Family Practice © Oxford University Press 1992
Vol. 9, No. 4 Printed in Great Britain
Health Checks in General Practice: The Patient's Response PAUL NORMAN* AND MARK CONNER**
INTRODUCTION With the introduction of the new general practitioner (GP) contract in April 1990 increased emphasis has been placed on the provision of preventive services in general practice. Particular attention has been focused on the dual goals of "surveillance for disease, disability and other problems, and general advice and counselling on the maintenance of good health and well-being by the adoption of a healthy lifestyle".1 Both these goals can be achieved through the provision of health checks. However, patients' responses to the provision of health checks in general practice are still to be fully examined. This paper assesses the patient's response in three ways. First, it considers the uptake of health checks in response to different invitation letters. Second, it assesses patients' satisfaction with their invitation letters and information received at the health check. Third, it examines the effect attendance at a health check has on patients' health beliefs. Considering the uptake of health checks firstly, early studies have shown this to have been mixed with a 53"% attendance rate,2 for example, not uncommon. This clearly limits their potential effectiveness at a population level and points to the need to identify effective ways of inviting patients to health checks. To date, two main invitation methods have been sug• Department of Psychology, University College of Swansea, Singleton Park, Swansea, SA2 8PP. •• Department of Psychology, University of Leedi, Leeds LS2 9JT.
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gested. The first involves the patient being invited opportunistically by their GP, or another health professional, during a routine consultation. The potential of this approach is great given that over 90"% of patients will consult their GP at least once every 3 years.3 Results obtained by this approach are, on first inspection, impressive. One Oxford practice reported that 94% of patients invited opportunistically attended a health check. However, only 25% of their target population had attended a health check after a period of 2.5 years.4 Inspection of other programmes employing opportunistic invitations leads to similar conclusions.5'6 In contrast, other practices have employed postal invitations to invite patients to health checks. Attendance rates in response to such an approach have been varied, ranging from 36 to 72%.7>8 However, given that the invitation letters can be sent to all the target population, these figures indicate that under certain conditions the sending of invitation letters can lead to high proportions of a target population attending a health check, and it is for this reason that this paper will focus on the use of invitation letters. The challenge is therefore to identify the factors which may influence the uptake of health checks in response to such invitations. It is clear that there are many possible derivatives of an invitation letter. They may differ in length, style and content. Perhaps more importantly they may differ in whether they contain an appointment time for the patient or whether they contain an
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Norman P and Conner M. Health checks in general practice: the patient's response. Family Practice 1992; 9: 481-487. With the advent of the new GP contract, the offering of health checks in general practice is on the increase. This paper assesses the patient's response to this development. Conducted in a single practice and including 872 patients aged between 30 and 41, the study assessed a number of different invitation letters to, and ways of giving feedback to patients at, a health check in terms of the uptake of the service, patients' satisfaction ratings, and changes in patients' health beliefs. A number of important findings emerged. First, almost twice as many patients attended a health check when their invitation letter contained an appointment than when it contained an open invitation. Second, patients' satisfaction with their invitation letters and the information received at the health check was high. However, the health check appeared to increase patients' beliefs in the importance of health professionals in maintaining health. Overall though, the results suggested that the patient's response to the health checks was a positive one, and this may be important in promoting future uptake of preventive services and compliance with advice.
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FAMILY PRACTICE—AN INTERNATIONAL JOURNAL microcomputers into general practice may make this task easier. In short, it is possible to give patients a print-out of the results of their health check and, on the basis of these results, generate 'personalized' letters which identify areas of concern. The present study therefore assessed patients' reactions to such written information in terms of its effect on satisfaction levels. A third way in which the patient's response to health checks can be assessed is by looking at changes in beliefs about their health. Part of the impetus behind the offering of health checks is the need, as articulated in the new GP contract, to "give advice, where appropriate, to a patient in connection with the patient's general health, and in particular about the significance of diet, exercise, the use of tobacco, the consumption of alcohol and the misuse of drugs and solvents".1 It is possible to argue then that a major aim of this advice is for patients to adopt new lifestyles and so take more responsibility for their health. There are no studies, to our knowledge, which have attempted to chart changes in patients' health beliefs as a result of attending a health check. Therefore, this issue was also addressed in the study by examining changes in the value patients place on their health and in their health locus of control beliefs; that is, the extent to which they see their health to be under the influence of internal factors, powerful others and chance. To recap, the present study sought to assess patients' responses to the offering of health checks in general practice, focusing on the use of different invitation letters and different ways of giving feedback at the health check. Patients' responses were assessed in three ways: first, in relation to attendance rates; second, in relation to satisfaction levels; and third, in relation to changes in health beliefs. METHODS Patients The study which forms part of a larger project being conducted by a university department, was conducted in a single rural practice in Norfolk, England, consisting of four GPs with a combined list size of approximately 6500 patients. For the purposes of the study, 872 male and female patients aged between 30 and 41 were selected to be invited to attend a health check at the practice. Invitation Letters The 872 patients were randomly allocated to receive either an invitation letter with an appointment time or an open invitation in which they were asked to contact the practice to make an appointment. Within each group, patients were further allocated to receive either a short invitation letter or a longer one which gave more information about the health check (e.g. the measures which would be taken). However, of the 872 patients who had been selected to be invited to a health check, 54 were removed from
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open invitation asking patients to make their own appointments. It is likely that these differences exert different pressures on patients to attend, and that knowledge of these differences might help explain the range of attendance rates reported for this invitation method. Looking at previous studies, which have been conducted in a number of different practices, it is difficult to draw any firm conclusions as many other factors may have contributed to the results obtained, such as the composition of the target groups (e.g. variations in age, social class) and the practices involved (e.g. size, location). Rather, it is necessary to examine the relative effectiveness of different types of invitation letters when they are running in parallel in a single practice with random allocation of the target group to the different letters under consideration. The study reported here was based on such a comparison and assessed the performance of four invitation letters. In short, the study sought to determine whether invitation letters with an appointment time led to a higher uptake than those containing an open invitation. Similarly, the effectiveness of sending relatively short and long letters was also assessed. The patient's response in terms of the uptake of the service offered is only one way of evaluating the performance of different invitation letters. It is appropriate to look at other responses. Patients' satisfaction with the care provided is one response which is likely to become increasingly important in the planning and development of services in general practice. This has been emphasized in the new GP contract which instructs Family Health Service Authorities to carry out consumer surveys aimed at measuring patients' satisfaction with services they receive.1 In the present context there are two aspects of care which can be examined in terms of patient satisfaction; namely, satisfaction with the way in which the patient is invited and satisfaction with the health check itself. Recent work has shown patients to report high levels of satisfaction with each aspect, with few differences in the perceptions of those invited opportunistically and those by letter.9 The present study aimed to extend this work by examining whether patients who are sent different types of invitation letters report differing levels of satisfaction with the invite and the health check. A further source of influence on patients' satisfaction levels may be the type of information and advice received at the health check. Ley highlighted the link between the quality and amount of information given to patients and both satisfaction10 and compliance." One way in which the information given to patients may be improved is through the provision of information leaflets. These have been found to lead to increased knowledge among patients attending a blood pressure clinic.12 However, the giving of personally relevant written information when patients are presenting with a range of problems may be more difficult.13 In relation to health checks, the recent introduction of
HEALTH CHECKS the study either because they had moved (n = 33), were not at their address (n = 17) or because their GP felt it inappropriate for them to be invited (n = 4 ) . The final sample sizes for the four randomly allocated invitation groups are given in Table 1. Patients who failed to attend their appointment or who failed to respond to the open invitation were not sent a reminder.
