Prevention and Management of Long Term Conditions

Description and Aims

This stream is a response to the challenge of long term conditions to health and health care services.   These conditions include diabetes, cardiovascular disease, asthma and chronic obstructive lung disease, cancer and mental illness.  They commonly occur as multi-morbidities.   The aim is conduct research in the community which informs improvement in health care and programs which aim to prevent and manage these conditions. 

Key Current Research Areas
·         Prevention

The program focuses on improving interventions to address the behavioural risk factors (especially Smoking, Nutrition, Alcohol and Physical activity) as well as physiological risk factors such as obesity and cardiovascular risk in primary health care.  This uses the 5As framework (ask/assess, advise, agree and assist, arrange), approaches tailored to health literacy levels and use of wearable technology and social media. 

·         Management

This program focuses on a patient centred approach based on the Chronic Care model and includes teamwork, information and communication systems (including e-health), self-management support and community resources.  This is the focus of work on diabetes, cardiovascular disease, asthma, COPD, cancer, mental illness and multi-morbidity. 

Key Partners

This research is conducted in partnership with primary health networks and local health districts along with other groups including  Aboriginal Health organisations.

Stream lead

Mark Harris leads the stream.  



AMPACe – Accelerometers for Monitoring Physical Activity in Primary Care

Our study aims to assess whether using an accelerometer is a feasible GP based intervention in promoting physical activity in patients with a BMI ≥ 30. The findings will also pave the way for a larger scale randomized control trial and provide an estimate of required size of the trial. 

Australian Prevention Partnership Centre (TAPPC)

The Centre aims to develop a systems approach to preventing lifestyle related chronic health problems. The research the centre conducts will help us learn about what works in chronic disease prevention. It will also investigate how to get the best prevention messages out to the community and give health decision makers the best evidence on preventing chronic disease

Further details at

Innovative Models Promoting Access & Coverage Team (IMPACT)

Innovative Models Promoting Access & Coverage Team (IMPACT)

The IMPACT study is a five-year international research program that aims to develop and evaluate models of care that enhance access to primary health care for vulnerable populations in six sites across Australia and Canada. 

Preventing chronic disease in patients with low health literacy using e-health in general practice.

Preventing chronic disease in patients with low health literacy using e-health in general practice.

This is a cluster randomised controlled trial of the effectiveness of an intervention which uses accessible and interactive information technology to support general practice nurses to better communicate with patients with low health literacy, to help them use information, set priorities, navigate referral and maintain behaviour change.


A cluster randomised controlled trial of nurse and general practitioner partnership for care of COPD

A cluster randomised controlled trial of nurse and general practitioner partnership for care of COPD

Determination of the impact of nurse and GP partnership on the quality of care and health outcomes for patients with COPD at six months and twelve months follow-up

A pilot study in managing Anxiety and Stress in Cross-Cultural Encounters among Chinese-Australians (Beyondblue community grant in collaboration with Chinese Australian Services Society)

This project involved the delivery of ‘Assertive Communication Skills’ to help Chinese-Australians manage their stress and anxiety in cross-cultural encounters in everyday settings. This project also sought to bridge the cultural gap by equipping participants with culturally appropriate skills.

A project to assess the effectiveness and feasibility of case finding of Chronic Obstructive Pulmonary Disease (COPD) by practice nurses in General Practice

This project investigated the prevalence of COPD diagnosis in an Australian general practice setting, and whether an intervention utilising practice nurses addresses under-diagnosis of COPD.

Absolute risk assessment in general practice – a pilot study to measure impact on prescribing and adherence to guidelines

Prevention of cardiovascular disease (CVD) is a priority for the Australian community and general practitioners (GPs) play a key role in this activity. This study aims to test the impact of ARA in general practice on prescribing of anti-hypertensive and lipid-lowering medications and adherence to guidelines.

Advance Care Planning in Australian Primary Care

This study explores the key stakeholders, general practitioners and patients' views on how Advance Care Planning is currently conceptualised and implemented.