Advancing general practice nursing in Australia: roles and responsibilities of primary healthcare organisations.

Objectives Given increased numbers and enhanced responsibilities of Australian general practice nurses, we aimed to delineate appropriate roles for primary health care organisations (PHCOs) to support this workforce. Methods A two-round online Delphi consensus process was undertaken between January and June 2012, informed by literature review and key informant interviews. Participants were purposively selected and included decision makers from government and professional organisations, educators, researchers and clinicians from five Australian states and territories Results Of 56 invited respondents, 35 (62%) and 31 (55%) responded to the first and second invitation respectively. Participants reached consensus on five key roles for PHCOs in optimising nursing in general practice: (1) matching workforce size and skills to population needs; (2) facilitating leadership opportunities; (3) providing education and educational access; (4) facilitating integration of general practice with other primary care services to support interdisciplinary care; and (5) promoting advanced nursing roles. National concerns, such as limited opportunities for postgraduate education and career progression, were deemed best addressed by national nursing organisations, universities and peak bodies. Conclusions Advancement of nursing in general practice requires system-level support from a range of organisations. PHCOs play a significant role in education and leadership development for nurses and linking national nursing organisations with general practices. What is known about the topic? The role of nurses in Australian general practice has grown in the last decade, yet they face limited career pathways and opportunities for career advancement. Some nations have forged interprofessional primary care teams that use nurses' skills to the full extent of their scope of practice. PHCOs have played important roles in the development of general practice nursing in Australia and internationally. What does this paper add? This study delineates organisational support roles for PHCOs in strengthening nurses' roles and career development in Australian general practice. What are the implications for practitioners? Effective implementation of appropriate responsibilities by PHCOs can assist development of the primary care nursing workforce.

Routine use of clinical management guidelines in Australian general practice.

Significant gaps remain between recommendations of evidence-based guidelines and primary health care practice in Australia. This paper aims to evaluate factors associated with the use of guidelines reported by Australian GPs. Secondary analysis was performed on a survey of primary care practitioners which was conducted by the Commonwealth Fund in 2009: 1016 general practitioners responded in Australia (response rate 52%). Two-thirds of Australian GPs reported that they routinely used evidence-based treatment guidelines for the management of four conditions: diabetes, depression, asthma or chronic obstructive pulmonary disease and hypertension - a higher proportion than in most other countries. Having non-medical staff educating patients about self-management, and a system of GP reminders to provide patients with test results or guideline-based intervention or screening tests, were associated with a higher probability of guidelines use. Older GP age was associated with lower probability of guideline usage. The negative association with age of the doctor may reflect a tendency to rely on experience rather than evidence-based guidelines. The association with greater use of reminders and self-management is consistent with the chronic illness model.

Building research capacity in south-west Sydney through a Primary and Community Health Research Unit.

The Primary and Community Health Research Unit was established in 2010 in south-west Sydney to build research capacity in primary and community health services and help generate evidence to underpin clinical activities. In 2011, six project teams participated in a 12-month researcher mentoring program, undertaking projects in quality improvement and service evaluation. Project teams were linked with academic mentors and participated in four research skill development workshops covering research design, research ethics, statistical analysis and academic writing. All project teams presented their work at two or more research conferences, and all are preparing manuscripts for publication in peer-reviewed journals. The Primary and Community Health Research Unit's approach to research capacity building in primary and community health services appears to be effective in supporting novice researchers to undertake research in their clinical settings. Sustainability is dependent on securing ongoing funding. Further analysis is needed to identify strengths and weaknesses of this approach.

The impact of a brief lifestyle intervention delivered by generalist community nurses (CN SNAP trial).

