Red Book 10th Edition

1. Table of Abbreviations .......................................................................................................................
4
2. About the Red Book............................................................................................................................9
3. Screening, case @nding and prevention principles .........................................................................11
1. Screening............................................................................................................................12
2. Case @nding........................................................................................................................14
3. Preventive activities and advice........................................................................................15
4. Opportunistic versus systematic prevention ...................................................................16
5. Bene@ts and harms of preventive health activities..........................................................17
6. Ethical implications of screening and case @nding .........................................................18
7. Shared decision making ....................................................................................................19
8. Screening and overdiagnosis ............................................................................................20
9. Screening tests of unproven bene@t .................................................................................21
10. Thinking holistically about your patient............................................................................23
4. Structure of the Red Book ................................................................................................................25
5. What's new in the 10th Ed Red Book ...............................................................................................27
6. Development and methodology ......................................................................................................32
7. Cancer ...............................................................................................................................................35
1. Bladder cancer ...................................................................................................................38
2. Breast cancer .....................................................................................................................40
3. Cervical cancer...................................................................................................................47
4. Colorectal cancer ...............................................................................................................52
5. Lung cancer ........................................................................................................................62
6. Oral cancer .........................................................................................................................63
7. Ovarian cancer ...................................................................................................................64
8. Pancreatic cancer ..............................................................................................................65
9. Prostate cancer..................................................................................................................67
10. Skin cancer .........................................................................................................................72
11. Testicular cancer................................................................................................................78
12. Thyroid cancer....................................................................................................................80
8. Cardiovascular..................................................................................................................................82
1. Atrial @brillation ..................................................................................................................84
2. Cardiovascular disease (CVD) risk ...................................................................................87
3. Kidney .................................................................................................................................95
9. Development and behaviour ......................................................................................................... 101
1. Developmental Delay and Autism .................................................................................. 103
2. Preventive activities in childhood .................................................................................. 108
10. Genetics ......................................................................................................................................... 116
1. Genetics........................................................................................................................... 118
11. Infectious diseases ....................................................................................................................... 125
1. Hepatitis B and C ............................................................................................................ 127
2. Immunisation .................................................................................................................. 135
3. Sexually transmissible infections including HIV ........................................................... 143
12. Injury prevention ............................................................................................................................ 152
1. Bullying and child abuse................................................................................................. 154
2. Elder abuse...................................................................................................................... 158
3. Falls.................................................................................................................................. 161
4. Intimate partner abuse and violence ............................................................................. 167
13. Mental health and substance use ................................................................................................ 172
1. Alcohol............................................................................................................................. 174
2. Anxiety ............................................................................................................................. 179
3. Dementia ......................................................................................................................... 183
4. Depression....................................................................................................................... 193
5. Eating disorders .............................................................................................................. 197
6. Perinatal mental health................................................................................................... 201
7. Gambling ......................................................................................................................... 206
8. Smoking and nicotine vaping ......................................................................................... 210
9. Suicide ............................................................................................................................. 214
14. Metabolic ....................................................................................................................................... 218
1. Coeliac ............................................................................................................................. 220
2. Diabetes........................................................................................................................... 222
3. Nutrition ........................................................................................................................... 228
4. Overweight and obesity .................................................................................................. 232
5. Physical activity .............................................................................................................. 237
6. Thyroid ............................................................................................................................. 243
15. Musculoskeletal disorders............................................................................................................ 246
1. Hip dysplasia ................................................................................................................... 248
2. Osteoporosis ................................................................................................................... 251
3. Scoliosis .......................................................................................................................... 256
16. Reproductive and women’s health................................................................................................ 258
1. Preconception ................................................................................................................. 260
2. First antenatal visit ......................................................................................................... 268
3. During pregnancy ............................................................................................................ 280
4. Interconception ............................................................................................................... 290
5. Perinatal mental health................................................................................................... 295
6. Postmenopause .............................................................................................................. 300
7. Breast cancer .................................................................................................................. 304
8. Cervical cancer................................................................................................................ 311
9. Ovarian cancer ................................................................................................................ 316
17. Miscellaneous................................................................................................................................ 317
1. Frailty ............................................................................................................................... 319
2. Hearing ............................................................................................................................ 323
3. Sleep and sleep-related disorders.................................................................................. 328
4. Oral health ....................................................................................................................... 336
5. Urinary incontinence ....................................................................................................... 341
6. Vision ............................................................................................................................... 346
18. Supplementary material................................................................................................................ 352
1. Acknowledgements ........................................................................................................ 353
2. Disclaimer........................................................................................................................ 356
3. Provided under licence ................................................................................................... 357
19. Appendices .................................................................................................................................... 358
1. Appendix 1 - Methods report.......................................................................................... 360
Table of Abbreviations
ACIR Australian Childhood Immunisation Register
ACQUIP Ambulatory Care Quality Improvement Project
ADA American Diabetes Association
AF Atrial @brillation
AHMAC Australian Health Ministers Advisory Council
ANRQ Antenatal Risk Questionnaire
ASHM Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine
ATAGI Australian technical Advisory Group on Immunisation
AUDIT-C Alcohol Use Disorder Identi@cation Test – Consumption
BBV Blood-borne virus
BCC Basal cell carcinoma
BMD Bone mineral density
BMI Body mass index
BP Blood pressure
BPD Borderline personality disorder
CAC Coronary artery calcium
CALD Culturally and linguistically diverse
4
CDC Centers for Disease Control and Prevention
CF Cystic @brosis
CHAT Community health approaches to
CHC Combined hormonal contraception
COPE Centre of Perinatal Excellence
CTFPHC Canadian Task Force on Preventive Health Care
CVS Chorionic villus sampling
DASH Dietary Approaches to Stop Hypertension
DASS Depression Anxiety Stress Scales
DBAS Dysfunctional beliefs and attitudes about sleep
DDH Developmental dysplasia of the hip
DLCN Dutch Lipid Clinic Network
DXA Dual energy X-ray absorptiometry
ECG Electrocardiogram
EPDS Edinburgh Postnatal Depression Scale
ERSPC European Randomized study of Screening for Prostate Cancer
FASD Fetal alcohol spectrum disorder
FBG Fasting blood glucose
FH Familial hypercholesterolaemia
FPU First pass urine
FRAX® Fracture Risk Assessment Tool
5
FSRH Faculty of Sexual and Reproductive Healthcare
FXS Fragile X syndrome
GP General practitioner
GPCOG General Practitioner Assessment of Cognition
GPMHSC General Practice Mental Health Standards Collaboration
GRADE Grading of Recommendations, Assessment, Development and Evaluation
HANAA Here and Now Aboriginal Assessment
HANDI Handbook of Non-Drug Interventions
HCV Hepatitis C Virus
HIV Human immunode@ciency virus
HPV Human papillomavirus
IGT Impaired glucose tolerance
IPAV Intimate partner abuse and violence
KDCP Koori dementia care project
LARC Long Acting Reversible Contraception
LBC Liquid Based Cytology
MBS Medicare Bene@ts Schedule
MET Metabolic equivalent of task
MHT Menopausal hormone therapy
MRI Magnetic resonance imaging
MSAC Medical Services Advisory Committee
6
NBCSP National Bowel Cancer Screening Program
NCIRS National Centre for Immunisation Research and Surveillance
NDIS National Disability Insurance Scheme
NHMRC National Health and Medical Research Council
NHS National Health Service
NICE The National Institute for Health and Care Excellence
NIPS National Immunisation Program Schedule
NIPT Non-invasive prenatal testing
NSAID nonsteroidal anti-infammatory drugs
OECD Organisation for Economic Cooperation and Development
OGTT Oral glucose tolerance test
OKQ One Key Question®
OSA Obstructive sleep apnoea
PEDS Parents’ Evaluation of Developmental Status
PGRTC Problem Gambling Research and Treatment Centre
PICO Population, intervention, comparator/control and outcomes
PID Pelvic infammatory disease
PRAMS Pregnancy Risk Assessment Monitoring System
PrEP Pre-exposure prophylaxis
PSA Prostate speci@c antigen
RACGP The Royal Australian College of General Practitioners
7
RANZCO Royal Australian and New Zealand College of Ophthalmologists
RANZCOG Royal Australian and New Zealand College of Obstetricians and Gynaecologists
RCT Randomised controlled trial
ROSE Risk-strati@ed Osteoporosis Strategy Evaluation
RUDAS Rowland Universal Dementia Assessment Scale
SCC Squamous cell carcinoma
SERM Selective oestrogen receptor modulators
SIDS Sudden infant death syndrome
SMA Spinal muscular atrophy
SNAP Smoking, nutrition, alcohol, physical
SNP Single nucleotide polymorphism
SOS SALT Osteoporosis Study
TGA Therapeutic Goods Administration
TIA Transient ischaemic attack
USPSTF US Preventive Services Task Force
WHO World Health Organization
8
About the Red Book
About the Red Book

Role of the general practice team in prevention
Each year, almost nine in 10 Australians visit a general practitioner (GP).1 With general practice at the
forefront of Australian healthcare, GPs are in a pivotal position to provide the highest standard of
preventive healthcare, in partnership with their patients. Preventive healthcare is important at all stages
of the lifecycle. Bene@ts include:
• maintaining and/or improving patients’ short- and long-term health

• addressing health disparities faced by disadvantaged and vulnerable population groups
• prevention of chronic disease
• early detection of speci@c disease through evidence-based screening
• empowering patients through health education and promotion.
Purpose and scope

The Royal Australian College of General Practitioners (RACGP) has published the Guidelines for
preventive activities in general practice (Red Book) since 1989. It is designed to provide the general
practice team with guidance on preventive care by providing a comprehensive and concise set of
recommendations applicable to the substantial portions of the general practice population rather than
speciLc subgroups. This means that, in general, recommendations apply to asymptomatic (low-risk)
people. However, there is an emphasis on equity, with recommendations aimed at major disadvantaged
groups at higher risk of disease and those who are less likely to receive preventive care. Additional
information is provided to tailor advice depending on a patient’s individual risk and need, with a focus
on the safe, elcient and effective use of healthcare resources in general practice. Widely accepted as
the main guide to the provision of preventive care in Australian general practice, the Red Book is one of
the most accessed resources produced by the RACGP. It provides a much-needed and valued synthesis
of the many aspects of preventive care relevant to our patient population. The Red Book has two
companion publications: the National guide to a preventive health assessment for Aboriginal and Torres
Strait Islander people (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelin
es/view-all-racgp-guidelines/national-guide/) (2nd edition), which is intended for all health professionals
delivering primary healthcare to Aboriginal and Torres Strait Islander peoples; and Putting prevention
into practice: Guidelines for the implementation of prevention in the general practice setting (https://ww
w.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/gree
n-book) (3rd edition), also known as the Green Book, which provides advice on how to implement
preventive care in practice. The Red Book supports evidence-based screening, case @nding and
preventive activities in primary care, covering primary (preventing the initial occurrence of a disorder)
and secondary (preventive early detection and intervention) activities. The Red Book does not attempt
to be a guide to broad public health messaging. In addition, the Red Book does not include:
9
About the Red Book
• management of risk factors or disease (eg what medications to use when treating
hypertension)
• activities that are rarely or uncommonly seen in general practice
• advice about travel medicine, for which up-to-date information can be obtained from:
◦ Australian Immunisation Handbook (https://immunisationhandbook.health.gov.au/con
tents/vaccination-for-special-risk-groups/vaccination-for-international-travellers)
◦ Centers for Disease Control and Prevention (CDC) (https://wwwnc.cdc.gov/travel/)
◦ World Health Organization (WHO) (https://www.who.int/travel-advice) .
Reference
1. The Royal Australian College of General
Practitioners (RACGP). General practice health of
the nation 2022. RACGP, 2022 (https://www.racg
p.org.au/getmedia/80c8bdc9-8886-4055-8a8d-ea
793b088e5a/Health-of-the-Nation.pdf.aspx)
[Accessed 16 October 2023].
10
About the Red Book
Screening, case ,nding and

prevention principles
11
Screening
Screening
Screening is de@ned as ‘the examination of asymptomatic people in order to classify them as likely or
unlikely to have a disease’.1 Screening is undertaken to detect early disease in apparently healthy
individuals. The WHO has produced guidelines for the effectiveness of screening programs.2 These
guidelines, and those of the National Health Service (NHS) in the UK,3 have been kept in mind in the
development of recommendations about screening in the Red Book, as detailed below. Condition
• It should be an important health problem.

• It should have a recognisable latent or early symptomatic stage.
• The natural history of the condition, including development from latent to declared disease,
should be adequately understood.
Test
• It should be simple, safe, precise and validated.
• It should be acceptable to the target population.
• The distribution of test values in the target population should be known and a suitable cut-off
level de@ned and agreed.
Treatment
• There should be an effective treatment for patients identi@ed, with evidence that early
treatment leads to better outcomes.
• There should be an agreed policy on who should be treated and how they should be treated.
Outcome
• There should be evidence of improved mortality, morbidity or quality of life as a result of
screening, and the bene@ts of screening should outweigh the harm.
• The cost of case @nding (including diagnosis and treatment of patients who are diagnosed)
should be economically balanced in relation to possible expenditure on medical care as a
whole.
Consumers
• Consumers should be informed of the evidence so they can make an informed choice about
participation in screening programs.
There are currently @ve population-based screening programs in Australia:4

• National Bowel Cancer Screening Program (https://www.health.gov.au/our-work/national-bowe
l-cancer-screening-program)
• BreastScreen Australia Program (https://www.health.gov.au/our-work/breastscreen-australia-p
rogram?utm_source=health.gov.au&utm_medium=redirect&utm_campaign=digital_transformat
ion&utm_content=breast-screening-1)
• National Cervical Screening Program (https://www.health.gov.au/our-work/national-cervical-sc
reening-program)
12
Screening
• Newborn bloodspot screening (https://www.health.gov.au/our-work/newborn-bloodspot-scree

ning)
• Newborn hearing screening (https://www.health.gov.au/resources/publications/national-frame
work-for-neonatal-hearing-screening) .
A sixth program, the National Lung Cancer Screening Program, will commence in 2025.
References
1. Morrison AS. Screening. In: Rothman KJ, 4. Department of Health and Aged Care. Population-
Greenland S, Lash TL, editors. Modern based health screening. Australian Government,
epidemiology. 2nd edn. Lippincott-Raven, 1998. 2021 (https://www.health.gov.au/our-work/popul
2. Principles and practice of screening for disease. ation-based-health-screening) [Accessed 18 May
2023].
J R Coll Gen Pract 1968;16(4):318.
3. UK National Health Services. What is screening?
UK National Screening Committee, 2021 (http
s://www.nhs.uk/conditions/nhs-screening/)
13
Case finding
Case finding
Case @nding is the examination of an individual or group suspected of having, or at risk of, a condition.
Case @nding is a targeted approach to identifying conditions in a select group of patients who may or
may not already have symptoms.5
Reference
1. 5. Aldrich R, Kemp L, Williams JS, et al. Using
socioeconomic evidence in clinical practice
guidelines. BMJ 2003;327(7426):1283–85.
14
Preventive activities and advice
Preventive activities and advice

Prevention includes all measures that protect, promote and maintain a patient’s health and wellbeing,
and activities that prevent disease, disability and death.6 Preventive activities continue across a
person’s lifespan, from preconception and the fetal stage to old age. In addition, prevention applies to
the natural history of disease, with preventive measures applied at any stage during the natural history
of a disease to prevent progression.6
Reference
Practitioners (RACGP). Putting prevention into
practice: Guidelines for the implementation of
prevention in the general practice setting. 3rd
edn. RACGP, 2018 (https://www.racgp.org.au/clini
cal-resources/clinical-guidelines/key-racgp-guidel
ines/view-all-racgp-guidelines/green-book)
15
Opportunistic versus systematic prevention
Opportunistic versus systematic

prevention
Most preventive activities are undertaken in Australia opportunistically; that is, when patients present
for other reasons, with the preventive activity being an add-on. 7 However, systematic approaches to
register and recall patients for some specific targeted conditions are important, including childhood
immunisations and screening for cervical, breast and colorectal cancers and diabetes. Proactive recall
of patients for screening is warranted for high-risk groups, those who may have difficulty accessing
services and for conditions where population coverage has been identified by the government as a
public health priority.5 In Australia, there is an increasing number of Medicare Benefits Schedule (MBS)
items for health assessments in particular population groups, namely Aboriginal and Torres Strait
Islander children and adults, refugees, people with an intellectual disability, those aged 45–49 years
with a risk factor and those aged ≥75 years. However, it is important that such ‘health checks’ involve
preventive interventions where there is clear evidence of their effectiveness.
References
1. Aldrich R, Kemp L, Williams JS, et al. Using 2. The Royal Australian College of General
socioeconomic evidence in clinical practice Practitioners (RACGP). Smoking, nutrition,
guidelines. BMJ 2003;327(7426):1283–85. alcohol, physical activity (SNAP): A population
health guide to behavioural risk factors in general
practice. 2nd edn. RACGP, 2015 (https://www.rac
gp.org.au/clinical-resources/clinical-guidelines/k
ey-racgp-guidelines/view-all-racgp-guidelines/sna
p) [Accessed 16 October 2023].
16
Benefits and harms of preventive health activities
Bene?ts and harms of preventive health

activities
There is evidence that some preventive activities are not effective and may even be harmful.
Determining whether a preventive activity is beneficial, harmful or of indeterminate effect (ie there is not
enough evidence on which to base a decision) requires a consistent, unbiased, evidence-based
approach. Screening of asymptomatic patients may lead to overdiagnosis, causing needless anxiety,
appointments, tests, drugs and even operations, and may leave the patient less healthy. Therefore, it is
crucial that evidence clearly demonstrates that the benefits outweigh those harms for each preventive
activity.
 Further reading
For further information on the stages of prevention and the social determinants of health
and illness: Putting prevention into practice (https://www.racgp.org.au/clinical-resources/
clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/green-book/understandi
ng-the-basics/about-prevention) | Guidelines for the implementation of prevention in the
general practice setting (Green Book) For further information on reducing patient harms
and avoiding low-value care: First do no harm: A guide to choosing wisely in general
practice (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelin
es/view-all-racgp-guidelines/Frst-do-no-harm/about-Frst-do-no-harm/introduction)
17
Ethical implications of screening and case finding
Ethical implications of screening and case

finding
Many clinicians confuse screening and case finding tests. Screening and case finding carry different
ethical obligations. Before initiating screening in asymptomatic individuals, clinicians must consider
whether the test results would change the management of the patient. If the results would not change
how the patient is managed, then the test should not be ordered.8 In addition, the potential harms
should be discussed with the patient, including overdiagnosis and false positives. In case finding, the
patient has presented with a particular problem, or has asked for some level of assistance or is
suspected to have, or be at risk of, a condition. In this situation, there is no guarantee of benefit of the
tests undertaken. It could be argued that there is at least some implied exposure to risk (eg performing
a colonoscopy to investigate abdominal pain).
Reference
The Royal Australian College of General

Practitioners (RACGP). First do no harm: A guide
to choosing wisely in general practice. RACGP,
2022 (https://www.racgp.org.au/clinical-resource
s/clinical-guidelines/key-racgp-guidelines/view-al
racgp-guidelines/first-do-no-harm/about-first-
do-no-harm/introduction) [Accessed 16 October
2023].
18
Shared decision making
Shared decision making

Taking a shared decision making approach is important when making screening decisions. Shared
decision making does not necessary require the use of decision tools; however, these can be useful.9,10
Shared decision making provides a collaborative approach in which the GP and patient jointly discuss:
• available treatment options (including the option of ‘no active treatment’ where it is
appropriate)
• the potential bene@ts of each option
• the potential harms of each option
• the patient’s individual values, preferences and circumstances.11,12
References
1. The Royal Australian College of General Del Mar C, Hoffmann T, Bakhit M. How can
Practitioners (RACGP). Management of type 2 general practitioners reduce antibiotic prescribing
diabetes: A handbook for general practice. in collaboration with their patients? Aust J Gen
RACGP, 2020 (https://www.racgp.org.au/getattac Pract 2022;51(1–2):25–30. doi: 10.31128/
hment/41fee8dc-7f97-4f87-9d90-b7af337af778/ AJGP-07-21-6084. [Accessed 16 October 2023].
Management-of-type-2-diabetes-A-handbook-for- Hoffmann TC, Légaré F, Simmons MB, et al.
general-practice.aspx) [Accessed 16 October Shared decision making: What do clinicians need
2023]. to know and why should they bother? Med J Aust
2. Branda M, LeBlanc A, Shah ND, et al. Shared 2014;201(1):35–39. doi: 10.5694/mja14.00002.
decision making for patients with type 2 diabetes: [Accessed 16 October 2023].
A randomized trial in primary care. BMC Health
Serv Res 2013;13:301. doi: 10.1186/
1472-6963-13-301. [Accessed 16 October 2023].
19
Screening and overdiagnosis
Screening and overdiagnosis

All clinicians need to be mindful of overdiagnosis. Overdiagnosis happens when a patient’s diagnosis
causes them more harm than good. This can happen when a healthy person undertakes a screening
test and is diagnosed with a very early form of a disease, but that disease would never have developed
further to cause your patient any symptoms.8,13 Harms of overdiagnosis include:
• physical and @nancial harm from unnecessary treatment

• stress and anxiety for patients, their families and carers
• potential for cascading of follow-up tests and/or treatments
• harms to other patients from an overburdened health system.8
References
The Royal Australian College of General 2. Wiser Healthcare. What is overdiagnosis.
Practitioners (RACGP). First do no harm: A guide Wiser Healthcare, n.d (https://www.wiserhealthca
to choosing wisely in general practice. RACGP, re.org.au/what-is-overdiagnosis/) [Accessed 16
2022 (https://www.racgp.org.au/clinical-resource October 2023].
s/clinical-guidelines/key-racgp-guidelines/view-al
racgp-guidelines/first-do-no-harm/about-first-
do-no-harm/introduction) [Accessed 16 October
2023].
20
Screening tests of unproven benefit

The Red Book provides information to assist GPs in caring for their patients, including in areas where
the evidence is uncertain or contentious. Screening activities are only recommended where evidence
demonstrates that bene@ts outweigh harms. Some tests are not recommended as screening tests in
low-risk or asymptomatic general practice populations, but may have value as diagnostic tests or as
tests or monitor disease progression. These are clearly highlighted. The RACGP resource First do no
harm: A guide to choosing wisely in general practice (https://www.racgp.org.au/clinical-resources/clinica
l-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/Frst-do-no-harm/about-Frst-do-no-harm/introd
uction) provides information for GPs and patients on screening tests and treatments that do not have
bene@t and may even cause harm.
 Further reading
For further information on screening tests of unproven bene@t and how GPs can
overcome overdiagnosis:
First do no harm: A guide to choosing wisely in general practice (https://www.racgp.org.a
u/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/@rs
t-do-no-harm/about-@rst-do-no-harm/introduction)
Responding to patient request for tests not considered clinically appropriate (https://ww
w.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-
guidelines/tests-not-considered-clinically-appropriate)
References
1. Morrison AS. Screening. In: Rothman KJ, 5. Aldrich R, Kemp L, Williams JS, et al. Using
Greenland S, Lash TL, editors. Modern socioeconomic evidence in clinical practice
epidemiology. 2nd edn. Lippincott-Raven,1998. guidelines. BMJ 2003;327(7426):1283–85.
[Accessed 18 May 2023].
2. Principles and practice of screening for disease.
J R Coll Gen Proact. 1968 Oct;16(4):318. PMCID: 6. The Royal Australian College of General
PMC2236670. Practitioners. Putting prevention into practice:
Guidelines for the implementation of prevention
3. UK National Health Services. What is screening?
in the general practice setting. 3rd edn. 2018 (htt
London: UK National Screening Committee, 2021.
ps://www.racgp.org.au/clinical-resources/clinica
4. Department of Health and Aged Care. Population- l-guidelines/key-racgp-guidelines/view-all-racgp-g
based health screening. Australian Government, uidelines/green-book) [Accessed 16 October
2021 (https://www.health.gov.au/our-work/popul 2023].
ation-based-health-screening) [Accessed 18 May
2023].
21
7. The Royal Australian College of General 10. Branda M, LeBlanc A, Shah ND, et al. Shared
Practitioners. Smoking, nutrition, alcohol, physical decision making for patients with type 2 diabetes:
activity (SNAP): A population health guide to A randomized trial in primary care. BMC Health
behavioural risk factors in general practice. 2nd Serv Res 2013;13:301. [Accessed 16 October
edn. 2015 (https://www.racgp.org.au/clinical-reso 2023].
urces/clinical-guidelines/key-racgp-guidelines/vie
11. Del Mar C, Hoffmann T, Bakhit M. How can
w-all-racgp-guidelines/snap) [Accessed 16 general practitioners reduce antibiotic prescribing
October 2023].
in collaboration with their patients? Aust J Gen
8. The Royal Australian College of General Pract 2022;51(1–2):25–30. doi: 10.31128/
Practitioners. First do no harm: A guide to AJGP-07-21-6084. [Accessed 16 October 2023].
choosing wisely in general practice. 2022 (http
12. Hoffmann TC, Légaré F, Simmons MB, et al.
s://www.racgp.org.au/clinical-resources/clinical- Shared decision making: What do clinicians need
guidelines/key-racgp-guidelines/view-all-racgp-gu
to know and why should they bother? Med J Aust
idelines/@rst-do-no-harm/about-@rst-do-no-harm/i 2014;201(1):35–39. [Accessed 16 October 2023].
ntroduction) [Accessed 16 October 2023].
13. Wiser Healthcare. What is overdiagnosis (http
9. The Royal Australian College of General s://www.wiserhealthcare.org.au/what-is-overdiag
Practitioners. Management of type 2 diabetes: A nosis/) [Accessed 16 October 2023].
handbook for general practice. 2020 (https://ww
w.racgp.org.au/getattachment/41fee8dc-7f97-4f 14. Nyblade, L., Stockton, M.A., Giger, K. et al. Stigma
87-9d90-b7af337af778/Management-of-type-2-di in health facilities: why it matters and how we can
abetes-A-handbook-for-general-practice.aspx) change it. BMC Med 17, 25 (2019). (https://doi.or
[Accessed 16 October 2023]. g/10.1186/s12916-019-1256-2)
22
Thinking holistically about your patient

For patients with different levels of risk, please refer to the notes section of the Lifecycle
chart.
In many cases, people experiencing disadvantage have complex needs and health problems. Social,
psychological, environmental and physical determinants of health impact on a patient’s health. It is
important for GPs to be aware of these factors and impacts in order to tailor their advice appropriately.7
In addition, some groups of people may delay or do not seek healthcare due to stigma, fear of
discrimination or previous negative experiences in the health system.14 Population groups in Australia
who tend to experience disadvantage, barriers to healthcare access, discrimination and stigma include:
• people who are socioeconomically disadvantaged

• Aboriginal and Torres Strait Islander people
• people from culturally and linguistically diverse (CALD) backgrounds
• people with serious mental illness
• LGBTIQA+ people
• people who are overweight and obese
• people with disability.
It is important that GPs discuss with individual patients their social situation and know local services in
their area they can refer patients to for assistance.7
LGBTIQA+ people
GPs have a signi@cant role to play in respecting and acknowledging those who are transgender and/or
non-binary through the use of correct names and pronouns and providing gender-alrming healthcare.
The terminology in this clinical guideline refects the clinical research which is focused on cisgender
people. The RACGP acknowledges further research is needed in the area of LGBTIQA+ healthcare, and
future editions will be continue to be updated to refect emerging evidence. Where there is evidence for
speci@c population groups, it is included within chapters under the Considerations for Aboriginal and
Torres Strait Islander peoples and Speci@c populations headings.
23
 Further reading
For more information on the impacts of stigma and clinical guidelines:
Impact of racism(to be released mid-2024) | National guide to a preventive health

assessment for Aboriginal and Torres Strait Islander people (3rd edition) (https://www.rac
gp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidel
ines/national-guide)
Equally Well Australia (https://www.equallywell.org.au/)
Mental health guidelines (https://www.racgp.org.au/clinical-resources/clinical-guidelines/
guidelines-by-topic/view-all-guidelines-by-topic/mental-health)
Weight stigma: Why everybody needs to act (https://www1.racgp.org.au/newsgp/gp-opini
on/weight-stigma-why-everybody-needs-to-act) | newsGP
Refugee health guidelines (https://www.racgp.org.au/clinical-resources/clinical-guideline
s/guidelines-by-topic/view-all-guidelines-by-topic/refugee-health)
Disability guidelines (https://www.racgp.org.au/clinical-resources/clinical-guidelines/guid
elines-by-topic/view-all-guidelines-by-topic/disability)
Aboriginal and Torres Strait Islander health guidelines (https://www.racgp.org.au/clinical-r
esources/clinical-guidelines/guidelines-by-topic/view-all-guidelines-by-topic/aboriginal-an
d-torres-strait-islander-health)
References
The Royal Australian College of General 2. Nyblade L, Stockton MA, Giger K, et al. Stigma
Practitioners (RACGP). Smoking, nutrition, in health facilities: Why it matters and how we
alcohol, physical activity (SNAP): A population can change it. BMC Med 2019;17:25. doi:
health guide to behavioural risk factors in general 10.1186/s12916-019-1256-2. [Accessed 16
practice. 2nd edn. RACGP, 2015 (https://www.rac October 2023].
ey-racgp-guidelines/view-all-racgp-guidelines/sna
24
Structure of the Red Book

Recommendations are listed in the table of recommendations for each topic under the following
categories:
 Screening  Case Lnding  Preventive advice and activities
How to use the Red book

The Red book should be used to guide both systematic (planned) opportunistic screening and
preventive activities in day-to-day general practice.
1 Lifecycle chart, screening and case Lnding age bars (pending) Use the lifecycle chart to quickly
check which activities should be performed according to your patient’s age group. Similarly, the
age bar in each topic highlights which age groups the speci@c topic recommendations apply to.
2 Prevalence and context of the condition/phase Read this section to understand the prevalence
of the disease/s, condition/s or phase in the Australian population.
3 Table of recommendations The table of recommendations divides the recommendations into

screening, case @nding and prevention activities. Read the table under each topic for a summary
of graded recommendations, including:
• whether the activity is recommended or not recommended

• who the recommendation applies to
• whether the activity has planned, regular intervals or can be undertaken
opportunistically.
Further information on the process and recommendation grade levels is available in the
Methodology (https://www.racgp.org.au/wip-sites/preventive-activities-in-general-practice/meth
odology) (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/
view-all-racgp-guidelines/preventive-activities-in-general-practice/methodology) section.
25
4 Further information Drop down to this section to read more information about the topic,
including justi@cations for the recommendations made in the table.
5 Considerations for Aboriginal and Torres Strait Islander peoples Check this section if your
patient is Aboriginal or Torres Strait Islander. Links to relevant recommendations in the National
guide to a preventive health assessment for Aboriginal and Torres Strait Islander people (3rd
edition) (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/vi
ew-all-racgp-guidelines/national-guide/acknowledgements) are provided if there are additional
activities for Aboriginal and Torres Strait Islander people.
6 SpeciLc populations Read this section to check for population groups that require a different
approach to screening, case @nding and prevention.
7 Resources
Refer to this section if you would like more information about the speci@c topic from RACGP
guidelines or other recommended resources.
 Further reading
The RACGP produces a range of clinical guidelines (https://www.racgp.org.au/clinical-res

ources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines) and practice
resources (https://www.racgp.org.au/running-a-practice/practice-resources) to assist GPs
and their practice teams, including several companion resources to the Red book: For all
health professionals who deliver primary healthcare to Aboriginal and Torres Strait
Islander people: National guide to a preventive health assessment for Aboriginal and
Torres Strait Islander people (3rd edition) (https://www.racgp.org.au/clinical-resources/cli
nical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/national-guide/)
For effective implementation of preventive activities in general practice: Putting

prevention into practice: Guidelines for the implementation of prevention in the general
practice setting (Green book) (https://www.racgp.org.au/clinical-resources/clinical-guideli
nes/key-racgp-guidelines/view-all-racgp-guidelines/green-book)
For improving and monitoring the quality and safety of health services: Standards for
general practices (5th edition) (https://www.racgp.org.au/running-a-practice/practice-stan
dards/standards-5th-edition/standards-for-general-practices-5th-ed-1) (the Standards).
26
What's new in the 10th Ed Red Book
What’s new in the 10th edition of the Red

book
Modified GRADE approach
The development of the Red book 10th edition involves a transition from using the National Health and
Medical Research Council FORM approach for guideline development to using the principles of the
GRADE approach (Grading of Recommendations, Assessment, Development and Evaluation). Further
information and details can be found in the ‘Development and methodology (https://
www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-
guidelines/preventive-activitie
s-in-general-practice/methodology) ’ section.
Topic format
The format for the topics has been revised and standardised using a prescribed template with word
limits to ensure chapters are concise and uniform. Each topic now includes standardised subheadings
to ensure GPs and other health professionals can quickly @nd the information they need.
Topic changes
New topics included for the @rst time in this 10th edition of the Red book are highlighted in red:
10th edition chapter 9th edition chapter
Lifecycle chart
Cancer
Breast Early detection of cancers
Cervical Early detection of cancers
Colorectal Early detection of cancers
Prostate Early detection of cancers
Skin Early detection of cancers
27
Bladder (new topic)
Lung (new topic)
Ovarian Early detection of cancers
Oral Early detection of cancers
Pancreatic
Testicular Early detection of cancers
Thyroid (new topic)
Cardiovascular
Atrial @brillation Prevention of vascular and metabolic disease
Cardiovascular disease risk Peripheral vascular diseaseA
Blood pressure, kidney, stroke and cholesterolA
Prevention of vascular and metabolic disease

(assessment of absolute cardiovascular risk)
Development and behaviour
Developmental delay and autism (new topic)
Preventive activities in childhood Preventive activities in children and young people
Genetics
Genetics Genetic counselling and testing
Infectious diseases
Hepatitis B and C (new topic)
Immunisation Preventive activities in older age; Communicable

diseases
Sexually transmitted disease Communicable diseases
Injury prevention
28
Bullying and child abuse (new topic)
Elder abuse (new topic)
Falls Preventive activities in older age
Intimate partner violence Psychosocial
Mental health
Alcohol Prevention of chronic disease (section titled ‘Early

detection of at-risk drinking’)
Anxiety (new topic)
Dementia Preventive activities in older age
Depression Psychosocial
Eating disorders (new topic)
Gambling (new topic)
Smoking and nicotine vaping Prevention of chronic disease
Suicide Psychosocial
Perinatal mental health (new topic)
Metabolic
Coeliac (new topic)
Diabetes Prevention of vascular and metabolic disease
Nutrition Prevention of chronic disease
Overweight and obesity Prevention of chronic disease (section titled

‘Overweight’)
Physical activity Preventive activities in older age; Prevention of chronic

disease
Thyroid (new topic)
29
Musculoskeletal disorders
Developmental dysplasia of the hip (new topic)
Osteoporosis Osteoporosis
Scoliosis (new topic)
Falls Preventive activities in older age
Women’s health
Preconception Preventive activities prior to pregnancy
Pregnancy – Lrst antenatal visit (new topic)
Pregnancy – during pregnancy (new topic)
Interconception (new topic)
Perinatal mental health (new topic)
Post menopause (new topic)
Miscellaneous
Frailty (new topic)
Hearing Preventive activities in older age
Sleep and sleep-related disorders (new topic)
Oral health Oral health
Urinary incontinence Urinary incontinence
Vision Preventive activities in older age

GlaucomaB
Screening and preventive activities of no proven beneLt
Screening and preventive activities of no Screening tests of unproven bene@t

proven bene@t
30
AThese topics in the 9th edition were combined into an overarching cardiovascular disease risk
chapter.
BIncorporated from the 9th edition.
Not included in the 10th edition:

• Preventive activities in middle age ( advice now incorporated within the relevant disease-
speci@c topics)
• Preventive activities in older age (advice now incorporated within the relevant disease-speci@c
topics, including infectious diseases, metabolic, musculoskeletal and miscellaneous).
31
Development and methodology

The previous version of the Red Book (9th edition) was developed by a team of GPs and experts using
the NHMRC FORM framework (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3053308/) . Evidence-
based recommendations were developed by adopting or adapting relevant existing guideline
recommendations (with preference given to Australian NHMRC-approved guidelines), or by using
systematic reviews of the evidence to inform recommendations where no suitable existing
recommendations were identi@ed. Given the broad scope of the Red Book, the current 10th edition was
developed using a similar pragmatic approach of adopting or adapting existing recommendations from
high-quality guidelines where possible (referred to as a meta-guideline approach), rather than the time-
and resource-intensive process of developing new recommendations with de novo systematic reviews
across all topics. This meta-guideline approach drew on the GRADE principles of considered judgement
and the grading conventions used by the GRADE approach.1,2
Development of Red book 10 recommendations

The process for developing the Red Book 10th edition recommendations consisted of the following
steps:
1. Scoping the topics to be covered by Red Book 10th edition

2. Identifying and assessing source guidelines (for recency, relevance, and quality)
3. Extracting potentially suitable source recommendations (only those relevant to prevention and
screening)
4. Assessing potentially suitable source recommendations with consideration of:
◦ applicability to the Australian general practice context
◦ the feasibility of implementing the recommendations
◦ a comparison with the recommendations and practice points in the Red Book 9th
edition
◦ consistency with recommendations in other guidelines on the same topic
◦ the evidence base underpinning the recommendations
5. Adopting, adapting or discarding selected source recommendations through a considered
judgement process involving the clinical leads for each topic, topic working groups and/or the
Red Book Executive Committee
Where no source recommendations were available, advice was sought from clinical leads for each topic
about possible landmark studies, or whether any trials were underway, and targeted literature searches
may have been undertaken where necessary. Where evidence was identi@ed, it was assessed and de
novo recommendations were developed if appropriate.
32
Grading of Red book 10 recommendations

Updating from the 9th to the 10th edition of the Red Book involved a transition from using NHMRC
FORM methods to a pragmatic meta-guideline approach based on the principles of GRADE, an
internationally recognised systematic and transparent approach to the development of guideline
recommendations that is considered the gold standard in guideline development. This approach mainly
affected the way in which the guideline recommendations were written (to be more actionable) and how
they were graded in terms of strength and direction. Source guidelines used different methodologies,
and therefore the strength of recommendations, refecting the strength of the underlying evidence base,
was conveyed in different ways. These differing systems of grading of source recommendations were
harmonised using a common language as de@ned in a set of decision rules, developed speci@cally for
the Red Book 10th edition. These rules helped ensure consistency in the assessment of source
recommendations and grading of Red Book 10th edition recommendations across the guideline topics
(for more detail, see Appendix 1: Methods report (https://www.racgp.org.au/clinical-resources/clinical-g
uidelines/key-racgp-guidelines/view-all-racgp-guidelines/preventive-activities-in-general-practice/appen
dices/appendix-1-methods-report) ). Assessing the suitability of all potential source recommendations
and grading the Red Book 10th edition recommendations occurred through a considered judgement
process by relevant clinical leads for each topic in collaboration with the Red Book Executive
Committee.
Grading conventions for recommendations in the Red book 10th edition

The terminology used to communicate the strength and direction of each recommendation in the Red
Book 10th edition is based on that recommended by the GRADE working group (eg a ‘strong’ or
‘conditional’ recommendation ‘for’ or ‘against’ an option).1 This terminology has been modi@ed for the
Red Book 10th edition for improved implementation across general practice settings. Practice points
have also been developed to address important aspects of care that are not addressed by relevant
source guidelines, or where evidence is lacking. The categories and their meaning are presented in the
table below.
Strength of recommendations in Red book 10
Recommendation Description
Recommended (Strong) Denotes strong con@dence that the bene@ts of an intervention

clearly outweigh the harms
Not recommended (Strong) Denotes strong con@dence that the harms of an intervention clearly
outweigh the bene@ts
Conditionally recommended Denotes uncertainty over the balance of bene@ts (e.g. when the
evidence quality is low or very low or when personal preferences or
costs are expected to impact the decision) and, as such, refers to
decisions where consideration of personal preferences is essential
for decision making
33
Recommendation Description
Generally not recommended Denotes uncertainty over the balance of harms (e.g. when the
evidence quality is low or very low or when personal preferences or
costs are expected to impact the decision) and, as such, refers to
decisions where consideration of personal preferences is essential
for decision making
Practice points Used to address important aspects of care that are not addressed
by relevant source guidelines, or where evidence is lacking.
These were developed by consensus of the Red book working
groups or Executive Committee
References
1. GRADE. Welcome to the GRADE working group. 2. Schünemann H. Criteria for applying or using
GRADE, 2023 (https://www.gradeworkinggroup.or GRADE. GRADE working group, 2016 (https://ww
g/) [Accessed 16 October 2023]. w.gradeworkinggroup.org/docs/Criteria_for_usin
g_GRADE_2016-04-05.pdf) [Accessed 16 October
2023].
34
Cancer
35
Cancer
Topics in this section
Bladder cancer (https://www.racgp.org.au/clinical-resources/clinical-guidelines/

key-racgp-guidelines/view-all-racgp-guidelines/preventive-activities-in-general-pr
actice/cancer/bladder-cancer) Breast cancer (https://www.racgp.org.au/clinical-
resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/pre
ventive-activities-in-general-practice/cancer/breast-cancer) Cervical cancer (http
s://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guideline
s/view-all-racgp-guidelines/preventive-activities-in-general-practice/cancer/cervi
cal-cancer) Colorectal cancer (https://www.racgp.org.au/clinical-resources/clini
cal-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/preventive-activitie
s-in-general-practice/cancer/colorectal-cancer) Lung cancer (https://www.racg
p.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racg
p-guidelines/preventive-activities-in-general-practice/cancer/lung-cancer) Oral
cancer (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racg
p-guidelines/view-all-racgp-guidelines/preventive-activities-in-general-practice/c
ancer/oral-cancer) Ovarian cancer (https://www.racgp.org.au/clinical-resources/
clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/preventive-acti
vities-in-general-practice/cancer/ovarian-cancer) Pancreatic cancer (https://ww
w.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-
all-racgp-guidelines/preventive-activities-in-general-practice/cancer/pancreatic-c
ancer) Prostate cancer (https://www.racgp.org.au/clinical-resources/clinical-gui
delines/key-racgp-guidelines/view-all-racgp-guidelines/preventive-activities-in-ge
neral-practice/cancer/prostate-cancer) Skin cancer (https://www.racgp.org.au/cl
inical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guideline
s/preventive-activities-in-general-practice/cancer/skin-cancer) Testicular cancer
36
(https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guide
lines/view-all-racgp-guidelines/preventive-activities-in-general-practice/cancer/t
esticular-cancer) Thyroid cancer (https://www.racgp.org.au/clinical-resources/cl
inical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/preventive-activi
ties-in-general-practice/cancer/thyroid-cancer)
37
Bladder cancer
Bladder cancer
Cancer | Bladder cancer
Prevalence and context of the condition

It is estimated that in 2023, more than 3100 people were diagnosed with bladder cancer in Australia.1
Incidence and mortality of bladder cancer is approximately three- to fourfold higher in males than
females.2
Table of recommendations
 Screening
Recommendation Grade How References

often
3
Screening for bladder cancer in asymptomatic adults Not N/A
is not recommended because there is insulcient recommended
evidence to assess the balance of bene@ts and harms. (Strong)
Further information
In 2011, the US Preventive Services Task Force found that there is inadequate evidence that treatment
of bladder cancer detected from screening leads to lowered rates of morbidity and mortality, and
similarly a lack of evidence regarding the harms of screening for bladder cancer.3
Considerations for Aboriginal and Torres Strait Islander

peoples
There are no speci@c recommendations for Aboriginal and Torres Strait Islander people.
38
Bladder cancer
References
Cancer Council. Types of cancer: Bladder cancer. 3. US Preventive Services Task Force. Bladder
Cancer Council, 2023 (https://www.cance cancer in Adults: Screening. USPSTF, 2011 (http
org.au/cancer-information/types-of-cancer/blad s://www.uspreventiveservicestaskforce.org/uspst
der-cancer) [Accessed 2 November 2023]. f/recommendation/bladder-cancer-in-adults-scre
Australian Institute of Health and Welfare. 2023. ening) [Accessed 4 April 2024].
Cancer data in Australia: Cancer incidence by age
visualisation. AIHW, 2023 (https://www.aih
gov.au/reports/cancer/cancer-data-in-australi
a/contents/cancer-incidence-by-age-visualisatio
n) [Accessed 28 March 2024].
39
Breast cancer
Breast cancer
Cancer | Breast cancer

Screening and case ?nding age bar
0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44* 45–49* 50–54 55–59 60–64 65-69 70–74 75–79 ≥80
*Case @nding

Breast cancer is the most common cancer in women and the second most common cause of cancer
deaths in women in Australia. In 2022, it was estimated that 20,640 new cases of breast cancer would
be diagnosed in Australia (20,428 in women, 212 in men). The risk of being diagnosed with breast
cancer by the age of 85 years is currently estimated as 1 in 8 (or 13%) for women and 1 in 668 (or
0.15%) for men.1
An assessment should be undertaken to understand a patient’s individual degree of risk (see Table 1) in
order to provide evidence-based guidance for preventive activities. Breast cancer risk is not normally
distributed: most women have a low (<4%) lifetime risk.2
Table 1. Risk of breast cancer3
Moderately increased Potentially high riskA or carrying

Average or slightly
Risk level (<4% of the female mutation (<1% of the female
higher
population) population)
Risk in Approximately 1.5 Approximately 1.5–3 More than threefold times the
relation to times the times the population population average
the population average average Individual risk may be higher or
population lower if genetic test results are
average known
Lifetime Between 9% and Between 12% and 25% Between 25% and 50%
prevalence 12.5%
of breast
cancer up
to age 75
years
40
Breast cancer
Relevant • No • One @rst-degree • Two @rst- or second-

history con@rmed relative degree relatives on one
family diagnosed with side of the family
history of breast cancer at diagnosed with breast
breast age <50 years or ovarian cancer, plus
cancer (without the one or more of the
• One @rst- additional following features on
degree features of the the same side of the
relative potentially high- family:
diagnosed risk group) ◦ additional
with breast • Two @rst-degree relative(s) with
cancer at relatives, on the breast or
age ≥50 same side of the ovarian cancer
years family, ◦ breast cancer
• One diagnosed with diagnosed
second- breast cancer before age 40
degree (without the years
relative additional ◦ bilateral breast
diagnosed features of the cancer
with breast potentially high- ◦ breast and
cancer at risk group) ovarian cancer
any age • Two second- in the same
• Two degree relatives, woman
second- on the same ◦ Ashkenazi
degree side of the Jewish
relatives on family, ancestry
the same diagnosed with ◦ breast cancer
side of the breast cancer, at in a male
family least one at age relative
diagnosed <50 years • One @rst- or second-
with breast (without the degree relative
cancer at additional diagnosed with breast
age ≥50 features of the cancer at age <45 years
years potentially high plus another @rst- or
• Two @rst- risk group) second-degree relative
or second- on the same side of the
degree family with sarcoma
relatives (bone/soft tissue) at
diagnosed age <45 years
with breast • Member of a family in
cancer at which the presence of a
age ≥50 high-risk breast cancer
years, but gene mutation (eg
on different BRCA1, BRCA2) has
sides (ie on been established
each side)
41
Breast cancer
of the
family
There are multiple risk factors for breast cancer (genetic, hormonal, lifestyle and environmental).3
However, BreastScreen, Australia’s national breast cancer screening program, focuses on age, inviting
all Australian women aged between 50 and 74 years for biennial mammographic screening. Women are
able to self-refer for biennial mammographic screening in BreastScreen from the age of 40 years.
Clinicians have an important role in identifying people with a strong family history of breast cancer, as
well as other cancers, associated with high-risk genetic variants (eg in BRCA1 and BRCA2) and offering
referral to a familial cancer service. The Genetics (https://www.racgp.org.au/clinical-resources/clinical-
guidelines/key-racgp-guidelines/view-all-racgp-guidelines/preventive-activities-in-general-practice/gene
tics/genetic-screening) chapter provides further information on family history and the use of the family
history questionnaire.
 Screening

often
2
Women at average risk or slightly higher than average Conditionally Every 2
risk of breast cancer should participate in recommended years
mammographic screening from ages 50 to 74 years
as part of the national BreastScreen program.
4
Screening by mammography is not recommended in Generally not N/A
women aged ≥75 years due to insulcient evidence to recommended
assess the balance of bene@ts and harms.
5
Clinical breast examination for breast cancer Generally not N/A
screening of average risk women in general practice is recommended
not recommended.
6
Do not use magnetic resonance imaging (MRI) as a Not N/A
stand-alone screening test for women at average risk recommended
of breast cancer. (strong)
42
Breast cancer
Do not use thermography in breast cancer screening Not N/A 789
or as an adjunctive tool to mammography. recommended

