Practice organisation

Many organisational activities can support the implementation of SNAP interventions within the practice.

Table 16

Table 16

Putting SNAP into practice

The main barriers to implementation of SNAP at the practice level include:

  • a lack of time (especially during consultations). Assessing or intervening in a consultation for single risk factors can take 2–10 minutes
  • practice information systems not geared to support SNAP assessment and management
  • a lack of organisation within the practice, including a team approach to management with responsibilities shared by many providers
  • difficulty linking with, getting support from, and referring to population health services
  • a lack of financial incentives or funding to pay for involvement of non-medical staff.

These barriers can be overcome, to some extent, by the development of a SNAP business model, including:

  • setting practice priorities
  • listing the roles each practice member currently undertakes and how SNAP interventions can be integrated into these existing roles and responsibilities
  • identifying training needs and ensuring all members of the team have appropriate training to undertake SNAP activities, (eg. motivational interviewing, Quit Program)
  • providing staff with some protected time to set up SNAP activity
  • reviewing the way in which appointments and follow-up are arranged
  • establishing information systems to support SNAP interventions
  • conducting ongoing quality improvement programs
  • developing links with local services (eg. health promotion services, local primary health agencies and networks, health-related non-government organisations and community groups).

Patients should be made aware of any out-of-pocket expenses they may be charged for the care provided by the general practice or referral service to support the SNAP activities.

The first task is to ensure agreement that managing SNAP risk factors in all patients is a high-priority practice goal. This needs to involve the practice leadership and requires engagement, collaboration and commitment from the entire team. This will usually require face-to-face practice meetings in order to identify needs and decide on your SNAP activity or project. Outlining the roles and contribution of each team member will help produce a shared model of how SNAP will work in the practice.

The model can be clarified by reviewing the following questions:

  • How is the practice currently performing in identifying, assessing and managing each of the SNAP risk factors in the practice population?
  • Have roles and responsibilities of team members been clearly defined?
    • Whose responsibility is it to do what?
    • How is it reported?
    • Who coordinates the practice management of SNAP?
  • Are staff adequately trained in the implementation of SNAP?
    • Where are the gaps in knowledge?
    • Where can any additional training be accessed?
  • How effective and appropriate are the following practice systems in supporting SNAP?
    • Practice record and computer system.
    • Access to additional data mining tools to identify at-risk patients.
    • Patient education materials and resources in the waiting and consulting rooms.
    • Practice website outlining what SNAP is and the practice commitment to SNAP interventions.
    • Appointment system and flow of consultations (eg. nurse assessment before GP consult).
    • Practice register and recall system.
    • New patient registration forms in recording of patients’ potential risk factors and seeking permission to contact a patient for preventive health activity, recalls and reminders.
  • How well does the practice link with health promotion services, self-help groups and organisations such as the Heart Foundation and Cancer Council?

These may be achieved by conducting a practice inventory in addition to a patient survey. The issues may be discussed more informally at practice meetings. There may be opportunities to link in with the local community groups and services, as well as local primary health agencies and networks, on SNAP activities – especially if there is a network of practice managers and/or nurses.

The next step is to draw up a practice plan. This should identify the problem or issue, how it will be dealt with, whose responsibility it is and where support, assistance or resources can be obtained.

Table 17

Table 17

Example of a practice plan for SNAP

SNAP interventions can be part of a successful business model for general practice and an attractive component of practice programs encouraging patients to attend the practice.

There are also a number of Commonwealth programs that may help provide financial support:

  • Practice Nurse Incentive Program to help fund practice nurses. 
  • Medicare features a suite of Health Assessments (items 701, 703, 705, 707) and CDM care planning services such as GP Management Plans (item 721) and Team Care Arrangements (item 723) that attract a rebate:
    • MBS health assessment items can be utilised to undertake a comprehensive assessment of a patient with complex care needs. Health assessments can also be utilised with specific groups (Aboriginal and Torres Strait Islander peoples, refugees and aged care residents) so needs are addressed in a targeted and culturally appropriate manner. Refer to Chapter 5 for more information.
    • CDM items apply for care to patients with at least one chronic or terminal medical condition and complex care needs. A Team Care Arrangement may be formulated for patients being managed by their GP under a GP Management Plan and who require multidisciplinary care from a team of healthcare providers, including the patient’s GP.

These patients are also eligible for Medicare rebates for certain allied health services on referral from their GP.

More information on allied health services under Medicare can be found on this page 

The roles and responsibilities for SNAP need to be shared among members of the practice team.

Table 18

Table 18

Key roles of the GP practice team when implementing SNAP interventions

Some team members may require training to perform these roles. Training may be available through local primary health agencies and networks, as well as courses and programs run by professional organisations such as the RACGP and Australian Primary Health Care Nurses Association (APNA), tertiary institutions, the Heart Foundation and Cancer Council. There are also online learning opportunities available through the NPS MedicineWise programs and private providers.