BACKGROUND: The risk factors for chronic disease, smoking, poor nutrition, hazardous alcohol consumption, physical inactivity and weight (SNAPW) are common in primary health care (PHC) affording opportunity for preventive interventions. Community nurses are an important component of PHC in Australia. However there has been little research evaluating the effectiveness of lifestyle interventions in routine community nursing practice. This study aimed to address this gap in our knowledge. METHODS: The study was a quasi-experimental trial involving four generalist community nursing (CN) services in New South Wales, Australia. Two services were randomly allocated to an 'early intervention' and two to a 'late intervention' group. Nurses in the early intervention group received training and support in identifying risk factors and offering brief lifestyle intervention for clients. Those in the late intervention group provided usual care for the first 6 months and then received training. Clients aged 30-80 years who were referred to the services between September 2009 and September 2010 were recruited prior to being seen by the nurse and baseline self-reported data collected. Data on their SNAPW risk factors, readiness to change these behaviours and advice and referral received about their risk factors in the previous 3 months were collected at baseline, 3 and 6 months. Analysis compared changes using univariate and multilevel regression techniques. RESULTS: 804 participants were recruited from 2361 (34.1%) eligible clients. The proportion of clients who recalled receiving dietary or physical activity advice increased between baseline and 3 months in the early intervention group (from 12.9 to 23.3% and 12.3 to 19.1% respectively) as did the proportion who recalled being referred for dietary or physical activity interventions (from 9.5 to 15.6% and 5.8 to 21.0% respectively). There was no change in the late intervention group. There a shift towards greater readiness to change in those who were physically inactive in the early but not the comparison group. Clients in both groups reported being more physically active and eating more fruit and vegetables but there were no significant differences between groups at 6 months. CONCLUSION: The study demonstrated that although the intervention was associated with increases in advice and referral for diet or physical activity and readiness for change in physical activity, this did not translate into significant changes in lifestyle behaviours or weight. This suggests a need to facilitate referral to more intensive long-term interventions for clients with risk factors identified by primary health care nurses. TRIAL REGISTRATION: ACTRN12609001081202.

Factors influencing participation in a vascular disease prevention lifestyle program among participants in a cluster randomized trial.

BACKGROUND: Previous research suggests that lifestyle intervention for the prevention of diabetes and cardiovascular disease (CVD) are effective, however little is known about factors affecting participation in such programs. This study aims to explore factors influencing levels of participation in a lifestyle modification program conducted as part of a cluster randomized controlled trial of CVD prevention in primary care. METHODS: This concurrent mixed methods study used data from the intervention arm of a cluster RCT which recruited 30 practices through two rural and three urban primary care organizations. Practices were randomly allocated to intervention (n = 16) and control (n = 14) groups. In each practice up to 160 eligible patients aged between 40 and 64 years old, were invited to participate. Intervention practice staff were trained in lifestyle assessment and counseling and referred high risk patients to a lifestyle modification program (LMP) consisting of two individual and six group sessions over a nine month period. Data included a patient survey, clinical audit, practice survey on capacity for preventive care, referral and attendance records at the LMP and qualitative interviews with Intervention Officers facilitating the LMP. Multi-level logistic regression modelling was used to examine independent predictors of attendance at the LMP, supplemented with qualitative data from interviews with Intervention Officers facilitating the program. RESULTS: A total of 197 individuals were referred to the LMP (63% of those eligible). Over a third of patients (36.5%) referred to the LMP did not attend any sessions, with 59.4% attending at least half of the planned sessions. The only independent predictors of attendance at the program were employment status - not working (OR: 2.39 95% CI 1.15-4.94) and having high psychological distress (OR: 2.17 95% CI: 1.10-4.30). Qualitative data revealed that physical access to the program was a barrier, while GP/practice endorsement of the program and flexibility in program delivery facilitated attendance. CONCLUSION: Barriers to attendance at a LMP for CVD prevention related mainly to external factors including work commitments and poor physical access to the programs rather than an individuals' health risk profile or readiness to change. Improving physical access and offering flexibility in program delivery may enhance future attendance. Finally, associations between psychological distress and attendance rates warrant further investigation. TRIAL REGISTRATION: ACTRN12607000423415.

