PDF Understanding Risk Management and Compliance, What is different after Monday, September 16, 2013

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I mean I take it before I go to bed at night but, [laughs] it's when you get to bed…it bubbles in here [pats tummy]… I get wind, terrible wind, just bubbling away in here.

Seemingly that's a side effect of them P11, Female, taking statin. Well they [legs] stiffened up. It felt as though you'd been stood in a bucket of concrete! And, I got diarrhoea and felt sick and had a fuzzy head with them. I went in [to the GP practice] and got them [statin] and she gave me a supply. I started taking them and all [of the] muscles in my back started jumping around like that [gestures with hands]. Respondent: Yes, because then it could be lifesaving! But I'm not too sure about [taking them] just for prevention? I mean there's no way that I would go and have a double breast operation, removal, just because I am at high risk of breast cancer—I just wouldn't do it P5, Female, refused statin.

I was aware of my cholesterol, and have been for over 15 years…[it is always] about 3. That's about what my cholesterol is, you know, always has been. P15, Male, taking statin. Twenty-five participants recalled being offered advice about their diet; 16 participants stated that they had made some changes to their eating habits based on that advice; 9 participants stated that they had made no changes to their eating habits; 4 participants could not recall being offered any advice. Participants were happy to discuss diet as part of their NHSHC, but how these discussions were broached had an impact on the participant's experience, especially when these discussions were framed in the context of losing weight.

Identification of individuals as obese had the potential to leave them with negative feelings about the whole assessment. For many participants, making small and sustainable changes to their diet by consuming less salt and fat was achievable, as long as it did not cause too much disruption to their daily routines. A number of older participants felt that making changes to their lifestyle was unnecessary at their age, and the provision of healthy eating information was not always accepted and was branded too generic.

There was a call for dietary advice that was CVD risk reduction focussed, as opposed to the normal information that could be picked up from any doctor's waiting room.

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Like the discussions about thresholds for cholesterol and how they seemed to alter frequently, people showed reluctance to make changes to their lifestyle, noting that any guidance they were given was likely to be subject to change. Many cited the consumption of eggs as an example, stating that previous guidance about healthy eating suggested that the consumption of eggs should be restricted; then the reverse was promoted—eggs were recommended as part of a healthy balanced diet Box 2.

I couldn't get over it. She [ the nurse] gave me some paraphernalia [about healthy eating] but it was a waste of money giving me that, because I just didn't bother with it…I'm quite happy [the way I am] P17, Male, taking statin. They say eat margarine, then butter is better for you, [then] don't eat margarine.

Then they decided, no, eggs are good for you P27, Male, discontinued statin. When asked to recall advice that had been offered with regard to physical activity levels, 10 participants recalled receiving advice and 2 went on to take action and increase their personal physical activity levels.

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Eight participants did not make any changes to physical activity levels based on the advice they were given; 19 participants could not recall being offered any advice about physical activity levels. Many enjoyed swimming, walking and group activities such as bowls on a regular basis. However, many found that due to their advancing age, they were restricted in what activities they could now undertake. These people preferred to incorporate physical activity into their daily lives, through activities such as gardening, which in itself was often challenging, especially when they had co-morbidities such as arthritis, and they were of the view that any physical activity intervention suggested to them would have to take these impairments into account if it were to be acceptable Box 3.

On average, I walk four miles a day.

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I go on the hills [and] climb P27, Male, discontinued statin. I mean I bowl twice a week; green bowling, lawn bowling, and in the wintertime it's once a week because we do carpet bowls and I walk up and down the village every day P11, Female, taking statin. I don't feel old, but then my body is telling me that I am. I tried running, because I used to be cross country at school.

But now I can't run 5 yards, and it's my body telling me that I'm old. I can garden and that, but I have got arthritis and so I battle a bit. I have got a thing that I kneel on to get up and down P28, Female, taking statin. Discussions about alcohol consumption were recalled less frequently. When asked to recall if they had been offered advice about alcohol consumption, five participants could recall being offered advice. For the majority of participants, alcohol consumption was not discussed but they felt that their alcohol consumption was within guideline amounts, and for those who had discussed their consumption with the nurse at the HHC, this had been reiterated during discussions.

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There was only a small minority who had decided to reject advice from the nurse Box 4. She said I was quite in the limit of what I drank. You know, because we have wine on a Sunday and a couple of brandies sometimes. Not two on a night, but one on a night, a couple of times a week P11, Female, taking statin. Four participants were smokers at the time of their risk assessment and were offered smoking cessation.

One of these smokers went on to quit smoking as a result of the smoking cessation offered during the risk assessment. Amongst those who had discussed smoking cessation and declined the invitation, there was a feeling that it was being offered to them too late in their lives to make any difference to their health Box 5. It's far too late. I mean 67, say I live another 20 year, [that would make me] 87, which would be brilliant but it would take 20 year minimum for my lungs to clear, minimum P15, Male, taking statin.

