problematic when exclusively presenting information verbally, which is common practice during a health check:

You know what I mean, you, you could take the time to look at it whereas, when, when it’s when it’s spoken to yer, it’s spoken then it’s gone.

QRISK2, 10_539, male, 51

This supports evidence for the benefit of presenting risk information visually.^23,77 Patients who feel overloaded with information that they cannot effectively process will be limited in the extent to which they understand their own personal CVD risk and appraise the implications.

Positive impact of presenting cardiovascular disease risk visually

One key feature of the JBS3 risk calculator, aside from the various risk metrics (10-year risk, heart age, event-free survival age), is the visual presentation of risk information. The interactive nature of the tool facilitates a more collaborative consultation between patient and health-care practitioner. It was often observed in the video-recorded health checks that practitioners would share their computer screen with patients to communicate CVD risk information (see Chapter 4).

Patients in the JBS3 group typically commented on the visual presentation of information, which was perceived positively and overcame some of the barriers related to verbal communication of information:

It was good that you could see the screen and how she actually . . . how she worked it out as well rather than somebody just telling you . . . I thought it was a good to see . . .

JBS3, 7_044, female, 54

There was also a common feeling that seeing information written on the screen, and the accompanying visuals, strengthened the message and aided recall (more than simply hearing it from the practitioner):

. . . because it was on the screen, I think that is such an aid to memory . . . you know it’s just that sort of interactive ability really to be able to see something, rather than just being told information. Because in any situation that is new to you, if there’s a lot of things going on and you are not sure what’s going on, you don’t hear . . . But if you see it, it is actually much, much clearer to you.

JBS3, 4_263, female, 61

Patients also reported that they took more notice of the information when presented graphically, and that the presentation influenced intentions to engage in positive behaviour change:

I certainly got the gist of what [practitioner] was saying and it’s quite graphic seeing it there on screen erm, you know heart age 65 and I’m, I’m not quite 60 so you’re thinking yeah I ought to do something about that and yeah the intention is there.

JBS3, 7_105, male, 59

This did not appear limited to one type of CVD risk information provided. Rather, visual presentation appeared to increase understanding and impact of 10-year risk (‘Yeah she did give me a percentage score, she did something on the computer that showed you erm what it was and that was quite good actually’; JBS3, 7_044, female, 54) and heart age (‘But the 65 was a big 65 on the screen’; JBS3, 7_105, male, 59) although was not commented on in terms of event-free survival age.

Positive perception of risk manipulation

The JBS3 calculator function that allows the practitioner to manipulate a patient’s CVD risk by altering modifiable risk factors was perceived positively by patients, with one describing it as ‘quite impressive really’ (JBS3, 8_162, female, 67):

Yes I think it helps, rather than somebody talking to you and saying, ‘well it’s like this, it’s like that’, but actually when you can see it and then by altering it, you know and saying, ‘if we put this information in you can see how . . . so if you were much heavier say, for example, or if you smoke, or if you do these sorts of things’, so I found that really helpful. Really clear and understandable from my point of view anyway.

JBS3, 4_263, female, 61

This also appeared to have more of an impact on patients, potentially increasing motivation to engage in behaviour change:

You can see the differences . . . not just somebody saying or if you do this, you can, you’d be better . . . or better off . . . shall we say, not better, better off, you know but if you can, if you can read it and you can, you can compare the two at the same time . . . You can, you can it, it has better more, more of an impact.

QRISK2, 10_539, male, 51

It was also evident that some patients had made positive lifestyle changes and followed practitioner recommendations based on their risk manipulation in JBS3:

I:

Erm do you remember being shown how your risk might change, you kind of mentioned it a little bit earlier how she said if you reduce your cholesterol erm it could have an effect on your risk.

P:

Yes she did yeah bring the percentages down and all this, all the above which is as I say I took on board . . . Which err you come out, I came out thinking well yes my lifestyle needs to change . . . because it’s an easy thing to slip into . . . I have made the effort and through that, through this meeting you know so it . . . the benefits are there it’s definitely done something for me . . . In as much as made me decide well ‘come on enough pull your finger out get on with this’, you’ve been told, you know.

JBS3, 4_394, male, 65

Theme summary

Patients are given a lot of information in health checks, which they can struggle to absorb and retain. There appeared to be benefits of visual presentation of CVD risk information and risk score manipulation within JBS3 to foster patient understanding of CVD risk and motivation to follow recommendations for behaviour change.