The RACGP’s Putting prevention into practice: guidelines for the implementation of prevention in the general practice setting (the Green book) can help guide the general practice in the development of a framework for SNAP activity. Visit the Green book  for more information.

The RACGP’s Guidelines for preventive activities in general practice (8th edition) (the Red book), and the National guide to a preventive health assessment in Aboriginal and Torres Strait Islander peoples, provide the evidence base for the clinical activities. 

The appointments system should facilitate the assessment and management of SNAP risk factors. Additional time may need to be spent with a patient who is having a SNAP assessment. Special individual or group education sessions with other practice staff may need to be arranged. Reminders may also be required for patients to book a follow-up visit. Electronic scheduling systems need to be sufficiently flexible to allow for this.

To streamline appointment scheduling and improve the flow of appointments for the patient, consider a model of nurse-led clinics for activities such as health checks clinics, education sessions and support visits. The patients see the nurse for 30–45 minutes for their screening assessment or health check, history and medication update (including over-the-counter medication documented), type 2 diabetes risk assessment by the Australian Type 2 Diabetes Risk Assessment Tool (AUSDRISK) and identification of CDM risk. The patient then moves to the GP with the collated information (most GPs can see 2–3 other patients while the nurse is doing the check).

Information systems can minimise time spent accessing and sorting information. A practice register should be able to generate recall lists of high-risk patients and identify patients overdue for follow-up or reminders. Computerised prompts can also remind the GP of the risk factors that need to be reviewed during the consultation.

Computer-based systems have been demonstrated to improve the quality of preventive care delivered in the primary care setting as recommended by the RACGP’s Quality health records in Australian primary healthcare: A guide .

A practice register is a complete and ordered list of patients. It should contain the patient’s:

  • name
  • gender
  • date of birth
  • address
  • phone number
  • reason for being on the register
  • dates of visits
  • smoking and alcohol status.

For SNAP, the register should contain patients known to have CVD (eg. have had a myocardial infarction, unstable angina, stroke, other vascular disease, hypertension, diabetes, or hyperlipidaemia). Local primary health agencies and networks may be able to provide assistance in setting up a practice register and/or involving the practice in a catchment-wide register.

If the patient agrees to be part of your practice recall system, a recall letter should be sent inviting the patient to return to the practice for a consultation, specifying the purpose of the visit (eg. review of smoking cessation), whether the patient will see the nurse as part of that visit and length of the appointment (eg. 30 minutes). The Department of Health has advised that recall is appropriate for follow-up of an existing problem or for preventive care.

Information from some SNAP activities may be uploaded to the Personally Controlled Electronic Health Record (PCEHR). Participating in the PCEHR and/or patient held records can help patients to take a more active role in their own health and monitor their progress. They can also act as vehicles for communication when patients move between different healthcare providers.

Risk assessment tools

Absolute risk assessment tools can provide an estimate of the likelihood of a cardiovascular event. There are several computerised versions of these tools, the best of which allow each of the SNAP risk factors, as well as blood pressure, lipids, family history, and conditions such as diabetes, to be considered. The risk information can be useful in helping to motivate patients to make a lifestyle change and to decide whether certain interventions, such as referral to a dietitian, are warranted.

A number of websites provide absolute cardiovascular risk assessment tools, including:

Other helpful risk assessment tools include the Lung Foundation’s ‘Check in with your Lungs’, which is a tool used to highlight smoking, occupational exposure and lung fitness. It can be used as a trigger for further investigation such as spirometery or PiKo-6 to screen for COPD.

A physical activity module that incorporates an assessment of physical activity, provides prompts and produces a physical activity prescription has been incorporated into some general practice software programs.

Patient education materials

Consulting room materials

Patient education materials handed directly to patients by the GP or practice nurse will have significant impact. These should ideally be stored on computers used in the consulting rooms. These materials should be tailored to the patient’s:

  • language (and be culturally appropriate)
  • health problems (eg. existing CVD)
  • readiness to change.

Consider a variety of resources to cater for differing levels of literacy and health literacy among the groups attending your practice. These materials should also be evidence-based and provide a balanced approach to the problem.

State health departments often have multilingual patient education materials available for download or for purchase. Check with your local state or territory health departments for multilingual resources and referral centres available to your area.

The NPS MedicineWise fact sheet Lifestyle Choices for Better Health that addresses preventive health in general practice,  discusses how lifestyle choices directly affect health, as well as how they can help prevent ill health and reduce the number of medications taken. Consumers can also electronically subscribe to the monthly Medicinewise Living publication, which offers up-to-date information on health issues, medicines and medical tests.

NPS MedicineWise offers a Medicines List in hard copy, online and via a smartphone application, providing consumers with a tool to better manage their medicines.

