Perceptions of Arabian Gulf Residents and Citizens about Physical Activity and Social Media Awareness Campaigns: A Qualitative Study.

Physical activity (PA) is crucial for preventing chronic diseases, but in Gulf Cooperation Council (GCC) countries (Oman, Bahrain, Kuwait, Qatar, Saudi Arabia, and the United Arab Emirates), PA levels are lower than in developed countries. The Gulf Health Council's social media PA awareness campaign responded to the public's need for discussion and motivation on this topic. A qualitative study was conducted using semi-structured Zoom interviews with 19 participants from GCC countries between 21 September and 21 October 2021. It aimed to explore PA barriers, facilitators, and perceptions of awareness campaigns. Interviews were transcribed, coded, and analyzed thematically. Facilitators for PA included health value, self-efficacy, persistence, variety, familiar consequences, social support, behavior change techniques, time management, starting at young age, and enjoyment. Barriers encompassed outdoor restrictions, limited amenities, age and weight biases, gym-centric views, lack of proficiency, and injury risk. The study also examined social media awareness campaigns' effectiveness, identifying themes like engagement, acceptability, reach, design, presentation, and perceived outcomes. Results underscore the complexity of PA facilitators and barriers in the GCC, highlighting the need for campaigns addressing values, perceptions, social connections, and practical challenges, emphasizing the role of research and public policy in boosting PA levels.

Muslim women's views and experiences of family planning in Saudi Arabia: a qualitative study.

BACKGROUND: Islamic beliefs are associated with decreased contraceptive use compared to other religions, and Muslim women's contraceptive needs are often unmet. Research is needed to provide an in-depth understanding of the complex set of barriers to Muslim women's contraceptive use. Therefore, we aimed to explore Muslim women's awareness and experiences with family planning in Saudi Arabia and investigate barriers to contraceptive use and access to family planning. METHODS: A qualitative study using semi-structured interviews with women in a public hospital, in Riyadh, Saudi Arabia, between January and June 2019. Data was analysed using reflexive thematic analysis. RESULTS: Twenty-eight women participated in the study. Women's contraceptive awareness was limited to two methods. Women expressed positive attitudes towards family planning and did not believe it is forbidden in Islam. Barriers to contraception use included lack of knowledge, misconceptions, fear of side effects, family and community and social norms. Many women expressed that they have the right to use contraception, even if their husbands disapprove. Our findings show that healthcare providers rarely offered contraceptive advice, even when requested. Healthcare providers often prescribe oral contraceptives without offering information on other methods available. CONCLUSION: Our findings suggest that education plays a fundamental role in reproductive autonomy. Men's role in family planning should be encouraged through sharing reproductive responsibility and supporting women's contraceptive choices. Efforts should be directed towards improving women's awareness of different methods of contraception.

Muslim women's perspectives on the barriers to sexually transmitted infections testing and diagnosis in Saudi Arabia.

Background: Muslim women are especially vulnerable to sexually transmitted infections (STI) and are at higher risk of under-detection. Evidence on the unique barriers to STI testing and diagnosis among Muslim communities is severely lacking. Understanding the complexity of accessing STI testing and diagnosis in Muslim communities is an area that requires further exploration. We aimed to explore the multilevel barriers to STI testing and diagnosis among Muslim women. Methods: We conducted qualitative semi-structured interviews informed by the ecological model of health. This study took place in Riyadh Saudi Arabia in 2019 with women aged over 18. Data were analysed using reflexive thematic analysis. Results: Twenty-eight women were interviewed from different ages, marital status, employment, and educational levels. Muslim women's perceived barriers to STI testing and diagnosis included personal, socio-cultural, and service-level barriers. Lack of knowledge about STIs, denial, and underestimating the seriousness of infection and symptoms were among the many individual barriers to STIs testing and diagnosis. Religious views towards extramarital sex and negative views of people with STIs is a significant barrier to STI testing and diagnosis. Lack of patient confidentiality and providers' judgement and mistreatment were also cited as barriers to seeking healthcare. Conclusion: Barriers to STI testing and diagnosis exist on many levels including personal, socio-cultural, religious, and healthcare services, and at policy level. Multilevel interventions are needed to reduce the stigma of STIs and facilitate access to sexual health services among Muslims. It is our recommendation that policy and research efforts are directed to enhance trust in the doctor-patient relationship through better clinical training as well as implementing stricter regulations to protect patients' confidentiality in healthcare settings.

