Healthy shopper? Blood pressure testing in a shopping centre Pop-Up in England

Improving detection of elevated blood pressure (BP) remains a public health need. We present results from a Pop-Up health check stationed in shopping centres in England. We hypothesise the rate of case detection is related to measurable ‘unhealthiness’ of the shopping centres. Methods

A Pop-Up health check was sited in four and three shopping centres sampled from the top ten unhealthiest and top 15 healthiest shopping regions respectively, following a report ranking towns/cities based on their unhealthy and healthy retail outlets. On one day in each shopping centre, people were approached and consented to BP testing. Outcome measure was people flagged with BP ≥ 140/90 mmHg (cases).

We detected 45 (22.6%) and 20 (13.1%) cases from testing 199 and 152 adults in the unhealthy and healthy locations respectively (relative risk 1.72; 95% confidence interval: 1.06 to 2.78). A measure of unhealthy retail outlets (e.g. fast-food outlets) within each shopping centre was associated with detection rate (R 2 = 0.61; p = 0.04).

An association exists between cases of suspect hypertension found in a health check Pop-Up and measured ‘unhealthiness’ of the shopping centre site. Results hint at strategies for public testing of BP, potentially in the context of reducing health inequalities.

Systemic hypertension is a major cause of mortality and morbidity despite availability of preventive interventions [ 1 , 2 ]. More than one in four adults in England have hypertension although many are unaware of it. Moreover, half the adult population in England simply do not know their blood pressure (BP) ‘numbers’. Identifying treatable hypertension is cost-effective and Public Health England has called for improvement in detection rates, especially in deprived groups, via outreach testing [ 3 ]. For example, it is estimated that people from the most deprived areas in England are 30% more likely than the least deprived to have elevated BP [ 3 ].

Retail short-term sales spaces, often referred to as Pop-Ups, are a common sight in shopping centres and other public spaces. Pop-Ups create a temporary retail environment that engages customers and generates a feeling of interactivity [ 4 ]. Research evidence suggests retail Pop-Ups increase ‘brand awareness’ and are effective marketing tools [ 5 , 6 ]. The Pop-Up retail sector is estimated to contribute more than £2 billion per year to the UK economy and large numbers of retail consumers visit Pop-Up shops [ 7 ].

In England, BP testing is typically carried out within primary care but other testing opportunities exist, including the National Health Service (NHS) Check Invitation and independent campaigns where testing is initiated directly in communities. To our knowledge, temporary Pop-Up health checks in shopping centres have not been explored and this is the main idea of this study.

Since 2009, adults aged 40–74 years in England have been entitled to an NHS Health Check, a scheme designed to find people with early signs of cardiovascular disease (CVD), kidney disease, type 2 diabetes or dementia [ 8 ]. Adults within the age range with no known pre-existing conditions are invited to attend a health check every 5 years. These checks are community based; they are delivered via general medical practices, community pharmacies or another community-based provider [ 9 ]. An individual’s CVD risk is predicted by taking into account their sociodemographic characteristics, cholesterol, blood pressure, history of smoking and family history [ 10 ]. Those found to be at a higher risk of CVD are placed on a ‘high risk’ register and offered annual reviews. Although a primary aim of the NHS Health Check was to reduce health inequalities, uptake of these checks is relatively low, with those at highest risk of CVD more likely not to attend [ 11 ]. A recent systematic review of the delivery and impact of the NHS Health Check concluded that published attendance, uptake, and prescribing rates are all lower than originally anticipated, and data on impact are limited, with very few studies reporting the effect of attendance on health-related behaviours [ 12 ]. Moreover, this study also found the uptake of the NHS Health Check to be relatively lower in those living in the most deprived areas. Other studies have also questioned the practicalities [ 13 ] and clinical effectiveness of this national prevention programme [ 14 ]. Hence, proactively seeking out people at risk of CVD in the community remains an unmet public health need.