Patient Satisfaction Shortly after patients had attended a health check they were sent a questionnaire to assess their perceptions of the way in which they had been invited and the health check itself. On the basis of earlier work,9 two five-item scales were produced to measure satisfaction with the invitation letter and with the health check. All items were scored on seven-point scales. In relation to the invitation letter, the items were concerned with specific aspects of the letter (e.g. "Was it easy to understand what the letter was about?") as well as more general feelings (e.g. "Overall then, how satis-
fied would you say you were with the way in which you were invited?"). Similarly, items concerned with the health check focused on both specific aspects (e.g. "How useful, do you think, was the information given to you?") as well as more general feelings of satisfaction. Both scales were found to have satisfactory levels of internal consistency as measured by Cronbach's alpha14 (0.67, 0.77). The questionnaire was sent by, and returned in a prepaid envelope to, the university department. The confidentiality of the questionnaire was emphasized, as was the fact that no individual responses would be passed back to practice staff. After two mailings, 280 of the 433 patients who attended a health check had returned completed questionnaires (64.7% response rate) concerning their views on the invitation letters and the health check. Patient Health Beliefs In addition to assessing patients' satisfaction with the invitation letters and the health check, the questionnaire sent to patients after they had attended also included items which were combined to produce a number of health belief scales. Four scales were considered; these being health value (four items, e.g. "How often do you think about your health?") and the internal (four items, e.g. "I am directly responsible for my health"), powerful others (four items, e.g. "Health professionals keep me healthy") and the chance (four items, e.g. "When I become ill, it's a matter of fate") subscales of the multidimensional health locus of control (HLOQ scale.1516 Again the scales showed satisfactory levels of internal consistency (health value, alpha = 0.80; internal HLOC, alpha = 0.64; powerful others HLOC, alpha = 0.70, chance HLOC, alpha = 0.70). In order to assess changes in health beliefs following attendance at a health check, patients' responses on these scales were compared to their responses on the same scales measured before they had been sent an invitation. This was achieved through the sending of questionnaires to all patients at the beginning of the project. In total, 225 (52.0%) patients who attended a health check sent back both questionnaires. Data Analysis For the attendance data, chi-square tests were employed to examine differences in uptake between the invitation letters. The patient satisfaction and patient health belief data were analysed using the MANOVA programme of the SPSS-X package. RESULTS Attendance Rates Of the 818 patients who were invited to attend a health check, 433 did so; an overall attendance rate of 52.9%. However, as can be ascertained from Table 1, the sending of letter invitations with appointments was
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The Health Check At the health check patients were seen individually by a practice nurse for between 25 to 30 minutes. Details about a range of health behaviours, including smoking behaviour, alcohol consumption, diet and exercise levels, were ascertained. In addition, some simple clinical measures were taken, such as blood pressure and weight. Where appropriate, patients were invited to attend more specialized health promotion clinics (e.g. quit smoking, weight reduction) at the practice. Feedback about the results of the health check to the patient was given in one of three ways. In the first, patients were given information about their results and appropriate health promotion advice verbally. In the second, as well as receiving verbal feedback and advice, patients also received a computer print-out of the results of their health check which the practice nurse highlighted with a marker pen as appropriate. In the third, in addition to the verbal feedback and the computer print-out, patients also received a 'personalized' letter summarizing their results and giving simple health promotion advice and information about more specialized health promotion clinics at the practice. This letter was generated on the basis of their smoking behaviour, alcohol consumption, blood pressure and weight, which was considered to be either normal or elevated. So, in total 16 different letters were produced to cover the various combinations of normal and elevated levels, with only one of these being given to the patient on the basis of his or her results. The three ways of giving feedback changed on a weekly basis, such that all patients attending a health check during 1 week would receive only verbal feedback, the next week verbal feedback and a computer print-out, and the following week verbal feedback, a computer print-out and a 'personalized' letter. This cycle continued throughout the study.