Muslim women's knowledge, views, and attitudes towards sexually transmitted infections in Saudi Arabia: A qualitative study.

BACKGROUND: The cultural sensitivity surrounding sexuality in Islamic communities has an impact on awareness and prevention of sexually transmitted infections (STIs). This study explores Muslim women's knowledge, views, and attitudes towards STIs and people living with HIV/AIDs in Saudi Arabia. METHODS: We conducted qualitative semi-structured interviews with Muslim women from Saudi Arabia. Interviews took place in a public hospital in Riyadh, Saudi Arabia in 2019. Data were transcribed, coded, and analysed using a reflexive thematic analysis. RESULTS: Twenty-eight women were interviewed, the majority were college educated and employed. Participants lacked knowledge about STIs, and there were significant misconceptions. The majority of women expressed extremely negative attitudes towards STIs, particularly towards people living with HIV/AIDS. Participants believed that judgemental attitudes and stigmatisation of people with HIV/AIDS were justified if an infection was transmitted through extramarital sex. Men were believed to be the source of STIs, and STIs were viewed as punishment from God for extramarital sexual relations that are forbidden in Islam. Protection against STIs was believed to be achieved by strengthening religious beliefs. CONCLUSION: Attitudes towards people with STIs, HIV/AIDS in particular, were highly influenced by religious views towards extramarital sex, as well as lack of knowledge and misconceptions. There is an urgent need for accurate information and improved awareness of sexual health including STIs among Muslims in Saudi Arabia. Public health efforts should be directed towards reducing stigma and discrimination against people living with HIV/AIDS in Saudi Arabia and other Islamic communities.

Barriers and facilitators to adopting healthier lifestyle among low-income women in Saudi Arabia: A qualitative study.

INTRODUCTION: Low socioeconomic status (SES) is significantly associated with increased levels of obesity, unhealthy diet, and physical inactivity leading to a higher risk of chronic diseases. This study aimed to explore low SES women's barriers and facilitators to engaging in a healthy lifestyle and their accounts in developing future behaviour change interventions. METHODS: Qualitative study using focus group interviews informed by the Capability Opportunity Motivation-Behavior (COM-B) framework. Interviews were conducted with a convenience sample, and data were analysed using thematic analysis. This study is conducted in partnership with Alnahda Society, a prominent nongovernmental organization in Riyadh, Saudi Arabia. RESULTS: We conducted five focus groups with a total of 29 participants. We identified five overarching themes from the data related to participants' definition of a 'healthy life', the difficulties they face that hinder their engagement with a healthy lifestyle, the methods and reasons for changing health behaviour and participants' views of an ideal future behaviour change intervention. Women's definition of a healthy lifestyle did not only include a healthy diet and physical activity but also emphasized the importance of improving mental wellness. Following a healthy lifestyle, although desired, is not always a priority for women with low SES due to the high cost, lack of availability of healthy options and time constraints. Many women in our sample discussed the need to have a routine and discipline to follow and maintain a healthy lifestyle. Family members' support for behaviour change was discussed as a facilitator to maintaining a healthy lifestyle. Women highlighted several reasons that would motivate them to change their health behaviour, including having or preventing health conditions, improving mental health, and managing weight. Participants also discussed the characteristics of an ideal behaviour change intervention. DISCUSSION: This study suggests that women with low SES are faced with several barriers to adopting a healthy lifestyle. Behaviour change intervention targeting this population needs to be tailored to address these barriers and facilitate behaviour change for people with limited resources. National policies to improve the availability and affordability of healthy options are also needed to reduce health disparities. PATIENT AND PUBLIC CONTRIBUTIONS: Women of low SES who took part in the study were given a chance at the end of each focus group discussion to reflect on the questions and add any areas important to them that were not covered during the interview. Experts working with disadvantaged populations in a nonprofit organization (Alnahda society) contributed to the design of the topic guide.

