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Abstract Background To evaluate the effectiveness of interventions used in primary care to improve health literacy for change in smoking, nutrition, alcohol, physical activity and weight (SNAPW). Methods A systematic review of intervention studies that included outcomes for health literacy and SNAPW behavioral risk behaviors implemented in primary care settings. We searched the Cochrane Library, Johanna Briggs Institute, Medline, Embase, CINAHL, Psychinfo, Web of Science, Scopus, APAIS, Australasian Medical Index, Google Scholar, Community of Science and four targeted journals (Patient Education and Counseling, Health Education and Behaviour, American Journal of Preventive Medicine and Preventive Medicine). Study inclusion criteria: Adults over 18 years; undertaken in a primary care setting within an Organisation for Economic Co-operation and Development (OECD) country; interventions with at least one measure of health literacy and promoting positive change in smoking, nutrition, alcohol, physical activity and/or weight; measure at least one outcome associated with health literacy and report a SNAPW outcome; and experimental and quasi-experimental studies, cohort, observational and controlled and non-controlled before and after studies. Papers were assessed and screened by two researchers (JT, AW) and uncertain or excluded studies were reviewed by a third researcher (MH). Data were extracted from the included studies by two researchers (JT, AW). Effectiveness studies were quality assessed. A typology of interventions was thematically derived from the studies by grouping the SNAPW interventions into six broad categories: individual motivational interviewing and counseling; group education; multiple interventions (combination of interventions); written materials; telephone coaching or counseling; and computer or web based interventions. Interventions were classified by intensity of contact with the subjects (High ≥ 8 points of contact/hours; Moderate >3 and Studies were analyzed by intervention category and whether significant positive changes in SNAPW and health literacy outcomes were reported. Results 52 studies were included. Many different intervention types and settings were associated with change in health literacy (73% of all studies) and change in SNAPW (75% of studies). More low intensity interventions reported significant positive outcomes for SNAPW (43% of studies) compared with high intensity interventions (33% of studies). More interventions in primary health care than the community were effective in supporting smoking cessation whereas the reverse was true for diet and physical activity interventions. Conclusion Group and individual interventions of varying intensity in primary health care and community settings are useful in supporting sustained change in health literacy for change in behavioral risk factors. Certain aspects of risk behavior may be better handled in clinical settings while others more effectively in the community. Our findings have implications for the design of programs.

Abstract Background People with low health literacy may not have the capacity to self-manage their health and prevent the development of chronic disease through lifestyle risk factor modification. The aim of this narrative synthesis is to determine the effectiveness of primary healthcare providers in developing health literacy of patients to make SNAPW (smoking, nutrition, alcohol, physical activity and weight) lifestyle changes. Methods Studies were identified by searching Medline, Embase, Cochrane Library, CINAHL, Joanna Briggs Institute, Psychinfo, Web of Science, Scopus, APAIS, Australian Medical Index, Community of Science and Google Scholar from 1 January 1985 to 30 April 2009. Health literacy and related concepts are poorly indexed in the databases so a list of text words were developed and tested for use. Hand searches were also conducted of four key journals. Studies published in English and included males and females aged 18 years and over with at least one SNAPW risk factor for the development of a chronic disease. The interventions had to be implemented within primary health care, with an aim to influence the health literacy of patients to make SNAPW lifestyle changes. The studies had to report an outcome measure associated with health literacy (knowledge, skills, attitudes, self efficacy, stages of change, motivation and patient activation) and SNAPW risk factor. The definition of health literacy in terms of functional, communicative and critical health literacy provided the guiding framework for the review. Results 52 papers were included that described interventions to address health literacy and lifestyle risk factor modification provided by different health professionals. Most of the studies (71%, 37/52) demonstrated an improvement in health literacy, in particular interventions of a moderate to high intensity. Non medical health care providers were effective in improving health literacy. However this was confounded by intensity of intervention. Provider barriers impacted on their relationship with patients. Conclusion Capacity to provide interventions of sufficient intensity is an important condition for effective health literacy support for lifestyle change. This has implications for workforce development and the organisation of primary health care.

