Evidence into policy in Australian primary health care

The APHCRI projects in this supplement have strengthened capacity and increased policy-relevant knowledge, but primary health care researchers and policymakers need to work much more closely together if evidence is to contribute to decision making

Nicholas B Mays FFPH

The Australian Primary Health Care Research Institute (APHCRI) is part of the Primary Health Care Research Evaluation and Development (PHCRED) strategy.1 The Institute was the most recent element of the PHCRED strategy to be established, beginning research activities following the appointment of the Research Advisory Board (RAB) in November 2003. APHCRI’s mission is to “provide national leadership in improving the quality and effectiveness of primary health care through the conduct of high quality priority-driven research and the support and promotion of best practice”.2 APHCRI has a specific focus on the links between primary health care evidence and policy. Its activities not only fund research programs, but also seek to build capacity within the research community and policy community to facilitate the adoption of evidence into policy. There are two important interdependent features in the APHCRI model adopted to fulfil this mission. Firstly, it is a “virtual” institute operating a “hub and spoke” model. The Institute comprises staff based at the Australian National University (the “hub”) and, within different streams of research activities, multiple “spokes” undertaking commissioned programs of research. Secondly, the Institute has a specific pool of funds to commission research — it both funds research and undertakes research. The Institute’s RAB sets the research priorities, oversees the independent assessment of applications for funding and determines the successful spokes. Groups compete to be commissioned within a particular stream of research, but, once successful, collaborate as part of the virtual institute. In this article, we provide an overview of the approach APHCRI has taken to bring research evidence to bear on policy formation. We also reflect on lessons learned through the process of conducting our fourth research stream. Linkage and exchange, APHCRI styleInfluencing policy with research evidence is not a simple “linear” proposition. Health policy draws on many information inputs apart from research evidence, including political realities.3 APHCRI has adapted the Canadian Health Services Research Foundation “linkage and exchange” approach4 in order to make its research products more useful to policymakers. APHCRI links together four groups of participants to exchange knowledge from their different perspectives. These are: Policymakers and decisionmakers in both the federal and state/territory spheres; Providers of primary health care services and the various organisations with which they are associated; Researchers; and Users of primary health care services, and the various organisations with which they are associated. Members of these four groups serve on the RAB. APHCRI’s research priorities are iterated with policy advisers and the RAB to ensure they are relevant to policy. Expert review committees, convened to assess applications within the different streams, include members with expertise across these groups. The assessment criteria for applications within streams reflect the emphasis on policy and provider expertise in addition to more usual academic criteria. Stream 4APHCRI organises its research programs in “streams”. Each stream has a particular focus and may have several spokes or individuals working within it (the numbers of the streams denote the chronological order in which they were announced). The Institute’s Stream 4 program (with $1.8 million funding in total) further sharpened the linkage and exchange focus. It aimed to increase both the capacity of researchers to respond to policy priorities and the capacity of policy advisers to utilise research evidence. A list of policy-relevant topics, approved by the RAB, was identified in consultation with the Australian Government Department of Health and Ageing. A total of 12 spokes were commissioned to address these topics, using a common methodology to address two broad questions: What do we know about the topic?; and What are the possible options for the Australian context? The first question focuses the systematic review that is synthesised by the research team. The second question requires the researchers to use the results of the review to develop evidence-based recommendations for ways forward for Australia’s primary health care system. The policy options include consideration of funding arrangements (existing and alternative), delivery arrangements and governance arrangements reflecting system-level perspectives. An overview of the steps, timelines and major activities that comprised Stream 4 is presented in the Box. Within this supplement, we summarise key findings from each spoke on the topics as follows: Chronic disease management (Cranston et al,6 Dennis et al7); Integration, coordination and multidisciplinary care (Jackson et al,8 Mitchell et al,9 Powell Davies et al10); Innovative models for comprehensive primary health care delivery (McDonald et al,11 Naccarella et al,12 Humphreys et al13); Innovative models for the management of mental health in primary health care settings (Griffiths and Christensen14); Children and young Australians, health