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BackgroundOngoing care for chronic conditions such as diabetes is best provided by a range of health professionals working together. There are challenges in achieving this where collaboration crosses organisational and sector boundaries. The aim of this article is to explore the influence of power dynamics and trust on collaboration between health professionals involved in the management of diabetes and their impact on patient experiences.MethodsA qualitative case study conducted in a rural city in Australia. Forty five health service providers from nineteen organisations (including fee-for-service practices and block funded public sector services) and eight patients from two services were purposively recruited. Data was collected through semi-structured interviews that were audio-taped and transcribed. A thematic analysis approach was used using a two-level coding scheme and cross-case comparisons.ResultsThree themes emerged in relation to power dynamics between health professionals: their use of power to protect their autonomy, power dynamics between private and public sector providers, and reducing their dependency on other health professionals to maintain their power. Despite the intention of government policies to support more shared decision-making, there is little evidence that this is happening. The major trust themes related to role perceptions, demonstrated competence, and the importance of good communication for the development of trust over time. The interaction between trust and role perceptions went beyond understanding each other's roles and professional identity. The level of trust related to the acceptance of each other's roles. The delivery of primary and community-based health services that crosses organisational boundaries adds a layer of complexity to interprofessional relationships. The roles of and role boundaries between and within professional groups and services are changing. The uncertainty and vulnerability associated with these changes has affected the level of trust and mistrust.ConclusionsCollaboration across organisational boundaries remains challenging. Power dynamics and trust affect the strategic choices made by each health professional about whether to collaborate, with whom, and to what level. These decisions directly influenced patient experiences. Unlike the difficulties in shifting the balance of power in interprofessional relationships, trust and respect can be fostered through a mix of interventions aimed at building personal relationships and establishing agreed rules that govern collaborative care and that are perceived as fair.

Policy contextObesity rates have increased in Australia and present a significant health challenge, particularly for people from low socio-economic communities and people with low health literacy. General practices have an important role to play in helping obese patients to manage their weight. The NHMRC guidelines for the management of overweight and obesity use the 5As model to guide practice: Ask, Assess, Advise, Assist, and Arrange. However, significant barriers exist to the implementation of Advice Assist (referral) and Arrange (follow-up). Barriers include the complexity of information involved in weight management and the level of patient's health literacy required to deal with this. A program of research was conducted to evaluate the feasibility and impact of a primary health care approach to weight management for obese patients tailored to their level of health literacy.Key messagesStrategies recommended at Primary Health Network level:> Training is needed for practice nurses (PNs) and general practitioners (GPs) in identifying and better supporting obese patients with low health literacy to manage their weight across the 5As. It is needed in particular to:o identify obese patients with low health literacy and differentiate low health literacy from low motivation;o tailor advice and education to their health literacy while not stigmatising patients; ando support patient navigation to evidence-based referral programs.> Simplified referral pathways for obese patients with low health literacy need to be developed.Strategies recommended at national and state government levels:> Readily available patient education materials on weight management that are appropriate for patients with low health literacy and for different language groups are required.> A funding model that supports GPs in being more proactive in the identification and support of obese patients with low health literacy is needed.> Training and remuneration of PNs is needed for the time spent tailoring advice and education for obese patients with low health literacy and providing them with navigation support to attend referral programs.

Background: Socioeconomically disadvantaged adults are both more likely to be obese and have lower levels of health literacy. Our trial evaluates the implementation and effectiveness of primary care nurses acting as prevention navigators to support obese patients with low health literacy to lose weight. Methods/Design: A pragmatic cluster randomised trial will be conducted. Twenty practices in socioeconomically deprived areas, 10 each in Sydney and Adelaide, will be recruited and randomised to intervention and control groups. Twenty to 40 eligible obese patients aged 40-70 years with a BMI ≥ 30 kg/m2 and with low health literacy will be enrolled per practice. The intervention is based on the '5As' of the chronic disease model approach - Assess, Advise, Agree, Assist and Arrange - and the recommendations of the 2013 Clinical practice guidelines for the management of overweight and obesity in adults, adolescents and children in Australia. In the intervention practices, patients will be invited to attend a health check with the prevention navigator who will assess the patient's risk and provide brief advice, assistance with goal setting and referral navigation. Provider training and educational meetings will be held. The providers' attitudes to obesity, confidence in treating obesity and preventive care they provide to obese people with low health literacy will be evaluated through questionnaires and interviews. Patients' self-assessment of lifestyle risk factors, perception of preventive care received in general practice, health-related quality of life, and health literacy will be assessed in telephone interviews. Patients' anthropometric measures will be recorded and their health service usage will be determined via linkage to the Australian government-held medical and pharmaceutical data. Discussion: Our trial will provide evidence for the effectiveness of practice nurses as prevention navigators to support better weight management for obese patients with low health literacy.

Policy contextObesity rates have increased in Australia and present a significant health challenge, particularly for people from low socio-economic communities and people with low health literacy. General practices have an important role to play in helping obese patients to manage their weight. The NHMRC guidelines for the management of overweight and obesity use the 5As model to guide practice: Ask, Assess, Advise, Assist, and Arrange. However, significant barriers exist to the implementation of Advice Assist (referral) and Arrange (follow-up). Barriers include the complexity of information involved in weight management and the level of patient's health literacy required to deal with this. A program of research was conducted to evaluate the feasibility and impact of a primary health care approach to weight management for obese patients tailored to their level of health literacy.Key messagesStrategies recommended at Primary Health Network level:> Training is needed for practice nurses (PNs) and general practitioners (GPs) in identifying and better supporting obese patients with low health literacy to manage their weight across the 5As. It is needed in particular to:o identify obese patients with low health literacy and differentiate low health literacy from low motivation;o tailor advice and education to their health literacy while not stigmatising patients; ando support patient navigation to evidence-based referral programs.> Simplified referral pathways for obese patients with low health literacy need to be developed.Strategies recommended at national and state government levels:> Readily available patient education materials on weight management that are appropriate for patients with low health literacy and for different language groups are required.> A funding model that supports GPs in being more proactive in the identification and support of obese patients with low health literacy is needed.> Training and remuneration of PNs is needed for the time spent tailoring advice and education for obese patients with low health literacy and providing them with navigation support to attend referral programs.

Background: There are significant gaps in the implementation and uptake of evidence-based guideline recommendations for cardiovascular disease (CVD) and diabetes in Australian general practice. This study protocol describes the methodology for a cluster randomised trial to evaluate the effectiveness of a model that aims to improve the implementation of these guidelines in Australian general practice developed by a collaboration between researchers, non-government organisations, and the profession.Methods: We hypothesise that the intervention will alter the behaviour of clinicians and patients resulting in improvements of recording of lifestyle and physiological risk factors (by 20%) and increased adherence to guideline recommendations for: the management of CVD and diabetes risk factors (by 20%); and lifestyle and physiological risk factors of patients at risk (by 5%). Thirty-two general practices will be randomised in a 1:1 allocation to receive either the intervention or continue with usual care, after stratification by state. The intervention will be delivered through: small group education; audit of patient records to determine preventive care; and practice facilitation visits adapted to the needs of the practices. Outcome data will be extracted from electronic medical records and patient questionnaires, and qualitative evaluation from provider and patient interviews.Discussion: We plan to disseminate study findings widely and directly inform implementation strategies by governments, professional bodies, and non-government organisations including the partner organisations. © 2013 Harris et al.; licensee BioMed Central Ltd.