A systematic review of interventions to enhance access to best practice primary health care for chronic disease management, prevention and episodic care.

BACKGROUND: Although primary health care (PHC) is a key component of all health care systems, services are not always readily available, accessible or affordable. This systematic review examines effective strategies to enhance access to best practice processes of PHC in three domains: chronic disease management, prevention and episodic care. METHODS: An extensive search of bibliographic data bases to identify peer and non-peer reviewed literature was undertaken. Identified papers were screened to identify and classify intervention studies that measured the impact of strategies (singly or in combination) on change in use or the reach of services in defined population groups (evaluated interventions). RESULTS: The search identified 3,148 citations of which 121 were intervention studies and 75 were evaluated interventions. Evaluated interventions were found in all three domains: prevention (n = 45), episodic care (n = 19), and chronic disease management (n = 11). They were undertaken in a number of countries including Australia (n = 25), USA (n = 25), and UK (n = 15). Study quality was ranked as high (31% of studies), medium (61%) and low (8%). The 75 evaluated interventions tested a range of strategies either singly (n = 46 studies) or as a combination of two (n = 20) or more strategies (n = 9). Strategies targeted both health providers and patients and were categorised to five groups: practice re-organisation (n = 43 studies), patient support (n = 29), provision of new services (n = 19), workforce development (n = 11), and financial incentives (n = 9). Strategies varied by domain, reflecting the complexity of care needs and processes. Of the 75 evaluated interventions, 55 reported positive findings with interventions using a combination of strategies more likely to report positive results. CONCLUSIONS: This review suggests that multiple, linked strategies targeting different levels of the health care system are most likely to improve access to best practice PHC. The proposed changes in the structure of PHC in Australia may provide opportunities to investigate the factors that influence access to best practice PHC and to develop and implement effective, evidence based strategies to address these.

Is there scope for community health nurses to address lifestyle risk factors? the community nursing SNAP trial.

BACKGROUND: This paper examines the opportunity and need for lifestyle interventions for patients attending generalist community nursing services in Australia. This will help determine the scope for risk factor management within community health care by generalist community nurses (GCNs). METHODS: This was a quasi-experimental study conducted in four generalist community nursing services in NSW, Australia. Prior to service contacts, clients were offered a computer-assisted telephone interview to collect baseline data on socio-demographics, health conditions, smoking status, physical activity levels, alcohol consumption, height and weight, fruit and vegetable intake and 'readiness-to-change' for lifestyle risk factors. RESULTS: 804 clients participated (a response rate of 34.1%). Participants had higher rates of obesity (40.5% vs 32.1%) and higher prevalence of multiple risk factors (40.4% vs 29.5%) than in the general population. Few with a SNAPW (Smoking-Nutrition-Alcohol-Physical-Activity-Weight) risk factor had received advice or referral in the previous 3 months. The proportion of clients identified as at risk and who were open to change (i.e. contemplative, in preparation or in action phase) were 65.0% for obese/overweight; 73.8% for smokers; 48.2% for individuals with high alcohol intake; 83.5% for the physically inactive and 59.0% for those with poor nutrition. CONCLUSIONS: There was high prevalence of lifestyle risk factors. Although most were ready to change, few clients recalled having received any recent lifestyle advice. This suggests that there is considerable scope for intervention by GCNs. The results of this trial will shed light on how best to implement the lifestyle risk factor management in routine practice.

Clients' experience of brief lifestyle interventions by community nurses.

