Table 5 Key domains, themes and illustrative quotes

 Environmental context and resources (physical opportunity)

Difficulty identifying eligible patients from records

“I print off the list of patients from and I trawl through them, looking, making sure that they’re all within that bracket, because there’s some that are underage (under 40) and some that are over the age (over 74), so it’s a pain, filtering those patients out, 19-year-olds and 90-odd-year-olds on there” [25]

 Knowledge (psychological capability)

Lack of understanding of CVD risk and purpose of NHS HC

“I’d had cholesterol tests, I’d had weight and height, I’d had more or less the whole health check very recently. So, I phoned up my GP and said ‘Look I’ve just had this’.. . I want to make sure that it’s worth my time and the GP’s time and the NHS time to do it.” [39]

 Environmental context and resources (physical opportunity)

Timing and location of NHS HCs increased attendance

“I mean we have the healthcare assistants are here at 8:30, so they can have early bloods done before they go to work, and the nurse can see them before they go to work, so we’re trying to offer those facilities to people to catch them.” [28]

“It’s very difficult for me to (go to the appointment) and hold on to a nine-to-five job. It means I have to take personal time off from my employer to do this. They don’t give you an option where you can go in the evening. I would have to take it off as annual leave, and do it in my own personal time.” [39]

Conducting NHS HCs in pharmacies

“Oh, very easy, I mean I just walked in there and booked myself in.. . I think I’d gone in the morning and I’d booked in for early afternoon and then went to do some shopping and went back.” [39]

“Some [pharmacies] are really struggling because they are out of town and in locations close to GP practices - which is where the pharmacies get a lot of their business from.” [48]

 Social influences (social opportunity)

Family history of illness

“. . family history is obviously, you know, a huge determinant of various things. OK not completely conclusive, but you know, law of averages, I thought I’m probably OK. So, it just slipped and then I never took up on it.” [39]

“I suppose the fact that my father died relatively young of a heart attack, probably made me fairly aware of the need to try and be healthy.. . I suppose I was thinking everybody needs to be careful when they get to their mid-fifties.” [39]

Interactions with GP/ being told to change

“I didn’t want to find out I had more medical problems, I have epilepsy. And I don’t need a doctor to tell me I need to stop smoking and lose weight.” [39]

 Beliefs about consequences (reflective motivation)

NHS HCs not always perceived beneficial for early detection

Virtually all of the service users (96; 99%) felt that the screening had been of benefit to them, with 29 (30.5%) stating that the screening had identified problems of which they were previously unaware [52].

“I don’t think there is an awful lot of value. I think you’ll pick up a few people a little bit earlier. Now whether that’s worth the cost, obviously it’s great for those individual patients, whether that’s worth the cost of running a programme like this. I’d be amazed if it was. “ [46]

NHS HCs provided opportunity to be proactive about health

“I just think it makes you more aware and if you do have any problems you have the chance to actually, you know, be proactive to it rather than reactive when maybe things are a bit too late.” [29]

 Emotion (automatic motivation)

Anxiety at receiving high risk result

“I got a letter from the doctor’s saying ‘as you are at a high risk of a stroke or heart attack’...well I nearly died, and I thought ‘well what have my results come up as?’ And so of course I made an appointment and I went on. “ [26]

Reassurance as a motivation to attend

“Well in one way it’s a reassurance if there’s nothing wrong. It’s an opportunity to be reminded that you should take care of your health.” [39]

 Knowledge (psychological capability)

HCPs perceptions of patients understanding of CVD risk

Several GPs made the point that the important message to convey to patients was to reduce their risk factors and the accuracy of the figures was less important than this central message [30].

Participants believed that most patients knew what constituted health-enhancing behaviours and the impact of risk behaviours on their health. Therefore, HCPs perceived little need to explain the importance of changing behaviour to patients [17].

HCPs familiarity with guidelines and associated tools

59% had either not heard of (30%) or were very unfamiliar with CMO’s PA guidelines [20].

