In a 3-page paper (excluding title page and references), evaluate the study according to research design methods, procedures and study results, for example, see Evaluating a quantitative study Include a discussion on how the study contributes to evidence-based practice (EBP) follow Rubric or Grading Criteria: (1) Evaluates research design (2) Evaluates methods/procedures and results. Please Read and Critique the following article:R E S EAR CH A R TIC L E  Open AccessThe impact of a brief lifestyle intervention delivered by generalist community nurses (CN SNAP trial)Mark F Harris* , Bibiana C Chan, Rachel A Laws, Anna M Williams, Gawaine Powell Davies, Upali W Jayasinghe, Mahnaz Fanaian, Neil Orr, Andrew Milat and on behalf of the CN SNAP Project TeamAbstractBackground:  The risk factors for chronic disease, smoking, poor nutrition, hazardous alcohol consumption, physical inactivity and weight (SNAPW) are common in primary health care (PHC) affording opportunity for preventive interventions. Community nurses are an important component of PHC in Australia. However there has been little research evaluating the effectiveness of lifestyle interventions in routine community nursing practice. This study aimed to address this gap in our knowledge.Methods: The study was a quasi-experimental trial involving four generalist community nursing (CN) services in New South Wales, Australia. Two services were randomly allocated to an ‘early intervention’ and two to a ‘late intervention’ group. Nurses in the early intervention group received training and support in identifying risk factors and offering brief lifestyle intervention for clients. Those in the late intervention group provided usual care for the first 6 months and then received training. Clients aged 30–80 years who were referred to the services between September 2009 and September 2010 were recruited prior to being seen by the nurse and baseline self-reported data collected. Data on their SNAPW risk factors, readiness to change these behaviours and advice and referral received about their risk factors in the previous 3 months were collected at baseline, 3 and 6 months. Analysis compared changes using univariate and multilevel regression techniques.Results: 804 participants were recruited from 2361 (34.1%) eligible clients. The proportion of clients who recalled receiving dietary or physical activity advice increased between baseline and 3 months in the early intervention group (from 12.9 to 23.3% and 12.3 to 19.1% respectively) as did the proportion who recalled being referred for dietary or physical activity interventions (from 9.5 to 15.6% and 5.8 to 21.0% respectively). There was no change in the late intervention group. There a shift towards greater readiness to change in those who were physically inactive in the early but not the comparison group. Clients in both groups reported being more physically active and eating more fruit and vegetables but there were no significant differences between groups at 6 months.Conclusion: The study demonstrated that although the intervention was associated with increases in advice and referral for diet or physical activity and readiness for change in physical activity, this did not translate into significant changes in lifestyle behaviours or weight. This suggests a need to facilitate referral to more intensive long-term interventions for clients with risk factors identified by primary health care nurses.Trial registration: ACTRN12609001081202Keywords: Primary health care, Lifestyle behaviors, Smoking, Nutrition, Alcohol, Physical activity, Community nursing *Correspondence: [email protected] Centre for Primary Health Care and Equity, School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW 2052, Australia © 2013 Harris et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Harris et al. BMC Public Health 2013, 13:375 Background In Australia, chronic diseases such as heart disease and diabetes are the leading causes of death and disability [1]. The risk factors for these conditions include risk behaviours (in smoking, nutrition, alcohol and physical activity) and overweight (SNAPW). These are prevalent in the community, with over 90% of adults not consuming the recommended five serves of vegetables per day, over half not consuming adequate amounts of fruit, 62% overweight or obese, one third, physically inactive, one in five smoke and 21% drink alcohol at levels which pose a risk to their health [2]. Primary health care (PHC) is an important setting for addressing lifestyle risk factors because of its accessibility, continuity, and comprehensiveness of the care provided [3]. There is evidence that clients expect to receive lifestyle intervention from PHC clinicians [4]. Lifestyle interventions delivered in PHC are effective in helping clients to stop smoking [5], reduce ‘at-risk alcohol’ consumption [6], improve weight, diet and physical activity levels [7-12]. The 5As (assess, advise (including motivational interviewing) and agree on goals, assist (including referral), and arrange (follow up) have been developed as a framework for addressing these risk factors in clinical practice [13,14]. In NSW, generalist community nurses frequently see clients in their own home, providing care for patients recently discharged from hospital, the aged and those with chronic diseases. Although the traditional community nursing model of practice includes health promotion activities, community nursing services have increasingly tended to provide shorter term more clinically focused services to individual clients [15,16]. Our previous research has shown that community health nurses consider the provision of lifestyle intervention appropriate to their role and it is well accepted by clients [17]. However, few studies have evaluated the effectiveness of lifestyle interventions provided by community