An efficacy trial of brief lifestyle intervention delivered by generalist community nurses (CN SNAP trial).
ABSTRACT 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.
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.
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.
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ABSTRACT: Modifiable behavioral risk factors are leading causes of mortality in the United States. Quantifying these will provide insight into the effects of recent trends and the implications of missed prevention opportunities. To identify and quantify the leading causes of mortality in the United States. Comprehensive MEDLINE search of English-language articles that identified epidemiological, clinical, and laboratory studies linking risk behaviors and mortality. The search was initially restricted to articles published during or after 1990, but we later included relevant articles published in 1980 to December 31, 2002. Prevalence and relative risk were identified during the literature search. We used 2000 mortality data reported to the Centers for Disease Control and Prevention to identify the causes and number of deaths. The estimates of cause of death were computed by multiplying estimates of the cause-attributable fraction of preventable deaths with the total mortality data. Actual causes of death. The leading causes of death in 2000 were tobacco (435 000 deaths; 18.1% of total US deaths), poor diet and physical inactivity (365 000 deaths; 15.2%) [corrected], and alcohol consumption (85 000 deaths; 3.5%). Other actual causes of death were microbial agents (75 000), toxic agents (55 000), motor vehicle crashes (43 000), incidents involving firearms (29 000), sexual behaviors (20 000), and illicit use of drugs (17 000). These analyses show that smoking remains the leading cause of mortality. However, poor diet and physical inactivity may soon overtake tobacco as the leading cause of death. These findings, along with escalating health care costs and aging population, argue persuasively that the need to establish a more preventive orientation in the US health care and public health systems has become more urgent.JAMA The Journal of the American Medical Association 04/2004; 291(10):1238-45. · 29.98 Impact Factor
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ABSTRACT: Risky behaviors are a leading cause of preventable morbidity and mortality, yet behavioral counseling interventions to address them are underutilized in healthcare settings. Research on such interventions has grown steadily, but the systematic review of this research is complicated by wide variations in the organization, content, and delivery of behavioral interventions and the lack of a consistent language and framework to describe these differences. The Counseling and Behavioral Interventions Work Group of the United States Preventive Services Task Force (USPSTF) was convened to address adapting existing USPSTF methods to issues and challenges raised by behavioral counseling intervention topical reviews. The systematic review of behavioral counseling interventions seeks to establish whether such interventions addressing individual behaviors improve health outcomes. Few studies directly address this question, so evidence addressing whether changing individual behavior improves health outcomes and whether behavioral counseling interventions in clinical settings help people change those behaviors must be linked. To illustrate this process, we present two separate analytic frameworks derived from screening topic tools that we developed to guide USPSTF behavioral topic reviews. No simple empirically validated model captures the broad range of intervention components across risk behaviors, but the Five A's construct-assess, advise, agree, assist, and arrange-adapted from tobacco cessation interventions in clinical care provides a workable framework to report behavioral counseling intervention review findings. We illustrate the use of this framework with general findings from recent behavioral counseling intervention studies. Readers are referred to the USPSTF (www.ahrq.gov/clinic/prevenix.htm or 1-800-358-9295) for systematic evidence reviews and USPSTF recommendations based on these reviews for specific behaviors.American Journal of Preventive Medicine 06/2002; 22(4):267-84. · 3.95 Impact Factor