Abstract Background With increasing rates of chronic disease associated with lifestyle behavioural risk factors, there is urgent need for intervention strategies in primary health care. Currently there is a gap in the knowledge of factors that influence the delivery of preventive strategies by General Practitioners (GPs) around interventions for smoking, nutrition, alcohol consumption and physical activity (SNAP). This qualitative study explores the delivery of lifestyle behavioural risk factor screening and management by GPs within a 45–49 year old health check consultation. The aims of this research are to identify the influences affecting GPs' choosing to screen and choosing to manage SNAP lifestyle risk factors, as well as identify influences on screening and management when multiple SNAP factors exist. Methods A total of 29 audio-taped interviews were conducted with 15 GPs and one practice nurse over two stages. Transcripts from the interviews were thematically analysed, and a model of influencing factors on preventive care behaviour was developed using the Theory of Planned Behaviour as a structural framework. Results GPs felt that assessing smoking status was straightforward, however some found assessing alcohol intake only possible during a formal health check. Diet and physical activity were often inferred from appearance, only being assessed if the patient was overweight. The frequency and thoroughness of assessment were influenced by the GPs' personal interests and perceived congruence with their role, the level of risk to the patient, the capacity of the practice and availability of time. All GPs considered advising and educating patients part of their professional responsibility. However their attempts to motivate patients were influenced by perceptions of their own effectiveness, with smoking causing the most frustration. Active follow-up and referral of patients appeared to depend on the GPs' orientation to preventive care, the patient's motivation, and cost and accessibility of services to patients. Conclusion General practitioner attitudes, normative influences from both patients and the profession, and perceived external control factors (time, cost, availability and practice capacity) all influence management of behavioural risk factors. Provider education, community awareness raising, support and capacity building may improve the uptake of lifestyle modification interventions.

Abstract Background The paper examines the key issues experienced in recruiting and retaining practice involvement in a large complex intervention trial in Australian General Practice. Methods Reflective notes made by research staff and telephone interviews with staff from general practices which expressed interest, took part or withdrew from a trial of a complex general practice intervention. Results Recruitment and retention difficulties were due to factors inherent in the demands and context of general practice, the degree of engagement of primary care organisations (Divisions of General Practice), perceived benefits by practices, the design of the trial and the timing and complexity of data collection. Conclusion There needs to be clearer articulation to practices of the benefits of the research to participants and streamlining of the design and processes of data collection and intervention to fit in with their work practices. Ultimately deeper engagement may require additional funding and ongoing participation through practice research networks. Trial Registration Current Controlled Trials ACTRN12605000788673

Background: Persisting systems gaps and fragmented care within and between primary and secondary healthcare teams are key national and international issues. For patients, this fragmentation is compounded by poor communication. Continuity and coordination of patient-centred care requires effective communication, coordination, teamwork, and judicious use of eHealth tools within a medical home and across the health neighbourhood. This Integrated Healthcare Homes and Neighbourhood (IHH&N) program is a response. Conceptual framework: General practice is the logical Healthcare Home and hub of the Healthcare Neighbourhood to coordinate care across primary, secondary, acute, aged and social sectors. Multidimensional integration of data/information, clinical & managerial workflow, and professional practice with a person-centred multidisciplinary team, underpinned by the Chronic Care Model, is essential. The Healthcare Neighbourhood includes primary ambulatory and secondary care services in a locality that relates largely to a hospital-based service provider. It is a logical denominator to assess the comparative effectiveness of interventions. Its size may vary based on geography and/or population requirements. Aim: To describe an Australian case study to (1) demonstrate the data, clinical, managerial and interprofessional integration required, and (2) highlight the governance, clinical, managerial and evaluation challenges. Setting and context: A network of general practice- and hospital-based services in SW Sydney established by the UNSW/SWSLHD Academic General Practice Unit to support its health services research and development (R&D) program. Methods: A mixed methods case study using data collected from review of protocol documents and publications, staff and patient interviews, participant observation, record linkage and EHR data quality assessment. A self-assessment of Informatics Capability Maturity (ICM) describes how the organisation collects, links, manages and shares information, manages technologies and change, governs data quality and use, and uses "business intelligence" to plan and monitor care. Key findings: Primary and secondary care clinicians fail to share data beyond traditional referral letters and discharge summaries. Quality, privacy and security standards were reported governance issues. Available tools to collect/extract, assess and manage the quality of data were inconsistent. Tools must be validated transparently and robustly within a data and clinical governance framework. The pseudonym-based record linkage was highly accurate, enabling reliable tracking of patient journeys across primary and secondary care services reliably. Sound-alike ethnic names were a common problem Serious data quality deficiencies persist in primary care and hospital systems. Feedback through structured data quality reports (SDQR) improved quality. The T2DM case finding algorithm was accurate and improved with increasing sample size and number of attributes. Record linkage of cases from general practices, Diabetes Clinic and local hospital suggest GP and clinic visits protect and renal complications predispose to admission. Australian and international collaborators highlighted shared common issues plus: interoperability, proprietary software and transparency; business model and sustainability; multiple ethical perspectives; and cognitive load on patients and clinicians from managing multi-morbidity. Conclusion & recommendations: IHH&N and integrated care requires integrated health data and systems, with local customisations and a sociotechnical approach to implementation. Governance, clinical, managerial and evaluation matters must be addressed through partnerships of local health districts, primary health networks and academic institutions. [ABSTRACT FROM AUTHOR]