By investigating the concentration of businesses and retail outlets that may reflect the state of peoples’ health in cities and towns, the Royal Society for Public Health (RSPH) published a league table of healthy and unhealthy shopping regions in the UK [ 15 ]. Measures were based on, for example, the presence of tanning salons, fast-food restaurants, bookmakers and payday lenders as indictors of ‘unhealthy’ retail outlets. The RSPH published these results as part of their initiative to reduce the negative influences on shopping areas. For example, the report aimed to promote the idea of a public health criterion to be a condition of licensing for all types of business.

We visited shopping centres in different locations in England to test a series of hypotheses on public engagement with our Pop-Up health check using the RSPH report results as a sampling frame. Primarily, our Pop-Up offered a free check for elevated intraocular eye pressure, a risk factor for the eye disease glaucoma [ 16 ] and this is the subject of another report. On 50% of the testing days, we offered a free BP check to investigate how this might encourage engagement with the eye health assessment. From this, we took the BP data to develop the hypothesis that the proportion of suspected cases of hypertension detected would vary by shopping centre location. More precisely, for this report, we hypothesised test results might be associated with a measure of the ‘unhealthiness’ of the shopping centre.

This was a prospective, cross-sectional study designed to capture BP measurements in people in the community using a Pop-Up in shopping centres across England. Our “Feeling the Pressure” Pop-Up was designed for use in covered areas (Fig. 1 ). The Pop-Up comprised two private testing areas and an open reception space designed to engage the public. The Pop-Up was assembled for two consecutive working days in different shopping centres across England during August 2016. All testing was performed by two optometrists assisted, in recruitment and administration, by assistants comprising volunteer undergraduate and postgraduate students. Primarily, the Pop-Up offered a free check on eye health. Additionally, on one of the two testing days in each centre the Pop-Up also offered a free BP check. In this report, we consider the BP data only. Fig.1 “Feeling the Pressure” Pop-Up pictured in a shopping centre atrium in (a) Bristol (The Galleries, BS1 3XD), (b) Coventry (Lower Precinct, CV1 1NQ), (c) Cambridge (The Grafton Centre, CB1 1PS). The Pop-Up was also located (not pictured) in Preston (St Georges, PR1 2TU), Stoke-on-Trent (Intu Potteries, ST1 1PS), Northampton (Weston Favell, NN3 8JZ) and Nottingham (Intu Broadmarsh, NG1 7LB). (People pictured are assistants and team members.) Our sampling of shopping centre locations attempted to follow the schema described in a recently published RSPH ( www.rsph.org.uk ) report ranking town/city centres based on the number and impact of the most harmful or unhealthy and the most beneficial or healthy businesses [ 15 ]. Four shopping centres were sampled from the reported top ten unhealthiest towns/cities. These were (with RSPH report ranking for most unhealthy town/city out of n = 70 towns/cities and initials of testing optometrists in parenthesis) in Preston (#1; LAE & DJT); Coventry (#3; LAE & PC); Northampton (#5; LAE & RS); Stoke-on-Trent (#9; LAE & DJT). Three shopping centres were sampled from the bottom of the list and, by implication, were amongst the top 15 healthiest towns/cities. These were in Nottingham (#55; LAE & RS); Bristol (#61; LAE & PC); Cambridge (#64; LAE & DJT). The sampling was purposeful but restricted by availability of shopping centres during the study period and logistics.

We determined our own unhealthy retail outlet score for each shopping centre based on a modified version of that used in the RSPH study. On the day of testing, the lead author (LAE) and two Pop-Up assistants surveyed all the retail outlets within the shopping centre by counting the number open to shoppers on the day of testing. They then established the retail outlets within each shopping centre which could be classed as one of four types: either a fast-food takeaway, a bookmaker, a tanning salon or a payday loan business, following the guidelines and descriptions used in the RSPH study. If there was any ambiguity about the nature of the retail outlet, as was the case for some counted as fast-food takeaways, then the notes (including photographs) collected on the day were reviewed by all authors and a consensus decision made. The number of these outlets as a proportion (percentage) of all retail outlets open on the day of testing within the shopping centre was then calculated to be our simple surrogate measure for the unhealthiness of the shopping centre. There […]

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