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ABSTRACT: Healthcare professionals, including nurses, frequently advise patients to improve their health by stopping smoking. Such advice may be brief, or part of more intensive interventions. To determine the effectiveness of nursing-delivered smoking cessation interventions. We searched the Cochrane Tobacco Addiction Group specialized register and CINAHL in July 2007. Randomized trials of smoking cessation interventions delivered by nurses or health visitors with follow up of at least six months. Two authors extracted data independently. The main outcome measure was abstinence from smoking after at least six months of follow up. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. Where statistically and clinically appropriate, we pooled studies using a Mantel-Haenszel fixed effect model and reported the outcome as a risk ratio (RR) with 95% confidence interval (CI). Forty-two studies met the inclusion criteria. Thirty-one studies comparing a nursing intervention to a control or to usual care found the intervention to significantly increase the likelihood of quitting (RR 1.28, 95% CI 1.18 to 1.38). There was heterogeneity among the study results, but pooling using a random effects model did not alter the estimate of a statistically significant effect. In a subgroup analysis there was weaker evidence that lower intensity interventions were effective (RR 1.27, 95% CI 0.99 to 1.62). There was limited indirect evidence that interventions were more effective for hospital inpatients with cardiovascular disease than for inpatients with other conditions. Interventions in non-hospitalized patients also showed evidence of benefit. Nine studies comparing different nurse-delivered interventions failed to detect significant benefit from using additional components. Five studies of nurse counselling on smoking cessation during a screening health check, or as part of multifactorial secondary prevention in general practice (not included in the main meta-analysis) found nursing intervention to have less effect under these conditions. The results indicate the potential benefits of smoking cessation advice and/or counselling given by nurses to patients, with reasonable evidence that intervention is effective. The evidence of an effect is weaker when interventions are brief and are provided by nurses whose main role is not health promotion or smoking cessation. The challenge will be to incorporate smoking behaviour monitoring and smoking cessation interventions as part of standard practice, so that all patients are given an opportunity to be asked about their tobacco use and to be given advice and/or counselling to quit along with reinforcement and follow up.Cochrane database of systematic reviews (Online) 02/2008; · 5.70 Impact Factor
STUDY PROTOCOLOpen Access
An efficacy trial of brief lifestyle intervention
delivered by generalist community nurses
(CN SNAP trial)
Rachel A Laws, Bibiana C Chan, Anna M Williams, Gawaine Powell Davies, Upali W Jayasinghe, Mahnaz Fanaian,
Mark F Harris*, the CN SNAP Project Team
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
* Correspondence: email@example.com
Centre for Primary Health Care and Equity, School of Public Health and
Community Medicine, University of New South Wales, Sydney NSW 2052,
Laws et al. BMC Nursing 2010, 9:4
© 2010 Laws et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
Smoking, nutrition, alcohol consumption and physical
activity (SNAP) are the main lifestyle risk factors for
chronic disease and a major cause of morbidity, mortal-
ity and impaired functioning [1,2]. In Australia, over
90% of adults do not consume the recommended five
serves of vegetables per day, over half do not consume
adequate amounts of fruit and 62% are overweight or
obese . Approximately one third of adults are classi-
fied as physically inactive, one in five (20%) smoke and
of the 59% of the population who drink alcohol, 21% do
so at a level which would pose a risk to their health .
The four SNAP risk factors have been shown to predict
a fourfold difference in mortality, equivalent to 14 years
in chronological age . In terms of morbidity, the
World Health Organization estimates that 80% of cardi-
ovascular disease, 90% of type 2 diabetes and 30% of all
cancers could be prevented if lifestyle risk factors were
Primary health care (PHC) has been identified as a
suitable setting to provide individual intervention for
lifestyle risk factors because of the accessibility, continu-
ity, and comprehensiveness of the care provided . Evi-
dence also suggests that brief lifestyle interventions
delivered in PHC are effective for smoking cessation 
and ‘at-risk alcohol’ consumption , while moderate to
high intensity interventions have shown promise for
improving weight, diet and physical activity levels in
high risk patients in PHC [8-12].
