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BackgroundChronic obstructive pulmonary disease (COPD) and asthma rank among the leading causes of respiratory morbidity, particularly in low- and middle-income countries. This qualitative study aimed to explore the healthcare pathways of patients with chronic respiratory disease, and factors influencing their ability to access healthcare in Vietnam, where COPD and asthma are prevalent.MethodsWe conducted 41 in-depth interviews among patients, including 31 people with COPD, eight with asthma and two with asthma-COPD overlap syndrome. Participants were recruited at provincial- or national-level health facilities in two urban and two rural provinces in Vietnam. The interviews were audio-recorded, transcribed, and analysed using thematic analysis.ResultsPatients’ healthcare pathways were complex and involved visits to multiple health facilities before finally obtaining a definitive diagnosis at a provincial- or national-level hospital. Access to healthcare was affected considerably by participants’ limited knowledge of their respiratory conditions, the availability of social support, especially from family members, the costs of healthcare as well as health system factors (including the coverage of public health insurance, the distance to health facilities, and attitude of healthcare providers).ConclusionThe study demonstrated the need for improved access to timely diagnosis and treatment of chronic lung disease within the lower level of the health system. This can be achieved by enhancing the communication skills and diagnostic capacity of local healthcare workers. Health education programmes for patients and caregivers will contribute to improved control of lung disease.

IntroductionAntimicrobial resistance is a global challenge that threatens our ability to prevent and treat common infectious diseases. Vietnam is affected by high rates of antimicrobial resistant infections, driven by the overuse of antibiotics and the Vietnamese government has recognised antimicrobial resistance as a health security priority. This study aimed to understand how people in Vietnam use antibiotics in community settings, and the factors that impact their practices and decision-making regarding antibiotics.MethodsWe conducted 43 qualitative in-depth interviews with 50 community members in two urban and two rural sites in Vietnam. We conducted iterative, inductive thematic analysis alongside data collection through a process of systematic debriefings based on detailed interview summaries. Through this process, we developed a coding framework that was then applied to transcribed interview data.ResultsFrequent and indiscriminate use of antibiotics was driven by the powerful appeal that antibiotics held for many Vietnamese consumers. Consumers were discerning in making decisions in their purchase and use of antibiotics. Consumers’ decisions were affected by perceptions of what constitutes high-quality medicine (effective, strong, accessible and affordable); privileging symptom control over diagnosis; social constructions of antibiotics as a trusted remedy with embodied evidence of prior efficacy, which is reinforced by advice from trusted sources in their community; and varied, generally incomplete, understanding of the concept of antibiotic resistance and its implications for individuals and for public health.ConclusionAntibiotic use at the community and primary care level in Vietnam is driven by community members’ social and economic response to what constitutes effective healthcare, rather than biomedical logic. Community-based interventions to reduce unnecessary antibiotic use need to engage with the entangled socio-structural factors that ‘resist’ current public health efforts to ration antibiotic use, alongside biomedical drivers. This study has informed the design of a community-based trial to reduce unnecessary antibiotic use.

Objectives To explore how decisions are made in real-life general practice consultations with older patients (65+ years), and examine how general practitioners (GPs) communicate risk and benefit information and evidence, and integrate patient preferences. Methods Secondary analysis of 20 video-recorded consultations with older patients in Australian primary healthcare settings. Consultations were analysed qualitatively using the Framework method and quantitatively using the Observer OPTION5 scale and the Assessing Communication about Evidence and Patient Preferences (ACEPP) tool. Results Overall, Observer OPTION5 and ACEPP scores were low, with mean total scores of 11.3 (out of 100) and 10.4 (out of 40) respectively. Together with qualitative findings, these results suggest that shared decision-making did not occur, and that healthcare options (including anticipated benefits and risks), evidence and patient preferences were rarely discussed in our sample of consultations with older people. GPs often unilaterally made treatment decisions (usually pharmacotherapy) while patients reverted to a passive decision-making role. Conclusion We observed a lack of shared decision-making in our primary care study, with little engagement of older patients in decisions about their health. Practice implications Training and support tools may be needed to enhance the capacity and self-efficacy of providers and older patients to share healthcare decisions.