Background: Integrated primary health care (PHC) relies on connectivity and seamless information-sharing across primary, secondary, acute, aged and social care. eHealth tools can promote a better patient journey and avoid duplication of care processes such as pathology and imaging or unplanned attendances at emergency departments and hospitalisations. Conceptual framework: This encompasses integration, Informatics Capability Maturity (ICM), multidisciplinary teamwork and data quality within the Australian National PHC Strategic Framework. Integration includes system, information and people elements that promote or support a team and shared care culture. The ICM reflects how an organisation collects, manages and shares information in the health neighbourhood, manages information communication technologies (ICT), data quality management and governance, and uses health "business intelligence" to achieve multidisciplinary integrated care. Aim: Assess the relationships between the ICM, systems and services integration and use eHealth tools by Integrated Primary Health Care Centres (IPHCCs). Setting: Seven IPHCCs in metropolitan and rural settings in 3 Australian states: an enhanced private general practice, four GP SuperClinics, a "HealthOne" private-public partnership and a Community Health Centre (CHC). These IPHCCs demonstrated a range of funding sources, ownership, organisational structures and leadership. Methods: Mixed methods case study. Data collected through document review, interviews with staff, non-participant observation of the IPHCC, data quality assessment of pseudonymised data from the EHR, and self-assessment of the ICM. A purposeful sample of patients were interviewed. Findings: The IPHCCs were at varying levels of ICM, using clinical and managerial eHealth tools with varying effectiveness for different ends; The lack of a common terminology and universal secure messaging system and limited "clinical coding" were significant barriers to data collection, integration and sharing; Various "work-arounds" were used by clinicians and managers to communicate and share information to compensate for the lack of technical, data and software integration; Patient engagement with eHealth tools, including the PCEHR, was minimal; and Improvement requires strong clinical leadership to ensure standards for data, metadata and secure messaging; a common terminology; integrated electronic decision support tools; accountable data quality management and information governance. Key lessons: Successful use of eHeath tools for system and service integration requires a skilled clinical informatics workforce; technical, semantic and software standards; adequate privacy and security; and clinical leadership to implement and monitor them to successful adoption. Conclusion & recommendations: 1. A multidisciplinary clinical informatics profession to bridge the divide between health, management and computer science in health care policy development and implementation with a patient-centred approach. 2. A common terminology across all health services, education and research sectors. 3. Secure messaging (building on and supported by the National Health Service Directory) 4. Integrated EHR data, metadata and applications to optimise EHR use. 5. Education of and culture change in the health professions to value good documentation, data quality management and information governance. Agencies to act on these recommendations include: Commonwealth and State Departments of Health, Education and Technology; Australian Commission for eHealth (replacing NEHTA); software industry; PHNs; LHDs/LHNs; Health professional bodies; and Higher education institutions. [ABSTRACT FROM AUTHOR]

Disease registries derived from Electronic Health Records (EHRs) are widely used for chronic disease management (CDM). However, unlike national registries which are specialised data collections, they are usually specific to an EHR or organization such as a medical home. We approached registries from the perspective of integrated care in a health neighbourhood, considering data quality issues such as semantic interoperability (consistency), accuracy, completeness and duplication. Our proposition is that a realist ontological approach is required to systematically and accurately identify patients in an EHR or data repository of EHRs, assess intrinsic data quality and fitness for use by members of the multidisciplinary integrated care team. We report on this approach as applied to routinely collected data in an electronic practice based research network in Australia.

Background: Several recent government policies aim to narrow the gap between optimal and current quality of care in the management of type 2 diabetes. This study examines trends in the quality of care and intermediate outcomes for patients between 1995 and 2004., Methods: Two dissimilar divisions of general practice in Sydney's southwest gathered diabetes patient data from 1995-2004 from participating general practices. Variables included frequency of assessment, body mass index, glycosylated haemoglobin, systolic blood pressure and total cholesterol., Results: Positive and significant changes occurred in glycosylated haemoglobin, total cholesterol and systolic blood pressure for patients in both divisions, though the mean values did not achieve guideline targets. There was no significant change in body mass index. There were significant differences between the divisions in most variables., Discussion: The current package of incentives and supports for diabetes care in general practice may be having a positive effect, however with more than half of the patients in this study having suboptimal control of their diabetes, there is a clear need for further systematic and multidisciplinary support.