Within the context of PHC, general practitioners have
been the main targets to deliver lifestyle interventions to
patients, but relatively little attention has been paid to
the role of nurses working in the PHC setting, in particu-
lar community health nurses. In Australia, generalist
community nurses (GCN) are uniquely placed to provide
individual lifestyle intervention because they: 1) fre-
quently see patient with existing chronic conditions that
may benefit from lifestyle change; 2) often have ongoing
contact with patients over an extended period of time,
providing the opportunity to offer intervention and foster
motivation through repeated contacts; 3) mainly see cli-
ents in their own home providing opportunity for obser-
vation of the living situation and intervention with the
wider family/carers; 4) may reach disadvantaged indivi-
duals and other segments of the population who have
poor contact with GPs. Furthermore, our previous
research has shown that community health nurses con-
sider the provision of lifestyle intervention an appropriate
component of their role as it fits well with their philoso-
phy of providing holistic care, is often relevant to the cli-
ents presenting issue and is well accepted by clients .
While the health education and promotion role of
community nurses is well recognised [13-17], few stu-
dies have evaluated the effectiveness of lifestyle interven-
tions provided by community nurses in routine practice.
A study in the USA reported that patients who received
smoking cessation counselling from a home health care
nurse were twice as likely to be continuously abstinent
at 12 months compared to those receiving usual nursing
care . Community nursing follow up has also been
shown to be effective in promoting abstinence and
retention rates in outpatient treatment of alcohol depen-
dent patients . While these findings are promising,
we are unaware of previous studies that have examined
the effectiveness of community nurses delivering inter-
vention across all four lifestyle risk factors in routine
Study Aim, Objectives and Hypotheses
The overall aim of this study is to evaluate the impact of
a brief lifestyle intervention delivered by GCNs in rou-
tine practice on changes in clients’ SNAP risk factors.
The study has three main objectives:
1. To develop an intervention to facilitate GCNs to
undertake lifestyle screening and brief intervention dur-
ing routine consultations and to promote referral of ‘at-
risk’ clients to available private and public services;
2. To evaluate the impact of these interventions on
change in clients’ lifestyle risk factors and related media-
tors (eg stages of change);
3. To describe the indicative costs and resources uti-
lised by the community nurse services in delivering the
It is hypothesised that:
1. 20% more clients who are at high risk (defined as
having at least one lifestyle risk factor) in the inter-
vention group will be offered evidence-based inter-
ventions to modify their risk factors compared with
clients in the comparison group.
2. Clients in the intervention group will be signifi-
cantly more likely to progress in their stage of
change compared to comparison clients.
3. Clients in the intervention group will have a
reduction in their lifestyle risk factor scores com-
pared to clients in the comparison group.
Study Design and Setting
This quasi-experimental study is being conducted in
GCN services in the state of NSW, Australia. Within
Australia, GCNs can be either registered or enrolled
nurses who perform a diversity of roles depending on
the service in which they work. The role has tradition-
ally focused on providing a range of nursing care in
Laws et al. BMC Nursing 2010, 9:4
Page 2 of 10
people’s homes such as assisting with activities of daily
living, wound management, chronic disease care, conti-
nence management, palliative care, medication manage-
ment, disability and dementia care. Coordination of care
with other service providers and health promotion has
also traditionally been a major part of their role.
A quasi-experimental design was chosen because it
was not feasible to randomise the intervention according
to individual patient or practitioners within the services.
GCN services have been randomly allocated to an ‘early
intervention’ group or ‘late intervention’ (comparison)
group. ‘Early intervention’ services are provided with
training and support for nurses in identifying and offer-
ing brief SNAP intervention for clients during routine
consultations (see service-level intervention). Data is
being collected from clients in both groups at baseline,
three months and six months to examine short and
medium term change in SNAP risk factors. This will
enable a comparison of client outcomes between early
and late intervention groups. After the six month data
collection point the ‘late intervention’ group will be
offered the same training and support as the early inter-
Power and Sample Size Calculation
The sample size calculation is based on the primary out-
comes of change in continuous self reported measures
of lifestyle risk factors rather than differences in propor-
tion of individuals in each risk category (secondary out-
comes). There is evidence that risk associated with diet,
physical activity and weight is continuous [20-22].
