This study aims to increase the capacity of community health services to address chronic disease risk factors of smoking, nutrition, alcohol and physical activity as part of their normal clinical work.

Project Status

Completed Projects

Chief Investigators

Mark Harris, Gawaine Powell Davies

Associate Investigators

Anna Williams, Rosslyn Eames-Brown, Cheryl Amoroso


Chronic diseases account for more than 80% of the overall disease burden and almost 50% of all deaths in Australia. Smoking, nutrition, alcohol and physical activity (SNAP) risk factors have been identified as major contributors to the increasing prevalence of chronic disease. Along with GPs, community health services (CHS) are in an ideal position to deliver brief interventions to reduce the risk of chronic disease. There is good evidence on the effectiveness of these brief interventions, but more information is needed to understand how to embed chronic disease risk factor prevention in community health as part of routine clinical care.

To address this question, the Health Promotion Strategies and Settings Branch, NSW Department of Health, funded the Community Health Risk Factor Management Project at the Centre for Primary Health Care & Equity, UNSW.


To increase the capacity of community health services to address chronic disease risk factors of smoking, nutrition, alcohol and physical activity as part of their normal clinical work.
1. To identify the scope for evidence based risk factor management (RFM) in selected community health teams
2. To develop and implement model/s of risk factor management that will increase the rate of evidence based RFM in selected community health teams
3. To describe the factors which influence the uptake of the model(s), rate of evidence based RFM, and the ability to sustain these overtime
4. To examine the transferability of RFM models across community health teams, and implications for capacity building and service development within community health teams / Area Health Services

Design and Method

The project was a collaborative feasibility study involving two Area Health Services and three community health teams and consisted of the following stages:
Stage 1: Assessment and Scooping (February to May 2006): RFM practices were assessed using a staff survey and a prospective audit of all clients seen over a two week period. Semi-structured interviews with a purposeful sample of clinicians and team leaders/ managers were conducted to explore attitudes towards RFM, barriers and enablers. These needs assessment findings were used to inform the model development stage of the project
Stage 2: Development and Testing (June 2006 to May 2007): Models to integrate RFM into routine practice were developed collaboratively with each team. This included organisational and system changes as well as the provision of clinician training and resources. The implementation of and testing of models occurred over a 6 month period
Stage 3: Evaluation and Review (June to October 2007): Changes in clinician knowledge, attitudes and practices were assessed by pre and post clinician survey (n=37) and prospective client audit. Factors influencing the uptake of risk factor management practices and issues related to sustainability and transferability were also explored through semi-structured interviews with participants (n=30). A client survey (n=181) and two client focus groups were also conducted to explore clients’ views of community health staff addressing lifestyle risk factors and recall of help received and self-reported lifestyle change.
Stage 4: Dissemination and Recommendations (November 2007 to February 2008): This stage involved consultation with participating teams and services, NSW Health and key stakeholders to reflect on the results of the project and to explore the transferability and utility of RFM models in community health.

Key Publications

Final Reports:

One page summary
Comprehensive summary

Appendix 1 Proj Adv Com TOR
Appendix 2 Needs Assessment Methods - Organisational and service profile
Appendix 3 Needs Assessment - Interviews
Appendix 4 Evaluation Methods - Clinician Survey
Appendix 5 Evaluation Methos - Audit
Appendix 6 Audit tool
Appendix 7 Model Evidence
Appendix 8 Service Dev Framework
Appendix 9 Snap screening questions
Appendix 10 Snap training program
Appendix 11 Snap Guide for clinicians
Appendix 12 Evaluation
Appendix 13 Client survey
Appendix 14 Client focus group
Appendix 15 Cost Analysis Methods

Should you wish to have the final reports, please contact Rachel Laws 02-93851488 or

Project Resources:
Snap screening questions
A framework for developing risk factor management models
Clinician training program - outline
Clinician guideline booklet: Helping people change SNAP
Model development - Evidence summary

October 2007 Newsletter
August 2007 Newsletter
February 2007 Newsletter

Conference Presentations:
Presentation from GP&PHC Conference 2006
Presentation from GP&PHC Conference 2007
Presentation from Health Care Reform Conference 2008
Presentation from GP & PHC Conference 2008
Presentation from NSW Health Promotion Symposium 2008

CHRFM Laws Beliefs and Attitudes
A Square Peg in a Round Hole? Approaches to Incorporating Lifestyle Counselling into Routine Primary Health Care

Baseline Risk Factor Management Survey


Rachael Laws Email:

Key Partners

NSW Health, South Eastern Sydney Illawarra Area Health Service, Hunter New England Area Health Service


NSW Health

Project lead centre
Project stream
Prevention and Management of Long Term Conditions
Project start date
Project end date