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Headline
Health check uptake following standard invitations was low (about 14%) and not increased by enhanced invitations using the question–behaviour effect, with or without a £5 incentive for questionnaire return.
Abstract
Background:
A national programme of health checks to identify risk of cardiovascular disease (CVD) is being rolled out but is encountering difficulties because of low uptake.
Objective:
To evaluate the effectiveness of an enhanced invitation method using the question–behaviour effect (QBE), with or without the offer of a financial incentive to return the QBE questionnaire, at increasing the uptake of health checks. The research went on to evaluate the reasons for the low uptake of invitations and compare the case mix for invited and opportunistic health checks.
Design:
Three-arm randomised trial and cohort study.
Participants:
All participants invited for a health check from 18 general practices. Individual participants were randomised.
Interventions:
(1) Standard health check invitation only; (2) QBE questionnaire followed by a standard invitation; and (3) QBE questionnaire with offer of a financial incentive to return the questionnaire, followed by a standard invitation.
Main outcome measures:
The primary outcome was completion of the health check within 6 months of invitation. A p-value of 0.0167 was used for significance. In the cohort study of all health checks completed during the study period, the case mix was compared for participants responding to invitations and those receiving ‘opportunistic’ health checks. Participants were not aware that several types of invitation were in use. The research team were blind to trial arm allocation at outcome data extraction.
Results:
In total, 12,459 participants were included in the trial and health check uptake was evaluated for 12,052 participants for whom outcome data were collected. Health check uptake was as follows: standard invitation, 590 out of 4095 (14.41%); QBE questionnaire, 630 out of 3988 (15.80%); QBE questionnaire and financial incentive, 629 out of 3969 (15.85%). The increase in uptake associated with the QBE questionnaire was 1.43% [95% confidence interval (CI) –0.12% to 2.97%; p = 0.070] and the increase in uptake associated with the QBE questionnaire and offer of financial incentive was 1.52% (95% CI –0.03% to 3.07%; p = 0.054). The difference in uptake associated with the offer of an incentive to return the QBE questionnaire was –0.01% (95% CI –1.59% to 1.58%; p = 0.995). During the study period, 58% of health check cardiovascular risk assessments did not follow a trial invitation. People who received an ‘opportunistic’ health check had greater odds of a ≥ 10% CVD risk than those who received an invited health check (adjusted odds ratio 1.70, 95% CI 1.45 to 1.99; p < 0.001).
Conclusions:
Uptake of a health check following an invitation letter is low and is not increased through an enhanced invitation method using the QBE. The offer of a £5 incentive did not increase the rate of return of the QBE questionnaire. A high proportion of all health checks are performed opportunistically and not in response to a standard invitation letter. Participants receiving opportunistic checks are at higher risk of CVD than those responding to standard invitations. Future research should aim to increase the accessibility of preventative medical interventions to increase uptake. Research should also explore the wider use of electronic health records in delivering efficient trials.
Trial registration:
Current Controlled Trials ISRCTN42856343.
Funding:
This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 84. See the NIHR Journals Library website for further project information.
Contents
- Plain English summary
- Scientific summary
- Chapter 1. Introduction
- Burden of disease
- Inequalities and cardiovascular risk
- The NHS Health Check programme
- Programme implementation
- Eligibility for the NHS Health Check programme
- Health check process
- Evidence of effectiveness
- Economic modelling for cost-effectiveness estimates
- Uptake of the NHS Health Check programme
- Evaluations of the roll-out of health checks
- Evidence regarding effective interventions to increase the uptake of health checks or screening
- How does the question–behaviour effect work?
- Recent systematic review and other evidence regarding the question–behaviour effect
- Financial incentives to increase questionnaire return rates
- What is the potential impact of the question–behaviour effect on socioeconomic inequalities in uptake?
- How might offering an incentive for questionnaire return affect the social patterning of responses to the question–behaviour effect?
- Will informed choice be evaluated?
- Uptake patterns
- Research objectives
- Context
- Chapter 2. Methods
- Trial design
- Setting
- General practice recruitment
- Individual participant recruitment
- Recruitment and randomisation
- Intervention rationale and development
- Patient and public involvement
- Justification of the incentive
- Details of the interventions received in each trial arm
- Sample size
- Blinding
- Duration of the treatment period
- Outcome data collection
- Reliability and data checking
- Data analysis plan: data description
- Data analysis plan: inferential analysis
- Evaluation of the study as a rapid trial and analysis of the randomisation methods
- Statistical considerations
- Software for statistical analysis
- Economic evaluation
- Cohort study
- Process evaluation and qualitative study
- Ethical arrangements
- Research governance
- Chapter 3. Results 1: main trial results
- Chapter 4. Results 2: question–behaviour effect questionnaire responses
- Chapter 5. Results 3: evaluation of automated allocation at source in the context of a rapid trial
- Chapter 6. Results 4: cohort study of case mix for invited and opportunistic NHS health checks
- Chapter 7. Results 5: process evaluation and qualitative study
- Chapter 8. Discussion
- Invitation methods for health checks and the question–behaviour effect
- How do the results compare with those of other studies of the question–behaviour effect?
- The nature of the question–behaviour effect intervention used in this trial
- How did offering a financial incentive affect the impact of the question–behaviour effect intervention?
- Cost-effectiveness
- Rapid trials using electronic health records
- Uptake of health checks
- Conclusions from qualitative studies
- Opportunistic compared with invited health checks
- Strengths and limitations of this research
- Research recommendations
- Acknowledgements
- References
- Appendix 1. Trial question–behaviour effect questionnaire
- Appendix 2. Covering letter: question–behaviour effect questionnaire trial arm
- Appendix 3. Covering letter: question–behaviour effect questionnaire and incentive trial arm
- Appendix 4. Interview guide: health check trial – general practice staff
- List of abbreviations
About the Series
Article history
The research reported in this issue of the journal was funded by the HTA programme as project number 11/129/61. The contractual start date was in May 2013. The draft report began editorial review in January 2016 and was accepted for publication in June 2016. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HTA editors and publisher have tried to ensure the accuracy of the authors’ report and would like to thank the reviewers for their constructive comments on the draft document. However, they do not accept liability for damages or losses arising from material published in this report.
Declared competing interests of authors
none
Last reviewed: January 2016; Accepted: June 2016.
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