“They are saying it’s high, but I think it’s quite low”: exploring cardiovascular disease risk communication in NHS health checks through video-stimulated recall interviews with patients – a qualitative study

Background: NHS Health Check (NHSHC) is a national cardiovascular disease (CVD) risk identification and management programme. However, evidence suggests a limited understanding of the most used metric to communicate CVD risk with patients (10-year percentage risk). This study used novel application of video-stimulated recall interviews to understand patient perceptions and understanding of CVD risk following an NHSHC that used one of two different CVD risk calculators. Methods: Qualitative, semi-structured video-stimulated recall interviews were conducted with patients (n = 40) who had attended an NHSHC using either the QRISK2 10-year risk calculator (n = 19) or JBS3 lifetime CVD risk calculator (n = 21). Interviews were transcribed and analysed using reflexive thematic analysis. Results: Analysis resulted in the development of four themes: variability in understanding, relief about personal risk, perceived changeability of CVD risk, and positive impact of visual displays. The first three themes were evident across the two patient groups, regardless of risk calculator; the latter related to JBS3 only. Patients felt relieved about their CVD risk, yet there were differences in understanding between calculators. Heart age within JBS3 prompted more accessible risk appraisal, yet mixed understanding was evident for both calculators. Event-free survival age also resulted in misunderstanding. QRISK2 patients tended to question the ability for CVD risk to change, while risk manipulation through JBS3 facilitated this understanding. Displaying information visually also appeared to enhance understanding. Conclusions: Effective communication of CVD risk within NHSHC remains challenging, and lifetime risk metrics still lead to mixed levels of understanding in patients. However, visual presentation of information, alongside risk manipulation during NHSHCs can help to increase understanding and prompt risk-reducing lifestyle changes. Trial registration: ISRCTN10443908. Registered 7th February 2017

Cardiovascular disease risk communication in NHS Health Checks using QRISK®2 and JBS3 risk calculators: the RICO qualitative and quantitative study

Background The NHS Health Check is a national cardiovascular disease prevention programme. There is a lack of evidence on how health checks are conducted, how cardiovascular disease risk is communicated to foster risk-reducing intentions or behaviour, and the impact on communication of using different cardiovascular disease risk calculators. Objectives RIsk COmmunication in Health Check (RICO) study aimed to explore practitioner and patient understanding of cardiovascular disease risk, the associated advice or treatment offered by the practitioner, and the response of the patients in health checks supported by either the QRISK®2 or the JBS3 lifetime risk calculator. Design This was a qualitative study with quantitative process evaluation. Setting Twelve general practices in the West Midlands of England, stratified on deprivation of the local area (bottom 50% vs. top 50%), and with matched pairs randomly allocated to use QRISK2 or JBS3 during health checks. Participants A total of 173 patients eligible for NHS Health Check and 15 practitioners. Interventions The health check was delivered using either the QRISK2 10-year risk calculator (usual practice) or the JBS3 lifetime risk calculator, with heart age, event-free survival age and risk score manipulation (intervention). Results Video-recorded health checks were analysed quantitatively (n = 173; JBS3, n = 100; QRISK2, n = 73) and qualitatively (n = 128; n = 64 per group), and video-stimulated recall interviews were undertaken with 40 patients and 15 practitioners, with 10 in-depth case studies. The duration of the health check varied (6.8–38 minutes), but most health checks were short (60% lasting < 20 minutes), with little cardiovascular disease risk discussion (average < 2 minutes). The use of JBS3 was associated with more cardiovascular disease risk discussion and fewer practitioner-dominated consultations than the use of QRISK2. Heart age and visual representations of risk, as used in JBS3, appeared to be better understood by patients than 10-year risk (QRISK2) and, as a result, the use of JBS3 was more likely to lead to discussion of risk factors and their management. Event-free survival age was not well understood by practitioners or patients. However, a lack of effective cardiovascular disease risk discussion in both groups increased the likelihood of a maladaptive coping response (i.e. no risk-reducing behaviour change). In both groups, practitioners often missed opportunities to check patient understanding and to tailor information on cardiovascular disease risk and its management during health checks, confirming apparent practitioner verbal dominance. Limitations The main limitations were under-recruitment in some general practices and the resulting imbalance between groups. Conclusions Communication of cardiovascular disease risk during health checks was brief, particularly when using QRISK2. Patient understanding of and responses to cardiovascular disease risk information were limited. Practitioners need to better engage patients in discussion of and action-planning for their cardiovascular disease risk to reduce misunderstandings. The use of heart age, visual representation of risk and risk score manipulation was generally seen to be a useful way of doing this. Future work could focus on more fundamental issues of practitioner training and time allocation within health check consultations. Trial registration Current Controlled Trials ISRCTN10443908. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 50. See the NIHR Journals Library website for further project information

gaBERT — an Irish Language model

The BERT family of neural language models have become highly popular due to their ability to provide sequences of text with rich context-sensitive token encodings which are able to generalise well to many NLP tasks. We introduce gaBERT, a monolingual BERT model for the Irish language. We compare our gaBERT model to multilingual BERT and the monolingual Irish WikiBERT, and we show that gaBERT provides better representations for a downstream parsing task. We also show how different filtering criteria, vocabulary size and the choice of subword tokenisation model affect downstream performance. We compare the results of fine-tuning a gaBERT model with an mBERT model for the task of identifying verbal multiword expressions, and show that the fine-tuned gaBERT model also performs better at this task. We release gaBERT and related code to the community

