LAUSR

The uptake of health checks in primary care has been far from optimal and there is room for improvement in participation rates. Knowledge about what barriers and facilitators determine willingness to participate is essential. In the current issue of the European Journal of Preventive Cardiology, de Waard and colleagues evaluate determinants of participation and non-participation in health checks for cardiometabolic diseases in primary care in a systematic review including 39 European studies. The authors define a health check as the first step in a prevention programme where the next step would be a lifestyle intervention for individuals at high risk. The cardiometabolic diseases include cardiovascular disease, diabetes and chronic kidney disease and remain the number one cause of death worldwide. The most important risk factors are smoking, an unhealthy diet and physical inactivity, and promoting prevention of these modifiable factors in the population is urgent. The main message in this review is that it is not possible to build a ‘one size fits all’ programme for health checks. However, the authors identified that key facilitators for participating in a health check were interest in and responsibility for own risk. Major barriers were young age, smoking, being sceptical about prevention, lack of information and difficult access to appointments and, most important, low education, indicating possible low socioeconomic status. This is not a classical systematic review describing exposure and outcome of an intervention. The study used a more narrative and explorative synthesis approach because the included papers were heterogeneous in study design, in population and in facilitators and barriers described. The annual, time consuming and quite extensive check-up is a long-established tradition, particularly in North America, but its health benefits have been debated. Over-diagnosis and over-testing are concerns in health check activities aimed at people without symptoms. Focusing on risk factor assessment and management of potentially modifiable risk factors in specific segments is better advice. The European Society of Cardiology guideline on cardiovascular disease prevention (2016) abandons the annual check-up and replaces it with an ageand gender-specific focus. The recommendation is a health check for risk assessment in men above 40 years and in women above 50 years of age. The guideline emphasizes that risk assessment is not a one-time event; it should be repeated, for example, every five years. In addition, the threshold to check women should be higher than for men because the gender differential in cardiovascular risk prevails throughout life although declines with age. The systematic review by de Waard and colleagues adds to the current knowledge and is very timely considering the increasing interest from the general population as well as the health authorities in the prevention of chronic disease for all groups, including those with lower socioeconomic status, who have the most to gain. The authors point out that general practitioners and primary care nurses have a unique opportunity to identify people at high risk and assess their eligibility for a health check according to individual risks as the first step in preventing cardiometabolic disease. The main challenge is to encourage people to participate in health checks. It is well known that socioeconomic inequalities persist despite a decline in cardiovascular mortality. Is it possible that health checks could reduce this gap? The National Health Service Health Check programme was introduced in England almost 10 years ago, where all persons aged 40 to 74 years receive a free health check every five years to assess cardiovascular disease risk factors. In a recent microsimulation study, Mytton and colleagues showed that the benefits were greatest for those living in deprived areas, and thus the programme is reducing health inequalities. In addition, the authors