Population health and public health roles in Australian general practice.

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Volume 6, Number 2, July 2009
Building the Marjorie Jackson-Nelson Hospital
Guest Editorial
Justin Beilby
Professor; Executive Dean, Faculty of Health Sciences
University of Adelaide
Current perspective
Health reform is now a worldwide imperative. The overlapping groups of public
and population health and general practice are not immune, and are being
actively drawn into these discussions. In Australia there has been a burgeoning
of health system reviews that have created a new and exciting momentum
around prevention, public health and population health activities, which will
offer increased opportunities for general practice and primary care. The National
Health and Hospital Reform Commission (NHHRC),1 the Primary Health Care
Strategy2 and the National Preventative Health Taskforce3 have all signalled an
increasing importance for the whole spectrum of disease prevention, health
promotion and protection. This element of our health care system has clearly
been the ‘poor cousin’ when compared to the interest and funding that acute
hospital-based and general practice care generates. The terms of reference of
the NHHRC report use phrases such as ‘greater focus on prevention in the health
care system‘ and ‘improved frontline care to better promote healthy lifestyles and
prevent and intervene early in chronic illness’.1
This issue of the Bulletin provides an excellent summary of the broad public
and population health activities that involve general practitioners (GPs), their
practices and staff, and the Divisions of General Practice (Divisions). The articles
in the issue span the broad public and population health continuum. In the area
of protection, Litt & Pearce and Williams & Morgan highlight the role of general
practice in controlling pandemic influenza. Quigley and Somers both outline the
role of rural general practice in disaster management, while Benson concentrates
on refugee health and D’Onise on the care of the homeless. The unique
planning and service roles, that Divisions of General Practice have created, are
allowing innovative health promotion models to be established that are aimed
at improving ’the population health of the local communities’; as is discussed by
Kalucy et al.
Public Health
Bulletin SA
Public Health and
General Practice
Contents
4Population health and public health
roles in Australian general practice
9The interface between general practice
and public health
12 Preventing chronic disease in primary
health care: a work in progress
17 Population health role of the Divisions
of General Practice Network
21 How population health data can help
primary care services to improve
population health: a rural case study
26 Professional education and the role of
general practitioners in public health
and population health
29 The community-oriented
general practitioner
31 General practice: retrospective
reflections from a public
health perspective
32 General practice involvement in public
health oriented refugee health
35 The role of GPs in environmental
health: working with homeless people
38 General practice role in obesity
prevention from a population
health perspective
42 Preconception care in general practice
45 GP planning in a pandemic
50 The role of general practice in disaster
planning and response—bushfires
53 Communicable Disease Control Branch
Disease Surveillance and Investigation
Report 1 January to 31 March 2009

Public Health Bulletin
Other authors illustrate the potential of general practice
to influence and actively contribute to the prevention
agenda: Spurrier on obesity management; McLean et
al, preconception care; and Harris & Powell Davies,
chronic disease prevention. Kidd argues that a policy
and curricula framework underpins this crucial general
practice role, clearly identifying that GPs are integral
to any population health approach to improving the
health of their communities.
With the increased emphasis on population health
and the promotion of a healthy lifestyles, it is timely
to debate how to strengthen the contribution of
general practice in a creative and coordinated manner.
We are still a long way from a system that places the
same value on prevention and a population health
perspective as on acute care. General practice has
largely been reactive, responding to the need to
respond, diagnose and provide treatment to almost
90% of the population who visit a GP each year. What
we now require is the establishment of partnerships,
together with policy and funding levers, that will create
a more proactive, prevention-oriented general practice
that integrates a whole-of-life perspective for patients,
carers and their families.
Future perspective
There will be a number of crucial building blocks that
will be required to garner the full potential of general
practice. They will include, as priorities, workforce
development, coordinated national leadership that
integrates linkages with general practice, strengthening
of practice-based infrastructure, and fostering of
patient and family linkages with general practice and
primary health care services.
Lilley and Stewart state that ‘there will be an urgent
requirement for the existing population health
workforce, primary health care and non-government
sectors to increase their knowledge and understanding
of prevention, promotion and protection theory and
practice, within new organisational development
frameworks’.4 They argue that unless there is a
coordinated approach across health policy developers,
academic institutions and health professional colleges
to plan, train and develop a primary care population
health workforce, the true potential of this model
will not be reached. Within general practice training
programs, it will be crucial to establish educational
programs that, for example, teach the value of brief
intervention for smoking cessation programs, which
Helena Williams mentions as being a successful
GP intervention;5 foster the establishment of new
community-focused GPs which is the concern of
Scrimgeour; create local GP ‘epidemiologists’ and
public health specialists working with Divisions to
both measure local risk factor profiles and implement
new population health initiatives, as touched on by
a number of authors: Fraser, Kalucy et al and Helena
Williams; and establish ‘SNAP-like initiatives’ in their
practices as discussed by Harris & Powell Davies. These
training programs need to be created in partnership
with public and population health specialists in state
Health Departments, using resources such as the
national Public Health Education and Research Program
or National Health and Medical Research Council
Population Health Capacity Building Grants.
The establishment of the National Prevention Agency,
signalled in the recent Federal Budget, is a welcome
initiative.6 Once this agency is created, it is likely
that long-term Australia-wide goals and targets will
be established. These targets will no doubt include
reducing childhood and adult obesity; reducing
smoking prevalence, particularly among Indigenous
people and lower socioeconomic groups; reducing the
age-adjusted prevalence of diabetes, reducing harmful
levels of alcohol consumption; and making sure that
all children have a healthy start to life.7 GPs and their
practice-based teams will need to embrace and develop
programs to help meet these targets. Divisions, in
partnership with state jurisdictions, will have a role in
developing local ‘GP-friendly’ initiatives that align with
these goals and targets. Helena Williams has suggested
that establishing these types of partnerships, at both
local and national levels, has not been clearly flagged as
a priority within the current national initiatives.
Approximately two-thirds of the total burden of
disease in Australia and almost 80% of all deaths
can be attributed to six chronic diseases—cancer,
cardiovascular disease, mental disorders, injury, diabetes
and asthma.8 These diseases are, and will continue
to be, the core ‘business’ of general practice and
GPs and their staff. Increasingly, GPs will adopt the
role of coordinating and organising their acute and
preventive care services. Currently, general practice
is struggling to effectively manage these roles. Harris
& Powell Davies have listed practitioner, practice and
health system impediments to adoption of a true
population health role. In South Australia the GP
Plus policy initiative is attempting to overcome these
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Public Health and General Practice
impediments in partnership with general practice. The
NHHRC has argued for new infrastructure funding
and specific grant funding to support multidisciplinary
clinical services and care coordination services that
are tied to levels of enrolment of young families and
people with chronic and complex conditions.1 These
initiatives are worth exploring. All ‘enrolled’ patients
could automatically be offered a home care assessment,
a GP management plan, a team care arrangement
and the appropriate chronic disease (diabetes and
asthma) programs as discussed by Mc Namara et al. If
appropriate, they could be fully assessed for access to
Medicare mental health management item numbers.
In addition, well-baby checks and 45-year-old health
checks could be offered for eligible enrolled patients
and families.
The partnerships between public and population health
and general practice will inevitably continue to grow.
What we need to do now to efficiently use the skills
and expertise from both groups to improve the health
of our communities is to foster the development of the
GP public and population health workforce, establish
links with national leadership and build a general
practice infrastructure that actively manages a ‘specific’
group of people and their families.
Reference
1. National Health and Hospitals Reform Commission.
A healthier future for all Australians. Interim Report of
the National Health and Hospitals Reform Commission.
Australian Government, Canberra, 2008.
2. Department of Health and Ageing.
http://www.health.gov.au/internet/main/publishing.nsf/
Content/PHS-QuestionsandAnswers.
3. Department of Health and Ageing.
http://www.health.gov.au/internet/main/publishing.nsf/
Content/mr-yr08-dept-dept080708.htm.
4. Lilley K, Stewart D. The Australian preventive health
agenda: what will this mean for workforce development?
Aust New Zealand Health Policy 2009;6(1):14.
5. Miller M, Wood L. Smoking cessation interventions;
review of the evidence for best practice in health care
settings. National Tobacco Strategy occasional paper.
August 2001.
6. Department of Health and Ageing.
http:www.health.gov.au/budget2009.
7. Australian Institute of Health Policy Studies (AIHPS).
A vision for prevention in Australia. Discussion paper,
National Prevention Summit, AIHPS and Victorian Health
Promotion Foundation, 2008.
8. 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.
Volume 6, Number 2, July 2009 page 3

Public Health Bulletin
Population health and public health
roles in Australian general practice
John Fraser
Head, School of Rural Medicine
University of New England, Armidale, New South Wales
Background
Australian general practice extends from providing
individual patient care to addressing the health needs
of the broader population. The general practitioner
(GP) of the future will need clinical, population health
and public health skills to manage a multidisciplinary
team.1 This view is based on the observation that the
environmental and social determinants of health2
are intrinsically linked to the clinical presentations of
patients. It is also reflected in the Royal Australian
College of General Practitioners (RACGP’s) definition
that states:
‘General practice is the provision of primary
continuing comprehensive whole patient medical
care to individuals, families and their communities.’ 3
This integrated role between general practice,
population health and public health is promoted
internationally as it has the potential to improve health
outcomes.1 Furthermore, a combination of these skills is
consistent with recommendations of the World Health
Organization (WHO) for training health professionals
in the 21st century.4 The WHO considers that health
professionals require five core competencies—patient-
centred care, partnering (working with patients, health
professionals and communities), quality improvement,
information and communication technology and
a public health perspective. In contrast, recent
recommendations of the National Health and Hospitals
Reform Commission considers that strategies to
improve the health of communities and people should
focus on a population health perspective and
empower consumers to take more responsibility for
their own health.5
How do these approaches differ and
does this difference matter?
Some health professionals, including myself
(previously),6 have considered population health and
public health in general practice to be interchangeable.
However, this paper suggests that there are subtle
differences between these terms,7 and an exploration of
these differences is important in considering strategies
to improve equity of access in health care. An inverse
care law continues to exist in health care provision, with
the ‘availability of good health care varying inversely
with the need for it in the population’.8 This is relevant
to general practice as the majority of GPs will provide
population health to their patients.
In Australia, poorer disadvantaged groups, while using
some acute care services in general practice, are the
lowest users of preventive care—about 10–15% of the
population will not access a GP in any one year.9 The
inverse care law is likely to be particularly marked in
rural areas of Australia, as poor infrastructure, including
transport, and lower numbers of GPs reduce access to
health services. Additionally, rural GPs’ high workload
in meeting the demands of acute care often prevents
expansion of preventive health services.10 Therefore,
the most disadvantaged, who are most likely to benefit
from population health activities, often miss out on
accessing these interventions.
Traditionally, GPs consider that they have an obligation
in the main to their own population of patients, and
extending care to patients outside the surgery has
been seen to be beyond the scope of general practice.
However, some programs have been implemented to
reach disadvantaged groups outside the practice by
Australian Divisions of General Practice, Aboriginal
Medical Services and in some instances by rural
practitioners.10 These activities rely on salaried medical
practitioners and different models of health care
delivery to a fee-for-service practice. Considering the
health care of the entire population outside the surgery,
and implementing changes to improve health overall, is
a public health approach that needs to involve multiple
stakeholders in its implementation.11
These principles have been incorporated in the ‘towards
unity for health’ movement,12 which recognises that
partnership between individuals, organisations and
communities is needed to improve equity of access to
health care via community-based education, research
and service. Public health programs need to interact
and operate in a complex pentagon of intersecting
relationships between ‘health service providers, health
professionals, the community, policy makers and the
academic community’ to optimise outcomes.12 In reality,
this interaction is often suboptimal due to the differing
priorities of multiple stakeholders, and the need to
share power, resources and decision making in order
to collaborate.12
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Public Health and General Practice
The differences between population health and public
health have been incorporated in the updated RACGP
curriculum, with competencies prescribed from the
medical student level to continuing professional
development for GPs with a special interest in this
field.13 In GP registrar training, traditional population
health activities are, for example, giving ‘focused brief
advice’ about the lifestyle factors of smoking, nutrition,
alcohol and physical activity; and ‘implementing
preventive guidelines’ in practice.13 In contrast,
educational activities in continuing professional
development for GPs extend to a public health
approach such as ‘describing successful strategies
to encourage disadvantaged groups to present to
general practice for preventive care’ and ‘implementing
strategies in general practice to reduce injury and
violence’.13 These public health interventions require
skills in advocacy, and the ability to work in a team and
engage and negotiate with multiple stakeholders, as
identified by Boelen.12
This recognition is timely, as defining the differences
between population health and public health in
general practice can assist health professionals, health
providers, government, academics and patients12
contribute to and collaborate in health improvement
programs, as advocated by the National Health and
Hospitals Reform Commission, and in programs to train
future health professionals.
A continuum of roles in the interface
between population health and public
health in general practice
Population health has several interpretations in the
literature:14 a concept, referring to the health of a
defined population (such as a general practice patient
list); or a field of study linking health outcomes,
determinants of health and interventions. Within
Australian general practice, population health activities
are considered to be those core practices—such
as screening and preventive health services (e.g.
immunisations)15—that can be provided to a defined
population. However, defining populations can be
problematic. For instance, patients of a medical practice
are often shared between a number of GPs, and some
patients, particularly the disadvantaged, don’t see a GP
at all in any one year.
The GP’s role in screening and immunisation is well
recognised as having significant impact on the health
of Australians.16 In contrast, the GP’s effectiveness
in promoting lifestyle change is more limited,17 with,
at most, 2–4% of patients changing their lifestyle
behaviours after brief advice from a doctor. Broader
public health and new public health approaches are
needed to modify the socioeconomic determinants of
health2,16 and encourage patients to practise health-
promoting behaviours.16
A comparison between primary health care and
general practice is important to this discussion
as developments in public health, including ‘new’
public health philosophy, are key to exploring these
differences. The RACGP’s definition of general practice
differs markedly from primary health care as defined by
the WHO’s Declaration at Alma-Ata.18 Primary health
care considers stakeholders who need to be involved
in organisational change to allow ‘toward unity for
health’12 to improve health via a public health approach.
A comparison of the two definitions shows primary
health care to be much broader in outlook than general
practice, extending the definition to include health care
as a tool for social and economic development. Primary
health care is universally available, rather than being
provided to patients who are able to access a general
practice in the private sector. General practice within
Australia is a component of primary health care, which is
also provided by nurses and other health professionals.
Some components of primary health care’s philosophy,
such as self-determination and the promotion of social
and economic development, share many similarities
with public health. Public health began with a
community-led movement to improve living conditions
in the 19th century, and was a process focused on
environmental health with limited input from doctors.16
Today, public health continues to be a socially driven
movement focusing on improving the health of
all people.19 As a discipline, it is a ‘combination of
science, practical skills and beliefs that is directed to
the maintenance and improvement of the health of all
people’.11 It is multidisciplinary in focus, with medical
doctors, nurses, health promoters, epidemiologists,
sociologists, environmental officers and health
economists working in the field.
Calls for a ‘new’ public health movement arose from
the Ottawa Charter for Health Promotion in 1986.20
Limited progress in delivering primary health care’s aims
resulted in recognition of the importance of health
Volume 6, Number 2, July 2009 page 5