A Qualitative Exploration of Two Risk Calculators Using Video-Recorded NHS Health Check Consultations

Background: The aim of the study was to explore practitioner-patient interactions and patient responses when using QRISK®2 or JBS3 cardiovascular disease (CVD) risk calculators. Data were from video-recorded NHS Health Check (NHSHC) consultations captured as part of the UK RIsk COmmunication (RICO) study; a qualitative study of video-recorded NHSHC consultations from 12 general practices in the West Midlands, UK. Participants were those eligible for NHSHC based on national criteria (40-74 years old, no existing diagnoses for cardiovascular-related conditions, not on statins), and practitioners, who delivered the NHSHC. Method: NHSHCs were video-recorded. 128 consultations were transcribed and analysed using deductive thematic analysis and coded using a template based around Protection Motivation Theory. Results: Key themes used to frame the analysis were Cognitive Appraisal (Threat Appraisal, and Coping Appraisal), and Coping Modes (Adaptive, and Maladaptive). Analysis showed little evidence of CVD risk communication, particularly in consultations using QRISK®2. Practitioners often missed opportunities to check patient understanding and encourage risk- reducing behaviour, regardless of the risk calculator used resulting in practitioner verbal dominance. JBS3 appeared to better promote opportunities to initiate risk-factor discussion, and Heart Age and visual representation of risk were more easily understood and impactful than 10-year percentage risk. However, a lack of effective CVD risk discussion in both risk calculator groups increased the likelihood of a maladaptive coping response. Conclusions: The analysis demonstrates the importance of effective, shared practitioner-patient discussion to enable adaptive coping responses to CVD risk information, and highlights a need for effective and evidence-based practitioner training

Towards the development of a UK Peatland Code: Payments for Ecosystem Services (PES) Pilot Research Project

This Final Report describes research into the rationale and basis for the development of a UK Peatland Code. The development of the Code was supported by the latest relevant research evidence, via an international expert workshop, and by feedback from the Code’s Steering Group and 17 individuals/organisations from across the UK. The Code was launched in September 2013, at the start of an 18-month pilot phase of operation, in which the Code will be further developed, and is available online: http://www.iucn-uk-peatlandprogramme.org/peatland-code. There is growing interest in the creation of new markets to facilitate private investment in the provision of ecosystem services, and this was a key emphasis of Defra’s 2011 Natural Environment White Paper. The White Paper led to the formation of an Ecosystem Markets Taskforce to identify business opportunities in the natural environment that recommended the development of a UK Peatland Code in its report in March 2013. Subsequently in May 2013, Defra published an action plan for developing the potential for payments for ecosystem services in which it committed to work in partnership with the IUCN and others to support the testing, development and launch later in 2013 of a pilot UK Peatland Code. UK peatlands are a relevant place to explore the potential to pay for ecosystem services, given the range and importance of ecosystem services that they supply, and that fact that many of these service are not widely or fully paid for via agricultural support payments or by markets. This has led to the degradation of many peatlands through inappropriate burning, overWgrazing and drainage, leading to reductions in carbon storage, water quality and biodiversity. Investing in conserving and restoring peatlands is therefore a key tool to help deliver the UK’s climate change obligations, whilst helping meet other national and international obligations on biodiversity and water quality. Although there is growing interest from the private sector in paying for some of these ecosystem services, and there have been a small number of bilateral agreements to pay for peatland restoration via the Corporate Social Responsibility market, there is a need to develop guidance, frameworks and monitoring to provide sponsors with the confidence necessary to restore peatlands on any significant scale. This Payment for Ecosystem Service (PES) pilot research project therefore conducted the research necessary to develop and launch a UK pilot Peatland Code, designed to support markets that could pay for the restoration and reWwetting of degraded peatlands across the UK. The research project and subsequent Code drew significantly on Defra’s PES Best Practice Guide, first identifying a saleable ecosystem service and prospective buyers and sellers, based on previous work and new market research conducted as part of this project (Phase 1 in the PES Guide). The Code establishes the principles for a peatland PES scheme, and resolves a number of technical issues, to make it possible for buyers and sellers to work together for peatland restoration (Phase 2 in the PES Guide). The Code also provides guidance on contracts and monitoring (Phases 3 and 4 of the PES Guide), and takes a bundled approach to PES (a ‘premium carbon’ scheme that provides a range of coWbenefits), whilst not ruling out the possibility of layered schemes (e.g. using the Code to elicit payments for climate mitigation benefits on top of existing schemes that pay for water quality benefits) (Phase 5 of the PES Guide). The research offers a number of insights into the creation of markets for ecosystem services linked to peatland restoration. It also offers insights of more general relevance to the creation and implementation of new markets for ecosystem services, which may be of relevance to other habitats and ecosystems in the UK, and to the development of new PES schemes internationally