(strong)
 Case ?nding

often
Undertake mammographic screening from ages 40 to Conditionally At least 5
74 years for women at moderately increased risk. recommended every 2

years
 Preventive activities and advice

often
3
Counsel all women that the following are associated Practice point N/A
with lower breast cancer risk:
• physical activity
• maintaining a normal body mass index (for
postmenopausal breast cancer)
• minimising alcohol consumption
• having children
• breastfeeding
5
It is recommended that all women, whether or not they Practice point N/A
undergo mammographic screening, are aware of how
their breasts normally look and feel, and promptly
report any new or unusual changes (such as a lump,
nipple changes, nipple discharge, change in skin
colour, skin texture, pain in a breast) to their GP. No
one method for women to use when checking their
breasts is recommended over another.
43
Breast cancer
Further information
Screening
For asymptomatic, average-risk women, BreastScreen Australia recommends screening mammograms
every two years for women aged 50–74 years and actively recalls women in this age bracket.2 However
women at average risk may choose to commence mammography through BreastScreen from the age
of 40 years.
For women at moderate risk, annual mammograms from age 40 years may be recommended. Annual
mammograms are not recommended for women with a single relative diagnosed at age >50 years,
because there is no clear evidence of bene@t.10
Ongoing surveillance strategies for women at high risk of breast cancer may include imaging with MRI.
A Medicare rebate (https://www9.health.gov.au/mbs/fullDisplay.cfm?type=item&q=63464&qt=item) is

available for MRI scans for asymptomatic patients aged <60 years at high risk of breast cancer.11
Reviews of evidence from randomised controlled trials of mammography estimate rates of

overdiagnosis of breast cancer of between 11% and 19%.12 More recent modelling data from the US
estimate that biennial screening from ages 40 to 74 years would result in 14 overdiagnosed cases of
breast cancer per 1000 women screened over the lifetime of screening (estimated range 4–37
overdiagnosed cases).13 Screening mammography in women aged 40–49 years reduces the risk of
dying of breast cancer, but the number of deaths averted is much smaller than in older women, and the
number of false-positive tests and unnecessary biopsies is larger.13
There is controversy on how to screen women with dense breasts. The current evidence is insulcient
to assess the balance of bene@ts and harms of supplemental screening for breast cancer using breast
ultrasound or MRI in women identi@ed to have dense breasts on an otherwise negative screening
mammogram.4
Thermography is associated with high false-positive and false-negative rates and is not recommended
as a screening modality. Polygenic risk scores to determine breast cancer risk may have a role in the
future, but are not currently recommended in general practice.
A single nucleotide polymorphism (SNP)-based breast cancer risk assessment test should only be
undertaken after an in‐depth discussion led by a clinical professional familiar with the implications of
genetic risk assessment and testing, including the potential insurance implications. Genetic testing
should be offered only with pre- and post-test counselling to discuss the limitations, potential bene@ts
and possible consequences.14
Estimated risks for factors for which there is sulciently strong evidence of an association with risk of
breast cancer (ie factors for which the body of evidence was classi@ed as either ‘Convincing’ or
‘Probable’, are summarised in table 5.2 of the 2018 Cancer Australia publication Risk factors for breast
cancer: A review of the evidence.15
44
Breast cancer

peoples
For speci@c recommendations for Aboriginal and Torres Strait Islander people, please refer to the
Prevention and early detection of breast cancer (https://www.racgp.org.au/clinical-resources/clinical-gu
idelines/key-racgp-guidelines/view-all-racgp-guidelines/national-guide/chapter-15-prevention-and-early-
detection-of-cance/prevention-and-early-detection-of-breast-cancer) chapter in the National guide to a
preventive health assessment for Aboriginal and Torres Strait Islander people.
Speci?c populations
For women at potentially high risk or carrying a mutation, offer referral to a familial cancer clinic for
risk assessment, possible genetic testing and a risk reduction management plan.
Individualised surveillance and risk reduction plan, including consideration of associated risks for other
cancers (eg ovarian), may include:
• regular clinical breast examination and annual breast imaging with mammography, MRI or
ultrasound
• chemoprevention with selective oestrogen receptor modulators (SERMs; eg tamoxifen or
raloxifene) or aromatase inhibitors (eg exemestane and anastrozole)16
• mastectomy and/or salpingo-oophorectomy.
Resources
iPrevent (https://www.petermac.org/iprevent) is a validated tool to help in the assessment of breast
cancer risk.
References
Cancer Australia. Breast cancer –in Australia 4. U.S. Preventive Services Task Force (USPSTF).
statistics. Australian Government, 2024 (http://w Breast cancer: Screening. USPSTF, 2023 (http://w
ww.canceraustralia.gov.au/cancer-types/breast-c ww.uspreventiveservicestaskforce.org/uspstf/dra
ancer/statistics#:~:text=In%202022%2C%20it%2 ft-recommendation/breast-cancer-screening-adul
0is%20estimated,or%2013%25%20for%20female ts#fullrecommendationstart) [Accessed 19 May
[Accessed 21 February 2024]. 2023].
Department of Health and Aged Care. 5. Cancer Australia. Early detection of breast
BreastScreen Australia program. Australian cancer. (http://www.canceraustralia.gov.au/resou
Government, 2024 (http://www.health.gov.au/ rces/position-statements/early-detection-breast-
our-work/breastscreen-australia-program) cancer) [Position statement] Australian
[Accessed
21 February 2024]. Government, 2015 [Accessed 16 May 2023].
Cancer Australia. Breast cancer: The risk factors.
Australian Government, 2024 (http://ww
breastcancerriskfactors.gov.au/) [Accessed
21
February 2024].
45
Breast cancer
Cancer Council. Magnetic resonance imaging Henderson JT, Webber, EM, Weyrich M, Miller M,
screening in high-risk women. In: Screening: Melnikow J. Screening for breast cancer: A
Breast cancer prevention policy. Cancer Council, comparative effectiveness review for the U.S.
2014 (http://www.cancer.org.au/about-us/policy- Preventive Services Task Force. Evidence
and-advocacy/prevention-policy/national-cancer- synthesis no. 231. Agency for Healthcare
prevention-policy/breast-cancer/screening#magn Research and Quality, 2023. [Accessed 16 May
etic) [Accessed 16 May 2023]. 2023].
Cancer Council. Thermography. In: Screening Trentham-Dietz A, Chapman CH, Jinani J, et al.
breast cancer prevention policy. Cancer Council, Breast cancer screening with mammography: An
2014 (http://www.cancer.org.au/about-us/policy- updated decision analysis for the U.S. Preventive
and-advocacy/prevention-policy/national-cancer- Services Task Force. Agency for Healthcare
prevention-policy/breast-cancer/screening#therm Research and Quality, 2023.
ography) [Accessed 16 May 2023]. [Accessed 16 May 2023].
Cancer Australia. Statement on use of The Royal Australian College of General
thermography to detect breast cancer. Australian Practitioners (RACGP). Genomics in general
Government, 2010 (http://www.canceraustralia.g practice. RACGP, 2022 (https://www.racgp.org.a
ov.au/resources/position-statements/statement- u/getattachment/a7b97d5a-5b5f-4d4b-ab3b-efa9
use-thermography-detect-breast-cancer) c08b1d6d/Genomics-in-general-practice.aspx)
[Accessed 16 May 2023]. [Accessed 22 February 2024].
Royal Australian and New Zealand College of 15. Cancer Australia. Risk factors for breast
Radiologists (RANZCR). Policy on use of cancer: A review of the evidence 2018. Australian
thermography to detect breast cancer. RANZCR, Government, 2018 (http://www.canceraustralia.g
2018 (http://www.ranzcr.com/college/document-l ov.au/publications-and-resources/cancer-australi
ibrary/policy-on-the-use-of-thermography-to-detec a-publications/risk-factors-breast-cancer-review-e
breast-cancer?searchword=thermography) vidence-2018) [Accessed 16 May 2023].
16. Cancer Australia. Risk-reducing medication
Cancer Australia. Advice about familial aspects of for women at increased risk of breast cancer due
breast cancer and epithelial ovarian cancer. to family history. Australian Government, 2018 (ht
Australian Government, 2015 (http://ww tp://www.canceraustralia.gov.au/publications-an
canceraustralia.gov.au/publications-and-resour d-resources/cancer-australia-publications/risk-re
ces/cancer-australia-publications/advice-about-f ducing-medication-women-increased-risk-breast-
amilial-aspects-breast-cancer-and-epithelial-ovari cancer-due-family-history) [Accessed 16 May
an-cancer) [Accessed 12 December 2023]. 2023].
11. Cancer Australia. MRI for high risk women.
Australian Government, n.d (http://www.cancerau
stralia.gov.au/clinical-best-practice/breast-cance
r/screening-and-early-detection/mri-high-risk-wo
men) [Accessed 16 May 2023].
46
Cervical cancer
Cervical cancer
Cancer | Cervical cancer

Screening age bar
0-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 ≥80

In 2021, cervical cancer was estimated to be the 13th most commonly diagnosed cancer recorded
among females, with 913 new cases of cervical cancer diagnosed in Australia.1 Aboriginal and Torres
Strait Islander women have a higher incidence of cervical cancer.
Under-screened women remain the most likely to develop cervical cancer. The main burden of cervical
cancer is in developing countries without screening programs or human papillomavirus (HPV)
vaccination.
The introduction of HPV vaccination in Australia has been instrumental in reducing HPV infection and
has placed Australia on track to reach the elimination of cervical cancer targets of 90:70:90
(vaccination: 90% of girls fully vaccinated with the HPV vaccine by age 15 years; screening: 70% of
women screened using a high-performance test by age 35 years, and again by age 45 years; treatment:
90% of women identi@ed with cervical disease receive treatment) by 2030.2 GPs play an important role
in achieving these targets by providing vaccination and encouraging participation in the cervical cancer
screening program to ensure early detection. Population level targets are beyond the scope of the Red
Book, which focuses on recommendations that can be implemented in practice.
 Screening

often
3
Cervical screening is not recommended in women Screening not N/A
under the age of 25 years. recommended
(strong)
47
Cervical cancer
Evidence does not support screening for women aged Practice point N/A 3
less than 25, even when they have experienced early

sexual activity. However, for those who experience
their @rst sexual activity at a young age (<14 years)
and who had not received the HPV vaccine before
sexual debut, a single HPV test between 20 and 24
years of age could be considered on an individual
basis but is not required.
Women and people with a cervix who have ever had Recommended Every 3
sexual contact aged between 25-74 years of age and (strong) @ve
are eligible for screening should have a HPV years.
screening test for cervical cancer. This can be on a
self-collected vaginal sample or on a clinician-
collected sample.
Women with a negative oncogenic HPV screen Practice point N/A 3
between the ages of 70–74 no longer require ongoing

routine screening.
3
Women who are 75 years or older who have never had Practice point N/A
a cervical screening test or have not had one in the
previous @ve years, may request a test and can be
screened. The sample can be clinician-collected or
self-collected, according to the woman’s choice.
Recommendations Grade How References

often
4
Administer one dose of the 9vHPV vaccine in Recommended From
immunocompetent adolescents and young adults (strong) age 9 to
from nine years of age and ensure catch up 26 years
vaccination up to 26 years. For more information,
refer to the Australian immunisation handbook (http
s://immunisationhandbook.health.gov.au/contents/vac
cine-preventable-diseases/human-papillomavirus-hpv)
.
48
Cervical cancer
Administering the HPV vaccine in adults aged ≥26 Generally not N/A 4
years is generally not recommended. recommended

However, some adults may bene@t from HPV
vaccination. When deciding whether to vaccinate
adults, consider:
• the likelihood of previous exposure to HPV
• the future risks of HPV exposure.
Further information
• A short course of topical oestrogen therapy could be considered in postmenopausal women,
people experiencing vaginal dryness, or trans men, prior to collecting the sample – for
example, daily for at least 2 weeks, ceasing 1–2 days prior to the appointment. The reason for
this should be explained (to reduce discomfort from the speculum and to improve the
diagnostic accuracy of any associated liquid-based cytology [LBC]).3
• When deciding whether to choose self-collection or clinician collection, people must be given
clear information by the supervising healthcare professional about the likelihood that HPV may
be detected and, if so, what follow-up will be required. If a person chooses self-collection, the
healthcare professional should provide information about how to collect the sample and how
they will receive the test results.3
• Cervical screening on a self-collected vaginal sample needs to be ordered and overseen by a
healthcare professional.* For details of self-collection, refer to the section on self-collected
vaginal samples in the National Cervical Screening Program: Guidelines for the management of
screen-detected abnormalities, screening in speciFc populations and investigation of abnormal
vaginal bleeding (https://www.cancer.org.au/clinical-guidelines/cervical-cancer/cervical-cancer-
screening/management-of-oncogenic-hpv-test-results/self-collected-vaginal-samples) .3
• When follow-up HPV testing is required after an initial positive oncogenic HPV test result, the
sample may be self-collected or collected by a clinician. The woman’s healthcare professional
should advise the woman of the follow-up that will be recommended if HPV is detected and
explain that a clinician-collected sample allows for refex LBC to be performed on the same
sample. This potentially avoids the need for an additional visit to collect a cervical sample for
LBC. HPV testing is not repeated on the clinician-collected sample in this circumstance.3
• Among those attending for a routine screening test, approximately 2% have HPV16/18
detected and approximately 6% have HPV (not 16/18) detected, although the latter varies by
age.3
*Only doctors and nurse practitioners can sign the pathology request for tests under current Medicare
Bene@ts Schedule (MBS) rules.

peoples
National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people, Chapter
49
Cervical cancer
15: Prevention and early detection of cervical cancer (https://www.racgp.org.au/clinical-resources/clini

cal-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/national-guide/chapter-15-prevention-an
d-early-detection-of-cance/prevention-and-early-detection-of-cervical-cancer) .
Speci?c populations
Screening in pregnancy5
• Routine antenatal and postpartum care should include a review of the woman’s cervical
screening history. Women who are due or overdue for screening should be screened.
• A woman can be safely screened at any time during pregnancy, provided that the correct
sampling equipment is used. An endocervical brush should not be inserted into the cervical
canal because of the risk of associated bleeding, which may distress women.
• All women who are due for cervical screening during pregnancy may be offered the option of
self-collection of a vaginal swab for HPV testing, after counselling by a healthcare professional
about the small risk of bleeding. Women testing positive for HPV (not 16/18) on a self-
collected sample should be advised to return so that a cervical sample for LBC can be
collected by the healthcare provider.
• For other speci@c populations, refer to the National Cervical Screening Program: Guidelines for
the management of screen-detected abnormalities, screening in speciFc populations and
investigation of abnormal vaginal bleeding (https://www.cancer.org.au/clinical-guidelines/cervi
cal-cancer/cervical-cancer-screening) .
Resources
National Cervical Screening Program: Guidelines for the management of screen-detected abnormalities,
screening in speciFc populations and investigation of abnormal vaginal bleeding (https://www.cancer.or
g.au/clinical-guidelines/cervical-cancer/cervical-cancer-screening) .
References
Australian Institute of Health and Welfare. Cancer 3. Cancer Council Australia. National Cervical
data in Australia. Cat. no. CAN 122. AIHW, 2023 Screening Program: Guidelines for the
(https://www.aihw.gov.au/reports/cancer/c management of screen-detected abnormalities,
ancer-data-in-australia) [Accessed 16 May 2022]. screening in speci@c populations and
Australian Centre for the Prevention of Cervical investigation of abnormal vaginal bleeding.
Cancer. National strategy for the elimination of Cancer Council Australia, 2022 (https://www.canc
cervical cancer in Australia: A pathway to achieve er.org.au/clinical-guidelines/cervical-cancer/cervi
equitable elimination of cervical cancer as a cal-cancer-screening) [Accessed 8 April 2024].
public health problem by 2035. Department of
Health and Aged Care, 2023 (https://www.healt
gov.au/sites/default/files/2023-11/national-str
ategy-for-the-elimination-of-cervical-cancer-in-aus
tralia.pdf) [Accessed 8 April 2024].
50
Cervical cancer
4. Australian Technical Advisory Group on 5. Cancer Council Australia. National Cervical

Immunisation (ATAGI). Australian immunisation Screening Program: Guidelines for the
handbook. Human papillomavirus (HPV). management of screen-detected abnormalities,
Department of Health and Aged Care, 2023. screening in speci@c populations and
Available at: (https://immunisationhandbook.heal investigation of abnormal vaginal bleeding.
th.gov.au/contents/vaccine-preventable-disease Chaper 14: Screening in pregnancy. Cancer
s/human-papillomavirus-hpv) [Accessed 8 April Council Australia, 2022 (https://www.cancer.org.a
2024]. u/clinical-guidelines/cervical-cancer/cervical-can
cer-screening/screening-in-pregnancy) [Accessed
8 April 2024].
51
Colorectal cancer
Colorectal cancer
Cancer | Colorectal cancer

Screening age bar (average risk)
0-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 ≥80

Australia has one of the highest incidence rates of colorectal cancer in the world. Colorectal cancer was
the third most commonly diagnosed cancer in Australia in 2018; an estimated 15,713 Australians were
diagnosed and 5326 died of the disease in 2022.1
Colorectal cancer screening using the immunochemical faecal occult blood test (iFOBT) is highly cost
effective. The current National Bowel Cancer Screening Program (https://www.health.gov.au/our-work/
national-bowel-cancer-screening-program) (NBCSP) sends iFOBT tests to people aged 50–74 years
every 2 years. Participation in the NBSCP in 2020–21 is only 41%2 and general practice plays an
important role in identifying those who are under-screened and in endorsing the NBCSP.
The National Health and Medical Research Council (NHMRC) endorsed an update to the Clinical
practice guidelines for the prevention, early detection and management of colorectal cancer (https://ww
w.cancer.org.au/clinical-guidelines/bowel-cancer/colorectal-cancer) in September 2023, which included
a recommendation to commence iFOBT screening for the general (average risk) population from age 45
years. Currently, the NBCSP will continue to send iFOBT kits to people aged 50–74 years.
Due to the potential harms of colonoscopy and additional costs to the health system of this procedure,
colonoscopy is only recommended as a screening test for people who are at least at moderate risk of
colorectal cancer.3
52
Colorectal cancer
Box 1. Identifying risk3
Adults without symptoms
Risk level Average
DeLnition People with no symptoms (age 45–74 years)
According to family history
Risk level Category 1: Category 2: Category 3: Individuals

Average or slightly Moderately at potentially higher
increased (age increased risk, where Lynch
45–74 years) syndrome has been
excluded
53
Colorectal cancer
DeLnition An individual An individual An individual should

should be advised should be advised be advised that their
that their risk of that their risk of risk of developing
developing developing colorectal cancer is at
colorectal cancer colorectal cancer least four times higher
is: is at least two than average, but
• near- times higher than could be up to 20
average average, but could times higher than
risk if no be up to four times average, if they have
family higher than any of the following:
history of average, if they • two @rst-
colorectal have any of the degree
cancer following: relatives and
• above • only one one second-
average, @rst- degree
but less degree relative with
than twice relative colorectal
the with cancer, with
average colorectal at least one
risk, if cancer diagnosed
they have diagnosed before age 50
only one before years
@rst- age 60 • two @rst-
degree years degree
relative • one @rst- relatives and
with degree two or more
colorectal relative second-
cancer and one degree
diagnosed or more relatives with
at age second- colorectal
≥60 years. degree cancer
relatives diagnosed at
with any age
This level of risk is colorectal • three or more
still not high cancer @rst-degree
enough to justify diagnosed relatives with
colorectal cancer at any age colorectal
screening by • two @rst- cancer
colonoscopy. degree diagnosed at
relatives any age.
with
54
Colorectal cancer
colorectal Include both sides of

cancer the family when
diagnosed assessing an
at any individual’s risk
age. category for colorectal
cancer. Criteria for
category 2 and
Include both sides category 3 can be met
of the family when by inclusion of
assessing an relatives from both
individual’s risk sides of the family.
category for
colorectal cancer.
Criteria for
category 2 and
category 3 can be
met by inclusion of
relatives from both
sides of the family.
Relative risk At least two times At least four times

higher than higher than average,
average, but could but could be up to 20
be up to four times times higher than
higher than average.
average.
Percentage of 98 1-2 <1

Australian
population4
Lifetime risk Approximately Approximately Approximately

to age 75 5–10% 15–30% 30–40%
years
(assuming no
colorectal
cancer
screening)
55
Colorectal cancer
 Screening
Recommendation Grade How often References
Immunochemical faecal occult blood testing Conditionally Every 2 5
(iFOBT) every 2 years is recommended starting at recommended years

age 45 years and continuing to age 74 years for
those at average risk of colorectal cancer.
6,7,8
Colonoscopy is not generally recommended for Generally not N/A
screening people at average or slightly increased recommended
risk according to their family history.
 Case ?nding
6
For people at moderately increased risk of Conditionally Colonoscopy
colorectal cancer: recommended every 5
• colonoscopy should be offered every 5 years
years starting at 10 years younger than
the earliest age of diagnosis of colorectal
cancer in a @rst-degree relative or age 50
years, whichever is earlier, to age 74
years.
3
For people at potentially higher risk of colorectal Conditionally Colonoscopy
cancer, where Lynch syndrome has been excluded: recommended every 5
• colonoscopy should be offered every 5 years
years starting at 10 years younger than
the earliest age of diagnosis of colorectal
cancer in a @rst-degree relative or age 40
years, whichever is earlier, to age 74
years.
56
Colorectal cancer
Refer the following individuals to a clinical Conditionally N/A 3,9
genetics service or familial cancer centre. recommended
People with a personal history of colorectal

cancer and any of the following features:
• isolated colorectal cancer diagnosed
under age 50 years*
• personal history of colorectal cancer and
a second Lynch syndrome associated
cancer (including two colorectal cancers)
a family history of one or more @rst-
degree or second-degree relatives with
colorectal or endometrial cancer, with at
least one of the cancers diagnosed under
age 50 years
a family history of two or more @rst-
degree or second-degree relatives with a
Lynch syndrome associated cancer,†
regardless of the age the cancers were
diagnosed.
People with a family history with any of these

features:
• family history of two or more @rst-degree
or second-degree relatives with colorectal
or endometrial cancer, at least one of the
cancers diagnosed under age 50 years
• family history of three or more @rst-degree
or second-degree relatives with a Lynch
syndrome related cancer,† regardless of
the age the cancers were diagnosed.
*As some familial cancer services may have a

lower referral age, please seek advice from your
local genetics service.
†Lynch syndrome–associated cancer includes
adenocarcinoma of the colorectum, endometrium,

small intestine, stomach, ovary, or pancreas,
transitional cell carcinoma of the ureter or renal
pelvis, cholangiocarcinoma, brain tumour,
sebaceous gland tumours, keratoacanthoma.
57
Colorectal cancer
For people at higher-than-average risk, consider in Practice point N/A 10
consultation with a healthcare professional (refer

to Further information) low-dose (100 mg) aspirin
daily from age 45 to 70 years.
Counsel all patients that the following are Practice point N/A 11
associated with lower colorectal cancer risk:

• eating a healthy diet, including plenty of
vegetables, fruit and whole grains while
minimising intake of red meat,
barbequed/grilled meat and processed
meat
• maintaining a healthy body weight
• undertaking regular physical activity
• avoiding or limiting alcohol intake
• not smoking.
Further information
Colonoscopy is not recommended as a screening test for people at average risk of colorectal cancer;
despite this, colonoscopy is common in high socioeconomic areas.3
Colonoscopy has indirect and direct harms including, rarely, death from the procedure (one in
10,000–14,000 colonoscopies). Harm may be caused by the bowel cleanout prior to the procedure (eg
dehydration, electrolyte imbalances), sedation used during the procedure (eg cardiovascular events), or
the procedure itself (eg colonic perforations, bleeding).4,12,13
General practice can play an important role in increasing participation in the NBCSP.10,11,14,15 Identifying
those who are under-screened when they consult, potentially using information accessed via the
National Cancer Screening Register, is an important element of this. The implementation of the
Alternative Access Model means that GPs can provide NBCSP kits to all eligible patients, including their
under-screened patients, as a key strategy to increase participation in bowel cancer screening.
Additional ways to increase screening participation include GP endorsement messages before the
NBCSP kit arrives (by SMS or letter), addressing individual patient concerns and barriers to screening,
and establishing recall and reminder systems.
Until a decision is reached by the NBCSP in relation to the recommendation to commence iFOBT
screening from age 45 years, GPs can order an iFOBT as a screening test for people aged 45–50 years
through their pathology provider.
58
Colorectal cancer
Aspirin use
Chemoprevention trials for calcium, some vitamin supplementation, selenium and statins, have
provided mixed evidence of bene@t. The strong evidence for bene@t has emerged from observational
studies of exposure to nonsteroidal anti-infammatory drugs, especially aspirin.10
Results from randomised controlled trials about the use of aspirin in the primary and secondary
prevention of colorectal cancer and adenomas are now available and point to a similar bene@t to that
associated with screening by colonoscopy in people aged <70 years.10 Aspirin is an affordable and
accessible option, and has other bene@ts such as cardiovascular protective effects, and relatively no
signi@cant side effects, although these side effects increase with age.10 It is important to note that the
bene@ts for aspirin in cancer prevention become apparent after a latency period of 10 years, and it is
less studied in older people, especially women.10

peoples
Participation in screening is under-represented by Aboriginal and Torres Strait Islander peoples. There
are several barriers to participation in the NBCSP for Aboriginal and Torres Strait Islander people,
including limited knowledge about bowel cancer and screening, privacy and storage of samples at
home, cultural norms about faeces and low English literacy. The Alternative Access Model was initially
piloted in Aboriginal Controlled Community Health Organisations and was shown to increase
participation in the NBCSP.14,16
For further speci@c recommendations for Aboriginal and Torres Strait Islander people, please refer to
the National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people,
Chapter 15: Prevention and early detection of cancer – Prevention and early detection of colorectal
(bowel) cancer (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/vi
ew-all-racgp-guidelines/national-guide/chapter-15-prevention-and-early-detection-of-cance/prevention-a
nd-early-detection-of-colorectal-(bowe) .
Resources
Colorectal cancer (https://www.cancervic.org.au/downloads/health-professionals/optimal-care-pathwa
ys/I-PACED_colorectal_resource_card_online.pdf) : A resource card for general practitioners, Optimal
Care Pathways, I-PACED (Implementing Pathways for Cancer Early Diagnosis) resources | Cancer
Council Victoria
59
Colorectal cancer
References
Cancer Australia. Bowel cancer: Bowel cancer 9. Cancer Institute NSW eviQ. Colorectal cancer
(colorectal cancer) in Australia statistics. Cancer or polyposis – Referring to genetics. Cancer
Australia, 2022 (https://www.canceraustralia.go Institute NSW eviQ, 2022 (http://www.eviq.org.au/
au/cancer-types/bowel-cancer/statistics) cancer-genetics/referral-guidelines/657-colorecta
[Accessed 27 June 2023]. l-cancer-or-polyposis-referring-to) [Accessed 27
Australian Institute of Health and Welfare. Cancer June 2023].
screening programs: Quarterly data. AIHW, 2023 10. Cancer Council Australia. Clinical practice
(http://www.aihw.gov.au/reports/can cer- guidelines for the prevention, early detection and
screening/national-cancer-screening-program management of colorectal cancer. 2.1.2
participation/contents/national-bowel-cancer-s Chemopreventive candidate agents. Cancer
creening-program/participation) [Accessed 27 Council Australia, 2023 (https://app.magicapp.or
June 2023]. g/#/guideline/noPKwE/section/Lwre0X)
Cancer Council Australia. Clinical practice [Accessed 31 October 2023].
guidelines for the prevention, early detection and 11. World Cancer Research Fund, American
management of colorectal cancer. Cancer Council Institute for Cancer Research. Continuous update
Australia, 2023 (https://www.cancer.org.a u/ project expert report 2018. Diet, nutrition,
clinical-guidelines/bowel-cancer/colorectal-can physical activity and colorectal cancer. WCRF,
cer) [Accessed 31 October 2023]. AICR, 2018 (https://www.wcrf.org/wp-content/upl
Emery JD, Pirotta M, Macrae F, et al. ‘Why don’t I oads/2021/02/Colorectal-cancer-report.pdf)
need a colonoscopy?’ A novel approach to [Accessed 8 April 2024].
communicating risks and benefits of colorectal Lew J-B, St John DJB, Macrae FA, et al.
cancer screening. Aust J Gen Pract Evaluation of the benefits, harms and cost-
2018;47(6):343–49. doi: 10.31128/ effectiveness of potential alternatives to iFOBT
AJGP-11-17-4386. [Accessed 31 October 2023]. testing for colorectal cancer screening in
Cancer Council Australia. Clinical practice Australia. Int J Cancer 2018;143(2):269–82.
guidelines for the prevention, early detection and [Accessed 8 April 2024].
management of colorectal cancer. 5. Summary of Australian Commission on Safety and Quality
recommendations for population screening. in Health Care. Third Australian atlas of
Cancer Council Australia, 2023 (https://app.magi healthcare variation. 2.1 Colonoscopy
capp.org/#/guideline/j1Q1Xj/section/Ea0BB1) hospitalisations, all ages. ACSQHC, 2018 (htt
[Accessed 31 October 2023]. p://www.safetyandquality.gov.au/our-work/health
Cancer Council Australia. Clinical practice care-variation/third-atlas-2018/atlas-2018-2-gastr
guidelines for the prevention, early detection and ointestinal-investigations-and-treatments/21-colo
management of colorectal cancer. 5. Summary of noscopy-hospitalisations-all-ages) [Accessed 27
recommendations for risk and screening based June 2023].
on family history. Cancer Council Australia, 2023 14. Department of Health and Aged Care.
(https://app.magicapp.org/#/guideline/jz5DdE/se Alternative access to bowel screening kits
ction/LpRPN0) [Accessed 31 October 2023]. training guide. Department of Health and Aged
Viiala CH, Zimmerman M, Cullen DJE, Hoffman Care, 2024 (http://www.health.gov.au/our-work/n
NE. Complication rates of colonoscopy in an ational-bowel-cancer-screening-program/alternati
Australian teaching hospital environment. Intern ve-access-to-bowel-screening-kits-for-healthcare-
Med J 2003;33(8):355–59. [Accessed 31 October providers/guide) [Accessed 27 June 2023].
2023]. 15. Trevena LJ, Meiser B, Mills L, et al. Which test
Rabeneck L, Paszat LF, Hilsden RJ, et al. Bleeding is best? A cluster-randomized controlled trial of a
and perforation after outpatient colonoscopy and risk calculator and recommendations on
their risk factors in usual clinical practice. colorectal cancer screening behaviour in general
Gastroenterology practice. Public Health Genomics;4:1–16. doi:
2008;135(6):1899–906, 906 e1. [Accessed 31 10.1159/000526628. Epub ahead of print. PMID:
October 2023]. 36195055. [Accessed 27 June 2023].
60
Colorectal cancer
16. D’Onise K, Iacobini ET, Canuto KJ. Colorectal

cancer screening using faecal occult blood tests
for Indigenous adults: A systematic literature
review of barriers, enablers and implemented
strategies. Prev Med 2020;134:106018. doi:
10.1016/j.ypmed.2020.106018. PMID: 32057956.
[Accessed 27 June 2023].
61
Lung cancer
Lung cancer
Cancer | Lung cancer

In Australia, lung cancer is the @fth most commonly diagnosed cancer and is the leading cause of
cancer death excluding non-melanoma cancers.1 It is estimated that, in 2023, more than 14,700 people
were diagnosed with lung cancer in Australia.1
Further information
On 2 May 2023, the Minister for Health and Aged Care, the Hon Mark Butler MP, announced Federal
Government investment of $263.8 million from 2023 to 2024 to implement a National Lung Cancer
Screening Program, for commencement by July 2025. This chapter will be updated when the program
commences.
Reference
1. Cancer Council. Lung cancer. Cancer Council,
2023 (https://www.cancer.org.au/cancer-informa
tion/types-of-cancer/lung-cancer) [Accessed 2
November 2023].
62
Oral cancer
Oral cancer
Cancer | Oral cancer

It is estimated that more than 700 people were diagnosed with oral cancer in 2023 in Australia.1
 Screening

often
2
Screening for oral cancer in asymptomatic adults is Not N/A
not recommended because there is insulcient recommended
evidence to assess the balance of bene@ts and harms. (Strong)
Further information
In 2013, the US Preventive Services Task Force (USPSTF) found that there is inadequate evidence for
the accuracy of diagnosis, bene@ts and harms of screening for oral cancer.2

peoples
References
1. Cancer Council. Mouth cancer. Australia: Cancer 2. US Preventive Services Task Force (USPSTF).
Council, 2023 (https://www.cancer.org.au/cancer- Oral cancer: Screening. USPSTF, 2013 (https://ww
information/types-of-cancer/mouth-cancer) w.uspreventiveservicestaskforce.org/uspstf/reco
[Accessed 3 November 2023]. mmendation/oral-cancer-screening) [Accessed
17 January 2024].
63
Ovarian cancer
Ovarian cancer
Cancer | Ovarian cancer

It is estimated that more than 1200 people were diagnosed with ovarian cancer in 2023 in Australia.1
 Screening

often
2
Screening for ovarian cancer in asymptomatic women Not N/A
is not recommended. recommended
(Strong)
Further information
In 2019, Cancer Australia found that there is currently no evidence available that screening for ovarian
cancer results in reduced mortality for women.2

peoples
References
1. Cancer Council. Ovarian cancer. Australia: Cancer 2. Cancer Australia. Testing for ovarian cancer in
Council, 2023 (https://www.cancer.org.au/cancer- asymptomatic women. Australia: Cancer
information/types-of-cancer/ovarian-cancer) Australia, 2019 (https://www.canceraustralia.go
[Accessed 3 November 2023]. v.au/publications-and-resources/position-statem
ents/testing-ovarian-cancer-asymptomatic-wome
n) [Accessed 3 November 2023].
64
Pancreatic cancer
Pancreatic cancer
Cancer | Pancreatic cancer

In Australia, pancreatic cancer is the eighth most commonly diagnosed cancer.1 In 2023, it is estimated
that more than 4500 people were diagnosed with pancreatic cancer and that one in 70 people will be
diagnosed by the time they are aged 85 years.1
 Screening
How
Recommendation Grade References
often
2
Screening for pancreatic cancer in asymptomatic Not N/A
adults is not recommended. recommended
(Strong)
Further information
In 2019, the US Preventive Services Task Force found that there are currently no accurate or validated
biomarkers for early detection of pancreatic cancer.2

peoples
There are no speci@c recommendations for Aboriginal and Torres Strait Islander people
Speci?c populations
People with a strong family history of pancreatic cancer should be referred to a familial cancer service,
geneticist or oncologist for possible genetic testing.3
65
Pancreatic cancer
References
Cancer Council. Types of cancer: Pancreatic 3. Cancer Council Victoria and Department of
cancer. Cancer Council, 2023 (https://www.cance Health Victoria. Optimal care pathway for people
org.au/cancer-information/types-of-cancer/pan with pancreatic cancer. 2nd edn, Cancer Council
creatic-cancer) [Accessed 3 November 2023]. Victoria, 2021 (https://www.cancer.org.au/asset
US Preventive Services Task Force. Pancreatic s/pdf/pancreatic-cancer-optimal-cancer-care-pat
cancer: Screening. Final recommendation hway) [Accessed 7 April 2024].
statement. USPSTF, 2019 (https://www.usprevent
iveservicestaskforce.org/uspstf/recommendatio
n/pancreatic-cancer-screening) [Accessed 7 April
2024].
66
Prostate cancer
Prostate cancer
Cancer | Prostate cancer

Shared decision making age bar in the general population
0-9 10-14 15-19 20-24 25-29 30-34 35-39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75–79 ≥80

Prostate cancer is the most commonly diagnosed cancer in Australian men with an estimated 25,500
new cases in 2023, with around one in seven eventually dying of prostate cancer. It is the third
commonest cause of cancer deaths in men (estimated 3743 deaths from prostate cancer in 2023).1,2
National population screening for prostate cancer is not recommended in Australia, nor in the United
States or Europe. Instead, Australian and international guidelines emphasise the need for men to be
given the opportunity to discuss the potential bene@ts and harms of prostate-speci@c antigen (PSA)
testing before deciding whether to be tested. Despite advances in diagnostic techniques, the risk of
overdiagnosis remains substantial and may lead to treatment for men who may never have become
symptomatic in their lifetime.3
Box 1. Identifying risk of prostate cancer3
Risk level Average Moderate High

Increased risk of At least 8–10-fold
2.5–3-fold of death due increased risk of death
to prostate cancer due to prostate cancer
DeLnition Men without family Men with a brother or Men with three affected
history multiple @rst-degree @rst-degree relatives
relatives diagnosed with diagnosed with prostate
prostate cancer cancer
67
Prostate cancer
 Screening

often
GPs should not order a prostate-speci@c antigen Practice point N/A 4
(PSA) test for men unless they provide informed

consent for screening.
3
Offer men the opportunity to discuss the potential Practice point N/A
bene@ts and harms of PSA testing as a screening test
for prostate cancer. Evidence-based decision support
tools can assist in this discussion.
3
For men aged 50–69 years at average* risk of prostate Conditionally Every
cancer who have been informed of the bene@ts and recommended two
harms of testing and who decide to undergo regular years
testing for prostate cancer, offer PSA testing every 2
years, and offer further investigation if total PSA is
greater than 3.0 ng/mL.
3
For men at moderately raised risk* of prostate cancer Conditionally Every
due to family history, offer testing every 2 years from recommended two
age 45 to 69 years. years
3
For men at high risk* of prostate cancer due to family Conditionally Every
history, offer testing every 2 years from age 40 to 69 recommended two
years. years
3
For men aged 50–69 years with initial total PSA >3.0 Practice point N/A
ng/mL, offer repeat PSA within 1–3 months. For those
with initial total PSA >3.0 ng/mL and up to 5.5 ng/mL,
measure free-to-total PSA percentage at the same
time as repeating the total PSA.
3
Advise men aged ≥70 years who have been informed Practice point N/A
of the bene@ts and harms of testing and who wish to
start or continue regular testing that the harms of PSA
testing may be greater than the bene@ts of testing in
men of their age.
68
Prostate cancer
*Refer to Box 1. Identifying risk of prostate cancer.
 Case ?nding

often
PSA testing in men who are likely to live less than Testing not N/A 3
another 7 years is not recommended (as any mortality recommended

bene@t from early diagnosis of prostate cancer due to (strong)
PSA testing is not seen within less than 6–7 years
from testing).
Digital rectal examination is not recommended as a Testing not N/A 3
routine addition to PSA testing in asymptomatic men recommended

interested in undergoing testing for early diagnosis of (strong)
prostate cancer.
Further information
The use of decision aids is recommended to help men make an informed choice about PSA testing. The
RACGP is updating its Should I have prostate cancer screening? (https://www.racgp.org.au/clinical-reso
urces/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/prostate-cancer-screening)
decision aid to assist this discussion between GPs and their patients.
Longer term follow-up from the large European Randomized study of Screening for Prostate Cancer
(ERSPC) trial has provided new estimates of bene@t from PSA testing with a number needed to screen
of 246 to prevent one prostate cancer death at 21 years’ follow-up.5
Changes in urological practice, including use of multiparametric magnetic resonance imaging (MRI),
transperineal biopsy and active surveillance for low-risk prostate cancer aim to reduce the harms of
overdiagnosis and overtreatment from PSA testing. Multiparametric MRI is more accurate at
diagnosing clinically signi@cant prostate cancers than trans-rectal ultrasound-guided biopsy and is
recommended in international guidelines as the next step along the diagnostic assessment in men with
raised PSA.6,7 This approach reduces the proportion of men with a raised PSA who require biopsy and
exposure to the potential harms of the procedure, and also reduces the diagnosis of clinically
insigni@cant disease.
69
Prostate cancer

peoples
While there are no speci@c recommendations for Aboriginal and Torres Strait Islander peoples, evidence
suggests that while there are lower rates of prostate cancer among Aboriginal and Torres Strait Islander
people, they may experience differences in treatment and mortality in comparison to non-Aboriginal
men. While further research is required to explain these differences, ongoing monitoring and efforts are
needed to ensure Aboriginal and Torres Strait Islander men have equitable access to best practice care.
Refer to the National guide to a preventive health assessment for Aboriginal and Torres Strait Islander
people, Chapter 15: Prevention and early detection of cancer (https://www.racgp.org.au/clinical-resourc
es/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/national-guide/chapter-15-prevent
ion-and-early-detection-of-cance/early-detection-of-prostate-cancer) – Early detection of prostate
cancer.
Speci?c populations
Men of African ancestry are at increased risk of prostate cancer but neither Australian nor US
guidelines make speci@c recommendations about PSA testing in this population.3,4 This increased risk
should be considered as part of shared decision making.
References
1. Australian Institute of Health and Welfare. 4. US Preventive Services Task Force. Prostate
Cancer. AIHW, 2022 (http://www.aihw.gov.au/rep cancer: Screening. Final recommendation
orts/australias-health/cancer) [Accessed 19 May statement. USPSTF, 2018 (https://www.usprevent
2023]. iveservicestaskforce.org/uspstf/recommendatio
Australian Institute of Health and Welfare. Cancer n/prostate-cancer-screening) [Accessed 7 April
data in Australia: Prostate cancer –Projection 2024].
method changes, updated long-term prostate 5. de Vos II, Meertens A, Hogenhout R, Remmers
cancer incidence projection. AIHW, 2023 (http:// S, Roobol MJ; ERSPC Rotterdam Study Group. A
www.aihw.gov.au/reports/cancer/cancer-d ata-in- detailed evaluation of the effect of prostate-
australia/contents/cancer-data-commentar ies/ speci@c antigen-based screening on morbidity
prostate-cancer-projection-method-changes-u and mortality of prostate cancer: 21-year follow-
pdated) [Accessed 18 October 2023] up results of the Rotterdam Section of the
Prostate Cancer Foundation of Australia; Cancer European Randomised Study of Screening for
Council Australia. PSA testing and early Prostate Cancer. Eur Urol 2023;84(4):426–34. doi:
management of test-detected prostate cancer: 10.1016/j.eururo.2023.03.016. [Accessed 7 April
Clinical practice guidelines. Cancer Council 2024].
Australia (https://www.cancer.org.au/clinical-guid
elines/prostate-cancer/psa-testing) [Accessed 23
May 2023].
70
Prostate cancer
6. European Association of Urology; European 7. National Institute for Health Care and
Association of Nuclear Medicine; European Excellence. Prostate cancer: Diagnosis and
Society for Radiotherapy & Oncology; European management. NICE guideline (NG131). NICE,
Society of Urogenital Radiology; International 2019, update 2021 (http://www.nice.org.uk/guida
Society of Urological Pathology; International nce/ng131/chapter/recommendations)
Society of Geriatric Oncology. [Accessed 7 April 2024].
EAU–EANM–ESTRO–ESUR–ISUP–SIOG
guidelines on prostate cancer. EAU, 2024 (http
s://uroweb.org/guidelines/prostate-cancer/chapt
er/introduction) [Accessed 7 April 2024].
71
Skin cancer
Skin cancer
Cancer | Skin cancer

Melanocytic and keratinocyte (non-melanocytic) skin cancer
Case ?nding age bar
0-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 ≥80

Australia has the world’s highest incidence of skin cancer.1 Skin cancer incidence and mortality is
higher in males than females.2 Melanoma (melanocytic skin cancer) is the third-most common invasive
cancer diagnosed in Australia. In 2021, an estimated 16,878 Australians were diagnosed with invasive
melanoma and a further 27,585 were diagnosed with a melanoma in situ (stage 0; early form of
melanoma).2 Melanoma incidence is similar for males and females up to the age of approximately 45
years but by age 80 years the incidence is twice as high for males than for females. Melanoma
incidence increases with age but is disproportionately high among young adults compared to other
cancers, and is the most commonly diagnosed cancer for the age group 20–39 years.2 Once a person
has developed a melanoma, they are at approximately 5- to 10-times higher risk of developing another
primary melanoma, although personal risk varies according to the presence of different risk factors.3
Keratinocyte cancers (non-melanocytic skin cancers), including basal cell carcinoma (BCC) and
squamous cell carcinoma (SCC), are common in the Australian population. It is estimated that over two-
thirds of Australians will develop a keratinocyte cancer in their lifetime, and many people develop
multiple skin cancers.4
Skin cancer is highly preventable through sun protection strategies.
It is estimated that skin cancer–related conditions account for approximately 3% of all health problems
managed in Australian general practice (not including primary care skin cancer clinics), and this is
higher in regional or remote areas and in areas associated with lower socioeconomic status.5
Identifying risk of melanoma

Use one of these validated melanoma risk assessment tools to determine risk level:
• Risk prediction tools (http://www.melanomarisk.org.au/) | Melanoma Institute Australia

• Melanoma risk predictor (https://publications.qimrberghofer.edu.au/Custom/QSkinMelanoma
Risk) | QIMR Berghofer Medical Research Institute
72
Skin cancer
The following are considered at high risk of melanoma:
• those with previous melanoma.
The following are considered at very high risk of melanoma:
• those with previous melanoma plus any of