Public Health Bulletin
promotion in achieving ‘Health for all by the year 2000
and beyond’.20 Implementation of the Ottawa charter
includes the following five strategies for success,20
which are also embodied in the ‘towards unity for
health’ movement:12 building health policy, creating
supportive environments, strengthening community
action, developing personal skills, and reorienting
health services.
Leadership in population health and public health in
general practice can extend to policy development;
advocacy with other stakeholders; and liaison with
general practice, population health and public health
practitioners to promote collaborative models of
health care. Those GPs with an interest in this field can
develop these leadership skills by considering further
studies in public health.13 A number of joint training
programs for general practice and public health have
also been developed.21–23
The application of population health and public health
approaches to a clinical presentation in Australian
general practice is demonstrated in the following
hypothetical case study.
Tensions in a broader continuum
In practice, barriers limit the application of activities
along the broader continuum of public health and
‘new’ public health approaches in general practice.1,24
Many aspects of the health care system create
disincentives to an expansion of these activities,
including a fee-for-service remuneration system that
rewards the number of patients seen; limited time;
limited training in population health and public
health; limited contact between GPs and other health
professionals within the health care system; lack of
status of public health work; and limited capacity for
GPs to expand their services to patients who are unable
or unwilling to attend their surgeries.24
These issues require a holistic approach to health
reform that includes consideration of the impact and
input from the five main stakeholders identified in the
‘towards unity for health’ concept—policy makers,
health professions, health managers, academic
institutions, and communities.12 Organisational
change requires a consideration of the interaction of
all stakeholders.12 Using population health and public
Population health
approach in
general practice
Robert has implemented several population health approaches in his practice based on preventive
guidelines.15 He routinely asks about the smoking status of his patients and provides brief advice about
smoking cessation when required. He advocates exercise classes provided by community health for
those patients with chronic obstructive airways disease. He routinely administers influenza vaccine and
pneumococcus vaccine to his patients. Concerned about the increase in lung cancers, he consults the
RACGP guidelines on the evidence of preventive activities in practice.15 He finds that there is no evidence
for routine chest X-ray screening preventing lung carcinomas in patients who are over 50 years of age.
Public health
approach in
general practice
Robert is approached by some of the community about the rise in lung carcinomas. He audits the five
patients, conducting a case series. He finds that all the patients have worked at a closed mine that
quarried asbestos. Robert notifies the public health unit of his concerns, and liaises with the cancer
registry, who confirm that a cancer cluster is present in the region. He explores what has happened
to the closed mine site to prevent further exposure of the population. He begins to ask all his patients
occupational health questions, and considers reviewing the literature on whether surveillance with
chest X-rays is needed for his patients with occupational exposure at the mine.
‘New’ public
health approach
in general
practice
Robert is made aware that the mine site has not been rehabilitated and that mine tailings are blowing
around the site. There are several roads nearby. He liaises with the local council and a working party
is formed to lobby for rehabilitation of the site. The council receives a grant to fence off the mine site
and divert roads from the area.
Leadership in
public health and
general practice
Robert liaises with a public health expert in the Department of Rural Health at his local university.
A literature review of asbestosis and lung disease is conducted. This is used to better inform the
profession on an approach to patients with occupational exposure to asbestos based on the evidence
and patient concerns. Robert publishes his literature review and case series.
Case study: Robert, a GP in a small country town, has seen five patients develop lung cancer in the last year.
They are all men aged over 65 years and three are non-smokers.
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Public Health and General Practice
health interchangeably can cause different stakeholders
to have different perceptions of each other’s roles.
A fee-for-service model offering preventive services
to the worried well8 does not work in a public health
approach that seeks to optimise equity of access for all.
An example of this is that health care is paid for by
government through a process of policy change that is
implemented by health care providers with input from
academics in policy development. Policy makers and
academic public health practitioners are often salaried,
and therefore removed from the actual day-to-day
running of a practice, and may not appreciate the
impact of policy change on GPs’ time, practice and
patients. There is some criticism25 of general practice’s
narrowly based individualistic lifestyle SNAP (smoking,
nutrition, alcohol, physical activity) approach by ‘new’
public health practitioners.16 This may reflect confusion
between general practice’s role3 in meeting the needs
of a defined practice population and primary health
care’s18 role in extending to the broader community the
organisational changes embodied in the ‘towards unity
for health’ approach.12
A previous review of the interface of general practice
and population health was conducted by Fry and Furler
in 2000.26 However, in this review the use of the term
‘public health’ was avoided. The authors undertook
this decision to emphasise ‘a concern with how general
practice and broader primary health care programs
can contribute to improving the health of whole
populations’, and because the media and general public
use ‘public health’ to describe publicly funded acute
hospital services.
The approach of excluding public health was, in
my opinion, problematic for general practice, as
peak organisations, such as the RACGP, have in
previous versions of the curriculum referred almost
interchangeably to ‘population health’ and ‘public
health.27 I encountered the difficulties in using these
terms interchangeably in a pilot project to train general
practice registrars in rural population health and public
health. The terms were defined as synonymous by
the stakeholder reference group appointed to advise
on the project.6 This blurring of definitions may have
contributed to some stakeholders describing an ‘unease
about coexistent clinical and population/(public) health
roles’ in the training pilot.
Such tension is reported elsewhere in the literature.
Kamien28 observes that most change concerning an
expanded population health and public health role in
general practice has, to date, been imposed by the
government. There can be a tension in maintaining
professional GP autonomy and incorporating population
health and public health role into general practice.29
This can extend to all of medicine, which is seen to
be in ‘schism’ and ‘competition’ with the paradigm
of public health as outlined by Boelen.12 This is based
on unequal power relationships within the ‘towards
unity to health’ pentagon of stakeholders, with
imposed changes by public health policy makers, health
providers and academics threatening the autonomy of
doctors and the rights of the community.12
Consistent with Boelen’s ‘toward unity for health’
model,12 Buetow and Docherty30 have warned that
change imposed without collaboration has the scope to
impair the doctor–patient relationship due to a prime
focus on population health based targets. Recently, a
similar debate has been raised in Britain, where a pay-
for-performance bonus for improved diabetes control
in general practice may be deleterious due to the strict
targets set.31
Conclusion
Improving the health of the Australian population
requires a combination of population and public
health interventions. While population health skills
are core skills used by all GPs, there is great potential
for GPs and other health professionals to implement
public health approaches to extend care to patients
presently not accessing health care services. GP
autonomy and input into the process are important
to avoid undermining these initiatives. There is a
continuum of roles in the interface of general practice
with population health in practice, public health,
‘new’ public health and leadership approaches.
True collaboration between stakeholders involves
clarification by GPs and other primary health care
providers, other sectors of the health system, public
health practitioners, government and patients of their
roles within this framework.32 A collaborative approach
is likely to overcome many of the present tensions
in attempting to increase the population health and
public health focus of Australian general practice. The
interface needs to be considered in training programs
for health professionals and in any planned health
care reforms. Advanced training for GPs in population
health and public health is emphasised in the
RACGP curriculum and has been developed in recent
programs.13,21,22,23
Volume 6, Number 2, July 2009 page 7

Public Health Bulletin
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long standing type 2 diabetes. Br Med J 2009;338:b800.
32. Hawe P. Working in collaboration with others. In: Kerr
C, Taylor R, Heard G (eds). Handbook of public health
methods. McGraw-Hill, Sydney, 1998.
page 8

Public Health and General Practice
The interface between general
practice and public health
Helena Williams
Chief Executive
General Practice Network South;
General Practitioner
‘Our patients can reasonably expect to have
their immediate medical needs attended to,
along with an examination of broader issues
which may have led to their presentation. It
follows logically that family physicians must have
a role in looking beyond illness, and trying to
shape behavioural, societal and environmental
influences on ill health.’1
‘Australia leaves its GPs to fend for themselves
in trying to construct systems for dealing with
the preventive load’.2
Introduction
The quotes above represent two views of the current
role of Australian general practice in public health.
This paper aims to explore the evolution of the role
more broadly, and also consider the challenges
surrounding general practice’s involvement in public
health, across the spectrum of promotion, protection
and prevention. The paper will also attempt to show
that general practice is increasingly—and indeed
strongly supports the idea of—taking on a greater
population health approach, despite the barriers that
exist within the structural and funding and financing
systems in Australia.
Since the Rudd Government came to power, a number
of health policy works have been commissioned,
including the National Health and Hospitals Reform
Commission report; the Primary Health Care Strategy
discussion paper; the National Preventative Health
Taskforce, and the Council of Australian Governments
(COAG) National Partnership Agreement on Hospital
and Health Workforce Reform. In South Australia (SA)
similar pieces of work have been completed or are
being drafted (for example the Chronic Disease Action
Plan for SA and the Primary Prevention Plan). Most of
these policy documents are consistent in emphasising
the importance of population health and primary
health care approaches in maintaining and achieving
wellness and health, and in optimally managing chronic
disease, thereby ultimately enhancing quality of life and
reducing hospital demand.
Only a few of these documents, however, overtly
recognise the capacity and role that general practice
is playing, or could potentially take on, in a broader
population health approach. It is interesting to note
that there was little interaction with grass roots general
practice in the development of, for example, the
Chronic Disease Action Plan for SA.
There is therefore little mention of general practice as a
key provider of primary prevention and risk intervention
services; or, indeed, little acknowledgement of how
general practice might assist governments by taking
on a greater role, given its daily interaction with
the majority of the population. There is significant
potential for increased population health impact within
general practice, with an increasing number of general
practitioners (GPs) now working within multidisciplinary
team models of care, along with practice nurses and
other allied health professionals.
General practice involvement in
prevention
General practice is doing many things well. There
is evidence, for example, for the effectiveness of
implementing clinic systems designed to increase the
assessment and documentation of tobacco use. Use
of these systems almost doubles the rate at which
clinicians intervene with those patients who smoke,
and results in higher rates of smoking cessation.
Brief cessation advice to smokers from GPs, delivered
opportunistically during routine consultations, has a
modest effect but substantial potential public health
impact. Brief advice delivered to smokers by nurses also
has a modest effect on the odds of quitting, compared
to no advice.3
General practice has been active for many years now in
systematic approaches to raising immunisation rates. It
has historically been supported by federal immunisation
practice incentive payments (which are separate to
Medicare fee-for-service items, and thereby provide a
more flexible funding stream to deliver this work) and
the work of the Divisions of General Practice.
Divisions have assisted general practices in their
successful efforts to achieve high immunisation rates.
They have delivered education, for example regarding
immunisation schedule changes and cold chain
transporting and storage of vaccines, particularly to
practice nurses, who are increasingly taking on this
work. Divisions have also been active in coordinating
GP and nurse attendance at such events as Nunga
Volume 6, Number 2, July 2009 page 9

Public Health Bulletin
immunisation days and newly arrived refugee
immunisation (NARI) clinics, taking these events out to
the community.
At the time of writing, a number of divisions are
providing a range of allied health services within
residential aged care facilities. These services relate to
oral health screening and dental care, as well as mental
health groups. Having ascertained what the priority
needs are by conducting needs analysis in the care
facilities, the divisions work closely with residential aged
care staff, the SA Dental Service, mental health nurses,
carers, GPs and practice nurses.
A significant proportion of general practices in Australia
participate in the National Primary Care Collaboratives
(NPCC), in the Australian Primary Care Collaboratives
(APCC), and in SA in the southern GP Plus Health Care
Network (50% participation). This participation has
provided significant support and incentives for practices
to access a range of tools and resources designed to
assist them to take a population health and continuous
quality improvement approach to addressing practice
population outcomes across a range of indicators (for
example recording and improving smoking status,
blood pressure measures and cervical screening rates).
The Practice Health Atlas™ (PHA)4 is a decision support
tool, designed by the Adelaide Western General Practice
Network, for GPs, nurses, managers and other practice
staff. It aims to inspire general practice teams to reflect
on their activities and to develop business models for
more effective health care services and outcomes. It
is based on the synthesis of relevant, high-quality and
timely practice population health data, as well as the
use of such data to predict future health care needs and
trends (intelligence). Further work is supporting practices
in the use of an ever-widening range of IT/IM tools
designed to improve risk and prevention activities (for
example the Doctors Control Panel).5
The success of these specific activities lies in general
practice teams taking a population health approach,
aided by the use of high-level data, to inform strategy
while not interfering with the individual doctor–patient
interaction.
Some data is being fed to registers (for example
the APCC online reporting system, the Australian
Childhood Immunisation Register or division-held
databases), where it can be benchmarked and then
shared with peers to enable the implementation of
practice strategies designed to improve outcomes.
Conversely, however, some prevention activities are
not proving to be successful. This may be, in part,
because the policies and implementation strategies
have not been developed in partnership with general
practice providers. For example, it is increasingly being
identified, through the SA Do it For Life program,
that comorbid mental health issues are proving to be
a significant barrier to patients being able to address
identified lifestyle risk factors. This was not predicted
in the early development of this program, and has
meant that state health services and local divisions
will increasingly need to meld lifestyle/risk intervention
and mental health programs to better support those
patients identified and referred from general practice.
In the southern region of Adelaide, in the first six
months of the 2008–09 financial year, some 849
45-49 yr old health checks (Medicare item 717) were
undertaken in general practices, out of an eligible
population of approximately 27,000. The reasons for
this are likely multifactorial, and might include the
time pressures of child rearing, mortgages and careers,
and the fact that this population does not recognise
that they are at risk or see their health as a priority. Of
equal relevance, however, is the likelihood that general
practice has difficulty with systematising new processes.
Discussion
General practice has often come under fire for focusing
on individual patient care to the detriment of public or
population health approaches. Some of this is likely to
be consumer driven, with patients attending GPs for
specific ailments they wish addressed and the savvy
and efficient GPs, wherever possible attempting to
address risk factors and prevention opportunistically
during those consultations. Patients, however, are
not necessarily open to such interventions at that
time. While there is some evidence for success in an
opportunistic approach, the impact of a systematic
and planned approach to prevention through general
practice would be spectacular. Indeed, there is evidence
that family physicians strongly endorse the importance
of delivering preventive care services but are frustrated
by the ineffectiveness of opportunistic approaches, and
require the use of support tools to do this.7
There is no doubt that the fee-for-service system
provides good incentives to provide acute episodic
care and increase access. However, the uptake of the
Medicare item 717 referred to above suggests it might
not be the optimal funding incentive for prevention
activities, many of which could be delivered by skilled
general practice nurses and allied health practitioners.
page 10

Public Health and General Practice
The lack of a comprehensive funding model to
support general practice in undertaking prevention
and promotion activities—particularly one that
supports practice nurses to increasingly undertake this
work—does little to support general practice to engage
systematically in prevention. It is also apparent that
general practices vary in their capacity and willingness
to embrace change. It seems that one of the greatest
barriers to optimal prevention in general practice is
not lack of knowledge but lack of a systematic and
integrated approach.8 Such an approach could be
achieved by improvements to the funding and financing
system in general practice, improved integration with
other providers and acknowledgement of the potential
impact of greater integration with general practice.
It is often quoted that approximately 85% of the
Australian population sees a GP at least once a year.9
There is no doubt that one of the major strengths of
general practice is its relationship with the individual
patient—the holistic ‘cradle to grave’ care provided, the
intimate knowledge of the social milieu in which the
patient exists, and the privileged position of GPs to raise
topics (such as overweight and obesity, smoking, drug and
alcohol intake), often for the first time, within the context
of the patient’s family history and environment. Indeed,
several studies have found that preventive activities
increase with increasing continuity of primary care.10
Summary
It is entirely possible to take an individual approach
to health care for each patient and, at the same time,
consider the whole practice population—indeed, to
consider and address population health needs across a
region. There is scope for a greater focus on preventive
care in general practice. Increasingly, there is a wider
range of tools/resources and partnerships to support
general practice to take on a greater systematic
approach. It is exciting to anticipate the impact that
could be achieved for a large proportion of the
population if only these opportunities were maximised
and supported by governments at every level, and for
long enough to enable system changes to be sustained
and entrenched.
References
1. Weller, D. Family medicine should focus on the sick:
negative position. In: Buetow S, Keneally T (eds)
‘Ideological debates in family medicine’. Nova Biomedical
Books, New York, 2007.
2. Russell GM. Is prevention unbalancing general practice?
Med J Aust 2005;183(2):104–105.
3. Miller M, Wood L. Smoking cessation interventions; review
of the evidence for best practice in health care settings.
National Tobacco Strategy occasional paper, August 2001.
4. http://www.awdgp.org.au/site/index.cfm?display=5462
5. http://pracsoftutilities.com/Home/tabid/36/Default.aspx
6. https://www.medicareaustralia.gov.au/statistics/mbs_item.
shtml
7. Anderson et al. Views of family physicians in southwestern
Ontario on preventive care services and performance
incentives. Fam Pract 2006;23(4):469–471.
8. Lemelin J, Hogg W, Baskerville N. Evidence to action:
a tailored multifaceted approach to changing family
physician practice patterns and improving preventive care.
CMAJ 2001;164:757–763.
9. Australian Institute of Health and Welfare (AIHW).
Australia’s health 2008. AIHW cat. no. AUS 99. AIHW,
Canberra, 2008.
10. Saultz JW, Lochner J. Interpersonal continuity of care
and care outcomes: a critical review. Ann Fam Med
2005;3:159–166.
Volume 6, Number 2, July 2009 page 11

Public Health Bulletin
Preventing chronic disease
in primary health care: a work
in progress
Mark Harris
Executive Director
Centre for Primary Health Care and Equity,
University of New South Wales
Gawaine Powell Davies
Chief Executive Officer
Centre for Primary Health Care and Equity,
University of New South Wales
Introduction
Chronic disease is an increasingly large part of the
burden of disease.1,2 Much is preventable—the risk
factors for vascular conditions, in particular, are well
understood; and effective strategies are known for
reducing the ‘SNAP’ behavioural risk factors (smoking,
poor nutrition, hazardous alcohol consumption and
physical inactivity) in individuals and populations.3,4
Primary health care has the potential to deliver
prevention to those at higher risk through its wide
reach, often-continuing relationships with patients/
clients, evidence-based interventions and acceptance
of risk factor management as a legitimate activity.5,6
The accepted approach in general practice is the ‘5As’
approach (Box 1). However, current practice does not
match this potential, and it is not well understood
how such work fits with other parts of primary health
care (for example community health). The potential
population health impact of widespread risk factor
management is not known.7
A number of studies have explored the factors that
influence the management of behavioural risk factors
in primary health care. These include clinicians’ lack
of knowledge and skill, their beliefs and attitudes (in
particular confidence and perceived effectiveness), practice
type, and perceived congruence with clinicians’ roles.8,9
This paper examines the role that primary health care
can play in chronic disease prevention, the barriers
and facilitators involved in clinicians addressing the
risk factors, and the organisational models needed to
support this role at the population level.
Methods
The focus of this paper is on general practice and
community health services, reviewing results from
studies conducted at the University of New South Wales
(UNSW) over the past 5 years. These include:
a feasibility study Smoking Nutrition Alcohol and >
Physical Activity (SNAP) implementation in general
practice, conducted in 2003–0410
evaluation of 45–49-year-old chronic disease >
prevention health checks in general practice in 200711
a feasibility study of behavioural risk factor >
management in community health in 2005.12
All studies received Human Research Ethics Committee
approvals and the informed consent of participants.
The paper also draws upon a review of national
preventive care policy initiatives in behavioural risk
factor management in Australian general practice
between 2001 and 2007, including the implementation
of health checks in general practice.13,14
Results
In this analysis we have used the 5As framework
(see Box 1).15
Box 1: The 5As approach
ASK: all patients about smoking, nutrition, alcohol and physical activity
ASSESS: readiness to change and dependence (on smoking and alcohol)
ADVISE: by providing brief, non-judgmental advice with patient education materials (such as Lifescripts) and motivational
interviewing
ASSIST: by providing motivational counselling and a prescription (Lifescript or pharmacotherapy if indicated for nicotine
or alcohol dependence)
ARRANGE: referral telephone support services, group lifestyle programs or an individual provider (eg dietician or exercise
physiologist), and a regular follow-up visit
page 12

