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


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.


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. 



Supporting newly arrived migrant mothers in Canterbury from Bangladesh and China

Culturally and linguistically diverse migrant mothers are more likely to experience lower levels of access to health care. This project, funded by Healthdirect Australia and conducted in Sydney Local Health District, aims to increase equity of access to information and health care for non-English speaking migrant mothers.

AMPACe – Accelerometers for Monitoring Physical Activity in Primary Care

AMPACe aims to assess the feasibility and any benefit of integrating accelerometer or activity tracker use in primary care as means of promoting physical activity. It follows on from a smaller 2016 pilot study.

Assessment and management of weight in young children

This project is undertaken in partnership with the Premiers Task Force on Child Obesity.  It involves the development of face to face and online training and quality improvement activities for GPs and practice nurses in management of overweight and obesity in children in general practice. 

Clinical Pathways: Multidisciplinary shared care plans

“Online shared care plans” is one of four subprojects in the “Clinical Pathways project”.



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.

Accelerometers for Monitoring Physical Activity in Primary Care Feasibility study

Physical inactivity is a growing health concern worldwide, and has been linked with multiple adverse health conditions including obesity and coronary heart disease. In Australia, more than half of the population do not meet the current recommendations for physical activity (PA). GP’s are in an excellent position to monitor PA in patients, which currently involves use of standardised questionnaires such as the GP Physical Activity Questionnaire (GPPAQ). These can be difficult to administer regularly owing to multiple factors such as lack of software integration. Our study aims to assess if accelerometers, or wrist based activity trackers, can be used in this setting as a potential new way for monitoring PA in patients at risk of physical inactivity. 




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.

Development of risk profiling matrix for chronic diseases and preventive smartphone application

This project aims to promote healthy ageing through a smartphone app-based intervention, specifically, by helping people prevent the onset of cardiovascular disease and type 2 diabetes mellitus.