Feasibility of a behavioural health pilot project in general practice for patients with high cardiovascular disease risk: A qualitative study

Study setting

This qualitative study was part of a larger mixed-methods study that evaluated the acceptability, feasibility, and likely effectiveness of the High Risk Prevention Programme (HRPP). A paper reporting the study’s quantitative findings has previously been published¹⁴. Study participants included patients and healthcare staff working at six aforementioned GP practices. These practices were selected based on geographical location and the size of the practice. Patients recruited to participate in the HRPP study were assigned to a General Practice Nurse (GPN) or Health Promotion Professional (HPP)-led one-to-one consultation programme that lasted for 6 weeks and focused on teaching patients how to self-manage their health behaviours.

Summary of the HRPP intervention

Patients were eligible to participate in the study if (1) they were 40 years old or older, (2) had a general medical services (GMS) or free doctor visit’s card¹, (3) had a high risk of CVD (i.e., having hypertension, overweight/obese, physically inactive, Type 2 diabetes, high cholesterol, 10-year Q-Risk score greater than 20%) and (4) were not enrolled/had no access to an alternative lifestyle behaviour change programme. Eligible patients were contacted by the GP staff via phone inviting them to participate in the HRPP study. It was determined that 9–12 patients would be recruited at each practice.

The intervention’s clinical impact was assessed by routine health tests measuring weight, height, waist circumference, blood glucose, total cholesterol, and interviews examining patients’ self-reported health behaviours, mental health, knowledge about one’s health, and motivation to live a healthier life. Patients filled out these assessments before undergoing the six-week programme (Time 1) and 12 months after completing the programme (Time 2) (see Figure 1)¹⁵.

Figure 1. Timeline of HRPP intervention and it's assessments.

Qualitative evaluation of the intervention

The focus of this paper is to evaluate the acceptability and feasibility of the intervention by analysing qualitative interview data which was collected via semi-structured interviews with a sample of patients and healthcare staff (GPNs and General Practitioners (GPs) who took part in the intervention). The study’s method was guided by the Standards for Reporting Qualitative Research (SRQR) guidelines¹⁶.

A purposive sampling technique was employed to recruit patients for the qualitative interviews. Selected patients who participated in the HRPP intervention were contacted by telephone, inquiring if they also wished to participate in the qualitative interviews. By employing purposive sampling of patients and healthcare staff, the aim was to focus on characteristics of a small sample of the population to answer the key research questions related to the acceptability and feasibility of the HRPP. We are not claiming that the sample that was interviewed in this study is representative of the overall population of patients who come from LSE areas and who are at risk for developing CVD; rather this sample was chosen solely to explore the lived experiences relating to the research questions under study.

Recruitment and interviewing of patients and healthcare staff occurred on an ongoing basis, with patients being recruited and interviewed first (between 14^th April 2021 and 14^th January 2022), followed by healthcare staff (between 22^nd March 2022 and 14^th April 2022). Semi-structured telephone interviews were conducted with both patients and healthcare staff by two researchers with previous experience in qualitative analysis. Due to the COVID-19 pandemic telephone interviews with participants were deemed as a feasible alternative to in-person interviews. The use of Zoom/MS teams was not possible due to several patients reporting difficulties using technologies. All interviews were audio-recorded, transcribed verbatim by a transcription company and anonymised by removing identifiable information related to the patient and the healthcare staff.

Interview questions were open-ended, assessing both patients’ and health care providers’ experiences of the intervention. The interview administered to patients included questions such as: “Did the programme help you manage your health issues?”, “Do you think there is a need for initiatives like this in your community?”. The interview administered to healthcare staff included questions such as: “How was the programme run in your practice?”, “How do you think patients engaged with the programme?” (see Appendix 1).

Researcher characteristics and reflexivity

The first author (ES) was a Research Assistant at the UCD School of Medicine and their prior academic background is in Psychology. The study team also contained other research staff and students at the UCD School of Medicine, and staff from UCD Schools of (1) Public Health, Physiotherapy and Sport Sciences, (2) Nursing, Midwifery and Health Systems, (3) Economics, and (4) Geography. Other members of the study team represented the Irish Heart Foundation, a heart health and stoke charity, as well as healthcare professionals working in health services in Ireland. The study participants were GPs and patients attending general practices involved in the HRPP.