promotion and prevention (McDonald et al,15 Hearn et al16); and Workforce (focus on competency-based training) (Glasgow et al17). Systematic review and interactions between policy advisers and researchersThe disparate nature of much of the published literature required careful consideration of the appropriate methods for systematically reviewing and synthesising such evidence. Stream 4 drew heavily on the Journal of Health Services Research and Policy supplement, “Synthesizing evidence for management and policy-making”,18 to underpin its approaches, particularly the narrative synthesis approach of Mays and colleagues.19 Additional funding was provided to Stream 4 participants to allow their engagement in structured meetings in Canberra on four separate occasions during the 12 months of the program. These served five main purposes: Facilitating agreement on methodological issues (eg, common approaches to searching for primary health care literature or economic literature, assignment of quality criteria to diverse literature, “stopping” rules to allow a decision to be made that enough material has been obtained); Minimising duplication of effort through sharing of material and, where more than one spoke was working on a topic, agreeing on how the work of one spoke would complement the work of others on that topic; Facilitating interactions with policy advisers to provide provisional results to them and to test emerging options for their policy relevance; Allowing access to international experts to ensure a high standard of review (eg, Nicholas Mays, Professor of Health Policy at the London School of Hygiene and Tropical Medicine, delivered a workshop on systematic review methods); and Ensuring that progress against stated milestones was achieved so that the results were delivered in a timely fashion. Presentation of resultsThe research teams were asked to present their results (preliminary and final) in different ways through the program. The intent was twofold — addressing the concern of policymakers that research results are often not delivered in a timely fashion, and presenting the final reports in a manner that was easily accessible. The structured research components in Canberra allowed presentation of early results, as did the meetings between the individual spokes and their reference groups and interactions with key stakeholders. Throughout this interaction, the independent nature of the process was maintained by careful attention to the scientific method involved in synthesis and critical internal and external review. The final reports were prepared for web-based presentation using the “1:3:25” approach,5 with one page summarising the key take-home messages, three pages providing an overview, and the longer report containing all the information, including full references and appendices where appropriate. What have we learned?Most spokes found the systematic review process very demanding. A number of participants had experience with the Cochrane approach to systematic reviews, but did not find this suitable for the kind of literature being surveyed. The volume of potential literature identified in the searches was very large, and making decisions about when to stop searching and how to adjudicate the relevance and weight that should be given to retrieved material was a challenge throughout the process. The result for most spokes was a greater proportion of the 12 months being spent on the review process than had been anticipated at the outset, with a relatively lesser proportion of time iterating potential options with key stakeholders. Researchers are accustomed to writing for research audiences. Most spokes found the production of the one- and three-page summaries of the options for non-research audiences challenging. Researchers tended to default into research writing mode — for example, qualifying statements in the summary documents to convey the sense of uncertainty around them rather than stating the implications for policy less ambiguously. While policy advisers played a significant role in priority setting for the research program, participation by policy advisers in the structured sessions in Canberra was more variable. Senior policy advisers usually had unanticipated demands being made on their time and thus were unable to attend. More junior policy advisers were hesitant to offer critical comments from a policy perspective on the material being discussed, and had to balance the commitment of being present for the full day against the other requirements of their roles. Engagement with senior policy advisers was more successful when the separate spokes arranged to meet with individuals outside the structured sessions. Locating the material on the Internet has made it easily accessible to Australian audiences and, to some extent, international audiences. The number of hits suggested the resources have been useful, and, interestingly, it seems the full reports are most often visited rather than the one- or three-page summaries. Anecdotal accounts suggest that the recent Australian Government intervention in the Northern Territory has resulted in much use being made of the reports by McDonald et al15 and Humphreys et al,13 although this can not be corroborated through analysis of APHCRI website activity. Anticipating future policy challenges in an explicit and timely fashion allows for a repository of relevant research information to be developed.20 What