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. 



No projects found.




Secondary Analysis of Data from Commonwealth Fund Survey (Australian Commission on Safety and Quality in Health Care)

The Commission on Safety and Quality in Health Care commissioned CPHCE undertake a secondary analysis of data from a Commonwealth Fund international study of quality and safety in primary care in nine countries, for which the Commission had led the Australian arm.  this paper delves into the details of the organisation and practices.

Shared absolute cardiovascular risk management in general practice

Shared decision making (SDM) between GPs and patients is ideal model for chronic disease. This study will test the feasibility of implementing SDM CVD Risk managment model in general practice.

Shifting ground, common ground. Understanding the evolving care practice. Inter-country comparative study Canada USA and Australia (Canadian Institute for Health Research)

This inter-country comparative study draws on existing research studies that the investigators are conducting into primary health care reform. It focuses on the development of multidisciplinary team work in primary care.

SNAP Decisions: A qualitative study of GPs’ decision-making in the screening and management of chronic disease risk factors: Smoking, Nutrition, Alcohol and Physical activity

The aim of this study is to develop a model of the decision-making process used by GPs when screening for and managing SNAP risk factors in patients presenting for a health check with more than one SNAP risk factor, and use this model to develop and test a framework for supporting GPs in behavioural risk factor screening and management.

South Western Sydney Area Health Service Chronic Disease Self Management Demonstration Project: Follow Up Study

The main objective of this paper was to assess the views of clinicians on the integration of CDSM into routine clinical activities and identify issues for sustainability.




No projects found.