Data analysis

The interview transcripts were analysed by authors JG and GM and audited by senior author WC. NVivo v12 software was used to store the transcribed interviews, perform data analysis identifying quotes for the relevant feasibility themes, and develop the coding scheme by which data was categorized into their respective themes. All members of the research team maintained reflexivity throughout data analysis by having regular meetings in which identified themes were discussed and when necessary, revised to reflect the various components of the model.

Acceptability and feasibility of the intervention were assessed using the inductive thematic analysis approach designed by Braun and Clark¹⁹. Inductive thematic analysis enabled us to use a data-driven/bottom-up approach in analysing the transcripts to find themes that arise from the interviews with study participants. An inductive approach (as opposed to a deductive approach) was chosen to allow emergence of potentially novel themes related to intervention’s acceptability and feasibility that were not previously thought of when designing the interview topics.

Ethics and consent

Ethical approval was granted by the UCD Human Research Ethics Committee on March 5th, 2021 (LS-20-19-Cullen), and the study is compliant with the Declaration of Helsinki. Written informed consent was obtained from the participants (patients and healthcare staff) who agreed to participate in the interview.

Patient interviews

From the 18 patients who were interviewed, 7 were male and 11 were female. Patients on average were 57.31 years old (SD = 8.9). Using the thematic analysis approach, four themes were identified from the interviews with patients (Figure 2).

Figure 2. Themes identified on patient interviews (n=18).

Theme 1: Motivation to change health behaviours

Patients pointed out that by participating in the HRPP, their confidence and motivation to improve their health behaviours had increased.

“I was just getting into the stride of it, getting my exercise in and all of that. I suppose I had confidence with the practice nurse supporting me every week, but I have managed to keep it going myself. As I said, I am very determined to get myself back on track.” — (Patient 15).

Patients also emphasized that the changes in their health behaviours was influenced by the encouragement they received from the programme and the GPN/Health Promotion Professional (HPP).

“I have to say, I found it brilliant. It was the kick-start that I needed. I knew I had to make the changes, but when I got on the programme and started talking to the practice nurse, it gave me the motivation to do what I needed to do.” — (Patient 15).

Theme 2: Practical benefits for patients

Patients thought that their lifestyle (e.g., diet and exercise) had changed after undergoing the intervention.

“I did 17,000 steps just in the garden alone on Monday, Tuesday, and Wednesday, and that was hard work because I was wheelbarrowing and everything. I never took a spray; I never stopped. Before this, I would do five minutes in the garden, then have to take the inhaler, come in for a rest, and go out again. The last three days were hard work, but I felt normal.” — (Patient 13).

They also pointed out that the programme had improved their knowledge about how to better manage their health issues (e.g., blood pressure, weight, cholesterol). They also thought it was beneficial that the intervention was carried out at their local GP practice.

"I thought it was very educational. You see, it suited me perfectly because it’s just up the road from me. The information was brilliant, so I found it very good. I thought it was brilliant.” — (Patient 7).

One patient even reported that a member of their family had improved their health behaviour due to the patient undergoing the intervention.

"I’m trying to introduce that to my daughter, like using olive oil—we use olive oil now in the house, and she also uses it. She’s healthy, but now she’s also trying to cut down on a lot of things, so it’s really worked.” — (Patient 9).

Patients expressed their satisfaction with the support they received from the GPN, since most of them did not have a similar support before partaking in the intervention.

“The practice nurse was great and explained everything to me, including what I should be doing better with my lifestyle, because I was put on blood pressure tablets to regulate my blood pressure. I had no idea before going to the doctor that my blood pressure was high. She started explaining to me about my diet and told me that giving up smoking about five years ago was a good start. She recommended things for me to do and to eat, and I got Vitamin B capsules, which I find great.” — (Patient 1).

Patients who had experience participating in similar intervention studies in the past felt that the previous projects had poor GP involvement, lacked in comprehensiveness and did not properly follow-up patients (as opposed to the HRPP intervention).

“I have done various programs over time, but not like this with a GP. Not in this way.” — (Patient 17).

Theme 3: Challenges experienced by patients

Some patients stated various factors for why they were not able to benefit from the programme.

“It was a bad time, the way things happened, with the young one having Covid, and we all had to isolate in the house. She showed me a few exercises to do at home while we were isolating, so that was good—just a few bits and pieces. As I say, I got very heavy, and I’m still very heavy now. I’m in awful pain with my legs and can’t walk because of arthritis. It’s not healthy—I need to lose a lot of weight because I have a young lad waiting for a kidney transplant, and I could be a possible donor for him. It’s just that it was a bad time for it to happen. I probably would have gotten more done and done better if things had been different.” — (Patient 14).