Achieving a shift in risk categories is more difficult to
demonstrate in the context of a brief intervention and
would require a very large sample size which is beyond
the scope and resources of this trial. Hence the focus is
on change in continuous measures of lifestyle risk fac-
tors as the primary outcomes.
A sample size of 360 clients in each group (total n =
720) is required to have 80% of power to detect the fol-
lowing difference between intervention and comparison
▪ Mean difference of 1 serve of fruit and vegetables
consumed (equivalent to 22% increase in the ‘early
▪ Mean difference of 1.2 for physical activity scores
as measured by a validated brief physical activity
assessment tool  (equivalent to a 29% increase in
mean scores in the ‘early intervention’ group);
▪ Mean difference of 0.6 for alcohol risk scores as
measured by the AUDIT-C tool  (equivalent to a
10% reduction in mean scores in the ‘early interven-
▪ Mean difference of 4.1 kg in self reported weight
(equivalent to a 4.4% weight reduction in the ‘early
This is based on 5% significance level and 80% power
(b = 0.8 and a = 0.05) allowing 20% lost to follow-up
and a design effect of 1.8 due to clustering. The
expected differences between intervention and compari-
son groups has been estimated based on previous
research . These differences are also considered
meaningful from a population health perspective. Base-
line prevalence of risk factors is based on NSW Health
Survey 2006 for individuals aged 45-74 years .
Generalist Community Nursing Services
Four GCN services were recruited to participate in the
trial. An expression of interest to participate in the trial
was sent out to all seven Area Health Services(AHS) in
NSW. In NSW, AHS are responsible for providing all
hospital-and community-based health care apart from
general practice and PHC services for specific popula-
tion groups such as Aboriginal and Torres Strait Islan-
ders. AHS were asked to nominate suitable GCN
services which were ranked and selected according to
the selection criteria provided in Table 1.
Recruitment of Clients
In order to reach the required sample size, GCN ser-
vices are required to recruit 180 clients each. Clients
referred to participating GCN services meeting the
selection criteria (Table 2) are invited to participate in
the study. Potential participants are contacted by phone
on the day of referral (where ever possible) by a trained
local recruitment officer. Clients who consent to take
part in the study then participate in a telephone inter-
view to collect baseline data (see data collection). A
total of 720 clients (average 180 clients per service) will
be recruited at baseline. We expect a 20% loss to fol-
low-up of clients of over the study period, leaving 576
clients (or 288 in each group).
Randomisation and Blinding
Services were randomly allocated to an ‘early interven-
tion’ or ‘late intervention’ (comparison) group. Randomi-
sations were performed by a person independent of the
research team. Staff involved in the client data collection
are independent of those involved in the intervention
and blind to which services were randomised to inter-
vention or comparison groups.
Intervention is being undertaken at two levels 1) Service
level intervention involving GCN services and nurses,
Laws et al. BMC Nursing 2010, 9:4
Page 3 of 10
undertaken by the researchers and 2) Client level inter-
vention undertaken by the participating nurses.
At the service-level, the intervention aims to increase
the capacity of the GCN to undertake a brief SNAP
intervention with clients. The design of the intervention
has been informed by our previous research reporting
on a theoretical model of the factors shaping the life-
style risk factor management practices of non GP PHC
providers . The model suggests lifestyle risk factor
management practices are shaped by: 1) clinician com-
mitment, in particular beliefs about role congruence, cli-
ent receptiveness and outcome expectations; and 2)
clinician capacity, including self-efficacy, role support
(provision of training, decision support tools, client edu-
cation materials and linkages to referral services) and
the extent to which lifestyle risk factor management
activities fit with clinicians’ way of working.
Specifically, the service-level intervention comprises of
the following components:
▪ A one day training program for participating
nurses delivered by the research team in conjunction
with local providers. The training specifically focus
on building clinician knowledge, skills and positive
attitudes relevant to the model constructs, with a
particular focus on developing behaviour change
skills such as motivational interviewing and goal set-
ting (learning objectives detailed in Table 3). An
emphasis is placed on experiential learning including
the use of role-plays with simulated clients (actors),
group discussions and activities, which have been
shown to be effective in improving knowledge, skills
and confidence related to lifestyle risk factor man-
▪ The integration of standard screening tools and
prompts for SNAP risk factors (see additional file 1)
into the service specific assessment process used by
the nurses (see additional file 1).