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found to produce a substantially higher attendance rate (69.7%) than the sending of open invitations (37.1%) (chi-square = 86.98, DF = 1, P < 0.001). In contrast, the length of the letter was found to have no effect on attendance rates (53.3% versus 52.7%) (chi-square = 0.03, DF = 1, NS). TABLE 1 Response to short and long invitation letters containing either an appointment or an open invitation to attend a health check: attendance rates. Figures are numbers (percentages) Letter type
199 200 210 209
Attended 135 143 80 75
(67.8%) (71.5%) (38.3%) (35.9%)
More detailed analysis revealed a number of sex differences in the attendance data with female patients being more likely to attend than male patients (61.7% versus 44.2%) (chi-square = 24.91, DF = 1, P < 0.001). However, the patterning of the attendance rates for each sex was the same, such that both males (60.1% versus 29.7%) (chi-square = 37.83, DF = 1, P < 0.001) and females (78.6% versus 44.7%) (chi-square = 50.30, DF = 1, P < 0.001) were more likely to attend in response to a letter containing an appointment time than one containing an open invitation. Patient Satisfaction As can be seen from the mean scores presented in Table 2, patients' satisfaction with their invitation letters was generally high, although female patients were found to be more satisfied (F = 4.09, DF = 1,277, P < 0.05) as were patients sent open invitations (F = 8.41, DF = 1,277, P < 0.01). Patients' satisfaction ratings for the health check were similarly high, and these ratings were not found to differ according to the type of letter sent, the type of feedback received at the health check or the sex of the patient. However, more detailed analyses revealed a significant interaction between the type of letter (appointment/open) and the type of feedback (verbal/print-out/letter) received for satisfaction with the health check (F = 4.27, DF = 2,27, P < 0.05). This showed that for patients sent an open invitation, the highest satisfaction ratings were obtained when they were given verbal feedback (mean = 5.51) and the lowest when they were given both verbal feedback and a computer print-out of their results (mean = 4.78). In contrast, for those sent letters with appointments the pattern was reversed, such that the lowest satisfaction ratings were obtained when they were given verbal feedback (mean = 4.95) and the
Variable
Satisfaction ratings Invitation Health check mean SD mean SD
Sex Male Female F value
0.98 5.85 0.99 6.10 4.09*
5.08 5.16
Letter Open Appts F value
0.82 6.23 1.06 5.88 8.41"
5.20 5.09
Length Short Long F value
6.04 5.97 0.27
1.05 0.94
5.13 5.14
Feedback Verbal Print-out Letter F value
6.08 5.% 5.97 0.44
1.07 0.90 0.99
1.23 1.22 0.24 1.21 1.23 0.49 1.24 1.21 0.01
5.16 5.15 5.09
1.26 1.22 1.21 0.10
Notes: • P < 0.05, • • P < 0.01. Responses scored on seven point scales, with high values reflecting high satisfaction.
highest when they were given both verbal feedback and a computer print-out of their results (mean = 5.33). Being given verbal feedback, a computer print-out and a 'personalized' letter attracted similar satisfaction ratings for those patients sent an open invitation (mean = 5.21) and those sent an appointment (mean = 5.02). Patient Health Beliefs Changes in patients' health beliefs following attendance at a health check were assessed by comparing responses on the post-health check questionnaire with those on the questionnaire sent out prior to the invitations. Table 3 presents the mean scores on the health belief scales under consideration. The only significant difference found between pre- and post-health check scores revealed an increase in patients' scores on the powerful others HLOC subscale (F = 18.61, DF = 1,224, P < 0.001). More detailed analyses indicated a significant interaction with the sex of the patient (F = 7.66, DF = 1,223, P < 0.01) such that female patients' scores on the powerful others HLOC subscale increased only slightly (3.72 to 3.96) compared with the marked increase for male patients (3.24 to 3.94) which brought their scores up to the level of the female patients. A further interaction was identified between
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Appts/Short Appts/Long Open/Short Open/Long
Invited
TABLE 2 Satisfaction ratings for the invitation letters and the health check as a function of the patient's sex, type of invitation letter received and type of feedback received at the health check (n = 280)
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HEALTH CHECKS
TABLE 3 Health beliefs among patients before receiving an invitation (time I) and after attending a health check (time 2) (n - 225) Health beliefs
Health value Internal HLOC Powerful Others HLOC Chance HLOC
Time 2
Time 1
F values
mean
SD
mean
SD
5.44 4.81 3.54 3.47
1.18 1.05 1.32 1.20
5.33 4.73 3.95 3.60
1.11 1.04 1.14 1.20
0.16 3.06 18.61"* 0.47
• • • / » < 0.001. Responses scored on seven point scales, with high values reflecting strongly held beliefs.
DISCUSSION The present study sought to assess the patient's response to attendance at health checks in general practice. Central to the study was the comparison of a number of different invitation letters and ways of giving feedback about the results of the health check. Three broad assessment criteria were employed: uptake of the service offered, patients' satisfaction with the service and changes in patients' beliefs about their health. In relation to the uptake of the service offered, it was found that by including an appointment in the invitation letter almost twice as many patients (69%) attended a health check than those sent an open invitation (37%). The obtained range of attendance rates mirrors those reported elsewhere for health checks in general practice employing letter invitations,78 with the attendance rate for the letters including an appointment being very similar to the 72% reported in an earlier study which also employed such letters.8 These results are also in line with studies which have compared invitation letters with and without appointments for women attending cervical cytology17 and breast cancer18 screening. Thus, the sending of invitation letters with appointments can be seen to produce greater attendance rates in a number of quite different contexts. In contrast, the length of the invitation letter was found to have no effect on subsequent attendance rates. Finally, the sending of invitation letters was found to bias attendance in favour of female patients. This finding is in contrast with earlier work which showed no such bias in the uptake of health checks in response to letter invitations.8 Turning now to consider patients' satisfaction with their invitation letters, it was found that their satisfaction ratings were generally high, although female patients were found to be more positive about their in-
vitation letters than were male patients. This may reflect a greater previous contact with invitation letters for preventive services and may also explain their • greater uptake of the offer of a health check in this study. In addition, those patients who were sent an open invitation reported themselves as being more satisfied with their invitation letter than those patients sent letters with appointments. One interpretation of this finding is that, as fewer patients sent open invitations attended a health check, those that did would have to have felt particularly positive about the invitation to then make an appointment. An alternative interpretation is that patients who are sent letters with appointments feel under pressure to attend the appointment they have been given, and it is this that is attenuating satisfaction ratings. This possibility is supported by earlier work which has found that, when compared with patients invited opportunistically who could therefore make their own appointments, patients sent letters with appointments were more likely to state that their appointment time was hard to keep.9 The implication for practices who wish to use letter invitations to invite patients to preventive services is that if they include appointments in order to increase uptake, attention needs to be paid to potential suitability of the appointment time. In addition, the option of changing the appointment for a more convenient one needs to be stressed. Patients' satisfaction ratings for the health check were also found to be high, with little variation across the various subgroups. However, a significant interaction was found between the type of invitation letter sent and the type of feedback received at the health check. Examination of the interaction revealed that for those patients sent open invitations, the highest ratings were obtained when they were given only verbal feedback and the lowest when they received verbal feedback and a computer print-out of the results of their health check. This pattern was reversed for those sent invitation letters with appointments. This interaction is difficult to interpret, although it is encouraging that those patients given the most information (i.e. verbal feedback, a computer print-out and a 'personalized' letter) gave high satisfaction ratings which did not
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the sex of the patient and changes in scores on the internal HLOC subscale (F = 4.95, DF = 1,223, P < 0.05). This showed female patients' scores to remain relatively stable (4.68 to 4.71) whilst male patients' scores decreased (5.03 to 4.75) to the level of female patients.