 Cognitive and interpersonal skills (psychological capability)

HCPs perceived need for training to deliver behavioural support

“[Training] would be good. As I say, we just learnt from our healthcare assistant what to do; basically, it was like kind of on the job training… It would be nice to understand it in depth more, wouldn’t it?” [28]

GPs reported a lack of specific training to implement behaviour change interventions, but some GPs believed that they did not need special training to implement behaviour change interventions. It was viewed as being intrinsic to their medical training [17].

HCP training to communicate risk

“You’ll have all the staff who may not be aware of what harm they could be doing…So I think the person would have to have the skill to know this patient doesn’t wish to know.” [19]

 Memory attention decision processes (psychological capability

Behavioural intervention before pharmacological intervention

Health professionals thought that patients were more likely to take medication rather than make lifestyle changes to reduce risk, as this was easier [30].

There was a view that as lifestyle change is possible, opting for medication as a first line treatment is not the best strategy [25].

 Environmental context and resources (physical opportunity)

Limited time/ resources to deliver NHS HC

The 10-min consultation was considered too short to perform the risk assessment, give patient-centred lifestyle advice, and fully explain any prescribed medication [19].

Appropriate space to deliver NHS HC

“I don’t think you come across very professional when you’re sitting in a kitchen and all huddled round and all on top of each other. And it’s not very nice for the patients, because…quite personal information.” [46]

Computer systems supporting NHS HC delivery

Difficulties with information technology and computer software were mentioned in over half of the studies; 39% of practice managers in one study reported difficulties with the clinical system, software or errors in the existing data [32].

 Social influences (social opportunity)

Taking account of patients’ social context

Nurses considered it important to understand people’s social context, so that conversations about risk could always be individually appropriate [19].

Ten felt that the nurse/HCA failed to provide tailored advice that took into account their individual capabilities… or their particular circumstances such as availability of recreational spaces and childcare issues [27].

 Social/professional role and identity (reflective motivation)

Role clarity in delivering NHS HCs

Some participants felt advocating for behaviour change was an essential part of their job, which by itself was an enough of an incentive [17].

Diversification of pharmacy staff role

The focus was on the benefits of delivering NHS Health Checks in pharmacies, with all feeling it offered immense job satisfaction, promoted the image of the pharmacy and provided a good opportunity for staff development [46].

 Beliefs about consequences (reflective motivation)

Belief that NHS HCs were beneficial in terms of preventive healthcare

“I think it’s a very good idea. We have a very high proportion of our patients who suffer with diabetes, almost 10% of our patients are diabetic so I thought this was an excellent opportunity to screen those earlier and pick them up and then you know be able to do something about it, you know, lifestyle management.” [41]

“I think really this is mass screening and there’s not a great deal of proof behind it…. Not entirely convinced with being told we have to offer a check to everyone.” [46]

Message framing

A frequently reported style was downplaying. Here health care professionals appeared to downplay the individual’s high-risk score by using phrases such as, ‘it is only slightly higher’ if the risk score was, for example, between 20 and 25%. As a consequence, some patients concluded that the risk was not particularly significant [26].

One strategy that many described was to concentrate on risk reduction without actually talking to a patient about risk scores explicitly at all. Thus, lifestyle advice and behaviour change were frequently raised not in terms of a patient’s cardiovascular risk per se, but in more general terms around the idea of maintaining or improving health [19].

 Beliefs about capabilities (reflective motivation)

HCP confidence in discussing and initiating behaviour change

There is a strong belief in the ability of healthcare professionals to motivate patients to change their lifestyle [25].

Pharmacy staff had also required a lot more training than initially anticipated and, even after being given this support, lacked confidence in delivering the new service [48].

 Optimism (reflective motivation)

HCPs varyingly optimistic about patient behaviour change after NHS HC

There was a clear rejection of pessimism about the possibility of lifestyle change [25].

Even if you access them, even if you find out that they’re a really high-risk score then getting these people to take on board you know the lifestyle changes, changes to their diet, exercising more. It’s very difficult to get them to take those changes on [28].