◦ multiple atypical naevi
◦ multiple primary melanomas
◦ family history of melanoma
• known carrier of high-risk variant in CDKN2A gene.
Use the following keratinocyte cancer risk assessment tool to determine risk level:
• Keratinocyte cancer risk score (https://publications.qimrberghofer.edu.au/p/qimr/qskinriskcal

culator) | QIMR Berghofer Medical Research Institute
Refer to the Resources section for further information on these tools.
 Screening
6,7,8
For individuals at average/below average risk Generally not N/A
of developing melanoma or keratinocyte recommended
cancer, regular skin checks are not
recommended.
 Case ?nding
6,7
Opportunistic examination of the skin is Conditionally Opportunistically
recommended for individuals at above- recommended (usually no more
average risk of developing melanoma or than once every
keratinocyte cancer. 12 months).
6,7
Regular skin checks are recommended for Conditionally At least every 12
individuals at high risk of developing recommended months.
melanoma or keratinocyte cancer.
73
Skin cancer
Individuals at very high risk of developing a Practice point Six-monthly 6
new primary melanoma should be checked

regularly by a clinician with six-monthly full
skin examination supported by total body
photography and dermoscopy. They and their
partner or carer should be educated to
recognise and document lesions suspicious
of melanoma.
Everyone regardless of their risk category Conditionally N/A 6,7
should be: recommended

• provided with education that raises
awareness of the early signs of skin
cancer
• be encouraged to be familiar with
their skin and get any suspicious new
or changing spots checked by a
doctor
9,10
The most common preventable cause of skin Recommended N/A
cancer is ultraviolet (UV) radiation exposure. (Strong)
All people (especially children, adolescents,
young adults) should be advised to be ‘sun
smart’ – broad-brimmed hat, covering
clothing, sunscreen, sunglasses and shade.
Every morning sunscreen should be applied to
the head, neck, arms and hands. It should be
reapplied after heavy sweating, bathing or
long sun exposure, especially if outdoors
when the UV Index is ≥3.
11
GPs should strongly counsel patients against Practice Point N/A
personal home use of sunbeds or sunlamps
for cosmetic tanning purposes.
12,13
Patients should be advised to avoid getting Practice Point N/A
sunburnt, especially to the point of blistering
and skin peeling, because multiple episodes
have been shown to increase the risk of
developing melanoma.
74
Skin cancer
Further information
Sun protection times are available from the Bureau of Meteorology. Apps for Apple and Android tablets
and smartphones or desktops provide real-time electronic alerts on recommended sun protection
times, current and maximum ultraviolet (UV) levels, and information on recommended exposure for
vitamin D. They are adjustable to speci@c geographic locations around Australia and internationally,
available at SunSmart Global UV (https://apps.apple.com/au/app/sunsmart-global-uv/id1571645042) .
Most Australian adults will maintain adequate vitamin D levels from sun exposure during typical day-to-
day outdoor activities. There is little evidence to suggest that sunscreen increases risk of vitamin D
de@ciency.14
Relevant validated risk tools (calculators) for the Australian population

available to help individuals assess risk
• Risk prediction tools (http://www.melanomarisk.org.au/) | Melanoma Institute Australia
• Melanoma risk predictor (https://publications.qimrberghofer.edu.au/Custom/QSkinMelanoma
Risk) | QIMR Berghofer Medical Research Institute
• Keratinocyte risk score (https://publications.qimrberghofer.edu.au/p/qimr/qskinriskcalculator)
| QIMR Berghofer Medical Research Institute
Each risk tool provides a valid assessment of personal risk, but they have been developed and
presented differently depending on the population for whom they are intended (ie people with or without
a previous melanoma) and because there is little evidence guiding optimal risk category classi@cation
and cut-points. The risk tools have been comprehensively developed but some rare risk factors may be
missing, such as immunosuppression (eg among organ transplant recipients).
Genetic risk assessment
Individuals with or at risk of a mutation in the CDKN2A gene or at high risk for new primary melanoma
In individuals with a strong family history of melanoma (ie three or more cases in @rst- or second-
degree relatives) considered where predictive features are present, such as multiple primary melanoma,
early age of onset, pancreatic cancer, or multiple other cancers, clinical genetic testing for CDKN2A or
other high-risk mutations and genetic counselling should be undertaken.6
Cancer Institute NSW eviQ guidelines (https://www.eviq.org.au/cancer-genetics/adult/genetic-testing-f

or-heritable-pathogenic-variants/1864-cdkn2a-genetic-testing) provide information on risk assessment
and clinical genetic testing for CDKN2A.15
75
Skin cancer

peoples
Aboriginal and Torres Strait Islander people are usually at lower risk of skin cancer, but their actual risk
will depend on the presence of risk factors including the level of skin pigmentation. When Aboriginal
and Torres Strait Islander people are diagnosed with skin cancer, they generally experience poorer
outcomes. Thus, it is important that they are provided with education that raises awareness of the early
signs of skin cancer, and are encouraged to be familiar with their skin and get any suspicious new or
changing spots checked by a doctor. It is also important to note that the acral lentiginous subtype of
melanoma, which accounts for approximately 1% of melanomas diagnosed in Australia, is the most
frequently diagnosed melanoma in persons with darker skin colour, is not related to sun exposure, and
often has a poor prognosis.16 For speci@c recommendations for Aboriginal and Torres Strait Islander
people, please refer to the National guide to a preventive health assessment for Aboriginal and Torres
Strait Islander people (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelin
es/view-all-racgp-guidelines/national-guide/) .
Speci?c populations
Immunosuppression is also a strong risk factor for skin cancer, and organ transplant recipients are at
very high (very much above average) risk of keratinocyte cancers.7
Resources
Educational tools and resources for health professionals to provide messages about skin cancer
prevention, vitamin D and the early detection and management of skin cancer:
Resources for health professionals (https://www.sunsmart.com.au/skin-cancer/health-professionals) |

SunSmart Sunscreen for skin cancer prevention (https://www.racgp.org.au/clinical-resources/clinical-g
uidelines/handi/a-z/s/sunscreen-for-skin-cancer-prevention) , Handbook of non-drug interventions
(HANDI) | RACGP
References
1. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Australian Institute of Health and
Torre LA, Jemal A. Global cancer statistics 2018: Welfare. Cancer data in Australia. Cat. no. CAN
GLOBOCAN estimates of incidence and mortality AIHW, 2022 (https://www.aihw.gov.au/
worldwide for 36 cancers in 185 countries. CA report
s/cancer/cancer-data-in-australia/contents/abou
Cancer J Clin 2018;68(6):394–424. t) [Accessed 11 May 2023].
76
Skin cancer
Cust AE, Badcock C, Smith J, et al. A risk 10. The Royal Australian College of General
prediction model for the development of Practitioners. Handbook of non-drug
subsequent primary melanoma in a population- interventions (HANDI). Sunscreen for skin cancer
based cohort. Br J Dermatol prevention. RACGP, 2014 (https://www.racgp.or
2020;182(5):1148–57. doi: 10.1111/bjd.18524. g.au/clinical-resources/clinical-guidelines/handi/
[Accessed 11 May 2023]. a-z/s/sunscreen-for-skin-cancer-prevention)
Olsen CM, Pandeya N, Green AC, Ragaini BS, Venn [Accessed 8 April 2024].
AJ, Whiteman DC. Keratinocyte cancer incidence Cancer Council Australia. Clinical practice
in Australia: A review of population-based guidelines for keratinocyte cancer > 2.1
incidence trends and estimates of lifetime risk. Strategies for protection from excessive
Public Health Res Pract exposure to ultraviolet radiation. Cancer Council
2022;32(1):e3212203. [Accessed 11 May 2023]. Australia, 2019. [Accessed 8 April 2024].
Reyes-Marcelino G, McLoughlin K, Harrison C, et al. Australian Institute of Health and Welfare 2016.
Skin cancer-related conditions managed in Skin cancer in Australia. Cat. no. CAN 96. AIHW,
general practice in Australia, 2000–2016: A 2016 (https://www.aihw.gov.au/reports/ca
nationally representative, cross-sectional survey. ncer/skin-cancer-in-australia/summary)
BMJ Open 2023;13:e067744. doi: 10.1136/ [Accessed 6 March 2024].
bmjopen-2022-067744. [Accessed 11 May 2023].
13. Cancer Council Victoria; Department of Health
Cancer Council Australia. Clinical practice Victoria. Optimal care pathway for people with
guidelines for the diagnosis and management of melanoma. 2nd edn. Cancer Council Victoria,
melanoma. Cancer Council Australia, 2019. 2021 (https://www.cancer.org.au/assets/pdf/mel
[Accessed 11 May 2023]. anoma-optimal-cancer-care-pathway) [Accessed
Cancer Council Australia. Clinical practice 6 March 2024].
guidelines for keratinocyte cancer > 3. Early 14. Australian Skin and Skin Cancer Research
detection of keratinocyte cancers. Cancer Council Centre. Position statement: Balancing the harms
Australia, 2019. [Accessed 11 May 2023]. and bene@ts of sun exposure. ASSC, 2023 (http
US Preventive Services Task Force; Mangione CM, s://www.assc.org.au/wp-content/uploads/2023/
Barry MJ, et al. Screening for skin cancer: US 01/Sun-Exposure-Summit-PositionStatement_V
Preventive Services Task Force Recommendation 1.9.pdf) [Accessed 8 April 2024].
Statement. JAMA 2023;329(15):1290–95. doi: 15. Cancer Institute NSW eviQ. CDKN2A –
10.1001/jama.2023.4342. PMID: 37071089. Genetic testing. Cancer Institute NSW eviQ, 2022
[Accessed 11 May 2023]. (http://www.eviq.org.au/cancer-genetics/adult/ge
US Preventive Services Task Force; Grossman DC, netic-testing-for-heritable-pathogenic-variants/18
Curry SJ, et al. Behavioral counseling to prevent 64-cdkn2a-genetic-testing) [Accessed 16 May
skin cancer: US Preventive Services Task Force 2023].
Recommendation Statement. JAMA 16. Chakera AH, Read RL, Stretch JR, Saw RPM.
2018;319(11):1134–42. doi: 10.1001/ Diverse presentations of acral melanoma. Aust
jama.2018.1623. PMID: 29558558. [Accessed 11 Fam Physician 2015;44(1–2):43–45. [Accessed
May 2023]. 16 May 2023].
77
Testicular cancer
Testicular cancer
Cancer | Testicular cancer

In Australia, testicular cancer is the second most common cancer in young men aged 20–39 years, not
including non-melanoma skin cancer.1 It is estimated that more than 1000 people were diagnosed with
testicular cancer in 2023 in Australia.1
 Screening

often
2
Screening for testicular cancer in adolescent or adult Not N/A
men is not recommended. recommended
(Strong)
Further information
In 2011, the USPSTF found that screening using clinical or self-examination is unlikely to offer health
bene@ts because of the very low incidence and high cure rate of testicular cancer.2 Potential harms
from screening include false-positive results, anxiety and harms from diagnostic tests or procedures.2

peoples
78
Testicular cancer
References
1. Cancer Council. Testicular cancer. Australia: 2. US Preventive Services Task Force. Testicular
Cancer Council, 2023 (https://www.cancer.org.a Cancer: Screening. USA: USPSTF, 2011 (https://w
u/cancer-information/types-of-cancer/testicular- ww.uspreventiveservicestaskforce.org/uspstf/rec
cancer) [Accessed 3 November 2023]. ommendation/testicular-cancer-screening)
[Accessed 17 January 2024].
79
Thyroid cancer
Thyroid cancer
Cancer | Thyroid cancer

In Australia, thyroid cancer is the ninth most commonly diagnosed cancer.1 It is estimated that more
than 4000 people were diagnosed with thyroid cancer in 2023 in Australia and that one in 79 people will
be diagnosed with the condition by the time they are 85 years of age.1
 Screening
How
often
2
Screening for thyroid cancer in asymptomatic adults is Not N/A
not recommended. recommended
(Strong)
Further information
In 2017, the USPSTF found that screening for thyroid cancer in asymptomatic people resulted in harms
that outweigh the bene@ts.2

peoples
80
Thyroid cancer
References
1. Cancer Council. Thyroid cancer. Australia: Cancer 2. US Preventive Services Task Force. Thyroid
Council, 2023 (https://www.cancer.org.au/cancer- Cancer: Screening. USA: USPSTF, 2017 (https://w
information/types-of-cancer/thyroid-cancer) ww.uspreventiveservicestaskforce.org/uspstf/rec
[Accessed 2 November 2023] ommendation/thyroid-cancer-screening)
[Accessed 17 January 2024]
81
Thyroid cancer
Cardiovascular
82
Thyroid cancer
Cardiovascular
Atrial @brillation (https://www.racgp.org.au/clinical-resources/clinical-guideline

s/key-racgp-guidelines/view-all-racgp-guidelines/preventive-activities-in-general-
practice/cardiovascular/atrial-@brillation) Cardiovascular disease (CVD) risk (htt
ps://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guideline
s/view-all-racgp-guidelines/preventive-activities-in-general-practice/cardiovascul
ar/cardiovascular-disease-cvd-risk) Kidney (https://www.racgp.org.au/clinical-re
sources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/preve
ntive-activities-in-general-practice/cardiovascular/kidney)
83
Atrial fibrillation
Atrial ?brillation
Cardiovascular | Atrial ?brillation

Case ?nding age bar
0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75–79 ≥80

Atrial @brillation (AF) is the most common recurrent arrhythmia in Australia, with estimates suggesting
that approximately 2–4% of the Australian population has AF and prevalence increasing with age.1,2 It is
expected that AF cases in people aged ≥55 years will increase over the next 20 years due to the ageing
population and improved survival from contributory diseases.1
AF can be persistent or paroxysmal. Although AF can be symptomatic (transient ischaemic attack [TIA],
stroke, breathlessness, reduced exercise capacity, palpitations, syncope or dizziness, fatigue,
weakness, chest discomfort),2–4 it can also be asymptomatic.1 Clinical AF is known to increase stroke
risk,5,6 but the stroke risk associated with subclinical AF, particularly low-burden or short-duration AF, is
less well understood.5,7,8 As of 2018, AF was listed as the underlying or associated cause of over
14,000 deaths in Australia (9.0% of total deaths).2
Screening for AF in asymptomatic people is undertaken to determine whether someone is at sulciently

high risk to require oral anticoagulants to prevent a thromboembolic event.
 Screening
5
Screening for AF, with an electrocardiogram Practice point N/A
(ECG) or other device, has insulcient
evidence to assess the balance of bene@ts
and harms in adults aged ≥50 years without:
• a diagnosis or symptoms of AF
• a history of TIA or stroke.
84
Atrial fibrillation
 Case ?nding
Opportunistic clinical palpation or Recommended Opportunistically. 1
auscultation is recommended to detect (Strong)

asymptomatic AF in people aged ≥65 years
(in the clinic or community).
If irregular, this should be followed by an ECG,
or by an ECG rhythm strip using a handheld
ECG. The presence of AF can be missed
when using automatic blood pressure
machines.
Further information
Apart from increasing age, AF risk factors and comorbidities include:1,9–13
• hypertension
• heart failure
• coronary artery disease
• valvular heart disease
• obesity
• diabetes
• chronic kidney disease
• family history of AF
• smoking
• obstructive sleep apnoea
• alcohol
• thyroid disease.

peoples
Cardiovascular disease prevention (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-
racgp-guidelines/view-all-racgp-guidelines/national-guide/chapter-11-cardiovascular-disease-preventio
n) chapter in the National guide to a preventive health assessment for Aboriginal and Torres Strait
Islander people.
85
Atrial fibrillation
References
NHFA CSANZ Atrial Fibrillation Guideline Working Noseworthy P, Kaufman E, Chen L, et al.
Group; Brieger D, Amerena J, et al. National Heart Subclinical and device-detected atrial fibrillation:
Foundation of Australia and the Cardiac Society Pondering the knowledge gap: A scientific
of Australia and New Zealand: Australian clinical statement from the American Heart Association.
guidelines for the diagnosis and management of Circulation. 2019;140(25): e944–63. doi: 10.1161/
atrial fibrillation 2018. Heart Lung Circ. CIR.0000000000000740. [Accessed 16 May
2018;27(10):1209–66. doi: (http://10.1 016/ 2023].
j.hlc.2018.06.1043.) Benjamin E, Go A, Desvigne-Nickens P, et al.
Australian Institute of Health and Welfare. Atrial Research priorities in atrial fibrillation screening:
fibrillation in Australia. Australian Government, A report from a National Heart, Lung, and Blood
2020 (https://www.aihw.gov.au/repo rts/heart- Institute virtual workshop. Circulation
stroke-vascular-diseases/atrial-fibrillatio 2021;143(4):372–88. doi: 10.1161/
in-australia) [Accessed 16 May 2023]. CIRCULATIONAHA.120.047633. [Accessed 16
National Institute for Health and Care Excellence May 2023].
(NICE). Atrial fibrillation: diagnosis and Ball J, Carrington M, McMurray J, et al. Atrial
management. NICE, 2021 (https://www.nic fibrillation: Profile and burden of an evolving
org.uk/guidance/ng196) [Accessed 16 May epidemic in the 21st century. Int J Cardiol.
2023]. 2013;167(5):1807–24. doi: 10.1016/
Yi JE, Lee YS, Choi EK, et al. CHA2DS2-VASc score ijcard.2012.12.093. [Accessed 16 May 2023].
predicts exercise intolerance in young and middle- Briffa T, Hung J, Knuiman M, et al. Trends in
aged male patients with asymptomatic atrial incidence and prevalence of hospitalization for
fibrillation. Sci Rep 2018;8:18039. doi: 10.1038/ atrial fibrillation and associated mortality in
s41598-018-36185-7. [Accessed 16 May 2023]. Western Australia, 1995–2010. Int J Cardiol 2016;
208:19–25. doi: 10.1016/j.ijcard.2016.01.196.
US Preventive Services Task Force; Davidson KW,
Barry MJ, et al. Screening for atrial fibrillation: US
Preventive Services Task Force recommendation Verma K, Wong M. Atrial fibrillation. Aust J Gen
statement. JAMA Pract 2019;48(10):694–99. doi: 10.31128/
2022;327(4):360–67. doi: 10.1001/ AJGP-12-18-4787. [Accessed 16 May 2023].
jama.2021.23732. [Accessed 16 May 2023]. Gallagher C, Hendriks JML, Elliott AD, et al.
Wolf P, Abbott R, Kannel W. Atrial fibrillation as an Alcohol and incident atrial fibrillation – a
independent risk factor for stroke: The systematic review and meta-analysis. Int J
Framingham Study. Stroke 1991;22(8):983–88. Cardiol. 2017;246:46–52. doi: 10.1016/
doi: 10.1161/01.STR.22.8.983. [Accessed 16 May ijcard.2017.05.133. [Accessed 16 May 2023].
2023].
Al-Makhamreh H, Al-Ani A, Alkhulaifat D, et al.
Impact of thyroid disease in patients with atrial
@brillation: Analysis from the JoFib registry. Ann
Med Surg (Lond). 2022;74:103325. doi: (http://1
0.1016/j.amsu.2022.103325.)
86
Cardiovascular disease (CVD) risk
Cardiovascular | Cardiovascular disease

(CVD) risk
Screening age bar
0–9 10–14 15–19* 20–24* 25–29* 30–34* 35–39* 40–44* 45–49# 50–54# 55–59# 60–64# 65–69# 70–74# 75–7
*Check blood pressure
opportunistically for people aged #Screen all people aged 45–79 years without known CVD
18–44 years

Cardiovascular disease (CVD) was the underlying cause of 25% of all deaths in Australia in 2019.1
Behavioural and biomedical risk factors for developing CVD include smoking, diabetes, raised blood
pressure (BP), dyslipidaemia, metabolic syndrome, physical inactivity and poor diet.1,2 It is estimated
that 57% of Australian adults had three or more key modi@able CVD risk factors in 2014–18.1
Additionally, family history of premature heart disease in a @rst-degree female relative aged <65 years or
a @rst-degree male relative aged <55 years, severe mental illness, and psychosocial stressors are
recognised risk factors for CVD.2,3
Use of the Australian CVD risk calculator (https://www.cvdcheck.org.au/calculator) is recommended to

assess risk and guide further management.
 Screening
Screening for high blood pressure (BP) in Generally not N/A 4
children and adolescents is generally not recommended

recommended.
87
Screening for hypertension in the general Recommended Opportunistically, 2, 5
population (from age 18 years) is (Strong) (Practice point)

recommended. Secondary causes and white
coat hypertension should be considered (refer
to Further information).
For further detail, please see the Heart
Foundation’s ‘Guidelines for the diagnosis and
management of hypertension in adults –
2016 (http://www.mja.com.au/journal/2016/2
05/2/guideline-diagnosis-and-management-h
ypertension-adults-2016) ’.
Routine measuring of cholesterol before age Generally not N/A 2, 6
45 years is generally not recommended, recommended

unless familial hypercholesterolaemia (http
s://www.racgp.org.au/clinical-resources/clini
cal-guidelines/key-racgp-guidelines/view-all-r
acgp-guidelines/genomics-in-general-practic
e/disease-speci@c-topics/familial-hyperchole
sterolaemia) is suspected.
2
Assessing cardiovascular disease (CVD) risk Recommended Every 5years
in all people aged 45–79 years using the (Strong) unless risk
Australian CVD risk calculator (https://www.c factors worsen.
vdcheck.org.au/calculator) is recommended. Intervals
Refer to the Australian guideline for assessing between
and managing cardiovascular disease risk (htt reassessments
ps://www.cvdcheck.org.au/overview) for risk (https://www.cvd
categorisation, management and follow-up. check.org.au/ide
ntify-risk-categor
y) of CVD risk
should be
determined
using the most
recent estimated
risk level as
baseline.
2, 7
Screening for CVD risk using a coronary Not N/A
artery calcium (CAC) score (https://www.racg recommended
p.org.au/clinical-resources/clinical-guideline (Strong)
s/key-racgp-guidelines/view-all-racgp-guidelin
es/@rst-do-no-harm/gp-resources/coronary-ar
tery-calcium-scoring) is not recommended in
the general population.
88
If the person has other signi@cant risk Practice point N/A 2
considerations (https://www.cvdcheck.org.a
u/reclassi@cation-factors-other-consideration
s) (eg family history, severe mental illness,
estimated glomerular @ltration rate [eGFR]
<45), consult the Australian cardiovascular
disease risk calculator (https://www.cvdchec
k.org.au/calculator) for further information.
Recommendation Grade How often Reference
Smoking cessation Recommended N/A 2
Encouraging, supporting and advising all (Strong)

people who smoke to quit is recommended.
Refer them to a behavioural intervention (eg
smoking cessation counselling program)
combined with a Therapeutic Goods
Administration–approved pharmacotherapy,
where clinically indicated.
2
Physical activity Recommended N/A
Regular, sustainable physical activity, such as (Strong)
an exercise program, is recommended to
reduce risk of CVD.
2
Healthy eating Recommended N/A
Following a healthy eating pattern low in (Strong)
saturated and trans fats is recommended. A
healthy eating pattern should consist of:
• plenty of vegetables, fruit and
wholegrains
• a variety of healthy protein-rich foods
from animal and/or plant sources
• unfavoured milk, yoghurt and cheese
• foods that contain healthy fats and
oils (eg olive oil, nuts and seeds, and
@sh).
89
Consume oily Lsh Conditionally N/A 2
Regular consumption of oily @sh is recommended

recommended to reduce risk of coronary
heart disease and death due to coronary
heart disease.
Restrict sodium Conditionally N/A 2
Restriction of sodium intake to lower BP is recommended

recommended.
Healthy weight Conditionally N/A 2
Achieving and maintaining a healthy weight is recommended

recommended.
Alcohol consumption Conditionally N/A 2
Reducing alcohol consumption where recommended

necessary, for people who consume alcohol,
is recommended. Refer to the national
guidelines (https://www.nhmrc.gov.au/health-
advice/alcohol) to reduce health risks from
drinking alcohol.
2
Aspirin Practice point N/A
It is currently unclear if the additional bene@ts
of taking aspirin for the primary prevention of
CVD outweigh the potential harms of
gastrointestinal bleeding. Refer to Further
information.
Further information
Blood pressure
Measure BP on at least two separate occasions with a calibrated mercury sphygmomanometer, or
automated device that is regularly calibrated against a mercury sphygmomanometer. For the Australian
CVD risk calculator (https://www.cvdcheck.org.au/calculator) , use the average of the last two seated,
in-clinic BP measurements, or two measurements at least 10 minutes apart if at the same visit.2 At the
patient’s @rst BP assessment, measure BP on both arms. Thereafter, use the arm with the higher
reading.
In patients who may have orthostatic hypotension (eg elderly, diabetic), measure BP in a sitting position
and repeat after the patient has been standing for at least two minutes.6
Ambulatory BP monitoring
90
If possible, use ambulatory BP monitoring or self-measurement or out-of-clinic measurements for

patients with:6
• unusual variation between BP readings in the clinic

• suspected ‘white coat’ hypertension
• hypertension that is resistant to drug treatment
• suspected hypotensive episodes.
Primary aldosteronism
Primary aldosteronism occurs in approximately 5–10% of patients with hypertension, and should be
suspected in patients with:6,8
• moderate to severe hypertension (sustained BP above 150/100 in three separate

measurements taken on different days)
• treatment-resistant hypertension (hypertension is controlled with four or more medications)
• hypokalaemia.
Referral to a specialist for investigation is recommended when primary aldosteronism is suspected.6

The management of primary aldosteronism: Case detection, diagnosis, and treatment: An Endocrine
Society clinical practice guideline (https://academic.oup.com/jcem/article/101/5/1889/2804729)
provides further information.
Cholesterol
If lipid levels are abnormal, a second con@rmatory sample should be taken on a separate occasion (as
levels may vary between tests) before making a treatment decision based on a risk assessment. A
fasting sample should be used when assessing elevated triglycerides.
Screening tests using capillary blood samples produce total cholesterol results that are slightly lower
than on venous blood. These may be used, providing they are con@rmed with full laboratory testing of
venous blood for patients with elevated lipid levels and there is good follow-up.
In adults with low CVD risk, blood tests results within @ve years may be used for review of CVD risk,
unless there are contrary reasons to review more regularly.
Lipoprotein(a)
There is currently no justi@cation for lipoprotein(a) screening in the general population.2
Prevention
It is important to communicate @ve-year CVD risk to patients to enable informed decisions about
reducing risk and improve compliance.2
Modi@able risk factors should be managed at all risk levels.
91
Managing CVD risk should always involve encouraging, supporting and advising appropriate healthy
lifestyle and behaviours, with or without BP-lowering and/or lipid-modifying pharmacotherapy. Once the
recommended management plan is identi@ed according to risk category, this needs to be further re@ned
in collaboration with the person, after discussing the risks and bene@ts of treatment options, and their
personal values and preferences.
People vary in what they @nd motivating; for some this is having targets in place. Set targets in
consultation with the person according to what is practicable and achievable for them.
Pre-existing cardiovascular disease requires preventive pharmacotherapy. Conditions include:2
• myocardial infarction
• angina
• other coronary heart disease
• stroke
• transient ischaemic attack
• peripheral vascular disease
• congestive heart failure
• other ischaemic CVD-related conditions.
Aspirin
As part of patient decision making, GPs may want to also consider the aspirin recommendation in
relation to bowel cancer prevention. Please refer to the Bowel cancer (https://www.racgp.org.au/wip-sit
es/preventive-activities-in-general-practice/cancer/colorectal-cancer) chapter.
Please also refer to the Atrial @brillation (https://www.racgp.org.au/wip-sites/preventive-activities-in-ge

neral-practice/cardiovascular/atrial-@brillation) , Kidney (https://www.racgp.org.au/wip-sites/preventive-
activities-in-general-practice/cardiovascular/kidney) and Diabetes (https://www.racgp.org.au/wip-sites/
preventive-activities-in-general-practice/metabolic/diabetes) chapters for further information on
screening and preventive activities.

peoples
Aboriginal and Torres Strait Islander people experience a higher burden, earlier onset and faster
progression of kidney disease, due to ongoing impacts of colonisation (CKD guidelines). CVD risk
assessments also need to commence earlier for Aboriginal and Torres Strait Islander people.
Assess CVD risk2
• Aboriginal and Torres Strait Islander people, without known CVD, aged 30–79 years.
Assess individual CVD risk factors2
• Aboriginal and Torres Strait Islander people, without known CVD, aged 18–29 years.
92
Assessment can be considered in younger age groups (aged 12–17 years). Please refer to the National
guide to a preventive health assessment for Aboriginal and Torres Strait Islander people, Chapter 11:
Cardiovascular disease prevention (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-
racgp-guidelines/view-all-racgp-guidelines/national-guide/chapter-11-cardiovascular-disease-preventio
n) .
Speci?c populations
There are some speci@c populations that are associated with high rates of CVD whose risk
assessments need to commence earlier than usual.2
Assess CVD risk2
• People with diabetes, without known CVD, aged 35–79 years.

• First Nations people, without known CVD (includes Aboriginal and Torres Strait Islander people
and Māori people), aged 30–79 years.
Assess individual CVD risk factors2
• First Nations people, without known CVD (includes Aboriginal and Torres Strait Islander people
and Māori people), aged 18–29 years.
People living with severe mental illness are sixfold more likely to die from CVD than people without
severe mental illness.9 For people living with severe mental illness, consider reclassifying estimated
CVD risk to a higher risk category, particularly if calculated risk is close to a higher risk threshold.2
People with reduced eGFR, or persistently raised urine albumin-to-creatinine ratio, are at increased CVD
risk.2
Resources
A guideline for GPs and other health professionals to support people who wish to quit smoking:
Supporting smoking cessation: A guide for health professionals (https://www.racgp.org.au/clinical-resour
ces/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/supporting-smoking-cessation) |
RACGP A guide for GPs and other health professionals to work with patients on the lifestyle risk
factors of smoking, nutrition, alcohol and physical activity (SNAP): Smoking, nutrition, alcohol, physical
activity (SNAP) (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/vie
w-all-racgp-guidelines/snap) | RACGP For further information about familial hypercholesterolaemia:
Familial hypercholesterolaemia (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-rac
gp-guidelines/view-all-racgp-guidelines/genomics-in-general-practice/disease-speci@c-topics/familial-h
ypercholesterolaemia) , Genomics in general practice (https://www.racgp.org.au/clinical-resources/clini
cal-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/genomics-in-general-practice/disease-sp
eci@c-topics/familial-hypercholesterolaemia) | RACGP The early identi@cation and optimal
management of people with type 2 diabetes: Management of type 2 diabetes: A handbook for general
practice (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-r
acgp-guidelines/diabetes/introduction) | RACGP Comprehensive guideline about CVD risk assessment
and management: Australian guideline for assessing and managing cardiovascular disease risk (http
93
s://www.cvdcheck.org.au/) | Australian Chronic Disease Prevention Alliance A risk assessment,

communication and management tool for health professionals: Australian CVD risk calculator (http
s://www.cvdcheck.org.au/calculator) | Heart Foundation, Australian Chronic Disease Prevention
Alliance Evidence-based advice on the health effects of drinking alcohol: Australian guideline to reduce
risks from drinking alcohol (https://www.nhmrc.gov.au/about-us/publications/australian-guidelines-red
uce-health-risks-drinking-alcohol) | National Health and Medical Research Council (https://www.nhmr
c.gov.au/about-us/publications/australian-guidelines-reduce-health-risks-drinking-alcohol) Further
information and resources to help improve the physical health, including cardiovascular health, of
people living with mental illness: Equally Well (https://www.equallywell.org.au/)
References
Australian Institute of Health and Welfare. Heart, U.S. Preventive Services Task Force; Krist AH,
stroke and vascular disease: Australian facts. Davidson KW, Mangione CM, et al. Screening for
AIHW, 2023 (https://www.aihw.gov.au/repo rts/ hypertension in adults: U.S. Preventive Services
heart-stroke-vascular-diseases/hsvd-facts) Task Force reaffirmation recommendation
[Accessed 15 May 2023]. statement. JAMA 2021;27;325(16):1650–56. doi:
Heart Foundation, Australian Chronic Disease 10.1001/jama.2021.4987. PMID: 33904861.
Prevention Alliance. Australian guideline for [Accessed 13 March 2024].
assessing and managing cardiovascular disease The Royal Australian College of General
risk. Department of Health and Aged Care, 2023 Practitioners. Genomics in general practice.
(https://www.cvdcheck.org.au) [Accessed 13 RACGP, 2022. [Accessed 13 March 2024].
March 2024]. The Royal Australian College of General
Gronewold J, Engels M, van de Velde S, et al. Practitioners. First do no harm: A guide to
Effects of life events and social isolation on choosing wisely in general practice. RACGP, 2023.
stroke and coronary heart disease. Stroke [Accessed 13 March 2024].
2021;52(2):735–47. doi: 10.1161/ Funder JW, Carey RM, Mantero F, et al. The
STROKEAHA.120.032070. [Accessed 13 March management of primary aldosteronism: Case
2024]. detection, diagnosis, and treatment: An Endocrine
Gartlehner G, Vander Schaaf EB, Orr C, et al. Society clinical practice guideline. J Clin
Screening for hypertension in children and Endocrinol Metab 2016;101(5):1889–916. doi:
adolescents: Systematic review for the U.S. 10.1210/jc.2015-4061. PMID: 26934393.
Preventive Services Task Force. Evidence [Accessed 13 March 2024].
Synthesis, no. 193. Rockville, MD: Agency for National Mental Health Commission. Equally Well
Healthcare Research and Quality (U.S.), 2020 (htt consensus statement: Improving the physical
ps://www.ncbi.nlm.nih.gov/books/NBK564973) health and wellbeing of people living with mental
[Accessed 13 March 2024]. illness in Australia. NMHC, 2016.
[Accessed 13 March 2024].
94
Kidney
Kidney
Cardiovascular | Kidney
Due to Australia’s ageing population, decreasing renal function is a signi@cant issue. However, people
can remain largely symptom free until 90% of kidney function is lost.
Kidney Health Australia de@nes chronic kidney disease (CKD) as an estimated or measured glomerular
@ltration rate (GFR) <60 mL/min/1.73m2 that is present for ≥3 months with or without evidence of
kidney damage,1 or evidence of kidney damage, with or without decreased GFR, that is present for ≥3
months, as evidenced by the following:1
• albuminuria
• haematuria after exclusion of urological causes
• structural abnormalities (eg on kidney imaging tests)
• pathological abnormalities (eg kidney biopsy).
CKD in itself is not a primary diagnosis. Attempts should be made to identify the underlying cause of
CKD and to fully specify it.1
People with the following are at increased risk of CKD:1,2
• diabetes
• hypertension
• established cardiovascular disease (ischaemic heart disease, chronic heart failure, peripheral
vascular disease or cerebral vascular disease)
• family history of kidney failure
• obesity (body mass index = 30 kg/m2)
• current or past smoker
• history of acute kidney injury
• structural renal tract disease, recurrent renal calculi or prostatic hypertrophy
• multisystem diseases with potential kidney involvement (eg systemic lupus erythematosus)
• gout
• incidental detection of haematuria or proteinuria.
There is a higher prevalence of kidney disease in Aboriginal and Torres Strait Islander people.3
95
Kidney
 Case ?nding

often
Detection of CKD should be targeted and focused Practice point For AKI: 1,2
with a history of: every

• acute kidney injury (AKI) year for
• family history of kidney failure. @rst
3 years
post-
AKI,
then
every 2
years
For
family
history
of
kidney
failure:
every 2
years
96
Kidney
Other testing for CKD with estimated GFR (eGFR), Refer to CVD risk Refer to 1, 4
creatinine and albumin-to-creatinine ratio is chapter for CVD risk

included as part of cardiovascular disease (CVD) individual (http
risk assessment and routine monitoring of chronic recommendations s://ww
diseases such as: w.racg
• diabetes (annually) p.org.a
• hypertension (annually) u/clinica
• established cardiovascular disease (every l-resourc
2 years) es/clinic
• obesity (every 2 years) al-guidel
• smoking (every 2 years). ines/ke
y-racgp-
Please refer to Further information for cautions guidelin
about overdiagnosis and underdiagnosis in CKD. es/view-
all-racg
p-guideli
nes/pre
ventive-
activitie
s-in-gen
eral-prac
tice/car
diovasc
ular/car
diovasc
ular-dise
ase-cvd-
risk)
chapter
Further information
Causes of kidney failure

Common causes of kidney failure include:1,5
• diabetic nephropathy 40%

• glomerular disease 18%
• hypertension/renal vascular disease 11%
• familial/hereditary kidney diseases 7%.
Other causes (24%) include tubulointerstitial disease, other systemic diseases affecting the kidney and
miscellaneous kidney disorders.
97
Kidney
Diabetic nephropathy
Diabetic nephropathy is the single leading cause of end-stage renal disease.1,2,5 It occurs in one in four
women and one in @ve men with type 2 diabetes,6 and is more common in Aboriginal and Torres Strait
Islander peoples.3,7
For further information on diabetic nephropathy, please refer to RACGP and Diabetes Australia’s
Management of type 2 diabetes: A handbook for general practice, Microvascular complications:
Nephropathy (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/vie
w-all-racgp-guidelines/diabetes/microvascular-complications-nephropathy) .
GFR testing1
GFR is accepted as the best overall measure of kidney function.1 In clinical practice, GFR is often
estimated (eGFR) from serum creatinine and other parameters, including sex and age, using a formula
such as that of the CKD epidemiology collaboration (CKD-EPI).
However, eGFR can be unreliable or misleading, and so care should be taken in accepting an eGFR at
face value.1,3 Factors that can impact the eGFR value include:
• acute changes in kidney function (eg AKI)

• on dialysis
• recent consumption of cooked meat (consider re-assessment when the individual has fasted
or speci@cally avoided a cooked meat meal within 4 hours of blood sampling)
• exceptional dietary intake (eg vegetarian diet, high protein diet, creatine supplements)
• extremes of body size
• conditions of skeletal muscle, paraplegia, or amputees (may overestimate eGFR)
• high muscle mass (may underestimate eGFR)
• aged <18 years
• severe liver disease present
• eGFR values >90 mL/min/1.73m2
• drugs (eg trimethoprim) interacting with creatinine excretion
• pregnancy.
Minor changes in eGFR (≤15% change) could be due to physiological or laboratory variability.
Overdiagnosis and underdiagnosis of CKD

There are concerns over the classi@cation of declining kidney function in older people, and the potential
for overdiagnosis.8,9 Management recommendations are based on absolute eGFR cut-off values,
irrespective of age.8 This may lead to overdiagnosis and overtreatment of patients who would
otherwise not progress to kidney failure.
98
Kidney
Conversely, younger patients (particularly Aboriginal and Torres Strait Islander patients and/or with
diabetes) with a rapidly declining eGFR that is still in the normal range may not be recognised as having
a clinical problem until their kidney function is substantially reduced.8 A study found that the use of an
age-percentile chart (https://ebm.bmj.com/content/27/5/288.long) showed potential to change GP
classi@cation of declining kidney function, in order to prevent both overdiagnosis and underdiagnosis.8

peoples
While major modi@able risk factors in Aboriginal and Torres Strait Islander people are the same as
those in non-Indigenous people (refer above), social and political determinants of the health such as
poverty, living conditions and racism contribute to rates of CKD in Aboriginal and Torres Strait Islander
populations.3 Diabetic nephropathy also occurs at higher rates for Aboriginal and Torres Strait Islander
peoples.3,7
Please refer to the National guide to a preventive health assessment for Aboriginal and Torres Strait
Islander people, Chapter 13: Chronic kidney disease prevention and management (https://www.racgp.or
g.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/national-guid
e/chapter-13-chronic-kidney-disease-prevention-and-m) .
Speci?c populations
People with severe socioeconomic disadvantage may also be at higher risk of CKD.3
Resources
Microvascular complications: Nephropathy (https://www.racgp.org.au/clinical-resources/clinical-guideli
nes/key-racgp-guidelines/view-all-racgp-guidelines/diabetes/microvascular-complications-nephropath
y) , Management of type 2 diabetes: A handbook for general practice | RACGP and Diabetes Australia
CKD management in primary care (https://kidney.org.au/health-professionals/ckd-management-handboo
k) | Kidney Health Australia
References
Kidney Health Australia. CKD management in National Aboriginal Community Controlled Health
primary care. 5th edn. KHA, 2024 (https://kidne Organisation and The Royal Australian College of
org.au/health-professionals/ckd-management-h General Practitioners. National guide to a
andbook) [Accessed 7 April 2024]. preventive health assessment for Aboriginal and
Torres Strait Islander people. 3rd edn. RACGP,
National Institute for Health and Care
2018. [Accessed 7 April 2024].
Excellence. Chronic kidney disease: Assessment
and management. NICE, 2021 (https://www.nic Department of Health and Aged Care. Australian
org.uk/guidance/ng203) [Accessed 7 April guideline for assessing and managing
2024]. cardiovascular disease risk. Department of Health
and Aged Care, 2023. [Accessed 7 April 2024].
99
Kidney
Australia and New Zealand Dialysis & Transplant Guppy M, Glasziou P, Beller E, et al. Kidney
Registry (ANZDATA). ANZDATA 46th annual trajectory charts to assist general practitioners in
report 2023 (Data to 2022). Chapter 1: Incidence the assessment of patients with reduced kidney
of kidney failure with replacement therapy. function: a randomised vignette study. BMJ Evid
ANZDATA, 2023 (https://www.anzdata.or Based Med 2022;27(5):288-95. [Accessed 12
au/wp-content/uploads/2023/09/ANZDATA_A April 2024].
R-2022-23_Chapter-1_F4.pdf) [Accessed 12 April Moynihan R, Glassock R, Doust J. Chronic kidney
2024]. disease controversy: How expanding definitions
Thomas MC, Weekes AJ, Broadley OJ, Cooper are unnecessarily labelling many people as
ME, Mathew TH. The burden of chronic kidney diseased. BMJ. 2013;29:347:f4298. doi: 10.1136/
disease in Australian patients with type 2 bmj.f4298. PMID: 23900313.
diabetes (the NEFRON study). Med J Aust [Accessed 12 April 2024].
2006;185(3):140–44. [Accessed 12 April 2024].
7. Australian Institute of Health and Welfare. The
health and welfare of Australia’s Aboriginal and
Torres Strait Islander peoples 2015. AIHW, 2015.
[Accessed 12 April 2024].
100
Kidney
101
Kidney
Developmental delay and autism (https://www.racgp.org.au/clinical-resources/cl

inical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/preventive-activi
ties-in-general-practice/development-and-behaviour/autism) Preventive
activities in childhood (https://www.racgp.org.au/clinical-resources/clinical-guid
elines/key-racgp-guidelines/view-all-racgp-guidelines/preventive-activities-in-gen
eral-practice/development-and-behaviour/childhood-development)
102
Developmental Delay and Autism
Development and behaviour |

Case 9nding age bar
0–9* 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75–79 ≥80
*Case Lnding from 0 – 5 years.