has followed Stream 4?Because of the largely positive experiences associated with the conduct of Stream 4, the RAB has continued to support the development of the linkage and exchange approach. Stream 6 is repeating the Stream 4 process, with a single focus on addressing the primary health care workforce shortage. Stream 7 provided opportunities for researchers involved in Stream 4 to compete for new linkage and exchange travelling fellowships, allowing Australian primary health care researchers to visit world-renowned international academic primary health care institutions in relevant comparator countries and consider their Stream 4 work in the context of these international settings. On their return, they will provide written reports of their findings and participate in a briefing to policy advisers in Canberra. What has been the impact of Stream 4?Improving the quality and effectiveness of primary health care requires the adoption of evidence into policy and practice. Has APHCRI’s research been taken up in policy? As Nutley et al report,21 direct or instrumental use of research findings to shape policy is unusual. Research evidence is only one source of information that policymakers draw upon. APHCRI does not expect to demonstrate direct links between its research programs and subsequent policy. However, it does expect to contribute to the policy processes through use of its research to assist with conceptualisation of issues and to mobilise support for key reforms. Conceptual use is illustrated by the provision of succinct summaries of relevant information or provision of new ways of framing issues or gaining further insights into the strengths and weaknesses of different options — all illustrated in the articles of this supplement. APHCRI’s Stream 4 program has contributed to debate and raised public discussion of crucial issues confronting Australia’s health system. An example of this is the contribution APHCRI’s Stream 4 program and related activities have made to mobilising support for discussion of the health system reforms necessary to meet the challenges posed by chronic disease. ConclusionAPHCRI’s development of the linkage and exchange approach through its Streams 4, 6 and 7 has been positively received by the primary health care research community. The RAB will continue to develop and implement refinements to this approach, with a view to enhancing the uptake of evidence in policy. Steps, timelines and major activities within Stream 4, Australian Primary Health Care Research Institute (APHCRI) Steps and timeline Major activity focus Setting priority research topics through iteration with Department of Health and Ageing then decision by RAB (Mar–Apr 2005) Clarifying national policy relevance and prioritising issues Call for responses addressing selection criteria (May 2005) Publication of opportunity in national press, through established email networks and on APHCRI website Optional information workshop for potential applicants (Jul 2005) Overview of APHCRI and Stream 4, with workshop presentation freely accessible on the Internet Assessment of responses by the ERC against selection criteria, with recommendations to the RAB (Aug 2005) Independent assessment of all applications initially, then meeting of the ERC to arrive at consensus scores and recommendations to the RAB Decision making by the RAB and commissioning of spokes (Aug 2005) Further discussion of applications, and identification of any issues needing clarification before announcement of decisions First research program component meeting in Canberra (Sep 2005) Discussion of overall program Identification and management of potential commonalities/synergies between spokes Development of shared approach to: systematically identifying relevant black literature; classifying studies; assessing strength of evidence; and synthesising results Research activities Scoping literature Refining questions Establishment of reference groups and stakeholder lists Second research program component meeting in Canberra (Oct 2005) Further specifying research questions Discussing initial mapping exercise Selecting studies Re-running the searches Research activities In-depth searches Discussions with reference groups and stakeholders Additional research program component meeting in Canberra (Jan 2006) Master class in systematic review methods with Nicholas Mays, Professor of Health Policy at the London School of Hygiene and Tropical Medicine Third research program component meeting in Canberra (May 2006) Key findings against key questions Report on key stakeholders engaged thus far and to be engaged Key learnings from the review process to date 1:3:25* report approach Research activities Formatting draft reports into a 1:3:25* template and development of options Fourth research program component meeting in Canberra (Sep 2006) Technical problems with template discussed Provisional options presented and commented on by participants 1:3:25* reports finalised and submitted to APHCRI (Oct–Nov 2006) Editing Standardising presentations Iterating with authors to ensure sense not changed 1:3:25* reports published on APHCRI website (Nov 2006) ERC = Expert Review Committee. RAB = Research Advisory Board. * The 1:3:25 approach uses one page to summarise the key take-home messages, three pages to provide an overview, and a longer report to give all the information, including full references and appendices where appropriate.5

