Australian Family Physician
Australian Family Physician


Volume 45, Issue 5, May 2016

Patients’ acceptance of SNAP assessment: An exploration

Charlotte Hespe Chun Wah Michael Tam Nicholas Zwar
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We previously described in Australian Family Physician a survey experiment that demonstrated patients’ acceptance of alcohol enquiry from their general practitioners (GPs) varied markedly depending on the reason for the initial presentation.1 A further qualitative study identified that the acceptability of these discussions was influenced by their perceived relevance. For many patients, this ‘was determined by whether the presenting complaint was seen to be an issue affected by alcohol drinking’.2

Is this finding isolated to assessment of drinking, or does it apply to other SNAP (smoking, nutrition, alcohol, physical activity) risk factors?3


We re-analysed data from the 66 questionnaire respondents from the intervention arm of the original survey experiment.1 In brief, the participants were adult patients who attended a general practice in Sydney, Australia in 2014. Two-thirds of the participants were female and the mean age was 53.6 years. Full demographics are available in the original paper.1 These participants rated the acceptability of GP enquiry (‘unacceptable’, ‘ambivalent’ or ‘acceptable’) of each of the four SNAP factors to 20 clinical vignettes. The vignettes were simple, written to a fifth grade student reading level,1 and based on the most frequent reasons for encounter and problems managed in Australian general practice.4

We ranked the vignette acceptability data and reported them descriptively. We used Friedman’s two-way analysis of variance (ANOVA) by ranks to analyse the differences in SNAP factor acceptability within the vignettes, and Wilcoxon signed rank test between specific factors (IBM SPSS Statistics 23).

This study was approved by the University of New South Wales’s (UNSW’s) Human Research Ethics Committee (reference number HC14074).


The variation in the acceptance of GP enquiry to all four SNAP factors was substantial, ranging from half of participants (least acceptable vignettes) to all (most acceptable; Table 1). There were variations in SNAP factor acceptability within the vignettes. The vignettes where these differences were statistically significant (P ≤ 0.05) were: cough, sore throat, back pain, skin rash, depression, diabetes, arthritis, high lipids, gastro-oesophageal reflux disease (GORD), bronchitis, asthma and urinary tract infection.

For example, while all participants reported smoking enquiry was acceptable in the asthma vignette, 85%, 81% and 92% did so for nutrition, alcohol and physical activity enquiry respectively (P < 0.0001).

Table 1. GP enquiry of SNAP risk factors – ranked by patient acceptability
Smoking(%)* Nutrition(%)* Alcohol(%)* Physical
Most acceptable vignettes 1 Asthma 100   GORD 100   GORD 99   Arthritis 99
2 Check-up 99   Diabetes 99   Diabetes 97   Hypertension 99
3 Hypertension 97   High lipids 99   Hypertension 97   Check-up 97
4 Bronchitis 96   Hypertension 97   Check-up 96   Diabetes 97
5 Cough 96   Check-up 96   Depression 96   High lipids 97
6 Diabetes 92   Depression 94   High lipids 96   Depression 92
7 Sore throat 92   Arthritis 88   Anxiety 86   Asthma 92
8 High lipids 91   Skin rash 88   Arthritis 83   Back pain 89
9 GORD 88   Anxiety 85   Blood test 82   GORD 89
10 Anxiety 83   Asthma 85   Skin rash 82   Anxiety 88
Least acceptable vignettes 11 Arthritis 82   Blood test 82   Asthma 81   Cough 83
12 Depression 82   Sore throat 82   UTI 79   Blood test 82
13 Blood test 82   Bronchitis 80   Bronchitis 77   Bronchitis 79
14 Prescription 73   UTI 79   Cough 74   Prescription 73
15 Skin rash 73   Cough 76   Sore throat 74   Sore throat 71
16 Test results 71   Prescription 73   Prescription 73   Test results 70
17 UTI 62   Test results 71   Test results 71   Skin rash 68
18 Immunisation 59   Back pain 62   Back pain 61   UTI 62
19 Back pain 58   Immunisation 59   Immunisation 59   Gov’t forms 59
20 Gov’t forms 56   Gov’t forms 55   Gov’t forms 58   Immunisation 58
*Proportion of participants who responded that enquiry of the specified lifestyle risk factor in the vignette was acceptable
GORD, gastro-oesophageal reflux disorder; UTI, urinary tract infection


Patients’ acceptance of GP enquiry for all four SNAP factors seems to vary depending on the reason for presentation. Ensuring that patients understand why we are interested in these issues may be a useful strategy; for instance, explicitly linking SNAP assessment to the presenting complaint.1,2


CW Michael Tam BSc(Med), MBBS, MMH(GP), FRACGP, Staff Specialist in General Practice, Fairfield Hospital – General Practice Unit, Prairiewood, NSW; Conjoint Senior Lecturer, UNSW Australia School of Public Health and Community Medicine, Sydney, NSW. m.tam@unsw.edu.au

Nicholas Zwar MBBS, MPH, PhD, FRACGP, Professor of General Practice, UNSW Australia – School of Public Health and Community Medicine, Sydney, NSW

Charlotte Hespe MBBS(Hons), DCH, GCUT, FRACGP, FAICD, Head, General Practice Research and conjoint Head, General Practice, University of Notre Dame Australia School of Medicine, Darlinghurst, NSW


This project was funded by an RACGP Family Medical Care, Education and Research Grant and the authors gratefully acknowledge the RACGP Foundation for their support.

  1. Tam CWM, Leong LH, Zwar N, Hespe C. Consultation contexts and the acceptability of alcohol enquiry from general practitioners – A survey experiment. Aust Fam Physician 2015;44(7):490–96. Available at www.racgp.org.au/afp/2015/july/consultation-contexts-and-the-acceptability-of-alcohol-enquiry-from-general-practitioners-%E2%80%93-a-survey-experiment [Accessed 4 April 2016]. Search PubMed
  2. Tam CWM, Leong L, Zwar N, Hespe C. Alcohol enquiry by GPs – Understanding patients’ perspectives: A qualitative study. Aust Fam Physician 2015;44(11):833–38. Available at www.racgp.org.au/afp/2015/november/alcohol-enquiry-by-gps-%E2%80%93-understanding-patients%E2%80%99-perspectives-a-qualitative-study [Accessed 4 April 2016]. Search PubMed
  3. The Royal Australian College of General Practitioners. Smoking, nutrition, alcohol and physical activity (SNAP): A population health guide to behavioural risk factors in general practice. 2nd edn. East Melbourne, Vic: RACGP, 2004. Available at www.racgp.org.au/your-practice/guidelines/snap [Accessed 4 April 2016]. Search PubMed
  4. Britt H, Miller GC, Henderson J, et al. General practice activity in Australia 2011–12. General practice series no. 31. Sydney: Sydney University Press, 2012. Search PubMed
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