Child development occurs rapidly across all domains early in life, with most milestones met in the Lrst
three years of life.1
Developmental domains that should be assessed are social, emotional, communication, cognition/Lne
motor/self-care and gross motor. More than one in Lve children are developmentally vulnerable in at
least one domain,2 with boys more vulnerable to delay in all domains. Parental health, including mental
health, can have a signiLcant impact on children’s health and lives in general, with an Australian survey
showing that 12% of parents living with children rated their health as fair or poor, with a rate of 21%
among Aboriginal and Torres Strait Islander people.3
Current estimates are that 7.4% of children aged 0–14 years have some level of disability, with the most
prevalent disabilities being intellectual (4.3%) and sensory and speech (3.2%).4 At Lve years of age, one
in Lve children is described as developmentally vulnerable in Australia.5 Missed or delayed reporting of
developmental delay may be associated with parental factors.6
Based on international data, the prevalence of autism spectrum disorder is thought to be 1–2%,7 with a
higher prevalence in males. The male to female ratio was previously thought to be 3–4 : 1, but more
recent data suggest this ratio is closer due to the ‘masking’ of symptoms by girls and a diagnostic bias
towards boys.7–9
Autism is a neurodevelopmental condition that affects child development in the Lrst few years of life
and remains present for life. Autism is characterised by differences or delays in social communication
and social interaction, which include problems with social or emotional reciprocity (a back-and-forward
sharing of emotions) and joint attention between carer and child, as well as restricted, repetitive
behaviour and interests and sensory issues. The latter can be a hypo- or hypersensitivity to any of the
Lve senses.9
103
Early detection allows remediation, support for families and planned proactive developmental
monitoring. Developmental delay is diagnosed when milestones are not met in one or more domains:
social, emotional, communication, cognition, Lne or gross motor. Developmental disability occurs when
there are functional impacts for a child’s physical, cognitive, language or behaviour. ‘Developmental
vulnerability’ is a term for children who are at risk of developmental delay because of child factors or
environmental factors.
In addition to general practice opportunities to detect and manage developmental delay, there are
children’s health services organised at state and territory levels. Parents are encouraged through
handheld personal health records to use Parents’ Evaluation of Developmental Status (PEDS) (https://w
ww.rch.org.au/ccch/peds/About_PEDS/) assessments at intervals from birth to Lve years. Refer to the
Preventive activities in childhood (https://www.racgp.org.au/wip-sites/preventive-activities-in-general-pr
actice/development-and-behaviour/childhood-development) (https://www.racgp.org.au/clinical-resourc
es/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/preventive-activities-in-general-pra
ctice/development-and-behaviour/childhood-development) chapter for more information.
 Screening
6
General population screening with Generally not N/A
standardised tools for developmental delay is recommended
not recommended in children aged <5 years.
10
Screening for speech and language delay is Not N/A
not recommended in the general population of recommended
children aged <5 years. (Strong)
11
General population screening for autism Generally not N/A
spectrum disorder in young children aged recommended
1.5–5 years is generally not recommended in
those for whom no concerns of autism
spectrum disorder have been raised (because
of insuacient evidence).
 Case 9nding
104
In children at risk of developmental delay (see

Box 1), assess achievement of milestones in 6, 12
Practice Point Opportunistically
social, emotional, communication, cognition,
Lne and gross motor domains.
In children aged <5 years:

• be alert for risk factors, including low
birthweight, premature birth, family
history of developmental delay,
prenatal exposure to alcohol and
Practice Point Opportunistically 6, 12
other drugs
• elicit parent/carer concerns about
developmental delay
• observe but do not formally assess
development.
Further information
When assessing child development, an understanding of the context in which child development occurs
will assist with both the assessment process and advising parents and carers about how their child is
going and how they can assist development. Particularly in the Lrst year, the development by the child
of secure attachment to their primary carer and the development of warm, responsive relationships will
accelerate their neurological development,13,14 enhancing their social, emotional and interpersonal
skills.
As child development progresses beyond age 12 months, two aspects are of great importance to
childhood development, namely play and the emergence of language skills. Play, particularly with
another person, provides opportunities to develop skills such as communicating, thinking, solving
problems, moving and being with other people, including other children. In a similar way, language skills,
which are a part of the broader communication developmental domain, provide opportunities for the
enhancement of development across all the domains. Making parents and carers aware of the
importance of providing opportunities for play, language and shared attention and interaction will
enhance development, which is particularly important for the child for whom there may be
developmental concerns.
When developmental concerns are fagged, a thorough assessment of the child’s development is
essential. This may involve assessment by allied health or non-GP specialists. If developmental delays
are conLrmed, outcomes for children have been shown to be improved by early intervention using
evidence-based programs, which are funded by the National Disability Insurance Scheme (NDIS) early
childhood approach. Children who do not fully meet the deLnition of developmental delay but still have
developmental concerns will also be supported through this program.
Pragmatic approaches in the GP context can include making the family’s journey to the doctor as easy
as possible. Be aware of the stress that attending appointments can cause young people with autism
and consider fexible approaches to consultations and offer support for families or carers. In recent
105
years there has been a drift away from using the terms ‘high functioning’ and ‘low functioning’ because
often the degree of functional impairment may not be determined by the level of autism, but more by
co-diagnoses that often accompany an autism diagnosis.13 Common co-occurring conditions include
intellectual disability,7 speciLc learning disorders,7 speech and language disorders, epilepsy and seizure
disorders,14 attention deLcit hyperactivity disorder (ADHD),14 anxiety15 and depression (more common
in older children and adolescents).15,16
Box 1. Factors indicating children at risk of developmental delay6,12

• Prematurity
• Low birthweight
• Birth complications
• Poor maternal health during pregnancy
• Prenatal exposure to alcohol or drugs
• Infections
• Genetic characteristics
• Trauma
• Maltreatment
• Exposure to toxins
• Lead poisoning
• Low socioeconomic status

peoples
For speciLc recommendations for Aboriginal and Torres Strait Islander people, please refer to the Child
health (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-ra
cgp-guidelines/national-guide/chapter-3-child-health/preventing-child-maltreatment-–-supporting-famili
e) chapter in the National guide to a preventive health assessment for Aboriginal and Torres Strait
Islander people.
Resources
The 'red fag (https://www.racgp.org.au/getattachment/21c724bc-9280-4262-814f-77366aa9e640/App
endix-3A.pdf.aspx) ' early intervention referral guide for children aged 0–5 years | Central Queensland
Hospital and Health Services
106
References
1. Children’s Health Queensland. Red flags early 9. Whitehouse AJO, Evans K, Eapen V, Wray J. A
identification guide (birth to 5 years) brochure. national guideline for the assessment and
Queensland Government, 2022 (http://www.childr diagnosis of autism spectrum disorders in
ens.health.qld.gov.au/wp-content/uploads/PDF/r Australia. Cooperative Research Centre for Living
ed-flags.pdf) [Accessed 21 May 2023]. with Autism, 2018 (https://www.autismcrc.com.a
2. Australian Government. Snapshot of early u/access/sites/default/Lles/resources/Nationa
childhood development in Australia 2012 – AEDI l_Guideline_Summary_and_Recommendations.pd
f) [Accessed 22 February 2024].
national report. Australian Government, 2013.
[Accessed 21 May 2023]. 10. U.S. Preventive Task Force (USPSTF). Speech
3. Australian Institute of Health and Welfare. A and language delay and disorders in children:
picture of Australia’s children 2012. Australian Screening. USPSTF, 2024 (https://www.uspreventi
Government, 2012 (https://www.aihw.gov.au/get veservicestaskforce.org/uspstf/recommendatio
media/31c0a364-dbac-4e88-8761-d9c87bc2dc2 n/speech-and-language-delay-and-disorders-in-ch
9/14116.pdf.aspx) [Accessed 22 February 2024]. ildren-age-5-and-younger-screening) [Accessed
22 February 2024].
4. Australian Institute of Health and Welfare.
11. U.S. Preventive Task Force (USPSTF). Autism
Australia’s children. Australian Government, 2022
(https://www.aihw.gov.au/reports/children-youth/ spectrum disorder in young children: Screening.
australias-children/contents/health/children-disa USPSTF, 2016 - :~:text=The USPSTF concludes
bilities) [Accessed 22 February 2024]. that there,of ASD have been raised.&text=The
USPSTF has made a,children 5 yea (https://ww
5. Australian Early Development Census. Australian
w.uspreventiveservicestaskforce.org/uspstf/reco
Early Development Census (AEDC) national report
mmendation/autism-spectrum-disorder-in-young-
2015. A snapshot of early childhood development
children-screening) [Accessed 22 February 2024].
in Australia. Commonwealth of Australia
Department of Education and Training, 2015. 12. Wallace IF. Universal screening of young
[Accessed 22 February 2024]. children for developmental disorders: Unpacking
the controversies. RTI Press, 2018 (https://www.n
6. Canadian Task Force on Preventive Health Care.
cbi.nlm.nih.gov/books/NBK554623/) [Accessed
Developmental delay (2016). Canadian Task
22 February 2024].
Force on Preventive Health Care, 2016 (https://ca
nadiantaskforce.ca/guidelines/published-guidelin 13. Ministries of Health and Education. New
es/developmental-delay/) [Accessed 22 February Zealand autism spectrum disorder guideline. 2nd
edn. Ministry of Health, 2016 (https://www.healt
h.govt.nz/publication/new-zealand-autism-spectr
2024].
um-disorder-guideline) [Accessed 22 February
7. Lord C, Charman T, Havdahl A, et al. The Lancet
2024].
Commission on the future of care and clinical
14. Hyman SL, Levy SE, Myers SM. Identification,
research in autism. Lancet
evaluation, and management of children with
2022;399(10321):271–334. doi: 10.1016/
s0140-6736(21)01541-5. [Accessed 22 February autism spectrum disorder. Pediatrics 2020;145
2024]. (1): e20193447. doi: 10.1542/peds.2019-3447.
[Accessed 22 February 2024].
8. Halladay AK, Bishop S, Constantino JN, et al. Sex
and gender differences in autism spectrum 15. Ip A, Zwaigenbaum L, Brian JA. Post-diagnostic
disorder: Summarizing evidence gaps and management and follow-up care for autism
identifying emerging areas of priority. Mol Autism spectrum disorder. Paediatr Child Health
2015;6:36. doi: 10.1186/s13229-015-0019-y. 2019;24(7):461–77. doi: 10.1093/pch/pxz121.
[Accessed 22 February 2024]. [Accessed 22 February 2024].
16. The Royal Children’s Hospital Melbourne
(RCH). Parents' evaluation of developmental
status (PEDS). Parkville, Vic: The Royal
Children’s
Hospital Melbourne (https://www.rch.org.au/ccc
h/peds/) [Accessed 22 February 2024].
107
Preventive activities in childhood
Development and behaviour | Preventive

activities in childhood
Screening age bar
0–9* 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75v79 ≥80
*Newborn screening
Introduction
Prevention and health promotion in the early years, from conception to 5 years of age, is important for
an individual’s lifelong health and wellbeing.1 It may also be an opportunity to redress health
inequalities.2,3 In adolescence, neurodevelopmental studies support the value of early intervention to
prevent ongoing harm.
Many infants and children visit their GP frequently, and adolescents visit at least once a year.4 This
frequent contact provides opportunities for disease prevention and health promotion.
Evidence provides moderate support for the hypothesis that ‘accessible, family-centred, continuous,
comprehensive, coordinated, compassionate and culturally effective care improves health outcomes for
children with special healthcare needs’.5 There is also evidence that supports the beneLcial impact of
similar care for children without special healthcare needs.6–7
 Screening
108
All newborns should have: Practice point Neonatally 8,9,10
• metabolic screening
• universal hearing screening
• a physical exam as outlined in the
Child Personal Health Record
◦ ACT: Blue (https://nla.gov.a
u/nla.obj-2864006598/view)
Book (https://www.health.ac
t.gov.au/sites/default/Lles/2
023-01/Baby%20Personal%2
0Health%20Record_Inner_20
22_FINAL.pdf)
◦ NSW: Blue Book (https://ww
w.health.nsw.gov.au/kidsfam
ilies/MCFhealth/Pages/chil
d-blue-book.aspx#:~:text=Su
mmary,copy%20of%20the%2
0Blue%20Book.)
◦ Queensland: Red Book (http
s://www.childrens.health.ql
d.gov.au/chq/information-fo
r-families/personal-health-re
cord/)
◦ Victoria: Green Book (http
s://www.betterhealth.vic.go
v.au/health/healthyliving/vict
orian-child-health-record)
◦ SA: Blue Book (https://ww
w.cafhs.sa.gov.au/resource
s/blue-book)
◦ WA: Purple Book (https://ww
w.cahs.health.wa.gov.au/Ou
r-services/Community-Healt
h/Child-Health/Child-Health-
appointments)
◦ NT: Yellow Book (https://nt.g
ov.au/wellbeing/pregnancy-b
irthing-and-child-health/bab
y-child-assessments-clinics)
◦ Tasmania: Blue Book (http
s://www.health.tas.gov.au/h
ealth-topics/child-and-youth-
health/child-health-and-pare
nting-service-chaps) .
109
 Case 9nding
For the psychosocial assessment of Practice point Opportunistically 11
adolescents, use the HEEADSSS assessment

(https://www.rch.org.au/clinicalguide/guidelin
e_index/Engaging_with_and_assessing_the_a
dolescent_patient/) , in which the patient is
asked about:
• Home life
• Education/employment
• Eating habits
• Activities
• Drug and alcohol use
• Sexuality
• Personal safety
• Suicidal ideation/depression.
Immunisation
12
Ensure immunisation in accordance with the Practice point As per the
Australian Immunisation Schedule. For immunisation
information, see the immunisation chapter (ht schedule
tps://www.racgp.org.au/clinical-resources/cli
nical-guidelines/key-racgp-guidelines/view-all-
racgp-guidelines/preventive-activities-in-gener
al-practice/infectious-diseases/immunisatio
n) .
Preventive counselling and advice
110
Neonatally, provide education and advice Practice point Neonatally 11, 13,14
about:
• the harms of passive smoking
• the prevention of sudden infant
deaths (SIDS; see Further
information)
• the need to use appropriate restraints
in motor vehicles
• the beneLts of breastfeeding.
Throughout childhood, provide education and Practice point Opportunistically 15,16,17
advice to parents regarding injury prevention,

sun protection, promotion of good oral health,
nutrition, physical activity and providing a
strong antismoking message. See Skin cancer
(https://www.racgp.org.au/clinical-resources/
clinical-guidelines/key-racgp-guidelines/view-
all-racgp-guidelines/preventive-activities-in-ge
neral-practice/cancer/skin-cancer) , Oral
health (https://www.racgp.org.au/clinical-reso
urces/clinical-guidelines/key-racgp-guideline
s/view-all-racgp-guidelines/preventive-activitie
s-in-general-practice/miscellaneous/oral-healt
h) , Nutrition (https://www.racgp.org.au/clinic
al-resources/clinical-guidelines/key-racgp-gui
delines/view-all-racgp-guidelines/preventive-a
ctivities-in-general-practice/metabolic/nutritio
n) , Physical activity (https://www.racgp.org.a
u/clinical-resources/clinical-guidelines/key-ra
cgp-guidelines/view-all-racgp-guidelines/prev
entive-activities-in-general-practice/metaboli
c/physical-activity) and Smoking and nicotine
vaping (https://www.racgp.org.au/clinical-res
ources/clinical-guidelines/key-racgp-guideline
s-in-general-practice/mental-health/smoking)
chapters.
18,19
Monitor weight and height in children aged Practice point At well child
2–6 years using age-speciLc body mass index visits or
charts (either CDC (https://www.cdc.gov/grow immunisation
thcharts/clinical_charts.htm) or WHO (http
s://www.who.int/toolkits/child-growth-standar
ds/standards/body-mass-index-for-age-bmi-fo
r-age) ).
111
Monitor weight and length in children aged <2 Practice point At well child 19
years using WHO growth charts (https://ww visits or

w.who.int/toolkits/child-growth-standards/sta immunisation
ndards/body-mass-index-for-age-bmi-for-age)
.
Breastfeeding and introduction of solid food
When the infant is ready, at around 6 months, Practice point start at 6 14
but not before 4 months, start to introduce a months

variety of solid foods (texture appropriate, in
any order, as long as iron-rich foods are
included), preferably while continuing to
breastfeed. Refer to the Australian dietary
guidelines (https://www.eatforhealth.gov.au/g
uidelines/guidelines) .
14, 20
Unless there is already an established allergy Practice point Before 12
to certain foods, all infants should be given months of age
the common food allergens (peanut, tree nuts,
cow’s milk, egg, wheat, soy, sesame, Lsh and
shellLsh), including smooth peanut butter/
paste, cooked egg, dairy and wheat products
before 12 months of age.
More information is available in First Do No

Harm: a guide to choosing wisely in general
practice (https://www.racgp.org.au/clinical-re
sources/clinical-guidelines/key-racgp-guidelin
es/view-all-racgp-guidelines/Lrst-do-no-harm/
gp-resources/excluding-allergenic-foods) .
Recommended
(Strong) for
peanuts
Further information
Table 1. Prevention of sudden infant deaths (SIDS)
Place on back to sleep for every sleep
Use a Lrm, fat, non-inclined sleep surface to reduce the risk of suffocation or wedging/entrapment
112
Feeding of human milk is recommended because it is associated with a reduced risk of SIDS
It is recommended that infants sleep in the parents’ room, close to the parents’ bed, but on a
separate surface designed for infants, ideally for at least the Lrst 6 months
Keep soft objects (eg pillows, pillow-like toys, quilts, comforters, mattress toppers and fur-like
materials) and loose bedding (eg blankets and non-Ltted sheets) away from the infant’s sleep area
to reduce the risk of SIDS, suffocation, entrapment/wedging and strangulation
Avoid smoke and nicotine exposure during pregnancy and after birth
Avoid alcohol, marijuana, opioids and illicit drug use during pregnancy and after birth
Avoid overheating and head covering in infants
It is recommended that infants be immunised in accordance with Australian guidelines
Do not use home cardiorespiratory monitors as a strategy to reduce the risk of SIDS
Supervised awake tummy time is recommended to facilitate development and to minimise the risk
of positional plagiocephaly. Parents are encouraged to place the infant on their tummy while awake
and supervised for short periods of time beginning soon after hospital discharge, increasing tummy
time incrementally to at least 15–30 minutes total daily by the age of 7 weeks
There is no evidence to recommend swaddling as a strategy to reduce the risk of SIDS
Table modiLed from Moon et al.21

peoples
The rates of stillbirth and neonatal deaths of Aboriginal and Torres Strait Islander infants were 1.5- and
2-fold higher than for non-Indigenous infants, respectively, in 2015–19.22 Aboriginal and Torres Strait
Islander infants are also more likely to be born premature or with low birthweight,23,24 and are more
likely to be hospitalised before one year of age.25
For speciLc recommendations for Aboriginal and Torres Strait Islander people, please refer to the Child
health (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-ra
cgp-guidelines/national-guide/chapter-3-child-health/preventing-child-maltreatment-–-supporting-famili
e) chapter in the National guide to a preventive health assessment for Aboriginal and Torres Strait
Islander people.
113
Resources
Australian dietary guidelines (https://www.eatforhealth.gov.au/guidelines/guidelines) | NHMRC First Do
No Harm: a guide to choosing wisely in general practice (https://www.racgp.org.au/clinical-resources/cli
nical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/Lrst-do-no-harm/gp-resources/excludin
g-allergenic-foods) | RACGP
References
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u/uploadedFiles/Main/Content/ccch/PB1_Earlyc Report no. CH42. NHMRC, 2002.
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2024].
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2. Marmot M. Fair society, healthy lives (the Marmot Australian Government, 2013 (https://www.healt
review). University College London, 2010 (https:// h.gov.au/resources/publications/national-framew
www.instituteofhealthequity.org/resource ork-for-neonatal-hearing-screening) [Accessed
reports/fair-society-healthy-lives-the-marmot-re 22 February 2024].
view) [Accessed 22 February 2024]. 10. . NSW Health. My personal health record (Blue
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childhoods: Current research insights into early w.health.nsw.gov.au/kidsfamilies/mcfhealth/publ
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National Investment for the Early Years/Centre for 2024].
Community Child Health Conference and The
Royal Children’s Hospital Melbourne, 2011.
Practitioners (RACGP), National Aboriginal
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4. Tylee A, Haller DM, Graham T, Churchill R, Sanci (NACCHO). National guide to a preventive health
LA. Youth-friendly primary-care services: How are assessment for Aboriginal and Torres Strait
we doing and what more needs to be done? Islander people. RACGP and NACCHO, 2018 (http
Lancet 2007;369(9572):1565–73. doi: 10.1016/ s://www.racgp.org.au/clinical-resources/clinical-
s0140-6736(07)60371-7. [Accessed 22 February guidelines/key-racgp-guidelines/view-all-racgp-gu
2024]. idelines/national-guide/chapter-3-child-health/pre
5. Kuhlthau KA, Bloom S, Van Cleave J, et al. venting-child-maltreatment-–-supporting-familie)
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6. Hadland SE, Long WE. A systematic review of the tionhandbook.health.gov.au/) [Accessed 22
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2014;18(4):891–98. doi: 10.1007/ assist sleeping your baby safely. Malvern, Vic:
s10995-013-1315-9. SIDS and kids, 2014. [Accessed 22 February
7. Long WE, Bauchner H, Sege RD, Cabral HJ, Garg 2024].
A. The value of the medical home for children
without special health care needs. Pediatrics
2012;129(1):87–98. doi: 10.1542/
peds.2011-1739.
114
14. Australasian Society of Clinical Immunology 21. Moon RY, Carlin RF, Hand I; Task Force on Sudden
and Allergy (ASCIA). Infant feeding and allergy Infant Death Syndrome and the Committee on
prevention clinical update. ASCIA, 2018 (https://w Fetus and Newborn. Sleep-related infant deaths:
ww.allergy.org.au/images/stories/pospapers/AS Updated 2022 recommendations for reducing
CIA_HP_Clinical_Update_Infant_Feeding_and_Alle infant deaths in the sleep environment. Pediatrics
rgy_Prevention_July2018.pdf) [Accessed 22 2022;150(1):e2022057990. doi: 10.1542/
February 2024]. peds.2022-057990. [Accessed 22 February 2024].
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randomized controlled trial in primary care. BMJ Aboriginal and Torres Strait Islander health
1999;318(7189):980–83. doi: 10.1136/ performance framework: Perinatal mortality.
bmj.318.7189.980. [Accessed 22 February 2024]. Australian Government, 2023 (https://www.indige
16. Clamp M, Kendrick D. A randomized controlled
trial of general practitioner safety advice for noushpf.gov.au/Measures/1-21-Perinatal-mortalit
families with children under 5 years. BMJ y) [Accessed 22 February 2024].
1998;316(7144):1576–79. doi: 10.1136/ 23. Australian Health Ministers’ Advisory Council.
bmj.316.7144.1576. [Accessed 22 February Clinical practice guidelines: Antenatal care –
2024]. Module 1. Department of Health and Ageing,
17. Stanton A, Grimshaw G. Tobacco cessation 2012 (https://consultations.health.gov.au/phd-to
interventions for young people. Cochrane bacco/clinical-practice-guidelines-antenatal-care-
Database Syst Rev 2013;8:CD003289. doi: module/supporting_documents/ANC_Guideline
10.1002/14651858.cd003289.pub5. [Accessed s_Mod1FINAL%20D13871243.PDF) [Accessed 27
22 February 2024]. February 2024].
18. Centres for Disease Control and Prevention 24. Shah PS, Zao J, Al-Wassia H, Shah V.
(CDC). Clinical growth charts. CDC, 2022 (http s:// Pregnancy and neonatal outcomes of Aboriginal
www.cdc.gov/growthcharts/clinical_charts.ht women: A systematic review and meta-analysis.
[Accessed 22 February 2024]. Womens Health Issues 2011;21(1):28–39. doi: (ht
tp://10.1016/j.whi.2010.08.005.)
1 . World Health Organization (WHO). Body mass
inder-for-age (BMI-for-age). WHO, 2006 (https://w 25. Bar-Zeev SJ, Kruske SG, Barclay LM, Bar-Zeev
ww.who.int/toolkits/child-growth-standards/stan NH, Carapetis JR, Kildea SV. Use of health
dards/body-mass-index-for-age-bmi-for-age) services by remote dwelling Aboriginal infants in
[Accessed 22 February 2024]. tropical northern Australia: A retrospective cohort
study. BMC Pediatr 2012;12:19. doi: 10.1186/
2 . de Silva D, Halken S, Singh C, et al. Preventing
1471-2431-12-19.
food allergy in infancy and childhood: Systematic
review of randomised controlled trials. Pediatr
Allergy Immunol. 2020 Oct;31(7):813-826. doi:
10.1111/pai.13273. [Accessed 22 February 2024].
115
Genetics
116
Genetics
Genetics (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-ra
cgp-guidelines/view-all-racgp-guidelines/preventive-activities-in-general-practic
e/genetics/genetic-screening)
117
Genetics
Genetics
Genetics
Advances in genomic medicine will continue to have a growing role in general practice. Genetic tests
are available for an increasing number of indications from preconception planning, during pregnancy,
for neonates (newborn screening), during childhood and through to adult-onset familial diseases such
as cancer, cardiac and neurodegenerative diseases. More detail is available in the RACGP Genomics in
general practice (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/vie
w-all-racgp-guidelines/genomics-in-general-practice/genomics-in-general-practice/background) 1
resource.
 Screening
1,2
Genetic carrier screening: Preconception and Practice point Prior to or
prenatal in early
All women/couples planning a pregnancy, or who are pregnancy
already pregnant, should have a comprehensive
family history recorded to identify relatives with
heritable genetic disorders, as well as the presence
of consanguinity.
118
Genetics
Information on carrier screening for genetic Practice point Prior to or 1,2
conditions should be offered to all women planning a in early

pregnancy or in the Lrst trimester of pregnancy, pregnancy
regardless of family history or ethnicity.
Options for carrier screening include screening with a
panel for a limited selection of the most frequent
conditions (eg cystic Lbrosis, spinal muscular
atrophy [SMA] and fragile X syndrome), or screening
with an expanded panel that contains many
disorders (up to hundreds).
MBS items (https://www9.health.gov.au/mbs/fullDis
play.cfm?type=item&q=73451&qt=item&criteria=734
51) are available for carrier screening for cystic
Lbrosis, SMA and fragile X syndrome.
Screening can be sequential or couple screening. In Practice point Prior to or 2
sequential screening, one member of the couple is in early

screened (usually the woman since the woman’s pregnancy
carrier status for X-linked conditions is relevant) and
the second member of the couple is only screened if
the Lrst member is a carrier of one or more
autosomal recessive conditions. In couple screening,
both members of the couple are screened at the
same time.
• All couples with a high chance of having a
child with one of the conditions screened for
should be referred for genetic counselling to
be informed of available reproductive
options and to assist with prenatal testing if
the woman in the couple is found to have a
high chance is pregnant when the result
becomes known.
• All pregnant women should be offered basic
screening for thalassemia carrier status by a
full blood examination at initial presentation.
Screening with speciLc assays for
haemoglobinopathies (eg high-performance
liquid chromatography [HPLC] or serum
protein electrophoresis [EPG], and
haemoglobinopathy gene DNA testing)
should be considered in high-risk ethnic or
population groups (Mediterranean, African
and Asian ethnicity).
119
Genetics
Prenatal screening for chromosomal conditions Practice point First 1,3
Screening or diagnostic testing for women at risk of trimester

carrying a baby with fetal chromosomal and genetic where
conditions is voluntary and should only be possible
undertaken as an informed decision by the pregnant
woman.
Acceptable Lrst-line screening tests for fetal
chromosome abnormalities in the Orst trimester
include either:
• combined Lrst trimester screening with
nuchal translucency and serum pregnancy-
associated plasma protein A (PAPP-A) and
beta human chorionic gonadotropin (βHCG)
measurements
OR
• cell-free DNA (cfDNA)-based screening (also
called non-invasive prenatal testing [NIPT]),*
usually available from 10 weeks. Second
trimester
The choice of Lrst-line screening test will depend on
local resources, patient demographics and individual
patient characteristics.
Pre-test counselling for cfDNA-based screening

should include informed decision making regarding
testing for fetal sex and sex chromosome
aneuploidy. The potential for other unanticipated
Lndings of relevance to maternal health (including
maternal genomic imbalances) should be included in
pre-test counselling.
Acceptable Lrst-line screening tests for chromosome

conditions in second trimester include:
• maternal serum screening (MA + AFP +
βHCG +UE3 +/– inhibin) and,
• cfDNA-based screening.
The choice of Lrst-line screening test will depend on

local resources, patient demographics and individual
patient characteristics.
If a screening test result indicates an increased

chance of a chromosome or genetic condition, the
woman should have access to genetic counselling
for further information and support. The available
options for prenatal diagnosis should be discussed
and offered.
120
Genetics
Routine population-based screening for genome- Not N/A 3
wide chromosome abnormalities and microdeletion recommended

syndromes is not recommended due to the absence (strong)
of well-performed clinical validation studies.
Familial hypercholesterolaemia (FH) Conditionally Once off 1
FH assessment should be conducted when an recommended

individual presents with:
• clinical features such as tendon xanthomata
• untreated low-density lipoprotein cholesterol
(LDL-C) >4.9 in adults mmol/L
• premature cardiovascular disease (CVD) or
a family history (https://www.racgp.org.au/c
linical-resources/clinical-guidelines/key-racg
p-guidelines/view-all-racgp-guidelines/geno
mics-in-general-practice/family-history) of
such (CVD aged <60 years).
Assess their probability of having FH using the Dutch

Lipid Clinic Network (DLCN) criteria. Offer referral to
a lipid disorders clinic if DLCN score ≥3.
While FH can be diagnosed clinically, a conLrmatory

DNA test allows for cascade screening within the
family of an affected patient. There is MBS funding
(https://www9.health.gov.au/mbs/fullDisplay.cfm?ty
pe=item&q=73352&qt=item&criteria=familial%20hyp
ercholesterolaemia) for genetic testing for FH. MBS
item 73352 can only be ordered by a specialist
physician to make the diagnosis; GPs can order the
test for cascade screening in unaffected relatives.
121
Genetics
Hereditary haemochromatosis (HHC) Conditionally Once off 1,4
Consider HHC in: recommended

• patients with liver disease of unknown
cause, including those with suspected
alcoholic liver disease
• family members of patients with HHC
• other increased risk groups – patients with
atypical arthritis, cardiomyopathy, chronic
fatigue, diabetes mellitus.
Test fasting transferrin saturation and serum ferritin.
Genetic testing for variants in the homeostatic iron

regulator (HFE) gene, rebatable via the MBS, is
recommended in:
• individuals with suspected iron overload (ie
fasting serum transferrin saturation >45% or
serum ferritin >200 μg/L in females or >300
μg/L in males)
• Lrst-degree relatives of patients with HHC
who are p.Cys282Tyr homozygous or
p.Cys282Tyr/p.His63Asp compound
heterozygous.
Breast cancer – refer to section on breast cancer (htt

ps://www.racgp.org.au/clinical-resources/clinical-gui
delines/key-racgp-guidelines/view-all-racgp-guideline
s/preventive-activities-in-general-practice/cancer/bre
ast-cancer) .
Colorectal cancer – refer to section on colorectal

cancer (https://www.racgp.org.au/clinical-resources/
clinical-guidelines/key-racgp-guidelines/view-all-racg
p-guidelines/preventive-activities-in-general-practice/
cancer/colorectal-cancer) .
*NIPT is not available through the MBS or covered by private health insurance.
 Case 9nding
122
Genetics
Those identiLed with a family history of a speciLc Practice point Prior to or 1,2
inherited disorder should be offered referral to a in early

genetic counselling service for information about pregnancy
carrier screening and prenatal diagnosis/
preimplantation genetic diagnosis for the condition.
Further information
Individuals and couples should be supported with advice to make informed decisions about genetic
testing that includes discussion of out-of-pocket expenses required for the test. MBS funding is
available for a limited number of genetic tests, some of which can be accessed in general practice
under speciLc criteria. (Note that NIPT is not available through the MBS, nor is it covered by private
health insurance.)
Family history remains an important tool in identifying individuals at increased genetic risk. Ideally, a
three-generation family history should be collected on all patients where possible, including Lrst-degree
relatives (ie children, siblings, parents) and second-degree relatives (ie aunts, uncles, grandparents).5
The use of a family history screening questionnaire (https://www.racgp.org.au/clinical-resources/clinic
al-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/genomics-in-general-practice/family-histor
y) can help identify individuals who may require a more detailed assessment of their family history of
cancer, heart disease or diabetes.

peoples
There are no additional recommendations for Aboriginal and Torres Strait Islander people.
Speci9c populations
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
Position statement Prenatal screening and diagnostic testing for fetal chromosomal and genetic
conditions (https://ranzcog.edu.au/wp-content/uploads/2022/05/Prenatal-Screening-and-Diagnostic-T
esting-for-Fetal-Chromosomal-and-Genetic-Conditions.pdf) 3 provides speciLc recommendations
related to genetic carrier screening in people of Eastern European (Ashkenazi) Jewish descent and
women with multiple pregnancies.
Resources
Genomics in general practice (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racg
p-guidelines/view-all-racgp-guidelines/genomics-in-general-practice/genomics-in-general-practice/back
ground) | RACGP – includes a suite of concise summaries on various clinical topics in genetics and
genomics:
123
Genetics
• Reproductive carrier screening (https://www.racgp.org.au/clinical-resources/clinical-guideline

s/key-racgp-guidelines/view-all-racgp-guidelines/genomics-in-general-practice/genetic-tests-a
nd-technologies/reproductive-carrier-screening)
• Prenatal testing (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-gui
delines/view-all-racgp-guidelines/genomics-in-general-practice/genetic-tests-and-technologie
s/prenatal-testing)
• Hereditary haemochromatosis (https://www.racgp.org.au/clinical-resources/clinical-guideline
s/key-racgp-guidelines/view-all-racgp-guidelines/genomics-in-general-practice/disease-speciL
c-topics/hereditary-haemochromatosis)
• Family history – Table 1. Family history screening questionnaire (https://www.racgp.org.au/clin
ical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/genomics-in-g
eneral-practice/family-history)
Dutch Lipid Clinic Network (DLCN) criteria (https://www.csanz.edu.au/for-professionals/position-state

ments-and-practice-guidelines/) , Cardiovascular Genetics – Familial hypercholesterolaemia (2016),
Diagnosis and management of familial hypercholesterolaemia – Position Statement | Cardiac Society
of Australia and New Zealand
References
1. The Royal Australian College of General 4. Gastroenterological Society of Australia.
Practitioners. Reproductive carrier screening. In: Clinical update for general practitioners and
Genomics in general practice. 2nd edn. RACGP, physicians: Haemochromatosis – Updated 2021.
2022 (https://www.racgp.org.au/clinical-resource GESA, 2021 (https://www.gesa.org.au/public/13/
s/clinical-guidelines/key-racgp-guidelines/view-al Lles/Education%20%26%20Resources/Clinical%2
racgp-guidelines/genomics-in-general-practice/ 0Practice%20Resources/Haemochromatosis/Ha
genetic-tests-and-technologies/reproductive-carri emochromatosis%20clinical%20update%20202
er-screening) [Accessed 5 April 2024]. 1_APPROVED.pdf) [Accessed 5 April 2024].
2. The Royal Australian and New Zealand College of 5. Bylstra Y, Lim WK, Kam S, et al. Family history
Obstetricians and Gynaecologists. Position assessment signiLcantly enhances delivery of
statement: Genetic carrier screening (C-Obs63). precision medicine in the genomics era Genome
RANZCOG, 2019 (https://ranzcog.edu.au/wp-cont Med 2021;13(1):3. doi: (https://doi.org/10.1186/s
ent/uploads/2022/05/Genetic-carrier-screeningC- 13073-020-00819-1.)
Obs-63New-March-2019_1.pdf)
3. The Royal Australian and New Zealand College of
Obstetricians and Gynaecologists. Position
statement: Prenatal screening and diagnostic
testing for fetal chromosomal and genetic
conditions (C-Obs59). RANZCOG, 2022 (https://ra
nzcog.edu.au/wp-content/uploads/2022/05/Pren
atal-Screening-and-Diagnostic-Testing-for-Fetal-C
hromosomal-and-Genetic-Conditions.pdf)
124
Genetics
Infectious diseases
125
Genetics
Infectious diseases
Hepatitis B and C (https://www.racgp.org.au/clinical-resources/clinical-guideline

practice/infectious-diseases/hepatitis-b-and-c) Immunisation (https://www.racg
p-guidelines/preventive-activities-in-general-practice/infectious-diseases/immun
isation) Sexually transmissible infections including HIV (https://www.racgp.org.a
u/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guid
elines/preventive-activities-in-general-practice/infectious-diseases/sexually-tran
smitted-infections-stis-and-hepatitis)
126
Hepatitis B and C
Hepatitis B and C
Infectious diseases | Hepatitis B and C

Screening age bar
0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75–79 ≥80
*Recommendations will depend upon speciLc risk factors.
Hepatitis B
Chronic hepatitis B impacts over 250 million people worldwide, with the majority infected either at birth
or during early childhood.1 If left untreated, chronic hepatitis B can lead to liver cirrhosis, liver failure
and hepatocellular carcinoma in up to 25% of those affected, resulting in an estimated 800,000 deaths
globally each year.1 In 2020, there were approximately 222,599 people living with chronic hepatitis B in
Australia, accounting for 0.9% of the population.1 The introduction of the hepatitis B vaccination in the
1980s has reduced new infections and the prevalence of chronic hepatitis B, particularly among
younger people.1
In Australia, as of 2021, only 72.5% of people living with chronic hepatitis B have been diagnosed, 26%
are engaged in care and 12.7% are receiving treatment.2 In addition, 70% of all people living with chronic
hepatitis B in Australia were born overseas, highlighting the importance of screening based on country
of birth, particularly among people born in areas with a high prevalence of hepatitis B.3
Exposure to the hepatitis B virus early in life carries the highest risk of chronic infection, whereas
exposure during adulthood typically results in a self-limiting acute infection in over 95% of cases.1
Therefore, most individuals with chronic infection acquired hepatitis B virus during birth or in early
childhood, particularly among people born in areas with a high prevalence of hepatitis B.
Other modes of transmission include sharing of injection equipment or items that may have blood on
them, and unprotected sex.4 For people growing up in some countries with high rates of hepatitis B,
transmission could also occur through injuries involving blood passing between a person living with
hepatitis B and another person; having an operation; receiving a blood transfusion; a dental visit; or
getting a tattoo.4
There is no cure for hepatitis B, but there is a vaccination and treatment to manage the infection. It is
also important to note that hepatitis B is an infection that carries stigma for certain community groups,
and culturally safe care and conversations are required.
127
Hepatitis B and C
Hepatitis C
Hepatitis C is a blood-borne virus that is one of the major causes of liver cirrhosis, hepatocellular
carcinoma and liver failure. Within Australia, it was estimated that approximately 117,000 people were
living with chronic hepatitis C in 2020. There were 9230 notiLcations of hepatitis C in 2019, 69% of
which in among.5
Hepatitis C is an infection that is associated with high-risk populations (eg people who inject drugs,
immigrants from high-prevalence countries, men who have sex with men [MSM]). For this reason, risks
may not be readily disclosed, so screening needs to be done with care and sensitivity to ensure the
safety and conLdence of patients, as well as helping to Lnd those who are unknowingly living with
hepatitis C.
Hepatitis C is transmitted by a blood-to-blood route. The main transmission routes include the sharing
of needles and auxiliary injecting equipment, perinatal transmission and sexual practices that lead to
sexual transmission.
Tattooing and piercing with unsterilised equipment have also been associated with the acquisition of
hepatitis C. Hepatitis C is now easily treated with oral medications that offer a 95% cure rate.
Hepatitis B
 Screening
1
At a minimum, all population groups at high risk (see Recommended Single
Box 1) should be offered testing to determine their (strong) screen
hepatitis B virus status. with
additional
testing if
the risk
factors
are
continuing
128
Hepatitis B and C
When testing for hepatitis B, the tests to be ordered Practice point N/A 1
are: hepatitis B surface antigen (HBsAg), hepatitis B (for the three

surface antibody (anti-HBs) and hepatitis B core qualitative
antibody (anti-HBc). tests)
Positive HBsAg indicates current infection, positive

anti-HBs indicates immunity (through vaccination or
past infection) and positive anti-HBc indicates past
or current infection (this test may occasionally give a
false-positive result). A history including country of
birth, overseas travel, vaccination and exposure
risks, and a physical examination are important to
distinguish between possible recent, acute or
chronic infection and to guide the addition of anti-
HBc IgM testing.
6
Infants, children, people with HIV, chronic liver Practice point N/A
disease and/or hepatitis C and others at high risk*
are recommended to receive the hepatitis B vaccine
if they are not immune.
*For a complete list of those at high risk, see the
Australian immunisation handbook (https://immunis
ationhandbook.health.gov.au/contents/vaccine-prev
entable-diseases/hepatitis-b) .
1,7
Recommend safe sexual practices to prevent Practice point N/A
hepatitis B and C.
1,7
Recommend safer injecting practices to minimise Practice point N/A
transmission of hepatitis B and C, such as needle
exchange and minimising the sharing of needles and
auxiliary injecting equipment.
Hepatitis C
 Screening
129
Hepatitis B and C
All individuals with a risk factor* for hepatitis C Recommended At initial 7,8
virus infection should be tested. (Strong) consultation

and
The appropriate initial screening test for hepatitis annually if
C virus infection is hepatitis C virus serology the risk of
(hepatitis C virus antibodies), which indicates exposure
exposure to hepatitis C virus, either current or past continues.
infection. 3-6 months
for people
Hepatitis C virus seronegative people with risk who inject
factors* for hepatitis C virus transmission should drugs.
be screened for hepatitis C virus infection.
*People at risk of hepatitis C virus infection

include:
• those with previous or current injecting
drug use
• those in custodial settings, such as prison
• those who have ever had an unsterile
tattoo or piercing
• those born in a high-prevalence region
• MSM
• those who have evidence of liver disease
• those who received a blood transfusion or
organ transplant before 1990
• those with coagulation disorders who
received blood products or plasma-
derived clotting factor treatment products
before 1993
• children born to hepatitis C virus-infected
mothers
• those who have had a needle-stick injury
• all pregnant women (refer to the First
antenatal visit chapter)
• those infected with HIV or hepatitis B
virus
• sexual partners of a hepatitis C virus-
infected person (individuals at higher risk
of sexual transmission include MSM and
people with hepatitis C virus–HIV
coinfection)
• migrants from high-prevalence regions
(Egypt, Pakistan, the Mediterranean and
Eastern Europe, Africa and Asia)
130
Hepatitis B and C
Recommend safe sexual practices to prevent Practice point N/A 1,7
hepatitis B and C.
Recommend safer injecting practices to minimise Practice point N/A 1,7
the transmission of hepatitis B and C, such as

needle exchange and minimising the sharing of
needles and auxiliary injecting equipment.
Further information
Sensitive history gathering is important to ensure people living with yet-to-be-diagnosed infection are
not missed.
A non-judgemental attitude and environment will facilitate disclosures on sexual matters. It is important
to ask open-ended questions, and to avoid assumptions about sexual orientation by using the term
‘partner’. Gentle enquiry about recent sexual activity, gender, number of partners, contraception
(including the use of condoms), travel history and immunisation status helps to inform decision
making. In addition, ask about risk factors for blood-borne viruses (hepatitis B, hepatitis C and HIV),
such as injecting drug use, tattooing and piercing. Investigations should be explained, and patients
should be asked for consent before tests such as HIV or hepatitis C are ordered. Refer to the Sexually
transmissible infections (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-gui
delines/view-all-racgp-guidelines/preventive-activities-in-general-practice/infectious-diseases/sexually-t
ransmitted-infections-stis-and-hepatitis) chapter for more information.
Hepatitis B
In Australia, routine adolescent Hepatitis B immunisation commenced in 1997 and routine infant
Hepatitis B immunisation commenced in May 2000. However, it is important to note that people born in
high-risk countries who then moved to and have grown up in Australia and people with other risk factors
should be offered testing to determine their status and not assumed that they are immune.9
It is important that appropriate consent is obtained, and pre-test counselling is provided before testing
for chronic hepatitis B. Given that most people living with chronic hepatitis B are from Culturally and
Linguistically Diverse (CALD) communities, it is essential that discussions are held before testing and
after diagnosis, and when necessary, with the assistance of an accredited interpreter.1
131
Hepatitis B and C
Box 1. Groups that should be screened for hepatitis B in Australia1,10
Populations with a higher prevalence of chronic hepatitis B
• People who inject drugs

• Men who have sex with men
• Aboriginal and Torres Strait Islander people
• People living with chronic hepatitis C
• People who have ever been incarcerated
People born overseas in regions with ≥2% chronic hepatitis B prevalence
• People born in North-east Asia

• People born in South-east Asia
• People born in the PaciLc Islands – Māori and PaciLc Islander people
• People born in North Africa
• People born in Central Asia
• People born in Southern Europe
• People born in Eastern Europe
• People born in Sub-Saharan Africa
Populations with a higher risk of onward transmission and/or adverse outcomes
• Pregnant women
• People receiving immunosuppressive therapy
• Healthcare workers
• People with other chronic liver diseases (eg metabolic-associated fatty liver
disease)
• People undergoing renal dialysis
• People living with HIV
• Household and sexual contacts of people with chronic hepatitis B
• Children born to mothers with chronic hepatitis B
• People with multiple sexual partners
Hepatitis C
Screening for hepatitis C should be provided if the patient is HIV positive or there is a history of injecting
drug use, because this increases the risk of transmission. If hepatitis C virus antibodies are detected,
current infection should be conLrmed by testing for hepatitis C virus RNA using a sensitive polymerase
chain reaction (PCR) assay.6
132
Hepatitis B and C

peoples
The hepatitis B immune status of all Aboriginal and Torres Strait Islander people should be
documented, and Aboriginal and Torres Strait Islander people should be offered hepatitis B
immunisation if they are not immune and not vaccinated.11
For speciLc advice about hepatitis B immunisation for Aboriginal and Torres Strait Islander people,
please refer to the Australian immunisation handbook (https://immunisationhandbook.health.gov.au/co
ntents/vaccine-preventable-diseases/hepatitis-b#recommendations) and the National guide to a
preventive health assessment for Aboriginal and Torres Strait Islander people (https://www.racgp.org.au/
clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/national-guide/cha
pter-14-sexual-health-and-blood-borne-viruses) .
Speci9c populations
All pregnant women should be screened for hepatitis B, hepatitis C, HIV and syphilis. Consider
screening pregnant women aged up to 29 years for chlamydia (and gonorrhoea, if the patient is at high
risk; see Sexually transmissible infections (https://www.racgp.org.au/clinical-resources/clinical-guidelin
es/key-racgp-guidelines/view-all-racgp-guidelines/preventive-activities-in-general-practice/infectious-di
seases/sexually-transmitted-infections-stis-and-hepatitis) ). See the Pregnancy – First antenatal visit (h
ttps://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guid
elines/preventive-activities-in-general-practice/reproductive-and-womens-health/Lrst-antenatal-visit)
chapter for more information.
Resources
Decision making in hepatitis B (https://ashm.org.au/resources/decision-making-in-hepatitis-b/) tool |
ASHM B positive: A guide for primary care providers (https://www.hepatitisb.org.au/) | ASHM Australian
immunisation handbook (https://immunisationhandbook.health.gov.au/contents/vaccine-preventable-di
seases/hepatitis-b)
References
1. Gastroenterological Society of Australia. 2. Australasian Society for HIV, Viral Hepatitis and
(GESA). Hepatitis B virus (HBV) consensus Sexual Health Medicine (ASHM). Viral hepatitis
statement. GESA, 2021 (https://www.gesa.org.a mapping project: Hepatitis B. Geographic
u/education/clinical-information/hbv-consensus- diversity in chronic hepatitis B prevalence,
statement/) [Accessed 31 January 2024]. management and treatment. ASHM, 2021 (http
s://ashm.org.au/wp-content/uploads/2023/09/Vi
ral-Hepatitis-Mapping-Project_National-Report-He
patitis-B-2021.pdf) [Accessed 21 February 2024].
133
Hepatitis B and C
3. Australian Government Department of Health and 7. Gastroenterological Society of Australia

Aged Care. Third national hepatitis B strategy (GESA). Australian recommendations for the
2018–2022. Department of Health and Aged management of hepatitis C virus infection: A
Care, 2019 (https://www.health.gov.au/resource consensus statement (2022). GESA, 2022 %26
s/publications/third-national-hepatitis-b-strateg Resources/Clinical Practice Resources/Hep C/
2018-2022?language=en) [Accessed 31 hepatitis C virus infection a consensus statement
January 2024]. 2022.pdf (https://www.gesa.org.au/public/13/Lle
4. Cancer Council Victoria. Hepatitis B & liver s/Education) [Accessed 31 January 2024].
cancer. Cancer Council Victoria, n.d - :~:text=In 8. Australasian Society for HIV, Viral Hepatitis and
some countries with high,visit, or getting a tattoo. Sexual Health Medicine (ASHM). Indications for
(https://www.cancervic.org.au/cancer-informatio HCV testing. ASHM, 2020 (https://testingportal.a
n/screening/hep-b-liver-cancer) [Accessed 31 shm.org.au/national-hcv-testing-policy/indication
January 2024]. s-for-hcv-testing/) [Accessed 25 January 2024].
5. National Cancer Control Indicators. Hepatitis B 9. Australasian Society for HIV, Viral Hepatitis and
and hepatitis C notification. National Cancer Sexual Health Medicine (ASHM). STI
Control Indicators, 2022 (https://ncci.canceraustr management guidelines for use in primary care:
alia.gov.au/screening-and-immunisation/notificat Standard asymptomatic check-up. ASHM, 2021
ion-hepatitis-b-and-c/hepatitis-b-and-c-notificatio (https://sti.guidelines.org.au/standard-asymptom
ns) [Accessed 16 May 2023]. atic-checkup/) [Accessed 16 May 2023].
6. Australian government Department of Health and 10. Australasian Society for HIV, Viral Hepatitis
Aged Care. Australian immunisation handbook. and Sexual Health Medicine (ASHM). Hepatitis B
Department of Health and Aged Care, 2023 virus testing and interpreting test results. ASHM,
(https://immunisationhandbook.health.go 2020 (https://testingportal.ashm.org.au/hepatiti
.au/contents/vaccine-preventable-diseases/hep s-b-virus-testing-and-interpreting-test-results/)
atitis-b) [Accessed 16 May 2023]. [Accessed 16 December 2023].
11. Lubel JS, Strasser SI, Thompson AJ, et al.
Australian consensus recommendations for the
management of hepatitis B. Med J Aust.
2022;216(9):478-–86. doi: 10.5694/mja2.51430.
[Accessed 16 December 2023].
134
Immunisation
Immunisation
Infectious diseases | Immunisation

Prevalence and context
Immunisation is recommended from birth for all children, and at particular ages throughout life,
according to the Australian immunisation handbook (https://immunisationhandbook.health.gov.au/) (this
is updated regularly).1
GPs need to be aware of groups with lower levels of age-appropriate immunisation.2 Lower
immunisation rates at 12 months3 have been associated with:
• being born overseas