nurses in routine practice [18-21]. The aim of this study was to evaluate the impact of a brief lifestyle intervention delivered by community health nurses as part of their routine practice on changes in clients’ SNAPW risk factors.MethodsStudy design and setting This study was conducted in four general community nursing services in New South Wales, Australia. Services were recruited via an expression of interest mailed to all Area Health Services (AHS) in NSW (n = 8). The design was quasi-experimental, with the services randomly allocated to an ‘early intervention’ (EI) group or ‘late intervention’ (LI) (comparison) group. EI services were provided with training and support for nurses in identifying clients with high risk and offering brief SNAPW intervention during routine consultations. The protocol for the study has been previously described [22]. Intervention The intervention was designed and implemented on two levels: (a) service level and (b) client level. Service-level intervention The service-level intervention was delivered by University staff and consisted of four components:  A 1-day training program in the assessment and management of the SNAPW risk factors (including motivational interviewing) for participating community nurses delivered by the research team in conjunction with local providers. The training included the use of role-plays with simulated clients (actors), group discussions and activities;  Integration of standardised screening tools and prompts for SNAPW risk factors into the service-specific assessment processes used by the nurses in the management of clients;  Development and distribution of a local service referral directory to each community nursing team to promote referral of clients for ongoing specialist management or more / ongoing intensive lifestyle intervention; and  Provision of client resources to all participating nurses. The resources included a written guide for nurses, written action plans for use with clients on each SNAPW risk factor, tape measures for measuring waist circumference and pedometers for loan to clients to encourage self-monitoring of physical activity. A nurse from each of the EI sites was seconded to work with the research team to develop the intervention and to support its implementation at the local level. Client-level intervention The client-level intervention was provided by the participating nurses. The goals of the clinical intervention were to achieve and maintain lifestyle changes consistent with current Australian recommendations [23]:  Moderate physical activity for at least 30 minutes/ day, including walking, jogging, swimming, aerobic activity, ball games, skiing, with circuit-type resistance training if possible, twice a week;  A diet low in saturated fats, sucrose and salt with increased portions of vegetables and fruit per day (up to seven portions) in order to achieve a diet where the percentage of energy from carbohydrates = 50%, saturated fats =2 serves of fruit per day Self report Change in consumption of > =5 serves of vegetables per day Self report Progression in stages of change On five point intentions scales [28] At risk clients offered evidence-based advice to modify their risk factors Recall over previous 3 months At risk clients offered evidence-based referral to modify their risk factors Recall over previous 3 months Collected by client telephone survey at baseline, 3 and 6 months. Harris et al. BMC Public Health 2013, 13:375 Page 5 of 11 Table 3 Characteristics of CN SNAPW trial clients at baseline Characteristics Total (n = 804) Early interv (n = 425) Late interv (379) N%N % N % Female 396 49.3 214 50.4 182 48.0 Aboriginal/ Torres Strait Islander 4 0.5 2 0.5 2 0.5 Language other than English 35 4.4 18 4.2 17 4.5 Employed 215 26.7 115 27.1 100 26.4 Unable to work (long-term sickness/ disability) 109 13.6 50 11.8 59 15.6 Retired from paid work 419 53.1 229 53.9 190 50.1 Age (yrs) 30-39 yrs 44 5.5 22 5.2 22 5.8 40-49 78 9.7 44 10.4 34 9.0 50-59 142 17.7 76 18.0 66 17.4 60-69 256 31.9 136 32.2 120 31.7 ≥ 70 280 35.2 143 34.3 137 36.1 Self-rated health status Poor or Fair 308 38.3 158 37.2 150 39.6 Self-rated mental health status: Downhearted or blue Most to all of the time 102 12.7 49 11.5 53 14.0 Health conditions Hypertension 395 49.1 225 52.9 170 44.9 Arthritis 277 34.5 155 36.5 122 32.2 High cholesterol 239 29.7 132 31.1 107 28.2 Cancer 213 26.5 123 28.9 90 23.7 Diabetes 185 23.0 102 24.0 83 21.9 Depression 132 16.4 66 15.5 66 17.4 Heart disease 132 16.4 55 15.9 55 17.1 no risk factors 18 (2.2%) 11 (2.6%) 7 (1.8%) 1 risk only 147 (18.3%) 76 (17.9% 71 (18.7%) 2 risks 328 (40.2%) 164 (38.6%) 159 (42.0%) 3 risks 215 (26.7%) 120 (28.2 95 (25.1%) 4 risks 92 (11.4%) 50 (11.8%) 42 (11.1%) 5 risks 9 (1.1%) 4 (0.9) 5 (1.3) < 0.05 ** p < 0.01 † p < 0.001. SE: standard error. Harris et al. BMC Public Health 2013, 13:375 Page 9 of 11 long-term continuing care. This presents a challenge for the community health care sector and to current practices regarding communication and linkage between primary health care and other services in the Australian health care system. Competing interests The authors declare that they have no competing interest in the conduct of this study. Authors’ contributions All authors contributed to the study design and reviewed and approved the final manuscript. Acknowledgements The authors wish to acknowledge the former Centre for Health Advancement, NSW Ministry of Health for funding the study. This paper is presented on behalf of the CN SNAP project team which includes: S Buckman, K Partington, A Mitchell, H Smith, J Asquith, R Whittaker, M Hilkmann, C Lisle, K Caines, S Clark, S Dunn, B Christl, M Mangold and R Phillips. Received: 12 September 2012 Accepted: 16 April 2013 Published: 22 April 2013 References 1. 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