▪ The development and dissemination of a local ser-
vice referral directory to each GCN team to promote
referral of clients for ongoing specialist management
or more/ongoing intensive lifestyle intervention
(such as the proactive telephone Quitline).
▪ The provision of resources to support the imple-
mentation of the intervention including a written
guide for nurses, written action plans for use with
clients on each SNAP risk factor, tape measures for
measuring waist circumference, and pedometers to
loan out to clients to encourage self monitoring of
incidental physical activity
Consultation has been undertaken with participating
sites to ensure that intervention activities are feasible to
deliver within routine practice. A nurse from each of
the early intervention sites has also be seconded to work
with the research team to develop the intervention and
to support its implementation at the local level.
Table 1 Selection criteria for recruiting generalist
community nursing services to participate in the trial
Types Selection Criteria
The team deliver GCN services to clients between 30
and 80 years of age
The team is able to recruit sufficient numbers of eligible
clients into the study in a given recruitment period
(based on trial sample size calculation).
The individual clinicians are interested in participating
and commit to undertaking training and intervention
Willingness of the service to accommodate a
recruitment officer to work on site to identify and
contact potentially eligible clients from client referrals.
Willingness of the service to review and modify service
assessment protocols to include standard tools for
identification SNAP risk factors (if not already included).
The team/services has the capacity to participate in
The team/service has the capacity to deliver SNAP
intervention to a given number of clients in a given
The team/service is broadly representative of
community nursing services statewide (choosing ‘typical
Willingness of the service to participate in project
management meetings with study management team
body to support the trial implementation (eg service
manager and AHS project/recruitment officer).
Teams/services undergoing concurrent changes in
management, structure or service deliver that would
impact on capacity to be involved in the trial.
Involvement in other service development activities that
may contaminant trial activities (eg concurrently
delivering self management program for clients).
Table 2 Selection criteria for recruiting clients to
participate in the trial
Types Selection criteria
Clients referred to community nursing services
Age 30-80 years
Able to read and understand English at a level that
enables the client to participate in a telephone
administered survey and to understand the participant
Palliative care clients
Clients receiving one off visit or service
Clients with significant cognitive impairment (unable to
complete telephone administer survey).
Clients who are currently receiving help in changing
their lifestyle from a health professional (other than their
GP) such as a dietitian or exercise physiologist
Clients who are currently attending a chronic disease
management program such as cardiac rehabilitation,
diabetes education program etc.
Clients who have attended the generalist community
nursing service in the previous six months (and
therefore may have already received lifestyle
Laws et al. BMC Nursing 2010, 9:4
Page 4 of 10
Client- Level Intervention
The aim of the client level intervention is to assist cli-
ents to make positive lifestyle changes by enhancing
readiness to change, supporting self management knowl-
edge and skills, and increasing self-efficacy. Specifically,
the goals of the intervention are to achieve and maintain
lifestyle changes consisted with current Australian
▪ Moderate physical activity for at least 30 minutes/
day including: walking, jogging, swimming, aerobic,
ball games, skiing with circuit-type resistance train-
ing if possible, twice a week;
▪ A diet low in saturated fats, sucrose and salt with
increased portions of vegetables and fruit per day
(up to 7 portions) in order to achieve a diet where the
percentage of energy from carbohydrates = 50%, satu-
rated fats <10% (and total fats < 30%, protein 1 g/kg
ideal body weight per day, fiber 15 g/1000 kcal).
▪ Weight reduction (if overweight) of ≥ 5 kg or 5%
of body weight;
▪ Smoking cessation (if smoker);
▪ Limit alcohol intake (if drinking) to ≤ 2 drinks/
day, including 1-2 alcohol free days/week.