Waiting room materials

The waiting room is an important place for patients to access health information. Material left in the waiting room can act as a prompt for patients to raise issues with the GP or other practice staff. Waiting room materials, including posters, may be available from health promotion units of state health departments, your primary care organisation and non-government organisations such as the Heart Foundation, Diabetes Australia, Cancer Council and other peak bodies.

Leaflets should be clear, simple and unbiased and, if possible, be available in the languages used by patients attending the practice. They need to be replenished periodically (ie. every 3–6 months). Posters are an important way of alerting patients to behavioural risk factors and the fact the GP may be able to help, but they need to be rotated regularly. A poster that is left in the practice for years will become all but invisible. Video materials are also available and can be played in the waiting room.

A practice notice board can provide information about self-help groups and local programs, as well as contact information for patients to self-refer. It is important to keep the notice board up-to-date. Some practices now provide computers in the waiting room that allow patients to access education material from selected websites.

NPS also has a MedicineWise Handbook, which is a hardcover consumer resource that is designed to be read by patients in waiting rooms. It defines health and medical terms and offers a summary of the main message on each page. 

Practice newsletter

A practice newsletter may be a useful way of informing patients about preventive issues. These should regularly contain information about the SNAP risk factors and strategies patients can use to help reduce their risk.

Practice website

Your practice website can also be used for patient education. All resources created should be made available online. Where possible, this information should be available in patients’ preferred language.

An increasing amount of information and educational materials is available online. Many patients will have previously accessed this information, or will do so after visiting the practice. It is therefore important your practice website features other recommended websites that provide unbiased and evidence-based information.

The Department of Health’s ‘Healthdirect Australia’ website is a good example of a useful online resource. Practices may consider placing this and other credible health information website links, such as Immunise Australia, Australian Childhood Immunisation Register and Quit Now, on their own websites.

Referral information

In accordance with the RACGP’s Standards for General Practices (4th edition), patients should be made aware of any potential out-of-pocket expenses charged by other healthcare professionals to support the SNAP activities.

A directory of referral information needs to be readily available in the practice. This should include:

  • counselling and self-help groups for smoking cessation (in addition to Quitline)
  • dietitian referral information
  • drug and alcohol counsellors and self-help groups
  • exercise physiologists and physiotherapists
  • local programs/councils and services for physical activity (eg. Heart Foundation walking programs)
  • a list of telephone health coaching services eg. 
  • State- and territory-based health coaching services, including, but not limited to:

Some private health funds also provide free telephone health advice and coaching for their members.

Information should also include more specialised services, such as diabetes and cardiac rehabilitation services.

Many local primary health agencies and networks have SNAP-related programs that have access arrangements to allied health workers such as dietitians, exercise physiotherapists and educators to support practices offering SNAP. 

Quality improvement activities need to be assigned as the responsibility of at least one staff member. This may be the practice manager or nurse. The practice needs to conduct a SNAP practice plan and consider the use of the plan, do, study, act (PDSA) tool.

In order to assess whether the practice is performing adequately, it is important to assess how frequently:

  • patients’ risk factors are assessed and recorded (coded to allow tracking in software)
  • patients are offered brief interventions
  • patients are referred to various referral services.

It may also be important to determine whether these result in any change in patient behaviour. This can be evaluated by conducting:

  • an audit of medical records
  • a patient survey (it is important to evaluate if your activities are meeting patient needs and expectations).

Auditing computerised records can be difficult depending on the software being used and the extent to which the information is recorded in a structured way. This is relatively easy for patients with diabetes, as most general practice software contains special modules for such patients. Other patient groups may be identified from prescribing records (eg. patients on antihypertensive or lipid-lowering drugs). Many pathology companies can provide you with a list of patients with high cholesterol and triglycerides. Information on SNAP risk factors may be listed in various parts of the computerised record.

Conducting a patient survey, asking patients who have received SNAP interventions to provide feedback on how helpful they found the support provided by the practice, is another potential approach. Conducting audits and surveys has privacy implications. Refer to the Office of the Australian Information Commissioner website for further information. RACGP members can also refer to the Handbook for the management of health information in private medical practice.

Providing effective behavioural interventions in general practice requires support from a number of sources. Public health, primary healthcare or community health services, organisations such as the Heart Foundation, Cancer Council and Lung Foundation self-help groups and local government can help by providing the practice with:

  • education and information materials
  • information systems
  • outreach programs and community education
  • referral services or programs.

Your local primary health agency or network may also be able to help with these, and with training for practice staff regarding what resources and programs are available. Establishing and maintaining these links may be made easier by designating a member of the practice to assume responsibility for liaison with these other services.