Public Health and General Practice
Ask: identification of patients at risk
This is the first step in preventive action. Figure 1 shows
the prevalence of risk factors in our evaluation of the
impact of a health check for patients aged 45–49
years in eight Sydney practices. At baseline, 97.5% of
participating patients had at least one, and the majority
two or more, SNAP risk factors, demonstrating ample
opportunity for intervention.16 This is similar to results
from the NSW Health Survey11,17 and our findings in
other studies in general practice and community health.10
Assess: assessment of level of risk and readiness
to change
The next step is to assess the patient’s level of risk and
motivation (usually in terms of readiness to change).
GPs and community health nurses vary in the frequency
with which they report assessing risk factors in their
patients (Figure 2).2,4 The introduction of the health
check in 2007 is likely to have increased the frequency.
Community health nurses seem ready to accept risk
factor assessment as part of their role, incorporating
SNAP questions into their discussions with the patient.12
The assessment of motivation or readiness to change
is much less frequent in both general practice and
community health services. This improved after training
0
10
20
30
40
50
60
70
80
90
Smoking Low fruit/veg BMI Alcohol Physical activity
%
study group n=118
NSW Health Survey
45–53 years
Figure 1: Presence of risk factors in participating patients presenting for 45–49 year old health check
in 2005–66 compared with similar age group in the NSW Health Survey 2003
0
10
20
30
40
50
60
70
Smoking Nutrition Alcohol Physical activity
%
2003–04
2007
Figure 2: Proportion of GPs at baseline reporting frequent assessment of SNAP
risk factors 2003–04 and 2007
Volume 6, Number 2, July 2009 page 13

Public Health Bulletin
but was still low in absolute terms. Clinicians seemed
to have difficulty incorporating assessment of readiness
to change into routine practice due to time constraints,
patients not interesteed and other reasons.
Advise: giving of brief advice, information
and goal setting
Primary health care providers seem willing to take
on the provision of brief advice, with rates greatly
increasing after the introduction of the health check
in general practice and a training workshop for GPs
in 2007 (Figure 3).3 Community nurses are more
comfortable with discussing collaborative goal setting
with patients than are GPs.
Arrange: arranging referral for
lifestyle interventions
Levels of referral for lifestyle interventions are very
low,18 although they improved somewhat after the
health check in 2007 (Figure 4).
Lack of patient motivation was one reason for not
using referrals. Several clinicians felt that patients were
reluctant to spend money on their health, and would
be disinclined to talk with the GP next time if they had
previously been referred.
Follow-up
The overall rate of follow-up was low, reflecting the
passive approach to managing preventive care taken
by most clinicians. This was true for both GPs and
community nurses.
Barriers to implementation
We identified significant barriers to the implementation
of preventive care in primary health care. These related
especially to assessment, referral and systematic follow-
up at the level of practitioner, practice or health service,
and the health system.
0
10
20
30
40
50
60
70
80
90
100
Smoking (n=20) Nutrition (n=93) Alcohol (n=62) Physical activity
(n=67)
%
pre
post
Figure 3: Information and advice patients with risk factors reported
receiving from the practice before and after a health check 2007
0
5
10
15
20
25
Smoking (n=20) Nutrition (n=93) Alcohol (n=62) Physical activity
(n=67)
%
pre
post
Figure 4: Referrals to other services before and after the health check as
reported by patients with the risk factor 2007
page 14

Public Health and General Practice
Practitioner barriers include:
expected effectiveness in changing patient behaviour >
congruence with practitioner roles >
perceived acceptability to clients, especially among >
community health nurses
other demands on practitioner time, including more >
acute problems
confidence in addressing risk factors and motivational >
counselling.
Practice or health service barriers relate largely to
capacity and include:
sharing roles within the patient care team >
the quality of links with referral services or programs >
information systems for identifying patients at risk for >
follow-up appointments etc.
lack of decision support systems for assessment >
and referral
accessibility of the practice/service, including >
availability of appointments.
Health system barriers include:
availability and accessibility of low-cost referral >
services and programs
workforce shortages, especially in outer urban and >
rural areas
lack of funding for preventive care (apart from some >
specific groups such as those aged 45–49 years)
lack of monitoring and reporting of provision of >
preventive care.
Discussion
Primary health care has a role in chronic disease
prevention, including identification, assessment and
brief advice in general practice and community health.
However, many providers find more complex assessment
of risk and readiness to change a challenge, and their
greatest weakness is in referral of high-risk patients for
more intensive individual or group interventions. Many
Divisions of General Practice report similar experiences
with referrals to group diabetes prevention programs for
patients aged 40–49 years. This is important given the
difficulty in providing more than brief interventions in
primary health care services for patients at high risk.
Barriers include patient and provider attitudes, and
provider confidence in the efficacy of interventions and
their ability to undertake lifestyle interventions given
their other roles and responsibilities. Practices and
other health services have limited capacity to provide
comprehensive interventions for those at high risk. These
are similar to the factors influencing chronic disease
management in primary health care. Our work suggests
that the model for preventive care outlined in Huang et
al.19 can be adapted along the lines of Figure 5.
Addressing preventive care needs dedicated time in
primary health care. For general practice this means
specific funding on either a fee-for-service or a
performance basis. Funding and workforce development
are also needed to make referral services more available
and accessible. However, these are unlikely to be enough
on their own. Teamwork needs to be facilitated both
within the primary health care practice and with referral
services to build system capacity.
Social context
Health system, community, health literacy
Organisational context
Guidelines, information systems, self
management support/education, teamwork
Shared decisions about preventive actions
Informed
consumer
(knowledge,
attitudes, skills)
Proactive
provider
(knowledge,
attitudes, skills)
Figure 5: Adaptation of chronic care model for preventive care (adapted from Huang et al.)
Volume 6, Number 2, July 2009 page 15

Public Health Bulletin
A number of issues remain unresolved. It is unclear how
broader population health initiatives fit with preventive
primary health care. The role of health checks for
chronic disease prevention in primary health care is
still uncertain: research has demonstrated a positive
impact of health checks on the frequency of preventive
care and achieved some outcomes, but has not
demonstrated cost effectiveness.20–22
Our own research continues. To date most has
comprised descriptive or uncontrolled time series
studies, but we are currently conducting several
controlled studies that should provide more information
on efficacy in the Australian context. Further research
is also needed to explore how there can be better
integration of service delivery between primary health
care and other preventive services and programs, and
how access to preventive care can be improved for
specific population groups, especially Indigenous and
socioeconomically disadvantaged communities.
Conclusion
Primary health care in Australia is well placed to
contribute to the prevention of chronic disease.
However, this potential is at least partially unrealised
due to a combination of practitioner, service and system
barriers. In particular, there are significant barriers in
the referral pathway from primary health care to more
specialised services and programs that provide intensive
interventions for people with the SNAP risk factors.
Overcoming these barriers will require action at all levels.
References
1. Mathers C, Vos T, Stevenson C. The burden of disease
and injury in Australia. AIHW cat. no. PHE 17. Australian
Institute of Health and Welfare, Canberra, 1999.
2. Britt E, Miller G, Charles J, Pan Y, Henderson J, Bayram
C et al. General practice activity in Australia 2005–2006.
AIHW cat. no. GEP 19. Australian Institute of Health and
Welfare, Canberra 2007.
3. Australian Institute of Health and Welfare (AIHW). Chronic
diseases and associated risk factors in Australia, 2001.
AIHW, Canberra, 2002.
4. Australian Institute of Health and Welfare (AIHW).
Indicators for chronic disease and their determinants.
AIHW cat. no. PHE 75. AIHW, Canberra, 2008.
5. Pegram R, Daniel J, Harris M, Humphries J, Kalucy L,
MacIsaac P, Mott K, Saunders R. General practice in
Australia 2004. Department of Health and Ageing,
Canberra, 2005.
6. Royal Australian College of General Practitioners (RACGP).
Putting prevention into practice: guidelines for the
implementation of prevention in the general practice
setting. RACGP, Melbourne, 2006.
7. Litt JC. Exploration of the delivery of prevention in the
general practice setting. PhD thesis, Flinders University,
South Australia, 2007.
8. Brotons C, Bjorkelund C, Bulc M, Ciurana R, Godycki-
Cwirko M, Jurgova E et al. Prevention and health
promotion in clinical practice: the views of general
practitioners in Europe. Prev Med 2005;40(5):595–601.
9. Bull F, Schipper E, Jamrozik K, Blanksby B. Beliefs and
behaviour of general practitioners regarding promotion of
physical activity. Aust J Public Health, 1995;19(3):300–304.
10. Harris MF, Hobbs C, Powell Davies G, Simpson S, Bernard
D, Stubbs A. Implementation of a SNAP intervention in
two divisions of general practice: a feasibility study. Med J
Aust 2005;183:s54–s58.
11. Amoroso C, Harris M, Ampt A, Laws RA, McKenzie S,
Williams AM, Jayasinghe UW, Zwar NA, Powell Davies G.
45-49 year old chronic disease prevention health checks in
general practice: utilisation, acceptability and effectiveness.
Centre for Primary Health Care and Equity, University
of New South Wales; and Australian Primary Research
Institute, Australian National University, 2008.
12. Laws R, Kirby S, Powell Davies PG, Williams A, Jayasinghe
U, Amoroso C, Harris MF. Should I and can I? A mixed
methods study of clinician beliefs and attitudes in the
management of lifestyle risk factors in primary health care.
BMC Health Serv Res 2008:8:44.
13. Harris MF, Laws R, Amoroso C. Moving towards a more
integrated approach to chronic disease prevention
in Australian general practice. Aust J Primary Health
2008;14:112–119.
14. Chan A, Amoroso C, Harris MF. New 45–49 year health
checks: GP uptake of MBS item 717. Aust Fam Physician
2008;37:765–768.
15. Goldstein MG, Whitlock EP, DePue J. Multiple behavioral
risk factor interventions in primary care: summary of
research evidence. Am J Prev Med 2004;27:61–79.
16. Amoroso C, Harris MF, Ampt M, Laws RA, McKenzie S,
Williams AM, Jayasinghe UW, Zwar NA, Powell Davies
G. Health check for 45-49 year old patients in general
practice: feasibility and impact on practices and patient
behaviour. Aust Fam Physician 2009;38:358–362.
17. Centre for Epidemiology and Research, NSW Department
of Health. New South Wales Adult Health Survey 2002.
NSW Public Health Bull 2003;14(S-4).
18. Amoroso C, Hobbs C, Harris MF. General practice capacity
for behavioural risk factor management: a snap-shot of
a needs assessment in Australia. J Primary Health Aust
2005;11:120–127.
19. Huang 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;85:69–91.
20. Bouleware LE, Barnes GJ, Wilson RF, Phillips K, Maynor
K, Hwang C, Marinopoulos S, Merestein D, Richardson-
McKenzie P, Bass EB, Powe NR, Daumit GL. Systematic
review: the value of the periodic health evaluation. Ann
Intern Med 2007;146:289–300.
21. Imperial Cancer Research Fund OXCHECK Study Group.
Effectiveness of health checks conducted by nurses in
primary care: final results of the OXCHECK study. BMJ
1995;310:1099–1104.
22. Engberg M, Christensen B, Karlsmose B, Lous J, Lauritzen
T. General health screenings to improve cardiovascular risk
profiles: a randomized controlled trial in general practice
with 5-year follow-up. J Fam Pract 2002;51(6):546–552.
page 16

Public Health and General Practice
Population health role of the
Divisions of General Practice
Network
Libby Kalucy
Director*
Ann-Louise Hordacre
Research Manager*
Sara Howard
Research Associate*
Cecilia Moretti
Research Associate*
* Primary Health Care Research and Information Service
Flinders University
What are Divisions of General Practice?
Divisions of General Practice provide services and
support to general practices to achieve health outcomes
for the community within defined catchment areas.
Divisions can achieve systemic improvements in local
primary care that cannot be achieved by individual
general practitioners working alone.1 Today the
Divisions Network, which is funded largely by the
Australian Government, consists of 111 Divisions
of General Practice (divisions), six state-based
organisations (SBOs), two hybrid SBO-divisions (in the
Northern Territory and the Australian Capital Territory)
and the Australian General Practice Network. With its
national coverage, the network has a workforce of
more than 3000 staff members with clinical, health
science, public health and management skills, adding
substantial infrastructure to primary care.2
Divisions address the needs of general practitioners
(GPs) and practices and the health of their populations,
and respond to local and national priorities. Unlike
some primary care organisations in the United Kingdom
and New Zealand, divisions have no contractual ‘hold’
over the general practices in their region. Their capacity
as change agents depends on the extent to which they
can persuade, inform and legitimise their activities.3
What is the population health
role of divisions?
Since the implementation of the divisions program, the
Australian Government has viewed divisions as playing
a significant role in population health,a implementing
and supporting health promotion, disease
prevention and treatment programs within identified
subpopulation groups.4 In this context, divisions are
expected to:
improve access to general practice services by >
considering the characteristics of the local population
and the potential mismatch between need, access
and use of general practice services
improve the quality of general practice services >
through stronger chronic disease and injury
prevention activities, better management of chronic
disease, earlier diagnosis and intervention.4
Whereas GPs might identify their practice population
as the people who attend the practice, a division
population includes the entire population of the defined
catchment area. In addition, divisions target specific
activities toward different subpopulations identified by
demography; health problem (or risk); or geographic,
political or administrative territory.5 Because divisions
fulfil multiple roles for multiple stakeholders, they
sometimes experience tension between their role as
a local support organisation for GPs and their role in
population health.5
Assessing population needs
A population health approach includes assessing
the needs of a defined population, then planning,
implementing and evaluating the strategies to address
these needs. Divisions have a dual role—supporting
general practice to obtain and use data about practice
populations, and identifying and addressing the needs
of the local community within the division population.
In Australia information technology and information
management (IM–IT) has been identified as an
indispensable element in a population health approach
at both the general practice and division levels.6
Using IM–IT to identify the needs of practice populations
has become simpler and more systematic due to business
management tools such as the Practice Health Atlas7
and Pen Computer Audit Tool.8 General practices using
these tools, with the support of their divisions and SBOs,
are better able to understand the sociodemographic and
health characteristics of their patients.
a The term ‘population health’ is used here rather than ‘public health’, which is associated with health care delivered
in the government-funded sector.
Volume 6, Number 2, July 2009 page 17

Public Health Bulletin
Data availability for needs assessment and planning at
the division population level has been enhanced by the
population health profiles prepared for each division in
Australia.b These profilesc demonstrate that individuals
using practices within a division do not always reside
within the division catchment. For example, in South
Australia in 2003–04 between 68% and 94% of people
attended general practices in the division in which they
resided. The lower figure is seen in urban divisions
with a mobile commuting population (e.g. Adelaide
Northern and Eastern Division, 68.5%), whereas in the
rural Eyre Peninsula Division 94% of GP attendances
were of individuals within the division catchment.
Divisions are aware of the difference between practice
population and division population, incorporating this
consideration into planning and implementing their
population health role.
Data are complemented by each division’s knowledge
of the local area acquired through multiple sources,
including community input. Divisions engage their local
populations in a number of ways such as community
education, forums and surveys. In 2006–07, 65% of
Australian divisions involved community members in
program evaluation, 57% in strategic planning and
48% in needs assessment. Divisions complete the
consultation process by providing feedback to consumer
and community members, often through websites,
community newspapers or division newsletters.2
A place at the planning table
In 2006–07 divisions were represented on more
than 2000 external committees, indicating strong
engagement with communities throughout Australia.2
Almost all divisions were represented on area,
district and regional health service committees,
and many sat on committees about specific local
issues. This collaborative approach is also reflected in
formal reciprocal agreements (or memorandums of
understanding) established between divisions and other
organisations—almost two-thirds of divisions reported
agreements with hospitals and half with mental health
services in 2006–07.
Divisions’ role in improving access
Limited access to primary health care services is more
common in rural and remote areas, where workforce
recruitment and retention is a major focus for divisions
(and government). Almost 80% of rural and remote
divisions are therefore involved in improving access
to locum services, compared to around 20% of
metropolitan divisions (Figure 1). Taking a different
approach, nearly 700 GPs were paid on an hourly or
sessional basis to address access barriers such as limited
practice hours or financial constraints in 2006–07.2 For
example, these GPs worked in youth health clinics or
in-school services, provided health checks or screening
Figure 1: Proportion (%) of divisions providing services to increase access to GP services by rurality, 2006–07
Data source: Annual Survey of Divisions 2006–07.2 Rurality calculated using Rural, Remote and Metropolitan Areas classification.9
ACCHS: Aboriginal Community Controlled Health Service.
Locum
services After hours
service Alternative/
expanded
locations
Increased
services in
ACCHS
settings
Addressing
financial
barriers
More flexible
hours
Metropolitan (N=54)
Rural (N=34)
Rural-Remote (N=14)
0
20
40
60
80
100
Type of service
Rurality
b Population Health Information Development Unit (PHIDU), University of Adelaide. www.publichealth.gov.au/publications/
population-health-profiles-of-the-divisions-of-general-practice.html.
c Table 3 of 2007 Supplementary profiles prepared by PHIDU
page 18

Public Health and General Practice
in hard to reach rural and remote settings, or specified
services for Indigenous Australians. To increase access to
allied health professionals, divisions directly contract them
to deliver services to their communities through federal
programs such as More Allied Health Services (MAHS)
and Access to Applied Psychological Services (ATAPS).
Divisions’ role in health promotion and
secondary prevention
Divisions have played a substantial role in furthering
prevention activities in primary health care through
implementing government policy and initiatives at the
state or national level, a task that GPs alone would
be ill equipped to do. Divisions tailor their approaches
to population health to suit the program and target
population through a combination of education,
practice support, recall systems, community awareness
and collaboration with other providers (Figure 2). As
previously identified, divisions are engaged to support
both practice populations (i.e. through practice support
or recall systems) and the division population or
subpopulations within their catchment (as is evident
in a community awareness approach). Divisions
typically aim to reach a broad population through their
prevention programs—most reported no specific target
for many of their prevention activities in 2006–07.2
Responding to local population
health needs
Divisions operate at a local level and are embedded
within the communities with which they work. This
on-the-ground understanding of their communities and
the conditions in which they live makes them ideally
placed to respond to disasters, public concerns and
ongoing health needs. To respond to disasters, divisions
require an emergency plan, and the ability and will to
put it into action. For example, in the February 2009
Victorian bushfire devastation, divisions in the affected
areas facilitated initial action and recovery, providing
information and support services including treatment
clinics and counselling. The coordinated response effort
shown by these Victorian divisions is a result of having
established emergency response plans formulated
with other local organisations. Similarly, divisions in
other areas of Australia have responded to their local
populations’ needs. Eight divisions reported responding
to the needs of drought-affected communities across
Australia from 2005 to 2007.2,10 Relief activities for
local northern Queensland divisions were targeted
toward communities affected by Cyclone Larry in
2006; and New South Wales and South Australian
divisions provided support to local communities after
the 2007 Newcastle floods and the 2005 Eyre Peninsula
bushfires, respectively.
Figure 2: Proportion (%) of divisions conducting prevention programs by approach, 2006–07
Data source: Annual Survey of Divisions 2006–07.2 The Lifescripts program involves a holistic approach to prevention,
incorporating risk factor management specifically in the areas of smoking, alcohol consumption, nutrition and physical activity.
Practice support
Recall system
Community
awareness Collaboration with
other orgs
Cervical screening (N=63)
Lifescripts (N=101)
Immunisation (N=119)
0
20
40
60
80
100
Approach
Program
Volume 6, Number 2, July 2009 page 19