• no private health insurance
• being in the highest or lowest socioeconomic quintile
• being of low birth weight.
All these factors are also associated with lower immunisation coverage at 24 months, with the
exception of low birth weight, which was only signiLcant in the very low birth weight category.3
Immunisation recommendations for non-Indigenous Australians without risk factors for vaccine-
preventable diseases Table 1. Vaccine recommendations for non-Indigenous Australians based on
age and pregnancy status This table is a summary of Australian immunisation handbook (https://imm
unisationhandbook.health.gov.au/) vaccine recommendations for non-Indigenous Australians based on
age and pregnancy status. Shaded cells represent vaccinations funded under the National
Immunisation Program (https://www.health.gov.au/topics/immunisation/when-to-get-vaccinated/natio
nal-immunisation-program-schedule?language=und) (NIP).a Parentheses indicate that these vaccines
are only recommended for a population sub-group. Further detail is provided in the corresponding
footnotes.
Disease/ Abbrev. Age

vaccine
At 2 4 6 months 12 18 4 years Adolescents
antigen
birth monthsb months months months
Hepatitis B HepB ✔ ✔* ✔* ✔* (✔)c
Diphtheria, DTPa/ ✔* ✔* ✔* ✔ ✔† • 12–

tetanus, dTpa year
pertussis
135
Immunisation
Poliomyelitis IPV ✔* ✔* ✔* ✔†
•
Haemophilus Hib ✔* ✔* ✔*
in-uenzae type
b
• • •
Pneumococcal 13vPCV check for
15vPCV medical
20vPCV risk
conditions
23vPPV
Check for medical risk
• •
Rotavirus
•
Measles, MMR • ‡,
mumps, f
rubella
Varicella VV ✔‡ ✔h
Meningococcal MenB ✔i • 15–

serogroup B (Refer year
to
footnote
i)
Meningococcal • 15–
serogroup MenACWY ✔j ✔j (Refer year
ACWY to
footnote NIP school
j) program dos
at 14–16 yea
j
Incuenza QIV ✔k
(annual) (Refer to
footnote k)
Human • 9–2
papillomavirus HPV
NIP school
program dos
at
14–16 years
Herpes zoster HZ
Key
136
Immunisation
DTPa = Diphtheria-tetanus-
DTPa = Diphtheria-tetanus-
DTPa = Diphtheria-tetanus- acellular pertussis vaccine
acellular pertussis vaccine
acellular pertussis vaccine (paediatric formulation)
(paediatric formulation) IPV =
(paediatric formulation) IPV = IPV = Inactivated
Inactivated poliomyelitis
Inactivated poliomyelitis vaccine poliomyelitis vaccine
vaccine 15vPCV = 15-valent
15vPCV = 15-valent pneumococcal 15vPCV = 15-valent
pneumococcal conjugate
conjugate vaccine pneumococcal conjugate
vaccine
vaccine
dTpa = Diphtheria-tetanus- dTpa = Diphtheria-tetanus-

dTpa = Diphtheria-tetanus-acellular
acellular pertussis vaccine acellular pertussis vaccine
pertussis vaccine (reduced antigen
(reduced antigen (reduced antigen
formulation) MenB = formulation) MenB =

formulation) MenB =
Meningococcal serogroup B Meningococcal serogroup
Meningococcal serogroup B
vaccine 20vPCV = 20-valent B vaccine 20vPCV =
vaccine 20vPCV = 20-valent
pneumococcal conjugate 20-valent pneumococcal
pneumococcal conjugate vaccine
vaccine conjugate vaccine
HepB = Hepatitis B
HepB = Hepatitis B vaccine HepB = Hepatitis B vaccine
vaccine MenACWY =
MenACWY = Meningococcal MenACWY = Meningococcal
Meningococcal serogroup
serogroup ACWY conjugate serogroup ACWY conjugate
ACWY conjugate vaccine
vaccine 23vPPV = 23-valent vaccine 23vPPV = 23-valent
23vPPV = 23-valent
pneumococcal polysaccharide pneumococcal polysaccharide
pneumococcal
vaccine vaccine
polysaccharide vaccine
Hib = Haemophilus
Hib = Haemophilus infuenzae type Hib = Haemophilus infuenzae
infuenzae type b vaccine
b vaccine MMR = Measles- type b vaccine MMR =
MMR = Measles-mumps-
mumps-rubella vaccine QIV = Measles-mumps-rubella
rubella vaccine QIV =
Quadrivalent seasonal infuenza vaccine QIV = Quadrivalent
Quadrivalent seasonal
vaccine seasonal infuenza vaccine
infuenza vaccine
* HepB, DTPa, IPV and Hib are administered at 2, 4 and 6 months of age using a combination
vaccine. The Lrst dose can be given as early as 6 weeks of age; refer to footnote (b).
† DTPa and IPV are administered at 4 years of age using a combination vaccine.
‡ MMRV [Measles, mumps, rubella and varicella] are administered at 18 months of age using a
combination vaccine.
a. The National Immunisation Program Schedule is available on the Australian Government here
[Department of Health immunisation website (https://www.health.gov.au/health-topics/immuni
sation/immunisation-throughout-life/national-immunisation-program-schedule) ]. (https://ww
w.health.gov.au/health-topics/immunisation/immunisation-throughout-life/national-immunisati
137
Immunisation
on-program-schedule) Contact your state/territory health department for further information on

any additional immunisation programs speciLc to your state or territory.
b. Vaccines scheduled at 2 months of age can be given as early as 6 weeks of age. The next
scheduled dose should still be given at 4 months of age.
c. A booster dose of hepatitis B vaccine is recommended at 12 months of age for infants who
were born preterm at <32 weeks’ gestation or whose birth weight was <2000 g, unless a blood
test 1 month after the Lnal dose of the primary course showed an anti-hepatitis B (HBs)
antibody titre of ≥10 mIU/mL.
d. DTPa [diphtheria-tetanus-acellular pertussis] vaccine is given in adolescence as dTpa (reduced
antigen formulation). School years during which school-based programs are delivered vary
among states and territories. Contact your state or territory health department for more details.
dTpa vaccine is recommended for any adult who wishes to reduce their likelihood of becoming
ill with pertussis. Adults aged ≥65 years are recommended to receive a dose of dTpa if they
have not had one in the past 10 years. Adults aged ≥50 years are recommended to receive a
booster dose of tetanus-containing vaccine if their last dose was more than 10 years ago.
[Adults aged ≥65 years are recommended to receive a dose of dTpa if they have not had one in
the past 10 years.] Adults with tetanus-prone wounds are recommended to receive a booster
dose of dT or dTpa if their last dose was more than 5 years ago.
e. dTpa vaccine is recommended and funded during each pregnancy. If a mother was not
vaccinated during pregnancy, maternal vaccination is recommended as soon as possible after
birth and preferably before hospital discharge.
f. MMRV should not be given as the Lrst dose of measles-containing vaccine in children aged <4
years.
g. 2 doses of MMR are recommended for adults born during or since 1966, unless the individual
is documented to be immune. MMR vaccine is recommended for women of childbearing age
who are seronegative for rubella. Vaccinated women should avoid pregnancy for 28 days after
vaccination.
h. A second dose of varicella vaccine is recommended to provide increased protection and
minimise the chance of breakthrough varicella in children and adolescents aged <14 years.
This could potentially be given at 4 years of age, or at any time up to 14 years of age (at least 4
weeks after the 1st dose). 2 doses of varicella vaccine are recommended for all adults who are
non-immune to varicella. Non-immune women are recommended to receive varicella vaccine
before they become pregnant.
i. MenB vaccine is recommended for all people aged ≥6 weeks who wish to reduce the likelihood
of becoming ill with meningococcal disease, and is recommended for infants and children
aged <2 years and adolescents aged 15–19 years. Bexsero is the only MenB vaccine that can
be used in infants and children aged <10 years. The doses required and the schedule depend
on the age at which the vaccine course is started and the presence of at-risk medical
conditions. For further details, refer to the Australian immunisation handbook (https://immunisa
tionhandbook.health.gov.au/vaccine-preventable-diseases/meningococcal-disease) . (https://i
mmunisationhandbook.health.gov.au/vaccine-preventable-diseases/meningococcal-disease)
j. MenACWY vaccine is recommended for all people ≥6 weeks of age who wish to reduce the
likelihood of becoming ill with meningococcal disease, as well as for infants and children aged
<2 years and adolescents aged 15–19 years. The doses required and the schedule depend on
the age at which the vaccine course is started, the brand used and the presence of at-risk
medical conditions. A single NIP-funded dose of MenACWY vaccine (Nimenrix®) is scheduled
at 12 months of age. A single dose of MenACWY vaccine (Nimenrix®) is also provided for
138
Immunisation
adolescents through a school-based program (14–16-year-olds); those aged 15–19 years who
did not receive the vaccine at school can receive it from their GP. For further details, refer to the
Australian immunisation handbook (https://immunisationhandbook.health.gov.au/vaccine-preve
ntable-diseases/meningococcal-disease) . (https://immunisationhandbook.health.gov.au/vacci
ne-preventable-diseases/meningococcal-disease)
k. Infuenza vaccine is recommended annually for all people aged ≥6 months who wish to reduce
the likelihood of becoming ill with infuenza. Infuenza vaccine is funded under the NIP for all
children ≥6 months to 59 months (<5 years) of age, people ≥5 years of age with certain medical
conditions predisposing them to severe infuenza. For older people aged ≥65 years, the
adjuvanted quadrivalent infuenza vaccine (aQIV, Fluad Quad®) is funded under the NIP and is
preferentially recommended over standard QIV. The QIV is funded under the NIP for adults with
a medical condition that predisposes them to severe infuenza, pregnant women, non-
Indigenous adults aged ≥65 years. For further details, refer to the ATAGI [Australian Technical
Advisory Group] advice on seasonal infuenza vaccines (https://www.health.gov.au/resources/
publications/atagi-advice-on-seasonal-infuenza-vaccines-in-2021) . (https://www.health.gov.a
u/resources/publications/atagi-advice-on-seasonal-infuenza-vaccines-in-2021)
l. A single dose of HPV vaccine is recommended and NIP-funded for adolescents and young
adults (ie aged ≤25years). A 3-dose schedule of HPV vaccine is recommended and NIP-funded
for immunocompromised adolescents and adults. School years at which the school-based
programs are delivered vary among states and territories. Contact your state or territory health
department for more details.
m. A 2-dose schedule of herpes zoster vaccine (Shingrix®) is recommended and funded under the
NIP for adults aged ≥65 years, 2–6 months apart.
Note: This table does not include recommendations on use of vaccines in the context of response to,
and control of, a disease outbreak, or (speciLcally) for travel outside Australia. Refer also to
Immunisation recommendations for Aboriginal and Torres Strait Islander people without risk factors for
vaccine-preventable diseases living in the ACT, NSW, Tas, Vic (http://www.ncirs.org.au/health-professio
nals/immunisation-schedules) and Immunisation recommendations for Aboriginal and Torres Strait
Islander people without risk factors for vaccine-preventable diseases living in the NT, QLD, SA, WA (htt
p://www.ncirs.org.au/health-professionals/immunisation-schedules)
Reproduced with permission from the National Centre for Immunisation Research and Surveillance (htt
ps://ncirs.org.au/health-professionals/immunisation-schedules) . Immunisation recommendations for
non-Indigenous Australians without risk factors for vaccine preventable diseases. March 2024 update.
NCRIS, 2024. Available at https://ncirs.org.au/sites/default/Lles/2024-03/
NCIRS_Immunisation%20schedule_non-
Indigenous%20people%20without%20risk%20factors_March%202024.pdf (https://ncirs.org.au/sites/de
fault/Lles/2024-03/NCIRS_Immunisation%20schedule_non-Indigenous%20people%20without%20ris
k%20factors_March%202024.pdf) [Accessed 6 April 2024].
State and territory health departments also fund some additional vaccines. Visit the National
Immunisation Program (https://www.health.gov.au/topics/immunisation/when-to-get-vaccinated/natio
nal-immunisation-program-schedule?language=und) for information on state and territory
immunisation schedules.
COVID-19 regulations change regularly. For information about the COVID vaccines, visit the Australian
139
Immunisation
immunisation handbook (https://immunisationhandbook.health.gov.au/contents/vaccine-preventable-dis

eases/covid-19) .
Vaccination guidance changes over time and vaccination providers are responsible for checking for the
latest information. Visit the Australian immunisation handbook (https://immunisationhandbook.health.go
v.au/contents/vaccine-preventable-diseases/covid-19) and the National Centre for Immunisation
Research and Surveillance (https://ncirs.org.au/health-professionals/immunisation-schedules) (NCIRS)
for the most up-to-date immunisation information.
Further information
The National Immunisation Program (https://www.health.gov.au/topics/immunisation/when-to-get-vac
cinated/national-immunisation-program-schedule?language=und) lists the recommended funded
vaccines for all Australian residents. There are other vaccines that are not funded but are
recommended in the Australian immunisation handbook (https://immunisationhandbook.health.gov.au/c
ontents/vaccine-preventable-diseases/) , depending on occupation or travel. There may be variability in
vaccines recommended/funded (eg hepatitis A vaccine).
Consent
Consent should be sought from someone with legal capacity before each vaccination. The individual
providing consent should have the intellectual capacity to understand speciLc information and agree
voluntarily without pressure, coercion or manipulation. The consent process should include written
advice about beneLts and harms of the vaccines, risk of not having the vaccine, and what to do after
receiving the vaccine.
Information on providing valid consent is available within the Australian immunisation handbook (http
s://immunisationhandbook.health.gov.au/contents/vaccination-procedures/preparing-for-vaccination#val
id-consent) .
Recording, setting up effective recall systems and assessing the need for
catch-up vaccinations
Information on recording on the Australian Immunisation Register (https://www.servicesaustralia.gov.a
u/australian-immunisation-register-for-health-professionals) , setting up effective recall systems (http
s://immunisationhandbook.health.gov.au/contents/vaccination-procedures) and on catch-up
vaccinations (https://immunisationhandbook.health.gov.au/contents/catch-up-vaccination) is available
within the Australian immunisation handbook.
Noti9cation of adverse events

The reporting of adverse events following vaccinations varies geographically. It is possible to report
directly to the Therapeutic Goods Administration (https://www.tga.gov.au/resources/resource/guidanc
e/reporting-adverse-events) from anywhere in Australia or by telephone on 1800 044 114.
140
Immunisation

peoples
Immunisation recommendations for Aboriginal and Torres Strait Islander people without risk factors for
vaccine-preventable diseases vary across states and territories. Refer to NCIRS advice for Aboriginal
and Torres Strait Islander people living in the Australian Capital Territory, New South Wales, Tasmania or
Victoria (https://ncirs.org.au/sites/default/Lles/2023-07/NCIRS%20Immunisation%20schedule%20fo
r%20Aboriginal%20and%20Torres%20Strait%20Islander%20people%20living%20in%20NSWVICACT%20
TAS_July2023.pdf) , and for those living in the Northern Territory, Queensland, South Australia and
Western Australia. (https://ncirs.org.au/sites/default/Lles/2023-11/NCIRS_Immunisation%20schedul
e_Aboriginal%20and%20Torres%20Strait%20Islander%20people_QLD%20NT%20WA%20SA_Novembe
r%202023.pdf)
For speciLc recommendations and advice for Aboriginal and Torres Strait Islander people, also please
refer to the Department of Health and Aged Care’s Immunisation for Aboriginal and Torres Strait
Islander people (https://www.health.gov.au/topics/immunisation/when-to-get-vaccinated/immunisatio
n-for-aboriginal-and-torres-strait-islander-people) and The Royal Australian College of General
Practitioners’ National guide to a preventive health assessment for Aboriginal and Torres Strait Islander
people (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-rac
gp-guidelines/national-guide/chapter-3-child-health/immunisation) .
Speci9c populations
Adults or children who develop asplenia, human immunodeLciency virus (HIV) infection or a
haematological malignancy, or who have received a bone marrow or other transplant, may not be Lt for
some vaccinations, or may require additional or repeat vaccinations.
Men who have sex with men (MSM) have additional vaccine recommendations:
• hepatitis A
• hepatitis B
• monkeypox (Mpox)
• human papillomavirus vaccine (HPV).
Meningococcal ACYW and B vaccination should also be considered.
Mpox is a viral illness easily transmitted via sexual activity. A worldwide outbreak in 2022 lead to a
successful vaccination campaign to reduce risk of transmission. All MSM are recommended to have a
completed Mpox vaccination.
MSM are at higher risk of HPV-related anal cancers. A completed HPV vaccine course is recommended
to reduce the risk of anal cancers later in life.
There have been regular outbreaks of meningococcal disease at large MSM gatherings, such as
parades, parties and other events that might attract attendance from an interstate or international
audience.
141
Immunisation
People with compromised immunity
Meningococcal B vaccination is recommended for people with compromised immunity, including those
living with HIV. There is some emerging evidence of reduction of gonococcal sexually transmitted
infections in people who have been vaccinated for Meningococcal B.
Certain vaccines may not be recommended for individuals with compromised immune systems due to
contraindications. Further, these people might require additional vaccine doses to increase their
protection.1 For more information on vaccination for people who are immunocompromised, refer to the
Australian immunisation handbook (https://immunisationhandbook.health.gov.au/contents/vaccination-f
or-special-risk-groups/vaccination-for-people-who-are-immunocompromised) .
For more information about vaccinations for special risk groups, refer to the Australian immunisation
handbook (https://immunisationhandbook.health.gov.au/contents/vaccination-for-special-risk-groups) .
Resources
Australian immunisation handbook (https://immunisationhandbook.health.gov.au/) Australian
Immunisation Register (AIR) (https://www.humanservices.gov.au/customer/services/medicare/australi
an-childhood-immunisation-register) | The AIR can be used to obtain information on the vaccination
history of individuals from birth to age 7 years given since 1 January 1996. The AIR can be contacted by
email (mailto:acir@humanservices.gov.au) or telephone on 1800 653 809. National Centre for
Immunisation Research & Surveillance (NCIRS) (http://www.ncirs.edu.au/) National Immunisation
Program (NIP) schedule (https://www.health.gov.au/health-topics/immunisation/immunisation-through
out-life/national-immunisation-program-schedule)
References
1. Department of Health and Aged Care. 3. Haynes K, Stone C. Predictors of incomplete
Australian immunisation handbook. Department immunisation in Victorian children. Aust N Z J
of Health and Aged Care, 2023 (https://immunisa Public Health 2004;28(1):72–79. [Accessed 15
tionhandbook.health.gov.au) [Accessed 15 April April 2024].
2024].
2. Ward K, Chow MYK, King C, Leask J. Strategies
to improve vaccination uptake in Australia, a
systematic review of types and effectiveness.
Aust N Z J Public Health 2012;36(4):369–77.
142
Sexually transmissible infections including HIV
Sexually transmissible infections including

HIV
Infectious diseases | Sexually

transmissible infections including HIV
Screening age bar – women for chlamydia and gonorrhoea
0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75–79 ≥80

In Australia in 2021 there were 86,916 diagnoses of chlamydia, 26,577 of gonorrhoea and 5,570 of
infectious syphilis.1 Young people aged 15–29 years are signiLcantly impacted by sexually
transmissible infections (STIs),2 with this age group accounting for 70% of all chlamydia notiLcations in
2021.1 NotiLcation rates of gonorrhoea and syphilis continue to increase in young people, with nearly
half of new gonorrhoea diagnoses and approximately one-third of new syphilis diagnoses occurring in
people aged ≤29 years.1
STIs are frequently seen in general practice, especially chlamydia, which is typically asymptomatic.3,4 It
is important to detect chlamydia early to prevent transmission to others and to minimise potential
complications, such as infertility.5 It may also be appropriate to screen for other STIs. The individual’s
age, sexual behaviour and community HIV or STI prevalence all infuence the level of risk and should
infuence the choice of STI screening tests.
In asymptomatic, sexually active people up to 29 years of age, the overall absolute risk of infection is
approximately 5% for chlamydia and 0.5% for gonorrhoea.6
Rates of gonorrhoea and syphilis are higher among men who have sex with men (MSM) and among
Aboriginal and/or Torres Strait Islander peoples, particularly those in remote communities.1 The rates of
gonorrhoea, syphilis and HIV have grown considerably in the past 5 years among heterosexual
populations, with considerable concern in recent years about syphilis in pregnant women leading to
increased cases of congenital syphilis.8
143
 Screening
9
Screening for chlamydia and gonorrhoea is Conditionally Opportunistically
recommended in all sexually active women recommended if indicated
aged ≤24 years, but only in those who are at (evidence is
increased risk (see Box 1) among women unclear on
aged ≥25 years. testing interval)
9
Although current evidence is insuacient to Practice point N/A
assess the balance of beneLts and harms of
screening for chlamydia and gonorrhoea in
heterosexual men, it should be considered in
order to prevent transmission to their partner/
s.
10
Test all pregnant women for syphilis during Recommended As per
routine antenatal screening in the Lrst (Strong) recommendation
trimester of pregnancy, or if presenting for the
Lrst time in late pregnancy without previous
antenatal care.
Recommend repeat testing early in the third
trimester (28–32 weeks) and at the time of
birth for women at high risk of infection or
reinfection.
Actively follow up pregnant women who do
not attend for testing.
 Case 9nding
144
Perform an asymptomatic STI check for Practice point Opportunistically 11
people who:
• have been exposed to any STI or
have a history of an STI within the
past 12 months
• are at increased risk of an STI (eg
new sexual partner, living or
travelling to areas of higher
prevalence in Australia or in other
countries)
• request STI testing
• are a partner of a special
subpopulation (eg MSM, sex
workers, pregnant women, Aboriginal
and Torres Strait Islander people,
trans and gender-diverse people) or a
partner of anyone meeting any of the
above.
STI testing is detailed in the Australasian

Society for HIV, Viral Hepatitis and Sexual
Health Medicine’s (ASHM) STI management
guidelines for use in primary care (https://sti.g
uidelines.org.au/standard-asymptomatic-che
ckup/) (see Further information for
recommended STI tests).
11
Asymptomatic Mycoplasma genitalium Practice point N/A
testing is not recommended (see Further
information for more details).
12
Advise people that safe sex is the use of Practice point Opportunistically
condoms and water-based lubricant during
anal or vaginal intercourse.
Safe sex can:
• prevent HIV transmission
• prevent pregnancy
• help prevent most STIs.
145
Further information
Identify the risk of an STI by taking a sexual history and clarifying sexual practices with the patient.11
Information and example questions on how to take a sexual history are available in the ASHM’s STI
management guidelines for use in primary care (https://sti.guidelines.org.au/sexual-history/) .
Any STI diagnosis detected in screening should lead to a comprehensive STI check (https://sti.guideline
s.org.au/sexual-history/) .11
Recommended STI tests

(As per the ASHM’s STI management guidelines for use in primary care (https://sti.guidelines.org.au/sta
ndard-asymptomatic-checkup/) )
Blood tests
Test Consideration
HIV (antigen/antibody Repeat if recent exposure (6-week window period if antigen/antibody

test) test)
Syphilis serology If recent exposure, repeat at 12 weeks and treat presumptively
Hepatitis B
HBsAg (hepatitis B
surface antigen)
Establish hepatitis B virus status and immunise if not previously
Anti-HBs (hepatitis B
documented
surface antibody)
Anti-HBc (hepatitis B
core antibody)
In Australia, routine adolescent hepatitis B immunisation commenced in 1997 and universal infant
hepatitis B immunisation commenced in May 2000. Therefore, people aged ≤34 years in 2020 and
who grew up in Australia can generally be assumed to have been vaccinated and do not need
testing.
Gonorrhoea and chlamydia testing
Site/specimen Test Consideration
146
Self-collected vaginal
A vaginal swab is more sensitive than FPU and is
swab
Nucleic acid the specimen of choice.
Urethral Lrst-pass urine
ampliLcation If speculum examination is indicated, then an
(FPU)
test (NAAT) endocervical swab can be collected in place of a
For MSM, oropharyngeal
vaginal swab.
and anorectal swabs
Sexual health consultation

Many patients and doctors feel uncomfortable discussing sexual histories even when indicated or the
patient is requesting STI testing. Taking a sexual history is an important part of the assessment and
management of STIs, and it should not be a barrier to offering STI testing.13
A non-judgemental attitude and environment will facilitate disclosures on sexual matters.14 It is

important to ask open-ended questions and to avoid assumptions about sexual orientation by using the
term ‘partner’. Gentle enquiry about recent sexual activity, gender, number of partners, contraception
(including the use of condoms), travel history and immunisation status helps inform decision making. In
addition, ask about the risks for blood-borne viruses (hepatitis B, hepatitis C and HIV), such as injecting
drug use, tattooing and piercing. Investigations should be explained, and patients should be asked for
consent before tests such as HIV or hepatitis C are ordered (see Hepatitis C (https://www.racgp.org.au/
clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/preventive-activitie
s-in-general-practice/infectious-diseases/hepatitis-b-and-c) section).
Some patients may present with a request for one speciLc test, such as ‘I want an HIV test’. It is
important to contextualise that HIV is relatively rare compared with infections such as chlamydia.
These presentations represent an excellent opportunity for STI screening as per the recommendations
and education. For people who may be at risk of HIV, this is an excellent opportunity to offer prevention
information, such as condom use or pre-exposure prophylaxis (PrEP).
Mycoplasma genitalium
Mycoplasma genitalium is a sexually transmitted bacterial STI. Mycoplasma genitalium can cause
urethritis, pelvic infammatory disease (PID), cervicitis and rectal infections. Mycoplasma genitalium
testing is only recommended in people who are symptomatic despite negative screening for chlamydia
or gonorrhoea. Further information is available in the ASHM’s STI management guidelines for use in
primary care (https://sti.guidelines.org.au/sexually-transmissible-infections/mycoplasma-genitalium/) .
Mycoplasma genitalium should not be routinely tested in asymptomatic people; however, if a person still
has STI like symptoms after a negative chlamydia/gonorrhoea test, it is advised a Mycoplasma
genitalium polymerase chain reaction (PCR) test is performed.
147
Contact tracing
Contact tracing is essential in reducing the transmission of STIs and HIV. It is the responsibility of the
diagnosing clinician to facilitate the process of notifying current and past partners. This may be through
a direct approach from the patient, their treating health professional or by using available online partner
notiLcation services, such as:
• www.letthemknow.org.au (http://www.letthemknow.org.au/)
• www.thedramadownunder.info/notify (http://www.thedramadownunder.info/notify) (for MSM)
• www.bettertoknow.org.au (http://www.bettertoknow.org.au/) (for Aboriginal and Torres Strait
Islander youth).
For more information and to determine ‘how far back to trace’, refer to the contact tracing manual at the
ASHM website (http://contacttracing.ashm.org.au/) or the NSW Government’s STI/HIV testing tool (http
s://stipu.nsw.gov.au/wp-content/uploads/STI-HIV-Testing-Tool-online.pdf) .
For HIV contact tracing, seek assistance from local sexual health services. Getting assistance from
local sexual health services is recommended for HIV and syphilis because it leads to more contacts
being tested and treated.15
Referral to sexual health services should be considered for problematic or repeated infections.16
In the case of a notiLable condition, the patient should be informed that case notiLcation to public
health authorities will occur. NotiLcation should be made as set by the department of health in the
relevant state or territory.
Box 1. Increased risk of chlamydia and gonorrhoea9
Women aged ≥25 years are at increased risk if they:
• have a new sexual partner, more than one sexual partner, a sexual partner
with concurrent partners or a sexual partner who has a sexually transmissible
infection (STI)
• practice inconsistent condom use when not in a mutually monogamous
relationship or have a previous or coexisting STI
• exchange sex for money or drugs and have a history of incarceration.
148

peoples
Aboriginal and Torres Strait Islander peoples are at higher risk of STIs and should also be screened for
gonorrhoea, chlamydia, syphilis and HIV. For speciLc recommendations and advice for Aboriginal and
Torres Strait Islander people, refer to the National guide to a preventive health assessment for Aboriginal
and Torres Strait Islander people (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-ra
cgp-guidelines/view-all-racgp-guidelines/national-guide/chapter-14-sexual-health-and-blood-borne-virus
es) .
Speci9c populations
Some subpopulations (eg MSM, sex workers, pregnant women, Aboriginal and Torres Strait Islander
people, trans and gender-diverse people) have special requirements for testing due to increased risk of
infection, adverse health outcomes, community prevalence or other factors.11 Further information is
available in the ASHM’s STI management guidelines for use in primary care (https://sti.guidelines.org.a
u/) .
Pregnant women
All pregnant women should be screened, with consent, for hepatitis B, hepatitis C, HIV and syphilis.11
Consider screening pregnant women up to 29 years of age for chlamydia (and gonorrhoea, if the patient
is at high risk). Untreated pregnant women infected with chlamydia have a 20–50% chance of infecting
their infant at delivery.17 See the First antenatal visit (https://www.racgp.org.au/clinical-resources/clinic
al-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/preventive-activities-in-general-practice/re
productive-and-womens-health/Lrst-antenatal-visit) chapter.
Repeat syphilis testing at 28–32 weeks of pregnancy and at delivery in all women at risk of STIs, and in
all women presenting with signs or symptoms of any other STI.
Repeat syphilis tests in all women in communities experiencing syphilis outbreaks. The Departments of
Health in each state and territory will issue alerts to clinicians in areas where a syphilis outbreak
occurs.
Men who have sex with men

MSM should be routinely screened for STIs (refer to the STIGMA guidelines (https://stipu.nsw.gov.au/w
p-content/uploads/STIGMA_Guidelines2019_Final-1.pdf) for further guidance).
Chlamydia pharyngitis can be associated with oral sex. Gonorrhoea can be transmitted via oral sex.
Throat swabs should be considered for chlamydia/gonorrhoea PCR in all MSM, but are worth
considering for all sexually active patients.11,18
149
References
1. The Kirby Institute. HIV, viral hepatitis and 9. U.S. Preventive Services Task Force (USPSTF).
sexually transmissible infections in Australia: Chlamydia and gonorrhea: Screening. USPSTF,
Annual surveillance report 2022. The Kirby 2021 (https://www.uspreventiveservicestaskforc
Institute, 2022 (https://www.kirby.unsw.edu.au/re e.org/uspstf/recommendation/chlamydia-and-go
search/reports/asr2022) [Accessed 11 norrhea-screening) [Accessed 11 September
September 2023]. 2023].
2. Department of Health and Aged Care. Fourth 10. Department of Health. Congenital syphilis in
national sexually transmissible infections strategy Victoria. Victoria State Government, 2022 (http
2018–2022. Australian Government, 2019 s://www.health.vic.gov.au/health-advisories/cong
(https://www.health.gov.au/resources/publi enital-syphilis-in-victoria) [Accessed 11
cations/fourth-national-sexually-transmissible-inf September 2023].
ections-strategy-2018-2022?language=en) 11. Australasian Society for HIV, Viral Hepatitis and
[Accessed 24 July 2023]. Sexual Health Medicine (ASHM). STI
3. Australasian Society for HIV, Viral Hepatitis and management guidelines for use in primary care.
Sexual Health Medicine (ASHM). HIV, viral ASHM, 2022 (https://sti.guidelines.org.au/)
hepatitis & STIs: A guide for primary care. Sydney: [Accessed 11 September 2023].
ASHM, 2014 (https://ashm.blob.core.windows.ne
12. NSW Health. Safe sex. Sydney: NSW Health, 2013
t/ashmpublic/HIV_Viral_Hepatitis_and_STIs_a_Gu
(https://www.health.nsw.gov.au/sexualhealt
ide_for_Clinical_Care_(4th_Edition).pdf)
h/Pages/safe-sex.aspx) [Accessed 25 January
2023].
4. Kong FY, Guy RJ, Hocking JS, et al. Australian
13. Pavlin NL, Parker R, Fairley CK, Gunn JM, Hocking
general practitioner chlamydia testing rates
J. Take the sex out of STI screening!Views of
among young people. Med J Aust
young women on implementing chlamydia
2011;194(5):249–52. doi: 10.5694/
screening in general practice. BMC Infect Dis
.1326-5377.2011.tb02957.x. [Accessed 13 May
2008;8:62. doi: 10.1186/
2016].
1471-2334-8-62. [Accessed 25 January 2023].
5. Hocking J, Fairley C. Need for screening for
14. Preswell N, Barton D. Taking a sexual history.
genital chlamydia trachomatis infection in
Aust Fam Physician 2000;29(5):533–39.
Australia. Aust N Z J Public Health
2003;27(1):80–81. doi: 10.1111/
.1467-842x.2003.tb00385.x. [Accessed 13 May 15. Ferreira A, Young T, Mathews C, Zunza M, Low
2016]. . Strategies for partner notification for sexually
transmitted infections, including HIV. Cochrane
6. Hocking JS, Temple-Smith M, Guy R, et al.
Database Syst Rev 2013;10:CD002843. doi:
Population effectiveness of opportunistic
10.1002/14651858.cd002843.pub2. [Accessed
chlamydia testing in primary care in Australia: a
25 January 2023].
cluster-randomised controlled trial. Lancet 2018;
392 (10156):1413–22. doi: 10.1016/ 16. Burnet Institute. Partner notification of sexually
s0140-6736(18)31816-6. [Accessed 13 May transmitted infections in New South Wales: An
2016]. informed literature review. Centre for Population
Health, 2010 (https://stipu.nsw.gov.a u/wp-
7. Cook RL, Hutchison SL, Ostergaard L. Systematic
content/uploads/NSW_STI_PN_PDF.pdf)
review: Noninvasive testing for Chlamydia
trachomatis and Neisseria gonorrhoeae. Ann
Intern Med 17. Honey E, Augood C, Templeton A, et al. Cost
2005;142(11):914–25. doi: 10.7326/ effectiveness of screening for Chlamydia
0003-4819-142-11-200506070-00010. [Accessed trachomatis: A review of published studies. Sex
13 May 2016]. Transm Infect 2002;78(6):406–12. doi: 10.1136/
sti.78.6.406. [Accessed 28 January 2016].
8. Department of Health. Congenital syphilis.
Victoria State Government, 2022 (http://www.heal
th.vic.gov.au/infectious-diseases/congenital-syph
ilis) [Accessed 21 August 2023].
150
18. Chow EPF, Fairley CK. The role of saliva in

gonorrhoea and chlamydia transmission to
extragenital sites among men who have sex with
men: New insights into transmission. J Int AIDS
Soc 2019;22(Suppl 6):e25354. doi: 10.1002/
jia2.25354. [Accessed 28 January 2016].
151
Injury prevention
152
Injury prevention
Bullying and child abuse (https://www.racgp.org.au/clinical-resources/clinical-g

uidelines/key-racgp-guidelines/view-all-racgp-guidelines/preventive-activities-in-
general-practice/injury-prevention/child-abuse-and-maltreatment) Elder abuse (h
ttps://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guideli
nes/view-all-racgp-guidelines/preventive-activities-in-general-practice/injury-prev
ention/elder-abuse) Falls (https://www.racgp.org.au/clinical-resources/clinical-g
uidelines/key-racgp-guidelines/view-all-racgp-guidelines/preventive-activities-in-
general-practice/injury-prevention/falls) Intimate partner abuse and violence (htt
s/view-all-racgp-guidelines/preventive-activities-in-general-practice/injury-preven
tion/intimate-partner-violence)
153
Bullying and child abuse
Injury prevention | Bullying and child abuse

Case 9nding age bar
0-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 7

Child abuse includes physical abuse, sexual abuse, emotional abuse and neglect as well as children
experiencing adult domestic violence.1 National Lgures refect high levels of child abuse in Australia.2
Sixty-two per cent of Australians have experienced child abuse and neglect and 40% of 16–24-year-olds
have experienced more than one type of abuse.3 The prevalence of sexual and emotional abuse is
higher among girls compared to boys, with rates of sexual abuse reported at 37% for girls and 19% for
boys, and rates of emotional abuse at 36% for girls and 25% for boys.4
Child abuse is most commonly perpetrated by someone within the family, or by a person known to the
child.1 (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-ra
cgp-guidelines/abuse-and-violence/children-and-young-people/child-abuse-and-neglect#ref-num-1)
Children less than one year of age are particularly vulnerable, especially to physical abuse and poor
attachment to parents.1 Child abuse is associated with immediate and long-term health problems
including in mental health, physical health and health risk behaviours, and increased use of health
services.2 People who have experienced child abuse and neglect are two times more likely to have had
six or more visits to a GP in a 12-month period.2
Bullying in children and young people has been deLned as ‘any unwanted aggressive behaviour(s) by a
peer or sibling that involves an observed or perceived power imbalance and is repeated multiple times
or is highly likely to be repeated’.5 Bullying can be direct (physical or verbal) or indirect (relational/social,
social exclusion, spreading rumours, psychological/stalking, cyberbullying). It is also common and
harmful, with up to half of children experiencing bullying at some stage.6,7 Bullying can result in
signiLcant increases in behavioural and mental health problems, including suicide.8,9
Sibling bullying can start in toddlers (typically aged 2–6 years) and is common between the ages of six
and nine years. Sibling bullying can involve two-way sibling bullying, with both parties being a bully and
a victim.1
154
 Case 9nding
1
Consider the risk of child abuse, if people caring for a Practice Opportunistically
child are presenting with the following factors: point
• hazardous use of alcohol or use of illicit
drugs, particularly during pregnancy
• a family violence situation (50% overlap with
intimate partner abuse and violence)
• mental health problems or intellectual
disability, which can compromise a parent’s
ability to care for their child
• poor attachment to the infant
• absence of social supports or isolation
• unstable housing or Lnancial situation
• history of own abuse or neglect or that of
another child in the family.
1
GPs and parent/carers should maintain an Practice Opportunistically
awareness and ask about the possibility of both peer point
and sibling bullying in children with risk factors. Refer
to Box 1.
Further information
All health practitioners need to be aware of their legal obligations under state or territory mandatory
reporting requirements when they suspect child abuse.1 While research shows that the response to
child abuse is challenging for GPs and can threaten the therapeutic relationship, strategies such as
reframing any reporting as seeking help for the child or emphasising mandatory reporting duty can help
maintain the therapeutic relationship.10 Health practitioners can play a crucial role in providing support
to families affected by adverse circumstances through offering ongoing supportive and trauma-
informed care and linking to services as required. GPs can intervene at three levels:
• Recognise risk factors and intervene early to reduce risk of abuse and neglect and prevent
harm (primary prevention).
• Recognise harm and respond appropriately to mitigate future harm (secondary prevention).
• Support the ongoing wellbeing of both the child and the family to manage the long-term
negative impacts of harm.
155
Unlike in the case of adult perpetrators, in situations where the child or adolescent is using violence,
young people who use violence against their parents are legally children and therefore their protection,
safety and developmental needs need to be taken into consideration.1
Box 1. Risk factors for peer and sibling bullying1

Individual:
• Physical (eg overweight, disability, chronic illness)

• Behavioural (eg externalising and disruptive behaviours including aggression,
learning disability)
• Gender (eg LGBTQIA+)
• Emotional dysregulation (eg impulsivity)
• Adverse childhood experiences
Family:
• Structural family characteristics (eg Lrst born, having an older brother, having
step-siblings)
• Domestic violence
• Financial diaculties
• Negative family dynamics (eg conficting partnerships, arguing, hostile
communication), interparental confict
• Parenting quality (eg harsh discipline or failure to discipline, lack of parental
warmth, neglect, interparental hostility and abuse)

peoples
For speciLc recommendations and advice for Aboriginal and Torres Strait Islander people, please refer
to the National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people,
Chapter 3: Child health: Preventing child maltreatment – Supporting families to optimise child safety
and wellbeing (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/vie
w-all-racgp-guidelines/national-guide/chapter-3-child-health/preventing-child-maltreatment-–-supportin
g-familie) .
Speci9c populations
Supporting parents who have experienced trauma to understand the effects on, and care for, their
children provides an opportunity to help transform cycles of intergenerational trauma to cycles of
nurturing and recovery.11
156
Health practitioners also have a role in preventing, detecting and managing abuse in their patients with
disabilities. People with disabilities are a vulnerable group within our society and among general
practice patients.1 They are at increased risk for neglect and for multiple forms of abuse, including
verbal, psychological, physical and sexual abuse.1
Resources
Abuse and violence – Working with our patients in general practice (White Book) (https://www.racgp.or
g.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/abuse-and-vio
lence/preamble) | RACGP Reporting child abuse and neglect (https://aifs.gov.au/resources/resource-sh
eets/reporting-child-abuse-and-neglect) | Australian Institute of Family Studies Guidelines (various) on
recognising child abuse and neglect (https://pathways.nice.org.uk/pathways/child-abuse-and-neglec
t#path=view%3A/pathways/child-abuse-and-neglect/recognising-child-abuse-and-neglect.xml&conten
t=view-node%3Anodes-response-to-alerting-features) | National Institute for Health and Care Excellence
(NICE) VEGA family violence education resources – free educational resources for health professionals
recognising and responding to child abuse and neglect (https://vegaproject.mcmaster.ca/) | VEGA
Family Violence Project
References
1. The Royal Australian College of General 7. Tucker CJ, Finkelhor D, Shattuck AM, Turner H.
ractitioners. Abuse and violence – Working with Prevalence and correlates of sibling victimization
our patients in general practice (White Book). 5th types. Child Abuse Negl 2013;37(4):213–23.
edn. RACGP, 2021. [Accessed 18 May 2023].
2. Mathews B, Pacella R, Scott JG, et al. The 8. Bowes L, Wolke D, Joinson C, Lereya ST, Lewis
prevalence of child maltreatment in Australia: . Sibling bullying and risk of depression, anxiety,
Findings from a national survey. Med J Aust and self-harm: A prospective cohort study.
2023;218(Suppl 6):S13–S18. Pediatrics 2014;134(4):e1032–39. [Accessed 18
3. Higgins, D.J., Mathews, B., Pacella, R., et al. The May 2023].
prevalence and nature of multi-type child . Dantchev S, Hickman M, Heron J, Zammit S,
maltreatment in Australia. Med J Aust 2023, Wolke D. The independent and cumulative effects
218(Suppl 6):S19–S25. of sibling and peer bullying in childhood on
4. Australian Institute of Family Studies. Child depression, anxiety, suicidal ideation, and self-
protection and Aboriginal and Torres Strait harm in adulthood. Front Psychiatry 2019;10:651.
Islander children. AIFS, 2020 (https://aifs.gov.au/r [Accessed 18 May 2023].
esources/policy-and-practice-papers/child-protec 1 . Kuruppu J, Humphreys C, McKibbin G, Hegarty K.
tion-and-aboriginal-and-torres-strait-islander) Tensions in the therapeutic relationship:
[Accessed 18 May 2023]. emotional labour in the response to child abuse
5. Wolke D, Tippett N, Dantchev S. Bullying in the and neglect in primary healthcare. BMC Prim Care
2022;23(1):48. [Accessed 18 May 2023].
family: Sibling bullying. Lancet Psychiatry
2015;2(10):917–29. [Accessed 18 May 2023]. 11. National Aboriginal Community Controlled Health
6. Jadambaa A, Thomas HJ, Scott JG, Graves N, Organisation and The Royal Australian College of
Brain D, Pacella R. Prevalence of traditional General Practitioners. National guide to a
bullying and cyberbullying among children and preventive health assessment for Aboriginal and
adolescents in Australia: A systematic review and Torres Strait Islander people. RACGP, 2018.
meta-analysis. Aust N Z J Psychiatry [Accessed 18 May 2023].
2019;53(9):878–88. [Accessed 18 May 2023].
157
Elder abuse
Elder abuse
Injury prevention | Elder abuse

Abuse of older people may be physical, emotional, sexual or Lnancial, and may include neglect. It can
occur in any setting, including in aged care facilities and in the community, and affects 16% of the
Australian population.1 Abuse of older people is linked to increased mortality and disability.1,2 Caring for
older people who are being abused is critical to the health of these patients.1,2 Risk factors for the
abuse of older people can be related to the individual, the perpetrator, relationships, the home and the
wider community. There are many barriers to the older person being able to disclose the abuse.1,2
 Screening
Routine screening for abuse of older people is not Practice N/A 1,3
recommended. point
 Case 9nding
Clinicians should be alert to symptoms and signs of Practice 1

Opportunistically
abuse. See further information. point
Be aware of carer stress as a contributing factor to Practice 1

N/A
elder abuse. point
158
Elder abuse
Further information
Risks factors at the individual level include:1,4,5 (https://www.racgp.org.au/clinical-resources/clinical-gui
delines/key-racgp-guidelines/view-all-racgp-guidelines/abuse-and-violence/speciLc-abuse-issues-for-ad
ults-and-older-people/abuse-of-older-people#ref-num-14)
• poor physical health or frailty

• cognitive impairment and dementia
• poor mental health, including psychiatric illness
• behavioural problems
• functional dependency (needing assistance with activities of daily living)
• low income or wealth
• trauma or past abuse
• ethnicity
• social isolation or loneliness and lack of social support
• gender.4
Risk factors related to the carer or care relationship include:1,4,5
• caregiver burden or stress

• mental health problems
• alcohol or substance use
• Lnancial dependency on the older person
• a history of trauma or abuse.
Relationship risk factors include a history of poor family relationships and unrealistic expectations of
caring. Being in a shared living situation is a risk factor for the abuse of older people. However, it is not
clear whether spouses or adult children of older people are more likely to be the perpetrators of abuse.2
Within residential aged care homes, abuse is more likely to occur where:2
• standards for healthcare, welfare services and care facilities for older people are low
• staff may be poorly trained, poorly remunerated and overworked
• the physical environment is deLcient
• policies operate in the interests of the institution rather than the residents.
For possible signs and symptoms of abuse in older people, see table 15.1 (https://www.racgp.org.au/cli
nical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/abuse-and-violence/s
peciLc-abuse-issues-for-adults-and-older-people/abuse-of-older-people) in the RACGP’s Abuse and
violence: Working with our patients in general practice.

peoples
There are no speciLc recommendations or advice for Aboriginal and Torres Strait Islander peoples.
159
Elder abuse
Resources
Abuse and violence: Working with our patients in general practice, 5th edition (https://www.racgp.org.au/
clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/abuse-and-violenc
e/preamble) (The White Book) | RACGP
References
1. The Royal Australian College of General 4. Johannesen M, LoGiudice D. Elder abuse: A
Practitioners. (RACGP). Abuse and violence: systematic review of risk factors in community
Working with our patients in general practice,. 5th dwelling elders. Age Ageing 2013 May;
edition. East Melbourne, Vic:edn. RACGP, 2021 (ht 42:292–98. [Accessed 24 August
tps://www.racgp.org.au/clinical-resources/clinica 2021].;42:292–98. doi: 10.1093/ageing/afs195.
l-guidelines/key-racgp-guidelines/view-all-racgp-g [Accessed 21 February 2024].
uidelines/abuse-and-violence/preamble)
5. Joosten M, Vrantsides F, Dow B. Understanding
[Accessed 31 January 2024]. elder abuse. A scoping study. Melbourne:
2. World Health Organization. (WHO). Elder abuse MelbourneThe University of Melbourne and
Abuse of older people 20220. Geneva: WHO, National Ageing Research Institute,
20220 (https://www.who.int/news-room/fact-she 2017:1092–110. (https://socialequity.unimelb.ed
ets/detail/abuse-of-older-people) [Accessed 21 u.au/__data/assets/pdf_Lle/0011/2777924/Elde
February 2024]. r-Abuse-A-Scoping-Study.pdf) [Accessed 24
August 2021].
3. Mikton C, Beaulieu M, Yon Y, Genesse JC, St-
Martin K, Byrne M, Phelan A, Storey J, Rogers M,
Campbell F, Ali P, Burnes D, Band-Winterstein T,
Penhale B, Lachs M, Pillemer K, Estenson L,
Marnfeldt K, Eustace-Cook J, Lacasse F.Mikton C,
Beaulieu M, Yon Y, et al. PROTOCOL: Global elder
abuse: A mega-map of systematic reviews on
prevalence, consequences, risk and protective
factors and interventions. Campbell Systematic
Reviews,Syst Rev 2022: ;18(2):e1227. doi:
10.1002/cl2.1227. [Accessed 21 February 2024].
160
Falls
Falls
Injury prevention | Falls

Approximately 30% of people aged ≥65 years report having one or more falls in the past 12 months,1
and this increases with age. Approximately 10% of falls in those aged ≥65 years result in a fracture.2
Falls are more prevalent in people with dementia, especially those with Parkinson’s dementia.3 Almost
half of those who experience a fall will have a repeat fall within the next year.3 Injuries are higher in
older people due to the prevalence of underlying disease and reduced physiological reserve.3 It is
important to ask patients whether they have experienced ‘near falls’ as well as falls.3
Most falls are caused by an interaction of multiple risk factors. Older people who fall are at risk of a
‘long lie’ because of their inability to get up from the fall without assistance, which can result in
hypothermia, bronchopneumonia, dehydration, pressure injuries, rhabdomyolysis and, in some
instances, death.3
Some falls are associated with a loss of conLdence, functional decline, social withdrawal, anxiety and
depression, increased use of medical services and a fear of falling. An older person is at greater risk of
institutionalisation following a fall.3
 Case 9nding
How
often
1,4
GPs should routinely ask about falls in interactions Recommended At least
with community-dwelling older (≥65 years) adults, (Strong) once a
asking whether they have experienced a fall in the year
past year, because falls will not often be
spontaneously reported.
How
often
161
Falls
All older adults should be advised on falls prevention Recommended Annually 1,4
and physical activity. Refer to Staying active and on (Strong)

your feet (https://www.activeandhealthy.nsw.gov.au/p
reventing-falls/staying-active-and-on-your-feet/) or the
Exercises for falls prevention (https://www.racgp.or
g.au/clinical-resources/clinical-guidelines/handi/hand
i-interventions/exercise/exercises-for-falls-preventio
n) in the Handbook of non-drug interventions (HANDI).
Older adults who had a single, non-severe fall but also Recommended Annually 1,4,5
have gait and or balance problems should be (Strong)

considered as being at ‘intermediate risk’ (see Figure
1) and would beneLt from a strength and balance
exercise intervention or physiotherapist referral.
1,4
Older adults at high risk (see Figure 1) should be Recommended Annually
offered a multifactorial falls risk assessment to (Strong)
inform individualised, tailored interventions.
Further information
The World guidelines for falls prevention and management for older adults: A global initiative (https://ww
w.ncbi.nlm.nih.gov/pmc/articles/PMC9523684/pdf/afac205.pdf) provides an algorithm for risk
stratiLcation, assessment and interventions for community-dwelling older adults (see Figure 1).
Opportunistic case Lnding begins with one question: ‘Have you fallen in the past 12 months?’ This
question is highly speciLc in predicting future falls, but it has low sensitivity because it does not
consider common risk factors, resulting in a high rate of false negatives.1 Tools that assess more than
one fall risk factor, such as the 3 Key Questions (3KQ), have higher sensitivity.1 The 3KQ are:
1. Have you fallen in the past year?