  1. Britt H, Miller GC, Henderson J, et al. General practice activity in Australia 2013–14. General practice series no.36. Sydney:Sydney University Press; 2014.
  2. Australian Bureau of Statistics. Australian Health Survey: Physical Activity 2011–12. Cat. no. 4364.0.55.004. Canberra: ABS;2013.
  3. Australian Institute of Health and Welfare. Tobacco smoking (NDSHS 2013 key findings). [Accessed 15 September 2014].
  4. Australian Bureau of Statistics. Australian Health Survey: Updated results 2011–2012. Cat no. 4364.0.55.003. Canberra: ABS;2013.
  5. Australian Institute of Health and Welfare. Tobacco smoking. 10 July 2014].
  6. Peto R, Lopez PR, Boreham J, Thun M, Heath C. Morbidity from smoking in developed countries 1950–2000. Oxford: Oxford University Press; 1994.
  7. English DR, Holman CD, Milne E, et al. The quantification of drug caused morbidity and mortality in Australia. Canberra: Commonwealth Department of Health and Human Services; 1995.
  8. Australian Bureau of Statistics. Profiles of Health, Australia 2011–13. Cat no. 4338.0. Canberra: ABS; 2014.
  9. World Health Organization. The optimal duration of exclusive breastfeeding: A systematic review. Geneva: WHO. [Accessed 10 July 2014].
  10. Begg S, Vos T, Barker B, Stevenson C, Stanley L, Lopez AD. The burden of disease and injury in Australia 2003, PHE 82.Canberra: AIHW; 2007.
  11. Australian Institute of Health and Welfare. Australia’s food and nutrition 2012: in brief. [Accessed 10 July 2014].
  12. National Health and Medical Research Council. Australian guidelines to reduce health risks from drinking alchol. Canberra: NHMRC; 2009.
  13. Australian Institute of Health and Welfare. Risk factors contributing to chronic disease. Cat No. PHE 157. Canberra: AIHW;2012.
  14. Australian Institute of Health and Welfare. Australia’s health 2012. Australia’s health series no.13. Cat. no. AUS 156. Canberra:AIHW; 2012.
  15. Australian Institute of Health and Welfare. Cardiovascular disease: Australian facts 2011. Cardiovascular disease series. CVD 53. Canberra: AIHW; 2011.
  16. Waters AM, Moon L. Socioeconomic inequalities in cardiovascular disease in Australia. AIHW bulletin no. 37. Cat. no. AUS 74. Canberra: AIHW; 2006.
  17. Harris M, Furler J. How can primary care increase equity in health? NSW Public Health Bull 2002;13(3):35–8.
  18. Dosh SA, Holtrop JS, Torres T, Arnold AK, Baumann J, White LL. Changing organizational constructs into functional tools: an assessment of the 5 A’s in primary care practices. Ann Fam Med 2005;3 Suppl 2:S50–2.
  19. Hung DY, Rundall TG, Tallia AF, Cohen DJ, Halpin HA, Crabtree BF. Rethinking prevention in primary care: applying the chronic care model to address health risk behaviors. Milbank Q 2007;85(1):69–91.
  20. Miller WR, Rose GS. Toward a theory of motivational interviewing. Am Psychol 2009;64(6):527–37.
  21. Lupu AM, Stewart AL, O’Neil C. Comparison of active-learning strategies for motivational interviewing skills, knowledge, and confidence in first-year pharmacy students. Am J Pharm Educ 2012;76(2):28.
  22. Daeppen JB, Fortini C, Bertholet N, et al. Training medical students to conduct motivational interviewing: a randomized controlled trial. Patient Educ Couns 2012;87(3):313–8.
  23. Anstiss T. Motivational interviewing in primary care. J Clin Psychol Med Settings 2009;16(1):87–93.
  24. Hinz JG. Teaching dental students motivational interviewing techniques: analysis of a third-year class assignment. J Dent Educ 2010;74(12):1351–6.
  25. White LL, Gazewood JD, Mounsey AL. Teaching students behavior change skills: description and assessment of a new Motivational interviewing curriculum. Med Teach 2007;29(4):e67–71.
  26. Burke PJ, Da Silva JD, Vaughan BL, Knight JR. Training high school counselors on the use of motivational interviewing to screen for substance abuse. Subst Abus 2005;26(3–4):31–4.Butler CC, Simpson SA, Hood K, et al. Training practitioners to deliver opportunistic multiple behaviour change counselling in primary care: a cluster randomised trial. BMJ 2013;346:f1191.
  27. Teixeira PJ, Silva MN, Mata J, Palmeira AL, Markland D. Motivation, self-determination, and long-term weight control. Int J Behav Nutr Phys Act 2012;9:22.
  28. Taggart J, Williams A, Dennis S, et al. A systematic review of interventions in primary care to improve health literacy for chronic disease behavioral risk factors. BMC Fam Pract 2012;13:49.
  29. Macdonald P, Hibbs R, Corfield F, Treasure J. The use of motivational interviewing in eating disorders: a systematic review. Psychiatry Res 2012;200(1):1–11.