Public Health Bulletin
Local need is not always based on critical events, but
may address long-term solutions to chronic problems
within the community. Many of the South Australian
Riverland’s GPs and a MAHS-funded Aboriginal health
worker provide health care to the local Indigenous
population from a bus, locally known as the Peelies
Bus, that visits all the major Riverland towns once a
fortnight. The Peelies Bus aims to reduce disparities in
the health and wellbeing of the Riverland Aboriginal
community by improving access to timely and culturally
appropriate services, and linking into existing services
rather than replacing them. The bus depends on a
close working relationship between the three partner
agencies (Riverland Division of General Practice Inc.,
Riverland Regional Health Service Inc. and Families SA).
It also benefits from the availability of ‘point of care’
pathology testing equipment. Results are available
on the same day, at the same location, compared to
the usual delays associated with waiting for results to
return from the laboratory.
Final comments
Divisions are already playing a role in improving
population health in their local communities. The
potential availability of more reliable practice data
through IM–IT development could mean that divisions
have a greater impact on health service planning and
policy.2 Division Network staff will need to add data
analysis to their existing skills set, and continue to
work with their practices to demonstrate the value
of a population rather than an individualist focus.11
Divisions’ unique understanding of the population
health characteristics within their catchments enables
them to engage in focused improvements in the quality
of, and access to, primary health care services.
References
1 Australian Government Department of Health and Ageing.
Overview of the Divisions of General Practice Program.
www.health.gov.au/internet/main/publishing.nsf/Content/
health-pcd-programs-divisions-index.htm.
2 Hordacre A-L, Howard S, Moretti C, Kalucy E. Moving
ahead. Report of the 2006-2007 Annual Survey of
Divisions of General Practice. Primary Health Care
Research and Information Service, Department of General
Practice, Flinders University; and Australian Government
Department of Health and Ageing, Adelaide, 2008.
3 Beacham B, Kalucy L, McIntyre E, Veale B. Focus on...
Understanding networks. Primary Health Care
Research and Information Service, Flinders University,
Adelaide, 2005.
4 Australian Government Department of Health and
Ageing. Divisions of General Practice: future directions.
Government response to the report of the review of
the role of Divisions of General Practice. Australian
Government Department of Health & Ageing,
Canberra, 2004.
5 Rogers W, Veale B, Weller, D. Linking general practice with
population health. National Information Service, Flinders
University, Adelaide, 1999.
6 Joint Advisory Group on General Practice and Population
Health. Coordination of population health activities in
general practice. Centre for General Practice Integration
Studies, University of NSW, Sydney, 2002.
7 Del Fante P, Allan D, Babidge E. Getting the most
out of your practice. The Practice Health Atlas and
business modelling opportunities. Aust Fam Physician
2006;35(1/2):34–38.
8 General Practice SA Inc. GPSA News. 2009 April;4(2).
9 Primary Health Care Research and Information Service.
Rural Remote Metropolitan Area (RRMA) classification.
www.phcris.org.au/fastfacts/fact.php?id=4801.
10 Hordacre A-L, Howard S, Moretti C, Kalucy E. Making
a difference. Report of the 2005-2006 Annual Survey
of Divisions of General Practice. Primary Health Care
Research & Information Service, Department of General
Practice, Flinders University; and Australian Government
Department of Health and Ageing, Adelaide 2007.
11 Moss JR, Mickan SM, Fuller JD, Procter NG, Waters BA,
O’Rourke PK. Mentoring for population health in general
practice divisions. Aust Health Rev 2006;30(1):46–55.
page 20

Public Health and General Practice
How population health data can
help primary care services to
improve population health: a rural
case study
Kevin Mc Namara
Research Fellow, Rural Pharmacy1; Lecturer, Pharmacy
Practice2
James A Dunbar
Director1
Prasuna Reddy
Professor3; Director, Health Services Research1
Benjamin Philpot
Research Associate1
Clare Vaughan
Research Associate1
Mark Morgan
Senior PHC RED Research Fellow1; General Practitioner
Edward Janus
Professor1; Director4
1 Greater Green Triangle University Department of Rural
Health (Flinders University and Deakin University)
2 Department of Pharmacy Practice, Monash University
3 School of Medicine, Flinders University
4 Department of General Internal Medicine, University of
Melbourne, Western Hospital
What is population health?
Population health can be defined as ‘the health
outcomes of a group of individuals, including the
distribution of such outcomes within the group’.1
This field of activity incorporates population-level
examinations of health outcomes, determinants of
health, and policies and interventions linking the two.1
A unique outcome from population health data is
the identification of ‘sick populations’, where a high
average level of disease risk in a population is directly
related to the proportion of people at very high risk.
In addition, population health data provides a greater
understanding of the interrelationship between multiple
determinants of health in affecting health outcomes.2
Despite such benefits, population health approaches
to health care have been criticised for being almost
exclusively quantitative and epidemiological in focus,
and consequently lacking the context or aptitude to
translate population-level information to changes in
clinical practice and health service delivery3. Using a
rural Australian case study, this paper illustrates how
population health data can in fact stimulate important
changes to general practice and primary health care.
Greater Health population
health surveys
During 2004–06 the Greater Green Triangle University
Department of Rural Health (aka Greater Health, a
collaboration between Flinders University in South
Australia and Deakin University in Victoria) undertook
three population health surveys in rural southeastern
South Australia and adjoining southwestern Victoria.4,5
Based on the World Health Organization’s MONICA
protocol6 and the more recent European Health Risk
Monitoring project7, these population-based surveys
drew stratified random samples from local electoral
rolls, and sought to examine the prevalence of chronic
disease risk factors and related health behaviours
among them. Both laboratory and non-laboratory tests,
as well as self-completed patient surveys, were used to
collect the data.
The surveys were undertaken following local and
international consultation about the major health
challenges to the region. Consultation occurred in
two brainstorming days 3 months apart, in which
local health professionals examined the available
pool of epidemiological data. Divisions of General
Practice participated in the analysis, leading to the
setting of heart disease and diabetes as local priorities
for intervention. A consensus was reached that such
surveys were essential as part of a concerted effort to
improve the health status of the region.
Using population health data for
general practice
The resulting research has given rise to a basic report
and an ongoing series of peer-reviewed publications
that present the results of this work (see Box 1).
These publications demonstrate the high prevalence
of chronic disease risk factors in the region, and the
evidence–treatment gaps in their management. Such
findings act to confirm the health priorities of the
region; advocate for interventions to policymakers and
service providers; and, importantly, provide baseline
data against which the success of future population-
level interventions could be measured.
Volume 6, Number 2, July 2009 page 21

Public Health Bulletin
Benefits of this data to general practice and other
primary care services are both direct and indirect.
Published results give a direct insight into the health
behaviours and co-morbidities associated with chronic
diseases. This allows general practitioners (GPs) to
engage in more comprehensive primary care screening
tailored to individual patients. Clinically relevant findings,
which can be used by GPs, include the following:
Young people are not given sufficient advice >
about smoking and may warrant more systematic
screening by GPs.8
People in the age group 45–54 years are at >
the highest risk of depression.9
Most people with diet-related cardiovascular risk >
factors report low levels of dietary advice from GPs
or other health professionals.10
The majority of patients with diagnosed hypertension >
are undertreated, with diagnosed men less likely to
receive drug treatment or achieve blood pressure less
than 140/90 mmHg.4
Almost all adults with diabetes or established >
cardiovascular disease have at least one suboptimal
lipid parameter.11
Central obesity, an independent risk factor for >
diabetes and myocardial infarction, appears to
be even more prevalent with the burgeoning
obesity epidemic.5
Box 1 Summary of published peer-review papers by topic
Overweight, obesity and metabolic syndrome5
The prevalence of overweight and obesity combined was 74.1% (69.7–78.5) in males and 64.1% (59.5–68.7) in females.
According to International Diabetes Federation criteria, the overall prevalence of metabolic syndrome was 31.8% (28.6–
35.1). With only 30% of the population within the ‘normal weight’ range, urgent action is required at the highest level to
change unhealthy lifestyle habits by improving diet, increasing physical activity and making our environments supportive of
these objectives.
Hypertension4
This study emphasises suboptimal detection and treatment of hypertension, especially in men, in rural Australia. This will
have serious future consequences in terms of cardiovascular outcomes if left unaddressed. Overall, one-third of participants
had hypertension and one-third of those were not aware of a previous diagnosis. Only half of those diagnosed were
treated and half of the treated actually achieved blood pressure control.
Physical activity20
One-fifth of adults in rural Australia were inactive, with few individuals engaged in daily physical activity at moderate to
vigorous intensity to achieve health benefits. Leisure-time physical activity has the most potential for improvements to be
made at a population level.
Psychosocial9
A third of the rural population reported psychological distress, with the highest prevalence observed in middle-aged men
and women. Thus, health professionals should attend not only to physical health, but also to mental health status, in this
age group. It is also important to target prevention strategies to the 20% who reported moderate levels of psychological
distress, in order to prevent the development of more serious conditions.
Metabolic syndrome and depression18
Our data show an association between metabolic syndrome and the cognitive and affective components of depression in
a rural population, with the prevalence of depression in individuals with metabolic syndrome being 50% higher. Based on
the findings of this study, awareness of depressive symptoms as part of metabolic syndrome could be as important in clinical
management as chronic diseases.
Smoking cessation8
We found that the overall prevalence of smoking was 15% when adjusted, the rate decreasing with age. Those smokers
in the 25–44 years age group were most likely to want to stop but were less likely to have received advice on smoking
cessation than older smokers. This suggests a need for greater vigilance in proactively targeting younger smokers.
page 22

Public Health and General Practice
Based on the epidemiological data showing low
identification rates and evidence–treatment gaps, there
is a direct case for GPs to use the newer Medicare
item numbers for chronic disease management. They
allow GPs more consulting time, and they fund practice
nurses to do screening and case management. They
reimburse disease management plans and reviews,
and also allow the patient access to a number of allied
health professionals. Some of the commonly used item
numbers for management of chronic diseases and
chronic disease risk are discussed in Table 1. During
patient consultation, population data can also help
primary care practitioners by raising awareness of
important issues such as:
potential comorbid conditions for certain patient groups >
major evidence–treatment gaps that should be >
addressed, such as screening for depression in
patients with diabetes and heart disease
the allocation of practice resources to meet the needs >
of local patients.
Indirectly, population-level efforts to reduce the average
exposure to such chronic disease risk factors generate
a disproportionate reduction in the number of people
who are considered at high risk.2 The obvious benefit to
general practice from such efforts is to reduce excessive
levels of demand on GP services stemming from
epidemic levels of risk factors such as obesity, and allow
GPs to focus more on high-risk individuals.
Table 1: Commonly used Medicare item numbers in chronic disease prevention, detection and management
Item
number
Title DescriptionaEligibility
717 45-year-old
health check
A one-off health check, with GPs encouraged to consider
lifestyle and biochemical risk factors, and family history.
Practice nurses and other health professionals can assist.
45–49-year-old
patients at risk of
chronicb condition(s)
713 Type 2 diabetes
risk evaluation
Review of diabetes prevention activities for patients with a
‘high risk’ score identified by the Australian Type 2 Diabetes
Risk Assessment Tool.
Much of the work can be done by practice nurses.
High-risk diabetic
patients aged
40–49 years
721– 731 Enhanced Primary
Care (EPC) Chronic
Disease Management
(CDM)
Preparation or review of GP management plans (GPMPs);
coordinating, implementing or reviewing team care
arrangements (TCAs) with input from other professionals.
Can involve other health professionals.
Patients with a chronicb
or terminal medical
condition
10997 Monitoring and
support
Practice nurses and Aboriginal health workers provide
monitoring and support services.
Patients with
a GPMP or TCA
700 & 702 Health assessments
for older persons
In-depth assessment containing medical, social, physical and
psychological components.
Information can be collected by, for example, practice nurses.
Older patients
(75+ or, ATSI 55+)
710 Aboriginal and Torres
Strait Islander (ATSI)
adult health check
To facilitate early detection and intervention for common and
treatable conditions that cause considerable morbidity and early
mortality (e.g. circulatory, respiratory, endocrine conditions).
ATSI adults aged
15–54 years
900 & 903 Medication
management reviews
Patient referred to accredited pharmacist for medication
review and management plan for implementation by GP and
community pharmacist.
2517–2526
& 2620–
2635
Management of
diabetic patients
A number of items for various aspects of management and
completion of the diabetes cycle of care.
Much of the work can be done by practice nurses.
Patients with established
diabetes mellitus
2710–2713 GP mental
health plans
Early intervention, assessment and management in parallel with
EPC and CDM items.
Practice nurse can provide general assistance with development
of plan.
Patients with mental
disorders
a Further details see Medicare Benefits Schedule for further details
http://www.health.gov.au/internet/mbsonline/publishing.nsf/Content/Medicare-Benefits-Schedule-MBS-1
b A chronic condition is a disease likely to go on for 6 months or more.
Volume 6, Number 2, July 2009 page 23

Public Health Bulletin
Using population health data for
specific conditions: obesity
Obesity was a primary focus of attention following the
Greater Health surveys, which found that 68.9% of
the adult population was considered either overweight
(38.9%) or obese (30.0%).5 In addition to improving
public awareness of the problem through media
releases and health forums, several projects were also
initiated to complement existing state and federal
initiatives.
Projects run directly through the University Department
of Rural Health (UDRH) included Food and Move,
designed to promote healthy eating and regular
physical activity for young people in the secondary
school setting.12 The Primary Health Care Research,
Evaluation and Development (PHC RED) program
run through the UDRH was able to award research
bursaries to local health and education practitioners
so that capacity for addressing such issues at a service-
delivery level was enhanced. Relevant PHC RED projects
involved investigating the delivery of best practice
obesity management through surveying GPs,13 and
identification of barriers to selling healthy food in
school canteens.14
Local organisations were also able to use the risk factor
information independently to advocate for action in
the region. The Heart of Corangamite is a network of
community agencies and health promotion practitioners
in one of the surveyed regions. The network was
formed to combine resources and prioritise strategies
to respond to the Greater Health survey findings. Its
key objectives include: increasing consumption of
fruit, vegetables, water and low-fat dairy products;
and increasing opportunities for active transport and
access to established sporting and recreation clubs
and organisations in the region. Meanwhile, a Healthy
Active Regional Transport program was funded in the
Limestone Coast area to promote cycling in rural areas,
using survey data to establish the need for physical
activity interventions.
Summary
Population health data from the Greater Health survey
has helped to inform future directions for primary care
in the region. Several new models of care aimed at
supporting general practice with high-risk patients have
been examined. Initiatives include:
the development of a diabetes prevention program >
that has now been adopted throughout Victoria15
managed clinical networks, with clinical pathways >
for co-morbid depression in acute coronary
syndrome16,17
collaborative care for patients with diabetes, >
coronary heart disease or both18
improving attendance at cardiac rehabilitation > 19
community pharmacy support for general practice in >
the prevention of cardiovascular disease (see http://
www.greaterhealth.org/research for details).
A close alignment of activities within Greater
Health between public health, health services and
workforce programs ensures that the momentum for
dissemination of findings and addressing evidence–
treatment gaps was maintained. Formal and informal
networks across general practice and other health and
related professions further facilitated dissemination.
Improved management of chronic diseases, including
cardiovascular disease and diabetes, and their risk factors
requires a change in the way GPs approach their work,
particularly patient consultations. It requires them to:
see their patients as belonging to populations at risk >
use available MBS item numbers to fund >
identification, review and management plans for at-
risk patients to measure the risk factors
ensure that treatment is directed to the targets set in >
national guidelines.
It requires teamwork, particularly delegating screening
and case management tasks to practice nurses, and
arranging administrative staff to maintain disease
registers for call, recall and clinical auditing.
page 24