BackgroundOf the estimated 10 million people affected by (TB) each year, one-third are never diagnosed. Delayed case detection within the private healthcare sector has been identified as a particular problem in some settings, leading to considerable morbidity, mortality and community transmission. Using unannounced standardised patient (SP) visits to the pharmacies, we aimed to evaluate the performance of private pharmacies in the detection and treatment of TB.MethodsA cross-sectional study was undertaken at randomly selected private pharmacies within 40 districts of Vietnam. Trained actors implemented two standardised clinical scenarios of presumptive TB and presumptive multidrug-resistant TB (MDR-TB). Outcomes were the proportion of SPs referred for medical assessment and the proportion inappropriately receiving broad-spectrum antibiotics. Logistic regression evaluated predictors of SPs’ referral.ResultsIn total, 638 SP encounters were conducted, of which only 155 (24.3%) were referred for medical assessment; 511 (80·1%) were inappropriately offered antibiotics. A higher proportion of SPs were referred without having been given antibiotics if they had presumptive MDR-TB (68/320, 21.3%) versus presumptive TB (17/318, 5.3%; adjusted OR=4.8, 95% CI 2.9 to 7.8). Pharmacies offered antibiotics without a prescription to 89.9% of SPs with presumptive TB and 70.3% with presumptive MDR-TB, with no clear follow-up plan.ConclusionsFew SPs with presumptive TB were appropriately referred for medical assessment by private pharmacies. Interventions to improve appropriate TB referral within the private pharmacy sector are urgently required to reduce the number of undiagnosed TB cases in Vietnam and similar high-prevalence settings.

Objectives Heart age calculators are increasingly popular around the world as a way to promote and communicate cardiovascular disease (CVD) risk assessment to patients/consumers. While they have intuitive appeal, the implicit assumptions behind heart age calculator algorithms have important implications for informed decision making and screening programs. This presentation compares the use of heart age in three countries to illustrate potential problems for disease mongering and inadvertently expanding screening programs, and how to avoid these problems. Methods Analysis of the use of heart age calculators to promote CVD prevention guidelines in the UK, New Zealand and Australia; including content analysis of social media reactions amongst the general public and health professional communities to demonstrate potential problems. Results The different approaches to heart age in different countries illustrates how some design decisions and message targeting can lead to inadvertent harm, in terms of scaring/medicalising low risk people and expanding screening. A recent heart age campaign in the UK caused a backlash from GPs for encouraging cholesterol testing in young people, and led to confusion amongst the 80% of users who received older heart age results and medication recommendations. Apart from being a test for an ‘important health problem’, the Heart Age calculator met none of Public Health England’s own assessment criteria for a potentially useful screening test. In contrast, New Zealand’s heart age calculator has been aimed at GPs with clear explanations of absolute risk that reduce the chance of harm; while Australia is currently trialling a consumer-driven approach that may encourage more testing but avoids explicit medication recommendations. Conclusions This analysis shows how some features of heart age calculators may lead to harms, and how to avoid them. We recommend that the results of heart age calculators should explicitly explain how they relate to the absolute risk of a CVD event, and avoid making recommendations for medication or tests for age groups beyond existing screening programs. When used to encourage younger people to seek unnecessary cholesterol and blood pressure tests, or recommend medication to people at low risk of a heart attack or stroke based on older heart age, they may cause more harm than benefit.