Systematic Review of Mindfulness-Based Interventions for Weight Management Among Pre- and Post-bariatric Surgery Patients.

Context: Bariatric surgery has been an effective treatment for severe obesity. However, it can be challenging for bariatric-surgery patients to reach and maintain long-term weight loss. Behavioral interventions may be beneficial in reducing weight and improving the psychological outcomes of bariatric patients. Objective: The review intended to evaluate the benefits of mindfulness training for weight management among pre- and postoperative, bariatric-surgery patients and to help determine the design of the most effective mindfulness program for them. Design: The research team performed a systematic narrative review by searching the Medline, Excerpta Medica Database (EMBASE), PsycINFO, Web of Knowledge, PubMed, and CENTRAL databases. The search terms included mindfulness-based therapy, stress reduction, relaxation therapy, meditation, and acceptance and commitment therapy. Eligible studies included those using interventions that examined the impact of mindfulness on weight loss for bariatric-surgery patients. Due to the heterogeneity of the included studies, the research team conducted a narrative synthesis rather than a meta-analysis. Setting: The review took place in the Community Health Sciences Department at the College of Applied Medical Sciences of King Saud University in Riyadh, Kingdom of Saudi Arabia. Outcome Measures: Primary outcomes included indicators of body-weight change, such as kilograms, pounds, or BMIs. Secondary outcomes included changes: (1) in eating behavior, such as in binge eating, grazing behavior, craving behavior, and emotional eating, (2) in caloric intake, (3) in mental health, including a reduction in anxiety or depression, (4) in quality of life, (5) mindfulness acceptability and practice, (6) in physical activity, and (7) in glycated hemoglobin (HbA1c). Results: The research team included eight studies in the review. One study aimed to explore the impact of mindfulness on pre-operative patients, and the remaining seven studies measured the impact among postoperative individuals. Most studies suggested that mindfulness-based interventions can have a positive impact on weight outcomes and eating behaviors. The team also found promising effects for mental health outcomes, including anxiety and depression. It's important to note that the included studies reported no strategies that examined treatment fidelity and the monitoring of an intervention's delivery. Conclusions: Preliminary results suggest that mindfulness-based interventions can be useful in tackling eating disorders and in promoting weight loss among bariatric individuals. Further studies are warranted in this area to make explicit recommendations that inform pre- and post-bariatric guidelines. The field needs further well-developed studies to understand the impact of mindfulness on weight loss in the long term.

Sexual and reproductive health knowledge, perceptions and experiences of women in Saudi Arabia: a qualitative study.

BACKGROUND: There is no formal sexual and reproductive health (SRH) education currently offered in Saudi Arabia. Lack of knowledge and misconceptions are evident among Saudi women, which can lead to negative sexual and reproductive experiences. The aim of this study is to explore Saudi women's SRH knowledge, perceptions and experiences. METHODS: Qualitative semi-structured interviews with Saudi women were conducted. Interviews took place in a public hospital in Riyadh, Saudi Arabia. Interviews were conducted in Arabic, recorded and transcribed verbatim, to allow for thematic analysis of the data. The following themes were identified: experience with menarche, deep-rooted negative views towards sex, difficulty discussing SRH topics, knowledge of sex and reproduction, generational gap, sources of SRH information and the role of the mother. RESULTS: A total of 28 women, both married and unmarried, aged 20-50 years were interviewed. A profound lack of SRH knowledge was observed among Saudi women which contributed greatly to negative experiences both in childhood and adulthood. Lack of knowledge about menstruation often caused emotional distress for young girls, and menarche was associated with bad memories and negative emotions. Lack of knowledge about sexual intercourse and the deep-rooted negative views towards sex were linked with physical and psychological issues for women. Women rarely received information from their parents or teachers and preferred the internet for their SRH information. CONCLUSION: There is a substantial unmet need for SRH education for women in Saudi Arabia. It is our recommendation that SRH education should be tailored to meet Saudi women's unique needs, while understanding specific socio-cultural barriers to SRH education and discussions. Research and policy efforts should be directed towards regulating and producing evidence-based health information on the internet, particularly Arabic language websites.