Public Health and General Practice
References
1. Kindig D, Stoddart G. What Is population health? Am J
Public Health 2003;93(3):380–383.
2. Jamrozik K. Guest editorial. Public Health Bulletin SA:
Epidemiology and Public Health 2008;5(3):1–2.
3. Raphael D, Bryant T. The limitations of population health
as a model for a new public health. Health Promot Int
2002;17(2):189–199.
4. Janus ED, Bunker SJ, Kilkkinen A, Mc Namara K, Philpot
B, Tideman P, Tirimacco R, Laatikainen TK, Heistaro S,
Dunbar JA. Prevalence, detection and drug treatment
of hypertension in a rural Australian population: the
Greater Green Triangle Risk Factor Study. Intern Med J
2008;38(12):879–886.
5. Janus ED, Laatikainen T, Dunbar JA, Kilkkinen A, Bunker
SJ, Philpot B et al. Overweight, obesity and metabolic
syndrome in rural southeastern Australia. Med J Aust
2007;187(3):147–152.
6. World Health Organization. MONICA Project (monitoring
trends and determinants in cardiovascular disease):
a major international collaboration. J Clin Epidemiol
1988;41(2):105–114.
7. Tolonen H, Kuulasmaa K, Laatikainen T, Wolf H. European
Health Risk Monitoring project: recommendation for
indicators, international collaboration, protocol and manual
of operations for chronic disease risk factor surveys. 2002.
http://www.ktl.fi/publications/ehrm/product2/title.htm.
8. Chapman A, Bunker S, Dunbar A, Philpot B, Mc Namara
K, Baird A, Vartiainen E, Laatikainen T, Janus ED. Rural
smokers: a prevention opportunity for GPs. Aust Fam
Physician 2009;30(5):352–356.
9. Kilkkinen A, Kao-Philpot A, O’Neil A, Philpot B, Reddy P,
Bunker S et al. Prevalence of psychological distress, anxiety
and depression in rural communities in Australia. Aust J
Rural Health 2007;15(2):114–119.
10. Mc Namara K, Laatikainen T, Philpot B, Dunbar J. Dietary
advice to patients receiving pharmacotherapy
for cardiovascular disease: is it being delivered? GP &
PHC Research Conference: Working Together, Sydney,
Australia, 2007.
11. Janus ED, Tideman P, Kilkkinen A, Bunker SJ, Philpot B,
Tirimacco R, Mc Namara K, Heistaro S, Laaitikainen TK.
Dyslipidaemia in rural Australia: prevalence, awareness,
prevention and treatment gaps. [under review]
12. Vaughan C, Heistaro S, Dunbar J, Laatikainen T. A
secondary school based intervention project promoting
health eating and participation in regular physical activity.
Victorian Department of Human Services (DHS) Rural
Health Conference: Going for Gold 2006, Ballarat,
Australia, 2006.
13. Brown K, Keeble-Buckle F, Boak R, Dunbar A. Investigation
of overweight and obesity management in a rural primary
health care setting. GP & PHC Research Conference,
Sydney, Australia, 2007.
14. Fielding M, Kilkkinen A, Boak R. What stops schools selling
healthy food? GP & PHC Research Conference, Perth,
Australia, 2006.
15. Laatikainen T, Dunbar JA, Chapman A, Kilkkinen A,
Vartiainen E, Heistaro S et al. Prevention of type 2 diabetes
by lifestyle intervention in an Australian primary health
care setting: Greater Green Triangle (GGT) Diabetes
Prevention Project. BMC Public Health 2007;7:249.
16. Reddy P, Dunbar JA, O’Neil A, Morgan MA, Wolff AM,
Janus ED. Depression in acute coronary syndrome: has
the evidence been implemented? Aust J Rural Health
2008;16:245–246.
17. Reddy P, Dunbar J, Morgan M, O’Neil A. Coronary heart
disease and depression: getting evidence into clinical
practice. Stress and Health 2008;24:223–230.
18. Dunbar JA, Reddy P, Davis-Lameloise N, Philpot B,
Laatikainen T, Kilkkinen A et al. Depression: an important
comorbidity with metabolic syndrome in a general
population. Diabetes Care 2008;31(12):2368–2373.
19. De Angelis C, Bunker S, Schoo A. Exploring the barriers
and enablers to attendance at rural cardiac rehabilitation
programs. Aust J Rural Health 2008;16:137–142.
20. Vaughan C, Kilkkinen A, Philpot B, Brooks J, Schoo A,
Laatikainen T et al. Physical activity behaviours of adults in
the Greater Green Triangle region of rural Australia. Aust J
Rural Health 2008;16(2):92–99.
Volume 6, Number 2, July 2009 page 25

Public Health Bulletin
Professional education and the role
of general practitioners in public
health and population health
Michael Kidd
General Practitioner;
Executive Dean, Faculty of Health Sciences,
Flinders University;
Past President, The Royal Australian College of
General Practitioners (2002–06)
Background
The role of public health and population health
in general practice and general practitioner (GP)
education is not new. Hippocrates, arguably the first
general medical practitioner to record the details of his
observations about patients and use these in teaching
his students, recognised risk factors across his patient
population for chronic disease and mental health
problems. Among his many aphorisms, Hippocrates
noted that ‘Sudden death is more common in those
who are naturally fat, than in the lean’ and ‘If during
an illness there is weeping involuntarily, it is well.
But if weeping occurs in spite of oneself, it is bad.’1
These observations made about his patient population
predated the Australian Government’s cardiovascular
disease prevention and mental health awareness
programs by many centuries. Over the millennia, by
whatever name you choose (apothecary, GP, family
doctor), general medical practitioners throughout the
world have been specialists in observing, protecting,
promoting and restoring the health of the people of
their local communities.
General practice and population
health in Australia
GPs in Australia specialise in many ways, one of which
is in understanding the health care challenges facing
their own unique patient populations. The 2006
definition of general practice by The Royal Australian
College of General Practitioners (RACGP) states that
‘General practice is the provision of primary continuing
comprehensive whole patient medical care to
individuals, families and their communities.’2
In 2003 the Australian Government Department of
Health and Ageing, in conjunction with the General
Practice Partnership Advisory Council and the National
Public Health Partnership Group, released a joint
consensus statement on the role of general practice
in population health. This included a definition of the
public health roles of general practice:
‘...the prevention of illness, injury and
disability, reduction in the burden of illness and
rehabilitation of those with a chronic disease.
This recognises the social, cultural and political
determinants of health. This is achieved through
the organised and systematic responses to
improve, protect and restore the health of
populations and individuals. This includes both
opportunistic and planned interventions in the
general practice setting.’3
Registrars training in general practice around Australia
are regularly reminded that GPs are ideally placed
to incorporate public health-based activities, such
as preventive care and health promotion, into their
consultations. Given that there are almost 100 million
consultations between Australians and their chosen GP
each year,4 and that over 85% of all people in Australia
visit a GP at least once every year,5 opportunistic
prevention and health promotion has been one way of
incorporating population health into general practice.
One of the great achievements of Australia’s network
of Divisions of General Practice has been the successful
incorporation of population health initiatives across
general practice in discrete geographic regions.
Probably the best examples of this success have been
in immunisation and chronic disease prevention and
management programs.
RACGP Curriculum for Australian
General Practice
In 2007 the RACGP issued the new Curriculum
for Australian General Practice.6 One of its core
components concerns population health and public
health. The RACGP’s approach has been to seek to
further strengthen the incorporation of population
health into Australian general practice. In the words of
the RACGP Curriculum Statement:
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Public Health and General Practice
‘There is considerable overlap between population
and public health, and differing models of this
interface have been developed. A continuum can
be considered between population health activities
within general practices, public health activities
with the community, and what have been termed
“new public health” movements which include
the engagement of communities, organizational
development, and specialization or leadership in
fields such as policy development.’6
‘In general practice, population health represents
an extension and expansion of existing clinical
roles toward an emphasis on prevention and a
focus on groups or populations rather than on
individual patients. This may involve activities
such as immunization, risk assessment and
management, patient education and screening in
which general practitioners are already engaged
within their practice. General practice public
health also involves notification of disease of
public importance.’6
To support Australia’s GPs in their population health
and public health roles, the RACGP has developed a
number of key resources for use in general practice.
These include RACGP: guidelines for preventive
activities in general practice,7 now in its seventh edition;
SNAP: a population health guide to behavioural risk
factors in general practice;8 and RACGP: putting
prevention into practice.9 The RACGP has also endorsed
resources that provide advice to patients on ways
to work with their GP in preventive care and health
promotion activities.10,11
The RACGP Curriculum Statement also reminds
GPs about the importance of the social determinants
of health.
‘Population based health activities in general
practice should include, as a priority, activities
that are designed to meet the specific needs of
disadvantaged population groups. General practice
also has an important advocacy role around the
structural issues that affect health status, especially
for socially disadvantaged groups.’6
In some locations, such as rural and remote regions
and in many Aboriginal medical services, there is an
even wider scope for GPs to combine the role of family
doctor and public health practitioner. This includes
involvement in activities such as health service planning
and environmental health, and advocacy for community
participation in health promotion activities.12
There is growing awareness that the strongest gains
from general practice population health activities
result from two approaches: i) better integration of
the professional disciplines working in primary care,
including general practice nurses, nurse practitioners,
community-based allied health professionals, Aboriginal
health workers and other community health workers;
and ii) improved partnerships between general practice
and both public health services and consumer and
community organisations.6
The RACGP curriculum for population health and
public health outlines the learning objectives across
the five professional domains of general practice:
communication skills and the patient–doctor
relationship; applied professional knowledge and skills;
population health and the context of general practice;
professional and ethical roles; and the organisational
and legal dimensions. The specific objectives under
each domain are outlined in Table 1.6 These objectives
are augmented in the RACGP curriculum by specific
learning objectives across the professional life of a
GP—from medical student to prevocational doctor
to vocational registrar to the career-long continuing
professional development of experienced GPs.
Further career education
During their subsequent careers many GPs gain
additional skills in areas such as epidemiology, health
program management, evaluation, biostatistics and
health economics.12 There are many Australian GPs
who have gained qualifications such as a Master
of Public Health, and there are many GP members
among the Fellows of the Australasian Faculty of Public
Health Medicine of the Royal Australasian College of
Physicians, all contributing to the public health and
population health focus of Australian general practice.
Volume 6, Number 2, July 2009 page 27

Public Health Bulletin
References
1. Lloyd GER (ed.). Hippocratic writings. Penguin Books,
London, 1978.
2. The Royal Australian College of General Practitioners
(RACGP). Definition of general practice and general
practitioner. RACGP, Melbourne, 2006.
3. Australian Government Department of Health and Ageing.
The role of general practice in population health: a joint
consensus statement of the General Practice Partnership
Advisory Council and the National Public Health Partnership
Group. Department of Health and Ageing, Canberra, 2003.
4. Health Insurance Commission. Medicare Benefits Schedule
statistics report, 2005. www.medicareAustralia.gov.au/
providers/health_statistics/statistical_reporting/medicare.htm
5. Britt H, Miller GC, Knox S et al. General practice activity
in Australia 2004–2005. Australian Institute of Health and
Welfare (AIHW) cat. no. GEP 18. AIHW, Canberra, 2005.
6. The Royal Australian College of General Practitioners
(RACGP). Curriculum for Australian General Practice.
RACGP, Melbourne, 2007. www.racgp.org.au/curriculum
7. The Royal Australian College of General Practitioners
(RACGP). Guidelines for preventive activities in general
practice (7th edn). RACGP, Melbourne 2009. www.racgp.
org.au/guidelines/redbook
8. The Royal Australian College of General Practitioners
(RACGP). Putting prevention into practice (2nd edn).
Melbourne: RACGP, Melbourne, 2006. www.racgp.org.au/
guidelines/greenbook
9. The Royal Australian College of General Practitioners
(RACGP). SNAP: a population health guide to behavioural
risk factors in general practice. RACGP, Melbourne, 2004.
www.racgp.org.au/guidelines/snap
10. L Rowe, Kidd MR. Save your life – and the lives of those
you love. Allen and Unwin, Sydney, 2007.
11. L Rowe. Kidd MR. A wellness check for every adult
Australian. Aust Fam Physician 2008;37(10):837–839.
12. Fraser J. Population and public health in Australian general
practice: changes, challenges and opportunities. Aust Fam
Physician 2005;34(3):177–179.
Table 1: RACGP curriculum: learning objectives in the five domains of general practice – population health
and public health
1. Communication skills and the patient–doctor relationship
Enabling patients to take control of their health involves two-way communication in the formation of a
>
patient–doctor partnership.
GPs need to be able to assess risk factors of both individual patients and the broader population, and explain and implement
>
preventive health interventions in general practice, including the modification of lifestyle risk factors.
2. Applied professional knowledge and skills
GPs need to be able to describe the epidemiology of common conditions encountered in Australia and internationally,
>
as well as the recommended preventive activities conducted in the Australian community, including general practice; and
access current guidelines for screening and prevention.
GPs need to be able to assess the health needs of a specific population, for example the elderly, men, women and young people.
>
3. Population health and the context of general practice
GPs need to be able to describe national health priorities, methods for assessing the health status of a community,
>
and population health and public health approaches to prevention in general practice and the broader community.
4. Professional and ethical role
GPs need to be able to compare and contrast their professional and ethical roles in their obligations to patients and the
>
broader community, for example the rights of the individual versus the rights of the community, or patient confidentiality
versus the public good. They also need to be able to describe methods of infectious disease control.
GPs need to liaise with other health professionals to optimise population health care outcomes, and advocate
>
on behalf of patients.
5. Organisational and legal dimensions
GPs need to be able to describe the role of population-based general practice activities within the context of the Australian
>
health system, as well as work effectively within these systems to improve the health of patients and the broader community.
GPs also need to be able to describe the medico-legal duties of the GP in public health.
>
Source: from The Royal Australian College of General Practitioners, 20076
page 28

Public Health and General Practice
The community-oriented
general practitioner
David Scrimgeour*
Public Health Medical Officer
Aboriginal Health Council of South Australia
The concept of community-oriented
primary care
In South Africa in the 1940s, a team of health workers
led by Dr Sidney Kark and his wife Emily, working in a
socioeconomically deprived area of Natal, developed
an approach to primary health care which came to
be known as community-oriented primary care, or
COPC. This approach recognised the socioeconomic
determinants of health but focused on interventions
that can be developed from within the health sector.
There was an emphasis on health care workers
maintaining a close involvement with a defined
community, with ongoing monitoring and surveillance
of health status and risk factors to allow appropriate
modifications to program development over time.1
The features of COPC, as described by Kark, are
outlined in Table 1. The first essential feature listed is
the ‘complementary use of clinical and epidemiological
skills’. In other words, the COPC approach generally
relies on a multidisciplinary team, with a key role for
personnel with skills in both general medical practice
and public health. The ideal COPC practitioner might be
called the ’community-oriented GP‘: someone who is a
general practitioner with public health skills, working as
part of a team providing comprehensive primary health
care to a defined community.
The rise of apartheid in South Africa in the 1950s
led to the demise of COPC in that country, but the
approach was taken to Israel by the Karks, who moved
to Jerusalem in 1959.3 It has also had a following in the
United States,4 and in recent years has been revived in
South Africa through the work of Stephen Tollman and
Kathy Kahn.5
Relevance of community-oriented
primary care for Australia
In Australia the term COPC has received little attention,
but the approach has many similarities to the
community health centre movement which emerged
in the 1970s and has persisted to some extent,
particularly in Victoria and to a lesser extent in South
Australia. There are also examples where mainstream
GPs, particularly in country areas, have extended their
practices to include elements of COPC.
However, the most outstanding example of this
approach in Australia has been the Aboriginal
Community-Controlled Health Service (ACCHS)
movement, where GPs, in association with Aboriginal
Health workers and nurses, have worked in a
community-oriented capacity. In some areas state or
territory Health Departments employ GPs to provide
services to Aboriginal communities. While these GPs
are individually community-oriented, working within an
organisation such as an ACCHS significantly increases
the effectiveness of the community-oriented approach.
The first ACCHS was established in Redfern in 1971.
With now over 120 ACCHSs across Australia, these
services have become the major provider of primary
health care to Aboriginal people in all geographic
Table 1: Essential and highly desirable features of community-oriented primary care2
Essential features:
complementary use of epidemiological and clinical skills
>
a defined population for which the service is responsible >
defined programs to address community health problems >
ommunity involvement in promoting its health >
health service accessibility: geographic, fiscal, social and cultural >
Highly desirable features:
integration, or at least coordination, of curative, rehabilitative, preventive and promotive care
>
a comprehensive approach extending to behavioural, social and environmental determinants >
a multidisciplinary team >
mobility, including outreach capability, of the health team >
extension of community health programs into broader programs of community development >
* The author acknowledges the useful comments of fellow community-oriented GP Nick Williams on an earlier draft of this paper.
Volume 6, Number 2, July 2009 page 29

Public Health Bulletin
regions of the country. Compared to COPC, the
ACCHS movement has placed greater emphasis on the
importance of community ownership and management
of primary health care, but the features of COPC
outlined in Table 1 are instantly recognisable as the
features that have characterised the approach taken by
most ACCHSs.
One of the key roles within ACCHSs has been that
of the community-oriented GP. Some GPs have come
to work in ACCHSs bringing public health skills with
them. More commonly, a GP who commences working
within the ACCHS sector recognises after some time
that the approach required is different from that of
mainstream general practice, and he or she then
obtains some up-skilling in public health, either formally
or informally. With this combination of skills, and
working within an organisation with close links to the
community, the GP is able to take a COPC approach,
even if this term is not known.
However, it is regrettable that the need for specific
education and training for GPs to work in Aboriginal
health has not received the attention it deserves.
Training in COPC requires developing a combination of
both general practice skills and particular community-
oriented public health skills. The fact that GPs working
with Aboriginal people need to become culturally
competent has been well recognised, but GPs working
with a disadvantaged community and taking a
community-oriented approach require professional skills
that differ somewhat from mainstream fee-for-service
general practice, and this has not been recognised.
If anything, the opportunities for training and support
for community-oriented GPs have decreased. While
many medical schools previously had departments of
community medicine, the recent trend has been toward
establishment of separate departments of general
practice and public health, with less opportunity for
combining the skills taught in both departments.
Of greater concern, perhaps, are the trends in
government Aboriginal health policy. Over the past
decade there has been a turn away from support
for Aboriginal self-determination and for the role
of Aboriginal community organisations. The current
government’s focus is also on directing funds for
Aboriginal primary health care to mainstream general
practice. Within ACCHSs, funding imperatives have
increased the use of Medicare Enhanced Primary Care
items, which has encouraged an individualistic fee-for-
service, rather than a community-oriented, approach.
These policy directions ignore the fundamental role
that ACCHSs have played in developing an appropriate
style of primary health care for Aboriginal people, and
show inadequate recognition of the importance of the
community-oriented GP.
Both these trends, in academia and in government,
reflect the pervasiveness of the neo-liberal ideology
which has become dominant since the 1970s. This
viewpoint sees people, including Aboriginal people,
as individual producers and consumers rather than
recognising that they are participants in communities. It is
exemplified by Margaret Thatcher’s oft-quoted statement
that ‘there is no such thing as society, only individual
men and women’.6 Arguably, this downplaying of the
role of community has been particularly destructive to
contemporary Aboriginal society.
Conclusion
There are good reasons to revive the concept of the
community-oriented GP, particularly in the area of
Aboriginal health. One way to do this is to apply pressure
to governments to reconsider current mainstreaming
policies. Despite the lack of evidence for such policies,
they support general practice rather than ACCHSs
and their community-oriented GPs. Another way is to
promote the concept within the health professions.
Perhaps there is a need for a College of Aboriginal
Health,7 which would ensure training and support
for GPs and other health practitioners who wish to
make a contribution to ameliorating Australia’s most
embarrassing public health issue—the gap in health
status between Aboriginal and non-Aboriginal people.
References
1. Tollman S. Community oriented primary care: origins,
evolution, applications. Soc Sci Med 1991;32(6):633–642.
2. ibid, p. 637.
3. Abramson J. Community-oriented primary care – strategy,
approaches and practice: a review. Public Health Rev
1988;16:35–98.
4. Nutting P, Wood M, Connor E. Community-oriented
primary care in the Unites States: a status report. JAMA
1985;253:1763–1766.
5. Tollman S, Kahn K, Sartorius B, Collinson M, Clark S,
Garenne M. Implications of mortality transition for primary
health care in rural South Africa: a population-based
surveillance study. The Lancet 2008;372(99642):893–901.
6. Harvey D. A brief history of neo-liberalism. Oxford
University Press, 2007, p. 23.
7. Parker R. Why Australia needs a national college of
Aboriginal and Torres Strait Islander health. Med J Aust
2008;190(1):34–36.
page 30