Nicholas J Glasgow MD, FRACGP · John E Marley MD, FRCP(Edin), FRACGP · Linda J Kristjanson RN, MN, PhD · Janette A Donovan BA, GradDipPubHealth · Sally J Hall RN, GradCertClinMan · Mark F Harris DRACOG, FRACGP, MD · David M Lyle MB BS, PhD, FAFPHM · Elizabeth J Kerr BA(Off Mgt), GradDipAET · Frith Rayner BA, GradDipJournalism

Objective: To review the literature for any promising strategies for the primary care management of mild-to-moderate asthma and chronic obstructive pulmonary disease (COPD) in adults.Methods: Using “MeSH” terms for COPD, asthma and primary health care, we conducted an extensive literature search for relevant meta-analyses, systematic reviews, narrative reviews, reports and individual studies. Grey literature was also included. We chose a narrative review approach because of substantial heterogeneity of study designs in the literature.Results: 1119 articles of potential relevance were retained, of which 246 were included in our review. There was insufficient evidence to determine whether general practitioners with a special interest (GPwSI) in respiratory care improved the diagnosis and management of mild-to-moderate COPD. An asthma service involving GPwSI increased respiratory drug costs but reduced the costs for less specific drugs. No clear benefit has been shown for practice nurse-run asthma clinics in primary care compared with usual care in altering asthma morbidity, quality of life, lung function or medication use. Evidence to determine the effectiveness of practice nurse-run COPD clinics could not be found. Self-management education, GP review and action plans may produce short-term benefits for asthma patients, particularly those with moderate-to-severe disease, but the evidence for a similar approach to patients with mild-to-moderate COPD is equivocal. There has been poor uptake of respiratory clinical guidelines relevant to primary care — partly because most guidelines are based on moderate-to-severe disease. Spirometry programs in primary care are useful for differential diagnosis of asthma and COPD. Spirometry may alter the management of mild asthma, but there is a lack of evidence that it alters the management of COPD in primary care.Conclusion: The role of primary health care in management of mild-to-moderate asthma and COPD requires further investigation using randomised controlled trials.

Josephine M Cranston BSc(Hons) · Alan J Crockett PSM, MPH, PhD · John R Moss MSocSci, MB BS, FCHSE · Robert W Pegram BSc, MB BS, MHSM · Nigel P Stocks MB BS, MD, FRACGP

Objectives: To review the effectiveness of chronic disease management interventions for physical health problems in the primary care setting, and to identify policy options for implementing successful interventions in Australian primary care.Methods: We conducted a systematic review with qualitative data synthesis, using the Chronic Care Model as a framework for analysis between January 1990 and February 2006. Interventions were classified according to which elements were addressed: community resources, health care organisation, self-management support, delivery system design, decision support and/or clinical information systems. Our major findings were discussed with policymakers and key stakeholders in relation to current and emerging health policy in Australia.Results: The interventions most likely to be effective in the context of Australian primary care were engaging primary care in self-management support through education and training for general practitioners and practice nurses, and including self-management support in care plans linked to multidisciplinary team support. The current Practice Incentives Payment and Service Incentives Payment programs could be improved and simplified to encourage guideline-based chronic disease management, integrating incentives so that individual patients are not managed as if they had a series of separate chronic diseases. The use of chronic disease registers should be extended across a range of chronic illnesses and used to facilitate audit for quality improvement. Training should focus on clear roles and responsibilities of the team members.Conclusion: The Chronic Care Model provides a useful framework for understanding the impact of chronic disease management interventions and highlights the gaps in evidence. Consultation with stakeholders and policymakers is valuable in shaping policy options to support the implementation of the National Chronic Disease Strategy in primary care.