Background Dien Bien Province in northwest Vietnam is predominantly populated with ethnic minority groups, who experience worse maternal and child health outcomes than the general population. Various factors are associated with maternal health care utilisation in Vietnam, including ethnic minority status, which is recognised as a key determinant of inequity in health outcomes. The aim of this study is to explore how and why ethnic minority women utilise maternal health services, and the factors that influence women and families’ decisions to access or not access facility-based care. Methods We used a qualitative approach, interviewing primary health care professionals (n = 22) and key informants (n = 2), and conducting focus groups with Thai and Hmong women (n = 42). A thematic analysis was performed. Results There were three main themes. 1. Prioritising treatment over prevention: women talked about accessing health services for health problems, such as unusual signs or symptoms during pregnancy, and often saw limited utility in accessing services when they felt well, or for a normal physiological event such as childbirth. Health professionals also saw their role as being mainly treatment-oriented, rather than prevention-focused. 2. Modernisation of traditional practices: health professionals and ethnic minority women discussed recent improvements in infrastructure, services, and economic circumstances that had increased access to health services. However, these improvements were less pronounced in Hmong communities, suggesting inequity. 3. Perceptions of quality influenced service utilisation: both health professionals and ethnic minority women perceived primary care facilities to be of lower quality compared to hospital, and some women made decisions about accessing services based on these perceptions, preferring to travel further and spend more to access higher quality services. Health professionals’ perceptions of low service quality appeared to influence their referral practices, with even uncomplicated cases referred to higher level services as a matter of course. Conclusions Primary health care facilities were technically available and accessible to ethnic minority women, however these services were likely to be underutilised if they were perceived to be of low quality. Some women had the means to access higher quality facilities, but others were limited to lower quality facilities, potentially reinforcing inequities in health outcomes. Electronic supplementary material The online version of this article (10.1186/s12884-019-2375-7) contains supplementary material, which is available to authorized users.

ObjectivesTo explore older people’s perspectives and experiences with shared decision-making (SDM) about medication for cardiovascular disease (CVD) prevention.Design, setting and participantsSemi-structured interviews with 30 general practice patients aged 75 years and older in New South Wales, Australia, who had elevated CVD risk factors (blood pressure, cholesterol)orhad received CVD-related lifestyle advice. Data were analysed by multiple researchers using Framework analysis.ResultsTwenty eight participants out of 30 were on CVD prevention medication, half with established CVD. We outlined patient experiences using the four steps of the SDM process, identifying key barriers and challenges: Step 1. Choice awareness: taking medication for CVD prevention was generally not recognised as a decision requiring patient input; Step 2. Discuss benefits/harms options: CVD prevention poorly understood with emphasis on benefits; Step 3. Explore preferences: goals, values and preferences (eg, length of life vs quality of life, reducing disease burden vs risk reduction) varied widely but generally not discussed with the general practitioner; Step 4. Making the decision: overall preference for directive approach, but some patients wanted more active involvement. Themes were similar across primary and secondary CVD prevention, different levels of self-reported health and people on and off medication.ConclusionsResults demonstrate how older participants vary widely in their health goals and preferences for treatment outcomes, suggesting that CVD prevention decisions are preference sensitive. Combined with the fact that the vast majority of participants were taking medications, and few understood the aims and potential benefits and harms of CVD prevention, it seems that older patients are not always making an informed decision. Our findings highlight potentially modifiable barriers to greater participation of older people in SDM about CVD prevention medication and prevention in general.

The NHS ‘Heart Age Test’ has expanded cardiovascular disease (CVD) risk assessment in the UK to include younger people ( 30 years to do the test, stating: ‘Having a heart age older than your chronological age means that you are at a higher risk of having a heart attack or stroke.’ But does older heart age really mean high risk? The calculator will give you an older age if at least one CVD risk factor is higher than the level set as ‘optimal’; but this does not necessarily mean you are at high risk of a CVD event in the next 10 years. Is there evidence to support PHE’s promotion of the Heart Age Test? To find out, we evaluated the Heart Age Test according to PHE’s own UK National Screening Committee (UK NSC) criteria. This analysis suggests heart age is not a good screening test. ### 1. The condition should be an important health problem as judged by its frequency and/or severity CVD is an important health problem. The rate of death from CVD has declined throughout the UK in the last 3 decades,1 but CVD remains the leading cause of death in males and second leading cause of death in females, with around 160 000 people in the UK dying from CVD every year. ### 2. There should be a simple, safe, precise, and validated screening test Though the Heart Age Test calculator is simple and physically safe to use, it is not precise or validated. Heart age is estimated from the lifetime risk of CVD, relative to people of the same age, sex, and ethnicity who have ‘optimal’ risk factor levels (for example, non-smoker, systolic blood pressure