Furthermore, one patient said they felt let down by the intervention.

“So, I have to say, I was disappointed. I engaged in it and followed everything—all the guidelines—and I didn’t lose any weight. There were no noticeable changes in me. I was strict about it because I was ready to make a change, and I still am. So, that was just disappointing.” — (Patient 17).

Theme 4: Lifestyle management and healthcare supports

Most patients said that they were better able to manage their lifestyle due to the checking in and the support they received from the GPN/HPP.

“I think that aspect of checking in and the support is really a good idea because making life changes like that requires that kind of support. So, I definitely think that’s a good thing to continue with” — (Patient 17).

In terms of support from the healthcare staff, patients liked how the one-to-one aspect of the intervention helped them strengthen their relationship with their local GP practice. Patients also stated that while face-to-face consultations were preferable, telephone consultations were also an acceptable communication method.

“Well, personally, I liked the one-to-one aspect of it and having everything explained to me on a one-to-one level—what to eat and what not to eat—and just building up that relationship with somebody to explain things to you personally.” — (Patient 2).

Interviews with healthcare staff

Healthcare staff consisted of four GPs, four GPNs, one Practice Manager and one Health Promotion Professional (HPP). Seven female and three male healthcare staff participated in the interviews. All the interviewed healthcare staff were delivering the PN-led intervention, except for the one HPP who was delivering the HPP-led intervention. On average, they were working 13.1 years (SD = 10.05) in their respective roles. Four themes were identified from the interviews with the healthcare staff (Figure 3).

Figure 3. Themes identified on healthcare staff interviews (n=10).

Theme 1: Positive experience of the programme and its benefits

Healthcare staff reported improvements in managing overall patient health in their practices when HRPP was introduced. Healthcare staff mentioned observing improvements in their patients’ lifestyles, diets and medication use through the programme’s education and follow-up activities.

“I think the program overall has actually proved quite beneficial, not just for the patients but for us, as healthcare workers, trying to manage patients.” — (Healthcare staff 1 (GPN)).

Healthcare staff also mentioned that the HRPP could leave a positive mark on the local community, in different geographic areas.

“I think programs like this in communities can be extremely valuable. So, I think it’s very valuable across the community in all sorts of areas, to be honest.” — (Healthcare staff 9 (GPN)).

For many healthcare staff it was the first time that they offered such an intervention to their patients. And those who had offered a similar programme before, said that the HRPP programme is unique due to it having a clear structure, having non-medical elements (e.g., diet, exercise aspects) and being rooted in the community.

“I suppose the beauty of this project is that you were rooted in the community, and whenever you had the opportunity to meet the patients, you were meeting them in an environment they were used to—in their own GP clinic.” — (Healthcare staff 6 (HPP)).

Theme 2: Logical challenges

Recruitment difficulties due to the Covid pandemic were highlighted by the healthcare staff as one of the roadblocks for smoothly implementing the intervention. Additionally, several healthcare staff felt they did not have enough time to deliver the intervention.

“It has been challenging at points, mainly because of Covid, and there are a few bottlenecks in the structure of the program, specifically around time constraints and the recruitment of patients.” — (Healthcare staff 6 (HPP)).

According to the healthcare staff, in settings where the intervention was not delivered by the HPP, GPNs were the ones carrying out most of the intervention which posed a significant additional amount of work on their part, often making them feel overburdened.

“I suppose there was a lot of pressure put on the practice nurse. She had to recruit patients, consent them, and then, I suppose, the admin part where she had to upload the consents and contact details before I could contact the patients. That seemed to put a lot of pressure on those practice nurses because it was additional work on top of their regular duties.” — (Healthcare staff 6 (HPP)).

One of the GPNs said that they would not participate in the intervention again if they were offered to do so, due to the added workload.

“If we were offered to do a similar program again in terms of research, we’d probably say no, because it took up so much time [….] As of this year, we’ve got more work than ever, and it was just one of those things that added to your workload—it took up time, involved a lot of filling in scores, uploading information, and calling people in [….]. Generally, I enjoyed it, but I probably wouldn’t sign up for it again, is the truth.” — (Healthcare staff 3 (GPN)).

Theme 3: Patient engagement

Most participants reported a high level of patient engagement with the programme which was enhanced through the interest and motivation generated by the GPN.