Public Health and General Practice
Public Health and General Practice
General practice: retrospective
reflections from a public
health perspective
Douglas Shaw
Public Health Physician
Communicable Disease Control Branch
SA Health
This reflective paper describes a little of my personal
and professional journey from general practitioner to
public health physician. The journey is intentionally
incomplete, as I continue to enjoy working at the
interface between general practice and public health.
On graduation from medical school, I made the
transition from being an impoverished student to
an overworked, but reasonably well paid, resident
medical officer. This enabled me to finance a number
of overseas trips to what seemed to me to be exotic
locations. From these adventures I developed a desire
to experience living, learning and working in another
country and culture on a longer term basis.
I had completed my family medicine training, mostly
in rural practices, and achieved Fellowship of the Royal
Australian College of General Practitioners (RACGP).
However, I soon realised that my ability to function as a
family doctor in another culture would have significant
limitations, particularly because of my lack of cultural
awareness and limited language ability. I decided
that, with adequate preparation, I could more readily
contribute towards the broader prevention of illness
and enhancement of health in these settings. This led
to postgraduate training in public health and my first
experience of living, learning and working in another
culture—in Cambodia. The nature of the work was
focused on improving mother and child health. Based
on a community development approach, this was
achieved through the implementation of key health
interventions delivered through a partnership between
the health services and village health workers. In
addition, I now had an opportunity to start learning the
language and understanding the culture.
A combination of circumstances led to my departure
from Cambodia after 3 years. My positive, and
negative, experiences during this time had reinforced
my commitment to a public health approach. I then
completed specialist training in public health medicine
in Australia and, at the start of 2001, returned to
Cambodia, this time for another 6 years. My role in
public health had expanded from mother and child
health to now include prevention, care, support and
advocacy for people living with HIV and AIDS. The role
also provided for the provision of public health input for
a range of community development initiatives.
In reflecting on this journey, I see a number of parallels
between general practice and public health. My initial
decision to train in general practice was based on
a desire to address the health of the whole person,
while recognising the need for support from my
specialist colleagues. The parallel is that I see public
health as addressing the health of whole communities
even though public health medicine is considered a
‘speciality’! I do miss some clinical aspects of general
practice, in particular the process of taking a good
history, conducting an appropriate examination and
ordering relevant tests, thus leading to a diagnosis
and the development of a management plan with the
patient. However, there are equivalent processes in
public health disease surveillance that provide some
compensation for this loss—identifying a greater than
expected number of cases of a particular condition;
collecting relevant and timely epidemiological data
for analysis; taking action to identify the source or
determinants; and preventing further cases. Just as
in general practice, some diagnoses remain elusive,
so not every outbreak is ‘solved’; and while many
patients in general practice get better without a specific
management plan, many outbreaks also end without
any active public health intervention!
These shared perspectives between general practice
and public health provide opportunities for increased
cooperation between health professionals in both
disciplines. Working at the interface between general
practice and public health is both frustrating and
rewarding—frustrating because the heavy workload of
a busy general practice physically limits opportunities
for practice staff to become involved in public health
responses to the extent they would like; and rewarding
in the provision of public health ‘specialist’ support to
enable general practices to become more involved in
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Public Health Bulletin
public health research and responses. I certainly see a
place for public health professionals, particularly those
with a background in general practice, in supporting
public health initiatives implemented through the
RACGP and Divisions of General Practice.
With the increasing use of information technology,
coupled with greater assurances on the security and
confidentiality of information, many general practices
are well placed to provide timely and relevant data on
a wide range of public health issues. In turn, public
health professionals can provide basic and advanced
epidemiological and data analysis skills to support
general practice staff in operational, and more formal,
research activities. They can also conduct the literature
reviews and the research required to recommend
effective or evidence-based ‘tools’ that general
practices can use, in individual patient consultations, to
address preventive and public health concerns.
Much has been written about the tension between
the individual–clinical approach to health and the
community–population approach to health. In practice,
there is no dichotomy, although resources are usually
skewed towards the clinical approach. As other
papers in this publication attest, a combination of
both approaches is possible. When this collaboration
is expanded to encompass a multisectoral response to
health issues, the goal of general practice—the health
of the whole person—and the goal of public health—
the health of the whole community—are seen to be
inseparable. My return to working in the health system
in Australia 2 years ago has been enriched by my
experiences of living, learning and working overseas.
The interface between general practice and public
health is an exciting place to work.
General practice involvement
in public health oriented
refugee health
Jill Benson
Senior Medical Officer, Migrant Health Service;
Director, Health in Human Diversity Unit
Discipline of General Practice
University of Adelaide
Introduction
Most health professionals in Australian general
practices deal with public health issues every day
without necessarily being conscious that this is what
they’re doing. When working with people of refugee
backgrounds, in particular, it is much more important
to be conscious of public health issues as they have
a greater impact on the everyday health of this
population. A general practice is unlikely to achieve
successful health outcomes without taking into account
the myriad aspects of health promotion, protection
and prevention that affect the health of refugees,
originating from their countries of origin and in transit,
as well as in Australia.
Background
Australia has a long history of people coming to our
shores seeking asylum from persecution because
of their ‘race, religion, nationality, membership of a
particular social group or political opinion’.1 Our ways
and timeframes for ascertaining whether their fear
of persecution is ‘well-founded’1 have often been
questioned, but the fact remains that Australia takes
more UN-certified refugees per head of population than
other developed nations.2
Currently, Australia accepts approximately 13 000
refugees per year, of which about 1300 come to South
Australia. These comprise 30% from Africa (mostly
Sudan, Congo, Burundi, Liberia, Sierra Leone), 40%
from the Middle East (Afghanistan, Iran, Iraq) and 30%
from elsewhere (Burma, China, Nepal).3 About half of
those who come as refugees are aged under 18 years,
and many families are headed by women with up to
12 children. Some have spent more than 10 years in
overcrowded and extremely unsafe refugee camps,
where they have experienced untreated infectious
diseases, poor sanitation and deficient diets.
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Public Health and General Practice
Public Health and General Practice
Such a background will be unimaginable for most
Australian health professionals. Even those refugees
who do not come from developing countries have
experienced hardship and poverty following their
decision to flee their country—during their flight, in
refugee camps and in resettlement. As well as taking
account of the cultural, social and religious differences
between Australia and the countries of origin of most
refugees, health professionals need to develop skills
in screening for, diagnosing and treating unfamiliar
physical and psychological problems. Public health is
paramount in the approach to all these issues.
Promotion
For people who have had minimal schooling and for
whom survival has been their main priority, most of our
concepts of health are completely unknown. Physiology,
anatomy and disease causation need to be explained,
sometimes many times, before any management
plan is implemented. This is especially so for chronic
health problems that require long-term treatment and
follow-up. Health system literacy is as important as
health literacy. The best laid plans will come to nothing
without an understanding of how the Australian
health system works, how to get medication, what
happens with a referral, and the actual role of a general
practitioner (GP) or allied health professional.
The environment in which patients are seen needs
to be ‘safe’. This includes ‘cultural safety’, where the
patient’s cultural and other differences are treated with
respect. Some of this will be obvious. For example,
because of the need to fast during Ramadan, the GP
may need to alter medication regimens. However,
some will be more subtle, for example the need to
ask for and gain permission before touching the
patient to take their blood pressure or examine them.
To ensure that patients’ cultural safety is maintained,
health professionals need to be ‘culturally aware’.
This means being as conscious as possible not only
of their own ethnicity but also of their otherwise
unconscious expectations of themselves, the patients
and the world in general, based on their own cultural
upbringing.4 Most members of a general practice team
aim to be non-judgmental, especially when dealing
with refugee patients, but only a small percentage of
motives, beliefs and reactions are conscious. There is
likely to be a difference between doctor and patient in
communication styles, approaches to completing tasks,
notions of time, decision-making styles and attitudes
toward disclosure.5
In many countries there are diseases that mean
stigma, severe morbidity or certain death as there is no
treatment or only limited access to appropriate health
care. This can include most mental health problems,
cancer and blood-borne viruses such as hepatitis B
and HIV. People of refugee background may be very
reluctant to be tested for or diagnosed with these
diseases as they may not realise they can be treated
here. Fully informed consent for many investigations will
involve a discussion about the possibilities of treatment
in Australia if a positive result is found.6 This might
mean a much longer preamble to procedures we might
take for granted, such as a Pap smear or mammogram;
or allowing extra time for a discussion about diagnosing
such things as depression or hepatitis C.
One of the constant challenges for any GP is that
of follow-up of patients, and this tends to increase
with people of refugee background. It is important to
recognise the barriers to health-seeking behaviour, such
as different expectations of cure rather than treatment,
and social issues such as poverty or lack of transport.
Many refugee patients have not had the experience of
keeping appointments, having regular antenatal visits,
follow-up investigations or taking long-term medication
for chronic disease.
Protection
Protection of the public is one of the basic tenets of
public health. Many of the infectious diseases seen in
refugee patients are not going to be problems for the
rest of the community. Schistosomiasis and malaria
are two of the most important infectious diseases to
diagnose and treat in this population, but neither of
these will spread to the rest of the South Australian
population as we do not have the appropriate vectors
here. However, they can cause significant morbidity and
occasional mortality, and must be screened for as they
may be asymptomatic.
On the other hand, people of refugee background
have some of the highest incidences of tuberculosis,
hepatitis B, hepatitis C and taenia solium in our
community.7 Again, these may be asymptomatic, but
their identification and appropriate treatment are
important not only for the health of the patient but
also because of the potential public health implications.
GPs need to be aware of their legal obligations to notify
many of these diseases to the public health authorities.
Because of the need for cultural sensitivity and support,
the general practice team is probably the best placed
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Public Health Bulletin
to explain the public health implications, to do the
necessary contact tracing and to follow up many of
these diseases.
A constant struggle in general practice is to balance
evidence-based medicine and the principles of
self-management. In caring for refugee patients
the additional parameters of health literacy, slowly
moving through the stages of change, and the often
overwhelming social, historical and cultural factors add
another level of difficulty to this balance. For many
who have struggled to survive in a hostile environment
and whose only health care has been the short-term
treatment of infectious diseases, an injection and a
letter of advocacy may be all they are expecting from
their GP visit.
Nothing is likely to happen in general practice if the GP
does not understand the patient and the patient does
not understand the doctor. Health is not just about
treating the test result with the right medication. The
use of an interpreter of appropriate language, dialect,
gender and religion is paramount for good health
care, especially if dealing with mental health problems,
sexual health, domestic violence or other sensitive
issues. The legal requirements of confidentiality and
informed consent oblige all GPs to use the Translating
and Interpreting Service (TIS) Doctors Priority Line to
their utmost capacity.8
Prevention
Good preventive health care at the primary health
level is an everyday occurrence for Australian GPs. For
patients of refugee background, the social determinants
of health will often need to be addressed before any
other preventive activities are attempted. If housing,
education, safety, transport and other issues related to
poverty and resettlement difficulties are not dealt with,
a patient is unlikely to view a screening Pap smear or
lifestyle advice as a priority.
Preventive health screening will involve a different range
of investigations, which may include post-traumatic
stress disorder, haemoglobinopathies, parasites and
vitamin D deficiency.9
Severe developmental delay in children, often due
to the mental health problems of the parents or the
child, will need urgent referral to a multidisciplinary
team. This, however, assumes that the age of the child
matches that of the visa, a difficult feat in itself.10
Being aware of the potential for serious mental health
problems in adolescents of refugee background can
avert an escalation of these problems. Spanning
two cultures, dealing with the past, struggling with
language issues, living in a single-parent household,
and often caring for younger siblings or unwell parents
make adolescents a particularly vulnerable group.
Unknown, undocumented or erratic immunisation
histories mean that most refugee patients will need a
program of catch-up vaccinations, which is best done
with the help of one of the experienced nurses who run
the New Arrival Refugee Immunisation (NARI) clinics for
local councils.
Risk factors for vitamin D deficiency such as dark skin
or being fully covered by clothing should alert GPs to
do further investigations. Diet is another risk factor,
not just because of the relative malnutrition suffered
by many refugees on arrival, but because of the higher
incidence of dental caries and diabetes as their diets
change to the Western diet of high sugar and fat.11
Early education and regular follow-up of dietary and
exercise practices is of extreme importance.
Conclusion
Optimum health care for Australia’s refugee population
requires a different skill set to ‘usual’ general practice.
It is not just about screening using the template for
the 714 Medicare item number, using a TIS interpreter
and treating exotic parasites;9 it is also about dealing
with the more complex public health issues that
underlie good care—health promotion, protection and
prevention.
References
1. Office of the High Commission of Human Rights. United
Nations Convention and Protocol Relating to the Status
of Refugees. Geneva, 1951. http://www.unhchr.ch/html/
menu3/b/o_c_ref.htm
2. United Nations High Commissioner for Refugees, Division
of Operational Services. 2006 global trends: refugees,
asylum seekers, returnees, internally displaced and stateless
persons. Geneva, 2007.
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3. Australian Government, Department of Immigration
and Citizenship. Fact Sheet 60: Australia’s refugee and
humanitarian program. Canberra, 2008. http://www.immi.
gov.au/media/fact-sheets/60refugee.htm#g
4. Benson J, Thistlethwaite J. Mental health across cultures: a
practical guide for health professionals. Radcliffe Publishing,
Oxford, 2008.
5. Multicultural Mental Health Australia. Cultural awareness
tool. 2003. http://www.mmha.org.au/mmha-products/
books-and-resources/cultural-awareness-tool-cat
6. Australian Society of Infectious Diseases Writing Group.
Diagnosis, management and prevention of infections in
recently arrived refugees. Sydney, 2009. http://www.asid.
net.au/downloads/RefugeeGuidelines.pdf
7. Martin J, Mak D. Changing faces: a review of infectious
disease screening of refugees by the Migrant Health
Unit, Western Australia, in 2003 and 2004. Med J Aust
2006;185(11/12):607–610.
8. Australian Government, Department of Immigration and
Citizenship. Translating and Interpreting Service (TIS)
National. http://www.immi.gov.au/living-in-australia/help-
with-english/help_with_translating/index.htm
9. Benson J, Smith M. Early health assessment of refugees.
Aust Fam Physician 2007;36(1/2):41–43.
10. Benson J, Williams J. Age determination in refugee
children. Aust Fam Physician 2008;37(10):821–824.
11. Kingsford Smith D, Szuster F. Aspects of tooth decay
in recently arrived refugees. Aust N Z J Public Health
2000;24(6):623–626.
The role of GPs in
environmental health: working
with homeless people
Katina D’Onise
Public Health Physician
Communicable Disease Control Branch
SA Health
What is environmental health?
The medical profession has long recognised the
importance of a healthy environment for both
preventing disease and supporting health. Over 2000
years ago, Hippocrates wrote the seminal text, On
airs, waters and places, that set the foundations for
environmental health practice.1 He described physical,
chemical and biological features of the environment
that can exert an influence on health and wellbeing.
The accumulated knowledge over time on the
importance of the environment to health has led to
sophisticated environmental health infrastructure
and management systems. This progress has been
central to a significant reduction in communicable
diseases, improvement in quality of life and increased
life expectancy over the last 100 years. Unfortunately,
despite past successes, some populations still live in
poor environmental conditions, leading to high rates of
diseases such as Shigella, hepatitis A, post-streptococcal
glomerulonephritis and chronic serous otitis media.
GPs and environmental health
While many of the features of environmental health
practice are outside the health system, general
practitioners (GPs) play an important role in advocacy
of mitigation of the effects of poor environmental
conditions on the health of their clients. The following
exploration of the impact of the environment on
homeless people and the role GPs can play illustrates
the fundamental importance of the environment to
health, and how the issues highlighted over 2000 years
ago have not been completely resolved today.
Volume 6, Number 2, July 2009 page 35