2. Do you feel unsteady when standing or walking?
3. Do you have worries about falling?1
162
Falls
Figure 1. Algorithm for falls prevention for older adults.
Reproduced from Montero-Odasso et al. with permission from Oxford Academic.1 Medications should
be regularly reviewed, and patients should be encouraged to keep a medication review card.3,6 Reduce
doses to address side effects and dose sensitivity and stop medications that are no longer needed.
Certain medications, such as psychotropic drugs, those with anticholinergic or sedative effects and
those with hypotensive or orthostatic hypotensive side effects, can contribute to falls.3,6 Although
treatment of osteoporosis does not reduce the number of falls, it may reduce the number of falls that
result in a fracture. Refer to the osteoporosis chapter (https://www.racgp.org.au/clinical-resources/clini
cal-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/preventive-activities-in-general-practice/
musculoskeletal/osteoporosis) (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-rac
gp-guidelines/view-all-racgp-guidelines/preventive-activities-in-general-practice/musculoskeletal/osteo
porosis) for information on the prevention of osteoporosis.3,6 For individuals at a moderately high to
high risk of falls, a home assessment should be considered. Occupational therapy interventions can
help identify falls hazards, raise awareness of falls risks and implement safety strategies.6,7 When
referring patients, it is essential to specify fall prevention as the goal. The Quickscreen assessment tool
(https://neura.edu.au/resources-tools/quickscreen) , developed and validated for use in an Australian
population, includes home assessment tests, as well as simple assessments of medication use, vision,
sensation and balance. However, payment is required to access this tool. Active management of other
risk factors involves:6,7
163
Falls
• using a multidisciplinary team (eg podiatrist regarding foot problems, optometrist regarding
avoidance of multifocal lenses, physiotherapist or nurse regarding urge incontinence)
• referring to relevant medical specialists (eg ophthalmologist for cataract surgery, cardiologist
for consideration of pacemaker)
• investigation of the causes of dizziness
• optimal management of other medical conditions that may increase the risk of falls (eg
Parkinson disease, multiple sclerosis, dementia).
Falls can be prevented through both pharmacological and non-pharmacological means.3

Pharmacological-related prevention of falls includes:3
• deprescribing where possible, including a pharmacist review of medications where appropriate

(refer to Part A: Deprescribing (https://www.racgp.org.au/clinical-resources/clinical-guidelines/
key-racgp-guidelines/view-all-racgp-guidelines/silver-book/part-a/deprescribing) in the Silver
Book)
• reducing or ceasing psychotropic medications
• reviewing medications with a dehydrating effect/those contributing to postural hypotension (eg
diuretics, laxatives)
• ensuring the patient is replete of vitamin D by checking the baseline, and supplement if
required (low levels of vitamin D may make no difference to the risk of falling in individuals, but
being vitamin D replete reduces the rate of falling)
• ensuring the patient is replete of vitamin B12.
Non-pharmacological approaches to the prevention of falls include:3
• managing other medical conditions (as required)

• addressing the causes of postural hypotension: encourage adequate hydration; reduce salt in
the diet where possible; review medications; consider graduated light pressure stockings (if
tolerated); suggest small frequent meals rather than large meals; advise mindful, slow postural
adjustments after rising in the morning, after meals and after defecation
• addressing undernutrition
• managing incontinence
• managing visual impairment: optometrist/ophthalmologist input, expedite necessary cataract
surgery
• managing hearing impairment: refer for audiology assessment
• developing an individualised exercise program to improve muscle strength, balance, endurance
and fexibility; referral to a physiotherapist for individual or group classes may assist with
improving muscle strength, balance, endurance and fexibility (eg commencing Tai Chi)
• referring to a physiotherapist for mobility assistive devices
• referring to a podiatrist for foot care and appropriate footwear
• referring to an occupational therapist for home assessment and environmental modiLcations
(eg fooring, furniture, lighting, handrails).
164
Falls

peoples
Screening for falls in Aboriginal and Torres Strait Islander people is from the age of ≥50 years. Refer to
the section on falls (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guideline
s/view-all-racgp-guidelines/national-guide/chapter-5-the-health-of-older-people/falls) in the National
guide to a preventive health assessment for Aboriginal and Torres Strait Islander people for speciLc
recommendations and advice.
Speci9c populations
Exercise programs targeting non-English-speaking patients may need to address cultural norms about
appropriate levels of physical activity.
Resources
RACGP aged care clinical guide (Silver Book) (https://www.racgp.org.au/silverbook) World guidelines for
falls prevention and management for older adults: A global initiative (https://www.ncbi.nlm.nih.gov/pmc/
articles/PMC9523684/pdf/afac205.pdf) Screening and intervention to prevent falls and fractures in older
people (https://www.nejm.org/doi/full/10.1056/NEJMoa2001500) Staying active and on your feet (http
s://www.activeandhealthy.nsw.gov.au/preventing-falls/staying-active-and-on-your-feet/) Exercises for
falls prevention (https://www.racgp.org.au/clinical-resources/clinical-guidelines/handi/handi-interventi
ons/exercise/exercises-for-falls-prevention) , Handbook of non-drug interventions (HANDI) | RACGP
References
1. Montero-Odasso M, van der Velde N, Martin FC, et 3. The Royal Australian College of General
al. World guidelines for falls prevention and Practitioners (RACGP). Falls. In: RACGP aged
management for older adults: A global initiative. care clinical guide – Silver Book: Part A. RACGP,
Age Ageing 2022;51(9):afac205. doi: 10.1093/ 2019 (https://www.racgp.org.au/clinical-resource
ageing/afac205. s/clinical-guidelines/key-racgp-guidelines/view-al
2. The Royal Australian College of General l-racgp-guidelines/silver-book/part-a/falls)
Practitioners (RACGP). Exercises for falls [Accessed 31 January 2024].
prevention. In: Handbook of Non-Drug 4. Lamb SE, Bruce J, Hossain A, et al. Screening
Interventions (HANDI). RACGP, 2014 (https://ww and intervention to prevent falls and fractures in
.racgp.org.au/clinical-resources/clinical-guidelin older people. N Engl J Med 2020;383:1848–59.
es/handi/handi-interventions/exercise/exercises- doi: 10.1056/nejmoa2001500. [Accessed 31
for-falls-prevention) [Accessed 31 January 2024]. January 2024].
5. Ganz DA, Latham NK. Prevention of falls in
community-dwelling older adults. N Engl J Med
2020;382:734–43. doi: 10.1056/
nejmcp1903252.[Accessed 31 January 2024].
165
Falls
6. Gillespie LD, Robertson MC, Gillespie WJ, et al. 7. Panel on Prevention of Falls in Older Persons;
Interventions for preventing falls in older people American Geriatrics Society; British Geriatrics
living in the community. Cochrane Database Syst Society. Summary of the updated American
Rev 2012;9:CD007146. doi: 10.1002/ Geriatrics Society/British Geriatrics Society
14651858.cd007146.pub3. [Accessed 31 January clinical practice guideline for prevention of falls in
2024]. older persons. J Am Geriatr Soc
2011;59(1):148–57. doi: 10.1111/
.1532-5415.2010.03234.x. [Accessed 31 January
2024].
166
Intimate partner abuse and violence
Injury prevention | Intimate Partner Abuse

and Violence
Intimate partner abuse and violence (IPAV) is not only physical; it can also be sexual, psychological,
social, cultural, Lnancial and spiritual. IPAV can be in-person or technology facilitated. IPAV is a
pervasive public health problem with short- and long-term impacts on the health of all members of the
family, particularly women and children.1 In Australia, 1 in 4 women and 1 in 17 men since the age of 15
years have experienced physical, sexual, emotional or economic abuse from a cohabiting partner.2 IPAV
often commences and escalates in pregnancy. Most survivors are women in heterosexual relationships;
however, men and non-binary people can experience IPAV, in same-sex and gender-diverse
relationships.3 (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/vi
ew-all-racgp-guidelines/abuse-and-violence/domestic-or-intimate-partner-abuse-violence/intimate-part
ner-abuse#ref-num-1) It is estimated that one-half to two-thirds of women survivors have children in
their care at the time of the violence, which results in behavioural, cognitive and health issues for their
children in later life.3 IPAV is a leading contributor to ill health and premature death among women,
mainly due to mental health issues.1 Social impacts include economic insecurity, isolation and
homelessness.4 Women who have experienced IPAV use healthcare services more than women not
experiencing IPAV.5
 Screening
Screening for IPAV in the general population is Not N/A 3
not recommended, because of insuacient recommended

evidence (to assess the balance of beneLts (Strong)
and harms).
Routinely screen for IPAV in pregnancy. Recommended As part of 3
(Strong) antenatal care
167
 Case 9nding
Ask all patients who present with clinical Recommended Opportunistically 3
indicators, particularly psychological (Strong)

symptoms, about possible experiences of
IPAV (see Box 1).
See Box 2 below for questions to ask and

statements to make if you suspect IPAV.
Further information
Women survivors identify healthcare providers as the professionals they would most trust with
disclosure of abuse.5 Therefore, consider asking all pregnant adult and adolescent women about IPAV
during antenatal care, because this is a time of high risk and there are interventions that have been
shown to work in this setting.3 However, there is insuacient evidence for screening the general
population attending general practice;6,7 there should be a low threshold for asking about IPAV,
particularly when the GP suspects underlying psychosocial problems.3
Provide Lrst-line support to women who disclose IPAV. This includes the LIVES approach:8
• Listening
• Inquiring about needs
• Validating women’s disclosure
• Enhancing safety
• Providing support/referrals.
This Lrst-line response should be in the context of a CARE approach of providing:9
• Choice and control

• Action and advocacy
• Recognition and understanding
• Emotional connection with the patient.
People can experience IPAV regardless of race, religious group, age, gender and socioeconomic status.
Those most at risk include:
• Aboriginal and Torres Strait Islander women, women from culturally and linguistically diverse
(CALD) backgrounds, women with intellectual or physical disabilities
• LGBTIQA+ people
• pregnant women
• women who are recently separated or divorced, or who are on low incomes
• women who aged <25 years
• women who have experienced child abuse or come from a family where abuse and violence
168
occurred.3
Risk assessment in migrant and refugee people needs to assess language proLciency, immigration
status and the individual’s eligibility for support services. Many will experience marginalisation from the
wider community through racism, as well as dislocation from their ethnocultural heritage.
Box 1. Clinical indicators where practitioners should think about asking patients directly
about intimate partner abuse and violence3
Psychological
• Insomnia, nightmares
• Diaculty concentrating and making decisions
• Confusion, memory issues
• Irritability, feeling overwhelmed
• Anxiety and panic disorder
• Depression
• Suicidal ideation
• Somatoform disorder
• Post-traumatic stress disorder – hyperalertness and hypervigilance
• Eating disorders
• Drug and alcohol use
• Poor self-esteem
Social
• Isolation from family and friends

• Homelessness
• Financial and food insecurity
Physical
• Injuries, including strangulation

• Bruises at various stages of healing
• Sexual assault
• Sexually transmissible infections
• Chronic pelvic and abdominal pain
• Chronic headaches
• Fatigue
• Miscarriage, premature labour and stillbirth
• Nausea, chronic diarrhoea and change in appetite
169
Box 2. Questions to ask and statements to make if you suspect intimate partner abuse
and violence3
• ‘How are things at home?’

• ‘Do you feel safe at home?’
• ‘Often people who have these types of health problems are experiencing
diaculties at home. Is this happening to you?’
• ‘Sometimes these symptoms can be associated with having been hurt in the
past. Did that ever happen to you?’
• ‘Has your partner physically threatened or hurt you?’
• ‘Is there a lot of tension in your relationship? How do you resolve arguments?’
• ‘Sometimes partners react strongly in arguments and use physical force. Is this
happening to you?’
• ‘Are you afraid of your partner? Have you ever been afraid of any partner?’
• ‘Have you ever felt unsafe in the past at home?’
• ‘Violence is very common in the home. I ask a lot of patients about abuse
because no one should have to live in fear of their partners.’
• ‘Has your partner ever controlled your daily activities?’
• ‘Has your partner ever threatened to physically hurt you?’

peoples
In Aboriginal and Torres Strait Islander communities across Australia, family violence (abuse by any
family member, including partners) is disproportionately high in comparison with the non-Indigenous
Australian population.3 In addition, Aboriginal and Torres Strait Islander women are more likely to
experience serious forms of violence, such as physical assault. This high prevalence is attributable to
the many interrelated elements that are associated with colonisation, kinship disruption, disconnection
from land and culture, including trauma, racism, unemployment and poverty.3
Refer to the Family abuse and violence (https://www.racgp.org.au/clinical-resources/clinical-guideline

s/key-racgp-guidelines/view-all-racgp-guidelines/national-guide/chapter-16-family-abuse-and-violence)
chapter in the National guide to a preventive health assessment for Aboriginal and Torres Strait Islander
people for speciLc recommendations and advice.
170
Resources
Abuse and violence – working with our patients in general practice, 5th edition (The White Book) (http
s://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guideline
s/abuse-and-violence/preamble) | RACGP Health care for women subjected to intimate partner or sexual
violence: A clinical handbook (https://apps.who.int/iris/bitstream/handle/10665/136101/WHO_RHR_14.2
6_eng.pdf?sequence=1) | WHO
References
1. World Health Organization (WHO), Department 5. Australian Institute of Health and Welfare.
of Reproductive Health and Research London Family, domestic and sexual violence. Australian
School of Hygiene and Tropical Medicine, South Government, 2023 (https://www.aihw.gov.au/repo
African Medical Research Council. Global and rts/domestic-violence/family-domestic-and-sexu
regional estimates of violence against women. al-violence) [Accessed 8 May 2023].
Prevalence and health effects of intimate partner
6. World Health Organization (WHO). Responding
violence and non-partner sexual violence. WHO,
to intimate partner violence and sexual violence
2013 (https://www.who.int/publications/i/item/9
against women. WHO clinical and policy
789241564625) [Accessed 1 November 2015].
guidelines. WHO, 2013 (https://www.who.int/publ
2. Australian Bureau of Statistics (ABS). Personal ications/i/item/9789241548595) [Accessed 1
safety, Australia. ABS, 2023 (https://www.abs.go November 2015].
.au/statistics/people/crime-and-justice/persona 7. O’Doherty LJ, Taft A, Hegarty K, Ramsay J,
l-safety-australia/latest-release) [Accessed 9 May Davidson LL, Feder G. Screening women for
2023]. intimate partner violence in healthcare settings:
3. The Royal Australian College of General Abridged Cochrane systematic review and meta-
Practitioners (RACGP). Abuse and violence – analysis. BMJ 2014;348:g2913. doi: 10.1136/
working with our patients in general practice. 5th bmj.g2913. [Accessed 1 November 2015].
edn. RACGP, 2021 (https://www.racgp.org.au/clini
8. World Health Organization (WHO). Health care
cal-resources/clinical-guidelines/key-racgp-guidel
for women subjected to intimate partner violence
ines/view-all-racgp-guidelines/abuse-and-violenc
or sexual violence: A clinical handbook. WHO,
e/preamble) [Accessed 22 February 2024].
2014 (https://www.who.int/publications/i/item/W
4. Boxall H, Doherty L, Lawler S, Franks C, Bricknell HO-RHR-14.26) [Accessed 8 May 2023].
S. The ‘Pathways to intimate partner homicide’
9. Tarzia L, Bohren MA, Cameron J, et al.
project: Key stages and events in male-
Women’s experiences and expectations after
perpetrated intimate partner homicide in
disclosure of intimate partner abuse to a
Australia. Research report 04/2022. ANROWS,
healthcare provider: A qualitative meta-synthesis.
2022 (https://www.anrows.org.au/publication/th
BMJ Open 2020;10:e041339. doi: 10.1136/
pathways-to-intimate-partner-homicide-project-
bmjopen-2020-041339. [Accessed 8 May 2023].
key-stages-and-events-in-male-perpetrated-intima
te-partner-homicide-in-australia/) [Accessed 22
February 2024].
171
Mental health and substance use
172
Mental health and substance use
Alcohol (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-rac
gp-guidelines/view-all-racgp-guidelines/preventive-activities-in-general-practice/
mental-health/alcohol) Anxiety (https://www.racgp.org.au/clinical-resources/clin
ical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/preventive-activiti
es-in-general-practice/mental-health/anxiety) Dementia (https://www.racgp.or
g.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-g
uidelines/preventive-activities-in-general-practice/mental-health/dementia)
Depression (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-
racgp-guidelines/view-all-racgp-guidelines/preventive-activities-in-general-practi
ce/mental-health/depression) Eating disorders (https://www.racgp.org.au/clinic
al-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/p
reventive-activities-in-general-practice/mental-health/eating-disorders) Perinatal
mental health (https://www.racgp.org.au/clinical-resources/clinical-guidelines/k
ey-racgp-guidelines/view-all-racgp-guidelines/preventive-activities-in-general-pra
ctice/mental-health/perinatal-depression) Gambling (https://www.racgp.org.au/
clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guideli
nes/preventive-activities-in-general-practice/mental-health/problem-gambling)
Smoking and nicotine vaping (https://www.racgp.org.au/clinical-resources/clinic
al-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/preventive-activitie
s-in-general-practice/mental-health/smoking) Suicide (https://www.racgp.org.a
u/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guid
elines/preventive-activities-in-general-practice/mental-health/suicide)
173
Alcohol
Alcohol
Mental health and substance use | Alcohol

Screening age bar
0–9 10–14 15 –19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75–79 ≥80

Alcohol is the most commonly used drug in Australia. Behind tobacco, alcohol is the second greatest
cause of drug-related harm. Approximately 8 out of 10 adults drink alcohol.1 In a 2019 survey, 76.6% of
the Australian population aged ≥14 years reported having consumed alcohol in the previous 12
months.1
Alcohol use has risks at any level, and can cause harm to the person who drinks, as well as the people
around them, particularly household members.3 Alcohol consumption has been associated with a range
of long-term conditions, such as cardiovascular disease; some cancers, including breast, colon,
oropharynx and liver cancer; type 2 diabetes; nutrition-related conditions; obesity; liver disease; mental
health conditions; alcohol use disorders; and cognitive impairment.3 It has also been associated with
risks to the fetus during pregnancy (eg fetal alcohol spectrum disorder [FASD]) and to the baby through
breastfeeding.3 In 2015, drinking alcohol contributed 14% of the burden due to homicide and violence,
and alcohol can contribute to family disruption, crime, road accidents, work-related harms and
community safety issues.3
Men tend towards higher levels of risk-taking behaviour, and thus have a greater overall risk of
immediate harm from drinking (eg road crashes, falls and self-harm),3 and the disease burden for men
is greater;4 however, women are more susceptible than men to the direct physiological effects of
alcohol. For women, the immediate effects of alcohol occur more quickly than for men; they also last
longer. In addition, lifetime risk of disease will climb at a faster rate for women once low levels of
alcohol use have been exceeded.3
 Screening
174
Alcohol
Screen adults aged ≥18 years, including Conditionally Every 2 years 4
pregnant women, for unhealthy alcohol use. recommended (Practice point)

The Alcohol Use Disorder IdentiLcation Test –
Consumption (AUDIT-C) tool can be used to
assess this.
Provide persons engaged in risky or
hazardous drinking with brief behavioural
counselling interventions to reduce unhealthy
alcohol use.
Advise healthy men and women drink no more Recommended Opportunistically 3
than 10 standard drinks* a week and no more (Strong)

than four standard drinks* on any one day to
reduce the risk of harm from alcohol-related
disease and injury.
*The Australian deLnition of a standard drink

is 10 g alcohol. Be aware of international
variation.
3
Advise children and people aged <18 years Recommended N/A
not to drink alcohol to reduce the risk of injury (Strong)
and other harms to health.
3
Advise women who are pregnant or planning a Recommended Opportunistically
pregnancy not to drink alcohol to prevent (Strong)
harm from alcohol to their unborn child. Refer
to the Preconception (https://www.racgp.or
g.au/clinical-resources/clinical-guidelines/ke
y-racgp-guidelines/view-all-racgp-guidelines/p
reventive-activities-in-general-practice/reprod
uctive-and-womens-health/preconception)
and During pregnancy (https://www.racgp.or
g.au/clinical-resources/clinical-guidelines/ke
y-racgp-guidelines/view-all-racgp-guidelines/p
reventive-activities-in-general-practice/reprod
uctive-and-womens-health/preconception)
chapters
3
Advise women who are breastfeeding that not Recommended Opportunistically
drinking alcohol is safest for their baby. (Strong)
175
Alcohol
Those with at risk patterns of alcohol Practice point N/A 3
consumption should be offered brief advice

on the risk of drinking.
Risky patterns of drinking are more common
in:
• young adults aged 18–25 years
• people aged >60 years
• people with mental or physical health
conditions
• people with a family history of
alcohol dependence
• people who use illicit drugs or take
medications that interact with
alcohol.
Be alert to drinking in young people aged <18

years.
Further information
Alcohol-related harm
The risk of alcohol-related harm rises with increasing alcohol consumption.3 There is no threshold of
alcohol consumption below which there is no risk. The National Health and Medical Research Council
(NHMRC) Australian guidelines to reduce health risks from drinking alcohol (https://www.nhmrc.gov.au/s
ites/default/Lles/documents/attachments/Alcohol/Australian%20guidelines%20to%20reduce%20healt
h%20risks%20from%20drinking%20alcohol.pdf) provide guidance such that if they are followed by a
healthy adult, the risk of dying from an alcohol-related condition or injury is less than 1 in 100. Some
people are recommended to abstain from alcohol to lower their risk of alcohol-related harm.
Role of the GP
Patients are positive towards the role of GPs in health promotion, and this is enhanced when:6
• there is perceived relevance of the alcohol enquiry dialogue to the consultation

• appropriate approach and language are used in the patient–doctor interaction
• unease regarding the moral and stigmatising dimension of alcohol consumption is alleviated.
Reasons for presenting can also infuence the perceived acceptability of alcohol questions by patients.7
176
Alcohol
Brief interventions
Alcohol brief interventions (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-g
uidelines/view-all-racgp-guidelines/snap/applying-the-5as-to-each-risk-factor) undertaken by GPs are
effective in reducing risky drinking.8
Assess whether there are possible harmful interactions between medications and alcohol for people
with a mental health problem made worse by alcohol (eg anxiety and depression) or for people taking
multiple medications.

peoples
to the Alcohol (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/vie
w-all-racgp-guidelines/national-guide/chapter-1-lifestyle/alcohol) section in the National guide to a
Speci9c populations
Individuals with health conditions that can be caused or worsened by alcohol consumption are at risk of
exacerbating their condition if they continue to drink.3 These conditions include alcohol dependence,
various liver diseases (eg alcoholic hepatitis, cirrhosis, non-alcoholic fatty liver disease and viral
hepatitis), pancreatitis and epilepsy.3 Commonly prescribed categories of medications including, but
not limited to, benzodiazepines, opioids, analgesics, antidepressants, anticoagulants, anticonvulsants,
antibiotics, antihistamines, anti-infammatories, antipsychotics and drugs used for the management of
conditions such as erectile dysfunction or diabetes are known to interact with alcohol, potentially
leading to severe side effects when used together.3
Resources
Australian guidelines to reduce health risks from drinking alcohol (https://www.nhmrc.gov.au/sites/defa
ult/Lles/documents/attachments/Alcohol/Australian%20guidelines%20to%20reduce%20health%20risk
s%20from%20drinking%20alcohol.pdf) | National Health and Medical Research Council
Smoking, nutrition, alcohol, physical activity (SNAP) (https://www.racgp.org.au/clinical-resources/clinical-

guidelines/key-racgp-guidelines/view-all-racgp-guidelines/snap) | RACGP
177
Alcohol
References
1. Australian Institute of Health and Welfare. 5. U.S. Preventive Services Task Force (USPSTF).
National drug strategy household survey 2019. Unhealthy alcohol use in adolescents and adults:
Australian Government, 2020 (https://www.aihw.g Screening and behavioral counseling
ov.au/getmedia/77dbea6e-f071-495c-b71e-3a63 interventions. USPSTF, 2018 (https://www.usprev
2237269d/aihw-phe-270.pdf?v=2023060518432 entiveservicestaskforce.org/uspstf/recommenda
5&inline=true) [Accessed 21 February 2024]. tion/unhealthy-alcohol-use-in-adolescents-and-ad
2. The Royal Australian College of General ults-screening-and-behavioral-counseling-interven
Practitioners (RACGP). Applying the 5As to each tions) [Accessed 21 February 2024].
risk factor. In: Smoking, nutrition, alcohol, physical 6. Leong L, Hespe C, Zwar N, Tam CWM. Alcohol
activity (SNAP). RACGP, 2015 (https://w enquiry by GPs – understanding patients’
ww.racgp.org.au/clinical-resources/clinical-guidel perspectives: A qualitative study. Aust Fam
ines/key-racgp-guidelines/view-all-racgp-guidelin Physician 2015;44(11):833–38. [Accessed 21
es/snap/applying-the-5as-to-each-risk-factor) February 2024].
[Accessed 18 October 2023]. 7. Leong L, Zwar N, Hespe C, Tam CWM.
3. National Health and Medical Research Council Consultation contexts and the acceptability of
(NHMRC). Australian guidelines to reduce health alcohol enquiry from general practitioners – a
risks from drinking alcohol. NHMRC, 2020 (http survey experiment. Aust Fam Physician
s://www.nhmrc.gov.au/sites/default/files/docum 2015;44(7):490–96. [Accessed 21 February
ents/attachments/Alcohol/Australian%20guidelin 2024].
es%20to%20reduce%20health%20risks%20fro m% 8. Beyer FR, Campbell F, Bertholet N, et al. The
20drinking%20alcohol.pdf) [Accessed 21 Cochrane 2018 review on brief interventions in
February 2024]. primary care for hazardous and harmful alcohol
4. Australian Institute of Health and Welfare consumption: A distillation for clinicians and
(AIHW). Alcohol, tobacco & other drugs in policy makers. Alcohol Alcohol
Australia. AIHW, 2023 (https://www.aihw.gov.au/r 2019;54(4):417–27. doi: 10.1093/alcalc/agz035.
eports/alcohol/alcohol-tobacco-other-drugs-austr [Accessed 21 February 2024].
alia/contents/drug-types/alcohol) [Accessed 21
February 2024].
178
Anxiety
Anxiety
Mental health and substance use | Anxiety

Case 9nding age bar
0–9* 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75–79 ≥80
*from age 8 years

Anxiety is the most common mental health condition experienced in the Australian population, affecting
17% of adults (aged 16–85 years) and 7% of children (aged 4–15 years).1 Anxiety commonly co-exists
with other mental health conditions, particularly depression.2,3 It is estimated that 23% of men and 34%
of women aged 16–85 years have experienced any anxiety disorder in their lives.1 Yet, feeling anxious is
also a common experience of all people, especially at times of ill health, when they are more likely to
consult their GP. So the GP’s task is not only to detect and offer appropriate treatment options to those
who meet the diagnostic criteria for anxiety, but also, equally, to offer reassurance and practical advice
to people in distress, aiming to prevent the progression of that worry to something more serious.
Fortunately, there are some very simple, brief questions the GP can use that are reasonably speciLc and
sensitive to the probability of an anxiety disorder;4,5 hence they can be used as part of a case Lnding
approach to more eaciently detect patients who need a more thorough assessment.
There is a risk of underdiagnosis and delayed diagnosis because many people do not seek treatment.
GPs should be aware of a patient’s worries about stigma and that under-reporting by patients is
common.6
 Screening
How
often
General population screening for anxiety is not 7,8

Generally not
recommended. N/A
recommended
179
Anxiety
 Case 9nding
How
often
Be alert to possible anxiety disorders in those aged Practice Point As 6,7,8
8–64 years, including pregnant and postpartum women required

(particularly in people with a history of an anxiety
disorder, possible somatic symptoms of an anxiety
disorder, in those who have experienced traumatic or
adverse childhood events or in those with insomnia).
Consider asking the person (aged 18–64 years) about Conditionally As 6
their feelings of anxiety, and their ability to stop or recommended required

control the worry, using the Generalized Anxiety
Disorder 2-item (GAD-2) (https://www.hiv.uw.edu/page/
mental-health-screening/gad-2) scale.
• If the person scores ≥3 on the GAD-2 scale,
consider an anxiety disorder and follow the
recommendations for assessment (see the
Common mental health problems: Identibcation
and pathways to care (https://www.nice.org.uk/
guidance/cg123/chapter/recommendations#as
sessment) guidelines).
• If the person scores <3 on the GAD-2 scale but
you are still concerned they may have an
anxiety disorder, ask the following: 'Do you Lnd
yourself avoiding places or activities and does
this cause you problems?'. If the person
answers 'yes' to this question, consider an
anxiety disorder and follow the
recommendations for assessment (see the
Common mental health problems: Identibcation
and pathways to care (https://www.nice.org.uk/
guidance/cg123/chapter/recommendations#as
sessment) guidelines).
Further information
For a common condition like anxiety, there is an overlap of symptoms with other conditions like
depression.6 This allows the introduction of a stepped care model in mental health care that attempts
to encourage people with milder symptoms of distress to engage in lower intensity interventions (eg
self-help and eMental Health programs) and allocate more intense interventions (eg medication and
individual psychotherapy) to those who are most likely to beneLt.9 In the context of inequitable
180
Anxiety
distribution of mental health care in Australia, ensuring resources reach those most in need remains an
ongoing challenge.10 The quiz (https://www.headtohealth.gov.au/quiz) on the Australian Government’s
Head to Health website is an example of such an approach,11 informed by algorithms developed using
Australian primary care population data to predict which patients presenting to the GP are likely to have
a more severe outcome from depression and anxiety symptoms at three months12 to help GPs and their
patients in navigating the system.

peoples
There are no speciLc recommendations or advice for Aboriginal and Torres Strait Islander peoples.
Speci9c populations
In 2018, 11% of anxiety disorders in women were attributable to intimate partner violence, and 27% of
anxiety disorders were attributable to child abuse and neglect.13 For more information on these topics,
refer to the Intimate partner violence (https://www.racgp.org.au/clinical-resources/clinical-guidelines/k
ey-racgp-guidelines/view-all-racgp-guidelines/preventive-activities-in-general-practice/injury-prevention/
intimate-partner-violence) and Bullying and child abuse (https://www.racgp.org.au/clinical-resources/cli
nical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/preventive-activities-in-general-practice/
injury-prevention/child-abuse-and-maltreatment) chapters.
Resources
Quiz (https://www.headtohealth.gov.au/quiz) | Australian Government Head to Health website Screen
for Child Anxiety Related Disorders (SCARED) (https://www.aacap.org/App_Themes/AACAP/docs/me
mber_resources/toolbox_for_clinical_practice_and_outcomes/symptoms/ScaredChild.pdf) tool
References
1. Australian Institute of Health and Welfare. 4. Sapra A, Bhandari P, Sharma S, Chanpura T, Lopp
Prevalence and impact of mental illness. L. Using Generalized Anxiety Disorder-2
Australian Government, 2024 (https://www.aihw.g (GAD-2) and GAD-7 in a primary care setting.
ov.au/mental-health/overview/prevalence-and-im Cureus 2020;12(5):e8224. doi: 10.7759/
pact-of-mental-illness) [Accessed 5 March 2024]. cureus.8224. [Accessed 5 March 2024].
2. Goldstein-Piekarski AN, Williams LM, Humphreys 5. Medscape. Generalized Anxiety Disorder 2
K. A trans-diagnostic review of anxiety disorder (GAD-2). Medscape, 2020 (https://reference.med
comorbidity and the impact of multiple exclusion scape.com/calculator/570/generalized-anxiety-di
criteria on studying clinical outcomes in anxiety sorder-2-gad-2) [Accessed 5 March 2024].
disorders. Transl Psychiatry 2016;6(6):e847. doi:
6. National Institute for Health and Care
10.1038/tp.2016.108.
Excellence (NICE). Common mental health
problems: IdentiLcation and pathways to care.
3. Tiller JW. Depression and anxiety. Med J Aust NICE, 2011 (https://www.nice.org.uk/guidance/cg
2013;199(S6):S28–31. doi: 10.5694/ 123/chapter/recommendations#step-1-identiLcat
mja12.10628. [Accessed 5 March 2024]. ion-and-assessment) [Accessed 5 March 2024].
181
Anxiety
7. U.S. Preventive Task Force (USPSTF). Anxiety in 11. Head to Health. Quiz. Department of Health
children and adolescents: Screening. USPSTF, and Aged Care, n.d (https://www.headtohealth.go
2022 (https://www.uspreventiveservicestaskforc v.au/quiz) [Accessed 5 March 2024].
.org/uspstf/recommendation/screening-anxiety- 12. Fletcher S, Spittal MJ, Chondros P, et al. Clinical
children-adolescents) [Accessed 5 March 2024]. efficacy of a decision support tool (Link-me) to
8. U.S. Preventive Task Force (USPSTF). Anxiety guide intensity of mental health care in primary
disorders in adults: Screening. USPSTF, 2023 (htt practice: A pragmatic stratified randomised
ps://www.uspreventiveservicestaskforce.org/usp controlled trial. Lancet Psychiatry
stf/recommendation/anxiety-adults-screening) 2021;8(3):202–14. doi: 10.1016/
[Accessed 5 March 2024]. S2215-0366(20)30517-4. [Accessed 5 March
. Ho FYY, Yeung WF, Ng THY, Chan CS. The efficacy 2024].
and cost-effectiveness of stepped care prevention 13. Australian Institute of Health and Welfare. What
and treatment for depressive and/or anxiety are the consequences of family, domestic and
disorders: A systematic review and meta-analysis. sexual violence? Australian Government, 2023
Sci Rep 2016;6(1):29281. doi: 10.1038/ (https://www.aihw.gov.au/family-domestic-
srep29281. [Accessed 5 March 2024]. and-sexual-violence/resources/fdsv-summary#co
1 . Meadows GN, Enticott JC, Inder B, Russell GM, nsequences) [Accessed 5 March 2024].
Gurr R. Better access to mental health care and
the failure of the Medicare principle of
universality. Med J Aust 2015;202(4):190–94. doi:
10.5694/mja14.00330. [Accessed 5 March 2024].
182
Dementia
Dementia
Mental health and substance use |

Dementia
Case 9nding age bar
0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75–79 ≥80

It is estimated that over 400,000 people in Australia are living with dementia. Dementia is the leading
cause of death in women and a leading cause of burden of disease overall.1,2 Dementia is the fourth-
highest cause of disease burden in women, responsible for 6.8 disability-adjusted life years (DALYs) per
1000 population. Dementia is the sixth-highest contributor to disease burden in men responsible for 5.8
DALY per 1000 population.3 The prevalence of dementia is increasing as the population ages.4
Although dementia is usually regarded as a disease of older age, younger-onset dementia is becoming
increasingly recognised. In 2019, more than 27,000 people were thought to be living with younger-onset
dementia in Australia.5
 Screening
6
General population Not NA
screening for dementia is recommended
not recommended. (strong)
183
Dementia
 Case 9nding
GPs should be alert to the Conditionally Opportunistically 6
symptoms and signs of recommended

dementia, which include not
just memory diaculties, but
also changes in personality,
behaviour and executive
function. These may be
detected opportunistically
and assessed using
questions addressed to the
person and/or their carer,
including formal cognitive
function tests and carer
scales. Symptoms such as
apathy and low mood may
lead the GP to consider
depression. Depression and
dementia may co-exist, and
both may need diagnosis
and management.
7,8,9,10,11,12,13,14,15,16,17,18,19,20,21
Be alert for dementia in Conditionally Opportunistically
those with increasing age. recommended
For other risk factors
known to be associated
with dementia, see Box 1.
184
Dementia
For people with any of the Practice point N/A 22,23
Lndings listed below*, over

several consultations
obtain a history from the
person and their family, and
perform a comprehensive
physical examination.
Consider administering of
one of the following
cognitive screening tests:
• Standardised Mini-
Mental State
Examination
(SMMSE) (http
s://www.ihacpa.go
v.au/sites/default/
Lles/2022-08/sm
mse-tool-v2.pdf)
• General
Practitioner
Assessment of
Cognition (GPCOG)
(https://gpcog.co
m.au/) (carer may
need to be
contacted)
• Kimberley
Indigenous
Cognitive
Assessment-Cog
(KICA-Cog) (http
s://www.dementi
a.org.au/sites/defa
ult/Lles/2012082
1_KICA_Instructio
n_Booklet.pdf) or
modiLed KICA-Cog
(https://www.nari.n
et.au/Handlers/Do
wnload.ashx?IDM
F=f413763e-bfe3-4
98a-9d4f-2d52e04
90e15)
• Rowland Universal
Dementia
Assessment Scale
185
Dementia
(RUDAS) (https://w
ww.dementia.org.a
u/resources/rowla
nd-universal-deme
ntia-assessment-s
cale-rudas) for
culturally and
linguistically
diverse (CALD)
communities
*Symptoms such as
memory loss or behaviour
change, concerned family
members, history of
repeated head trauma,
Down syndrome, elevated
cardiovascular risk,
depression or a history of
depression.
6
For people who are Practice point N/A
showing signs of dementia,
concerns or symptoms
should be explored when
Lrst raised, noted or
reported by the person,
carer(s) or family and
should not be dismissed as
‘part of ageing’.
24
Provide preventive advice in Practice point N/A
relation to the following
associations with
dementia. See Box 2.
186
Dementia
Further information
Dementia is a strong source of burden for carers and for the health system overall. It is vitally important
that GPs move to prevent as much dementia as possible through attention to the risk factors, and then
recognise and assist the person to manage their life if they develop dementia.
The best time to identify risk factors is earlier in life. GPs’ work in identifying and modifying
cardiovascular and other risk factors in midlife also reduces the risk factors for dementia. Dementia
risk scores may help.25 It may be helpful for GPs to mention the risk score to patients as a motivating
factor for behaviour change. The health assessments funded for midlife and the care plans for chronic
disease management may help with this.
GPs need to recognise and respond to the barriers to the identiLcation of dementia. These include:
• system-related factors (eg short consultation lengths)

• GP factors (eg diaculties of diagnosis and management)
• patient factors around stigma and a consequent reluctance to discuss dementia, or around
diaculties in understanding the concept26
• patients being investigated for dementia (eg in the case Lnding paradigm outlined above,
patients need to be aware of the reasons for the questionnaire investigations and follow-up
blood tests and referrals)
A preference not to be told the diagnosis should be respected. However, it is important that the person
and/or their carer understands that there is a problem with cognition that will need management. The
concept of secondary prevention (ie slowing the progression of the disease using the strategies
outlined above) can then be introduced (eg smoking cessation, correction of hearing impairment,
optimal management of other cardiac risk factors, diet and exercise).
Box 1. Risk factors associated with dementia (other than increasing age, which doubles
the risk for every Ove-year increase)
• A family history of Alzheimer’s disease and genetic factors6

• A history of repeated head trauma27
• Down syndrome
• Elevated cardiovascular risk6,27,28
• Depression or a history of depression6,27
• Low education levels28
• Smoking 14,27,
• Physical inactivity27,29
• Aboriginal and Torres Strait Islander status
• Low social contact27
• Hearing loss27
187
Dementia
Box 2. Risk reduction interventions for cognitive decline and dementia24
Physical activity interventions

• Physical activity should be recommended to adults with normal cognition to
reduce the risk of cognitive decline
• Physical activity may be recommended to adults with mild cognitive impairment
to reduce the risk of cognitive decline
Tobacco cessation interventions

• Interventions for tobacco cessation should be offered to adults who use tobacco
because they may reduce the risk of cognitive decline and dementia in addition to
having other health beneLts
Nutritional interventions
• A Mediterranean-like diet may be recommended to adults with normal cognition
and mild cognitive impairment to reduce the risk of cognitive decline and/or
dementia
• A healthy, balanced diet should be recommended to all adults
• Vitamins B and E, polyunsaturated fatty acids and multicomplex supplementation
should not be recommended to reduce the risk of cognitive decline and/or
dementia
Interventions for alcohol use disorders

• Interventions aimed at reducing or ceasing hazardous and harmful drinking
should be offered to adults with normal cognition and mild cognitive impairment
to reduce the risk of cognitive decline and/or dementia in addition to other health
beneLts
Cognitive interventions
• Cognitive training may be offered to older adults with normal cognition and with
mild cognitive impairment to reduce the risk of cognitive decline and/or dementia
Social activity
• There is insuacient evidence for social activity reducing the risk of cognitive
decline/dementia
• Social participation and social support are strongly connected to good health and
wellbeing throughout life, and social inclusion should be supported over the life
course
Weight management
• Interventions for midlife overweight and/or obesity may be offered to reduce the
risk of cognitive decline and/or dementia
Management of hypertension
188
Dementia
• Management of hypertension should be offered to adults with hypertension

• Management of hypertension may be offered to adults with hypertension to
reduce the risk of cognitive decline and/or dementia
Management of diabetes
• Management of diabetes in the form of medications and/or lifestyle interventions
should be offered to adults with diabetes
• Management of diabetes may be offered to adults with diabetes to reduce the
Management of dyslipidaemia
• Management of dyslipidaemia at midlife may be offered to reduce the risk of
cognitive decline and dementia
Management of depression
• There is currently insuacient evidence to recommend the use of antidepressant
medicines to reduce the risk of cognitive decline and/or dementia
• Management of depression in the form of antidepressants and/or psychological
interventions should be provided to adults with depression
Management of hearing loss