Sarah M Dennis MSc, PhD · Nicholas Zwar FRACGP, PhD · Rhonda Griffiths MSc, PhD · Martin Roland DM, FMedSci · Iqbal Hasan MB BS, MPH · Gawaine Powell Davies MHP · Mark Harris FRACGP, MD

Objective: To identify sustainable governance arrangements for health care organisations undertaking integrated health service delivery based on best available evidence.Method: Systematic review of the literature (1990–2006), supported by key informant interviews as an integrative process.Results: 16 studies met our selection criteria. All described enablers of and barriers to delivering integrated health services. We identified three models for integrated health care governance with a demonstrated ability to be sustained in the medium term. Common themes that emerged as the logical starting point for more ambitious integrated governance arrangements regionally were: the need for a clear separation between governance and operational management; and the need for local communities with the vision, leadership and commitment to extend health service integration. These themes were reinforced by interviews with key informants. Careful measurement of the process, impact and outcomes of such activities was often overlooked.Conclusion: State governments are increasingly attempting to work with non-government organisations and the private sector to maximise scarce resources in the face of increasing health care demand. Ambitious integration agendas must be underpinned by effective governance mechanisms that are appropriate to the undertaking, the stakeholders involved and the scale of delivery.

Claire L Jackson MPH, GradCertMgmt, FRACGP · Caroline Nicholson GradDipPhysio, MBA, GAICD · Jenny Doust BM BS, PhD, FRACGP · Lily Cheung BA(Communications) · John O’Donnell MB BS, DipRACOG, MHP

Objective: To examine policy and implementation issues around multidisciplinary care planning (MDP) as a means of improving outcomes for patients with chronic disease and/or complex care needs.Methods: We conducted a series of five systematic reviews of the literature from 1990 to 2006, sampling a spectrum of issues associated with chronic disease and complex health care needs, with a focus on planning and provision of multidisciplinary care.Results: Our review showed that MDP does improve many functional outcomes in the areas studied. Analysis of MDP programs involves examination of two groups of variables — the multidisciplinary components (a range of clinical perspectives and specialist knowledge) and team components (eg, communication and support). Implementing MDP requires changing patterns of interaction between care providers, alignment of roles and work practices, and changes to organisational arrangements.Conclusion: While MDP improves many functional outcomes, widespread implementation of MDP in standard practice will require complex and targeted strategies. Devising and testing such strategies is a prerequisite for widespread, routine use of MPD in chronic disease management.

Geoffrey K Mitchell FRACGP, PhD · Jennifer J Tieman BSc, MBA · Tania M Shelby-James BAppSc, MPH

Objectives: To identify the types of strategy used to coordinate care within primary health care (PHC) and between PHC, health services and health-related services in Australia and other countries that have comparable health systems, and to describe what is known about their effectiveness; to review the implications for health policy and practice in Australia.Methods: We conducted a systematic review of the literature (January 1995 to March 2006) relating to care coordination in Australia, the United States, the United Kingdom, New Zealand, Canada and The Netherlands. Our review was supplemented by consultations with academic experts and policymakers.Results: Six types of strategy were identified at patient/provider level, falling into two groups: (i) communication and support for providers and patients, and (ii) structural arrangements to support coordination. These were broadly consistent with existing typologies. All were associated with improved health and/or patient satisfaction outcomes in more than 50% of studies, and interventions using multiple strategies were more successful than those using single strategies.Conclusions: The largely incremental approach to improving coordination of care in Australia has involved a broad range of strategy types but has also perpetuated existing structural problems. Reforms in governance, funding and patient registration in primary health care would provide a stronger base for effective care coordination.

Gawaine Powell Davies BA, MHP · Anna M Williams BSc, MPH · Karen Larsen BSc, GradDipPH · David Perkins PhD · Martin Roland DM, FMedSci · Mark F Harris MD

Objective: To review the implementation and impact of different funding initiatives across the health systems of three different countries — England, New Zealand and Australia — on the achievement of multidisciplinary primary health care (PHC) and to reflect on policy implications for Australia.Methods: A systematic review of the literature involving three stages: (i) identification and description of initiatives; (ii) a systematic review of their implementation and impact from 1995 to mid 2006; and (iii) an updated review of published literature from mid 2006 to mid 2007.Results: Few studies employed control groups, and the results should therefore be interpreted with caution. In all three countries, funding has supported general practitioner access to a broad range of providers. In Australia, financial incentives have been the main mechanism for bringing about change, whereas in both England and New Zealand, they are part of a broader range of funding reforms including the introduction of capitation and practice-based commissioning. The lack of patient data makes it difficult to assess the extent to which the Australian financial incentives have generally improved population access to a broader range of PHC providers.Conclusion: Individual, patient-level, financial incentives may present significant impediments for population subgroups with complex needs. Alternative funding arrangements, such as capitation and contracting, could be more widely adopted in Australia to enhance access to care for vulnerable population groups without fundamentally changing the overall fee-for-service financing arrangements.