Lifestyle modification interventions in primary health care settings are an important means of addressing lifestyle risk factors. An essential factor for the success of lifestyle advice is the client's acceptance. Lifestyle interventions offered in general practice are well accepted by clients. However, little is known about how lifestyle interventions are accepted if offered by community nurses in the client's home. This study investigates the experience and perspectives of clients who were offered brief lifestyle interventions from community nurses, based on the 5As model. Semi-structured interviews were conducted with 20 clients who had received brief lifestyle interventions from community nurses as part of a larger intervention trial. All clients perceived the provision of lifestyle interventions to be an appropriate part of the community nurses' role. The advice and support offered was useful only to some, depending on personal preferences, experiences, perceived lifestyle risk and self-rated health. Offering brief lifestyle interventions did not affect the rapport between client and nurse and this puts community nurses in an ideal place to address lifestyle issues that can sometimes be sensitive. However, client-centredness must be emphasised to improve clients' uptake of lifestyle advice and support.

What predicts patient-reported GP management of smoking, nutrition, alcohol, physical activity and weight?

This study aimed to describe patient-reported management of behavioural risk factors in Australian general practice. Six hundred and ninety-eight eligible patients from 30 general practices in two rural and three urban Divisions of General Practice responded to a mailed invitation to participate and completed a questionnaire. Data were analysed using univariate and multi-level multivariate methods. The prevalence of risk factors varied between 12.6% for smoking and 72.6% for at-risk diet (56.2% were overweight). Most patients were at the action or maintenance phases of their readiness to change their risky behaviours. General practitioners (GPs) provided education or advice to between one-quarter and one-third of those at risk for each risk factor; 9.2% and 9.6% of patients reported having been referred for diet or physical activity interventions. Patient body mass index was associated with increased likelihood of receiving GP advice or referral for diet and physical activity interventions. Having poor diet or physical activity levels and being more ready for change were not associated with the likelihood of GP referral. The major challenge for general practice is to ensure that effective lifestyle interventions are provided to those who will most benefit. Patient-reported GP behavioural risk factor advice and referral is less frequent than is optimal. Priority needs to be given to those most at risk and ready to change their behaviour.

Multidisciplinary Team Care Arrangements in the management of patients with chronic disease in Australian general practice.

OBJECTIVE: To explore factors associated with the frequency of multidisciplinary Team Care Arrangements (TCAs) and the impact of TCAs on patient-assessed quality of care in Australian general practice. DESIGN AND SETTING: Data were collected as part of a cluster randomised controlled trial conducted in 60 general practices in New South Wales, the Australian Capital Territory and Victoria between July 2006 and June 2008. Multilevel logistic regression analysis evaluated factors associated with the frequency of TCAs recorded in the 12 months after baseline, and multilevel multivariable analysis examined the association between TCAs and patient-assessed quality of chronic illness care, adjusted for patient and practice characteristics. MAIN OUTCOME MEASURES: Frequency of TCAs; Patient Assessment of Chronic Illness Care (PACIC) scores. RESULTS: Of 1752 patients with clinical audit data available at 12-month follow-up, 398 (22.7%) had a TCA put in place since baseline. Women, patients with two or more chronic conditions, and patients from metropolitan areas had an increased probability of having a TCA. There was an association between TCAs and practices with solo general practitioners and those with greater levels of teamwork involving non-GP staff for the control group but not the intervention group. Patients who had a TCA self-assessed their quality of care (measured by PACIC scores) to be higher than those who did not. CONCLUSIONS: Findings were consistent with the purpose of TCAs--to provide multidisciplinary care for patients with longer-term complex conditions. Significant barriers to TCA use remain, especially in rural areas and for men, and these may be more challenging to overcome in larger practices.

Satisfaction with referral relationships between general practice and allied health professionals in Australian primary health care.