The client intervention involves GCNs providing a
brief intervention tailored to a client’s readiness to
change, in line with the evidenced-based 5As model 
(Figure 1) for one or more SNAP risk factors. Participat-
ing nurses screen clients for lifestyle risk factors as part
of the usual assessment process using a screening tool
(see additional file 1) incorporated into the service
specific assessment forms. A brief lifestyle intervention
is then provided over two or more visits and ‘at-risk’ cli-
ents referred to support services (such as proactive quit-
line) for more intensive intervention. It is intended that
the intervention be delivered as part of routine practice
in early intervention sites. Nurses are required to use
their clinical judgement to determine whether the inter-
vention is appropriate for the client.
The intervention has been informed by the Trans-
theoretical Model of Behavior Change  which postu-
lates that individuals are at different stages of readiness
to adopt a new behaviour and that individuals are
required to progress through various ‘stages of change’.
These stages include not thinking about change (pre-
contemplation), considering change in the next six
months (contemplation), making steps to prepare for
change in the next month (preparation), making changes
to behaviour (action) and maintaining behaviour change
for six months or more (maintenance) . The model
hypothesises that the balance of potential risks and ben-
efits of change (decisional balance) and self efficacy pre-
dict movement through these various stages .
Furthermore, evidence suggests that providing interven-
tions tailored to an individual’s stage of change (stage
matched) is more effective than providing the same
intervention to all individuals [34-37].
Late Intervention (comparison) group
Two of the four GCN services have been randomly allo-
cated to the ‘late intervention’ condition. These services
will not receive the study intervention till after the six
month data collection point and continue to deliver
Table 3 Nurse training program: Learning objectives
At the end of the training program nurses will be able to:
Create a legitimate opening to discuss lifestyle issues with clients
Assess lifestyle risk factors and readiness to change using the provided screening tools
Tailor their approach to clients stage of change (including managing client resistance, motivational interviewing
and goal setting)
Use action plans to negotiate goals for behaviour change with the client
At the end of the training program nurses will have a knowledge/understanding of:
How individual clinical intervention for lifestyle risk factors fits within broader framework of policies and programs
in this area.
Key recommendations/targets for behavioural risk factors
Strategies to assist clients in making lifestyle changes
Behaviour change principles (stage of change, tailoring of advice, importance of multiple interventions over time, small
incremental changes in behaviour)
Available referral services and how to refer clients for more intensive intervention
Lifestyle action plans and their application
The training program will aim to develop positive nurse attitudes with respect to:
The relevance of lifestyle risk factors to their role
The scope to make a difference to individuals, families and population health through lifestyle risk factor management
The likely effectiveness of brief intervention and how this fits with a range of other interventions at the community and
Their role as a facilitator of change for all clients rather than a provider of information only for clients interested or able
Client acceptability and managing client resistance and lack of motivation/capacity for lifestyle change
Laws et al. BMC Nursing 2010, 9:4
Page 5 of 10
‘usual care’. This will enable the effectiveness of the ser-
vice and client level intervention to be assessed in com-
parison to usual practice.
Study Outcomes, Measurements and Data Collection
The study outcomes, measurement tools and timeframe
for data collection is summarised in Table 4. The pri-
mary outcomes focus on measuring continuous self
reported measures of lifestyle risk factors, while second-
ary outcomes focus on the proportion of individuals in
‘at-risk’ categories. Mediator variables of interest include
client’s progress in their ‘readiness to change’ lifestyle
behaviours and change in nurse self-reported confidence
and attitudes in managing lifestyle risk factors.