A community-based, sport-led programme to increase physical activity in an area of deprivation: a qualitative case study.

BACKGROUND: Engaging in physical activity is essential for maintaining mental and physical health but a high proportion of adults are inactive, especially in areas of socioeconomic deprivation. We evaluated a novel exercise referral scheme funded by Sport England and run by a social enterprise in an area of socioeconomic deprivation in inner London. This study aimed to examine the experiences of participants and staff and to identify barriers and facilitators of implementation and participation in this and potentially similar projects. METHODS: Thirty-five semi-structured interviews with project participants (N = 25) and staff members involved with the project (N = 10) were conducted based at one centre in London in 2017/2018. The interview schedule was informed by the Theoretical Domains Framework. Data was analysed using the Framework method and NVivo software. RESULTS: Three themes emerged from the data: 'Not like your regular gym', Individual journeys and Practical aspects of the scheme. Study participants regarded the environment of the project centre as friendly and sociable. The project differed from a commercial gym by offering free or subsidised membership and the participation of people of all sizes and abilities. Classes were provided free of charge and this, together with mentor support, facilitated participation and continuation in the project. Participants reported changes not only in their physical activity level, but also in their physical and mental health. Additionally, their families' lifestyle changes were reported. Difficulties of accessing the project included lack of awareness of the project and lack of engagement from key referring groups. CONCLUSIONS: Providing free or subsidised classes incorporating individualised assessment, follow-up and support appeared to facilitate engagement in physical activity among socioeconomically deprived populations. The supportive social context of the centre was a major facilitator. Differing levels of abilities and health status among participants call for special attention. Increasing community and referrer awareness of available exercise referral schemes and enhancing communication between sources of referrals and project staff may help to address access issues.

Sexually transmitted infection knowledge and attitudes among Muslim women worldwide: a systematic review.

Extramarital sexual relations are forbidden in Islam, and sexual health information is not readily available in Islamic communities, especially for women. This review aimed to explore sexually transmitted infection (STI) knowledge and attitudes among Muslim women worldwide. A systematic review was conducted on seven electronic databases. We included qualitative and quantitative studies of female Muslim participants of reproductive age, focusing on STI knowledge and attitudes. A narrative synthesis approach was used with thematic analysis methods. Eighteen studies conducted in 13 countries were included. Three main themes were identified: poor knowledge and misconceptions; sources of sexual health information and information needs; and cultural influences on STI knowledge and attitudes. Generally, Muslim women had poor knowledge regarding STI signs and symptoms, prevention, diagnosis and treatment, in addition to many misconceptions. Negative attitudes towards people infected with HIV/AIDS were common, and attitudes were highly influenced by misconceptions and insufficient knowledge. Infected women tended to be subjected to more blame and judgement compared to men. While the review summarises knowledge and attitudes of Muslim women worldwide, we excluded studies that did not clearly state that the study participants were Muslim women, hence many countries with Muslim populations are not represented in this review. Negative attitudes towards STIs make it harder for women to access sexual health information, STI prevention and treatment. This review highlights the need for culturally sensitive sexual health education for Muslim women. Future sex education interventions would benefit from considering the wider personal and external barriers.

Factors influencing sexual and reproductive health of Muslim women: a systematic review.