  30. Hardcastle S, Blake N, Hagger MS. The effectiveness of a motivational interviewing primary-care based intervention on physical activity and predictors of change in a disadvantaged community. J Behav Med 2012;35(3):318–33.
  31. Chilton R, Pires-Yfantouda R, Wylie M. A systematic review of motivational interviewing within musculoskeletal health. Psychol Health Med 2012;17(4):392–407.
  32. Soderlund LL, Madson MB, Rubak S, Nilsen P. A systematic review of motivational interviewing training for general health care practitioners. Patient Educ Couns 2011;84(1):16–26.
  33. Smedslund G, Berg RC, Hammerstrom KT, et al. Motivational interviewing for substance abuse. Cochrane Database Syst Rev 2011;5:CD008063.
  34. Jensen CD, Cushing CC, Aylward BS, Craig JT, Sorell DM, Steele RG. Effectiveness of motivational interviewing interventions for adolescent substance use behavior change: a meta-analytic review. J Consult Clin Psychol 2011;79(4):433–40.
  35. Armstrong MJ, Mottershead TA, Ronksley PE, Sigal RJ, Campbell TS, Hemmelgarn BR. Motivational interviewing to improve weight loss in overweight and/or obese patients: a systematic review and meta-analysis of randomized controlled trials. Obes Rev 2011;12(9):709–23.
  36. Lai DT, Cahill K, Qin Y, Tang JL. Motivational interviewing for smoking cessation. Cochrane Database Syst Rev 2010(1):CD006936.
  37. Sharing Health Care: Guidelines for General Practitioners working with Chronic Conditions Melbourne: The Royal Australian College of General Practitioners; 2001.
  38. Nutbeam D. Building health literacy in Australia. Med J Aust 2009;191(10):525–6.
  39. von Wagner C, Steptoe A, Wolf MS, Wardle J. Health literacy and health actions: a review and a framework from health psychology. Health Educ Behav 2009;36(5):860–77.
  40. Australian Bureau of Statistics. Health literacy. Canberra: ABS; 2006.
  41. Chew LD, Griffin JM, Partin MR, et al. Validation of screening questions for limited health literacy in a large VA outpatient population. J Gen Intern Med 2008;23(5):561–6.
  42. Royal College of General Practitioners. Health Literacy: Report from an RCGP-led literacy workshop [Accessed 9 August 2014].
  43. DeWalt D, Callhan L, Hawk V, et al. Health literacy universal precautions toolkit. Rockville: Agency for Healthcare Research and Quality; 2010.
  44. United States Department of Health and Human Services. Physical activity guidelines advisory committee report. Washington DC: US DHHS; 2008.
  45. Supporting smoking cessation: a guide for health professionals. Melbourne: The Royal Australian College of General Practitioners; 2014.
  46. Higgins K, Cooper-Stanbury M, Williams P. Statistics on drug use in Australia 1998. Drug statistics series. Cat. no. PHE 16. Canberra: AIHW; 2000.
  47. Hill DJ, White VM, Scollo MM. Smoking behaviours of Australian adults in 1995: trends and concerns. Med J Aust 1998;168(5):209–13.
  48. The Tobacco Use and Dependence Clinical Practice Guideline Panel and Consortium Representatives. A clinical practice guideline for treating tobacco use and dependence: A US Public Health Service report. JAMA 2000;283(24):3244–54.
  49. Stead LF, Buitrago D, Preciado N, Sanchez G, Hartmann-Boyce J, Lancaster T. Physician advice for smoking cessation. Cochrane Database Syst Rev 2013;5:CD000165.
  50. Hughes JR. A quantitative estimate of the clinical significance of treating tobacco dependence. Am J Prev Med 2010;39(3):285–6.
  51. Wynn A, Coleman T, Barrett S, Wilson A. Factors associated with the provision of anti-smoking advice in general practice consultations. Br J Gen Pract 2002;52(485):997–9.
  52. He J, Vupputuri S, Allen K, Prerost MR, Hughes J, Whelton PK. Passive smoking and the risk of coronary heart disease--a meta-analysis of epidemiologic studies. N Engl J Med 1999;340(12):920–6.
  53. World Health Organization. Report on passive smoking and children. Geneva: WHO; 2000.
  54. Stead LF, Perera R, Bullen C, et al. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev 2012;11:CD000146.
  55. Cahill K, Stevens S, Perera R, Lancaster T. Pharmacological interventions for smoking cessation: an overview and network meta-analysis. Cochrane Database Syst Rev 2013;5:CD009329.
  56. Gibbons RD, Mann JJ. Varenicline, smoking cessation, and neuropsychiatric adverse events. Am J Psychiatry
  57. 2013;170(12):1460–7.
  58. Hughes JR, Stead LF, Hartmann-Boyce J, Cahill K, Lancaster T. Antidepressants for smoking cessation. Cochrane Database Syst Rev 2014;1:CD000031.
  59. National Health and Medical Research Council. Clinical practice guidelines for the management of overweight and obesity in adults, adolescents and children in Australia. Canberra: NHMRC; 2013.