All participants had engaged with the NHSHC programme insofar as they had attended their assessment, been offered advice and gone on to attend at least one annual review—making them already somewhat compliant with the programme. Nevertheless, the advice they were offered at the time of assessment and subsequent initiation and adherence to lifestyle changes and lipid lowering medications was highly variable within the sample.

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Discussions about lifestyle changes were broached variably, with discussion about diet happening most frequently. Discussion about physical activity and alcohol consumption happened much less frequently and indicates an area for improvement within the programme.

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People were more receptive to making small but manageable changes to their lifestyle and they were open to the provision of information about how to reduce CVD risk through dietary changes. However, they were confused and somewhat undermined by the fact that guidance could be subject to change. When it came to the promotion of increased physical activity, people highlighted that there would need to be consideration of those who experienced co-morbidities often associated with ageing.

Side effects from statin were the main reason for discontinuation of drug treatment. How discussions about side effects were handled by health professionals had a great bearing on a participant's decision to try a different brand or to discontinue treatment on a permanent basis. Participants did not distinguish between the effect of statin to lower cholesterol or its promoted overall preventative effects. The promised benefits from this universal intervention are theoretical rather than proven at this stage in the production of empirical evidence. This qualitative study indicates first a level of variability amongst health-care professionals in raising for discussion, post-test, different aspects of the available drug and lifestyle treatments.

Secondly, it indicates that patients experiencing side effects from statins are more likely to remain adherent if GPs are willing to listen to their concerns and review medication. Thirdly, the study emphasizes that for patients deemed to be at high risk the Health Check is not so much an event as the start of a process of adaptation to a new lifestyle which requires far more personalized and tailored advice on diet and activity suitable for people in later age and possibly with existing co-morbidities. Socioeconomic status, ethnicity and gender have all been positively associated with increased risk of CVD and it is known that many interventions can actually increase health inequalities.

Although statins have been found to be effective in the primary prevention of CVD, 35 previous studies have found that overall adherence to treatment is low, with only half of those prescribed statin taking them on a daily basis. The focus in these studies has been on initial assessments and conversion of invitations into assessments for example. Less attention has been paid to the longer term adherence amongst those individuals who have been identified as at high risk of CVD. It is important, especially in a time of depleted budgets, to ensure that any intervention is offered to the right people, at the right time and most importantly that those people are accepting of and compliant with the intervention.

This study suggests that attention needs to be paid to a more sophisticated prescription of prophylactic medications to reduce CVD risk and also to better explanation of their virtues and value to patients. The study also suggests the need for provision of more tailored lifestyle advice and access to appropriate services to facilitate sustained changes to factors that could increase CVD risk. Findings in this study are derived from a relatively small number of interviews with individuals identified as at high risk. With qualitative studies generalizability achieved through having a large, representative sample, is not the aim.

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Rather, we seek insights developed through looking at issues in great depth, but further studies of compliance in patients from more deprived quintiles or from populations with different ethnicity are clearly called for. Participants were asked to recall what lifestyle advice and medical intervention had been offered to them some time ago.

Findings were drawn from interviews with people who were already compliant with some aspects of the NHSHC programme. We have no data from people who:. Further qualitative research is needed to understand the needs and experiences of these two groups and should include representation from ethnically diverse populations.

The views expressed in this article are those of the authors and not necessarily those of the funding body. We would like to thank our participants who agreed to give their thoughts and opinions about what it was like to be identified as at high risk of CVD, the GP practices that helped with recruitment and our colleagues at the four former Tees PCTs. National Center for Biotechnology Information , U.

J Public Health Oxf.

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Published online Sep Shucksmith , Professor, Public Health 1, 2. Author information Copyright and License information Disclaimer. Address correspondence to R.

McNaughton, E-mail: ku. This article has been cited by other articles in PMC. Abstract Background The Department of Health introduced a risk assessment, management and reduction programme, NHS Health Checks, which aimed to reduce premature morbidity and mortality from cardiovascular diseases for those aged 40— Methods Qualitative data were collected through 29 semi-structured interviews with a purposive sample of individuals who had been identified as at high-risk of CVD.

Conclusions Attention needs to be paid to the way prophylactic medications are prescribed and explained to high-risk patients. Keywords: public health, screening, health services. Background It is widely believed that the majority of deaths that are attributed to cardiovascular diseases CVD could be prevented through the early identification of risk factors for example, underlying physiological conditions such as hypertension, dyslipidaemia, diabetes and chronic kidney disease and through the facilitation of lifestyle changes.

Methods Data described in this study were collected through 29 semi-structured interviews with patients who had received an NHSHC between and Sex Male Female No. Open in a separate window. Statin adherence All participants were asymptomatic before attending their Health Check; they had been invited for assessment, not sought it out.