Background: Previous health literacy research has often focused on individual functional health literacy, ignoring the cultural contexts through which many people experience health care. Objective: We aimed to explore the nature of maternal health literacy among ethnic minority women in a low-resource setting in Vietnam. Methods: Using a qualitative approach, we conducted focus groups with 42 pregnant women, mothers, and grandmothers of children younger than age 5 years from the Thai and Hmong ethnic groups. Semi-structured interviews were conducted with key informants and thematic analysis was performed. Key Results: The findings of our thematic analysis aligned well with the concept of distributed health literacy. We found that ethnic minority women drew upon family and social networks of health literacy mediators to share knowledge and understanding, assess and evaluate information, communicate with health professionals, and support decision-making. Family members were also involved in making health decisions that had the potential to negatively affect women and children's health. Conclusions: Family members are an important source of information for ethnic minority women, and they influence decision-making. Relatives and husbands of pregnant women could be included in maternal health education programs to potentially strengthen the health literacy of the whole community. The distributed health literacy concept can be used to strengthen health promotion messages and to reduce the risk of negative health outcomes. [ HLRP: Health Literacy Research and Practice . 2019;3(1):e31–e42.] Plain Language Summary: Distributed health literacy refers to how health literacy skills and practices are distributed through social networks. This concept applies well to the maternal health context in Vietnam. Older women are trusted sources of information, and family influences decision-making during pregnancy. Women's limited autonomy increases the importance of family involvement. Distributed health literacy could be used to strengthen health promotion messages.

Background: Cardiovascular disease (CVD) prevention guidelines are generally based on the absolute risk of a CVD event, but there is increasing interest in using ‘heart age’ to motivate lifestyle change when absolute risk is low. Previous studies have not compared heart age to 5-year absolute risk, or investigated the impact of younger heart age, graphical format, and numeracy. Objective: Compare heart age versus 5-year absolute risk on psychological and behavioral outcomes. Design: 2 (heart age, absolute risk) × 3 (text only, bar graph, line graph) experiment. Setting: Online. Participants: 570 Australians aged 45–64 years, not taking CVD-related medication. Intervention. CVD risk assessment. Measurements: Intention to change lifestyle, recall, risk perception, emotional response, perceived credibility, and lifestyle behaviors after 2 weeks. Results: Most participants had lifestyle risk factors (95%) but low 5-year absolute risk (94%). Heart age did not improve lifestyle intentions and behaviors compared to absolute risk, was more often interpreted as a higher-risk category by low-risk participants (47% vs 23%), and decreased perceived credibility and positive emotional response. Overall, correct recall dropped from 65% to 24% after 2 weeks, with heart age recalled better than absolute risk at 2 weeks (32% vs 16%). These results were found across younger and older heart age results, graphical format, and numeracy. Limitations: Communicating CVD risk in a consultation rather than online may produce different results. Conclusions: There is no evidence that heart age motivates lifestyle change more than 5-year absolute risk in individuals with low CVD risk. Five-year absolute risk may be a better way to explain CVD risk, because it is more credible, does not inflate risk perception, and is consistent with clinical guidelines that base lifestyle and medication recommendations on absolute risk. National Heart Foundation of Australia, NHMRC