Julie McDonald MPH · Mark F Harris DRACOG, FRACGP, MD · Jacqueline Cumming MA, DipHealthEcon, PhD · Gawaine Powell Davies BA, MHP · Pippa Burns BSc(Hons), MPH

Objective: To review innovative models of primary care in different countries in order to identify potential mechanisms for reforming primary care policy in Australia.Methods: We conducted a narrative review and synthesis of evidence about models of primary care from four English-speaking comparator countries (New Zealand, Canada, the United Kingdom and the United States) and one European country (The Netherlands), with a particular focus on the relevance and applicability of these models to Australia.Results: We identified four key mechanisms for bringing about reform in primary care: flexible funding, quality frameworks, regional-level primary care organisations, and primary care infrastructure. These mechanisms are interdependent.Conclusion: There are tensions and tradeoffs involved in balancing professional and bureaucratic control and in linking quality and accountability mechanisms. Enhanced linkage between researchers, policymakers and professional groups could assist in exploring options for effective primary care reform.

Lucio Naccarella BSc(Hons), PhD · Donna Southern BSc(Hons), GradDipEpiBiostat · John Furler MB BS, GradDipPubHealth, PhD · Anthony Scott PhD · Lauren Prosser BAppHealthSc(Hons) · Doris Young MB BS, MD, FRACGP · Hal Swerissen BAppSc(Psych), GradDipPsych, MAppPsych · Elizabeth Waters GDBIS, MPH, DPhil

Successful, “innovative” primary health care (PHC) models exist that have adapted to the specific circumstances of their rural and remote context. A typology of discrete, integrated, comprehensive and outreach rural and remote services exists rather than a “one coat fits all” PHC health service model. Successful models are characterised by macro-scale environmental enablers (supportive health policy, federal–state relations, and community readiness) and five essential service requirements (workforce organisation and supply; funding; governance, management and leadership; linkages; and infrastructure). Service sustainability depends on ensuring that key systemic service requirements are met at the local level in ways that accord with, and are supported by, the broader macro-scale environmental enablers. Based on these principles, these model types are amenable to generalisation and evaluation in other regions.

John S Humphreys BA, PhD, DipEd · John Wakerman MB BS, MTropHlth · Robert Wells BA · Pim Kuipers BA(Hons), MHumServ, PhD · Judith A Jones BA(Hons), GradDipAppSci(Comp), MSPD · Phil Entwistle BSc, MTropHlth, PhD

Objective: To consider the implications for mental health policy of a recent synthesis of the literature on the effectiveness of different service delivery models for depression in primary care.Methods: A discussion based on the results of several systematic reviews of primary care models for depression management. Primary care was defined broadly within a prevention, early-intervention, treatment and recovery/support framework, and incorporated both community and general practice settings.Results: There were promising effective models for depression interventions both in the broader community and in general practice settings.Conclusions: There is a need to support evidence-based models for depression care, including innovative new technologies for facilitating consumer self-management of depression. The ability of practitioner training and guideline implementation to improve consumer outcomes for depression is limited. Policies and incentives are required to facilitate the reorganisation of general practice and, in particular, the implementation of care management as well as enhanced care and guided self-help in these settings.