A qualitative study of cardiovascular disease risk communication in NHS Health Check using different risk calculators: protocol for the RIsk COmmunication in NHS Health Check (RICO) study. BMC family practice, 20(1), 11.

Background NHS Health Check is a national cardiovascular disease (CVD) risk assessment programme for 40–74 year olds in England, in which practitioners should assess and communicate CVD risk, supported by appropriate risk-management advice and goal-setting. This requires effective communication, to equip patients with knowledge and intention to act. Currently, the QRISK®2 10-year CVD risk score is most common way in which CVD risk is estimated. Newer tools, such as JBS3, allow manipulation of risk factors and can demonstrate the impact of positive actions. However, the use, and relative value, of these tools within CVD risk communication is unknown. We will explore practitioner and patient CVD risk perceptions when using QRISK®2 or JBS3, the associated advice or treatment offered by the practitioner, and patients’ responses. Methods RIsk COmmunication in NHS Health Check (RICO) is a qualitative study with quantitative process evaluation. Twelve general practices in the West Midlands of England will be randomised to one of two groups: usual practice, in which practitioners use QRISK®2 to assess and communicate CVD risk; intervention, in which practitioners use JBS3. Twenty Health Checks per practice will be video-recorded (n = 240, 120 per group), with patients stratified by age, gender and ethnicity. Post-Health Check, video-stimulated recall (VSR) interviews will be conducted with 48 patients (n = 24 per group) and all practitioners (n = 12–18), using video excerpts to enhance participant recall/reflection. Patient medical record reviews will detect health-protective actions in the first 12-weeks following a Health Check (e.g., lifestyle referrals, statin prescription). Risk communication, patient response and intentions for health-protective behaviours in each group will be explored through thematic analysis of video-recorded Health Checks (using Protection Motivation Theory as a framework) and VSR interviews. Process evaluation will include between-group comparisons of quantitatively coded Health Check content and post-Health Check patient outcomes. Finally, 10 patients with the most positive intentions or behaviours will be selected for case study analysis (using all data sources). Discussion This study will produce novel insights about the utility of QRISK®2 and JBS3 to promote patient and practitioner understanding and perception of CVD risk and associated implications for patient intentions with respect to health-protective behaviours (and underlying mechanisms). Recommendations for practice will be developed

Outcome of malignant spinal cord compression at a cancer center: Implications for palliative care services

One hundred sixty-six patients presented to a cancer center with malignant spinal cord compression (SCC) proven by magnetic resonance imaging (MRI). The majority of patients (92%) were treated with radiotherapy. Changes in functional capability over time were assessed using performance (PS) and neurological status (NS). Over the course of treatment, there was no significant change in PS or NS. The median survival from confirmation of SCC was 82 days (range 1-1349 days). Survival was significantly better for those presenting with good functional status. One hundred thirteen patients (68%) were discharged from hospital; 88 (78%) were discharged home, 11% were sent to another hospital, 4% were transferred to a rehabilitation unit, and 5% went to a hospice. Fifty-three patients (32%) died before discharge. The confirmation that PS and NS have prognostic significance in the functional outcome of patients with SCC may prove helpful in decisions regarding care planning for individual patients with SCC who are discharged from hospital. J Pain Symptom Manage 2000;19:257-264. (C) U.S. Cancer Pain Relief Committee, 2000

Psychological interventions for improving adherence to inhaled therapies in people with cystic fibrosis

