title: Explaining the variation in the management of lifestyle risk factors in primary health care: a multilevel cross sectional study.
abstract: BACKGROUND
  Despite evidence for the effectiveness of interventions to modify lifestyle behaviours in the primary health care (PHC) setting, assessment and intervention for these behaviours remains low in routine practice. Little is known about the relative importance of various determinants of practice.This study aimed to examine the relative importance of provider characteristics and attitudes, patient characteristics and consultation factors in determining the rate of assessment and intervention for lifestyle risk factors in PHC.
  
  
  METHODS
  A prospective audit of assessment and intervention for lifestyle risk factors was undertaken by PHC nurses and allied health providers (n = 57) for all patients seen (n = 732) over a two week period. Providers completed a survey to assess key attitudes related to addressing lifestyle issues. Multi-level logistic regression analysis of patient audit records was undertaken. Associations between variables from both data sources were examined, together with the variance explained by patient and consultation (level 1) and provider (level 2) factors.
  
  
  RESULTS
  There was significant variance between providers in the assessment and intervention for lifestyle risk factors. The consultation type and reason for the visit were the most important in explaining the variation in assessment practices, however these factors along with patient and provider variables accounted for less than 20% of the variance. In contrast, multi-level models showed that provider factors were most important in explaining the variance in intervention practices, in particular, the location of the team in which providers worked (urban or rural) and provider perceptions of their effectiveness and accessibility of support services. After controlling for provider variables, patients' socio-economic status, the reason for the visit and providers' perceptions of the 'appropriateness' of addressing risk factors in the consultation were all significantly associated with providing optimal intervention. Together, measured patient consultation and provider variables accounted for most (80%) of the variation in intervention practices between providers.
  
  
  CONCLUSIONS
  The findings highlight the importance of provider factors such as beliefs and attitudes, team location and work context in understanding variations in the provision of lifestyle intervention in PHC. Further studies of this type are required to identify variables that improve the proportion of variance explained in assessment practices.
authors.affiliation: Centre for Primary Health Care & Equity, School of Public Health and Community Medicine, University of New South Wales, Sydney NSW, Australia. r.laws@unsw.edu.au
authors.forename: Rachel A
authors.initials: RA
authors.lastname: Laws
authors.forename: Upali W
authors.initials: UW
authors.lastname: Jayasinghe
authors.forename: Mark F
authors.initials: MF
authors.lastname: Harris
authors.forename: Anna M
authors.initials: AM
authors.lastname: Williams
authors.forename: Gawaine
authors.initials: G
authors.lastname: Powell Davies
authors.forename: Lynn A
authors.initials: LA
authors.lastname: Kemp
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001291:Attitude of Health Personnel; D003376:Counseling; D003430:Cross-Sectional Studies; D005260:Female; D015438:Health Behavior; D006801:Humans; D008019:Life Style; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D010348:Patient Care Team; D011320:Primary Health Care / Q000379:methods*; D012307:Risk Factors; D012959:Socioeconomic Factors; D055815:Young Adult