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. 



Exploring immunisation providers’ views towards delivery of routine immunisations in the COVID-19 era and the rollout of COVID-19 vaccines through General Practice

International travellers are a primary factor in the spread of infectious diseases across borders and have been instrumental in spreading SARS-CoV-2 around the world. Diasporic people who travel back to their countries of origin to visit friends and relatives (VFR travellers) are at increased risk of acquiring a range of infectious diseases during travel, compared to other travellers. Pre-travel assessment and advice is an important opportunity to address VFR issues regarding health beliefs, health behaviours, current health status and pre-existing conditions.

General Practitioners (GPs) are an important source of pre-travel advice for travellers. An Australian population-based survey found that almost 90% of travellers used their general practitioner for travel health advice (1). Despite this, there has been little published research on the practice of travel medicine in primary care in Australia or internationally(2, 3) and few address the provision of travel medicine advice to migrant Australians travelling to visit friends and relatives (4). A 2012 study of GPs in migrant-rich suburbs of Sydney found a lack of awareness of the need for pre-travel health assessment of migrant Australians, particularly among migrant GPs (4). Further research is needed to identify barriers to care among a more generalisable sample of Australian GPs.

Traveller behaviour may differ in the post-COVID era and the practice of travel medicine is likely to change. Understanding GP knowledge, and perception of travel risks and barriers to the provision of advice is important, with previous research indicating a need for directed education and awareness of the need for opportunistic targeting of VFR travellers (5). 

A cross-sectional survey of GPs practicing in Australia will be conducted. GPs will be sampled from the AMA Medical Directory of Australia database. Depending on contact details, GPs will be emailed a link to an online survey or posted a hard-copy survey and invited to participate.

Implementation of a decision support triage tool in specialist-general practitioner shared care

This study will guide the implementation of the shared care team model by evaluating a decision support triage tool that will assist in the selection of patient scenarios at ‘low-intermediate risk’ of complications for shared care, further refine the roles of cancer specialists and GPs, and inform the development of supporting resources.

Mental Health Literacy Training and Education for the primary health workforce

CPHCE is working with a consortium (Swinburne, University, University of Newcastle and North Coast PHN) to develop education and training materials to improve mental health literacy responsiveness in primary care and specialist health settings. This project is a component of the Health Literacy Initiative that is being managed by the Mental Health Commission of NSW.

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.

SHAReD: Shared Health Arrangements Research & Development

The SHAReD study aims to improve the coordination of care between mental health services and primary care to better manage risk factors for heart disease and diabetes and improve the health of people living with severe mental illness. It will introduce telehealth and web-based shared care plans between consumers, mental health services and general practices allowing them to better communicate with each other and plan care. We will evaluate the quality of care provided and consumers’ experience, as well as the impact on quality of life. We will weigh up the costs and benefits to inform its dissemination across NSW. 




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.

An evaluation of the development, implementation, feasibility and impact of a tailored intervention to improve the quality of care for Aboriginal and Torres Strait Islander peoples attending urban general practice

This study aims to develop and evaluate strategies to improve the acceptability of health care provided to Aboriginal and Torres Strait Islander patients who attend mainstream general practice in urban Sydney.

Analysis of patterns of diabetes care and their outcomes from division registers

Division registers provide longitudinal data on the quality of care and health outcomes for patients with diabetes in general practice. The Macarthur and Southern Highlands Divisions have 9 been established for more than 9 years.




No projects found.