Kathleen M Griffiths BSc(Hons), PhD · Helen Christensen BA(Hons), MPsych, PhD

Objective: To determine what preventive models or programs are most likely to improve patterns of growth faltering in children aged under 5 years in remote Australian Indigenous communities.Methods: Nine electronic databases and the websites of key stakeholder, government and non-government agencies were searched. Two reviewers independently assessed articles for inclusion and for study quality. All types of study design were eligible.Results: 140 studies assessing a diverse range of interventions were identified. Of these, 51 articles referring to 44 individual programs and 7 review articles met the review criteria. The evidence for the effectiveness of many interventions to prevent growth faltering is not strong, and any observed effects are modest. Community-based nutrition education/counselling and multifaceted interventions involving carers, community health workers and community representatives, designed to meet program best-practice requirements and address the underlying causes of growth faltering, may be effective in preventing growth faltering. Other interventions, such as food distribution programs, growth monitoring, micronutrient supplementation and deworming should only be considered in the context of broader primary health care programs and/or when there is an identified local need.Conclusion: For remote Indigenous communities, development and implementation of programs should involve a consideration of the evidence for potential impact, strength of community support and local feasibility. Given the lack of strong evidence supporting programs, any new or existing programs require ongoing evaluation and refinement.

Elizabeth L McDonald PhD · Ross S Bailie MD, MPhil(MCH), FAFPHM · Alice R Rumbold BSc(Hons), MPH, PhD · Peter S Morris MB BS, FRACP, PhD · Barbara A Paterson FFPHM, MPH, MRCGP

Objectives: To identify key barriers to effective engagement of primary health care (PHC) providers and families in promoting healthy weight among children aged 2–6 years, and to examine promising interventions to identify policy goals to overcome these barriers.Methods: We conducted a literature review of published and unpublished articles from January 1990 to February 2006 using keywords relating to childhood obesity, risk factors, prevention, populations and primary care provider interventions, constraints and models. We identified barriers to engagement by PHC providers. Appraisal of “promise” was based on best available evidence and consideration of strengths and weaknesses of interventions in specific contexts and settings.Results: Of 982 interventions aimed at the primary prevention of overweight and obesity among children, few related to 2–6-year-olds, with only 45 interventions meeting the inclusion criteria and 11 ranking highly on key criteria. Areas of weakness were low-level engagement by PHC providers, focus on single risk factors rather than a multidimensional approach, and lack of a population focus. A range of administrative, attitudinal, knowledge, skills and training issues were identified as barriers to effective engagement of different PHC providers with parents and other early childhood service providers.Conclusions: Engagement of PHC providers in prevention of childhood obesity requires a systematic approach involving practice protocols, assessment tools, client support material and referral pathways, as well as adequate training and sufficient staff for implementation. A more comprehensive approach could be promoted by increased collaboration, agreed role delineation, consistent public health messages and better coordination between PHC providers and other service providers, facilitated at service policy and administration level.

Lydia A Hearn EdD, MSc, BA(Hons) · Margaret R Miller MAppSc, GradDipPubAdm, GradDipDiet · Renee Campbell-Pope BHSc

Objective: To review the literature on the effectiveness of competency-based education (CBE) as a means of equipping the Australian general practice workforce to deliver optimal chronic disease outcomes to articulate policy options for the Australian context.Methods: Systematic review of the literature (1991–2005) using a narrative approach followed by analysis of the findings using the actors/context/ processes/content framework of Buse et al.Results: Few high-quality studies were identified. National policy options include incorporating clear statements about education and training, research and evaluation in any policy document targeting chronic disease; and provision of funding to enhance general practice teaching facilities and/or facilitate the development of supportive coordinating and administrative structures for training practices. Designers of CBE should consider five key questions: Are the educational objectives of the CBE clearly aligned with the chronic disease or workforce-related outcomes of interest? Is the design of the CBE sound? Have similar educational programs targeting the same outcomes been identified and every attempt made to maximise synergies between programs? Are the educational designers fully aware of and working within the existing complexity of the training environment? Are all involved in the program actively managing the process of change?Conclusions: Policy options range from those relatively simple and achievable to more complex and difficult. The full report is available at http://www.anu.edu.au/aphcri/Domain/Workforce/final_25_glasgow.pdf.

Nicholas J Glasgow MD, FRACGP, FAChPM · Robert Wells · James Butler BEcon, MPolEcon, PhD · Anna Gear BMedSci