  60. Welborn TA, Dhaliwal SS, Bennett SA. Waist-hip ratio is the dominant risk factor predicting cardiovascular death in Australia. Med J Aust 2003;179(11–12):580–5.
  61. Wang Y, Rimm EB, Stampfer MJ, Willett WC, Hu FB. Comparison of abdominal adiposity and overall obesity in predicting risk of type 2 diabetes among men. Am J Clin Nutr 2005;81(3):555–63.
  62. World Health Organization Expert Consultation. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet 2004;363(9403):157–63.
  63. National Health and Medical Research Council. Australian dietary guidelines. Canberra: NHMRC; 2013.
  64. Steptoe A, Perkins-Porras L, McKay C, Rink E, Hilton S, Cappuccio FP. Behavioural counselling to increase consumption of fruit and vegetables in low income adults: randomised trial. BMJ 2003;326(7394):855.
  65. Miller M, Pollard C, D. P. A public health nutrition campaign to promote fruit and vegetables in Australia. In: Worsley A, editor. Multidisciplinary approach to food choice Proceedings of Food Choice Conference. Adelaide: University of Adelaide; 1993.
  66. Bhattarai N, Prevost AT, Wright AJ, Charlton J, Rudisill C, Gulliford MC. Effectiveness of interventions to promote healthy diet in primary care: systematic review and meta-analysis of randomised controlled trials. BMC Public Health 2013;13:1203.
  67. Ammerman AS, Lindquist CH, Lohr KN, Hersey J. The efficacy of behavioral interventions to modify dietary fat and fruit and vegetable intake: a review of the evidence. Prev Med 2002;35(1):25–41.
  68. Bjelakovic G, Nikolova D, Gluud LL, Simonetti RG, Gluud C. Antioxidant supplements for prevention of mortality in healthy participants and patients with various diseases. Cochrane Database Syst Rev 2008(2):CD007176.
  69. World Health Organization. Obesity: preventing and managing the global epidemic. Report of a WHO consultation. World Health Organ Tech Rep Ser 2000;894:i–xii, 1–253.
  70. Guidelines for preventive activities in general practice, 8th edn. Melbourne: The Royal Australian College of General Practitioners; 2013.
  71. Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Arch Intern Med 1998;158(16):1789–95.
  72. Babor TF, Higgins-Biddle JC, Saunders JB, Monteiro MG. AUDIT—the alcohol use disorders identification test: guidelines for use in primary care, 2nd edn. Geneva: World Health Organization; 2001. [Accessed 10 July 2014].
  73. Pilling S, Yesufu-Udechuku A, Taylor C, Drummond C, Guideline Development G. Diagnosis, assessment, and management of harmful drinking and alcohol dependence: summary of NICE guidance. BMJ 2011;342:d700.
  74. Department of Health and Ageing. Guidelines for the Treatment of Alcohol Problems. Canberra: DoHA; 2009.
  75. Tam CW, Zwar N, Markham R. Australian general practitioner perceptions of the detection and screening of at-risk drinking,and the role of the AUDIT-C: a qualitative study. BMC Fam Pract 2013;14:121.
  76. Bradley KA, Bush KR, Epler AJ, et al. Two brief alcohol-screening tests From the Alcohol Use Disorders Identification Test (AUDIT): validation in a female Veterans Affairs patient population. Arch Intern Med 2003;163(7):821–9.
  77. Rehm J, Room R, Taylor B. Method for moderation: measuring lifetime risk of alcohol-attributable mortality as a basis for drinking guidelines. Int J Methods Psychiatr Res 2008;17(3):141–51.
  78. Pluijm SM, Smit JH, Tromp EA, et al. A risk profile for identifying community-dwelling elderly with a high risk of recurrent falling: results of a 3-year prospective study. Osteoporos Int 2006;17(3):417–25.
  79. Fletcher PC, Hirdes JP. Risk factor for accidental injuries within senior citizens’ homes: analysis of the Canadian Survey on Ageing and Independence. J Gerontol Nurs 2005;31(2):49–57.
  80. Aira M, Hartikainen S, Sulkava R. Community prevalence of alcohol use and concomitant use of medication--a source of possible risk in the elderly aged 75 and older? Int J Geriatr Psychiatry 2005;20(7):680–5.
  81. Foxcroft DR, Ireland D, Lister-Sharp DJ, Lowe G, Breen R. Longer-term primary prevention for alcohol misuse in young people: Cochrane systematic review. Int J Epidemiol 2005;34:758–9.
  82. Whitlock EP, Polen MR, Green CA, Orleans T, Klein J, Force USPST. Behavioral counseling interventions in primary care to reduce risky/harmful alcohol use by adults: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2004;140(7):557–68.
  83. Ballesteros J, Gonzalez-Pinto A, Querejeta I, Arino J. Brief interventions for hazardous drinkers delivered in primary care are equally effective in men and women. Addiction 2004;99(1):103–8.
  84. Ballesteros J, Duffy JC, Querejeta I, Arino J, Gonzalez-Pinto A. Efficacy of brief interventions for hazardous drinkers in primary care: systematic review and meta-analyses. Alcohol Clin Exp Res 2004;28(4):608–18.