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FAMILY PRACTICE—AN INTERNATIONAL JOURNAL letters with appointments can be seen to be a rather 'hardsell' policy, offering a service whose utility is as yet unproven. Second, in relation to the satisfaction data, some researchers have noted that work which attempts to assess patients' reactions to the services they receive may be influenced by strong social desirability effects.920-21 This may be the case in the present study given the high satisfaction ratings. Furthermore, where significant differences were found in the satisfaction data, the actual differences between satisfaction ratings were quite small. As a result, it is difficult to draw strong conclusions on the basis of the satisfaction data alone. Overall though, the data do suggest that patients' responses to health checks in general practice have been positive. A number of conclusions can be drawn from the results of this study. First, when letter invitations are employed to invite patients to health checks, the inclusion of an appointment will lead to increased uptake. Second, patients' satisfaction with these letters are generally high, although practices should consider the convenience of appointment times sent to patients. Third, patients are generally satisfied with the information they receive at the health check, with the results pointing to further exploration of the use of 'personalized' letters based on the results of the health check. Finally, the apparent increase in patients' beliefs about the role of health professionals in maintaining their health is a worrying finding as it points to the possible medicalization of health promotion. This is potentially at odds with the goals of the new contract which can be seen to place an emphasis on encouraging patients to take more responsibility for their health.
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REFERENCES Department of Health and the Welsh Office. General Practice in the National Health Service. A New Contract. London: HMSO 1989. Pill R, French J, Harding K, Stott N. Invitation to attend a health check in a general practice setting: comparison of attenders and non-attenders. J R Coll Gen Pract 1988; 38: 53-56. Stott NCH, Davis RH. The exceptional potential in each primary care consultation. J R Coll Gen Pract 1979; 29: 201-205. Sacks G, Marsden R. Evaluation of a practice-based programme of health checks: financial costs and success at risk detection. J R Coll Gen Pract 1989; 39: 369-372. Sanders D, Fowler G, Mant D, Fuller A, Jones L, Marzillier J. Randomized controlled trial of antismoking advice by nurses in general practice. J R Coll Gen Pract 1989; 39: 273-276. Norman P, Fitter M. The potential and limitations of opportunistic screening: data from a computer simulation of a general practice screening programme. BrJGenPract 1991; 41: 188-191. Mann JI, Lewis B, Shepherd J, Winder AF, Fenster S, Rose L, Morgan B. Blood lipid concentrations and other cardiovascular risk factors: distributions.
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vary according to the way in which they had been invited. For this reason, the production of 'personalized' letters based on the results of the health check may be preferable, although it is clear that more work into the patient's reception of this kind of information-giving is needed. The third focus of the study was to examine changes in patients' beliefs about their health. This was achieved by sending patients questionnaires prior to them receiving their invites, and again after they had attended a health check. Although the present study only considered a narrow range of health beliefs, concentrating on more general beliefs about health, a number of interesting findings emerged. These showed patients' beliefs about the importance of the role of health professionals in maintaining their health to be stronger after attendance at the health check. More detailed analyses revealed that this was principally due to a shift in the beliefs of male patients. In addition, a similar effect was found in relation to beliefs about the extent to which one's health is under one's own control such that the strength of these beliefs, for male patients, was found to decrease following attendance at a health check. These findings are disappointing inasmuch as part of the impetus behind the offering of health checks and health promotion advice is that patients should take more responsibility for their own health. Instead the health checks appear to be reinforcing, on the part of female patients, and encouraging, on the part of male patients, the view that their health is under the control of powerful others (i.e. health professionals). The effects that such belief changes have on health-relevant behaviours is worthy of further study. Future work should also consider changes among more specific beliefs as a result of attending a health check. Particular emphasis should be placed on beliefs dealing with patients' perceptions of the role of lifestyle factors in promoting health and their motivation to adopt healthier lifestyles. Perhaps most importantly though, future work needs to show that these initiatives produce behavioural change; that is, that patients adopt healthier lifestyles. This may be particularly relevant in relation to the type of feedback patients are given at the health checks. Given that failures to follow advice have been attributed to failures of memory and understanding on the part of the patient,19 the use of 'personalized' letters which are based on patients' results may have considerable potential in both supporting the advice given by health professionals at the health check and encouraging behavioural change. At this point it is worth sounding two cautionary notes. First, one of the main foci of this paper has been on ways of encouraging the uptake of health checks. Put another way, it can be seen to be identifying ways for practices to increase the numbers of patients attending health promotion clinics which, given the funding arrangements of the new OP contract, also increases income. Moreover, the use of invitation
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Norman P. Social learning theory and the prediction of attendance at screening. Psychol Health 1991; 5: 231-239. Wallston KA, Wallston BS. Who is responsible for your health?: the construct of health locus of control. In Sanders G, Suls J (eds) Social Psychology of Health and Illness. Hillsdale, NJ: Erlbaum, 1982. Wilson A, Leeming A. Cervical cytology: a comparison of two call systems. Br Med J 1987; 295: 181-182. Williams EMI, Vessey MP. Randomised trial of two strategies offering women mobile screening for breast cancer. Br Med J 1989; 299: 158-159. Ley P. Comprehension, memory, and the success of communications with the patient. J Inst Health Ed 1972; 10: 23-29. Sullivan D . Opportunistic health promotion: d o patients like it? JR Coll Gen Pract 1988; 38: 24-25. Locker D, Dunt D. Theoretical and methodological issues in sociological studies of consumer satisfaction with medical care. Soc Sci Med 1978; 12: 283-292.
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prevalence and detection in Britain. Br Med J 1988; 296: 1702-1706. Norman P, Fitter M. Predicting attendance at health screening: organisational factors and patients' health beliefs. Counsell Psychol Q 1991; 4: 143-155. Norman P, Fitter M. Patients' views on health screening in general practice. Fam Pract 1991; 8: 129-132. Ley P. Communicating with patients: improving communication, satisfaction and compliance. London: Croom Helm, 1988. Ley P, Jain VK, Skilbeck CE. A method for decreasing patients' medication errors. Psychol Med 1976; 6: 599-601. Laher M, O'Malley K, O'Brien E, O'Hanrahan M, O'Boyle C. Educational value of printed information for patients with hypertension. Br Med J 1981; 282: 1360-1361. Sloan PJM. Survey of patient information booklets. Br MedJ 1984; 288: 915-919. Cronbach LJ. Coefficient alpha and the internal structure of tests. Psychometrika 1951; 16: 297-334.