Changes in clients’ lifestyle risk factors is self reported
and captured through a 15 minute telephone survey
conducted with clients at baseline (prior to first nurse
visit), three and six months. The telephone survey is
being conducted by trained independent data collectors
blinded to the group allocation (intervention or compar-
ison) of services. Measures of lifestyle risk factors used
in the survey are based on validated tools as detailed in
Table 4. Nurse outcomes are being measured using a
web-based survey adapted from the Preventive Medicine
Attitudes and Activities Questionnaire (PMAAQ) 
administered at baseline, six and 12 months. All data
collection tools have been piloted prior to use.
Change in clients’ lifestyle risk factors between early
intervention and late (comparison) services will be
assessed using multilevel models. Because this is a
quasi-experimental study, clients in the intervention
group are not randomly allocated and may have charac-
teristics that are related to outcomes independent of the
intervention . Co-variates will be included in the
analysis to adjust for baseline differences between the
Figure 1 5As model of brief lifestyle intervention using the transtheoretical model of behaviour change.
Laws et al. BMC Nursing 2010, 9:4
Page 6 of 10
intervention and control groups . Regression method
for clustered data or multilevel models will be used to
adjust for confounding client variables such as age, gen-
der, locality (rural versus urban), socio-economic status,
existing health conditions and number of contacts with
the nurse. Thus, this method is used to estimate inter-
vention effect after adjustment for client characteristics
In the study we will use multilevel models in which
three repeated measures (the level 1 units) are nested
within clients (level 2 units) . Multilevel models can
accommodate unbalanced data due to attrition or miss-
ing values. Linear multilevel models would be used for
continuous response variables and multilevel logistic
models used for binary responses. The independent vari-
ables will be intervention (1 = intervention & 0 = con-
trol), time (0 = baseline, 1 = three months & 2 = six
months) as a continuous variable, sex, age, health status
of the client and the interaction between intervention
and time. This model will allow us to test for a signifi-
cant interaction between time and intervention, which
would indicate an effect of the intervention on outcomes
Change in nurses risk factor management confidence,
attitudes and practice scores between early and late
intervention services (comparison) will be assessed for
clustering and, if this is not significant, comparison will
be made between the change in early and late interven-
tion providers using unilevel multivariate methods.
As this is a complex intervention delivered within the
context of normal practice, a qualitative evaluation of
the implementation process is important in interpreting
the study findings . A qualitative evaluation will spe-
cifically explore the acceptability, usefulness and sustain-
ability of the study intervention for both GCNs and
It is proposed that nurse focus groups be conducted
in each early intervention service along with indivi-
dual interviews with team managers and project officers
(n = 8) to explore the:
▪ experience of implementing SNAP risk factor
management in routine practice (appropriateness,
Table 4 Study Outcomes and Measurement
Outcomes Measurement Time point
The number and % of high risk clients offered evidence based interventions to modify their risk factors Client telephone
Baseline, 3 and
Change in mean physical activity scores as measured by a brief validated physical activity tool Client telephone
Baseline, 3 and
Change in mean alcohol intake score as measured by the validated AUDIT-C tool  Client telephone
Baseline, 3 and
Change in mean number of serves of fruit and vegetables as measured by validated questions from the
NSW Health survey 
Baseline, 3 and
Mean self reported weight change Client telephone
Baseline, 3 and
Change in the number and percentage of clients who report smokingClient telephone
Baseline, 3 and
Change in number and percentage of clients reporting adequate levels of physical activity Client telephone
Baseline, 3 and
Change in the number and percentage of clients reporting ‘at risk’ alcohol consumption Client telephone
Baseline, 3 and
Change in the number and percentage of clients consuming >=2 serves of fruit per dayClient telephone
Baseline, 3 and
Change in the number and percentage of clients consuming >=5 serves of vegetables per day Client telephone
Baseline, 3 and
Change in nurse self reported SNAP risk factor assessment and management scoresClinician survey Baseline, 6 and
Intermediate outcomes (mediator variables)
Progression in stages of change (number and % high clients in each stage of change) as measured
by five point intention scales 
Baseline, 3 and
Change in nurse self reported confidence and attitude scores for SNAP management measured
by nurse survey.