Chronic diseases require a multidisciplinary approach to provide patients with optimal care in general practice. This often involves general practitioners (GPs) referring their patients to allied health professionals (AHPs). The Team-link study explored the impact of an intervention to enhance working relationships between GPs and AHPs in general practice regarding the management of two chronic diseases: diabetes and ischaemic heart disease (IHD) or hypertension. The Measure of Multidisciplinary Linkages (MoML) questionnaire was developed to assess professional interactions and satisfaction with various aspects of the multidisciplinary relationship. Questionnaires were completed at baseline and 6 months by GPs (n=29) participating in the Team-link project and by AHPs (n=39) who had a current working relationship with these GPs. The Chronic Care Team Profile (CCTP) and Clinical Linkages Questionnaire (CLQ) were also completed by GPs. There were significant changes from baseline to 6 months after the intervention measures for individual items and overall MoML scores for GPs, especially items assessing 'contact', 'shared care' and 'satisfaction with communication'. The comparable item in the CLQ, 'Shared Care', also showed significant improvement. However, there were no statistically significant correlations between the change in overall 'Referral Satisfaction' scores in the GP MoML and the CLQ. The CCTP also improved and was a weak negative correlation between the GP MoML and two of the subscores of this instrument. There were no changes in AHP measure. This study demonstrates that the instrument is sensitive to differences between providers and conditions and is sensitive to change over time following an intervention. There were few associations with the other measures suggesting that the MoML might assess other aspects of teamwork involving practitioners who are not collocated or in the same organisation.

Development and early experience from an intervention to facilitate teamwork between general practices and allied health providers: the Team-link study.

BACKGROUND: This paper describes the development and implementation of an intervention to facilitate teamwork between general practice and outside allied and community health services and providers. METHODS: A review of organizational theory and a qualitative study of 9 practices was used to design an intervention which was applied in four Divisions of General Practice and 26 urban practices. Clinical record review and qualitative interviews with participants were used to determine the key lessons from its implementation. RESULTS: Facilitating teamwork across organizational boundaries was very challenging. The quality of the relationship between professionals was of key importance. This was enabled by joint education and direct communication between providers. Practice nurses were key links between general practices and allied and community health services. CONCLUSIONS: Current arrangements for Team Care planning provide increased opportunities for access to allied health. However the current paper based system is insufficient to build relationships or effectively share roles as part of a patient care team. Facilitation is feasible but constrained by barriers to communication and trust.

Health improvement and prevention study (HIPS) - evaluation of an intervention to prevent vascular disease in general practice.

BACKGROUND: The Health Improvement and Prevention Study (HIPS) study aims to evaluate the capacity of general practice to identify patients at high risk for developing vascular disease and to reduce their risk of vascular disease and diabetes through behavioural interventions delivered in general practice and by the local primary care organization. METHODS/DESIGN: HIPS is a stratified randomized controlled trial involving 30 general practices in NSW, Australia. Practices are randomly allocated to an 'intervention' or 'control' group. General practitioners (GPs) and practice nurses (PNs) are offered training in lifestyle counselling and motivational interviewing as well as practice visits and patient educational resources. Patients enrolled in the trial present for a health check in which the GP and PN provide brief lifestyle counselling based on the 5As model (ask, assess, advise, assist, and arrange) and refer high risk patients to a diet education and physical activity program. The program consists of two individual visits with a dietician or exercise physiologist and four group sessions, after which patients are followed up by the GP or PN. In each practice 160 eligible patients aged between 40 and 64 years are invited to participate in the study, with the expectation that 40 will be eligible and willing to participate. Evaluation data collection consists of (1) a practice questionnaire, (2) GP and PN questionnaires to assess preventive care attitudes and practices, (3) patient questionnaire to assess self-reported lifestyle behaviours and readiness to change, (4) physical assessment including weight, height, body mass index (BMI), waist circumference and blood pressure, (5) a fasting blood test for glucose and lipids, (6) a clinical record audit, and (7) qualitative data collection. All measures are collected at baseline and 12 months except the patient questionnaire which is also collected at 6 months. Study outcomes before and after the intervention is compared between intervention and control groups after adjusting for baseline differences and clustering at the level of the practice. DISCUSSION: This study will provide evidence of the effectiveness of a primary care intervention to reduce the risk of cardiovascular disease and diabetes in general practice patients. It will inform current policies and programs designed to prevent these conditions in Australian primary health care. TRIAL REGISTRATION: ACTRN12607000423415.