BACKGROUND: In Islamic societies, issues related to sexual and reproductive health (SRH) are rarely discussed and considered sensitive subjects. This review aimed to identify any personal, religious, cultural, or structural barriers to SRH service and education among Muslim women worldwide. METHODS: A search for qualitative and quantitative studies was conducted on seven electronic databases. A narrative synthesis using thematic analysis was conducted. RESULTS: Fifty-nine studies were included from 22 countries: 19 qualitative, 38 quantitative and two mixed methods. Many Muslim women have poor SRH knowledge, and negative attitudes which influence their access to, and use of SRH services. Barriers to contraception use among Muslim women included a lack of basic reproductive knowledge, insufficient knowledge about contraception, misconceptions, and negative attitudes. Women had negative attitudes towards family planning for limiting the number of children but not for child spacing, which reflected religious views towards family planning. Religious and cultural beliefs were barriers to contraception use and access to SRH services and information. Family and the community have a significant impact on women's contraceptive use and access to SRH services. Husband and family opposition played a significant role in contraception access and use. Fear of stigmatization and being labelled as having pre-marital sexual relations among unmarried women acted as the main barrier to accessing contraception and seeking SRH information and services. CONCLUSION: The findings reveal that there are multiple levels of factors that influence Muslim women's SRH. Poor SRH knowledge and practices among Muslim women is complex matter that is affected by personal, community, cultural, religious factors and existing policies and regulations. All these factors overlap and are affected by each other. There is an urgent need for interventions addressing modifiable barriers to SRH education and services to improve knowledge, informed choice and access to services to facilitate better sexual and reproductive wellbeing for Muslim women. It is important to note that while this review aimed to report findings on Muslim women, we acknowledge that significant variations exist within every culture and religion.

Engagement with advice to reduce cardiovascular risk following a health check programme: A qualitative study.

BACKGROUND: The success of a cardiovascular health check programme depends not only on the identification of individuals at high risk of cardiovascular disease (CVD) but also on reducing CVD risk. We examined factors that might influence engagement and adherence to lifestyle change interventions and medication amongst people recently assessed at medium or high risk of CVD (>10% in the next 10 years). METHOD: Qualitative study using individual semi-structured interviews. Data were analysed using the Framework method. RESULTS: Twenty-two participants (12 men, 10 women) were included in the study. Four broad themes are described: (a) the meaning of 'risk', (b) experiences with medication, (c) attempts at lifestyle change, and (d) perceived enablers to longer-term change. The experience of having a health check was mostly positive and reassuring. Although participants may not have understood precisely what their CVD risk meant, many reported efforts to make lifestyle changes and take medications to reduce their risk. Individual's experience with medications was influenced by family, friends and the media. Lifestyle change services and family and friends support facilitated longer-term behaviour change. CONCLUSIONS: People generally appear to respond positively to having a CVD health check and report being motivated towards behaviour change. Some individuals at higher risk may need clearer information about the health check and the implications of being at risk of CVD. Concerns over medication use may need to be addressed in order to improve adherence. Strategies are required to facilitate engagement and promote longer-term maintenance with lifestyle changes amongst high-risk individuals.

Health checks and cardiovascular risk factor values over six years' follow-up: Matched cohort study using electronic health records in England.

BACKGROUND: The National Health Service (NHS) in England introduced a population-wide programme for cardiovascular disease (CVD) prevention in 2009, known as NHS Health Checks. This research aimed to measure the cardiovascular risk management and cardiovascular risk factor outcomes of the health check programme during six years' follow-up. METHODS AND FINDINGS: A controlled interrupted time series study was conducted. Participants were registered with general practices in the Clinical Practice Research Datalink (CPRD) in England and received health checks between 1 April 2010 and 31 December 2013. Control participants, who did not receive a health check, were matched for age, sex, and general practice. Outcomes were blood pressure, body mass index (BMI), smoking, and total cholesterol (TC) and high-density lipoprotein cholesterol (HDL). Analyses estimated the net effect of health check by year, allowing for the underlying trend in risk factor values and baseline differences between cases and controls, adjusting for age, sex, deprivation, and clustering by general practice. There were 127,891 health check participants and 322,910 matched controls. Compared with controls, health check participants had lower BMI (cases mean 27.0, SD 4.8; controls 27.3, SD 5.6, Kg/m2), systolic blood pressure (SBP) (cases 129.0, SD 14.3; controls 129.3, SD 15.0, mm Hg), and smoking (21% in health check participants versus 27% in controls), but total and HDL cholesterol were similar. Health check participants were more likely to receive weight management advice (adjusted hazard ratio [HR] 5.03, 4.98 to 5.08, P < 0.001), smoking cessation interventions (HR 3.20, 3.13 to 3.27, P < 0.001), or statins (HR 1.24, 1.21 to 1.27, P < 0.001). There were net reductions in risk factor values up to six years after the check for BMI (-0.30, -0.39 to -0.20 Kg/m2, P < 0.001), SBP (-1.43, -1.70 to -1.16 mm Hg, P < 0.001), and smoking (17% in health check participants versus 25% in controls; odds ratio 0.90, 0.87 to 0.94, P < 0.001). The main study limitation was that residual confounding may be present because randomisation was not employed; health check-associated measurement introduced differential recording that might cause bias. CONCLUSIONS: Our results suggest that people who take up a health check generally have lower risk factor values than controls and are more likely to receive risk factor interventions. Risk factor values show net reductions up to six years following a health check in BMI, blood pressure, and smoking, which may be of public health importance.

