Patient Perception, Preference and Participation
‘Check it out!’ Decision-making of vulnerable groups about participation in a two-stage cardiometabolic health check: A qualitative study

https://doi.org/10.1016/j.pec.2014.10.010Get rights and content

Highlights

  • Two-stage cardiometabolic screening is potentially cost-effective.

  • Cost-effectiveness is hampered by a lack of participation among vulnerable groups.

  • Reasons for not completing a risk factor questionnaire are mainly cognitive.

  • Reasons for not attending further testing are mainly affective.

  • Focus should be on promoting informed choices by providing accurate information.

Abstract

Objective

Exploring determinants influencing vulnerable groups regarding (non-) participation in the Dutch two-stage cardiometabolic health check, comprising a health risk assessment (HRA) and prevention consultations (PCs) for high-risk individuals.

Methods

Qualitative study comprising 21 focus groups with non-Western (Surinamese, Turkish, Moroccan) immigrants aged 45–70, adult children from one of these descents, native Dutch with a lower socioeconomic status, and healthcare professionals working with these groups.

Results

Reasons for not completing the HRA included (flawed) risk perceptions, health negligence, (health) illiteracy, and language barriers. A face-to-face invitation from a reliable source and community outreach to raise awareness were perceived as facilitating participation. Reasons for not attending the PCs overlapped with completing the HRA but additionally included risk denial, fear about the outcome, its potential consequences (lifestyle changes and medication prescription), and disease-related stigma.

Conclusion

Reasons for not completing the HRA were mainly cognitive, whereas reasons for not attending the PCs were also affective.

Practice implications

When designing a two-stage health check, choice of invitation method seems important, as does training healthcare professionals in techniques to effectively handle patients’ (flawed) risk perceptions and attitudinal ambivalence. Focus should be on promoting informed choices by providing accurate information.

Introduction

In most Western countries (including The Netherlands) mortality and morbidity of cardiovascular disease, diabetes, and kidney failure are higher for people with a lower socioeconomic status (SES) and for non-Western immigrants [1], [2]. Moroccan, Turkish, and especially Hindustani Surinamese immigrants are at higher risk of developing diabetes [3]. Prevalence of cardiovascular disease is particularly high in the latter two groups [4], [5], [6]. Health checks are currently implemented to identify those at increased risk of cardiometabolic disease (CMD) [7], [8], [9]. However, individuals participating in health checks are more often health-conscious, higher-educated, affluent people [10], [11]. Participation is lower among people with a heightened risk, e.g. individuals of non-Western descent or with a lower SES [12].

Few studies specifically investigated (non-)participation in cardiometabolic health checks of non-Western immigrants or lower SES groups. The literature mostly concerns (non-)attendance in cancer screening or cardiometabolic screening in the general population [13], [14], [15], [16]. Results from studies on cancer screening might provide reasons for (non-)participation generalizable to cardiometabolic screening. However, risk perceptions and beliefs regarding cancer differ from those regarding CMD: perceived risk and worries are higher for cancer than for CMD [17]. Thus, more insight into determinants of (non-)participation in a cardiometabolic health check is needed, specifically among vulnerable groups to enable them to make an informed decision about participation.

Several studies concluded that a two-stage approach could be a cost-effective screening strategy for cardiometabolic risk [18], [19]. The Dutch cardiometabolic health check follows a two-stage approach and comprises a short risk stratification tool (health risk assessment: HRA) for people aged 45–70 years, and two prevention consultations (PCs) including a blood test with the GP for those at increased risk according to the HRA. During the PCs patients receive information about their risk profile, followed by lifestyle advice and, if necessary, medication prescription. However, this approach implies that patients can refrain from participation on two separate occasions, which may represent an even greater problem among difficult-to-reach groups. Indeed, pilot studies showed substantial dropout rates in both stages [20]. In-depth research focusing on determinants related to (not) completing a HRA and (non-)participation in subsequent PCs separately is scarce. Moreover, vulnerable groups require special attention. Therefore, this study investigates which informational, practical, and psychosocial determinants influence the decision of different vulnerable groups to (not) participate in the HRA and the PCs.

Section snippets

Sample and recruitment

This study was approved by the Medical Ethical Committee of the Leiden University Medical Center (CME-09-126). Participants’ verbal informed consent was audio-taped. Purposive sampling by key persons was used to conduct focus groups with non-Western immigrants (45–70 years, except Surinamese: 35–70 years because of their higher diabetes risk); adult children of non-Western immigrants (18–45 years); lower SES native Dutch (45–70 years); and health professionals working with the target

Demographics

In total, 125 participants took part in the focus groups, of whom 119 filled out the background information questionnaire. Table 2 presents these participants characteristics. Many Surinamese participants were retired and participants in the other groups were often unemployed or disabled. Female participants mainly reported housekeeping as their occupation in daily life. The majority of the adult children (mainly female) combined their education or job with housekeeping.

Information factors

A personal invitation

Discussion

In this study we have identified factors influencing (non-)participation in a two-stage cardiometabolic health check among difficult-to-reach, vulnerable populations. The kind of invitation and the source was thought to influence the decision-making process, as recognized by studies in the general population [31], [32], [33]. A multi-strategy approach combining mailed letters, telephone calls, and/or especially face-to-face strategies seems useful for increasing uptake in vulnerable groups [34]

Contributors

MC, SD, WG, and AS filed the proposal for this study. The design, execution, and analysis were mainly done by IG and MC, in close collaboration with the research team. The paper was written by IG and critically revised by all authors. All authors had full access to all of the data in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis. IG is guarantor.

Funding

This study was funded by the Dutch Heart foundation, the Dutch Diabetes Foundation, and the Dutch Kidney foundation in a collaboration called LekkerLangLeven [Living nice and long], grant number 2008.20.005. The views presented in this manuscript are those of the authors and do not necessarily reflect those of the study funders.

Competing interests

None of the authors have other financial relationships with organizations that might have an interest in the submitted work.

Ethical approval

This study was approved by the Medical Ethical Committee of Leiden University Medical Center (CME-09-126).

Data sharing

Anonymized transcripts and coding tree are available from the corresponding author.

Transparency

The lead author (IG) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained.

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