Patient experiences of telephone outreach to enhance uptake of NHS Health Checks in more deprived communities and minority ethnic groups: A qualitative interview study.

BACKGROUND
The NHS Health Checks preventative programme aims to reduce cardiovascular morbidity across England. To improve equity in uptake, telephone outreach was developed in Bristol, involving community workers telephoning patients amongst communities potentially at higher risk of cardiovascular disease and/or less likely to take up a written invitation, to engage them with NHS Health Checks. Where possible, caller cultural background/main language is matched with that of the patient called. The call includes an invitation to book an NHS Health Check appointment, lifestyle questions from the Health Check, and signposting to lifestyle services.


OBJECTIVE
To explore the experiences of patients who received an outreach call.


DESIGN/SETTING/PARTICIPANTS
Thematic analysis of semi-structured interviews with 24 patients (15 female), from seven primary care practices, who had received an outreach call.


RESULTS
The call increased participants' understanding of NHS Health Checks and overcame anticipated difficulties with making an appointment. Half reported that they would not have booked if only invited by letter. The cultural identity/language skills of the caller were important in facilitating the interaction for some who might otherwise encounter language or cultural barriers. The inclusion of lifestyle questions and signposting prompted a minority to make lifestyle changes.


CONCLUSIONS
Participants valued easily generalizable aspects of the intervention-a telephone invitation with ability to book during the call-and reported that it prompted acceptance of an NHS Health Check. A caller who shared their main language/cultural background was important for a minority of participants, and improved targeting of this would be beneficial.