  85. Fell JC, Voas RB. The effectiveness of reducing illegal blood alcohol concentration (BAC) limits for driving: evidence for lowering the limit to .05 BAC. J Safety Res 2006;37(3):233–43.
  86. Taylor B, Irving HM, Kanteres F, et al. The more you drink, the harder you fall: a systematic review and meta-analysis of how acute alcohol consumption and injury or collision risk increase together. Drug Alcohol Depend 2010;110(1–2):108–16.
  87. Lunetta P, Smith GS, Penttila A, Sajantila A. Unintentional drowning in Finland 1970-2000: a population-based study. Int J Epidemiol 2004;33(5):1053–63.
  88. Driscoll TR, Harrison JE, Steenkamp M. Alcohol and drowning in Australia. Inj Control Saf Promot 2004;11(3):175–81.
  89. Kaye S, Darke S. Non-fatal cocaine overdose among injecting and non-injecting cocaine users in Sydney, Australia. Addiction 2004;99(10):1315–22.
  90. O’Kane CJ, Tutt DC, Bauer LA. Cannabis and driving: a new perspective. Emerg Med (Fremantle) 2002;14(3):296–303.
  91. Sullivan LE, Fiellin DA, O’Connor PG. The prevalence and impact of alcohol problems in major depression: a systematic review. Am J Med 2005;118(4):330–41.
  92. Morris EP, Stewart SH, Ham LS. The relationship between social anxiety disorder and alcohol use disorders: a critical review. Clin Psychol Rev 2005;25(6):734–60.
  93. Abrams K, Kushner M, Medina KL, Voight A. The pharmacologic and expectancy effects of alcohol on social anxiety in individuals with social phobia. Drug Alcohol Depend 2001;64(2):219–31.
  94. Moore AA, Whiteman EJ, Ward KT. Risks of combined alcohol/medication use in older adults. Am J Geriatr Pharmacother 2007;5(1):64–74.
  95. Weathermon R, Crabb DW. Alcohol and medication interactions. Alcohol Res Health 1999;23(1):40–54.
  96. Odendaal HJ, Steyn DW, Elliott A, Burd L. Combined effects of cigarette smoking and alcohol consumption on perinatal outcome. Gynecol Obstet Invest 2009;67(1):1–8.
  97. Rehm J, Baliunas D, Borges GL, et al. The relation between different dimensions of alcohol consumption and burden of disease: an overview. Addiction 2010;105(5):817–43.
  98. Australian Health Ministers’ Advisory Council. Clinical Practice Guidelines: Antenatal Care – Module 1. Canberra: Australian Government Department of Health and Ageing; 2012.
  99. Kaner EF, Dickinson HO, Beyer F, et al. The effectiveness of brief alcohol interventions in primary care settings: a systematic review. Drug Alcohol Rev 2009;28(3):301–23.
  100. Apodaca TR, Longabaugh R. Mechanisms of change in motivational interviewing: a review and preliminary evaluation of the evidence. Addiction 2009;104(5):705–15.
  101. Lundahl B, Burke BL. The effectiveness and applicability of motivational interviewing: a practice-friendly review of four metaanalyses. J Clin Psychol 2009;65(11):1232–45.
  102. Bertholet N, Daeppen JB, Wietlisbach V, Fleming M, Burnand B. Reduction of alcohol consumption by brief alcohol intervention in primary care: systematic review and meta-analysis. Arch Intern Med 2005;165(9):986–95.
  103. Raistrick D, Heather N, Godfrey C. Review of the effectiveness of treatment for alcohol problems. London: National Treatment Agency for Substance Misuse; 2006.
  104. Department of Health and Ageing. Quick Reference Guide to the Treatment of Alcohol Problems: Companion Document to The Guidelines for the Treatment of Alcohol Problems. Canberra: DoHA; 2009.
  105. National Institute for Health and Clinical Excellence. Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence. NICE clinical guideline 115. London: NICE; 2011.
  106. Brown W, Bauman A, Bull F, Burton N. Development of evidence-based physical activity recommendations for adults (18–64 years). Report prepared for the Australian Government Department of Health, August 2012.
  107. Bauman A, Bellew B, Vita P, Brown W, Owen N. Getting Australia active: towards better practice for the promotion of physical activity. Melbourne: National Public Health Partnership; 2002.
  108. Winzenberg T, Shaw KA. Screening for physical inactivity in general practice - a test of diagnostic accuracy. Aust Fam Physician 2011;40(1–2):57–61.
  109. Ridgers ND, Timperio A, Crawford D, Salmon J. Validity of a brief self-report instrument for assessing compliance with physical activity guidelines amongst adolescents. J Sci Med Sport 2012;15(2):136–41.
  110. Tudor-Locke C, Craig CL, Brown WJ, et al. How many steps/day are enough? For adults. Int J Behav Nutr Phys Act 2011;8:79.
  111. Tudor-Locke C, Craig CL, Beets MW, et al. How many steps/day are enough? For children and adolescents. Int J Behav Nutr Phys Act 2011;8:78.
