☰ Table of contents
The lifestyle risk factors of smoking, nutrition, alcohol and physical activity (SNAP) are common among patients attending general practice.1 They contribute significantly to the burden of disease, largely due to their effect on the incidence and complications of chronic diseases such as diabetes, cardiovascular disease (CVD), chronic respiratory disease and some cancers.2 General practitioners (GPs) and their teams can make an important contribution to managing each of the SNAP lifestyle behaviours, including smoking,3,4 dietary change,5 hazardous drinking,6 physical activity7,8 and weight.9,10
Each of these risk factors may interact with the others throughout the lifecycle and need to be considered together rather than separately.11 The 5As is an internationally accepted framework for organising the assessment and management of behavioural risk factors in primary healthcare.12–14 It consists of the following:
- Ask – A systematic approach to asking all patients about their SNAP, which may occur opportunistically as they present for other conditions and/or by recall for health checks.
- Assess – Assess readiness to change, and dependence (for smoking and alcohol).
- Advise – Provide brief, non-judgemental advice with patient education materials.
- Assist/agree – Work with the patient to set agreed goals for behaviour change; provide motivational interviewing; refer to telephone support services, group lifestyle programs or individual providers (eg dietitian or exercise physiologist); consider pharmacotherapy.
- Arrange – Regular follow-up visits to monitor maintenance and prevent relapse.
Progress along the pathway from assessment and advice to goal setting, referral and follow-up is associated with increased patient motivation and behaviour change.15 A number of evidence-based preventive care guidelines are based on the 5As framework.9
What are the key equity issues and who is at risk?
- The greatest burden of chronic illness is experienced by socioeconomically disadvantaged groups, including Aboriginal and Torres Strait Islander peoples, who access preventive healthcare less frequently than other groups.16–18 Aboriginal and Torres Strait Islander peoples have a significantly lower life expectancy at birth than non-Indigenous Australians. This is attributable, to a significant extent, to inequities in prevalence and care for chronic diseases.19,20 This gap appears to be widening and is the widest seen globally between Indigenous and non-Indigenous populations.21 Multimorbidity is more common in disadvantaged groups and is associated with higher levels of psychosocial stress.22,23
- The uptake of preventive and screening services in primary healthcare is significantly related to higher levels of education, health motivation, and self-rated health, as well as to particular cultural groups. Immigrant groups undergo fewer preventive consultations and screening tests, and have overall less primary care utilisation.24 Aboriginal and Torres Strait Islander peoples and socioeconomically deprived people have higher risks of disease, but are less likely to be offered preventive interventions.25
- Socioeconomic disadvantage is associated with higher rates of smoking and alcohol use, poorer diets and lower levels of physical activity. The higher rates are a product of social, environmental and individual factors.
- Smoking rates show significant inequities across groups. Most disadvantaged groups continue to have higher smoking rates. Smoking status varies by education level, employment status, socioeconomic status (SES), geographic location and Indigenous status.26,27 Nationally, the prevalence of smoking among Aboriginal and Torres Strait Islander peoples (45%) is more than double that of non-Indigenous Australians, and is up to 82% in remote communities.28,29 Smoking is also more prevalent in people with long-term mental illness.30
- Overweight and obesity rates are higher in socioeconomically disadvantaged groups and the gap is widening.31–33 Aboriginal and Torres Strait Islander peoples have higher rates of being overweight and obese as well as a higher incidence of vascular disease.34 Aboriginal and Torres Strait Islander communities in remote regions face significant access barriers to nutritious and affordable food.35,36Nutritious food tends to cost more in rural and remote areas, and cost may also be an issue in low SES groups.37,38 Low-income groups are less likely to be offered interventions to prevent being overweight.39
- Alcohol may produce a greater burden of harm in more socially disadvantaged groups partly through the more hazardous pattern of drinking and partly through reduced access to resources to mitigate harm.40–43 Recognition and treatment are also impeded by the social stigma associated with problematic use of alcohol.44–46
What can GPs do?
- Interventions targeting Aboriginal and Torres Strait Islander peoples could include individual and group interventions delivered in primary healthcare and community settings to promote improved health literacy and awareness of behavioural risk factors.47 Financial assistance to enable healthier food choices may be effective.48 The Centre for Excellence in Indigenous Tobacco Control (CEITC) provides resources and strategies at www.ceitc.org.au Improvements in physical activity for Aboriginal and Torres Strait Islander patients may be achieved by linking health advice with locally available and appropriate community sport and recreation programs, as well as social support programs such as group activities.34,49
- Provide motivational interviewing for at-risk patients with low SES.50–52 Individual behavioural counselling is more likely to be effective for patients from disadvantaged backgrounds if linked to community resources, and if financial and access barriers are addressed.53,54 Interventions to improve physical activity among socially disadvantaged patients would ideally be linked to community programs that improve the physical environment, are culturally acceptable and address cost barriers.55–57Supportive provider attitudes are also important in building self-efficacy among patients from these groups.58
- Be aware that behavioural risk factors are not simply a matter of ‘individual lifestyle choices’. For example, racism and stress may be drivers of smoking for Aboriginal and Torres Strait Islander peoples and dietary choices may be shaped significantly by availability, cost and distribution of healthy food.
- Quality improvement activities, especially clinical audit and practice plans, can help improve the assessment and recording of behavioural risk factors.59