An efficacy trial of brief lifestyle intervention delivered by generalist community nurses (CN SNAP trial).

BACKGROUND: Lifestyle risk factors, in particular smoking, nutrition, alcohol consumption and physical inactivity (SNAP) are the main behavioural risk factors for chronic disease. Primary health care (PHC) has been shown to be an effective setting to address lifestyle risk factors at the individual level. However much of the focus of research to date has been in general practice. Relatively little attention has been paid to the role of nurses working in the PHC setting. Community health nurses are well placed to provide lifestyle intervention as they often see clients in their own homes over an extended period of time, providing the opportunity to offer intervention and enhance motivation through repeated contacts. The overall aim of this study is to evaluate the impact of a brief lifestyle intervention delivered by community nurses in routine practice on changes in clients' SNAP risk factors. METHODS/DESIGN: The trial uses a quasi-experimental design involving four generalist community nursing services in NSW Australia. Services have been randomly allocated to an 'early intervention' group or 'late intervention' (comparison) group. 'Early intervention' sites are provided with training and support for nurses in identifying and offering brief lifestyle intervention for clients during routine consultations. 'Late intervention site' provide usual care and will be offered the study intervention following the final data collection point. A total of 720 generalist community nursing clients will be recruited at the time of referral from participating sites. Data collection consists of 1) telephone surveys with clients at baseline, three months and six months to examine change in SNAP risk factors and readiness to change 2) nurse survey at baseline, six and 12 months to examine changes in nurse confidence, attitudes and practices in the assessment and management of SNAP risk factors 3) semi-structured interviews/focus with nurses, managers and clients in 'early intervention' sites to explore the feasibility, acceptability and sustainability of the intervention. DISCUSSION: The study will provide evidence about the effectiveness and feasibility of brief lifestyle interventions delivered by generalist community nurses as part of routine practice. This will inform future community nursing practice and PHC policy. TRIAL REGISTRATION: ACTRN12609001081202.

Quality of life of Australian chronically-ill adults: patient and practice characteristics matter.

BACKGROUND: To study health-related quality of life (HRQOL) in a large sample of Australian chronically-ill patients and investigate the impact of characteristics of patients and their general practices on their HRQOL and to assess the construct validity of SF-12 in Australia. METHODS: Cross sectional study with 96 general practices and 7606 chronically-ill patients aged 18 years or more using standard SF-12 version 2. Factor analysis was used to confirm the hypothesized component structure of the SF-12 items. SF-12 physical component score (PCS-12) and mental component score (MCS-12) were derived using the standard US algorithm. Multilevel regression analysis (patients at level 1 and practices at level 2) was applied to relate PCS-12 and MCS-12 to patient and practice characteristics. RESULTS: There were significant associations between lower PCS-12 or MCS-12 score and poorer general health (10.8 (regression coefficient) lower for PCS-12 and 7.3 lower for MCS-12), low socio-economic status (5.1 lower PCS-12 and 2.9 lower MCS-12 for unemployed, 0.8 lower PCS-12 and 1.7 lower MCS-12 for non-owner-occupiers, 1.0 lower PCS-12 for less well-educated) and having two or more chronic conditions (up to 2.7 lower PCS-12 and up to 1.5 lower MCS-12 than those having a single disease). Younger age was associated with lower MCS-12 (2.2 and 6.0 lower than middle age and older age respectively) but higher PCS-12 (4.7 and 7.6 higher than middle age and older age respectively). Satisfaction with quality of care (regression coefficient = 1.2) and patients who were married or cohabiting (regression coefficient = 0.6) was positively associated with MCS-12. Patients born in non-English-speaking countries were more likely to have a lower MCS-12 (1.5 lower) than those born in Australia. Employment had a stronger association with the quality of life of males than that of females. Those attending smaller practices had lower PCS-12 (1.0 lower) and MCS-12 (0.6 lower) than those attending larger practices. At the patient level (level 1) 42% and 21% of the variance respectively for PCS-12 and MCS-12 were explained by the patients and practice characteristics. At the practice level (level 2), 73% and 49% of the variance respectively for PCS-12 and MCS-12 were explained by patients and practice characteristics. CONCLUSION: The strong association between patient characteristics such as socio-economic status, age, and ethnicity and SF-12 physical and mental component summary scores underlines the importance of considering these factors in the management of chronically-ill patients in general practice. The SF-12 appears to be a valid measure for assessing HRQOL of Australian chronically-ill patients.