Background: Vietnam has made notable progress in reducing maternal mortality rates during the past 2 decades, but this overall improvement conceals regional and ethnic inequalities. Ethnic minorities in Vietnam experience high rates of poverty and mortality, and they face communication and cultural barriers when accessing health services. Poor communication with health professionals combined with limited health literacy is concerning, particularly in the maternal health context, and may exacerbate existing inequalities. Objective: This study explores primary health care professionals' perceptions of the quality of their communication with ethnic minority women during and after pregnancy. Methods: Semi-structured interviews were conducted with 22 primary health care professionals in Dien Bien province. A thematic analysis was performed using a framework analysis method. Key Results: Health professionals had mostly positive perceptions about their communication with ethnic minority women. However, they generally perceived the effectiveness of their communication as being based on women's individual capacities to understand health information (both the language used and the content) and factors such as ethnic and cultural differences, rather than reflecting on the suitability of information and materials or on their own communication skills. This placed much of the burden of communication and understanding health information on ethnic minority women and their families. Conclusions: Health professionals perceived of communication as being mainly a one-way street for the provision of health information, and rarely acknowledged the interactive nature of communication. Patient-professional communication and health literacy in Dien Bien province may be improved through the introduction of patient-centered communication skills training that applies health literacy approaches at the health professional level. [ Health Literacy Research and Practice . 2017;1(4):e163–e172.] Plain Language Summary: We looked at how primary health care professionals in Vietnam perceive their communication with ethnic minority women, particularly about pregnancy. Health professionals generally perceived the quality and effectiveness of their communication as being based on ethnic minority women's individual capacities and limitations. Applying a health literacy approach to communication skills training could improve patient-professional communication and health literacy.

Background: Primary cardiovascular disease (CVD) prevention in older people is challenging as they are a diverse group with varying needs, frequent presence of comorbidities, and are more sus- ceptible to treatment harms. Moreover the potential benefits and harms of preventive medi- cation for older people are uncertain. We explored GPs’ decision making about primary CVD prevention in patients aged 75 years and older. Method: 25 GPs participated in semi-structured interviews in New South Wales, Australia. Tran- scribed audio-recordings were thematically coded and Framework Analysis was used. Results: Analysis identified factors that are likely to contribute to variation in the management of CVD risk in older people. Some GPs based CVD prevention on guidelines regardless of patient age. Others tailored management based on factors such as perceptions of prevention in older age, knowledge of limited evidence, comorbidities, polypharmacy, frailty, and life expectancy. GPs were more confident about: 1) medication and lifestyle change for fit/ healthy older patients, and 2) stopping or avoiding medication for frail/nursing home patients. Decision making for older patients outside of these categories was less clear. Conclusion: Older patients receive different care depending on their GP’s perceptions of ageing and CVD prevention, and their knowledge of available evidence. GPs consider CVD prevention for older patients challenging and would welcome more guidance in this area. NHMRC

Background Guidelines on cardiovascular disease (CVD) risk reassessment intervals are unclear, potentially leading to detrimental practice variation: too frequent can result in overtreatment and greater strain on the healthcare system; too infrequent could result in the neglect of high risk patients who require medication. This study aimed to understand the different factors that general practitioners (GPs) consider when deciding on the reassessment interval for patients previously assessed for primary CVD risk. Methods This paper combines quantitative and qualitative data regarding reassessment intervals from two separate studies of CVD risk management. Experimental study: 144 Australian GPs viewed a random selection of hypothetical cases via a paper-based questionnaire, in which blood pressure, cholesterol and 5-year absolute risk (AR) were systematically varied to appear lower or higher. GPs were asked how they would manage each case, including an open-ended response for when they would reassess the patient. Interview study: Semi-structured interviews were conducted with a purposive sample of 25 Australian GPs, recruited separately from the GPs in the experimental study. Transcribed audio-recordings were thematically coded, using the Framework Analysis method. Results Experiment: GPs stated that they would reassess the majority of patients across all absolute risk categories in 6 months or less (low AR = 52 % [CI95% = 47–57 %], moderate AR = 82 % [CI95% = 76–86 %], high AR = 87 % [CI95% = 82–90 %], total = 71 % [CI95% = 67–75 %]), with 48 % (CI95% = 43–53 %) of patients reassessed in under 3 months. The majority (75 % [CI95% = 70–79 %]) of patients with low-moderate AR (≤15 %) and an elevated risk factor would be reassessed in under 6 months. Interviews: GPs identified different functions for reassessment and risk factor monitoring, which affected recommended intervals. These included perceived psychosocial benefits to patients, preparing the patient for medication, and identifying barriers to lifestyle change and medication adherence. Reassessment and monitoring intervals were driven by patient motivation to change lifestyle, patient demand, individual risk factors, and GP attitudes. Conclusions There is substantial variation in reassessment intervals for patients with the same risk profile. This suggests that GPs are not following reassessment recommendations in the Australian guidelines. The use of shorter intervals for low-moderate AR contradicts research on optimal monitoring intervals, and may result in unnecessary costs and over-treatment. Electronic supplementary material The online version of this article (doi:10.1186/s12875-016-0499-7) contains supplementary material, which is available to authorized users.

