Enhanced Invitations Using the Question-Behavior Effect and Financial Incentives to Promote Health Check Uptake in Primary Care

Abstract

Background Uptake of health checks for cardiovascular risk assessment in primary care in England is lower than anticipated. The question-behavior effect (QBE) may offer a simple, scalable intervention to increase health check uptake. Purpose The present study aimed to evaluate the effectiveness of enhanced invitation methods employing the QBE, with or without a financial incentive to return the questionnaire, at increasing uptake of health checks. Methods We conducted a three-arm randomized trial including all patients at 18 general practices in two London boroughs, who were invited for health checks from July 2013 to December 2014. Participants were randomized to three trial arms: (i) Standard health check invitation letter only; (ii) QBE questionnaire followed by standard invitation letter; or (iii) QBE questionnaire with offer of a financial incentive to return the questionnaire, followed by standard invitation letter. In intention to treat analysis, the primary outcome of completion of health check within 6 months of invitation, was evaluated using a p value of .0167 for significance. Results 12,459 participants were randomized. Health check uptake was evaluated for 12,052 (97%) with outcome data collected. Health check uptake within 6 months of invitation was: standard invitation, 590 / 4,095 (14.41%); QBE questionnaire, 630 / 3,988 (15.80%); QBE questionnaire and financial incentive, 629 / 3,969 (15.85%). Difference following QBE questionnaire, 1.43% (95% confidence interval −0.12 to 2.97%, p = .070); following QBE questionnaire and financial incentive, 1.52% (−0.03 to 3.07%, p = .054). Conclusions Uptake of health checks following a standard invitation was low and not significantly increased through enhanced invitation methods using the QBE.

A systematic review of factors influencing NHS health check uptake: invitation methods, patient characteristics, and the impact of interventions

“…Uptake in the intervention arm was 33.5% compared to 29.3% in the control arm, an absolute difference of 4.2% and a relative difference of 14.3% in NHSHC attendance. However, McDermott and colleagues [25] found that mailing patients a Question-Behaviour Effect questionnaire (with or without an incentive for returning the questionnaire) 1 week before invitation letters did not significantly improve uptake in the intervention groups compared to the control group. These researchers found that uptake was higher for intervention group individuals who returned the questionnaire, but when examining the intervention group as a whole (i.e., in an intention to treat analysis), there was no significant effect of including a questionnaire (p = .070) or a questionnaire plus incentive (p = .054) compared to controls.…”

“…The length of studies (including the follow up period) varied from 6 months [23] to 4 years [22]. Six studies achieved a strong quality assessment rating [9,20,21,[23][24][25] and three achieved a moderate rating [19,22,26]. There were only two randomised controlled trials identified [21,25], with the remaining studies consisting of one observational cohort [9] and six cross sectional studies [19,20,[22][23][24]26].…”

“…Findings on ethnicity presented a mixed picture across the studies: some found that attendance was significantly higher in certain ethnic groups and others found that uptake did not differ by patient ethnicity. Uptake was found to be higher in patients from Asian groups (including South Asian and Asian-Indian groups) [20,[24][25][26]; Black groups (including Black African and Black Caribbean groups) [20,25]; and mixed ethnicity groups [24,25]. Contrary to other findings, Cook and colleagues [26] found that amongst females, uptake rates were lowest for Black African patients, however they observed higher uptake rates amongst Black Caribbean patients of both genders in line with other studies reporting high uptake amongst Black patients.…”

“…Where a significant effect of deprivation on uptake was found, the majority of studies reported that this was due to lower uptake in more deprived groups ( [9,21,25,26]; see Table 5). However, in other studies, this relationship was dependent on whether analyses were adjusted for other factors or not.…”

“…Quintile/tertile 1 refers to the most deprived group. Note that some studies [19,22,25,26] coded deprivation so that quintile/tertile 1 referred to the least deprived group, but that this has been reversed for the current narrative synthesis in order to match other studies' reporting standards and enhance comparability across studies. IMD = Index of Multiple Deprivation, AOR = adjusted odds ratio.…”