• There is insuacient evidence to recommend the use of hearing aids to reduce the
• Screening followed by provision of hearing aids should be offered to older people
for timely identiLcation and management of hearing loss

peoples
GPs should be aware of the increased risk for dementia for Aboriginal and Torres Strait Islander people.
This particularly applies to those who have suffered trauma, for example the Stolen Generations.6 For
speciLc recommendations and advice, refer to the Dementia (https://www.racgp.org.au/clinical-resourc
es/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/national-guide/chapter-5-the-healt
h-of-older-people/dementia) section in the National guide to a preventive health assessment for
Aboriginal and Torres Strait Islander people and the Best-practice guide to cognitive impairment and
dementia care for Aboriginal and Torres Strait Islander people attending primary care (https://www.racg
p.org.au/getattachment/b5e33105-dde0-474d-83c3-ef5d80e09634/Best-practice-guide-to-cognitive-im
pairment-and-dementia-care-for-Aboriginal-and-Torres-Strait-Islander-people-attending-primary-care.pd
f.aspx) .
189
Dementia
Speci9c populations
GPs should be aware that culturally and linguistically diverse (CALD) populations may have culturally
speciLc understandings of and attitudes towards dementia and how it should be managed.7 Ethno-
speciLc workers may be able to assist GPs who are concerned about undertaking primary or secondary
prevention in this context.
Resources
Cognitive screening tests:
• Standardised Mini-Mental State Examination (SMMSE) (https://www.ihacpa.gov.au/sites/defau

lt/Lles/2022-08/smmse-tool-v2.pdf)
• General Practitioner Assessment of Cognition (GPCOG) (https://gpcog.com.au/) (Carer may
need to be contacted)
• Kimberley Indigenous Cognitive Assessment-Cog (KICA-Cog) or modiLed KICA-Cog (https://w
ww.dementia.org.au/professionals/assessment-and-diagnosis-dementia/kimberley-indigenou
s-cognitive-assessment-tool-kica)
• Rowland Universal Dementia Assessment Scale (RUDAS) (https://www.dementia.org.au/resour
ces/rowland-universal-dementia-assessment-scale-rudas) for CALD communities
Journal articles:
• Dementia prevention, intervention, and care: 2020 report of the Lancet Commission (https://ww
w.thelancet.com/article/S0140-6736(20)30367-6/fulltext)
• Future Directions for Dementia Risk Reduction and Prevention Research: An International
Research Network on Dementia Prevention Consensus (https://content.iospress.com/articles/j
ournal-of-alzheimers-disease/jad200674)
• Dementia Risk Scores and Their Role in the Implementation of Risk Reduction Guidelines (http
s://www.frontiersin.org/articles/10.3389/fneur.2021.765454/full)
References
1. Grossberg GT, Christensen DD, Griffith PA, Kerwin 3. Australian Institute of Health and Welfare.
DR, Hunt G, Hall EJ. The art of sharing the Australian burden of disease study. Australian
diagnosis and management of Alzheimer’s Government, 2023 (https://www.aihw.gov.au/repo
disease with patients and caregivers: rts/burden-of-disease/australian-burden-of-disea
Recommendations of an expert consensus panel. se-study-2023/contents/about) [Accessed 5
Prim Care Companion J Clin Psychiatry March 2024].
2010;12(1):cs00833. doi: 10.4088/
PCC.09cs00833oli.
Dementia in Australia. Australian Government,
2. Robinson L, Gemski A, Abley C, et al. The 2023 (https://www.aihw.gov.au/reports/dementi
transition to dementia – individual and family a/dementia-in-aus/contents/summary)
experiences of receiving a diagnosis: A review. Int [Accessed 5 March 2024].
Psychogeriatr 2011;23(7):1026–43. doi: 10.1017/
S1041610210002437.
190
Dementia
5. Dementia Australia. About younger-onset 14. Anstey KJ, von Sanden C, Salim A, O’Kearney
dementia. Dementia Australia, n.d (https://yod.de . Smoking as a risk factor for dementia and
mentia.org.au/about-younger-onset-dementia) cognitive decline: A meta-analysis of prospective
[Accessed 17 May 2023]. studies. Am J Epidemiol 2007;166(4):367–78.
6. Cognitive Decline Partnership Centre, The doi: 10.1093/aje/kwm116. [Accessed 5 March
University of Sydney. Clinical practice guidelines 2024].
and principles of care for people with dementia. 15. Alzheimer’s Disease International (ADI). World
The University of Sydney, 2016 (https://cdpc.sydn Alzheimer report 2014. Dementia and risk
ey.edu.au/research/clinical-guidelines-for-dement reduction. An analysis of protective and
ia/) [Accessed 5 March 2024]. modiLable risk factors. ADI, 2014 (https://www.al
7. Boustani M, Peterson B, Hanson L, et al. zint.org/u/WorldAlzheimerReport2014.pdf)
Screening for dementia in primary care: A [Accessed 6 March 2024].
summary of the evidence for the U.S. Preventive 16. Beydoun MA, Beydoun HA, Gamaldo AA, Teel A,
Services Task Force. Ann Intern Med Zonderman AB, Wang Y. Epidemiologic studies of
2003;138(11):927–37. doi: 10.7326/ modifiable factors associated with cognition and
0003-4819-138-11-200306030-00015. [Accessed dementia: Systematic review and meta-analysis.
5 March 2024]. BMC Public Health 2014;14(1):643. doi:
8. National Collaborating Centre for Mental Health. 10.1186/1471-2458-14-643. [Accessed 6 March
Dementia: A NICE-SCIE guideline on supporting 2024].
people with dementia and their carers in health 17. Flicker L, Holdsworth K. Aboriginal and Torres
and social care. National Institute for Health and Strait Islander people and dementia: A review of
Care Excellence, 2006. [Accessed 5 March 2024]. the research. A report for Alzheimer’s Australia.
. Gao S, Hendrie HC, Hall KS, Hui S. The Alzheimer’s Australia, 2014. [Accessed 6 March
relationships between age, sex, and the incidence 2024].
of dementia and Alzheimer disease: A meta- 18. Broe T, Wall S. The Koori dementia care project
analysis. Arch Gen Psychiatry (KDCP): Final report. Dementia Collaborative
1998;55(9):809–15. doi: 10.1001/ Research Centres, 2013 (http://ww
archpsyc.55.9.809. [Accessed 5 March 2024]. w.dementiaresearch.org.au/images/dcrc/output-f
1 . Lautenschlager NT, Cupples LA, Rao VS, et al. Risk iles/1288-cb55_Lnal_report_with_amendments.p
of dementia among relatives of Alzheimer’s df) [Accessed 5 March 2024].
disease patients in the MIRAGE study: What is in 19. Smith K, Flicker L, Lautenschlager NT, et al.
store for the oldest old? Neurology High prevalence of dementia and cognitive
1996;46(3):641–50. doi: 10.1212/WNL.46.3.641. impairment in Indigenous Australians. Neurology
[Accessed 5 March 2024]. 2008;71(19):1470–73. doi: (http://10.1212/01.wn
11. Lenoir H, Dufouil C, Auriacombe S, et al. l.0000320508.11013.4f.)
Depression history, depressive symptoms, and 20. Australian Health Ministers’ Advisory
incident dementia: The 3C study. J Alzheimers Dis Council’s (AHMAC) National Aboriginal and
2011;26(1):27–38. doi: 10.3233/ Torres Strait Islander Health Standing Committee.
JAD-2011-101614. [Accessed 5 March 2024]. Cultural respect framework 2016–2026 for
12. Fleminger S, Oliver DL, Lovestone S, Rabe-Hesketh Aboriginal and Torres Strait Islander health.
S, Giora A. Head injury as a risk factor for AHMAC, 2016 (https://nacchocommunique.Lle
Alzheimer’s disease: The evidence 10 years on; a s.wordpress.com/2016/12/cultural_respect_fram
partial replication. J Neurol Neurosurg Psychiatry ework_1december2016_1.pdf) [Accessed 14
2003;74(7):857–62. doi: 10.1136/jnnp.74.7.857. March 2024].
[Accessed 5 March 2024]. 21. Smith K, Flicker L, Shadforth G, et al. ‘Gotta be
13. Anstey KJ, Eramudugolla R, Hosking DE, sit down and worked out together’: Views of
Lautenschlager NT, Dixon RA. Bridging the Aboriginal caregivers and service providers on
translation gap: From dementia risk assessment ways to improve dementia care for Aboriginal
to advice on risk reduction. J Prev Alzheimers Dis Australians. Rural Remote Health
2015;2(3):189–98. doi: 10.14283/jpad.2015.75. 2011;11(2):1650. doi: 10.22605/RRH1650.
[Accessed 5 March 2024]. [Accessed 14 March 2024].
191
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22. Bradley K, Smith R, Hughson JA, et al. Let’s 26. Magin P, Juratowitch L, Dunbabin J, et al.
CHAT (Community Health Approaches To) Attitudes to Alzheimer’s disease testing of
dementia in Aboriginal and Torres Strait Islander Australian general practice patients: A cross-
communities: Protocol for a stepped wedge sectional questionnaire-based study. Int J Geriatr
cluster randomised controlled trial. BMC Health Psychiatry 2016;31(4):361–66. doi: 10.1002/
Serv Res 2020;20(1):208. doi: 10.1186/ gps.4335. [Accessed 5 March 2024].
s12913-020-4985-1. [Accessed 14 March 2024]. 27. Livingston G, Huntley J, Sommerlad A, et al.
23. Haralambous B, Dow B, Tinney J, et al. Help Dementia prevention, intervention, and care: 2020
seeking in older Asian people with dementia in report of the Lancet Commission. Lancet
Melbourne: Using the cultural exchange model to 2020;396(10248):413–46. doi: 10.1016/
explore barriers and enablers. J Cross Cult S0140-6736(20)30367-6. [Accessed 5 March
Gerontol 2014;29(1):69–86. doi: 10.1007/ 2024].
s10823-014-9222-0. [Accessed 14 March 2024]. 28. Anstey KJ, Lipnicki DM, Low LF. Cholesterol as a
24. World Health Organization (WHO). Risk reduction risk factor for dementia and cognitive decline: A
of cognitive decline and dementia: WHO systematic review of prospective studies with
guidelines. WHO, 2019 (https://iris.who.int/ meta-analysis. Am J Geriatr Psychiatry
bitstream/handle/10665/312180/978924155054 2008;16(5):343–54. doi: 10.1097/01 [Accessed 5
3 eng.pdf?sequence=17) [Accessed 5 March March 2024].
2024]. 2 . Barnes DE, Yaffe K. The projected effect of risk
25. Anstey KJ, Zheng L, Peters R, et al. Dementia factor reduction on Alzheimer’s disease
risk scores and their role in the implementation of prevalence. Lancet Neurol 2011;10(9):819–28.
risk reduction guidelines. Front Neurol doi: 10.1016/S1474-4422(11)70072-2. [Accessed
2022;12:765454. doi: 10.3389/ 5 March 2024].
fneur.2021.765454. [Accessed 5 March 2024].
192
Depression
Depression

Depression
Case-9nding age bar
0–9 10–14* 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75–79 ≥80
*from age 12 years

Major depressive disorder is a high-prevalence condition in Australia. It is estimated that 9% of men and
14% of women aged 16–85 years have experienced at least one depressive episode in their lives, with a
12-month prevalence of 4% and 6%, respectively.1 A depressive episode may occur in the absence of
major depressive disorder (eg as a consequence of seasonal associated disorder).1 Given that GPs
provide most of all mental health care, including depression care. in Australia, it is appropriate that they
use screening and case Lnding according to population groups as outlined in the recommendations
below. This is in light of mixed evidence for the effectiveness of universal screening for major
depressive disorder, depending on the context of the patient population, and the level of system support
available.
 Screening
2,3,4
General population screening for depression is Generally not N/A
not recommended. recommended
 Case 9nding
193
Depression
Be alert to signs of depression in adolescents Conditionally At every 5,6,7,8,9,10

aged 12-18 years with risk factors. See Box 1. recommended encounter
Be alert for the various symptoms of

depression (eg low mood, substance use,
insomnia, anhedonia, suicidal thoughts, fatigue
and persistent somatic complaints) in the Conditionally 3, 5,11,12,13
Opportunistically
adult population. If present, use one of the recommended
validated mental health assessment tools to
undertake further assessment (see Further
information).
Further information
Although there is evidence that depression screening instruments have reasonable sensitivity and
speciLcity, the evidence for improved health outcomes and the cost-effectiveness of screening for
depression in primary care remain unclear. There is evidence for routine screening for depression in the
general adult population in the context of staff-assisted support to the GP in providing depression care,
case management and coordination (eg via practice nurses).14 There is insuacient evidence to
recommend routine screening in adults or adolescents where case management and coordination are
not available.2,3,14 There is insuacient evidence to recommend screening in children.5 Clinicians should
maintain a high level of awareness for depressive symptoms in patients at high risk of depression and
make appropriate clinical assessments wherever the risk is high.11
Consider the use of the HEADSSS assessment tool (https://www.rch.org.au/clinicalguide/guideline_ind

ex/Engaging_with_and_assessing_the_adolescent_patient/) for the assessment of depression in
adolescents aged 12–18 years.
Consider using Sphere-12 (https://www.racgp.org.au/getattachment/0cda86c7-cf66-49bd-b62b-296e6

5248e9e/attachment.aspx) , the K10 anxiety and depression test (http://www.beyondblue.org.au/the-fa
cts/anxiety-and-depression-checklist-k10) , the Depression Anxiety Stress Scales (DASS) (http://www
2.psy.unsw.edu.au/dass) or the Depression self-report questionnaire (DMI-10 and DMI-18) (https://ww
w.blackdoginstitute.org.au/docs/default-source/psychological-toolkit/dmi-10.pdf?sfvrsn=2) for the
assessment of depression in adults.15
194
Depression
Box 1. Risk factors for depression in adolescents aged 12–18 years5–10
• History of depression
• Family history of depression
• Other psychiatric disorders, including substance misuse
• Chronic medical conditions
• Unemployment
• Low socioeconomic status
• Older adults with signiLcant life events (eg illness, cognitive decline, bereavement
or institutional placement)
• All family members who have experienced family violence
• Lesbian, gay and bisexual peoples
• Experience of child abuse
• Deliberate self-harm
• Comorbid mental health or chronic mental health conditions
• Experience of a major negative life event (including being bullied)

peoples
Universal screening for depression is not recommended among Aboriginal and Torres Strait Islander
peoples. Identify those people in whom the risk of depression is greater as part of annual health
assessments. Consider using one of the ‘social and emotional wellbeing’ or mental health assessment
tools to guide the conversation. Options include the Kessler Psychological Distress Scale (K-5), the Here
and Now Aboriginal Assessment (HANAA) tool, the Patient Health Questionnaire (PHQ)-9, PHQ-9
adapted, PHQ-2 and link-me.16
Medications are not recommended for the primary prevention of depression.16
to the Prevention of depression (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-rac
gp-guidelines/view-all-racgp-guidelines/national-guide/chapter-17-mental-health/prevention-of-depressi
on) section in the National guide to a preventive health assessment for Aboriginal and Torres Strait
Islander people.
References
Mental health. Australian Government, 2024 (http
s://www.aihw.gov.au/mental-health) [Accessed 6
March 2024].
195
Depression
2. U.S. Preventive Services Task Force (USPSTF). 1 . Chown P, Kang M, Sanci L, Newnham V, Bennett
Depression and suicide risk in children and DL. Adolescent health: Enhancing the skills of
adolescents: Screening. USPSTF, 2022 (https://w general practitioners in caring for young people
ww.uspreventiveservicestaskforce.org/uspstf/rec from culturally diverse backgrounds – GP
ommendation/screening-depression-suicide-risk- resource kit. 2nd edn. NSW Centre for the
children-adolescents) [Accessed 5 March 2024]. Advancement of Adolescent Health and
3. U.S. Preventive Services Task Force (USPSTF). Transcultural Mental Health Centre, 2008.
Depression and suicide risk in adults: Screening. [Accessed 5 March 2024].
USPSTF, 2023 (https://health.gov/healthypeople/t 11. National Institute for Health and Clinical
ools-action/browse-evidence-based-resources/de Excellence (NICE). Depression in adults:
pression-and-suicide-risk-adults-screening) Treatment and management. NICE guideline
[Accessed 5 March 2024]. (http
s://www.nice.org.uk/guidance/ng222) [NG222].
4. Canadian Task Force on Preventive Health Care. NICE, 2022 [Accessed 5 March 2024].
Depression in adults. Canadian Task Force on 12. Health Quality Ontario. Screening and
Preventive Health Care, 2013 (https://canadian management of depression for adults with
taskforce.ca/guidelines/published-guidelines/de chronic diseases: An evidence-based analysis.
pression/) [Accessed 5 March 2024]. Ont Health Technol Assess Ser 2013;13(8):1–45.
5. Siu AL; U.S. Preventive Services Task Force. [NG222]. NICE, 2022 [Accessed 5 March 2024].
Screening for depression in children and 13. King M, Semlyen J, Tai SS, et al. A systematic
adolescents: U.S. Preventive Services Task Force review of mental disorder, suicide, and deliberate
recommendation statement. Ann Intern Med self harm in lesbian, gay and bisexual people.
2016;164(5):360–66. doi: 10.7326/M15-2957. BMC Psychiatry 2008;8(1):70. doi: 10.1186/
[Accessed 5 March 2024]. 1471-244X-8-70. [NG222]. NICE, 2022 [Accessed
6. Joffres M, Jaramillo A, Dickinson J, et al. 5 March 2024].
Recommendations on screening for depression in 14. Siu AL, Bibbins-Domingo K, Grossman DC, et al.
adults. CMAJ 2013;185(9):775–82. doi: 10.1503/ Screening for depression in adults: US Preventive
cmaj.130403. [Accessed 5 March 2024]. Services Task Force recommendation statement.
7. Lereya ST, Copeland WE, Zammit S, Wolke D. JAMA 2016;315(4):380–87. doi: 10.1001/
Bully/victims: A longitudinal, population-based jama.2015.18392. [NG222]. NICE, 2022
cohort study of their mental health. Eur Child [Accessed 5 March 2024].
Adolesc Psychiatry 2015;24(12):1461–71. doi: 15. General Practice Mental Health Standards
10.1007/s00787-015-0705-5. [Accessed 5 March Collaboration (GPMHSC). Suicide prevention and
2024]. Lrst aid resource tool kit. GPMHSC, 2016 (http
8. Sanci L, Lewis D, Patton G. Detecting emotional s://gpmhsc.org.au/guidelines/index/2b9b5c4a-1
disorder in young people in primary care. Curr 8f5-48b3-b30c-813080dfab9d) [Accessed 5
Opin Psychiatry 2010;23(4):318–23. doi: 10.1097/ March 2024].
YCO.0b013e32833aac38. [Accessed 5 March 16. The Royal Australian College of General
2024]. Practitioners (RACGP); National Aboriginal
. Thapar A, Collishaw S, Pine DS, Thapar AK. Community Controlled Health Organisation
Depression in adolescence. Lancet (NACCHO). National guide to a preventive health
2012;379(9820):1056–67. doi: 10.1016/ assessment for Aboriginal and Torres Strait
S0140-6736(11)60871-4. [Accessed 5 March Islander people. RACGP and NACCHO, 2018 (http
2024]. s://www.racgp.org.au/clinical-resources/clinical-
guidelines/key-racgp-guidelines/view-all-racgp-gu
idelines/national-guide/chapter-17-mental-healt
h/prevention-of-depression) [Accessed 5 March
2024].
196
Eating disorders
Eating disorders
Mental health and substance use | Eating

disorders

There are approximately 1 million Australians living with eating disorders, comprising approximately
25,000 with anorexia nervosa, 100,000 with bulimia nervosa, 500,000 with binge eating disorder and
350,000 with other forms of eating disorders.1 Anorexia nervosa has one of the highest mortality rates
of any mental illness, with approximately 450 deaths from anorexia nervosa every year in Australia.1
The prevalence of eating disorders is higher among athletes, women, younger adults aged 18–29 years
and transgender individuals. It is also important to understand that eating disorders in men and
individuals from diverse or minority populations (eg LGBTQIA+/gender diverse, ethnic minority groups,
Aboriginal and Torres Strait Islander people) are often missed and that they may face poorer outcomes
due to delayed diagnosis and a lack of access to services.2,3 Various biological, psychological, social
and environmental factors, such as genetics, the presence of other mental health conditions, trauma,
perfectionism, rigidity, social pressure related to appearance and childhood adversity, are associated
with a higher risk of developing an eating disorder.
Eating disorders are serious and potentially life-threatening mental illnesses with complex aetiology
that can present to primary care in myriad ways. Patients will more often present with an eating
disorder than for an eating disorder, and, as such, GPs with their skilled generalist approach are ideally
placed with curious questioning to provide a safe space for patients to explore help seeking at any
stage.4
There is an opportunity to improve the detection and management of eating disorders in Australian
primary care settings, particularly when patients present for ‘other’ issues or with unexplained low body
mass index (BMI) and one or more symptoms related to an eating disorder.5
Although the evidence for screening is insuacient,4 implementing opportunistic case Lnding in high-
risk groups is likely to improve access to early intervention, accurate diagnosis and treatment, which
will improve outcomes for individuals and the community.2
197
Eating disorders
 Screening
Recommendation Grade How o
Screening for eating disorders (eg binge eating disorder, bulimia nervosa and anorexia Not N/A
nervosa) is not recommended in adolescents and adults. recommended
(Strong)
 Case 9nding
Assess the risk of eating disorders. Practice point N/A

When assessing for an eating disorder or deciding whether to refer people for
assessment, consider the information in Box 1.
GPs have a vital role in prevention by educating about the risks of dieting, which is a Practice point N/A
risk factor for the development of both eating disorders and obesity, by:
• discouraging unhealthy dieting; instead, encourage and support the use of
positive eating and physical activity behaviours that can be maintained on an
ongoing basis
• promoting a positive body image among all adolescents
• encouraging families to have body-positive conversations that do not focus
on weight but celebrate health
• encouraging families to engage in family-centred/led activities such as
healthy family meals and routine and regular physical activity
Further information
Screening for eating disorders has the potential to improve health outcomes, such as quality of life or
function, if it leads to early detection and effective treatment. However, the current evidence on whether
screening improves health outcomes is unclear.6
198
Eating disorders
GPs can also implement sensitive weighing practices at every opportunity, being mindful of the
Academy of Eating Disorder position statement on preventing Childhood Obesity,9 which states:
Weighing [children] should only be performed when there is a clear and compelling need for the
information. The height and weight of a child should be measured in a sensitive, straightforward and
friendly manner, in a private setting. Height and weight should be recorded without remark.
Refer to the Preventive activities in childhood chapter (https://www.racgp.org.au/clinical-resources/clini

cal-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/preventive-activities-in-general-practice/d
evelopment-and-behaviour/childhood-development) for information on measuring the height and
weight of a child. Further, BMI assessment should be considered just one part of an overall health
evaluation and not as the single marker of a child’s health status.
Box 1. Assessing for an eating disorder7
Potential indicators of an eating disorder include:

• an unusually low or high BMI or body weight for age
• rapid weight loss
• dieting or restrictive eating practices
• family members or carers reporting a change in eating behaviour
• social withdrawal, particularly from situations that involve food
• other mental health problems
• a disproportionate concern about weight or shape
• problems managing a chronic illness that affects diet, such as diabetes or
coeliac disease
• menstrual or other endocrine disturbances, or unexplained gastrointestinal
symptoms
• physical signs of:
◦ malnutrition, including poor circulation, dizziness, palpitations, fainting or
pallor
◦ compensatory behaviours, including laxative or diet pill misuse, vomiting
or excessive exercise
• abdominal pain that is associated with vomiting or restrictions in diet and cannot
be fully explained by a medical condition
• unexplained electrolyte imbalance or hypoglycaemia
• atypical dental wear (eg erosion)
• taking part in activities associated with a high risk of eating disorders (eg
professional sport, fashion, dance, or modelling).

peoples
There are no speciLc recommendations or advice for Aboriginal and Torres Strait Islander people.
199
Eating disorders
Speci9c populations
It is important to understand that men and individuals from diverse or minority populations (eg
LGBTIQA+/gender diverse, ethnic minority groups) with eating disorders are often missed and may face
poorer outcomes due to delayed diagnosis and a lack of access to services.2
Resources
Eating disorders: A professional resource for general practitioners (https://www.nedc.com.au/assets/NE
DC-Resources/NEDC-Resource-GPs.pdf) | National Eating Disorders Collaboration
Weighing an individual with an eating disorder (https://insideoutinstitute.org.au/assets/weighing%20a
n%20individual%20with%20an%20eating%20disorder.pdf) | Inside Out Institute for Eating Disorders
Weekly weighing (https://www.cci.health.wa.gov.au/~/media/CCI/Mental-Health-Professionals/Eating-
Disorders/Eating-Disorders---Information-Sheets/Eating-Disorders-Information-Sheet---Weekly-Weighin
g.pdf) | Centre for Clinical Interventions
References
1. Inside Out Institute for Eating Disorders. About 6. U.S. Preventive Services Task Force (USPSTF).
eating disorders. Inside Out Institute for Eating Depression and suicide risk in adults: Screening.
Disorders, 2023 (https://insideoutinstitute.org.au/ USPSTF, 2023 (https://health.gov/healthypeople/t
about-eating-disorders/) [Accessed 23 May ools-action/browse-evidence-based-resources/de
2023]. pression-and-suicide-risk-adults-screening)
2. Bryant E, Spielman K, Le A, et al. Screening, [Accessed 5 March 2024].
assessment and diagnosis in the eating 7. National Institute for Health and Care
disorders: Findings from a rapid review. J Eat Excellence (NICE). Eating disorders: Recognition
Disord 2022;10(1):78. doi: 10.1186/ and treatment. NICE, 2020 (https://www.nice.or
s40337-022-00597-8. [Accessed 23 May 2023]. g.uk/guidance/ng69/chapter/Recommendation
3. Burt A, Mitchison D, Doyle K, Hay P. Eating s#identiLcation-and-assessment) [Accessed 5
disorders amongst Aboriginal and Torres Strait March 2024].
Islander Australians: A scoping review. J Eat 8. Neumark-Sztainer D. Preventing obesity and
Disord 2020;8(1):73. doi: 10.1186/ eating disorders in adolescents: What can health
s40337-020-00346-9. [Accessed 23 May 2023]. care providers do? J Adolesc Health
4. Rowe E. Early detection of eating disorders in 2009;44(3):206–13. doi: 10.1016/
general practice. Aust Fam Physician .jadohealth.2008.11.005. [Accessed 5 March
2017;46(11):833–38. [Accessed 23 May 2023]. 2024].
5. Ivancic L, Maguire S, Miskovic-Wheatley J, . Academy for Eating Disorders. Position

Harrison C, Nassar N. Prevalence and statements: Guidelines for childhood obesity
management of people with eating disorders prevention programs. Academy for Eating
presenting to primary care: A national study. Aust Disorders (https://www.aedweb.org/get-
N Z J Psychiatry 2021;55(11):1089–100. doi: involved/
advocacy/position-statements/guidelines-for-chil
10.1177/0004867421998752. [Accessed 23 May dhood-obesity-prevention-programs) [Accessed
2023]. 23 May 2023].
200
Perinatal mental health
Reproductive and women’s health |

Screening age bar
0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75–79 ≥80

The perinatal period (the time from conception to 12 months after birth) is a time of signiBcant change
for parents. Subsequently, it can be a high-risk time for the onset and relapse of mental health
conditions.1 It is estimated that perinatal depression and anxiety affects 1 in 5 mothers and 1 in 10
fathers/partners.1,2
 Screening
1
Assess psychosocial risk factors as early as Recommended As early
practical in pregnancy and again after the birth using (strong) as
the Antenatal Risk Questionnaire (ANRQ) (https://w practical
ww.cope.org.au/health-professionals/clinical-tools-h in
ealth-professionals/) . pregnancy,
again
after birth.
201
Screening women for a possible depressive or Recommended Complete 1
anxiety disorder using the Edinburgh Postnatal (strong) for the Brst
Depression Scale (EPDS) (https://www.cope.org.au/ depression postnatal
health-professionals/clinical-tools-health-profession screening
als/) is recommended. 6–12
Practice point
weeks
for anxiety
after birth
and repeat
screening
at least
once in
the Brst
postnatal
year.
Routinely screen for intimate partner violence. Recommended Consider 3,4
Explain to all women that asking about family (strong) more than
violence is routine part of postnatal care. Ask about once.
family violence only when alone with the woman,
using validated screening tools (https://www.racg
p.org.au/clinical-resources/clinical-guidelines/key-ra
cgp-guidelines/view-all-racgp-guidelines/abuse-and-
violence/resources-1/useful-tools) .
Further information
Perinatal depression
Common symptoms of perinatal depression:5
• Loss of interest or pleasure in everyday life

• Physical symptoms (eg lethargy, numbness)
• Cognitive symptoms (eg negative thinking)
• Behavioural symptoms (eg withdrawal)
• Emotional symptoms (eg tearfulness)
Depression in the perinatal period is identiBed by the presence of a number of symptoms experienced
over a period of time, typically two weeks or more. Moderate to severe perinatal depression can also
affect a parent’s ability to care for their baby and/or other children in their care.5 Any discussion of
suicide should be taken seriously, with treatment from a mental health professional or other appropriate
person immediately sought.6
202
Perinatal anxiety
Although pregnancy and the arrival of a new baby can be very exciting, most women experience some
worries about things like having a healthy pregnancy, delivering the baby, keeping their baby safe and
potential impacts on their relationship, career or Bnances. For some people, those worries can become
overwhelming and unmanageable.6
Common symptoms of perinatal anxiety:7
• Anxiety or fear that interrupts thoughts and interferes with daily tasks
• Panic attacks: outbursts of extreme fear and panic that are overwhelming and feel diacult to
bring under control
• Anxiety and worries that keep coming into the woman’s mind and are diacult to stop or control
• Constantly feeling irritable, restless or ‘on edge’
• Having tense muscles, a ‘tight’ chest and heart palpitations
• Finding it diacult to relax and/or taking a long time to fall asleep at night
• Anxiety or fear that stops the woman going out with her baby
• Anxiety or fear that leads the woman to check on her baby constantly
Information on key considerations before screening and psychosocial assessment (https://www.healt

h.gov.au/resources/pregnancy-care-guidelines/part-e-social-and-emotional-screening) is available at
the Pregnancy care guidelines.
Be aware that anxiety disorders are very common in the perinatal period and should be considered in
the broader clinical assessment.
Non-birthing partners
Information on assessing perinatal mental health in non-birthing partners (https://www.cope.org.au/he
alth-professionals/health-professionals-3/review-of-new-perinatal-mental-health-guidelines/) is
available in Part B – Screening and psychosocial assessment of the Centre of Perinatal Excellence’s
(COPE) Mental health care in the perinatal period Australian clinical practice guideline.

peoples
When screening Aboriginal and/or Torres Strait Islander women, consider language and the cultural
appropriateness of the tool.1,4 It is important to note that EPDS scores among Aboriginal and Torres
Strait Islander women may be ineuenced by factors such as understanding of the language used,
mistrust of mainstream services or fear of consequences of depression being identiBed (ie involvement
of child protection services).1 If use of the EPDS is considered inappropriate, involvement of an
Aboriginal Health Worker may facilitate assessment of symptoms of depressive or anxiety disorders.1
203
The Kimberley Mum’s Mood Scale (KMMS) (https://kahpf.org.au/kmms) has been developed for use in
Aboriginal and Torres Strait Islander populations; however, it has only been validated for use in the
Kimberley region and may not be applicable for Aboriginal and Torres Strait Islander women in other
areas.1
Where possible, seek guidance/support from an Aboriginal and/or Torres Strait Islander worker or
professional worker or professional when screening Aboriginal and/or Torres Strait Islander woman for
depression and anxiety.1
For further information, refer to the Prevention of depression (https://www.racgp.org.au/clinical-resourc

es/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/national-guide/chapter-17-mental-
health/prevention-of-depression) section in the National guide to a preventive health assessment for
Aboriginal and Torres Strait Islander people.
SpeciAc populations
Perinatal depression and anxiety are more commonly reported among the following population
subgroups:1,2
• people with a prior history of mental illness

• Aboriginal and Torres Strait Islander peoples
• migrant women (including refugees, asylum seekers)
• women living in rural and remote areas
• women experiencing pregnancy in adolescence
• women experiencing intimate partner violence
• LGBTIQA+ parents
• women who experienced birth trauma.
For screening in women from a culturally and linguistically diverse (CALD) background, use
appropriately translated versions of the EPDS with culturally relevant cut-off scores. Consider language
and the cultural appropriateness of the tool.1
Resources
Further information on the identiBcation and management of abuse and violence: Abuse and violence –
working with our patients in general practice (https://www.racgp.org.au/clinical-resources/clinical-guideli
nes/key-racgp-guidelines/view-all-racgp-guidelines/abuse-and-violence/preamble) | RACGP Guideline
for the early identiBcation of mental health conditions in the perinatal period for women and/or their
partners Mental health care in the perinatal period: Australian clinical practice guideline (https://www.cop
e.org.au/health-professionals/health-professionals-3/review-of-new-perinatal-mental-health-guidelines/) |
COPE Guidelines on all aspects of pregnancy care, including social and emotional screening:
Pregnancy care guidelines (https://www.health.gov.au/resources/pregnancy-care-guidelines) |
Department of Health and Aged Care A broad collection of resources for GPs to help patients with
mental health illness: Resources for GPs (https://gpmhsc.org.au/ResourceSection/Index/aa96bb9f-b39
c-4c90-821f-5a9be3a42d20) | GPMHSC
204
References
1. Highet NJ; Expert Working Group and Expert 4. Department of Health and Aged Care. Clinical
Subcommittees. Mental health care in the practice guidelines: Pregnancy care. Australian
perinatal period: Australian clinical practice Government, 2020 (https://www.health.gov.au/re
guideline. COPE, 2023 (https://www.cope.org.au/ sources/pregnancy-care-guidelines) [Accessed
wp-content/uploads/2023/06/COPE_2023_Perina 22 February 2024].
tal_Mental_Health_Practice_Guideline.pdf)
5. Centre of Perinatal Excellence (COPE).
Perinatal depression: A guide for health
2. PwC Consulting Australia. The cost of perinatal professionals. COPE, 2023 (https://www.cope.or
depression and anxiety in Australia. Gidget g.au/wp-content/uploads/2017/11/COPE_Perinat
Foundation Australia, 2019 (https://www.pc.gov.a al-Depression_Health-Prof-Fact-Sheet-2023.pdf)
u/__data/assets/pdf_file/0017/250811/sub75 [Accessed 22 February 2024].
2-mental-health-attachment.pdf) [Accessed 22
6. Black Dog Institute. Anxiety and depression
February 2024]. during pregnancy and the postnatal period (http
3. The Royal Australian College of General s://www.blackdoginstitute.org.au/wp-content/upl
Practitioners (RACGP). Abuse and violence – oads/2022/06/Depression-during-pregnancy.pd
working with our patients in general practice (The f) [Accessed 22 February 2024].
White Book). 5th edn. RACGP, 2021 (https://ww
w.racgp.org.au/clinical-resources/clinical-guidelin Perinatal anxiety: A guide for health
es/key-racgp-guidelines/view-all-racgp-guideline
professionals. COPE, 2023 (https://www.cope.or
s/abuse-and-violence/preamble) [Accessed 22 g.au/wp-content/uploads/2023/07/COPE_Perinat
February 2024].
al-Anxiety_Health-Prof-Fact-Sheet-2023.pdf)
205
Gambling
Gambling

Gambling
Case Anding age bar
0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75–79 ≥80

It is estimated that over 7% of Australians are at risk of gambling-related harms.1 In Australia, 48% of
men and 28% of women gamble at least weekly. Of these, 53% of men who gamble and 38% of women
who gamble experience or are at risk of experiencing gambling-related harm.1 When the impact of
gambling on others is considered, even low-risk gambling affects other people (usually family
members), rising to an impact of six people per typical problem gambler.2 Gambling-related harms
include effects on relationships, health, emotional wellbeing, Bnances and work/study, in addition to
cultural harms and criminal activity.3 There has been extraordinary growth in recent years in
opportunities to gamble, both in-person and online, leading to concern about the potential for
associated harm, and a call for more research into the potential for screening in healthcare settings.4
While GPs wait for screening tools to be validated and tested in primary care to demonstrate improved
health outcomes for gamblers, a case Bnding approach is warranted, given the opportunities afforded
GPs by knowing their patients over time and within the context of their families and communities.
 Case Anding
206
Gambling
In patients experiencing stress, mental health issues Practice Opportunistically 5,6,7,8
or substance use problems; in people experiencing point

or perpetrating domestic violence; in people
experiencing relationship breakdown; and/or in
people with symptoms of compulsive gambling (see
Box 1), ask about gambling behaviours (eg sports
betting, wagering, card playing, pokies, casino
gambling, online gambling). For example, ‘In the past
12 months, have you or someone you are close to
ever had issues with gambling?’
Further information
Calls for a public health approach to gambling will hopefully see reductions in the future rates of
problem gambling, along the same lines as the success Australia has had in smoking cessation and
immunisation. Health professional awareness of the problem is one factor within a larger conceptual
framework required to address this problem.9
This approach allows for GPs to offer brief interventions, such as motivational interviewing or referral to
gambling support helplines and websites, for patients who report gambling issues.
Box 1. Symptoms of compulsive gambling (gambling disorder)10

• Being preoccupied with gambling, such as constantly planning gambling
activities and how to get more gambling money
• Needing to gamble with increasing amounts of money to get the same thrill
• Trying to control, cut back or stop gambling without success
• Feeling restless or irritable when you try to cut down on gambling
• Gambling to escape problems or relieve feelings of helplessness, guilt, anxiety or
depression
• Trying to get back lost money by gambling more (chasing losses)
• Lying to family members or others to hide the extent of your gambling
• Risking or losing important relationships, a job or school or work opportunities
because of gambling
• Asking others to bail you out of Bnancial trouble because you gambled money
away
207
Gambling

peoples
For speciBc recommendations and advice for Aboriginal and Torres Strait Islander people, please refer
to the Gambling (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/v
iew-all-racgp-guidelines/national-guide/chapter-1-lifestyle/gambling) section in the National guide to a
Resources
Gambling Help Online (https://aifs.gov.au/resources/resource-sheets/gambling-help) , an online
counselling, information and support service for problem gambling issues (includes contact details for
local face-to-face counselling and support)
National telephone counselling services:
• National Gambling Helpline, 1800 858 858

• National Debt Helpline, 1800 007 007
References
1. Australian Institute of Health and Welfare. . Sharman S, Butler K, Roberts A. Psychosocial risk
Gambling in Australia. Australian Government, factors in disordered gambling: A descriptive
2023 (https://www.aihw.gov.au/reports/ systematic overview of vulnerable populations.
australia Addict Behav 2019; 99:106071. doi: 10.1016/
2024].
-welfare/gambling) [Accessed 22 February .addbeh.2019.106071. [Accessed 22 February
2024].
2. Goodwin BC, Browne M, Rockloff M, Rose J. A
typical problem gambler affects six others. Int . Australian Institute of Family Studies. The impact
Gambling Stud 2017;17(2):276–89. doi: 10.1080/ of gambling problems on families. Australian
14459795.2017.1331252. [Accessed 22 February Government, 2014 (https://aifs.gov.au/
2024]. resources/policy-and-practice-papers/impact-ga
3. Langham E, Thorne H, Browne M, Donaldson P, mbling-problems-families) [Accessed 22 February
Rose J, Rockloff M. Understanding gambling- 2024].
related harm: A proposed definition, conceptual 7. Victorian Responsible Gambling Foundation
framework, and taxonomy of harms. BMC Public (VRGF). One simple question on the path to
Health 2016;16:80. doi: 10.1186/ recovery. VRGF, 2022 (https://responsiblegamblin
s12889-016-2747-0. [Accessed 22 February g.vic.gov.au/about-us/news-and-media/one-simp
2024]. le-question-on-the-path-to-recovery/) [Accessed
. Blank L, Baxter S, Woods HB, Goyder E. Should 22 February 2024].
screening for risk of gambling-related harm be 8. Problem Gambling Research and Treatment
undertaken in health, care and support settings?A Centre (PGRTC). Guideline for screening,
systematic review of the international evidence. assessment and treatment in problem gambling.
Addict Sci Clin Pract 2021;16(1):35. doi: 10.1186/ Monash University, 2011. [Accessed 22 February
s13722-021-00243-9. [Accessed 22 February 2024].
2024].
208
Gambling
9. Browne M, Langham E, Rawat V, et al. 10. Mayo Clinic. Compulsive gambling. Mayo
Assessing gambling-related harm in Victoria: A Clinic, 2022 (https://www.mayoclinic.org/disease
public health perspective. Victorian Responsible s-conditions/compulsive-gambling/symptoms-ca
Gambling Foundation, 2016 (https://responsibleg uses/syc-20355178) [Accessed 22 February
ambling.vic.gov.au/resources/publications/asses 2024].
sing-gambling-related-harm-in-victoria-a-public-he
alth-perspective-69/) [Accessed 22 February
2024].
209
Smoking and nicotine vaping

Screening age bar
0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75–79 ≥80

Australia has made major progress in tobacco control, with population prevalence of smoking falling
substantially since the 1960s. Australia has one of the lowest smoking rates among the Organisation
for Economic Co-operation and Development (OECD) countries.1 In 2019, 11% of Australians smoked
tobacco daily, down from 12.2% in 2016 and 24% in 1991.2 In recent years, smoking rates have also
fallen for Aboriginal and Torres Strait Islander peoples, but the prevalence remains unacceptably high
(37% in 2018–19).1,3 Despite the decline in prevalence, smoking remains the behavioural risk factor
responsible for the highest levels of preventable disease and premature death.1
Smoking rates are ineuenced by socioeconomic status, with higher rates in low socioeconomic status
communities. Smoking rates remain high in key population groups, including people with mental illness.
Smoking in pregnancy has serious adverse effects for both the mother and developing fetus.
Many people start smoking in during adolescence, with 80% of long-term smokers having started
smoking before the age of 20 years.4 The prevalence of e-cigarette use is on the rise, even among
individuals who have never smoked before. From 2016 to 2019, the percentage of people who had tried
e-cigarettes increased from 8.8% to 11.3%.2 Although the use of e-cigarettes grew across various age
groups, the increase was particularly signiBcant among young adults. Among individuals aged 18–24
years, almost two-thirds (64%) of current smokers and one-Bfth (20%) of non-smokers reported
experimenting with e-cigarettes. In addition, among those who had tried e-cigarettes, the frequency of
use also escalated, with a greater number of people using them at least once a month (rising from
10.3% in 2016 to 17.9% in 2019).2 There is increasing evidence that non-smokers who use e-cigarettes
are more likely than those avoiding e-cigarettes to start cigarette smoking and become current
smokers.5
Up to half of all smokers can be expected to die from a smoking-related condition.6
210
 Screening
1
Ask patients whether they are currently smoking Recommended At every
and document their smoking status. (Strong) opportunity
Also ask about and document the use of vaping starting
products. from the
age of 10
years
1
All patients who smoke should be offered brief Recommended At every
advice to quit smoking. (Strong) visit
Set quit goals, offer Therapeutic Goods
Administration (TGA)-approved pharmacotherapy
(nicotine replacement therapy, varenicline or
bupropion), referral to a smoking cessation service
(see Further information) and follow up as
appropriate.
1,6
For patients who have not been able to quit with the Conditionally N/A
combination of behavioural support and approved recommended
pharmacotherapy, consider the use of nicotine e-
cigarettes to assist smoking cessation. This needs
to be preceded by an evidence-informed shared
decision-making process where the lack of
evidence on long-term safety and the current
unapproved status of nicotine e-cigarettes is
discussed.
1
All patients who vape should be advised to quit Practice point At every
vaping. visit
Offer brief cessation advice in routine
consultations and appointments, whenever
possible.
211
Further information
The delivery of smoking cessation advice is likely to be one of most effective interventions in reducing
mortality.8 Some smokers may not be ready to quit, but may still beneBt from brief advice about
smoking cessation.
Using the Ask Assess Help model (https://www.racgp.org.au/getattachment/dac134bf-dcde-416c-93d

e-250cccc5d02b/attachment.aspx?disposition=inline) as part of shared decision making by
considering readiness to quit.
Nicotine dependence can be assessed by asking about the:
• number of minutes between waking and smoking the Brst cigarette

• number of cigarettes smoked a day
• type of craving or withdrawal symptoms experienced in previous quit attempts.2
There is a high likelihood of nicotine dependence if the person smokes within 30 minutes of waking and
smokes more than 10–15 cigarettes a day.
Referrals to Quitline, SMS cessation services and online cessation support (https://www.health.gov.au/t
opics/smoking-and-tobacco/smoking-and-tobacco-contacts) are all effective and may complement
brief interventions delivered by clinicians.
See RACGP’s Supporting smoking cessation: A guide for health professionals (https://www.racgp.org.a
u/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/supporting-smok
ing-cessation) for more information on smoking cessation advice and follow up.

peoples
For speciBc recommendations for Aboriginal and Torres Strait Islander people, please refer to the
Smoking (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-
racgp-guidelines/national-guide/chapter-1-lifestyle/smoking) section in the National guide to a
Resources
Supporting smoking cessation: A guide for health professionals (https://www.racgp.org.au/clinical-resou
rces/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/supporting-smoking-cessation) |
RACGP
212
References
1. The Royal Australian College of General . Baenziger ON, Ford L, Yazidjoglou A, Joshy G,
Practitioners (RACGP). Supporting smoking Banks E. E-cigarette use and combustible
cessation: A guide for health professionals. 2nd tobacco cigarette smoking uptake among non-
edn. RACGP, 2021 (https://www.racgp.org.au/clini smokers, including relapse in former smokers:
cal-resources/clinical-guidelines/key-racgp-guidel Umbrella review, systematic review and meta-
ines/view-all-racgp-guidelines/supporting-smokin analysis. BMJ Open 2021;11:e045603. doi:
-cessation) [Accessed 17 May 2023]. 10.1136/bmjopen-2020-045603. [Accessed 23
2. Australian Institute of Health and Welfare. February 2024].
National drug strategy household survey 2019. . U.S. Department of Health and Human Services.
Australian Government, 2020 (https://www.aihw.g Smoking cessation: A report of the surgeon
ov.au/reports/illicit-use-of-drugs/national-drug-str general – executive summary. U.S. Department
ategy-household-survey-2019/contents/summar of Health and Human Services, 2020
[Accessed 23 February 2024]. (https://www.hhs.gov/sites/default/Bles/2020-ce
3. Australian Bureau of Statistics (ABS). National ssation-sgr-executive-summary.pdf) [Accessed
Aboriginal and Torres Strait Islander health 23 February 2024].
survey. Canberra: ABS, 2019 (https://www.abs.go . Hartmann-Boyce J, Lindson N, Butler AR, et al.
.au/statistics/people/aboriginal-and-torres-strai Electronic cigarettes for smoking cessation.
t-islander-peoples/national-aboriginal-and-torres- Cochrane Database Syst Rev 2022;11:CD010216.
strait-islander-health-survey/latest-release) doi: 10.1002/14651858.CD010216.pub7.
[Accessed 23 February 2024]. [Accessed 23 February 2024].
. Department of Health and Aged Care. Young . Anthonisen NR, Skeans MA, Wise RA, et al. The
people and tobacco smoking. Australian effects of a smoking cessation intervention on
Government, 2023 (https://www.health.gov.au/to 14.5-year mortality: A randomized clinical trial.
pics/smoking-and-tobacco/smoking-and-tobacc Ann Intern Med. 2005;142(4):233. doi: 10.7326/
-throughout-life/smoking-and-tobacco-and-youn 0003-4819-142-4-200502150-00005. [Accessed
g-people) [Accessed 23 February 2024]. 23 February 2024].
213
Suicide
Suicide
Mental health and substance use | Suicide