Objective: Although current guidelines around the world recommend using absolute risk (AR) thresholds to decide whether cardiovascular disease (CVD) risk should be managed with lifestyle or medication, the use of AR in clinical practice is limited. The aim of this study was to explore the factors that influence general practitioner (GP) and patient decision making about CVD risk management, including the role of risk perception. Methods: Qualitative descriptive study involving semi-structured interviews with 25 GPs and 38 patients in Australia in 2011-2012. Transcribed audio-recordings were thematically coded and a Framework Analysis method was used. Results: GPs rarely mentioned AR thresholds but were influenced by their subjective perception of the patient’s risk and motivation, and their own attitudes toward prevention, including concerns about medication side effects and the efficacy of lifestyle change. Patients were influenced by individual risk factors, their own motivation to change lifestyle, and attitudes toward medication: initially negative, but this improved if medication was more effective than lifestyle. High perceived risk led to medication being recommended by GPs and accepted by patients, but this was not necessarily based on AR. Patient perceptions of high risk also increased motivation to change lifestyle, particularly if they were resistant to the idea of taking medication. Conclusions: Perceived risk, motivation, and attitudes appeared to be more important than AR thresholds in this study. CVD risk management guidelines could be more useful if they include strategies to help GPs consider patients’ risk perception, motivation, and attitudes as well as evidence-based recommendations. NHMRC, National Heart Foundation of Australia

Background: Cardiovascular disease (CVD) prevention guidelines encourage assessment of absolute CVD risk - the probability of a CVD event within a fixed time period, based on the most predictive risk factors. However, few General Practitioners (GPs) use absolute CVD risk consistently, and communication difficulties have been identified as a barrier to changing practice. This study aimed to explore GPs’ descriptions of their CVD risk communication strategies, including the role of absolute risk. Methods: Semi-structured interviews were conducted with a purposive sample of 25 GPs in New South Wales, Australia. Transcribed audio-recordings were thematically coded, using the Framework Analysis method to ensure rigour. Results: GPs used absolute CVD risk within three different communication strategies: ‘positive’, ‘scare tactic’, and ‘indirect’. A ‘positive’ strategy, which aimed to reassure and motivate, was used for patients with low risk, determination to change lifestyle, and some concern about CVD risk. Absolute risk was used to show how they could reduce risk. A ‘scare tactic’ strategy was used for patients with high risk, lack of motivation, and a dismissive attitude. Absolute risk was used to ‘scare’ them into taking action. An ‘indirect’ strategy, where CVD risk was not the main focus, was used for patients with low risk but some lifestyle risk factors, high anxiety, high resistance to change, or difficulty understanding probabilities. Non-quantitative absolute risk formats were found to be helpful in these situations. Conclusions: This study demonstrated how GPs use three different communication strategies to address the issue of CVD risk, depending on their perception of patient risk, motivation and anxiety. Absolute risk played a different role within each strategy. Providing GPs with alternative ways of explaining absolute risk, in order to achieve different communication aims, may improve their use of absolute CVD risk assessment in practice. NHMRC