| BACKG ROU N D
The NHS (UK National Health Service) Health Check programme, introduced in 2009, became a statutory public health service in England in 2013. Local authorities are responsible for offering an NHS Health Check every 5 years to individuals aged 40-74 who are not on a relevant disease register. The programme aims to prevent heart disease, stroke, type two diabetes and kidney disease, using a combination of risk assessment, communication of risk and risk management. 1 The programme is one of the largest public health prevention programmes in the world, with over 6 million people in England having received a Health Check since 2013. 1 Currently the main providers of NHS Health Checks are primary care practices, although they have also been offered in a range of community settings. [2][3][4] Regardless of provider, primary care follow up any risks identified. 1 Critiques of the programme have included the risk of widening health inequalities, 5 with concerns amongst primary care clinicians that it attracts the "worried well," and that those who could benefit most were least likely to attend. 6,7 An evaluation of implementation of NHS Health Checks in North West England found support amongst GPs for targeting people expected to be at high risk. 8 This brings with it a requirement to define "high-risk" individuals or groups, identify them locally and find methods of increasing the number who attend health checks.
Socio-economic deprivation is associated with increased morbidity and mortality from cardiovascular diseases. 9,10 Cardiovascular risk is also known to vary for different ethnic groups, with, for example, South Asians bearing a disproportionate burden of heart disease. 11 Several studies have looked at NHS Health Check coverage (the percentage of people who are eligible for an NHS Health Check who have received one) or uptake (the percentage of those invited for an NHS Health Check who receive one) in relation to deprivation or ethnicity. While those from the least deprived areas are most likely to take up an invitation to an NHS Health Check, coverage was consistently found to be higher in more deprived areas, which may reflect existing targeting. 3 Coverage amongst different ethnic groups was also found to be comparable to, or higher than, that in "White British" groups. 3 However, evidence on uptake in different ethnic groups was mixed, with conflicting findings. 3 Analyses were limited by high levels of missing ethnicity data in primary care practice records, with uptake significantly lower for those with this data missing. 12,13 Qualitative research with staff delivering health checks found perceptions that people from black and minority ethnic groups were less likely to attend, with language and cultural issues seen as major barriers. 14 Various methods aimed at increasing uptake of invitations to NHS Health Checks have been investigated. A review of evidence found modified invitation letters [15][16][17][18] and use of text messages 15 to be promising methods for the general eligible population. 3 However, it is of particular interest to understand how to increase uptake amongst groups who may be at higher risk of cardiovascular disease.
The limited evidence on the effectiveness of invitations to NHS Health Checks by telephone suggests they may increase uptake compared with invitations by letter 19 or may increase the number of health checks completed for patients from deprived areas or minority ethnic groups. 3,20 Qualitative research with primary care staff delivering health checks found that some practices were using telephone calls to build on existing relationships with patients or to target those who had not responded to a written invitation. 14 Qualitative research has also explored the involvement of community ambassadors/engagement workers to increase uptake in specific communities. Reported benefits included their ability to communicate using language people understood and connected with 2,3,21 and, where the ambassador/worker involved was known and trusted, their endorsement of the health check influenced people to attend. 2 Telephone outreach has been developed in Bristol which involves specially trained community workers or interpreting service staff telephoning patients amongst communities where people may be at higher risk of cardiovascular disease, and/or less likely to take up a written invitation, to engage them with the NHS Health Checks programme. The intervention was intended, where possible, to match outreach caller cultural background and main language with that of the patient called. The outreach call includes an invitation to book an appointment for a health check, and if this is accepted, the lifestyle questions (eg, on physical activity, smoking and alcohol consumption) from the health check are completed on the telephone, with the aim of saving time during the face-toface health check appointment. Where appropriate, outreach callers may also signpost people to local lifestyle services, based on responses to the lifestyle questions. Telephone outreach has been piloted in ten primary care practices in Bristol, with targeting of eligible registered patients who are identified as residing in areas of high deprivation or as potentially requiring cultural or language support.
Bristol is a culturally and ethnically diverse city, with 16% of the population from black and minority ethnic groups, and 15% of residents having been born outside the UK. Nine per cent of Bristol residents do not speak English as their main language. 22 The gap in healthy life expectancy between the most deprived and least deprived 10% within Bristol places the local authority area in the worst quintile in England, at 16.3 years for men and 16.7 years for women. Cardiovascular disease is the largest cause of years of life lived in less than ideal health or lost due to premature mortality in Bristol. 22 The objective of the telephone outreach intervention was to engage people from communities with potentially higher health need with the NHS Health Checks programme, to help reduce inequalities in health.
The objective of this study was to explore in depth the experiences and perspectives of patients who received a telephone outreach call to invite them to take part in an NHS Health Check.

| ME THODS
Patients from seven primary care practices who had received an outreach telephone call were asked at the end of the call whether they were willing to be contacted by a researcher to discuss taking part in this study. Those who agreed to being contacted were sampled purposefully to maximize diversity regarding primary care practice, outreach caller, NHS Health Check invitation acceptance status, age, gender and ethnicity and invited to take part in a semi-structured interview. 23 Sample size was driven by the concept of "information power, 24 " with continuous assessment as data collection progressed of the adequacy of the information within our sample with regard to meeting our study objective.
All interviews were carried out by EB and took place by telephone or face-to-face according to participants' preferences.
Participants whose main language was not English had the option of an interpreter being present to facilitate the interview. Interviews lasted between 8 and 54 minutes. A topic guide was used to focus the interviews, informed by a review of relevant literature and suggestions from our multiprofessional study team, and modified as data analysis progressed (please see Appendix S1).
With informed consent, interviews were audio recorded, transcribed verbatim, anonymized and imported into NVivo 10 (QSR International). Transcripts were analysed thematically 25 using a data-driven inductive approach to identify patterns and themes of particular salience for participants and across the data set.
Analysis began alongside data collection, with ideas from early analysis informing later data collection. Analysis of individual transcripts commenced with open coding and an initial coding framework was developed, which was added to and refined as new data were gathered. A subset of 12% of the transcripts were double coded by EB and JH to inform the coding framework and ensure robust analysis. Codes were built into broader categories through comparison across transcripts and higher-level recurring themes were developed (please see Appendix S2). Members of the study team met regularly to discuss emerging themes, and the public health professionals responsible for commissioning the local Health Checks programme and management of the telephone outreach project (AC and VH) were closely involved throughout research design, data collection and analysis.
To assist with the development of the study, three patients from local areas of high deprivation and with experience of receiving a telephone outreach call for NHS Health Checks were recruited via existing primary care patient feedback groups. They met with EB and TS, as well as an independent facilitator and a translator, and reviewed the draft study documentation, recruitment procedures and topic guide. The feedback they provided was used to refine the design of the study patient information sheet, as well as the procedures for telephoning patients who had agreed to being contacted about the research.
Informed consent was obtained and documented for all participants to participate in the study and for anonymized quotes to be used in publications reporting the study findings. Written consent was obtained for face-to-face interviews. Participants who chose to be interviewed by telephone provided verbal consent. This was documented at the beginning of the interview by audio-recording the participant verbally confirming their agreement to each of the points contained in the written consent form. All participants were provided with study information in writing a minimum of 1 week before giving consent. The study, including the consent and anonymization procedures used, was approved by the South West-Frenchay NHS research ethics committee (Reference 15/SW/0231).