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Vol. 9, No. 4 Printed in Great Britain
Health Checks in General Practice: The Patient's Response PAUL NORMAN* AND MARK CONNER**
INTRODUCTION With the introduction of the new general practitioner (GP) contract in April 1990 increased emphasis has been placed on the provision of preventive services in general practice. Particular attention has been focused on the dual goals of "surveillance for disease, disability and other problems, and general advice and counselling on the maintenance of good health and well-being by the adoption of a healthy lifestyle".1 Both these goals can be achieved through the provision of health checks. However, patients' responses to the provision of health checks in general practice are still to be fully examined. This paper assesses the patient's response in three ways. First, it considers the uptake of health checks in response to different invitation letters. Second, it assesses patients' satisfaction with their invitation letters and information received at the health check. Third, it examines the effect attendance at a health check has on patients' health beliefs. Considering the uptake of health checks firstly, early studies have shown this to have been mixed with a 53"% attendance rate,2 for example, not uncommon. This clearly limits their potential effectiveness at a population level and points to the need to identify effective ways of inviting patients to health checks. To date, two main invitation methods have been sug• Department of Psychology, University College of Swansea, Singleton Park, Swansea, SA2 8PP. •• Department of Psychology, University of Leedi, Leeds LS2 9JT.
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gested. The first involves the patient being invited opportunistically by their GP, or another health professional, during a routine consultation. The potential of this approach is great given that over 90"% of patients will consult their GP at least once every 3 years.3 Results obtained by this approach are, on first inspection, impressive. One Oxford practice reported that 94% of patients invited opportunistically attended a health check. However, only 25% of their target population had attended a health check after a period of 2.5 years.4 Inspection of other programmes employing opportunistic invitations leads to similar conclusions.5'6 In contrast, other practices have employed postal invitations to invite patients to health checks. Attendance rates in response to such an approach have been varied, ranging from 36 to 72%.7>8 However, given that the invitation letters can be sent to all the target population, these figures indicate that under certain conditions the sending of invitation letters can lead to high proportions of a target population attending a health check, and it is for this reason that this paper will focus on the use of invitation letters. The challenge is therefore to identify the factors which may influence the uptake of health checks in response to such invitations. It is clear that there are many possible derivatives of an invitation letter. They may differ in length, style and content. Perhaps more importantly they may differ in whether they contain an appointment time for the patient or whether they contain an
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Norman P and Conner M. Health checks in general practice: the patient's response. Family Practice 1992; 9: 481-487. With the advent of the new GP contract, the offering of health checks in general practice is on the increase. This paper assesses the patient's response to this development. Conducted in a single practice and including 872 patients aged between 30 and 41, the study assessed a number of different invitation letters to, and ways of giving feedback to patients at, a health check in terms of the uptake of the service, patients' satisfaction ratings, and changes in patients' health beliefs. A number of important findings emerged. First, almost twice as many patients attended a health check when their invitation letter contained an appointment than when it contained an open invitation. Second, patients' satisfaction with their invitation letters and the information received at the health check was high. However, the health check appeared to increase patients' beliefs in the importance of health professionals in maintaining health. Overall though, the results suggested that the patient's response to the health checks was a positive one, and this may be important in promoting future uptake of preventive services and compliance with advice.
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FAMILY PRACTICE—AN INTERNATIONAL JOURNAL microcomputers into general practice may make this task easier. In short, it is possible to give patients a print-out of the results of their health check and, on the basis of these results, generate 'personalized' letters which identify areas of concern. The present study therefore assessed patients' reactions to such written information in terms of its effect on satisfaction levels. A third way in which the patient's response to health checks can be assessed is by looking at changes in beliefs about their health. Part of the impetus behind the offering of health checks is the need, as articulated in the new GP contract, to "give advice, where appropriate, to a patient in connection with the patient's general health, and in particular about the significance of diet, exercise, the use of tobacco, the consumption of alcohol and the misuse of drugs and solvents".1 It is possible to argue then that a major aim of this advice is for patients to adopt new lifestyles and so take more responsibility for their health. There are no studies, to our knowledge, which have attempted to chart changes in patients' health beliefs as a result of attending a health check. Therefore, this issue was also addressed in the study by examining changes in the value patients place on their health and in their health locus of control beliefs; that is, the extent to which they see their health to be under the influence of internal factors, powerful others and chance. To recap, the present study sought to assess patients' responses to the offering of health checks in general practice, focusing on the use of different invitation letters and different ways of giving feedback at the health check. Patients' responses were assessed in three ways: first, in relation to attendance rates; second, in relation to satisfaction levels; and third, in relation to changes in health beliefs. METHODS Patients The study which forms part of a larger project being conducted by a university department, was conducted in a single rural practice in Norfolk, England, consisting of four GPs with a combined list size of approximately 6500 patients. For the purposes of the study, 872 male and female patients aged between 30 and 41 were selected to be invited to attend a health check at the practice. Invitation Letters The 872 patients were randomly allocated to receive either an invitation letter with an appointment time or an open invitation in which they were asked to contact the practice to make an appointment. Within each group, patients were further allocated to receive either a short invitation letter or a longer one which gave more information about the health check (e.g. the measures which would be taken). However, of the 872 patients who had been selected to be invited to a health check, 54 were removed from
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open invitation asking patients to make their own appointments. It is likely that these differences exert different pressures on patients to attend, and that knowledge of these differences might help explain the range of attendance rates reported for this invitation method. Looking at previous studies, which have been conducted in a number of different practices, it is difficult to draw any firm conclusions as many other factors may have contributed to the results obtained, such as the composition of the target groups (e.g. variations in age, social class) and the practices involved (e.g. size, location). Rather, it is necessary to examine the relative effectiveness of different types of invitation letters when they are running in parallel in a single practice with random allocation of the target group to the different letters under consideration. The study reported here was based on such a comparison and assessed the performance of four invitation letters. In short, the study sought to determine whether invitation letters with an appointment time led to a higher uptake than those containing an open invitation. Similarly, the effectiveness of sending relatively short and long letters was also assessed. The patient's response in terms of the uptake of the service offered is only one way of evaluating the performance of different invitation letters. It is appropriate to look at other responses. Patients' satisfaction with the care provided is one response which is likely to become increasingly important in the planning and development of services in general practice. This has been emphasized in the new GP contract which instructs Family Health Service Authorities to carry out consumer surveys aimed at measuring patients' satisfaction with services they receive.1 In the present context there are two aspects of care which can be examined in terms of patient satisfaction; namely, satisfaction with the way in which the patient is invited and satisfaction with the health check itself. Recent work has shown patients to report high levels of satisfaction with each aspect, with few differences in the perceptions of those invited opportunistically and those by letter.9 The present study aimed to extend this work by examining whether patients who are sent different types of invitation letters report differing levels of satisfaction with the invite and the health check. A further source of influence on patients' satisfaction levels may be the type of information and advice received at the health check. Ley highlighted the link between the quality and amount of information given to patients and both satisfaction10 and compliance." One way in which the information given to patients may be improved is through the provision of information leaflets. These have been found to lead to increased knowledge among patients attending a blood pressure clinic.12 However, the giving of personally relevant written information when patients are presenting with a range of problems may be more difficult.13 In relation to health checks, the recent introduction of
HEALTH CHECKS the study either because they had moved (n = 33), were not at their address (n = 17) or because their GP felt it inappropriate for them to be invited (n = 4 ) . The final sample sizes for the four randomly allocated invitation groups are given in Table 1. Patients who failed to attend their appointment or who failed to respond to the open invitation were not sent a reminder.