Behaviour change techniques associated with adherence to prescribed exercise in patients with persistent musculoskeletal pain: Systematic review.

PURPOSE: Exercise (planned, structured, repetitive movement) improves pain and function in people with persistent musculoskeletal pain (PMSK), but adherence is often poor. This systematic review evaluates the evidence from randomized controlled trials (RCTs) on the effectiveness of interventions to improve exercise adherence in people with PMSK and describes the content, context, and theoretical underpinning of behaviour change interventions designed to increase adherence. METHODS: Nine electronic databases were searched from inception dates to August 2017. Studies were included if they were RCTs that included adults with PMSK ≥3 months; ≥one measure of exercise adherence, exercise prescribed to both groups, and employed ≥one behaviour change technique (BCT) in the treatment group. Independent data extraction, theory coding, BCT taxonomy coding, and quality assessment using Cochrane Risk of Bias (RoB) tool was conducted by two reviewers. RESULTS: Eight RCTs (five low, three high RoB) met inclusion criteria. Five trials reported between-group differences in exercise adherence, favouring the treatment group. Three trials reported theoretical underpinning. There was moderate evidence that five BCTs, social support, goal setting, instruction of behaviour, demonstration of behaviour, and practice/rehearsal, improved exercise adherence. Interventions employing ≤seven BCTs, unique to those included in the control group, were most effective at enhancing exercise adherence. CONCLUSIONS: Limited moderate-quality evidence supports using a small number of BCTs to enhance exercise adherence in people with PMSK. Further research should explore the associations and synergies between BCTs and explicitly report how theory was utilized. This may inform recommendations for health care professionals working with this population. Statement of contribution What is already known on this subject? Exercise (i.e., planned, structured, repetitive movements) improves pain and function in people with persistent musculoskeletal pain (PMSK). Many people with PMSK do not adhere to exercises prescribed by a health care professional. Little research has explored how to enhance adherence to prescribed exercise in people with PMSK. What does this study add? Moderate-quality evidence from eight trials suggests behaviour change interventions enhance exercise adherence. Social support, goal setting, demonstration, instruction, and rehearsal were employed in effective interventions. Interventions with ≤7 behaviour change techniques were more effective at improving adherence than those employing >7.

Implementing multiple health behaviour change interventions for cardiovascular risk reduction in primary care: a qualitative study.

BACKGROUND: The implementation of multiple health behaviour change interventions for cardiovascular risk reduction in primary care is suboptimal. This study aimed to identify barriers and facilitators to implementing multiple health behaviour change interventions for cardiovascular disease (CVD) risk reduction in primary care. METHODS: Qualitative study using semi-structured interviews informed by the Theoretical Domains Framework. Interviews were conducted with a purposive sample of healthcare professionals working in the implementation of the NHS Health Check programme in London. Data were analysed using the Framework method. RESULTS: Thirty participants were recruited including ten general practitioners, ten practice nurses, seven healthcare assistants and three practice managers from 23 practices. Qualitative analysis identified three main themes: healthcare professionals' conceptualising health behaviour change; delivering multiple health behaviour change interventions in primary care; and delivering the health check programme. Healthcare professionals generally recognised the importance of health behaviour change for CVD risk reduction but were more sceptical about the potential for successful intervention through primary care. Participants identified the difficulty of sustained behaviour change for patients, the lack of evidence for effective interventions and limited access to appropriate resources in primary care as barriers. Discussing changing multiple health behaviours was perceived to be overwhelming for patients and difficult to implement for healthcare professionals with current primary care resources. The health check programme consists of several components that are difficult to fully complete in limited time. CONCLUSIONS: Advancing the prevention agenda will require strategies to support the delivery of behaviour change interventions in primary care. Greater emphasis needs to be given to promoting behaviour change through supportive environmental context. Further research is needed to evaluate current external lifestyle services to improve the intervention outcomes.