 Environmental context and resources (physical opportunity)

Lack of funded services to refer patients to

Healthcare professionals expressed the importance of making referrals to external lifestyle services to support patients through the behaviour change process, but these services had difficulties with long waiting lists, budget cuts causing the discontinuation of some services and were not always offered at times that suited the working population [17].

 Beliefs about consequences (reflective motivation)

Regular attendance is important

The belief that attending regular appointments would reduce CVD risk predicted adherence to the programme [35].

 Knowledge (psychological capability)

Patient understanding of CVD risk and its implications after NHS HC

Two-thirds of patients ...rating their understanding of the CVD risk score highly (4 or above on a scale of 1 to 5, 5 indicating a high level of understanding) [18].

“The conclusion was I have a 6% chance of getting heart disease, which on one hand sounds good because 6 people out of 100, but then if I’m one of those 6 … so I feel very unclear about it. I thought, well how close to 10 is 6?” [40]

 Environmental context and resources (physical opportunity)

Time and cost as a barrier to adherence

A number of patients, especially from lower socio-economic groups, encountered barriers in adopting healthy eating, citing the cost of eating fresh fruit and vegetables [27].

Social and material factors were not seen as real impediments to lifestyle change [25].

Adherence to behavioural support influenced by mode of communication of risk

A higher proportion [of HCPs] thought that most patients complied with advice received during a consultation with the electronic calculator than the paper risk charts [30].

 Social influences (social opportunity)

Support from others to change

Participants also spoke about the importance of family and friends in supporting the changes they made. The significance of family networks, particularly immediate family relatives, reveals that social ties are an aspect of people’s everyday lives that could enable or constrain desired changes in behaviour [50].

 Social professional role and identity (reflective motivation)

Patient engagement is influenced by HCP role

In some interviews, participants discussed how different clinicians influenced the success of behaviour change interventions. Some thought that if the intervention was delivered by a GP it would have a bigger influence on patients. Others argued that patients might be more open and engaged with interventions delivered by nurses and HCAs, due to the ease of the relationship. One manager thought that patients would be more open in community settings rather than with their healthcare provider [17].

 Beliefs about capabilities (reflective motivation)

Changes perceived to be achievable

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 [34].

 Beliefs about consequences (reflective motivation)

Contradictory guidelines

People showed reluctance to make changes to their lifestyle, noting that any guidance they were given was likely to be subject to change…. stating that previous guidance about healthy eating suggested that the consumption of eggs should be restricted; then the reverse was promoted [26].

Perceptions of what constitutes healthy behaviour

A number of people in this group reported drinking well in excess of the recommended units of alcohol but were unconvinced about how many units were considered harmful:

Pt E: If I go out on a Saturday night, I’ll have 10 pints.

Int: Right, and do you see this as a risk to your health?

Pt E: No because I am only having 10 pints a fortnight – one must balance the other [26].

 Intentions (reflective motivation)

NHS HCs as a ‘wake-up call’

It’s really good. It makes you aware of what problems are around. What you can get and that. It is really good. It teaches you. it’s an eye-opener for people who would want to do things properly [45].

Several people chose not to try and lower their cardiovascular risk because they believed death from a heart attack would be preferable to dying from a protracted illness or living into extreme old age: “I am not afraid of death. If I go, I go but I want it to be quick.” [26]

 Optimism (reflective motivation)

Fatalistic views about disease

“You can be as careful as you want; you can eat as healthily as you want; you can do all the exercise you want and you could still get ill. It is like J’s mother who lived to be 101, smoked like a trooper, never had a cigarette out of her hand and she died of something silly.” [26]

 Intention (reflective motivation)

Likelihood of attending future NHS HC

”I think, well, I eat healthily, you know, and I believe in a healthy lifestyle. I know there are other internal things which could go wrong. But yeah, I would definitely have it again if it came up next week, you know, I didn’t realise it was all about different things.” [29]

 Environmental context and resources (physical opportunity)

Accuracy of recording is compromised by multiple methods of invitation

The combination of opportunistic NHS HCs and the delay in time between patients receiving an invitation and attending an NHS HC also caused problems for participants when reporting quarterly data: ‘a health check received doesn’t correlate for a health check offered [37].