Patient Satisfaction Shortly after patients had attended a health check they were sent a questionnaire to assess their perceptions of the way in which they had been invited and the health check itself. On the basis of earlier work,9 two five-item scales were produced to measure satisfaction with the invitation letter and with the health check. All items were scored on seven-point scales. In relation to the invitation letter, the items were concerned with specific aspects of the letter (e.g. "Was it easy to understand what the letter was about?") as well as more general feelings (e.g. "Overall then, how satis-
fied would you say you were with the way in which you were invited?"). Similarly, items concerned with the health check focused on both specific aspects (e.g. "How useful, do you think, was the information given to you?") as well as more general feelings of satisfaction. Both scales were found to have satisfactory levels of internal consistency as measured by Cronbach's alpha14 (0.67, 0.77). The questionnaire was sent by, and returned in a prepaid envelope to, the university department. The confidentiality of the questionnaire was emphasized, as was the fact that no individual responses would be passed back to practice staff. After two mailings, 280 of the 433 patients who attended a health check had returned completed questionnaires (64.7% response rate) concerning their views on the invitation letters and the health check. Patient Health Beliefs In addition to assessing patients' satisfaction with the invitation letters and the health check, the questionnaire sent to patients after they had attended also included items which were combined to produce a number of health belief scales. Four scales were considered; these being health value (four items, e.g. "How often do you think about your health?") and the internal (four items, e.g. "I am directly responsible for my health"), powerful others (four items, e.g. "Health professionals keep me healthy") and the chance (four items, e.g. "When I become ill, it's a matter of fate") subscales of the multidimensional health locus of control (HLOQ scale.1516 Again the scales showed satisfactory levels of internal consistency (health value, alpha = 0.80; internal HLOC, alpha = 0.64; powerful others HLOC, alpha = 0.70, chance HLOC, alpha = 0.70). In order to assess changes in health beliefs following attendance at a health check, patients' responses on these scales were compared to their responses on the same scales measured before they had been sent an invitation. This was achieved through the sending of questionnaires to all patients at the beginning of the project. In total, 225 (52.0%) patients who attended a health check sent back both questionnaires. Data Analysis For the attendance data, chi-square tests were employed to examine differences in uptake between the invitation letters. The patient satisfaction and patient health belief data were analysed using the MANOVA programme of the SPSS-X package. RESULTS Attendance Rates Of the 818 patients who were invited to attend a health check, 433 did so; an overall attendance rate of 52.9%. However, as can be ascertained from Table 1, the sending of letter invitations with appointments was
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The Health Check At the health check patients were seen individually by a practice nurse for between 25 to 30 minutes. Details about a range of health behaviours, including smoking behaviour, alcohol consumption, diet and exercise levels, were ascertained. In addition, some simple clinical measures were taken, such as blood pressure and weight. Where appropriate, patients were invited to attend more specialized health promotion clinics (e.g. quit smoking, weight reduction) at the practice. Feedback about the results of the health check to the patient was given in one of three ways. In the first, patients were given information about their results and appropriate health promotion advice verbally. In the second, as well as receiving verbal feedback and advice, patients also received a computer print-out of the results of their health check which the practice nurse highlighted with a marker pen as appropriate. In the third, in addition to the verbal feedback and the computer print-out, patients also received a 'personalized' letter summarizing their results and giving simple health promotion advice and information about more specialized health promotion clinics at the practice. This letter was generated on the basis of their smoking behaviour, alcohol consumption, blood pressure and weight, which was considered to be either normal or elevated. So, in total 16 different letters were produced to cover the various combinations of normal and elevated levels, with only one of these being given to the patient on the basis of his or her results. The three ways of giving feedback changed on a weekly basis, such that all patients attending a health check during 1 week would receive only verbal feedback, the next week verbal feedback and a computer print-out, and the following week verbal feedback, a computer print-out and a 'personalized' letter. This cycle continued throughout the study.
