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Table 3 Website development based on iterative user feedback

From: Implementing cardiovascular disease prevention guidelines to translate evidence-based medicine and shared decision making into general practice: theory-based intervention development, qualitative piloting and quantitative feasibility

Development stage Example user feedback Major changes made
Stage 1: Intervention development based on Behaviour Change Wheel process Healthy Heart Study GP interview: ‘The calculator of course doesn’t include certain factors…if someone does do a lot of exercise I would…think their risk is probably lower.’ [16]
Healthy Heart Study patient interview: ‘The visual presentation of the result…because it’s a picture instead of numeric, I think I’ll take more interest…when you see red and green…that seems to have more of a impact on me, you know…the numbers don’t, you know?’ [22]
• Develop new risk calculator to more clearly explain risk factor roles in assessment versus management guidelines (psychological capability), supported by links to existing audit and feedback strategies (reflective motivation)
• Link risk calculator to patient decision aid with colour coded icon arrays to help GPs explain probability of CVD event to patients (psychological capability) and access up-to-date intervention effects on their risk (physical opportunity)
Stage 2: Co-design of content with GPs GP focus group: “Is it possible you need to quote something along the lines of ‘no evidence regarding dose or exact dose’ or something? Cos patients ask you a lot of ‘how much should I take?’… It could be good with a bit of extra information and a little bit more about the doses and the side effects and costs and so on” • Less statistical information and more practical issues for GP evidence summaries
• Include complementary and alternative medicine options to show lack of effect on CVD outcomes
Stage 3: GP conference feedback on prototype website GP conference feedback: ‘Improved diet’ is very vague and after all, the benefit is only with the Mediterranean diet and has not been shown with other ‘improved diets’.
GP interview: ‘So are there explanations…for alcohol, you want to put what moderate’s not going to calculate BMI for you?’
• Rewording risk factors and interventions to be clearer
• Automatic calculation of body mass index and risky drinking
• Changed icon array shades to cater to vision impairments and black/white printing
Stage 4a: GP and patient interview feedback on functional website GP interview: ‘It’s directed towards the risk factor they’ve actually identified?... I think this is really good the summary… it’s really comprehensive…let’s not waste any time talking at length about smoking if you’re not even considering it…whereas what about your diet… oh yes I’m keen to know about that’
Patient interview: ‘With the button where it says print…it automatically comes up with the print page ahead of viewing it, so maybe it’s better to view it first and have the option to print later so you don’t have to print it’
• Add print button for 2 page summary of single intervention selected by GP
• View decision aid information in separate tab before printing
• Change summary table in full 9 option decision aid to more clearly show effects on risk
Stage 4b: GP and patient interview feedback on final website at GP interview: ‘The patient would be given an ipad…give it to the nurse or hand it back to reception…doing the AUSDIAB [diabetes risk assessment] at reception was really good…enter it on the patient file…if it was high then I would need know’
Patient interview: ‘I have to talk to the doctor about the cholesterol lowering medication, and blood pressure and aspirin…I can take this [decision aid] with me next time I go to see her’
• No further changes made to GP website or linked resources
• Implementation suggestions still need to be addressed:
1. Auto-population of risk factors from patients’ electronic record;
2. Low health literacy version of decision aid;
3. Pre-consultation access to risk calculator/decision aid
Stage 5: Feasibility study with GPs using final website over 1 month GP open response comments reflecting key implementation issues:
‘If it could be somehow linked to practice software so I remember to do it and the values are prefilled that would be ideal.’
‘Needs to have some in different languages to show people outcomes for those with poor English understanding.’
‘More time to be scheduled to counsel patients on lifestyle modification and CVD risk calculator use.’
• Feedback generally positive with some contrasting views on format preferences
• Confirmed implementation issues identified in stage 4b:
1. Auto-population of risk factors from patients’ electronic record
2. Low health literacy version of decision aid;
3. Pre-consultation access to risk calculator/decision aid