[2005-2008] The use of family history in the risk assessment and primary prevention of heart disease
Researcher Name: Paula Saukko and Hannah Farrimond
Affiliated Staff: Philip Evans (Peninsula Medical School), Nadeem Qureshi, Jo Middlemass, Joe Kai, Sarah Armstrong, and Tracey Sachs (Nottingham), Steve Humphries (Cardiovascular Genetics, UCL), Paula Yoon (CDC, Washington)
Project Start Date: 01.01.2005
Project End Date: 01.03.2008
Contact Details: Hannah Farrimond , Paula Saukko , Philip Evans , Nadeem Qureshi , Joe Kai , Steve Humphries h.r.farrimond@ex.ac.uk
Funder: The project is funded by the Department of Health’s Genetics Based Health Services Programme. It is led by Dr Nadeem Qureshi from the Primary Care Team at the University of Nottingham, the qualitative and local study lead being Dr Paula Saukko from Egenis.
Background: Coronary heart disease (CHD) is the leading cause of mortality in the developed world. Epidemiological and genetic studies have indicated that CHD has a genetic component but genetic tests for a susceptibility to heart disease are not on the cards any time soon.Family history of heart disease is, however, a proven risk factor for heart attack and angina, and clinicians are encouraged to assess it as part of global risk evaluation for CHD (which also includes assessment of cholesterol, blood pressure, diabetes and smoking). Clinicians and practice nurses, however, rarely take family history of CHD, and the clinical utility and patient implications of this assessment have not really been evaluated. Knowledge of the impact of family history assessment is therefore needed, particularly as taking family history is increasingly suggested as a preventive strategy for a number of common illnesses.
Aims and Objectives: What are the psychological, behavioural and economic impacts of including a family history of heart disease into routine coronary heart disease (CHD) risk assessments?
What is the impact of being identified as ‘high risk’ of CHD over the short and longer term?
How does family history of heart disease impact on the motivation both to seek treatment and engage in behaviour change?
Research Methods: Quantitative randomised controlled trial with 24 practices in the South West and Nottingham. Twelve practices received risk calculations for patients without family history (controls) and six practices received risk calculations including family history (intervention). High risk participants are followed-up. Questionnaires assessing psychological and behavioural change are given at baseline, two weeks after results and six months later.
Nested qualitative study. ‘High risk’ participants (n=38) are interviewed two weeks and six months later. Six focus groups are also being conducted with clinicians from the family history intervention practices.
Key Findings: For many participants, being identified as ‘high risk’ came initially as a ‘shock’. This was less the case for those with a positive family history. Making sense of being ‘high risk’ was an ongoing process. Participants often switched from feeling vulnerable to feeling not at risk within the same conversation, suggesting their identity as ‘high risk’ is neither stable nor established.
Most ‘high risk’ participants were in older middle-age (55-65) years. As a consequence, many reported co-morbidity, ranging from a bad back to more serious illnesses such as cancer. This had two consequences. For some, it lessened the importance of being identified as at risk of CVD as being ‘the least of my worries’. It also meant that although many participants were keen to change as a consequence of the intervention, they were stopped by physical barriers, particularly in relation to exercise. On the other hand, many in this age group were very engaged with the notion of ‘living a healthy lifestyle’ and further dietary change is possible within this mind-set.
Health is a ‘joint project’ for many couples in this social context. Participants talked about the ‘we’ rather than the ‘I’, particularly in relation to diet and potential changes.
Family history was an orienting factor which motivated the initiation of risk assessments as much as subsequent behaviour changes.
Wider implications for policy: CHD risk assessments and interventions need to take account of the distinct social context of ‘high risk’ participants, particularly in relation to their age, class and their understanding of health as a communal practice.
There may be a case for targeting younger individuals who will be the ‘high risk’ patients of the future as the potential for change may be greater in this age group.
Family history resonates with many individuals as a motivator to seek assessment and monitoring. It should therefore be included in health promotion materials encouraging people to have CVD risk assessments in primary care, as is the case with diabetes.
If family history is to be included as an identifying ‘marker’ of risk in CVD primary prevention, as the current NICE preliminary guidelines are suggesting, further guidance will be needed on how to assess family history and utilise it effectively within clinical consultations, as well as on how to record family history systematically and consistently across the NHS.
Project Update:
Publications: Farrimond, H., Saukko, P.M., Evans, P.H. and Qureshi, N. (in press), 'Making sense of being at ‘high risk’ of coronary heart disease', Psychology and Health.
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