Quality of chronic disease care in general practice: the development and validation of a provider interview tool.

BACKGROUND: This article describes the development and psychometric evaluation of an interview instrument to assess provider-reported quality of general practice care for patients with diabetes, cardiovascular disease and asthma--the Australian General Practice Clinical Care Interview (GPCCI). METHODS: We administered the GPCCI to 28 general practitioners (family physicians) in 10 general practices. We conducted an item analysis and assessed the internal consistency of the instrument. We next assessed the quality of care recorded in the medical records of 462 of the general practitioners' patients with Type 2 diabetes, ischaemic heart disease/hypertension and/or moderate to severe asthma. This was then compared with results of the GPCCI for each general practice. RESULTS: Good internal consistency was found for the overall GPCCI (Cronbach's alpha = 0.75). As far as the separate sub-scales were concerned, diabetes had good internal consistency (0.76) but the internal consistency of the heart disease and asthma subscales was not strong (0.49 and 0.16 respectively). There was high inter-rater reliability of the adjusted scores of data extracted from patients' medical notes for each of the three conditions. Correlations of the overall GPCCI and patients' medical notes audit, combined across the three conditions and aggregated to practice level, showed that a strong relationship (r = 0.84, p = 0.003) existed between the two indices of clinical care. CONCLUSION: This study suggests that the GPCCI has good internal consistency and concurrent validity with patients' medical records in Australian general practice and warrants further evaluation of its properties, validity and utility.

Developments in Australian general practice 2000-2002: what did these contribute to a well functioning and comprehensive Primary Health Care System?

BACKGROUND: In recent years, national and state/territory governments have undertaken an increasing number of initiatives to strengthen general practice and improve its links with the rest of the primary health care sector. This paper reviews how far these initiatives were contributing to a well functioning and comprehensive primary health care system during the period 2000-2002, using a normative model of primary health care and data from a descriptive study to evaluate progress. RESULTS: There was a significant number of programs, at both state/territory and national level. Most focused on individual care, particularly for chronic disease, rather than population health approaches. There was little evidence of integration across programs: each tended to be based in and focus on a single jurisdiction, and build capacity chiefly within the services funded through that jurisdiction. As a result, the overall effect was patchy, with similar difficulties being noted across all jurisdictions and little gain in overall system capacity for effective primary health care. CONCLUSION: Efforts to develop more effective primary health care need a more balanced approach to reform, with a better balance across the different elements of primary health care and greater integration across programs and jurisdictions. One way ahead is to form a single funding agency, as in the UK and New Zealand, and so remove the need to work across jurisdictions and manage their competing interests. A second, perhaps less politically challenging starting point, is to create an agreed framework for primary health care within which a collective vision for primary health care can be developed, based on population health needs, and the responsibilities of different sectors services can be negotiated. Either of these approaches would be assisted by a more systematic and comprehensive program of research and evaluation for primary health care.

Mechanisms underpinning interventions to reduce sexual violence in armed conflict: A realist-informed systematic review.

