This sample of individuals referred to community nurses had a high prevalence of lifestyle risk factors and associated health conditions that could benefit from lifestyle change. Participants had higher rates of obesity (40.5% compared to 32.1%), and were more likely to have multiple risk factors (40.4% compared to 29.5%) than in the population of a similar age at large [30
]. Only a small proportion had received lifestyle advice or referral in the previous three months, despite the majority considering or attempting lifestyle change. The proportion of at-risk clients who were considered suitable candidates for intervention (at risk, ready or attempting change without recent advice or referral) was high for all risk factors. The absolute opportunity for intervention was highest for nutrition and physical activity, because of the higher prevalence of these risk factors in this patient group. This suggests that there is a considerable scope for GCNs to address lifestyle risk factors in these clients.
This raises the question of the most appropriate models of lifestyle intervention for community nursing clients. The community nursing SNAP trial will be testing the feasibility and effectiveness of applying the 5As model of brief lifestyle intervention within the community nursing context [21
]. This consists of 1) screening clients for lifestyle risk factors as part of the routine assessment process 2) assessing readiness to change 3) providing brief advice tailored to the clients stage of change 4) referring to support services for more intensive interventions if appropriate 5) following up progress at subsequent visits. These baseline findings suggest however that intervening with this group is not going to be easy because of their age and associated co-morbidities, with almost half having three or more conditions. Participants were also more than twice as likely to report suffering from depression, compared to those in the 2007 National Survey of Mental Health and Wellbeing [31
]. This is consistent with the finding that depression is a common co-morbidity with chronic disease conditions or multiple lifestyle risk factors [32
It will be important to provide appropriate levels of support at the practitioner and service level to enable lifestyle risk factor management to be provided as part of routine practice. Our previous research with community health staff suggested that clinicians' views and perceptions can influence the extent to which they intervene to address lifestyle risk factors. We found that lifestyle risk factor management practices reflect clinician beliefs about whether they should and can address lifestyle issues. Clinician beliefs about their capacity for risk factor management reflected their views about self-efficacy, role support, and the fit between risk factor management ways of working [15
]. It is important, therefore, to address community nurse attitudes in order to improve the delivery of lifestyle interventions to clients. It is also imperative to provide them with the necessary training (such as assess SNAPW risks and readiness to change, conduct motivational interviewing, assist clients in goal setting and offer the appropriate level of intervention) to boost their confidence in engaging in these tasks.
Many of the participants in this sample were discharged from hospital or recovering from post-surgical wounds or other illness. Their GPs might not have an opportunity to offer advice on lifestyle risk factor management yet. The process of recovery can create both opportunities and barriers for risk factor interventions. On the one hand, clients are likely to be focused on their health and on regaining normal functioning. This provides opportunities for staff at different stages of care (hospital doctors, community nurses and GPs) to support lifestyle change. On the other hand, the other demands of self-care and managing illness may overshadow lifestyle changes, and any changes that are made might not be sustained once previous health is restored.
For the minority of participants who recalled having received advice or referral, GPs and hospital doctors were the main sources of advice. GPs are often considered the 'front line' for risk factor interventions in primary health care. The incidence of recall of any recent advice from GPs was only 2.4% for alcohol consumption, 4.7% for physical activity, 4.8% for advice and 13.8% for quitting smoking. This is similar to the ranges reported from studies in general practice [35
]. It suggests that there are still missed opportunities for lifestyle advice in primary medical practice. It also means that there are opportunities for GCNs to reinforce these messages at a time when patients are likely to focus more on improving their health.
Our previous research [36
] demonstrates that lifestyle intervention by GPs is possible in general practice. However there needs to be more coordination in assisting and referring clients should more intensive intervention be required. In particular, more group based programs especially to address diet and weight may be required to achieve effective outcomes [36
About half of the participants with poor nutrition or who were overweight/obese who recalled receiving advice had seen a dietitian. This is promising, given the evidence for effectiveness of interventions by dietitians [38
], and suggests that GCNs may need to coordinate their education and advice with the dietitians whom their clients have seen, on a case-by-case basis or through in-service education. 'Family and friends' formed another important source of advice for all four SNAP risk factors. Social support can be important in initiating as well as maintaining lifestyle changes, and GCNs are well placed to encourage this through their contact with clients and their family/carers at home.
One implication for primary health care is to establish stronger links between providers and services for risk factor management to address varying needs of clients and opportunities at different stages of recovery from surgery or illness. This may need to involve GCNs (limited by the stage at which they see the patient), the general practice (limited by time, practitioners' coaching skills and communication with GCNs) and community based programs (currently limited by availability, accessibility and not being well known by GPs or GCNs). By focusing on illness prevention such as offering SNAPW risk factor lifestyle management could potentially minimise the need for medication or hospitalisation in the future.
A key challenge is that providers and services (GCNs, GPs and community based programs) have different funding models, and traditionally integration of care across these services has been poor [39
]. The Australian Government recently funded Medicare Locals (NGOs) that have strong local governance, including broad community and health professional representation and have strong links to Local Hospital Networks, Local Health Districts, local communities, health professionals and service providers including GPs, allied health professionals and Aboriginal Medical Services [40
]. Medicare Locals will be responsible for providing better integrated care making it easier for patients to navigate the local health care system and should be well placed to coordinate care the management of lifestyle risk factor management.
The data collected relied solely on clients' self-report. This could contribute to inaccurate reporting. However, the use of the computerised assisted telephone interview with software that had a built-in logic to skip questions that were not applicable and probe for more detail when warranted enhanced completion rate and minimised missing data. Social desirability may also contribute to respondents providing answers more favourable than the actual behaviours.