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found to produce a substantially higher attendance rate (69.7%) than the sending of open invitations (37.1%) (chi-square = 86.98, DF = 1, P < 0.001). In contrast, the length of the letter was found to have no effect on attendance rates (53.3% versus 52.7%) (chi-square = 0.03, DF = 1, NS). TABLE 1 Response to short and long invitation letters containing either an appointment or an open invitation to attend a health check: attendance rates. Figures are numbers (percentages) Letter type
199 200 210 209
Attended 135 143 80 75
(67.8%) (71.5%) (38.3%) (35.9%)
More detailed analysis revealed a number of sex differences in the attendance data with female patients being more likely to attend than male patients (61.7% versus 44.2%) (chi-square = 24.91, DF = 1, P < 0.001). However, the patterning of the attendance rates for each sex was the same, such that both males (60.1% versus 29.7%) (chi-square = 37.83, DF = 1, P < 0.001) and females (78.6% versus 44.7%) (chi-square = 50.30, DF = 1, P < 0.001) were more likely to attend in response to a letter containing an appointment time than one containing an open invitation. Patient Satisfaction As can be seen from the mean scores presented in Table 2, patients' satisfaction with their invitation letters was generally high, although female patients were found to be more satisfied (F = 4.09, DF = 1,277, P < 0.05) as were patients sent open invitations (F = 8.41, DF = 1,277, P < 0.01). Patients' satisfaction ratings for the health check were similarly high, and these ratings were not found to differ according to the type of letter sent, the type of feedback received at the health check or the sex of the patient. However, more detailed analyses revealed a significant interaction between the type of letter (appointment/open) and the type of feedback (verbal/print-out/letter) received for satisfaction with the health check (F = 4.27, DF = 2,27, P < 0.05). This showed that for patients sent an open invitation, the highest satisfaction ratings were obtained when they were given verbal feedback (mean = 5.51) and the lowest when they were given both verbal feedback and a computer print-out of their results (mean = 4.78). In contrast, for those sent letters with appointments the pattern was reversed, such that the lowest satisfaction ratings were obtained when they were given verbal feedback (mean = 4.95) and the
Variable
Satisfaction ratings Invitation Health check mean SD mean SD
Sex Male Female F value
0.98 5.85 0.99 6.10 4.09*
5.08 5.16
Letter Open Appts F value
0.82 6.23 1.06 5.88 8.41"
5.20 5.09
Length Short Long F value
6.04 5.97 0.27
1.05 0.94
5.13 5.14
Feedback Verbal Print-out Letter F value
6.08 5.% 5.97 0.44
1.07 0.90 0.99
1.23 1.22 0.24 1.21 1.23 0.49 1.24 1.21 0.01
5.16 5.15 5.09
1.26 1.22 1.21 0.10
Notes: • P < 0.05, • • P < 0.01. Responses scored on seven point scales, with high values reflecting high satisfaction.
highest when they were given both verbal feedback and a computer print-out of their results (mean = 5.33). Being given verbal feedback, a computer print-out and a 'personalized' letter attracted similar satisfaction ratings for those patients sent an open invitation (mean = 5.21) and those sent an appointment (mean = 5.02). Patient Health Beliefs Changes in patients' health beliefs following attendance at a health check were assessed by comparing responses on the post-health check questionnaire with those on the questionnaire sent out prior to the invitations. Table 3 presents the mean scores on the health belief scales under consideration. The only significant difference found between pre- and post-health check scores revealed an increase in patients' scores on the powerful others HLOC subscale (F = 18.61, DF = 1,224, P < 0.001). More detailed analyses indicated a significant interaction with the sex of the patient (F = 7.66, DF = 1,223, P < 0.01) such that female patients' scores on the powerful others HLOC subscale increased only slightly (3.72 to 3.96) compared with the marked increase for male patients (3.24 to 3.94) which brought their scores up to the level of the female patients. A further interaction was identified between
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Appts/Short Appts/Long Open/Short Open/Long
Invited
TABLE 2 Satisfaction ratings for the invitation letters and the health check as a function of the patient's sex, type of invitation letter received and type of feedback received at the health check (n = 280)
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TABLE 3 Health beliefs among patients before receiving an invitation (time I) and after attending a health check (time 2) (n - 225) Health beliefs
Health value Internal HLOC Powerful Others HLOC Chance HLOC
Time 2
Time 1
F values
mean
SD
mean
SD
5.44 4.81 3.54 3.47
1.18 1.05 1.32 1.20
5.33 4.73 3.95 3.60
1.11 1.04 1.14 1.20
0.16 3.06 18.61"* 0.47
• • • / » < 0.001. Responses scored on seven point scales, with high values reflecting strongly held beliefs.
DISCUSSION The present study sought to assess the patient's response to attendance at health checks in general practice. Central to the study was the comparison of a number of different invitation letters and ways of giving feedback about the results of the health check. Three broad assessment criteria were employed: uptake of the service offered, patients' satisfaction with the service and changes in patients' beliefs about their health. In relation to the uptake of the service offered, it was found that by including an appointment in the invitation letter almost twice as many patients (69%) attended a health check than those sent an open invitation (37%). The obtained range of attendance rates mirrors those reported elsewhere for health checks in general practice employing letter invitations,78 with the attendance rate for the letters including an appointment being very similar to the 72% reported in an earlier study which also employed such letters.8 These results are also in line with studies which have compared invitation letters with and without appointments for women attending cervical cytology17 and breast cancer18 screening. Thus, the sending of invitation letters with appointments can be seen to produce greater attendance rates in a number of quite different contexts. In contrast, the length of the invitation letter was found to have no effect on subsequent attendance rates. Finally, the sending of invitation letters was found to bias attendance in favour of female patients. This finding is in contrast with earlier work which showed no such bias in the uptake of health checks in response to letter invitations.8 Turning now to consider patients' satisfaction with their invitation letters, it was found that their satisfaction ratings were generally high, although female patients were found to be more positive about their in-
vitation letters than were male patients. This may reflect a greater previous contact with invitation letters for preventive services and may also explain their • greater uptake of the offer of a health check in this study. In addition, those patients who were sent an open invitation reported themselves as being more satisfied with their invitation letter than those patients sent letters with appointments. One interpretation of this finding is that, as fewer patients sent open invitations attended a health check, those that did would have to have felt particularly positive about the invitation to then make an appointment. An alternative interpretation is that patients who are sent letters with appointments feel under pressure to attend the appointment they have been given, and it is this that is attenuating satisfaction ratings. This possibility is supported by earlier work which has found that, when compared with patients invited opportunistically who could therefore make their own appointments, patients sent letters with appointments were more likely to state that their appointment time was hard to keep.9 The implication for practices who wish to use letter invitations to invite patients to preventive services is that if they include appointments in order to increase uptake, attention needs to be paid to potential suitability of the appointment time. In addition, the option of changing the appointment for a more convenient one needs to be stressed. Patients' satisfaction ratings for the health check were also found to be high, with little variation across the various subgroups. However, a significant interaction was found between the type of invitation letter sent and the type of feedback received at the health check. Examination of the interaction revealed that for those patients sent open invitations, the highest ratings were obtained when they were given only verbal feedback and the lowest when they received verbal feedback and a computer print-out of the results of their health check. This pattern was reversed for those sent invitation letters with appointments. This interaction is difficult to interpret, although it is encouraging that those patients given the most information (i.e. verbal feedback, a computer print-out and a 'personalized' letter) gave high satisfaction ratings which did not
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the sex of the patient and changes in scores on the internal HLOC subscale (F = 4.95, DF = 1,223, P < 0.05). This showed female patients' scores to remain relatively stable (4.68 to 4.71) whilst male patients' scores decreased (5.03 to 4.75) to the level of female patients.