Sexual violence is recognised as a widespread consequence of armed conflict and other humanitarian crises. The limited evidence in literature on interventions in this field suggests a need for alternatives to traditional review methods, particularly given the challenges of undertaking research in conflict and crisis settings. This study employed a realist review of the literature on interventions with the aim of identifying the mechanisms at work across the range of types of intervention. The realist approach is an exploratory and theory-driven review method. It is well suited to complex interventions as it takes into account contextual factors to identify mechanisms that contribute to outcomes. The limited data available indicate that there are few deterrents to sexual violence in crises. Four main mechanisms appear to contribute to effective interventions: increasing the risk to offenders of being detected; building community engagement; ensuring community members are aware of available help for and responses to sexual violence; and safe and anonymous systems for reporting and seeking help. These mechanisms appeared to contribute to outcomes in multiple-component interventions, as well as those relating to gathering firewood, codes of conduct for personnel and legal interventions. Drawing on pre-existing capacity or culture in communities is an additional mechanism which should be explored. Though increasing the risk to offenders of being detected was assumed to be a central mechanism in deterring sexual violence, the evidence suggests that this mechanism operated only in interventions focused on gathering firewood and providing alternative fuels. The other three mechanisms appeared important to the likelihood of an intervention being successful, particularly when operating simultaneously. In a field where robust outcome research remains likely to be limited, realist methods provide opportunities to understand existing evidence. Our analysis identifies the important potential of building in mechanisms involving community engagement, awareness of responses and safe reporting provisions into the range of types of intervention for sexual violence in crises.

Socio-demographic factors, behaviour and personality: associations with psychological distress.

BACKGROUND: Anxiety, psychological distress and personality may not be independent risk factors for cardiovascular disease; however they may contribute via their relationship with unhealthy lifestyle behaviours. This study aimed to examine the association between psychological distress, risk behaviours and patient demographic characteristics in a sample of general practice patients aged 40-65 years with at least one risk factor for cardiovascular disease. DESIGN: Cross-sectional analytic study. METHODS: Patients, randomly selected from general practice records, completed a questionnaire about their behavioural risk factors and psychological health as part of a cluster randomized controlled trial of a general practice based intervention to prevent chronic vascular disease. The Kessler Psychological Distress Score (K10) was the main outcome measure for the multilevel, multivariate analysis. RESULTS: Single-level bi-variate analysis demonstrated a significant association between higher K10 and middle age (p = 0.001), high neuroticism (p = 0), current smoking (p = 0), physical inactivity (p = 0.003) and low fruit and vegetable consumption (p = 0.008). Socioeconomic (SES) indicators of deprivation (employment and accommodation status) were also significantly associated with higher K10 (p = 0). No individual behavioural risk factor was associated with K10 on multilevel multivariate analysis; however indicators of low SES remained significant (p < 0.001). CONCLUSIONS: When all factors were considered, psychological distress was not associated with behavioural risk factors for cardiovascular disease. Other underlying factors, such as personality type and socioeconomic status, may be associated with both the behaviours and the distress.

Integrated primary health care in Australia.

INTRODUCTION: To fulfil its role of coordinating health care, primary health care needs to be well integrated, internally and with other health and related services. In Australia, primary health care services are divided between public and private sectors, are responsible to different levels of government and work under a variety of funding arrangements, with no overarching policy to provide a common frame of reference for their activities. DESCRIPTION OF POLICY: Over the past decade, coordination of service provision has been improved by changes to the funding of private medical and allied health services for chronic conditions, by the development in some states of voluntary networks of services and by local initiatives, although these have had little impact on coordination of planning. Integrated primary health care centres are being established nationally and in some states, but these are too recent for their impact to be assessed. Reforms being considered by the federal government include bringing primary health care under one level of government with a national primary health care policy, establishing regional organisations to coordinate health planning, trialling voluntary registration of patients with general practices and reforming funding systems. If adopted, these could greatly improve integration within primary health care. DISCUSSION: Careful change management and realistic expectations will be needed. Also other challenges remain, in particular the need for developing a more population and community oriented primary health care.