Multiple health behaviour change interventions for primary prevention of cardiovascular disease in primary care: systematic review and meta-analysis.

BACKGROUND: It is uncertain whether multiple health behaviour change (MHBC) interventions are effective for the primary prevention of cardiovascular disease (CVD) in primary care. A systematic review and a meta-analysis were performed to evaluate the effectiveness of MHBC interventions on CVD risk and CVD risk factors; the study also evaluated associations of theoretical frameworks and intervention components with intervention effectiveness. METHODS: The search included randomised controlled trials of MHBC interventions aimed at reducing CVD risk in primary prevention population up to 2017. Theoretical frameworks and intervention components were evaluated using standardised methods. Meta-analysis with stratification and meta-regression were used to evaluate intervention effects. RESULTS: We identified 31 trials (36 484 participants) with a minimum duration of 12 months follow-up. Pooled net change in systolic blood pressure (16 trials) was -1.86 (95% CI -3.17 to -0.55; p=0.01) mm Hg; diastolic blood pressure (15 trials), -1.53 (-2.43 to -0.62; p=0.001) mm Hg; body mass index (14 trials), -0.13 (-0.26 to -0.01; p=0.04) kg/m2; serum total cholesterol (14 trials), -0.13 (-0.19 to -0.07; p<0.001) mmol/L. There was no significant association between interventions with a reported theoretical basis and improved intervention outcomes. No association was observed between intervention intensity (number of sessions and intervention duration) and intervention outcomes. There was significant heterogeneity for some risk factor analyses, leading to uncertain validity of some pooled net changes. CONCLUSIONS: MHBC interventions delivered to CVD-free participants in primary care did not appear to have quantitatively important effects on CVD risk factors. Better reporting of interventions' rationale, content and delivery is essential to understanding their effectiveness.

Changes in cardiovascular disease risk and behavioural risk factors before the introduction of a health check programme in England.

A population-based programme of health checks was introduced for adults in England in 2011 for the primary prevention of cardiovascular diseases (CVD) and risk factors management. The aim was to evaluate changes in cardiovascular risk and behavioural risk factors in a health check eligible population in England from 1994 to 2013, by using repeated cross-sectional design using seven surveys of the Health Survey for England. Measures included traditional CVD risk factors and behavioural risk factors. Linear trends were estimated allowing for sampling design. The surveys comprised 49,805 adults aged 45 to 74years; 30,639 were free from cardiovascular comorbidity; 16,041 (52%) had complete data for quantitative risk factors. Between 1994 and 2013, systolic blood pressure decreased by 3.1 (95% confidence interval 2.5 to 3.6) mmHg per decade in men and 5.0 (4.5 to 5.5) in women. Total cholesterol decreased by 0.20 (0.16 to 0.24) mmol/l per decade in men; 0.23 (0.19 to 0.26) in women. Smoking declined by 6% (5% to 8%) per decade in men; 7% (6% - 8%) in women. The proportion with CVD-risk ≥20% declined by 6.8% per decade in men; 2.4% in women. Multiple behavioural risk factors were strongly associated with estimated CVD-risk, but improving trends in traditional CVD risk factors were inconsistent with increasing indicators of adiposity. Long-term declines in traditional risk factors contributed to reductions in estimated CVD-risk prior to the introduction of a health check programme. Behaviour change interventions for multiple risk factor exposures remain a key area for future research.