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FAMILY PRACTICE—AN INTERNATIONAL JOURNAL letters with appointments can be seen to be a rather 'hardsell' policy, offering a service whose utility is as yet unproven. Second, in relation to the satisfaction data, some researchers have noted that work which attempts to assess patients' reactions to the services they receive may be influenced by strong social desirability effects.920-21 This may be the case in the present study given the high satisfaction ratings. Furthermore, where significant differences were found in the satisfaction data, the actual differences between satisfaction ratings were quite small. As a result, it is difficult to draw strong conclusions on the basis of the satisfaction data alone. Overall though, the data do suggest that patients' responses to health checks in general practice have been positive. A number of conclusions can be drawn from the results of this study. First, when letter invitations are employed to invite patients to health checks, the inclusion of an appointment will lead to increased uptake. Second, patients' satisfaction with these letters are generally high, although practices should consider the convenience of appointment times sent to patients. Third, patients are generally satisfied with the information they receive at the health check, with the results pointing to further exploration of the use of 'personalized' letters based on the results of the health check. Finally, the apparent increase in patients' beliefs about the role of health professionals in maintaining their health is a worrying finding as it points to the possible medicalization of health promotion. This is potentially at odds with the goals of the new contract which can be seen to place an emphasis on encouraging patients to take more responsibility for their health.
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REFERENCES Department of Health and the Welsh Office. General Practice in the National Health Service. A New Contract. London: HMSO 1989. Pill R, French J, Harding K, Stott N. Invitation to attend a health check in a general practice setting: comparison of attenders and non-attenders. J R Coll Gen Pract 1988; 38: 53-56. Stott NCH, Davis RH. The exceptional potential in each primary care consultation. J R Coll Gen Pract 1979; 29: 201-205. Sacks G, Marsden R. Evaluation of a practice-based programme of health checks: financial costs and success at risk detection. J R Coll Gen Pract 1989; 39: 369-372. Sanders D, Fowler G, Mant D, Fuller A, Jones L, Marzillier J. Randomized controlled trial of antismoking advice by nurses in general practice. J R Coll Gen Pract 1989; 39: 273-276. Norman P, Fitter M. The potential and limitations of opportunistic screening: data from a computer simulation of a general practice screening programme. BrJGenPract 1991; 41: 188-191. Mann JI, Lewis B, Shepherd J, Winder AF, Fenster S, Rose L, Morgan B. Blood lipid concentrations and other cardiovascular risk factors: distributions.
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vary according to the way in which they had been invited. For this reason, the production of 'personalized' letters based on the results of the health check may be preferable, although it is clear that more work into the patient's reception of this kind of information-giving is needed. The third focus of the study was to examine changes in patients' beliefs about their health. This was achieved by sending patients questionnaires prior to them receiving their invites, and again after they had attended a health check. Although the present study only considered a narrow range of health beliefs, concentrating on more general beliefs about health, a number of interesting findings emerged. These showed patients' beliefs about the importance of the role of health professionals in maintaining their health to be stronger after attendance at the health check. More detailed analyses revealed that this was principally due to a shift in the beliefs of male patients. In addition, a similar effect was found in relation to beliefs about the extent to which one's health is under one's own control such that the strength of these beliefs, for male patients, was found to decrease following attendance at a health check. These findings are disappointing inasmuch as part of the impetus behind the offering of health checks and health promotion advice is that patients should take more responsibility for their own health. Instead the health checks appear to be reinforcing, on the part of female patients, and encouraging, on the part of male patients, the view that their health is under the control of powerful others (i.e. health professionals). The effects that such belief changes have on health-relevant behaviours is worthy of further study. Future work should also consider changes among more specific beliefs as a result of attending a health check. Particular emphasis should be placed on beliefs dealing with patients' perceptions of the role of lifestyle factors in promoting health and their motivation to adopt healthier lifestyles. Perhaps most importantly though, future work needs to show that these initiatives produce behavioural change; that is, that patients adopt healthier lifestyles. This may be particularly relevant in relation to the type of feedback patients are given at the health checks. Given that failures to follow advice have been attributed to failures of memory and understanding on the part of the patient,19 the use of 'personalized' letters which are based on patients' results may have considerable potential in both supporting the advice given by health professionals at the health check and encouraging behavioural change. At this point it is worth sounding two cautionary notes. First, one of the main foci of this paper has been on ways of encouraging the uptake of health checks. Put another way, it can be seen to be identifying ways for practices to increase the numbers of patients attending health promotion clinics which, given the funding arrangements of the new OP contract, also increases income. Moreover, the use of invitation
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Norman P. Social learning theory and the prediction of attendance at screening. Psychol Health 1991; 5: 231-239. Wallston KA, Wallston BS. Who is responsible for your health?: the construct of health locus of control. In Sanders G, Suls J (eds) Social Psychology of Health and Illness. Hillsdale, NJ: Erlbaum, 1982. Wilson A, Leeming A. Cervical cytology: a comparison of two call systems. Br Med J 1987; 295: 181-182. Williams EMI, Vessey MP. Randomised trial of two strategies offering women mobile screening for breast cancer. Br Med J 1989; 299: 158-159. Ley P. Comprehension, memory, and the success of communications with the patient. J Inst Health Ed 1972; 10: 23-29. Sullivan D . Opportunistic health promotion: d o patients like it? JR Coll Gen Pract 1988; 38: 24-25. Locker D, Dunt D. Theoretical and methodological issues in sociological studies of consumer satisfaction with medical care. Soc Sci Med 1978; 12: 283-292.
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prevalence and detection in Britain. Br Med J 1988; 296: 1702-1706. Norman P, Fitter M. Predicting attendance at health screening: organisational factors and patients' health beliefs. Counsell Psychol Q 1991; 4: 143-155. Norman P, Fitter M. Patients' views on health screening in general practice. Fam Pract 1991; 8: 129-132. Ley P. Communicating with patients: improving communication, satisfaction and compliance. London: Croom Helm, 1988. Ley P, Jain VK, Skilbeck CE. A method for decreasing patients' medication errors. Psychol Med 1976; 6: 599-601. Laher M, O'Malley K, O'Brien E, O'Hanrahan M, O'Boyle C. Educational value of printed information for patients with hypertension. Br Med J 1981; 282: 1360-1361. Sloan PJM. Survey of patient information booklets. Br MedJ 1984; 288: 915-919. Cronbach LJ. Coefficient alpha and the internal structure of tests. Psychometrika 1951; 16: 297-334.
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