Objective: To understand general practitioners’ (GPs) use of individual risk factors (blood pressure and cholesterol levels) versus absolute risk in cardiovascular disease (CVD) risk management decision-making. Design: Randomised experiment. Absolute risk, systolic blood pressure (SBP), cholesterol ratio (total cholesterol/high-density lipoprotein (TC/HDL)) and age were systematically varied in hypothetical cases. High absolute risk was defined as 5-year risk of a cardiovascular event >15%, high blood pressure levels varied between SBP 147 and 179 mm Hg and high cholesterol (TC/HDL ratio) between 6.5 and 7.2 mmol/L. Setting: 4 GP conferences in Australia. Participants: 144 Australian GPs. Outcomes: GPs indicated whether they would prescribe cholesterol and/or blood pressure lowering medication. Analyses involved logistic regression. Results: For patients with high blood pressure: 93% (95% CI 86% to 96%) of high absolute risk patients and 83% (95% CI 76% to 88%) of lower absolute risk patients were prescribed blood pressure medication. Conversely, 30% (95% CI 25% to 36%) of lower blood pressure patients were prescribed blood pressure medication if absolute risk was high and 4% (95% CI 3% to 5%) if lower. 69% of high cholesterol/high absolute risk patients were prescribed cholesterol medication (95% CI 61% to 77%) versus 34% of high cholesterol/ lower absolute risk patients (95% CI 28% to 41%). 36% of patients with lower cholesterol (95% CI 30% to 43%) were prescribed cholesterol medication if absolute risk was high versus 10% if lower (95% CI 8% to 13%). Conclusions: GPs’ decision-making was more consistent with the management of individual risk factors than an absolute risk approach, especially when prescribing blood pressure medication. The results suggest medical treatment of lower risk patients (5-year risk of CVD event

Recruiting general practitioners (GPs) for participation in primary care research is vitally important, but it can be very difficult for researchers to engage time-poor GPs. This paper describes six different strategies used by a research team recruiting Australian GPs for three qualitative interview studies and one experimental study, and reports the response rates and costs incurred. Strategies included: (1) mailed invitations via Divisions of General Practice; (2) electronic newsletters; (3) combining mailed invitations and newsletter; (4) in-person recruitment at GP conferences; (5) conference satchel inserts; and (6) combining in-person recruitment and satchel inserts. Response rates ranged from 0 (newsletter) to 30% (in-person recruitment). Recruitment costs per participant ranged from A$83 (in-person recruitment) to A$232 (satchel inserts). Mailed invitations can be viable for qualitative studies, especially when free/low-cost mailing lists are used, if the response rate is less important. In-person recruitment at GP conferences can be effective for short quantitative studies, where a higher response rate is important. Newsletters and conference satchel inserts were expensive and ineffective.

Objectives: To identify factors that influence the extent to which general practitioners use absolute risk (AR) assessment in cardiovascular disease (CVD) risk assessment. Design, setting and participants: Semi-structured interviews with 25 currently practising GPs from eight Divisions of General Practice in New South Wales, Australia, between October 2011 and May 2012. Data were analysed using framework analysis. Results: The study identified five strategies that GPs use with patients in different situations, defined in terms of the extent to which AR was used and the reasons given for this: the AR-focused strategy, used when AR assessment was considered useful for the patient; the AR-adjusted strategy, used to account for additional risk factors such as family history; the clinical judgement strategy, used when GPs considered that their judgement took multiple risk factors into account as effectively as AR; the passive disregard strategy, used when GPs lacked sufficient time, access or experience to use AR; and the active disregard strategy, used when AR was considered to be inappropriate for the patient. The strategies were linked with different opportunity, capability and motivation barriers to the use of AR. Conclusions: This study provides an in-depth insight into the factors that influence GPs’ use of AR in CVD risk assessment. The results suggest that GPs use a range of strategies in different situations, so different approaches may be required to improve the use of AR guidelines in practice. NHMRC