Public Health Bulletin
Homelessness
There is a lot of debate about definitions of
homelessness as ‘a home’ means different things
for different people. What is consistent is that being
homeless is not as simple as having inadequate or
no housing. Having a home means that a person
has access to shelter and good functioning health
hardware (such as running water, storage facilities
and cooking facilities). It also includes the security and
social connectedness that having a home can provide.
Homelessness is a lack of any of these integral aspects.
Health impacts of homelessness
People who are homeless generally have multiple
markers of social disadvantage, including social
exclusion, unemployment, low education levels and
limited access to healthy food choices. These factors
can combine in different ways to produce poor health
outcomes. In fact, across the spectrum of homelessness,
from living in a boarding house to sleeping on the
street, there is an increase in disease with reduced
access to any form of shelter.2
Homeless people have a greater risk of chronic disease,
infectious diseases such as respiratory tract and skin
infections, mental illness, substance abuse disorders
and poor oral health than the general population. The
increased rate of death is difficult to quantify but has
been estimated at between three and eight times the
risk of death in the general population.3,4 The average
age of death is between 42 and 52 years.3
GPs’ role and ways of working with
homeless people
This highly complex social problem requires a system-
wide approach. In dealing with the health issues of
this group of people, health professionals need to
look beyond what the health system can provide. They
need to include services such as housing and social
services, and consider issues of safety, food security and
social support. On an individual general practice level,
there are a number of steps the health professional
can consider to improve the quality of the service they
provide for homeless people.
The first step is increasing the accessibility of a general
practice to homeless people by providing health care
that is respectful, focuses on effective communication,
is holistic in its approach and is flexible in addressing
client needs. There are often a number of complex
issues to manage as well as a need for client advocacy,
which often requires longer, bulk-billed appointments.
Key to this increased responsiveness is to systematically
identify people who are homeless. Homeless people
are not a homogeneous, easily identifiable group. The
traditional face of homelessness, an elderly man with
alcohol dependence, is changing. In fact, the fastest
growing subsection of homeless communities is families
with children.5
Understanding the social context that homeless people
live in is integral to effective clinical care. For example,
a homeless person may be isolated socially and have
no carer when they are unwell. This makes moving
around to carry out normal self-care duties such as
finding a toilet, running water, food and a safe place
to rest at night potentially impossible. As such, health
professionals should carefully consider the environment
in which the homeless people live when making
decisions regarding their health care. For example,
when prescribing medication, GPs need to be aware
that there may be no fridge for storage of drugs and no
clean water when deciding on which drug formulation
to prescribe. Drugs that have a street value should be
prescribed with caution, as homeless people may be
at risk of violence from others who seek to take their
medication. Overdose or adverse events are a potential
risk with some drugs due to the multiple complex social
and health issues that most homeless people have.
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It has been demonstrated that the ideal model of
health care for homeless people involves the use of
a multidisciplinary team, including a GP, who work
together with complementary skills.6 For GPs, this may
be facilitated by making use of Enhanced Primary Care
Medicare item numbers, such as those for chronic
disease and for clients who are Aboriginal or Torres
Strait Islanders. Box 1 provides an example of one such
program model established in Adelaide specifically to
provide appropriate health care for homeless people.
Conclusion
The ongoing importance of a healthy environment to
human health is exemplified by the adverse effects of
a poor environment on vulnerable populations such as
homeless people. While many important environmental
health issues are being well managed outside the
health care system, GPs have an important role to play
in wider advocacy for health-promoting environments
and for mitigation of the effects of a poor environment
on the health of their clients.
Beyond good communicable disease control,
environmental health’s involvement is expanding into
promoting healthy environments to prevent chronic
disease. An example of this is the Heart Foundation’s
‘Active by Design’ program, which promotes the use
of urban planning to encourage physical activity.7 The
persistence of environmentally related diseases, and the
new approaches required for chronic disease control,
ensure the ongoing relevance of environmental health
for GPs today.
References
1. Hippocrates. On airs, waters and places. http://classics.mit.
edu/Hippocrates/airwatpl.mb.txt.
2. Kermode M, Crofts N, Miller P, Speed B, Streeton J.
Health indicators and risks among people experiencing
homelessness in Melbourne, 1995–1996. Aust N Z J Public
Health 1998;22(4):464–470.
3. O’Connell J. Premature mortality in homeless populations:
a review of the literature. National Health Care for the
Homeless Council, Nashville, 2005.
4. Hwang SW. Homelessness and health. Can Med Assoc J
2001;164(2):229–233.
5. Chamberlain C, MacKenzie D. Counting the homeless
Australia 2006. Australian Bureau of Statistics, Canberra,
2008.
6. Abdul-Hamid W, Cooney C. The homeless. Postgrad Med J
1996;72:667–670.
7. Heart Foundation. Active by design. 2009. http://www.
heartfoundation.org.au/Professional_Information/Lifestyle_
risk/Physical_Activity/Active_by_Design/Pages/default.aspx.
Box 1: A holistic primary health care program
for homeless people: No Pulgi program
The No Pulgi program in Adelaide is an example of
a primary health care service that was developed to
specifically address the largely unmet health needs of
homeless people, particularly their chronic needs.
No Pulgi is a collaborative effort initiated by
Nunkuwarrin Yunti of South Australia Inc., Aboriginal
Sobriety Group Inc. and the Royal District Nursing
Services. It is supported by SA Health and the Office
for Aboriginal and Torres Strait Islander Health’s
Aboriginal Primary Health Care Access Program. Other
key agencies involved with the service include Drug
and Alcohol Services South Australia and the Street to
Home service. It was developed to better address the
health needs of homeless people, acknowledging that
this is a difficult and complex task that would best be
tackled by a partnership model.
No Pulgi provides outreach primary health care services
to day centres and other places where people live
and gather in the city, including the Adelaide city
parklands. The service is free and flexible, and has
strong links with homeless service providers to ensure
holistic care that also includes social and environmental
domains. The service also works in partnership with
other groups in the sector, including social services, to
ensure seamless service delivery and the best quality
of care.
Volume 6, Number 2, July 2009 page 37

Public Health Bulletin
General practice role in obesity
prevention from a population
health perspective
Nicola Spurrier
Consultant Paediatrician and Public Health Consultant
Paediatrics and Child Health
Flinders University
Introduction
Rates of obesity have increased significantly in the past
20 years in westernised countries. Recent estimates
report 52% of Australian women, 67% of Australian
men and 23% of Australian children aged 2–16 years
are overweight or obese.1,2 While there has been some
recent debate (mainly in the media) about whether
or not this represents a true epidemic,3 children and
adults classified as obese experience much greater
levels of comorbid health problems, including long-
term cardiovascular, orthopaedic, neurological and
endocrine disease.4,5 In addition, greater levels of
psychological distress, stigmatisation and lower quality
of life are experienced by both children and adults with
obesity.6,7,8
Obesity, as compared to other chronic health
conditions, brings to mind (for both patient and
practitioner) a range of negative images, thoughts and
emotions: disappointment, laziness, failure, poor self-
esteem, excuses, lack of will-power, poor self-control
etc. Obesity counselling was reported by primary care
physicians to be frustrating and not professionally
gratifying.9 In a systematic review of primary care
physicians’ knowledge, attitudes, beliefs and practices
regarding childhood obesity, physicians reported that
management of obesity was very important, but the
vast majority considered themselves not competent in
treating it.9
At a population level, government policy tends to
focus on individual responsibility to maintain a healthy
weight.10 This is in contrast to overwhelming evidence
that increasing rates of obesity are secondary to our
obesogenic environments.11 There is a clear need
for policies supporting environmental change in the
community, for example the regulation of food industry
advertising to children and the accessibility of public
transport.
The vast majority of weight loss trials, both in children
and adults, report moderate results at best, with
long-term outcomes suggesting that many individuals
regain their weight without ongoing intervention.12,13
When considered from the perspective of a negatively
perceived chronic disease, combined with the fact
that rising rates of obesity appear to stem from
environmental factors, it is not surprising that general
practitioners (GPs) report low self-efficacy at managing
patients with obesity. A preventive approach to the
management of obesity can assist the primary care
practitioner generate both a positive clinical outcome
and professional satisfaction.
In this paper I will describe potential areas where
GPs could provide substantial input and leverage in
obesity prevention. Most of these suggestions are
small individual steps but, together, they contribute
to the multilevel population approach necessary for
tackling an environmentally based complex health
issue.11 Grief and Talamayan (p. 631) call for a need
to shift the paradigm in primary care settings from
treatment of obesity to prevention of overweight
and obesity.14 They suggest that this would include
‘proactive reprioritization of addressing weight issues in
the office setting’ (primary prevention) and ‘integrating
treatment strategies to prevent progression of obesity’
(secondary prevention).14 This approach is similar to the
new clinical discipline, ‘lifestyle medicine’, described by
Egger, Binns and Rossner (p. 143) as ‘the application of
environmental, behavioural, medical and motivational
principles to the management of lifestyle-related
health problems in a clinical setting’.15 Characteristics
and differences between this form of practice and
conventional medical practice are given in Table 1.
Prevention of obesity
Prevention can be considered at a number of levels.
Primary prevention aims to prevent the onset of obesity
in a normal weight population. Secondary prevention
aims to reduce the impact of obesity and prevent the
onset of obesity-related comorbidities in those already
above a healthy weight. Obviously, many primary
prevention strategies (for example, making aspects of
the environment less obesogenic) have the potential
to improve the health of both normal-weight and
overweight individuals.
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Primary prevention
Advocacy
As noted by Fraser, GPs could (time and energy permitting)
initiate or become involved with community projects that
focus on enhancing physical activity and dietary patterns
of individuals through environmental change.16
Provision of nutrition advice to new parents
Developing healthy eating patterns in very young
children is recognised to be a key early step in
supporting lifelong dietary habits.17 For example,
avoiding overly sweet, salty and fatty foods in the early
weaning period, and offering a wide variety of different
fruits, vegetables and cereals, may positively influence
the acceptance of core food groups by children. On the
other hand, certain actions associated with provision
of food, for example using food treats to reward good
behaviour or giving food to allay discomfort, may set
up lifelong expectations and habits.18 Anticipatory
guidance by family doctors and paediatricians is
standard practice in the United States, and covers many
areas of child development.19 GPs in Australia could
consider expanding their role to not only provide advice
regarding when to wean and what to feed young
infants, but also counsel parents regarding behaviours
that support healthy dietary patterns later in life.
Nutrition advice to pregnant mothers
Evidence shows that parental dietary patterns and
physical activity behaviours are associated with those
of their children.20 Parents may act as role models
for children for these behaviours (for example not
liking vegetables and being fussy eaters). Children
are also directly exposed to both the household food
environment and an environment that is either more
or less supportive of physical activity or sedentary
behaviour.20 Pregnancy is a time when many women
focus on their own health to enhance the growth
and development of their unborn child. For example,
smoking cessation occurs at higher rates in the
pregnant population.21 A woman may be particularly
receptive to nutritional and physical activity education
during this time, with long-term benefits both for
herself and her children and family.22
Reorientation of a general practice surgery
to support healthy lifestyle
A general practice with a real commitment to
improving the lifestyle of individual patients may wish
to consider characteristics of the surgery and behaviour
of the practice staff in supporting lifestyle change. For
example, Grief & Talamayan suggest improvements in
the standardised dietary and physical activity education
brochures that are available in patient waiting areas.14
This could be extended to include information about
active community events (bike rides, local fairs etc.).
Waiting rooms of many clinics offer a collection of
‘women’s magazines’, the majority of which will
Table 1: Differences between conventional medicine and lifestyle medicinea
Conventional medicine Lifestyle medicine
Treats individual risk factors Treats lifestyle causes
Patient is often a passive recipient of care Patient is an active partner in care
Patient is not required to make big changes Patient is required to make big changes
Treatment is often short-term Treatment is almost always long-term
Responsibility falls mostly on the clinician Responsibility falls mostly on the patient
Medication is often the ‘end’ treatment Medication may be needed, but as an adjunct to lifestyle change
Emphasis is on diagnosis and prescription Emphasis is on motivation and compliance
Goal is disease management Goal is primary/secondary/tertiary disease prevention
Little consideration of environment Consideration of environment
Side effects are balanced by the benefits Side effects are seen as part of the outcome
Referral to other medical specialities Referral (also) to allied health professionals
Doctor generally operates independently on a one-to-one basis Doctor is coordinator of a team of health professionals
a From Egger et al. 200915
Volume 6, Number 2, July 2009 page 39

Public Health Bulletin
include pseudoscientific advice on the latest diets. While
I am not suggesting complete removal of such items,
balancing this with positive and accurate information is
important. The placement of sweets and chocolates to
assist charity fundraising in medical clinics undermines
attempts to assist patients improve their lifestyles, as
does the traditional giving of jellybeans to appease
children after immunisations.
Supporting breastfeeding
GPs have a substantial role in supporting breastfeeding,
and many GPs are accredited lactation consultants.
Breastfeeding has shown a small but significant and
consistent association with reduced risk of childhood
obesity, controlling for socioeconomic variables.23
Secondary prevention
Screening
The mainstay of secondary prevention is screening.
The GP works in a professional environment ideal
for obesity screening. Orientating a primary care
practice to routinely measure and correctly interpret
the height and weight of all patients is the first step
in ensuring that overweight and obese individuals
receive intervention in accordance with the National
Health and Medical Research Council clinical practice
guidelines.24 An Australian study showed that weight
status cannot be accurately performed by visualisation
alone, and that all children should have height and
weight measured and correctly interpreted.25 Despite
this, up to 80% of physicians report relying on clinical
impression.9 Gerner et al. showed that, in Australian GP
practices, measuring equipment is often not available
and, if present, is not accurate.26 The new Medicare-
funded ‘Healthy Kids Check’ at 4 years of age is one
structured opportunity for such screening. Screening in
this context goes beyond anthropometrics, to include
nutritional and physical activity screening. Grief and
Talamayan argue that a nutrition history should be
taken for all patients as a benchmark.14
Management to prevent progression
Focusing on improving physical activity and improved
dietary patterns is a less stigmatising and more
sustainable approach to management of individuals
with overweight and obesity than focusing simply on
weight. To provide consistent and accurate goals for
patients, GPs need to be familiar with age-appropriate
national physical activity and nutritional guidelines, and
have educational brochures of these available. Provision
of an exercise prescription could become as standard as
a pharmaceutical prescription.27
Working as a multidisciplinary team
Lifestyle medicine recognises the need for referral
to allied health specialists. Developing collaborative
partnerships and referral pathways to nutrition
specialists, exercise physiologists and psychologists
is an important part of obesity management.15 The
Enhanced Primary Care Program in Australia has the
potential to improve patient access to appropriate
lifestyle support specialists by providing Medicare
benefits for allied health disciplines involved in chronic
disease management.28
Conclusions
The complexity of issues that the patient with obesity
may present with can be daunting. Considering the
efficacy of intervention trials, general practice appears
to be a disappointingly unsuccessful environment in
which to manage this condition. However, with the
adoption of a broader population paradigm, GPs can
leverage at many levels to enhance the lifestyles of both
individual patients and the greater community.
References
1. Australian Institute of Health and Welfare (AIHW). Australia’s
health 2008. Cat. no. US99. AIHW, Canberra, 2008.
2. Department of Health and Ageing. Australian national
children’s nutrition and physical activity survey: main
findings. Australian Government, Canberra, 2007.
3. Gill TP, Baur LA, Bauman AE, Steinbeck KS, Storlien LH,
Fiatarone Singh MA et al. Childhood obesity in Australia
remains a widespread health concern that warrants
population-wide prevention programs. Med J Aust
2009;190(3):146–148.
4. Guh DP, Zhang W, Bansback N, Amarsi Z, Birmingham CL,
Anis AH. The incidence of co-morbidities related to obesity
and overweight: as systematic review and meta-analysis.
BMC Public Health 2009;9:88.
5. Reilly JJ, Methven E, McDowell ZC, Hacking B, Alexander
D, Steward L et al. Health consequences of obesity. Arch
Dis Child 2003;88:748–752.
6. Wardle J, Cooke L. The impact of obesity on
psychological well-being. Best Prac Res Clin Endocrin Met
2005;19(3):421–440.
7. de Wit LM, van Straten A, van Herten M, Penninx BW,
Cuijpers P. Depression and body mass index, a u-shaped
association. BMC Public Health 2009;9:14.
8. Bish CL, Blanck HM, Maynard LM, Serdula MK, Thompson
Nj, Khan LK. Health-related quality of life and weight loss
practices among overweight and obese US adults: 2003
behavioral risk factor surveillance system. MedGenMed
2007;9(2):35.
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9. van Gerwen M, Franc C, Rosman S, Le Valliant M, Pelletier-
Fleury N. Primary care physicians’ knowledge, attitudes,
beliefs and practices regarding childhood obesity: a
systematic review. Obes Rev 2008;10:227–236.
10. Kumanyika S, Brownson RC (eds). Handbook of obesity
prevention: a resource for health professionals. Springer
Science+Business Media LLC, New York, 2007.
11. Swinburn B, Egger G, Fezeela R. Dissecting obesogenic
environments: the development and application of a
framework for identifying and prioritizing environmental
interventions for obesity. Prev Med 1999;29:563–570.
12. Franz MJ, VanWormer JJ, Crain AL, Boucher JL, Histon
T, Caplan W et al. Weight-loss outcomes: a systematic
review and meta-analysis of weight-loss clinical trials
with a minimum 1-year follow-up. J Am Diet Assoc
2007;107(10):1755–1767.
13. Oude Luttikhuis H, Baur L, Jansen H, Shrewsbury VA,
O’Malley C, Stolk RP et al. Interventions for treating
obesity in children (review). The Cochrane Library 2009,
issue 2. The Cochrane Collaboration, published by John
Wiley & Sons Ltd.
14. Grief SN, Talamayan KS. Preventing obesity in the primary
care setting. Prim Care Clin Office Pract 2008;35:625–643.
15. Egger GJ, Binns AF, Rossner SR. The emergence of ‘lifestyle
medicine’ as a structured approach for management of
chronic disease. Med J Aust 2009;190(3):143–145.
16. Fraser J. Population and public health in Australian general
practice: changes, challenges and opportunities. Aust Fam
Phys 2005;34(3):177–179.
17. Campbell K, Hesketh K, Crawford D, Salmon J, Ball K,
McCallum Z. The Infant Feeding Activity and Nutrition
Trial (INFANT), an early intervention to prevent childhood
obesity: cluster-randomised controlled trial. BMC Public
Health 2008 31;8:103.
18. Clark HR, Goyder E, Bissell P, Blank L, Peters J. How do
parents’ child-feeding behaviours influence child weight?
Implications for childhood obesity policy. J Public Health
(Oxf) 2007;29(2):132–141.
19. Groner JA, Skybo T, Murray-Johson L et al. Anticipatory
guidance for prevention of childhood obesity: design of
the MOMS project. Clin Pediatr 2009; 25:doi:10.1177/000
9922809331799.
20. Spurrier NJ, Magarey AM, Golley R, Curnow F, Sawyer MG.
Relationships between the home environment and physical
activity and dietary patterns of preschool children: a cross-
sectional study. Int J Behav Nutr Phys Act 2008;5(1):31.
21. Solomon LJ, Quinn VP. Spontaneous quitting: self-initiated
smoking cessation in early pregnancy. Nicotine Tob Res
2004;6(S2):S203–S216.
22. Asbee SM, Jenkins TR, Butler JR et al. Preventing excessive
weight gain during pregnancy through dietary and lifestyle
counselling: a randomised controlled trial. Obstet Gynecol
2009;113(2,Pt1):305–312.
23. Adair LS. Methods appropriate for studying the
relationships of breast-feeding to obesity. J Nutr
2009;139(2):408S–411S.
24. National Health and Medical Research Council. Clinical
practice guidelines for the management of overweight and
obesity in children and adolescents. Commonwealth of
Australia, Canberra, 2003.
25. Spurrier NJ, Magarey A, Wong C. Recognition and
management of childhood overweight and obesity by
clinicians. J Paediatr Child Health 2006;42:411–418.
26. Gerner B, McCallum Z, Sheehan J, Harris C, Wake M. Are
general practitioners equipped to detect child overweight/
obesity? Survey and audit. J Paediatr Child Health
2006;42(4):206–211.
27. Chakravarthy MV, Joyner MJ, Booth FW. An obligation for
primary care physicians to prescribe activity to sedentary
patients to reduce the risk of chronic health conditions.
Mayo Clin Proc 2002;77(2):165–173.
28. Australian Government Department of Health and Ageing.
Enhanced Primary Care (EPC) Program. http://www.health.
gov.au/epc.
Volume 6, Number 2, July 2009 page 41