Clinician survey Baseline, 6 and
Laws et al. BMC Nursing 2010, 9:4
Page 7 of 10
feasibility, client receptiveness, factors affecting
▪ usefulness of components of the intervention and
additional supports required for sustained uptake;
▪ sustainability of the intervention and issues to
consider in transferring to other GCN teams
Semi-structured telephone interviews will also be con-
ducted with a sample of clients (n = 20-25) from early
intervention sites who recall receiving lifestyle interven-
tion from a GCN. Clients will be purposefully sampled
according to age, gender, health and socio-economic
status of clients. The interviews will aim to explore:
▪ acceptability of SNAP screening;
▪ acceptability and usefulness of the brief lifestyle
intervention provided by the community nurse;
▪ acceptability and usefulness of referral to support
All interview and focus group data would be tran-
scribed verbatim and subject to thematic analysis using
Nvivo 8  to identify convergence and divergence of
The project was approved by the UNSW Human
Research Ethics Committee (HREC) and the HREC in
each AHS. All participants are requested to provide
their informed consent.
Lifestyle risk factors need to be tackled at multiple levels
including individual intervention provided by health
professionals as well as through population health
approaches. Much of the focus in health professional
interventions to date has been on general practitioners,
with relatively little attention paid to nurses outside of
general practice. Community health nurses are well
placed to deliver lifestyle interventions to clients and
their involvement should make these types of interven-
tion more accessible to the population, but little is
known about the effectiveness of such interventions
delivered in routine practice.
This study is a complex intervention trial examining
the effectiveness lifestyle risk factor management deliv-
ered by GCNs. The trial is unique in that it is being
delivered as part of routine practice (without additional
nurse resources) and aims to examine the impact of
brief intervention on multiple lifestyle risk factors. The
collection of quantitative outcome data will provide new
information about the efficacy of such an approach at
both the clinician and client level. This will be supple-
mented by the qualitative evaluation which will provide
important contextual information about the feasibility,
acceptability and sustainability of this approach for both
nurses and clients. Together this information will help
inform future community nursing practice and PHC
• defining the roles of GCNs in assessing and inter-
vening with clients to modify lifestyle risk factors
• identifying competencies for vocational training
and continuing education of GCNs
• organisation of care and the place of health pro-
motion interventions in the care pathway for GCN
• investment in health promotion programs invol-
• the role of referral pathways linking PHC with sup-
port services for lifestyle risk factor management
including both public and private providers
The findings and intervention materials of the study
will be disseminated using a knowledge transfer exchange
strategy. This will include dissemination of key findings
using peer reviewed journals, conference presentations,
the formulation of simple research summaries tailored
for practitioner, service managers and policy makers.
Additional file 1: SNAP screening tools and prompts. This document
provides the SNAP screening tools and prompts used in the trial
(integrated into the standard nursing assessment forms used by early
Click here for file
The authors would like to acknowledge the Centre for Health Advancement,
NSW Department of Health for funding the study. This paper is presented
on behalf of the CN SNAP project team which includes: Milat A, Orr N,
Buckman S, Partington K, Mitchell A, Smith H, Asquith J, Whittaker R,
Hilkmann M, Lisle C, Caines K, Clark S, Dunn S, Christle B, Mangold M and
All authors have contributed to study design and have reviewed and
approved the final manuscript. In particular, RAL and BC have lead the
development of data collection tools and processes, RAL and MFH
intervention design and UJW statistical analysis methods. RAL wrote the first
draft of the manuscript.
The authors declare that they have no competing interest in the conduct of
Received: 14 January 2010
Accepted: 23 February 2010 Published: 23 February 2010
Laws et al. BMC Nursing 2010, 9:4
Page 8 of 10
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Cite this article as: Laws et al.: An efficacy trial of brief lifestyle
intervention delivered by generalist community nurses (CN SNAP trial).
BMC Nursing 2010 9:4.
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