  112. Tudor-Locke C, Craig CL, Aoyagi Y, et al. How many steps/day are enough? For older adults and special populations. Int J Behav Nutr Phys Act 2011;8:80.
  113. Schmidt MD, Cleland VJ, Shaw K, Dwyer T, Venn AJ. Cardiometabolic risk in younger and older adults across an index of ambulatory activity. Am J Prev Med 2009;37(4):278–84.
  114. Department of Health and Ageing. National physical activity recommendations for children 0-5 years. Canberra: Department of Health and Ageing; 2012.
  115. Okely AD, Salmon J, Trost SG, Hinkley T. Discussion paper for the development of physical activity recommendations for children under five years. Canberra: Department of Health and Ageing; 2008.
  116. Department of Health and Ageing. National physical activity and sedentary behaviour guidelines for children (5–12 years). Canberra: Department of Health and Ageing; 2012.
  117. Okely AD, Salmon J, Vella SA, et al. A Systematic Review to update the Australian Physical Activity Guidelines for Children and Young People. Report prepared for the Australian Government Department of Health and Ageing, June 2012.
  118. Okely AD, Salmon J, Vella SA, et al. A Systematic Review to Inform the Australian Sedentary Behaviour Guidelines for Children and Young People. Report prepared for the Australian Government Department of Health and Ageing, June 2012.
  119. Department of Health and Ageing. National physical activity and sedentary behaviour guidelines for young people (13–17 years). Canberra: Department of Health and Ageing; 2012.
  120. Department of Health and Ageing. National physical activity and sedentary behaviour guidelines for adults (18–64 years). Canberra: Department of Health and Ageing; 2012.
  121. Department of Health and Ageing. National Physical activity recommendations for older Australians (65 years and older). Canberra: Department of Health and Ageing; 2012. [Accessed 16 January 2015].
  122. Sims J, Hill K, Hunt S, et al. National physical activity recommendations for older Australians: Discussion document. Canberra: Australian Government Department of Health and Ageing; 2006.
  123. Orrow G, Kinmonth AL, Sanderson S, Sutton S. Effectiveness of physical activity promotion based in primary care: systematic review and meta-analysis of randomised controlled trials. BMJ 2012;344:e1389.
  124. Kolt GS, Schofield GM, Kerse N, Garrett N, Ashton T, Patel A. Healthy Steps trial: pedometer-based advice and physical activity for low-active older adults. Ann Fam Med 2012;10(3):206–12.
  125. Prince SA, Saunders TJ, Gresty K, Reid RD. A comparison of the effectiveness of physical activity and sedentary behaviour interventions in reducing sedentary time in adults: a systematic review and meta-analysis of controlled trials. Obes Rev 2014.
  126. American College of Sports Medicine, American Heart Association. Exercise and acute cardiovascular events: placing the risks into perspective. Med Sci Sports Exerc 2007;39(5):886–97.
  127. Cleland V, Granados A, Crawford D, Winzenberg T, Ball K. Effectiveness of interventions to promote physical activity among socioeconomically disadvantaged women: a systematic review and meta-analysis. Obes Rev 2013;14(3):197–212.
  128. Pavey T, Taylor A, Hillsdon M, et al. Levels and predictors of exercise referral scheme uptake and adherence: a systematic review. J Epidemiol Community Health 2012;66(8):737–44.
  129. Jordan JL, Holden MA, Mason EE, Foster NE. Interventions to improve adherence to exercise for chronic musculoskeletal pain in adults. Cochrane Database Syst Rev 2010(1):CD005956.
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This guide has been designed to assist GPs and practice staff (the GP practice team) to work with patients on the lifestyle risk factors of smoking, nutrition, alcohol and physical activity (SNAP).

Organisations working with general practices, such as primary care organisations, public health services and other agencies that provide resources and training for primary healthcare staff, may also find this guide valuable.

The SNAP guide is based on the best available evidence at the time of publication. It adopts the most recent National Health and Medical Research Council (NHMRC) levels of evidence and grades of recommendations. Recommendations in the tables are graded according to levels of evidence and the strength of recommendation.

The levels of evidence are coded by the roman numerals I–IV, while the strength of recommendation is coded by the letters A–D. Practice points (PP) are employed where no good evidence is available.

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