“They engaged quite well. I do think that our nurse, who was the one doing it for us, did a lot of follow-ups. She kept the motivation going. I don’t know if they necessarily would have had that without her encouragement. Some probably would, others wouldn’t... I could tell she was keeping them motivated.” — (Healthcare staff 10 (GP)).

However, it was noted that there were inconsistencies in participation over time.

“Some really engaged well for the first six months, but then when you hit the three-month, six-month, and nine-month reviews, they’ve really fallen off, unless they are quite motivated.” — (Healthcare staff 1 (GPN)).

Patient engagement in the programme was also dependent on personal characteristics such as their age, literacy, English-language proficiency and housing status, as reported by some healthcare staff members

“Patients who lacked - their English was not their first language. And, on some occasions, sometimes a family member would come in with them, a daughter or a son and a lot of the education was done through the family who would have a little bit better English.... probably the most challenging group obviously was the homeless group where they don’t have options or the facilities. You know you really have to go through what is being provided for them in a certain setting and trying to get them to make a different choice. You know, have more vegetables and stuff like that but it is very difficult obviously for them” — (Healthcare staff 4 (GPN)).

“I suppose by developing new ideas, they’re more aware that they can push past their own limitations, or what they perceive their limitations to be. One thing that struck me surprisingly was the level of illiteracy among patients. I think I have around 70 patients, and easily five or six of them couldn’t read at all, which just shocked me.” — (Healthcare staff 1 (GPN)).

Additionally, some healthcare staff pointed out that, due to not meeting the study eligibility criteria, private patients and those without a medical or doctor visit card would not be able to access the programme.

“There is a significant gap in Irish healthcare because paradoxically now if you don’t have a medical card you are excluded from the Chronic Disease Prevention Programme and from this and there isn’t another structure you can get involved in it” — (Healthcare staff 8 (GP)).

Some healthcare staff pointed out that the programme should be expanded to include younger patients, which was in line with the aims of the programme from a prevention perspective

“But I think that in a general way, if this was to be expanded, I think that to try to include as many younger patients as possible because I think that we are in a time now when you know obesity, cholesterol values, BPs, we are seeing all that in younger patients. So, I think there is room there for expansion in an age bracket but of course, that is all to do with resources and all the rest” — (Healthcare staff 9 (GPN)).

Ideas on how to increase patient involvement in managing their health were offered by the healthcare staff. One solution proposed was to offer patients more flexible options for participating in the intervention, including choosing the best time for their appointment and weather to attend it in-person or over the phone.

“To improve engagement, I think having the flexibility for patients to decide whether it’s face-to-face or virtual, and the timing of appointments, with an option for flexibility, would probably be the main things that come to mind.” — (Healthcare staff 2 (GP)).

Theme 4: Programme management

Most healthcare staff indicated that most of the programme’s management was done by GPNs.

“I would say it was a semi-team effort, in that probably myself and our nurse, who was organising and doing most of the work for it, did really the bulk of it.” — (Healthcare staff 2 (GP)).

Participants reported using a mix of strategies to engage with patients, which involved both virtual and face-to-face contact.

“I think the majority would prefer face-to-face and maybe find that they engage better in that format rather than virtually. There were some patients who initially declined to take part because they weren’t keen on the virtual aspect of it at all.” — (Healthcare staff 2 (GP)).

They also highlighted the importance of engaging patients in their healthcare and fostering communication between GP and patient during patient visits, which previously was overlooked and lacking. These were also key factors in enhancing patient health awareness and improving patient management.

“It’s a really great avenue to capture them, engage with them, and have an open conversation about their health, then empower them with knowledge going forward.” — (Healthcare staff 6 (HPP)).

Key findings

Our study aimed to investigate the feasibility and acceptability of a novel behavioural health self-management pilot project entitled the High Risk Prevention Programme (HRPP) in general practice setting for patients who come from low socioeconomic (LSE) areas and are at a high risk for developing cardiovascular disease (CVD). Based on our findings, the pilot HRPP was feasible and acceptable with both patients rand healthcare staff reporting positive experiences of participating in the intervention.

During the interview, 17 out of 18 patients reported positive self-perceived lifestyle changes, in terms of eating healthier, exercising more and even positively affecting the health behaviours of other family members. Besides collecting qualitative data from a selected number of participants, quantitative data was collected from all patients pre and post intervention to assess the likely effectiveness of the HRPP programme.