Public Health Bulletin
Preconception care in general
practice: reproductive health plans
facilitate public health action
Dr Angela McLean
Public Health Physiciana
Dr Richard Henshaw
Medical Directora
Dr Hilary Whittle
General Practitionera
Dr Adrienne Pope
Director, Business Developmenta
Dr Tricia Davies
Medical Practitionera
a Repromed, Adelaide, South Australia
Introduction
The importance of maternal and paternal health in
the development of a healthy baby is clear. The role
of the general practitioner (GP) is crucial in delivering
public health messages and facilitating public health
action for potential parents prior to conception, and
can help minimise the risk of adverse outcomes for
both mother and baby. As stated by the United States
Centers for Disease Control in 2006, the main goal
of preconception care is to provide health promotion,
screening and interventions for women of reproductive
age to reduce risk factors that might affect future
pregnancies.1
Presentations to GPs due to pregnancy-related issues
are common, and provide an excellent opportunity
to deliver public health messages and actions to help
improve the health of the population, both current
and future. Routine use of a ‘reproductive health
plan’ in general practice will enhance health literacy
and community knowledge about reproductive health
issues, thus enhancing public health benefits. Early
prenatal care is often too late. It has been recognised
that preconceptional health promotion needs to be
integrated into women’s general health encounters
during the potential childbearing period.2 This period
spans from menarche to menopause and should not be
limited only to those years when pregnancy is desired.
Public health action in primary care
improves neonatal outcome
One clear example of the benefits of public health action
in the general practice setting is the use of preconception
folic acid following identification of the link between
folic acid supplementation and reduced neural tube
defects. In South Australia the prevalence of neural tube
defects significantly declined from 2.0 per 1000 births
in 1966 to 1.1 per 1000 births in 1999.3 Although the
reduction may be attributed, in part, to other medical
advances, the contribution of supplementation is clear.
Short-term campaigns to promote public awareness of
preconception folic acid supplementation have been
effective. Ongoing reminders, advice and support
from GPs can maintain the momentum to produce an
important health outcome.
Routine preconception care in general
practice—a common theme
General practitioners are in the unique situation of
seeing unreferred patients repeatedly over years.4 They
have the opportunity to get to know their patients
extremely well and to gain their trust and respect.
This places the GP in an excellent position to facilitate
the modification of lifestyle factors that impact on
reproductive health. Advice on appropriate levels of
exercise and ensuring protection from potentially toxic
substances in the environment at work and at home are
common themes in the general practice setting, and
have particular value in the preconception period. Issues
such as maintaining a healthy weight, appropriate
nutritional intake, and avoiding the use of cigarettes,
alcohol and other drugs are important for both the
male and female partner.
The increasing prevalence of obesity can be assumed to
correlate with reduced fertility rates, and the risk applies
to both males and females who are overweight. During a
preconception consultation, measuring weight and height
to enable calculation of the body mass index (BMI) is a
quick and effective way to assess this for both partners.
The GP is well placed to advise on the significant decline
in fertility with age (Figure 1). The ovarian reserve can
be expected to diminish rapidly from the mid 30s and
to be extremely low by the age of 40 years. The myth
that regular menstrual cycles indicate that ‘all is well’
needs to be debunked. GPs can assist their patients in
assessing ovarian reserve through the use of techniques
such as the ‘egg-timer’ test, which uses a combination
of the anti-Müllerian hormone (AMH) level and the
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antral follicle count from a baseline ovarian ultrasound
scan. As the main providers of prescriptions for
hormonal contraception, GPs are uniquely positioned
to enquire proactively about future pregnancy plans.
They can provide give accurate information regarding
fertility and age when consulted for contraceptive
advice by women aged 35 years and over, particularly
those who have not yet started a family. The AMH
component of the egg-timer test is accurate even when
a woman is currently taking hormonal contraception,
and AMH is far superior to FSH in identifying women
with reduced ovarian reserve.5 The GP will need to refer
patients to specialists where the need dictates. Early
referral is advised should the presence of moderate to
severe endometriosis or polycystic ovarian syndrome
(PCOS) be suspected. Aside from the fertility issues,
women with PCOS may have significant future health
implications and need particular attention paid to their
cardiovascular risk factors.
Specific medical conditions
Although public health initiatives must consider the
community as the unit of concern, it is the individual
within the community that presents a specific, unique
situation requiring individualised management.
Appropriate treatment of specific conditions can
minimise potentially serious obstetric outcomes, and
medication review is essential. Teratogenic medication
should be avoided, and stabilisation of medical
conditions such as diabetes, thyroid disturbances and
cardiac disease achieved. Potential exacerbation of
immune disease and the effects of mental health issues
in pregnancy need to be considered.
Advances in medical genetics continue to escalate, and
the provision of counselling needs to be considered
in situations where a genetic condition is present or
suspected. Similarly, the provision of information about
the increased chance of chromosomal abnormalities
with increased maternal age should start in general
practice, and be incorporated into the reproductive
health planning process. The chance of a woman giving
birth to a baby with trisomy 21 (Down syndrome)
increases dramatically with maternal age, as shown in
Figure 2.
Utilising public health initiatives:
immunisation and cancer prevention
Immunisation illustrates public health in action and, in
the preconception situation, provides another example
where general practice and public health initiatives
are interlinked. All women contemplating pregnancy
should have their rubella and varicella immunity
assessed. Vaccination for these diseases is a simple way
to reduce risk to mother and baby. Precautions may
need to be taken to ensure pregnancy does not occur
either during a course of immunisation or in the month
after the last vaccination. Influenza vaccination is also
recommended as there are special risks in pregnancy.
The Pap smear check should be up to date prior to a
planned pregnancy and, particularly in older women or
those with a family history of breast cancer, checks of
the breasts to exclude a pre-existing malignancy may
be warranted.
Figure 1: Pregnancy rate (natural conception) by maternal age
0
5
10
15
20
25
30
23
25
27
29
31
33
35
37
39
41
43
45
47
Maternal age
Natural pregnancy rate
(% per month)
Volume 6, Number 2, July 2009 page 43

Public Health Bulletin
Communicable disease
The control of communicable disease has special
importance in the pregnant woman, and the GP can
provide public health advice regarding the infections
relevant to this group of patients. Toxoplasmosis, listeria
and the more common salmonella and campylobacter
present a risk to the foetus, so the preconception
discussion should include information regarding safe
food handling and preparation, foods likely to be a
source of listeria and the avoidance of handling ‘kitty-
litter’. Other communicable diseases of relevance are
the sexually transmitted diseases, particularly in regard
to their potential contribution to infertility.
Maximising the message and
minimising the risks and the cost
Social trends have clearly affected reproductive health
in many countries including Australia. Delays in
childbearing due to changes in the roles of women in
society have had a significant impact upon reproductive
health. There are implications for an individual woman
due to the reduction in her ovarian reserve and her ability
to spontaneously fall pregnant, with the consequence of
broader health care and economic implications.
The time has come for a ‘reproductive health plan’
to be a routine part of general practice. Planning in
advance should increase community understanding of
the effects of maternal age on natural fertility rates,
and reduce the risk of women leaving childbearing
until after their ovarian reserve is significantly depleted.
This aspect of planning would have particular public
health benefit, as increased maternal age at the time
of first pregnancy is associated with increased demand
for reproductive medical procedures—at a high cost
to the community. A reproductive health plan may
also help contribute to improved community health
and wellbeing by identifying potentially preventable
problems. To maximise their utility, such plans would
need to span the potential childbearing period from
menarche to menopause, and should not be limited
only to those years when pregnancy is desired.
Conclusion
In South Australia the Government’s very useful
Perinatal Practice Guidelines are widely available,
providing GPs and other professionals with clear
guidance on appropriate management of patients
before and during pregnancy.6 Reproductive health
plans are not currently recommended as standard
practice; however, with the broad range of potentially
preventable health issues that would be addressed, we
need to consider how such plans could add value to the
South Australian community.
References
1. United States Centers for Disease Control and Prevention.
Recommendations to improve preconception health and
health care—United States: a report of the CDC/ATSDR
Preconception Care Work Group and the Select Panel on
Preconception Care. MMWR 2006;55(RR-6):1–23. http://
www.cdc.gov/mmwr/PDF/rr/rr5506.pdf
2. Freda MC, Moos MK, Curtis M. The history of preconception
care: evolving guidelines and standards. Maternal and Child
Health Journal 2006;10(5S):S43–S52.
3. Chan A, Pickering J, Haan EA, Netting M, Burford A,
Johnson A, Keane RJ. Folate before pregnancy: the impact
on women and health professionals of a population-based
health promotion campaign in South Australia. Obstet
Gynecol Surv 2002;57(1):8–10.
4. Mann L. The general practitioner and the ‘new genetics’.
Med J Aust 2003;179(2):109–111.
5. Tremellen K, Kolo M, Gilmore A, Lekamge DN. Anti-
Müllerian hormone as a marker of ovarian reserve. Aust N Z
J Obstet Gynaecol 2005;45(1):20–24.
6. South Australian Government. South Australian Perinatal
Practice Guidelines. Last reviewed 21 October 2008. http://
www.health.sa.gov.au/PPG/Default.aspx?tabid=222.
0.0
0.4
0.8
1.2
1.6
2.0
2.4
2.8
3.2
20-24
Age of mother at delivery
Percentage chance
25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45
Figure 2: Risk of delivery of a live baby with Down syndrome (trisomy 21) by maternal age at the time of delivery
Source: www.genetics.com.au/factsheet/fs28.html
page 44

Public Health and General Practice
Public Health and General Practice
GP planning in a pandemic*
John Litt
Senior Lecturer in General Practice
Flinders University;
Chairman
SA Primary Care Pandemic Influenza Planning
Committee
Rod Pearce
Craft Representative for General Practice
Australian Medical Association;
General Practitioner
Background
The 1918–19 influenza pandemic killed more than
10 000 Australians.1 Extrapolating these mortality rates
to the current Australian population indicates that an
estimated 200 000 people would be killed by a similar
influenza pandemic today.2 The other estimated effects
are shown in Box 1.3
Human-to-human transmission has been implicated
in up to 25% of cases of H5N1 avian influenza. With
a mortality rate of 62%, it is fortunate that sustained
human-to-human transmission has not yet occurred.4
With the recent outbreak of H1N1 swine influenza, the
need for general practitioners (GPs) to be prepared has
escalated.
Why do GPs need to be prepared?
There are a number of good reasons why GPs will need
to be prepared for pandemic influenza (PI).5,6 These
include: workload/business continuity, medico-legal,
ethical and personal reasons.
Business continuity
In a pandemic outbreak of influenza, one in four people
within the community may be affected. This will have
a significant impact on the workload of the general
practice, which may have a similar number of staff
absent for the same reasons. In addition, some staff
may choose not to come to work. Without a number
of changes, it will not be feasible for GPs to carry on as
usual, as well as dealing with the increased workload.5,7
Most patients contracting PI will be urged to stay at
home.3 Many will likely contact their GP and some will
want to see them, even when alternative arrangements
are available, for example flu clinics. Conservative
estimates suggest that there would be an additional
20 GP consultations per week if every GP in Australia
was working and only 50% of those affected saw their
G P. 3,7,8
To cope with the increased workload, GPs will need to:
review the practice’s infrastructure and staff >
reduce/cancel non-clinical activities, including >
meetings and teaching
consider offering some consultations by phone and >
bolstering telephone triage
discuss amalgamating or teaming up with >
neighbouring practices
delegate, alter, share or defer some tasks, for >
example prevention visits, minor surgery, routine
home visits, chronic disease management visits.5–7
Medico-legal
There is no guarantee that emergency powers
legislation will extend to providing (or altering) the
medico-legal circumstances of clinical practice.9 Practice
staff will expect a safe work place. Similarly, any
delegation of clinical tasks will need to be accompanied
by appropriate training and support.6,10
* Editor’s Note: Pandemic planning is a continuing priority action of governments. Most planning anticipates new diseases that are
highly infectious and associated with high morbidity and mortality. Whilst the current H1N1 pandemic is less severe than forms
assumed in pandemic planning, current experience will be incorporated into future planning.
Box 1: Potential impact of pandemic influenza if
we are not prepared
> 40% of the population (8.5 million Australians) would
show clinical signs of infection and 2.4% of those
affected would die (around 200 000 people)
> 50% of the population may not go to work at the peak
of the pandemic
> several waves of infection, each lasting up to 12 weeks,
could occur, with disruption to services that could last
as long as 2 years
Volume 6, Number 2, July 2009 page 45

Public Health Bulletin
Ethical
Practices will need to recognise that there may be
a range of views, conflicting values and possible
stigmatisation associated with working during a
pandemic.11–13 Does the GP have a duty of care to
continue working in the face of significant personal
risk of harm? This has generated significant debate
in the literature, with some arguing that ‘professional
codes of conduct do not insist on normal working
when there is personal risk’.14 Most GPs themselves
indicate that they would keep working,10,15 which is
what happened in the SARS outbreak16 and previous
pandemics. Nevertheless, concern about being
adequately protected against PI will likely influence
their preparedness to keep working. A recent Australian
survey found that less than half of a sample of hospital
health care workers believed that antivirals like
oseltamavir would protect them against PI.17
Personal
In the event of a pandemic, GPs have expressed a
strong sense of moral obligation to look after their
families and their patients and staff, provided that
they can reduce the risk of PI to themselves and their
families.10,14 The importance of adequate and early
prophylaxis is highlighted in a recent modelling study.
The investigators found that, providing antivirals are
distributed to contacts before exposure in the early
stages of a pandemic, the probability of an outbreak
can be considerably reduced.18
Unfortunately, most Australian general practices are not
currently prepared for PI;15,19 some are even confident
that it would not greatly affect their work.12
Where can GPs get good information?
The Australian Government has been active in PI
planning. The Australian Health Management Plan for
Pandemic Influenza 20083 includes a number of annexes,
including one for primary care. In addition, there are
published checklists to assist GPs with planning5,6,20
and a range of web sites, both Australian (http://www.
flupandemic.gov.au; http://www.pandemic.net.au/
resources.html) and international (WHO http://www.who.
int/csr/disease/influenza/pandemic/en/; CDC http://www.
cdc.gov/flu/Pandemic/). These documents cover the major
issues, including business continuity, communication,
triaging of patients, infection control and quarantine,
clinical management, use of antivirals, vaccination and
planning for particular needs. The case study (at the
end of the article) provides an outline of some of the ‘
on-the-ground’ issues that practices may face.
What is the GP’s main role during
a pandemic?
GPs will have a key role in keeping the primary health
care system functioning.5,6,20 They will need to prioritise
their workload so that they can continue to manage
patients with acute and chronic illnesses, in addition
to providing health-related advice. Patients will ask
their GP for advice on how to manage both suspected
and actual PI cases at home. GPs will also need to
be advocates for public health strategies to minimise
the spread of PI,3,7 especially given both the limited
pandemic awareness and the variable likely adherence
by the public to using masks and social distancing
techniques.21,22
What issues need further discussion,
planning and resolution?
Protection of frontline workers and their families
If Australian GPs and their staff are going to have an
estimated extra 600 000 consultations per week, they
will be working hard to keep up with the demand.
They will want immediate assurance that there will be
access to antiviral medication, vaccinations (when and
if available) and national personal protective equipment
(PPE) stockpiles.19 They need to be confident that they
will be able to go home to their family and not pass on
the disease (see Box 2).10
Masks for personal protection need to be fit-tested
for individual face shapes, to choose the make that
provides an adequate seal during normal movements
(see http://www.flupandemic.gov.au/internet/
panflu/publishing.nsf/Content/safeuse-dvd-1 for a
demonstration of how to fit PPE). The testing process
takes about 30 minutes and requires a sealed room
and specialised equipment. In the SARS outbreak over
97% of GPs wore masks.23 In order for masks to be
immediately accessible, this fit-testing needs to occur
before the start of a pandemic.
Box 2: From The Advertiser
South Australia’s first (death from influenza in 2007)
– a 48-year-old receptionist who died at the Royal
Adelaide Hospital on Tuesday – worked at a doctor’s
surgery in Adelaide’s northern suburbs. (The Advertiser
29 August 2007)
page 46