| RE SULTS
Information about the study was sent by post to 50 patients (33 women) who received a telephone outreach call. This written study information was followed up with telephone contact by a researcher a week later. Thirteen patients (nine female) declined to participate in the study, either by returning a postal opt-out slip or verbally when follow-up contact was made by phone.

| Receiving an NHS Health Check invitation by telephone
Participants were pleased to be proactively contacted by telephone and offered a health check. The majority of participants said that they did not think anything needed to change about how the outreach calls were made.
However, five participants mentioned that they would be less likely to answer a call if it came from an unknown number. Three female participants reported some minor initial concern regarding an unexpected call from their health centre. A number of participants mentioned that, after booking their appointments during the outreach call, they had received confirmation by text or letter; thus, the outreach call did not preclude providing written information to meet some of these preferences.
A third of participants mentioned having had a health concern on their mind at the time of the outreach call but stated that they would not have initiated contact with the health service to address this. They welcomed the call to invite them for an NHS Health Check, which they saw as either addressing those concerns directly and/or as an opportunity to discuss their concerns with a health professional.

| Who telephones, and how they communicate
Participants noted the outreach caller's connection to their primary care practice, but beyond this, caller identity was not presented as an important factor in most interviews. However, particular communication skills, or aspects of the identity of the caller, were presented by participants as having facilitated, or occasionally hindered, the interaction to a range of degrees.
Friendliness and a lack of duress in how the invitation was extended were mentioned by the greatest number of participants, but these were presented as helpful rather than essential aspects:

| Completing part of the health check during the outreach call
The telephone outreach intervention included completing part of the NHS Health Check during the telephone call by asking patients who accepted the invitation to an NHS Health Check about their weight, relevant family health history, smoking status, alcohol consumption and physical activity. Most participants said that it was acceptable to be asked these types of questions on the telephone. While several participants mentioned that they had been asked the questions again at their NHS Health Check appointment, most did not consider this a problem, and two said that this had been a brief check of the information recorded during the outreach call.
Two participants reported a negative experience related to this part of the telephone call. Jess described her experience of being asked the questions as "quite difficult," partly because the caller's main language was not English, but also because she thought the caller was not being receptive to her responses:

