A realistic evaluation approach to understanding the uptake of cardiovascular health checks

  • Ruth Ann Dryden

    Student thesis: Doctoral ThesisDoctor of Philosophy


    Background: Individuals from low socio-economic backgrounds have higher rates of morbidity and premature mortality from cardiovascular risk factors compared to those from more affluent backgrounds.

    Hearty Lives Dundee is a complex intervention which aims to address this health inequality. The intervention targets cardiovascular health checks at population groups who are likely to be at high risk, but tend not to engage with traditional services. Practitioners have tried to increase engagement with the target groups through a number of strategies. These included community and workplace-based assessments, and General Practice-run health checks supported by an outreach facility. The aim of this thesis was to explore what works at increasing patient uptake of cardiovascular health checks, for what groups, in what circumstances, and why?

    Methods: A Realistic Evaluation was undertaken using a mixed methods approach. Routine data was extracted from the Hearty Lives database and descriptive statistics reported on patients attending the community-based opportunistic service and the GP-based service. A total of thirty semi-structured interviews and one focus group (n=5) were conducted with patient attenders and non-attenders of community and General Practice-based health checks. Seven staff from the Hearty Lives programme were also interviewed. Thematic analysis was undertaken using Ritchie and Spencer’s Framework approach.

    Results: Attenders at health checks were more likely to be female and older, regardless of the setting. Uptake varied by the number and type of invitation method. Cardiovascular risk was greater in the target population presenting opportunistically but was confounded by the older age of this group.

    Patient engagement relied on the interaction of a number of factors which varied according to setting; accessibility, invitation method, personal circumstances, cues to action and barriers. A continuum existed from barriers to motivators to attendance depending on the presence or absence of a cue to action, e.g. family history or symptoms. The concept of preventive health checks for cardiovascular disease was not well understood as some patients did not perceive a need to attend without symptoms. Additionally, the health check was viewed as optional by many and not treated with the same seriousness as perceived ‘compulsory’ cancer screenings.

    Discussion: The complex lives of the intended target population merit a range of accessible services to reduce barriers to preventive health care. The Realistic Evaluation approach provided transferable knowledge of how to effectively engage with people from different backgrounds and care utilisation preferences, which could easily inform similar NHS services.
    Date of Award2012
    Original languageEnglish
    SponsorsNHS Tayside & British Heart Foundation
    SupervisorColin McCowan (Supervisor), Markus Themessl-Huber (Supervisor), Brian Williams (Supervisor) & Frank Sullivan (Supervisor)


    • Realistic evaluation
    • Inequalities
    • Cardiovascular disease
    • Mixed methods
    • Health checks
    • Primary Care

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