Comparison with existing literature

The HRPP fills a gap in the current literature, providing an intervention that addresses CVD-risk among participants from LSE areas. A key aspect of our intervention, highlighted during the interviews was the improved communication and strengthened relationship between the patient and healthcare staff. Furthermore, patients reported increased motivation to engage in positive health behaviours as a direct result of the encouragement and support received during the intervention. Past studies show that improved patient-provider relationship can increase patient satisfaction, engagement in their healthcare and yield better outcomes regarding managing chronic disease^20,21.

Several healthcare staff in our study pointed out that the intervention added additional workload to their practice, especially overburdening GPNs. Our findings are in line with the current literature that described lack of time and resources as one of the barriers for successful implementation of health interventions/research in a general practice setting^22,23. If the HRPP is implemented at a larger scale, GPN workload must be acknowledged. Previous studies show that GP healthcare staff would be more willing to participate in research studies if their participation was monetarily incentivized^24,25. GPNs could receive payment for their participation in carrying out the intervention and/or their participation in the HRPP could be incorporated into their daily work schedule. In this pilot project, the Health Promotion Professional (HPP) was involved in delivering the intervention in three GP practices. However, future upscaling of the intervention could incorporate additional HPPs in other GP practices to alleviate the work of GPNs.

Methodological challenges

To our knowledge, this study is one of the first to investigate the feasibility of a novel behavioural health self-management intervention targeting patients at a high risk for developing CVD who come from LSE areas. Self-management interventions delivered at GP practices offer a convenient setting for implementing targeted self-management interventions. Our study provides evidence of high perceived acceptability and feasibility.

Several unique challenges were identified with the study population and with implementing the intervention. Patients for whom English was not their first language and/or who lacked literacy skills were hard to reach and often an additional family member had to be present during the intervention sessions to function as the interpreter between the healthcare staff and the patient. Homelessness posed additional challenges in delivering appropriate intervention content to patients. For example, some discussion points (e.g., eating more fruits or vegetables) cannot be easily accomplished by those with limited access to fresh and healthy food and cooking facilities. Additionally, those without a medical card were unable to participate in the intervention. Although medical cards in Ireland are issued to individuals who have low socioeconomic status, there are several people who, due to various reasons, are unable to obtain a medical card²⁶. It is estimated that about 31% of individuals eligible for a medical card in Ireland do not have it 26.

Due to Covid-19 restrictions interviews had to be carried out by telephone. While research shows that telephone interviews tend to be shorter and lack depth compared to email or in-person interviews²⁷, previous research highlights that there are no significant differences between telephone and face-to-face interviews²⁸.

Respondent bias might have occurred during the patient interviews because patients are attending their regular healthcare setting, and the intervention was carried out by the healthcare staff that provides regular healthcare to the patients. Their familiarity might have exacerbated respondent bias and thus affected the reliability of our findings.

Implications for policy and practice

Based on the recommendations received by study participants, the HRPP intervention could be implemented at a larger scale in additional Irish GP practices and future research should investigate the acceptability, feasibility and likely effectiveness of similar interventions targeting other chronic diseases and patients with different demographic characteristics. For example, during the interviews, healthcare staff expressed their wish to provide the intervention to younger patients to enhance the preventive aspect of the HRPP. Research shows that CVD risk is increasing in younger people, thus expansion of the intervention to those under the age of 50 is welcome²⁹. In fact, a second iteration of the HRPP has recently commenced and on this basis, it includes patients from the age of 18 years.

The findings from this study can also inform future policy and practice. Our study could pave the way for future research investigating the feasibility and likely effectiveness of similar self-management behavioural health programmes situated in GP practices. The self-management of chronic diseases has been championed by the HSE as a tool that should be implemented in a variety of healthcare fields, including GP practices when addressing CVD³⁰. The second iteration of the HRPP previously mentioned has also capitalised on this by establishing itself within the new infrastructure and intersectoral work in place from the development of Community Healthcare Networks and Sláintecare Healthy Communities. In this version of the HRPP, Irish Heart Foundation-employed Health Promotion Workers based within Community Specialist Teams link with GPs in local catchment areas to recruit patients that are suitable for the HRPP via GP referral systems. Future interventions could also target other chronic diseases included in the HSE’s ‘Chronic Disease Management Programme’ such as Type 2 diabetes, asthma and chronic obstructive pulmonary disease.