| D ISCUSS I ON
The telephone outreach intervention was positively received by the patients interviewed, with the majority reporting that they did not need much information or persuasion to accept the invitation to an NHS Health Check. Participants reported that the ease and immediacy of being able to book an appointment during the outreach call was a key factor in taking up the invitation. This finding is consistent with existing literature. For example, participants attending community-based health checks 21 reported a preference for telephone or in-person invitations, as they were seen as more "immediate and direct," as well as allowing them to ask questions-a benefit also mentioned by some of our participants.
The outreach callers were given motivational interviewing training as part of their preparation for delivering the telephone outreach intervention, to improve their ability to help participants overcome the intention-behaviour gap. Previous interventions to increase engagement with NHS Health Checks have used insights from behavioural science to overcome the intention-behaviour gap and have been shown to be effective. 18 Participants in our study highlighted that the telephone outreach call had simultaneously increased their knowledge/understanding of the NHS Health Checks programme and overcome anticipated difficulties with making an appointment-both getting around to trying, and the process once they did try.
These aspects of the intervention-providing a telephone call with information about, an invitation to, and an opportunity to book, an NHS Health Check-would be easily generalizable, as they could be carried out by primary care administration staff. This approach could also potentially be used for other services/interventions to increase uptake.
Language and cultural issues have been reported previously by staff delivering NHS Health Checks as major barriers to engaging with minority ethnic groups. 14 The Bristol telephone outreach intervention was intended, where possible, to match outreach caller cultural background and main language with that of the patient called, and our study included patients whose main language was not English where this had been achieved. These participants placed high value on receiving an outreach call from a known and trusted member of their community who was able to communicate with them in their own language. There were also data which indicated that a "mismatch" in main language between caller and patient could reduce the effectiveness of the intervention. Our data demonstrate that "matching" went beyond language, with interviews indicating that participants found it helpful if they could identify with the person who called them, such as Sonia, whose caller had spoken about her own and her husband's experiences of NHS Health Checks. Our linked qualitative evaluation with staff delivering the telephone outreach intervention found that "matching" was important-to capitalize on outreach workers' specialist skills and maximize the potential impact of the intervention. However, such matching could be difficult to achieve due to (a) ethnicity being poorly recorded in medical records, 12

| Strengths and limitations
This study was part of a larger evaluation carried out in collaboration with the local authority public health commissioners for NHS Health Checks. The overall project included a quantitative evaluation of the early stages of the telephone outreach intervention, 20 and a qualitative interview study with staff involved in delivering the intervention (T. J. Stone, E. Brangan, A. Chappell, V. Harrison, J. Horwood, unpublished data). Regular meetings of the project team allowed findings from different aspects of the work to inform ongoing data collection and analysis. The involvement of our local authority collaborators was critical in facilitating access for data collection, and meant findings could be communicated in a timely manner, and discussed more openly, than is possible in many academic studies. This both improved the quality of the research and increased its potential for impact locally.
The views of participants in this interview study are unlikely to be representative of all patients who received a telephone outreach call, as those who took part in an interview had all accepted the invitation for the NHS Health Check. While we wished to include the views of patients who had declined the invitation, this was not achieved.

| CON CLUS IONS
The clearest benefits identified in this research may be achievable with a simpler telephone outreach service-with calls made by primary care practice administrative staff providing information about, an invitation to, and an opportunity to book, an NHS Health Check.
Qualitative research indicates that this is an approach some practices are already taking for patients who do not respond to a written invitation. 14 It would thus be beneficial to pilot and evaluate a simplified telephone outreach intervention.
This approach would however forfeit two important opportunities: engaging groups who might otherwise encounter language or cultural barriers to taking up an invitation to an NHS Health Check and signposting patients to appropriate local lifestyle services.
Future research should thus explore in more detail which patients would benefit from an outreach caller with specialized training, skills or characteristics, and how best to implement "matching" of specialized callers and patients at a local level.

ACK N OWLED G EM ENTS
The authors thank all patients who participated in the interviews and the staff who helped with recruitment.

CO N FLI C T O F I NTE R E S T
The authors have no conflict of interest to declare.

AVA I L A B I LIT Y O F DATA A N D M ATE R I A L S
Due to confidentiality, and the nature of the consent obtained, the interview transcripts cannot be shared. For further information related to this data set, please contact the first author.