Background: Adherence to treatment, including inhaled therapies, is low in people with cystic fibrosis (CF). Although psychological interventions for improving adherence to inhaled therapies in people with CF have been developed, no previous published systematic review has evaluated the evidence for efficacy of these interventions. Objectives: The primary objective of the review was to assess the efficacy of psychological interventions for improving adherence to inhaled therapies in people with cystic fibrosis (CF). The secondary objective was to establish the most effective components, or behaviour change techniques (BCTs), used in these interventions. Search methods: We searched the Cochrane Cystic Fibrosis Trials Register, which is compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched databases (PubMed; PsycINFO; EBSCO; Scopus; OpenGrey), trials registries (World Health Organization International Clinical Trials Registry Platform; US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov), and the reference lists of relevant articles and reviews, with no restrictions on language, year or publication status. Date of search: 7 August 2022. Selection criteria: We included randomised controlled trials (RCTs) comparing different types of psychological interventions for improving adherence to inhaled therapies in people with CF of any age, or comparing psychological interventions with usual care. We included quasi-RCTs if we could reasonably assume that the baseline characteristics were similar in both groups. Data collection and analysis: Two review authors independently assessed trial eligibility and completed data extraction, risk of bias assessments, and BCT coding (using the BCT Taxonomy v1) for all included trials. We resolved any discrepancies by discussion, or by consultation with a third review author as necessary. We assessed the certainty of the evidence using GRADE. Main results: We included 10 trials (1642 participants) in the review (children and adolescents in four trials; adults in five trials; and children and adults in one trial). Nine trials compared a psychological intervention with usual care; we could combine data from some of these in a number of quantitative analyses. One trial compared a psychological intervention with an active comparator (education plus problem-solving (EPS)). We identified five ongoing trials. Psychological interventions were generally multi-component and complex, containing an average of 9.6 BCTs (range 1 to 28). The two most commonly used BCTs included 'problem-solving' and 'instruction on how to perform the behaviour'. Interventions varied in their type, content and mode of delivery. They included a problem-solving intervention; a paper-based self-management workbook; a telehealth intervention; a group training programme; a digital intervention comprising medication reminders and lung function self-monitoring; a life-coaching intervention; a motivational interviewing (MI) intervention; a brief MI intervention (behaviour change counselling); and a digital intervention combined with behaviour change sessions. Intervention duration ranged from 10 weeks to 12 months. Assessment time points ranged from six to eight weeks up to 23 months. Psychological interventions compared with usual care. We report data here for the 'over six months and up to 12 months' time point. We found that psychological interventions probably improve adherence to inhaled therapies (primary outcome) in people with CF compared with usual care (mean difference (MD) 9.5, 95% confidence interval (CI) 8.60 to 10.40; 1 study, 588 participants; moderate-certainty evidence). There was no evidence of a difference between groups in our second primary outcome, treatment-related adverse events: anxiety (MD 0.30, 95% CI -0.40 to 1.00; 1 study, 535 participants), or depression (MD -0.10, 95% CI -0.80 to 0.60; 1 study, 534 participants), although this was low-certainty evidence. For our secondary outcomes, there was no evidence of a difference between groups in terms of lung function (forced expiratory volume in one second (FEV1) % predicted MD 1.40, 95% CI -0.20 to 3.00; 1 study, 556 participants; moderate-certainty evidence); number of pulmonary exacerbations (adjusted rate ratio 0.96, 95% CI 0.83 to 1.11; 1 study, 607 participants; moderate-certainty evidence); or respiratory symptoms (MD 0.70, 95% CI -2.40 to 3.80; 1 study, 534 participants; low-certainty evidence). However, psychological interventions may improve treatment burden (MD 3.90, 95% CI 1.20 to 6.60; 1 study, 539 participants; low-certainty evidence). The overall certainty of the evidence ranged from low to moderate across these outcomes. Reasons for downgrading included indirectness (current evidence included adults only whereas our review question was broader and focused on people of any age) and lack of blinding of outcome assessors. Psychological interventions compared with an active comparator. For this comparison the overall certainty of evidence was very low, based on one trial (n = 128) comparing an MI intervention to EPS for 12 months. We are uncertain whether an MI intervention, compared with EPS, improves adherence to inhaled therapies, lung function, or quality of life in people with CF, or whether there is an effect on pulmonary exacerbations. The included trial for this comparison did not report on treatment-related adverse events (anxiety and depression). We downgraded all reported outcomes due to small participant numbers, indirectness (trials included only adults), and unclear risk of bias (e.g. selection and attrition bias). Authors' conclusions: Due to the limited quantity of trials included in this review, as well as the clinical and methodological heterogeneity, it was not possible to identify an overall intervention effect using meta-analysis. Some moderate-certainty evidence suggests that psychological interventions (compared with usual care) probably improve adherence to inhaled therapies in people with CF, without increasing treatment-related adverse events, anxiety and depression (low-certainty evidence). In future review updates (with ongoing trial results included), we hope to be able to establish the most effective BCTs (or 'active ingredients') of interventions for improving adherence to inhaled therapies in people with CF. Wherever possible, investigators should make use of the most objective measures of adherence available (e.g. data-logging nebulisers) to accurately determine intervention effects. Outcome reporting needs to be improved to enable combining or separation of measures as appropriate. Likewise, trial reporting needs to include details of intervention content (e.g. BCTs used); duration; intensity; and fidelity. Large trials with a longer follow-up period (e.g. 12 months) are needed in children with CF. Additionally, more research is needed to determine how to support adherence in 'under-served' CF populations