There are over 3000 deaths due to suicide in Australia each year,1 and hence this is a key priority for
governments and the healthcare system. Given that GPs see almost nine in 10 Australians each year,2
they are viewed as a key part of the solution to detecting people most at risk of suicide and offering
them appropriate interventions.3 Contact with primary healthcare services is common in the months or
weeks prior to suicide.1,4
The suicide rate is threefold higher for men than women.1 The causes of suicidality are complex and
diverse, but there is an association between suicide and psychiatric conditions,5 and there is some
evidence that treatment of mental health conditions can reduce risk.7 People affected by complex
mental health issues are anywhere from 10- to 45-fold more likely to die by suicide than the general
population.8 The risk is highest for those living with borderline personality disorder (BPD), one of the
most stigmatised and poorly understood conditions, but it is also high for those living with anorexia
nervosa (31-fold higher than in the general population) and schizophrenia (13-fold higher than in the
general population).8
Although traumatic experiences can increase the risk of suicide, the effects of trauma can be
protracted over a period of time or lifelong. For example, adverse childhood events can be a risk factor
for mental ill health. Historical experiences of trauma should not be discounted as a current risk factor
for suicidal behaviour and poor mental health.9
 Screening
10
Routine screening for suicide risk is not Not N/A
recommended. recommended
(Strong)
 Case Anding
214
Suicide
Be alert for the risk of attempted suicide in Practice point Opportunistically 11,12,13
those with:
• mental illness, especially mood
disorders, and alcohol and drug abuse
• previous suicide attempts or
deliberate self-harm
• recent loss or other adverse event
• access to harmful means, such as
medication or weapons
• legal or disciplinary problems
• relationship problems, such as
coneict with parents or intimate
partner
• bullying
• a family history of attempted or
completed suicide
• a recent bereavement
• chronic and terminal medical illness
as well as those:
• who are living alone
• who are/have been in prison
• who have been discharged from a
psychiatric hospital in the previous 12
months
• are women experiencing intimate
partner violence
Further information
Although there is lack of evidence for routine screening for suicide using a screening instrument, a case
Bnding approach rather than universal screening is recommended given that there are clearly deBned
patient groups known to be at greater risk. GPs should be alert for patients who are at higher risk of
self-harm and suicide. Mental health Brst aid strategies can be offered in general practice and are
recognised as an effective strategy for suicide prevention.3 The system-based strategy that has the
greatest estimated reduction in suicide deaths is GP capacity building and support.14
The General Practice Mental Health Standards Collaboration (GPMHSC) provides guidelines written
speciBcally for GPs to assist with suicide prevention and Brst aid.2 These guidelines provide the t (http
s://gpmhsc.org.au/guidelines/index/7b3a8bbb-844f-4716-a13a-46ed224908a0#main-content) ypes of
questions to ask those identiBed as being at risk (https://gpmhsc.org.au/guidelines/index/7b3a8bbb-8
44f-4716-a13a-46ed224908a0#main-content) and some effective strategies for managing risk. (http
215
Suicide
s://gpmhsc.org.au/guidelines/index/3196c496-3a69-4179-aaa9-97b23d17bb1e#main-content)
Conceptualising risk according to both static and dynamic factors can also assist the GP in the clinical
assessment of a patient regarding level of risk.15

peoples
There is a higher incidence of attempted suicide among Aboriginal and Torres Strait Islander peoples.1
For speciBc recommendations and advice for Aboriginal and Torres Strait Islander people, please refer
to the Prevention of suicide (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-
guidelines/view-all-racgp-guidelines/national-guide/chapter-17-mental-health/prevention-of-suicide)
section in the National guide to a preventive health assessment for Aboriginal and Torres Strait Islander
people.
SpeciAc populations
There is a higher incidence of attempted suicide in LGBTIQA+ communities.1
Resources
Suicide prevention and Grst aid: A resource for GPs (https://gpmhsc.org.au/guidelinessection/index/fd09
3e3b-ceff-4e0d-81c0-b04dfba936d1/suicide-prevention-and-Grst-aid) | GPMHSC Suicide (https://www.be
yondblue.org.au/mental-health/suicide-prevention) | Beyond Blue
References
1. Australian Institute of Health and Welfare. . Spottswood M, Lim CT, Davydow D, Huang H.
Suicide & self-harm monitoring. Australian Improving suicide prevention in primary care for
Government, 2023 (https://www.aihw.gov.au/suic differing levels of behavioral health integration: A
ide-self-harm-monitoring/data/suicide-self-harm- review. Front Med (Lausanne) 2022;9:892205.
monitoring-data) [Accessed 5 March 2024]. doi: 10.3389/fmed.2022.892205. [Accessed 6
March 2024].
Practitioners (RACGP). General practice: Health of . Hawton K, van Heeringen K. Suicide. Lancet
the nation 2022. RACGP, 2022 (https://www.rac 2009;373(9672):1372–81. doi: 10.1016/
gp.org.au/getmedia/80c8bdc9-8886-4055-8a8d-e S0140-6736(09)60372-X. [Accessed 6 March
a793b088e5a/Health-of-the-Nation.pdf.aspx) 2024].
[Accessed 6 March 2024]. . Austin MP, Highet N, The Guidelines Expert
3. General Practice Mental Health Standards Advisory Committee. Clinical practice guidelines
Collaboration (GPMHSC). Suicide prevention and for depression and related disorders – anxiety,
first aid: A resource for GPs. GPMHSC, 2016 (http bipolar disorder and puerperal psychosis – in the
s://gpmhsc.org.au/guidelinessection/index/fd09 perinatal period. A guideline for primary care
3e3b-ceff-4e0d-81c0-b04dfba936d1/suicide-prev health professionals. beyondblue, 2011.
ention-and-first-aid) [Accessed 6 March 2024]. [Accessed 6 March 2024].
216
Suicide
. Gaynes BN, West SL, Ford CA, et al. Screening for 12. Powell J, Geddes J, Deeks J, Goldacre M,
suicide risk in adults: A summary of the evidence Hawton K. Suicide in psychiatric hospital in-
for the U.S. Preventive Services Task Force. Ann patients. Risk factors and their predictive power.
Intern Med 2004;140(10):822–35. doi: Br J Psychiatry 2000;176(3):266–72. doi:
10.7326/0003-4819-140-10-200405180-00015. 10.1192/bjp.176.3.266. [Accessed 5 March
[Accessed 6 March 2024]. 2024].
. SANE. Decrease in suicide rates is not a time for 13. Favril L, Yu R, Uyar A, Sharpe M, Fazel S. Risk
celebration. SANE, 2017.Available at (http s:// factors for suicide in adults: Systematic review
www.sane.org/media-centre/media-releases-2 and meta-analysis of psychological autopsy
017/decrease-in-suicide-rates-is-not-a-time-for-ce studies. Evid Based Ment Health
lebration) [Accessed 5 March 2024]. 2022;25(4):148–55. doi: 10.1136/
ebmental-2022-300549. [Accessed 5 March
. Australian Institute of Health and Welfare. Stress
and trauma. Australian Government, 2024 2024].
(https://www.aihw.gov.au/reports/mental-health/ 1 . Black Dog Institute. An evidence-based systems
stress-and-trauma) [Accessed 14 March 2024]. approach to suicide prevention: guidance on
planning, commissioning and monitoring. Black
1 . U.S. Preventive Services Task Force
Dog Institute, 2016 (https://ww
(USPSTF). Suicide risk in adolescents, adults and
older adults: Screening. USPSTF, 2023 (https://w w.blackdoginstitute.org.au/wp-content/uploads/2
ww.uspreventiveservicestaskforce.org/uspstf/rec 020/04/an-evidence-based-systems-approach-to-
ommendation/suicide-risk-in-adolescents-adults- suicide-prevention.pdf?sfvrsn=0) [Accessed 5
and-older-adults-screening) [Accessed 5 March March 2024].
2024]. 15. Balaratnasingam S. Mental health risk
11. BeyondBlue. Suicide. Beyond Blue, n.d (http s:// assessment – a guide for GPs. Aust Fam
www.beyondblue.org.au/mental-health/suicid Physician 2011;40(6):366–69. [Accessed 5
-prevention) [Accessed 5 March 2024]. March 2024].
217
Suicide
Metabolic
218
Suicide
Metabolic
Coeliac (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-rac
metabolic/coeliac) Diabetes (https://www.racgp.org.au/clinical-resources/clinic
s-in-general-practice/metabolic/diabetes) Nutrition (https://www.racgp.org.au/cl
s/preventive-activities-in-general-practice/metabolic/nutrition) Overweight and
obesity (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-rac
metabolic/overweight-and-obesity) Physical activity (https://www.racgp.org.au/c
linical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelin
es/preventive-activities-in-general-practice/metabolic/physical-activity) Thyroid
lines/view-all-racgp-guidelines/preventive-activities-in-general-practice/metaboli
c/thyroid)
219
Coeliac
Coeliac
Metabolic | Coeliac
The prevalence of self‐reported non‐coeliac wheat sensitivity and gluten avoidance in Australia is
approximately 13.8%.1 However, the prevalence of proven coeliac disease is 1.2% in adult men and 1.9%
in adult women2 (based on symptoms, the presence of anti-transglutaminase antibodies and
histological features on duodenal biopsy).
 Screening
How
often
Screening for coeliac disease in the general Not

3
population is not recommended, because of recommended N/A
insuacient evidence. (strong)
Further information
There is insuacient evidence for population screening. Screening for anti-transglutaminase antibodies
may detect asymptomatic coeliac disease but may also cause harm associated with further
investigations and overtreatment. In 2017, the US Preventive Services Task Force (USPSTF) found
inadequate evidence on the accuracy of screening for coeliac disease; the potential beneBts and harms
of screening versus not screening or targeted versus universal screening; and the potential beneBts and
harms of treatment of screen-detected coeliac disease.3

peoples
There are no additional recommendations for this speciBc population.
220
Coeliac
SpeciAc populations
Testing for coeliac disease is appropriate for:4,5
• people with signs and symptoms, such as:

◦ persistent unexplained gastrointestinal symptoms
◦ delayed growth or weight loss
◦ prolonged fatigue
◦ persistent mouth ulcers
◦ iron, vitamin B12 or folate deBciency
• Brst-degree relative of a patient with coeliac disease
• people with associated conditions, such as:
◦ type 1 diabetes
◦ autoimmune thyroid disease
◦ irritable bowel syndrome in adults.
Resources
For further information on coeliac disease and patient information: Coeliac Australia website (https://co
eliac.org.au/)
References
1. Potter M, Jones M, Walker M, et al. Incidence and . Ludvigsson J, Bai J, Biagi F, et al. Diagnosis and
prevalence of self-reported non-coeliac wheat management of adult coeliac disease: Guidelines
sensitivity and gluten avoidance in Australia. Med from the British Society of Gastroenterology. Gut
J Aust 2020;212(3):126–31. doi: 10.5694/ 2014;1;63(8):1210–28. doi: 10.1136/
mja2.50458. gutjnl-2013-306578.
2. Anderson R, Henry M, Taylor R, et al. A novel . National Institute for Health and Care Excellence
serogenetic approach determines the community (NICE). Coeliac disease: Recognition,
prevalence of celiac disease and informs assessment and management. NICE, 2015 (htt
improved diagnostic pathways. BMC Med p://www.nice.org.uk/guidance/ng20) [Accessed
2013;11:188. doi: 10.1186/1741-7015-11-188. 21 March 2023].
3. US Preventive Services Task Force; Bibbins-
Domingo K, Grossman DC, et al. Screening for
celiac disease: US Preventive Services Task Force
recommendation statement. JAMA
2017:317(12):1252–57. doi: 10.1001/
jama.2017.1462.
221
Diabetes
Diabetes
Metabolic | Diabetes
Screening age bar
0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75–79 ≥80

Diabetes is a common condition, with approximately 1 in 20 Australians having diabetes. The
prevalence of diabetes increased 2.8-fold between 2000 and 2020.1 Type 2 diabetes is comparatively
more prevalent in lower than higher socioeconomic groups and in people living in remote and very
remote areas than in those living in urban areas.1 In 2020, approximately one in six pregnant women
had gestational diabetes.1 Aboriginal and Torres Strait Islander Australians were 2.9-fold more likely
than non-Indigenous Australians to have diabetes.2 The prevalence of diabetes increases with age, and
is 1.3-fold more common in men than in women.1 Type 2 diabetes occurs in 11.8% of general practice
encounters and 5.5% of patients in general practice.3
 Screening
General population of normal risk 4, 5

Conditionally Every 3
Assessing the risk of diabetes is recommended recommended years.
for those in the general population aged >40 years
without speciBc risk factors. Use a validated
screening tool to assess the risk of diabetes, such
as The Australian type 2 diabetes risk assessment
tool (https://www.health.gov.au/resources/apps-a
nd-tools/the-australian-type-2-diabetes-risk-asses
sment-tool-ausdrisk) (AUSDRISK).
222
Diabetes
High-risk population* Conditionally Every 3 5,6,7,8
In asymptomatic adults at high risk* of developing recommended years (every

type 2 diabetes, screen using fasting blood 12 months
glucose (FBG) or glycosylated haemoglobin for people
(HbA1c). with
impaired
*Adults at high risk of developing type 2 diabetes glucose
include people with any one of the following: tolerance
• overweight or obesity and age ≥40 years [IGT] and
• overweight or obesity, age 18–40 years impaired
and hypertension fasting
• overweight or obesity, age 18–40 years glucose
and clinical evidence of insulin resistance [IFG])
(acanthosis nigricans, dyslipidaemia) †Annually for
• a Brst-degree relative with diabetes Aboriginal

• a history of a cardiovascular event (eg and Torres
acute myocardial infarction, angina, Strait
peripheral vascular disease or stroke) Islander
• a high-risk ethnicity/background people
(Aboriginal and Torres Strait Islander†,
South Asian, South-east Asian, North
African, Latin American, Middle Eastern,
Māori or PaciBc Islander people [includes
individuals of mixed ethnicity])
• a history of gestational diabetes mellitus
(GDM)
• polycystic ovary syndrome (PCOS)
• taking antipsychotic medication.
An AUSDRISK score ≥12 also indicates high risk.
223
Diabetes
An oral glucose tolerance test (OGTT) is Conditionally Re-test every 4
recommended for people who have previously had recommended 1–3 years,
an intermediate hyperglycaemia result, such as depending
FBG (5.5–6.9 mmol/L). on result
(see Bgure 1,
Further information regarding the screening and Management
diagnosis of type 2 diabetes in asymptomatic of type 2
people is provided in Bgure 1, Management of type diabetes: A
2 diabetes: A handbook for general practice (http handbook
s://www.racgp.org.au/getattachment/a453b6a0-1 for general
44c-4080-a955-829030f5ff40/attachment.aspx?di practice (htt
sposition=inline) . ps://www.ra
cgp.org.au/g
etattachmen
t/a453b6a
0-144c-408
0-a955-8290
30f5ff40/att
achment.as
px?dispositi
on=inline) )
8
Highest-risk population Conditionally Every 3
In asymptomatic adults at very high risk** of recommended years, earlier
developing type 2 diabetes, screen using FBG or if BMI is
HbA1c. increasing
**Adults at very high risk of developing type 2 Every 12

diabetes include those with any one of the months for
following: people with
• impaired fasting glucose IGT and IFG
• impaired glucose tolerance
• overweight or obesityA, age 18–40 years
with one or more additional risk factors
and increasing body mass index (BMI)
• overweight or obesityA, age ≥40 years
and increasing BMI.
A BMI ≥25 kg/m2; speciBc cut-off points

recommended for South Asian and South-east
Asian people are BMI >23 kg/m2 for overweight
and BMI >27.5 kg/m2 for obesity.
224
Diabetes
People should follow a diet in line with the Practice point N/A 9
Australian dietary guidelines (https://www.eatforh

ealth.gov.au/guidelines) to help prevent diabetes.
People at high risk of developing type 2 diabetes Practice point N/A 4
may also beneBt from a structured weight loss,

healthy diet and exercise program to reduce their
risk of developing the condition. Even modest
weight loss (5–10%) may provide clinical beneBts,
and with further weight loss there are further
improvements.
All people who smoke should be offered advice to Recommended N/A 10
quit smoking. (strong)
Further information
Screening using AUSDRISK has the advantage of identifying patients without diabetes who are at high
risk for preventive activities. Those with an HbA1c 6.0–6.4% (42–46 mmol/mol) should be considered
at higher risk of developing diabetes and screening should be repeated in 1 year. Screening in those
with an HbA1c ≥6.5% (48 mmol/mol) should be repeated to conBrm the diagnosis of diabetes. Although
it does not require a fasting test, HbA1c may be inaccurate if the person has haemoglobinopathies or
other conditions.4
For further information see Preventing progression to type 2 diabetes (https://www.racgp.org.au/clinica

l-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/diabetes/preventing-prog
ression-to-type-2-diabetes) in Management of type 2 diabetes: A handbook for general practice.

peoples
Recommendations in some areas of diabetes care, including a lack of accuracy of AUSDRISK scores,
are different for Aboriginal and Torres Strait Islander people. Aboriginal and Torres Strait Islander
people should be screened annually with blood testing (FPG, random venous glucose or HbA1c) from
18 years of age.4,11
For speciBc recommendations for Aboriginal and Torres Strait Islander people, please refer to Type 2
diabetes prevention and early detection (https://www.racgp.org.au/clinical-resources/clinical-guideline
s/key-racgp-guidelines/view-all-racgp-guidelines/national-guide/chapter-12-type-2-diabetes-prevention-
and-early-de) in the National Guide to a preventive health assessment for Aboriginal and Torres Strait
Islander people.
225
Diabetes
Resources
Evidence-based recommendations for management of patients with type 2 diabetes: Management of
type 2 diabetes: A handbook for general practice (https://www.racgp.org.au/clinical-resources/clinical-g
uidelines/key-racgp-guidelines/view-all-racgp-guidelines/diabetes/introduction) | RACGP and Diabetes
Australia Further information on the identiBcation and management of hyperglycaemic emergencies:
Emergency management of hyperglycaemia in primary care (https://www.racgp.org.au/clinical-resource
s/clinical-guidelines/guidelines-by-topic/view-all-guidelines-by-topic/chronic-disease/emergency-mana
gement-of-hyperglycaemia) | RACGP and Australian Diabetes Society (ADS) Further information on the
management and support of patients during COVID-19: Diabetes management during coronavirus (http
s://www.racgp.org.au/clinical-resources/clinical-guidelines/guidelines-by-topic/view-all-guidelines-by-topi
c/chronic-disease/diabetes-management-during-coronavirus) | RACGP Guidance for GPs on managing
diabetic patients who fast during Ramadan: Diabetes management during Ramadan (https://www.racg
p.org.au/clinical-resources/clinical-guidelines/guidelines-by-topic/view-all-guidelines-by-topic/chronic-dis
ease/diabetes-management-during-ramadan) | RACGP Guidance and eow charts for the emergency
management of children with diabetic ketoacidosis (DKA) and hyperosmolar hyperglycaemic state
(HHS): Guideline for the early recognition of hyperglycaemia in children under 16 (https://www.racgp.or
g.au/clinical-resources/clinical-guidelines/guidelines-by-topic/view-all-guidelines-by-topic/chronic-disea
se/early-recognition-of-hyperglycaemia-in-children) | Clinical Excellence Queensland Evidence-based
recommendations the amount and kinds of foods to eat for health, wellbeing and prevention of chronic
disease: Australian dietary guidelines (https://www.eatforhealth.gov.au/guidelines) | National Health
and Medical Research Council To assess and manage cardiovascular risk in people with diabetes
aged 35–79 years without known atherosclerotic cardiovascular disease (CVD): Australian CVD risk
calculator (AusCVDRisk (https://www.cvdcheck.org.au/calculator) ), a risk assessment, communication
and management tool for health professionals
References
1. Australian Institute of Health and Welfare. 4. The Royal Australian College of General
(AIHW). Diabetes: Australian facts. AIHW, 2023 (h Practitioners (RACGP). Management of type 2
ttps://www.aihw.gov.au/reports/diabetes/diabete diabetes: A handbook for general practice.
[Accessed 2 August 2023]. RACGP, 2020 (https://www.racgp.org.au/clinical-r
2. 2. Australian Bureau of Statistics (ABS). National esources/clinical-guidelines/key-racgp-guideline
Aboriginal and Torres Strait Islander Health s/view-all-racgp-guidelines/diabetes/introductio
Survey. ABS, 2019 (https://www.abs.gov.au/statis n) [Accessed 31 January 2024].
tics/people/aboriginal-and-torres-strait-islander-p . Chen L, Magliano DJ, Balkau B, et al. AUSDRISK:
eoples/national-aboriginal-and-torres-strait-island An Australian type 2 diabetes risk assessment
er-health-survey/latest-release) [Accessed 2 tool based on demographic, lifestyle and simple
August 2023]. anthropometric measures. Med J Aust
2010;192(4):197–202. doi: 10.5694/
3. NPS MedicineWise. General practice insights
.1326-5377.2010.tb03507.x. [Accessed 31
report July 2019–June 2020 including analyses
January 2024].
related to the impact of COVID-19. NPS
MedicineWise, 2021 (https://www.nps.org.au/ass
ets/NPS/pdf/GPIR-Report-2019-20.pdf)
226
Diabetes
6. Australian Government Department of Health 9. National Health and Medical Research Council
and Ageing (DoHA). Background to the Australian (NHMRC). Australian dietary guidelines. NHMRC,
type 2 diabetes risk assessment tool. DoHA, 2010 2013 (https://www.eatforhealth.gov.au/guideline
(https://www.health.gov.au/sites/default/Bles/ba s) [Accessed 31 January 2024].
ckground-to-the-australian-type-2-diabetes-risk-as 10. The Royal Australian College of General
sessment-tool-ausdrisk.pdf) [Accessed 31 Practitioners (RACGP). Supporting smoking
January 2024]. cessation: A guide for health professionals. 2nd
. Martin A, Neale EP, Tapsell LC. The clinical utility edn. RACGP, 2019 (https://www.racgp.org.au/clini
of the AUSDRISK tool in assessing change in type cal-resources/clinical-guidelines/key-racgp-guidel
2 diabetes risk in overweight/obese volunteers ines/view-all-racgp-guidelines/supporting-smokin
undertaking a healthy lifestyle intervention. Prev g-cessation) [Accessed 31 January 2024].
Med Rep 2018;13:80–84. doi: 10.1016/
11. National Aboriginal Community Controlled
j.pmedr.2018.11.020. [Accessed 31 January
Health Organisation; The Royal Australian College
2024].
of General Practitioners (RACGP). National guide
. Wong J, Ross G, Zoungas S, et al. Management of to a preventive health assessment for Aboriginal
type 2 diabetes in young adults aged 18-30 years: and Torres Strait Islander people. 3rd edn. RACGP,
ADS/ADEA/APEG consensus statement. Med J 2018 (https://www.racgp.org.au/clinical-resource
Aust 2022;216(8):422–29. doi: 10.5694/ s/clinical-guidelines/key-racgp-guidelines/view-al
mja2.51482. [Accessed 31 January 2024]. l-racgp-guidelines/national-guide) [Accessed 31
January 2024].
227
Nutrition
Nutrition
Metabolic | Nutrition
Diet is the most important behavioural risk factor that can signiBcantly impact health.1 The quality and
quantity of foods and beverages we consume affects the health and wellbeing of individuals, society
and the environment. Therefore, improving nutrition has the potential to improve individual and public
health while reducing healthcare costs.1 Optimal nutrition is vital for the normal growth and physical
and cognitive development of infants and children. Nutrition plays an important role in maintaining a
healthy weight, enhancing quality of life and wellbeing, strengthening resistance to infections and
safeguarding against chronic diseases and premature death in all Australians.1 Conversely, inadequate
nutrition is linked to ill health.1
Numerous chronic diseases related to diet, such as cardiovascular disease, type 2 diabetes and certain
forms of cancer, are major causes of death and disability among Australians, and over one-third of all
premature deaths in Australia are from preventable chronic diseases.1 Many of these conditions are
closely associated with being overweight or obese.1 For speciBc information on overweight and obesity,
refer to the Overweight and obesity (http://~/clinical-resources/clinical-guidelines/key-racgp-guideline
s/view-all-racgp-guidelines/preventive-activities-in-general-practice/metabolic/overweight-and-obesity)
chapter.
Generally, Australians of all ages do not eat enough of the Bve food groups (vegetables, fruit, grains,
meat and alternatives, and dairy products and alternatives) and eat too much sugar, saturated fat,
sodium and food that is high in energy and low in nutrients (‘discretionary food’).2
Patients should be encouraged and Recommended Opportunistically. 1
supported to follow the Australian dietary (strong)

recommendations (https://www.eatforhealt
h.gov.au/guidelines/guidelines) which
includes eating Bve serves of vegetables (or
more, depending on age and life stage) and
two serves of fruit per day.
228
Nutrition
Choose a variety of nutritious foods from Practice point Opportunistically. 1
these Bve groups every day:

• plenty of vegetables, including
different types and colours, and
legumes/beans
• fruit
• grain (cereal) foods, mostly
wholegrain and/or varieties high in
cereal Bbre, such as bread, cereals,
rice, pasta, noodles, polenta,
couscous, oats, quinoa and barley
• lean meats and poultry, Bsh, eggs,
tofu, nuts/seeds and legumes/beans
• milk, yoghurt, cheese and/or their
alternatives, mostly reduced fat
(reduced fat milks are not suitable
for children under two years of age).
Limit the intake of foods and drinks

containing saturated fat, added salt, added
sugars and alcohol. See Box 1.
Care for food; prepare and store it safely.
1,3,4
Encourage, support and promote Recommended Discuss
breastfeeding. (strong) antenatally and
12 months of
age and beyond,
for as long as the
mother and child
desire.
Further information
Infants should be exclusively breastfed until around six months of age, when solid foods are introduced
(texture appropriate, in any order, as long as iron-rich foods are included) and at a rate that suits the
infant’s development4 (for further information, refer to the Eat for Health Infant feeding guidelines (http
s://www.eatforhealth.gov.au/sites/default/Gles/2022-09/170131_n56_infant_feeding_guidelines_summar
y.pdf) ). Breastfeeding in Australia has a high initiation rate at 96%, but this drops off quickly and only a
small percentage of women meet the current recommendation of exclusive breastfeeding until around
six months of age.4 Iron-fortiBed cereals, pureed meat, vegetables, fruit and other nutritious foods will
provide a variety of tastes and textures that should be encouraged. Breastfeeding should continue while
solid foods are introduced until 12 months of age and beyond, for as long as the mother and child
desire.4 The beneBts of breastfeeding include reduced risks of sudden infant death, necrotising
enterocolitis, gastrointestinal, respiratory and middle ear infections, being overweight and obese, type 1
229
Nutrition
and type 2 diabetes and dental issues and improved cognitive development.5 For babies whose
mothers cannot breastfeed or who discontinue breastfeeding early, infant formulas will need to be used
up to the age of 12 months, at which time cows’ milk (full fat up to the age of two years), combined with
an adequate diet, will provide the required nutrients and energy.
Reducing sugar intake will assist in reducing weight gain and dental decay.6
Because of the importance of the health outcomes that are determined by these nutritional issues,
assessment and the education of parents and carers regarding children’s nutrition can be of great
beneBt. For further information about good nutritional advice in children, please see the Eat for Health
guidelines (https://www.eatforhealth.gov.au/sites/default/Bles/2023-08/n55f_children_brochure.pdf) .
Box 1. Foods that adults should limit1
Adults should:
• limit the intake of foods high in saturated fat, such as many biscuits, cakes,
pastries, pies, processed meats, commercial burgers, pizza, fried foods, potato
chips, crisps and other savoury snacks
• replace high-fat foods, which contain predominantly saturated fats such as
butter, cream, cooking margarine, coconut and palm oil, with foods that contain
predominantly polyunsaturated and monounsaturated fats, such as oils, spreads,
nut butters/pastes and avocado
• limit the intake of foods and drinks containing added salt
• read labels to choose lower-sodium options among similar foods (do not add salt
to foods in cooking or at the table)
• limit the intake of foods and drinks containing added sugars such as
confectionary, sugar-sweetened soft drinks and cordials, fruit drinks, vitamin
waters, energy and sports drinks.

peoples
Growth failure (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/vie
w-all-racgp-guidelines/national-guide/chapter-3-child-health/growth-failure) section in the National
guide to a preventive health assessment for Aboriginal and Torres Strait Islander people. Visit the Eat for
Health website (https://www.eatforhealth.gov.au/guidelines/guidelines) for Aboriginal and Torres Strait
Islander information sheets, brochures and posters to assist implementing the Australian dietary
guidelines.
230
Nutrition
SpeciAc populations
Pregnancy and lactation bring nutritional risks due to increased nutrient requirements. It is important to
note that a mother's nutritional status signiBcantly impacts the wellbeing of both the fetus and the
infant.1
For people who are at high risk of cardiovascular disease, following a Mediterranean diet (https://www.r
acgp.org.au/clinical-resources/clinical-guidelines/handi/handi-interventions/nutrition/mediterranean-di
et-for-reducing-cardiovascular-dis) can reduce their risk.7 For people with hypertension, following a
DASH (Dietary Approaches to Stop Hypertension) diet (https://www.racgp.org.au/clinical-resources/clin
ical-guidelines/handi/handi-interventions/nutrition/dash-dietary-approaches-to-stop-hypertension-diet)
can prevent and control hypertension.7 For speciBc information, refer to the Cardiovascular disease risk
(https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-gui
delines/preventive-activities-in-general-practice/cardiovascular/cardiovascular-disease-cvd-risk)
chapter.
Resources
For up-to-date advice, including the Australian dietary guidelines and the Infant feeding guidelines: Eat
for Health website (https://www.eatforhealth.gov.au/guidelines/guidelines)
References
1. National Health and Medical Research Council 5. Australian Institute of Health and Welfare.
(NHMRC). Australian dietary guidelines. NHMRC, Australia’s children: Breastfeeding and nutrition.
2013 (https://www.eatforhealth.gov.au) Australian Government, 2022 (https://www.aihw.g
[Accessed 6 March 2024]. ov.au/reports/children-youth/australias-children/
2. 2. Australian Institute of Health and Welfare. Diet. contents/health/breastfeeding-nutrition)
Australian Government, 2023 (https://www.aihw.g [Accessed 23 May 2023].
ov.au/reports/food-nutrition/diet) [Accessed 3 6. Australian Institute of Health and Welfare.
October 2023]. Australia’s children: Dental health. Canberra:
3. National Health and Medical Research Council Australian Government, 2022 (https://www.aihw.g
(NHMRC). Eat for health: Infant feeding ov.au/reports/children-youth/australias-children/
guidelines. NHMRC, 2012 (https://www.eatforhea contents/health/dental-health) [Accessed 23 May
lth.gov.au/sites/default/files/files/the_guideline 2023].
s/n56b_infant_feeding_summary_130808.pdf) 7. The Royal Australian College of General
[Accessed 6 March 2024]. Practitioners (RACGP). Handbook of non-drug
. The Royal Australian College of General interventions (HANDI). RACGP, 2014 (https://ww
Practitioners (RACGP). Smoking, nutrition, w.racgp.org.au/clinical-resources/clinical-guidelin
alcohol, physical activity (SNAP). RACGP, 2015 (ht es/handi) [Accessed 6 March 2024].
tps://www.racgp.org.au/getattachment/bb78b78
1-1c37-498a-8ba3-b24a1a4288d9/Smoking-nutrit
ion-alcohol-physical-activity-SNAP.aspx)
231
Overweight and obesity
Metabolic | Overweight and obesity

Screening age bar
0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75–79 ≥80

In 2017–18, 67% of Australians aged ≥18 years had or were living with overweight or obesity (31% had
obesity).1 One in four children and adolescents aged 2–17 years had overweight or obesity (8.2% had
obesity).1 Genes and the physical and social environment are important risk factors for having
overweight and obesity, along with an imbalance between energy intake from the diet and energy
expenditure in physical activity and metabolism.
 Screening
232
Assess height, weight and calculate body Conditionally Opportunistically. 2
mass index (BMI) with caution (see Further recommended

information) in adults without a known eating
disorder and who are not pregnant (see Eating
disorders (https://www.racgp.org.au/clinical-r
esources/clinical-guidelines/key-racgp-guideli
nes/view-all-racgp-guidelines/preventive-activi
ties-in-general-practice/mental-health/eating-d
isorders) , First antenatal visit (https://www.ra
cgp.org.au/clinical-resources/clinical-guidelin
es/key-racgp-guidelines/view-all-racgp-guideli
nes/preventive-activities-in-general-practice/re
productive-and-womens-health/Brst-antenatal-
visit) and During pregnancy (https://www.racg
p.org.au/clinical-resources/clinical-guidelines/
key-racgp-guidelines/view-all-racgp-guideline
s/preventive-activities-in-general-practice/repr
oductive-and-womens-health/during-pregnanc
y) ).
3,4
Assess height, weight and calculate BMI using Conditionally Opportunistically.
age-appropriate charts (either Centers for recommended
Disease Control and Prevention [CDC] (http
s://www.cdc.gov/growthcharts/clinical_chart
s.htm) or World Health Organisation [WHO (htt
ps://www.who.int/toolkits/child-growth-stand
ards/standards/body-mass-index-for-age-bmi-
for-age) ]) in children and adolescents 6 years
and older without a known eating disorder and
who are not pregnant. See Eating disorders (ht
tps://www.racgp.org.au/clinical-resources/clin
ical-guidelines/key-racgp-guidelines/view-all-r
acgp-guidelines/preventive-activities-in-genera
l-practice/mental-health/eating-disorders) ,
First antenatal visit (https://www.racgp.org.a
u/clinical-resources/clinical-guidelines/key-ra
cgp-guidelines/view-all-racgp-guidelines/preve
ntive-activities-in-general-practice/reproductiv
e-and-womens-health/Brst-antenatal-visit) and
During pregnancy (https://www.racgp.org.au/c
linical-resources/clinical-guidelines/key-racgp-
guidelines/view-all-racgp-guidelines/preventiv
e-activities-in-general-practice/reproductive-an
d-womens-health/during-pregnancy)
233
Formal, structured interventions aimed at Generally not N/A 2,4
preventing weight gain are not recommended recommended

for healthy weight adults, children or
adolescents.
Further information
The recommendations in this chapter refer to the prevention of overweight and obesity and should be
read in conjunction with nutrition, physical activity and preventive activities in childhood.
The Australian guidelines, Clinical practice guidelines for the management of overweight and obesity in
adults, adolescents and children in Australia (https://www.nhmrc.gov.au/about-us/publications/clinical-
practice-guidelines-management-overweight-and-obesity) , are currently being updated and are due to
be released in 2024.
BMI precautions5
• Ethnicity: People with a South Asian, Chinese, other Asian, Middle Eastern, Black African or
African Caribbean family background are prone to central adiposity and their cardiometabolic
risk occurs at a lower BMI, so use lower BMI thresholds as a practical measure of overweight
and obesity:
◦ overweight: BMI 23–27.4 kg/m2
◦ obesity: BMI ≥27.5 kg/m2.
For people in these groups, obesity classes 2 and 3 are usually identiBed by reducing the thresholds
highlighted in Recommendation 1.2.7 (https://www.nice.org.uk/guidance/cg189/chapter/Recommenda
tions#identifying-and-assessing-overweight-obesity-and-central-adiposity) of the National Institute for
Heath and Care Excellence (NICE) guidance by 2.5 kg/m2.
• People with high muscle mass: Interpret BMI with caution in adults with high muscle mass
because it may be a less accurate measure of central adiposity in this group.
• People aged ≥65 years: Interpret BMI with caution in people aged ≥65 years, taking into
account comorbidities, conditions that may affect functional capacity and the possible
protective effect of having a slightly higher BMI when older.
Waist measurement
Waist measurement in adults with a raised BMI provides a more direct measure of central obesity.
Table 1. Waist size showing increased risk of chronic disease6
Gender Increased risk Greatly increased risk

Male ≥94 cm ≥102
234
Female ≥80 cm ≥88 cm
Weight stigma and shaming

Clinicians should be aware that patients living with overweight and obesity experience stigma in daily
life and in healthcare settings. Consent should be sought sensitively and at appropriate consultations
before engaging in anthropometric measurements. The clinical emphasis should be on health and
functional gains as a result of weight reduction/improved body composition.
Extreme diets
Advise against following extreme eating patterns that do not follow healthy eating pattern guidance, as
well as programs that focus on short-term weight reduction, because these have poor long-term
outcomes.5

peoples
Overweight and obesity (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guid
elines/view-all-racgp-guidelines/national-guide/chapter-1-lifestyle/overweight-and-obesity) section in
the National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people.
SpeciAc populations
Overweight and obesity rates differ across Australia, being higher in regional and remote areas, and in
low socioeconomic groups.1
Please refer to the Physical activity (https://www.racgp.org.au/wip-sites/preventive-activities-in-general-

practice/metabolic/physical-activity) (https://www.racgp.org.au/clinical-resources/clinical-guidelines/k
ey-racgp-guidelines/view-all-racgp-guidelines/preventive-activities-in-general-practice/metabolic/physic
al-activity) and Nutrition (https://www.racgp.org.au/wip-sites/preventive-activities-in-general-practice/m
etabolic/nutrition) (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guideline
s/view-all-racgp-guidelines/preventive-activities-in-general-practice/metabolic/nutrition) chapters for
relevant recommendations. This section will be reviewed when the updated Australian Clinical practice
guidelines for the management of overweight and obesity in adults, adolescents and children in Australia
(https://www.nhmrc.gov.au/about-us/publications/clinical-practice-guidelines-management-overweigh
t-and-obesity) have been released.
Resources
To assist GPs and practice staff work with patients on the modiBable risk factors of smoking, nutrition,
alcohol and physical activity:
235
Smoking, nutrition, alcohol, physical activity (SNAP) (https://www.racgp.org.au/clinical-resources/clinica

l-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/snap) | RACGP
For non-drug weight loss interventions:

Pre-meal water consumption for weight loss (https://www.racgp.org.au/clinical-resources/clinical-guid
elines/handi/handi-interventions/nutrition/pre-meal-water-consumption-for-weight-loss) , Handbook of
non-drug interventions (HANDI) | RACGP
Ten top tips for weight control (https://www.racgp.org.au/clinical-resources/clinical-guidelines/handi/h
andi-interventions/nutrition/ten-top-tips-for-weight-control) , Handbook of non-drug interventions
(HANDI) | RACGP
A free digital tool to discuss physical activity and nutrition with patients and monitor their progress:
RACGP Healthy Habits (https://www.racgp.org.au/healthy-habits) app
References
1. Australian Institute of Health and Welfare. 4. Canadian Task Force on Preventive Health
(AIHW). Overweight and obesity. AIHW, 2023 (htt Care. Obesity in children. Canadian Task Force on
ps://www.aihw.gov.au/reports/australias-health/ Preventive Health Care, 2015 (https://canadiantas
overweight-and-obesity) [Accessed 21 March kforce.ca/guidelines/published-guidelines/obesit
2023]. y-in-children/)
2. Canadian Task Force on Preventive Health Care. 5. National Institute for Health and Care
Obesity in adults. Canadian Task Force on Excellence (NICE). Obesity: IdentiBcation,
Preventive Health Care, 2015 (https://canadiantas assessment and management. Clinical guideline
kforce.ca/guidelines/published-guidelines/obesit (https://www.nice.org.uk/guidance/cg189)
-in-adults/) [Accessed 31 January 2024]. [CG189]. NICE, 2023 [Accessed 31 January 2024].
3. US Preventive Services Task Force (USPSTF). 6. Department of Health and Aged Care. Body
Obesity in children and adolescents: screening. mass index (BMI) and waist measurement.
2017 (https://www.uspreventiveservicestaskforc Australian Government, 2021 (https://www.healt
.org/uspstf/recommendation/obesity-in-childre h.gov.au/topics/overweight-and-obesity/bmi-and-
n-and-adolescents-screening) [Accessed 31 waist) [Accessed 31 January 2024].
January 2024].
236
Physical activity
Physical activity
Metabolic | Physical activity

Screening age bar
0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75–79 ≥80

In 2020–21, 3 in 10 adults aged 18–64 years did not perform at least 150 minutes of physical activity
per week, and 1 in 2 of those aged ≥65 years (47% of men and 52% of women) were insuaciently active,
with little change over the previous decade.1 In 2011–12, 83% of children aged 2–5 years, 88% of
children aged 5–12 years were insuaciently active for their age.1 In 2017–18, just over 1 in 10 (11%) of
those aged 5–17 years were suaciently active for their age, whereas just over 1 in 6 (16%) met the
recommended muscle strengthening activity guidelines.2 Insuacient physical activity contributes 2.5%
of the total burden of disease due to death or disability.1
The message that any physical activity is better than none is important.3 If a patient does not already
engage in regular physical activity, they can be encouraged to start by doing some, and then gradually
building up to the recommended amount.3 Advice, written physical activity materials and referral should
be tailored to age, disability and level of risk.
 Screening

often
4,5
General population: aged ≥18 years Recommended Every 2
Ask questions about the frequency, duration and (strong) years.
intensity of physical activity and sedentary behaviour.
6,7
Children and adolescents: aged 3–18 years Recommended Every 2
Ask questions about the frequency (in each week), (strong) years.
duration and intensity of physical activity and muscle
strengthening activities (see Further information).
237
Physical activity

often
General population: aged ≥18 years Recommended N/A 3,8
For substantial health beneBts, it is recommended (strong)

that adults should do:
• at least 2.5–5 hours (150–300 minutes) of
moderate-intensity aerobic physical activity,
or
• at least 1.25–2.5 hours (75–150 minutes) of
vigorous-intensity aerobic physical activity, or
• an equivalent combination of moderate- and
vigorous-intensity activity throughout the
week.
For additional health beneBts, it is recommended that

adults should also:
• do muscle strengthening activities at
moderate or greater intensity that involve all
major muscle groups on two or more days a
week
• limit the amount of time being sedentary;
replacing sedentary time with physical
activity of any intensity (including light
intensity) provides health beneBts.
3
People with disability, chronic conditions and people Recommended N/A
aged ≥65 years (strong)
To enhance functional capacity and prevent falls,
adults with disability, chronic conditions and older
adults (aged ≥65 years) should:
• do varied multicomponent physical activity
that emphasises functional balance and
progressive strength training at a moderate or
greater intensity on three or more days a
week.
238
Physical activity
Children (from birth to 2 years) should: Practice point N/A 8
• be physically active, particularly supervised

eoor-based play in safe environments
• not spend time in front of screens.
Toddlers and preschoolers (2–5 years) should:

• be physically active every day for at least
three hours, spread throughout the day,
• limit screen time to one hour per day.
Children and adolescents (5–17 years), including Recommended N/A 3,8
those with disability where possible, should: (strong)

• do at least an average of 1 hour (60 minutes)
per day of moderate- to vigorous-intensity,
mostly aerobic, physical activity across the
week
• do vigorous-intensity aerobic activities, as
well as those that strengthen muscle and
bone (see Box 1) at least three days a week
• limit sedentary time, particularly the amount
of recreational screen time.
Further information
Engaging in regular physical activity and avoiding long periods of sedentary behaviour can help
maintain a healthy weight and avoid a range of chronic illnesses.
Where possible, people should incorporate a variety of intensities of physical activity, as deBned
below:3,8
• Light: Movement where people do not think about it (light gardening, getting dressed,
stretching). The World Health Organization (WHO) deBnes light-intensity physical activity as
between 1.5 and 3 metabolic equivalents of task (METs); that is, activities with an energy cost
less than three times the energy expenditure at rest for that person. These activities can
include slow walking, bathing or other incidental activities that do not result in a substantial
increase in heart rate or breathing rate.3
• Moderate: Putting in effort, but not strenuous activity (gentle bike riding, brisk walk). According
to the WHO deBnition, on an absolute scale, ‘moderate intensity’ refers to physical activity that
is performed at an intensity between three and less than six times the intensity of rest. On a
scale of 0–10 relative to an individual’s personal capacity, moderate-intensity physical activity
is usually rated a 5 or 6.3
• Vigorous: out of breath and sweating (jogging, star jumps, sit-ups). On an absolute scale, the
WHO deBnition of vigorous-intensity activity as physical activity that is performed at ≥6.0
METS. On a scale of 0–10 relative to an individual’s personal capacity, vigorous-intensity
physical activity is usually rated a 7 or 8.3
239
Physical activity
Assessment of physical activity involves questions about minutes of activity and being sedentary each
day, and on how many days per week. Brief advice about increasing physical activity can be given in the
consultation with the support of:
• written materials (including an exercise prescription)

• tools such as the RACGP Healthy Habits conversation guide and app (https://healthyhabits.rac
gp.org.au/patient-pathway/getting-started/) and an activity tracker. The RACGP’s Handbook of
non-drug interventions (HANDI) provides further information on the use of pedometers for
increasing physical activity (https://www.racgp.org.au/clinical-resources/clinical-guidelines/ha
ndi/handi-interventions/device/pedometers-for-increasing-physical-activity) .
Assessment of physical activity should be supplemented by referral, especially for patients with risk
factors or physical or social barriers to physical activity. This may include:
• telephone counselling
• local community-based programs
• individual exercise physiology.
The choice of referral should be based on individualised shared decision making with the patient.
Box 1. Muscle strengthening activities for children and young people8

• running
• climbing
• swinging on monkey bars
• push-ups
• sit-ups
• lifting weights
• yoga

peoples
For speciBc recommendations for Aboriginal and Torres Strait Islander people, please refer to Physical
activity (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-r
acgp-guidelines/national-guide/chapter-1-lifestyle/physical-activity) in the National guide to a preventive
health assessment for Aboriginal and Torres Strait Islander peoples.
SpeciAc populations
Make sure to ask people with disability about their levels of physical activity.
240
Physical activity
For recommendations about physical activity during pregnancy, please refer to the First antenatal visit
delines/preventive-activities-in-general-practice/reproductive-and-womens-health/Brst-antenatal-visit)
and During pregnancy (https://www.racgp.org.au/wip-sites/preventive-activities-in-general-practice/repr
oductive-and-womens-health/during-pregnancy) (https://www.racgp.org.au/clinical-resources/clinical-g
uidelines/key-racgp-guidelines/view-all-racgp-guidelines/preventive-activities-in-general-practice/reprod
uctive-and-womens-health/during-pregnancy) chapters.
For recommendations about physical activity for falls prevention, please refer to the Falls (https://www.r
acgp.org.au/wip-sites/preventive-activities-in-general-practice/injury-prevention/falls) (https://www.rac
gp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/preventi
ve-activities-in-general-practice/injury-prevention/falls) chapter.
Resources
To assist GPs and practice staff work with patients on the modiBable risk factors of smoking, nutrition,
alcohol and physical activity: Smoking, nutrition, alcohol, physical activity (SNAP) (https://www.racgp.or
g.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/snap) |
RACGP
A free digital tool to discuss physical activity and nutrition with patients and monitor their progress:
RACGP Healthy Habits (https://www.racgp.org.au/healthy-habits) app
For exercise interventions to use with patients: Handbook of non-drug interventions (HANDI) (https://ww
w.racgp.org.au/clinical-resources/clinical-guidelines/handi/handi-interventions)
References
1. Australian Institute of Health and Welfare. 4. Smith B, Bellew B, Milton K, Rocha G, Harris M.
(AIHW). Insuacient physical activity. AIHW, 2022 The primary and secondary healthcare domain
(https://www.aihw.gov.au/reports/australias-heal and physical activity. In: Bellew B, Nau T, Smith B,
th/insuacient-physical-activity) [Accessed 14 Bauman A, editors. Getting Australia active III. A
March 2023]. systems approach to physical activity for policy
2. Australian Institute of Health and Welfare makers. The Australian Prevention Partnership
IHW). Physical activity. AIHW, 2021 (https://ww Centre and The University of Sydney, 2020 (http
s://preventioncentre.org.au/resources/getting-au
w.aihw.gov.au/reports/children-youth/physical-
ac [Accessed 27 October 2023].
tivity) stralia-active-3-a-systems-approach-to-physical-a
ctivity/) [Accessed 2 February 2024].
3. World Health Organization (WHO). WHO
guidelines on physical activity and sedentary
behaviour. WHO, 2020 (https://www.who.int/publi
cations/i/item/9789240015128) [Accessed 2
February 2024].
241
Physical activity
5. O’Connor EA, Evans CV, Rushkin MC, et al. . Bull FC, Al-Ansari SS, Biddle S, et al. World Health
Behavioral counseling interventions to promote a Organization 2020 guidelines on physical activity
healthy diet and physical activity for and sedentary behaviour. Br J Sports Med
cardiovascular disease prevention in adults with 2020;54:1451–62. doi: 10.1136/
cardiovascular risk factors: updated systematic bjsports-2020-102955. [Accessed 2 February
review for the U.S. Preventive Services Task 2024].
Force. Agency for Healthcare Research and . Australian Government Department of Health and
Quality (U.S.), 2020 (https://www.ncbi.nlm.nih.go Aged Care. Physical activity and exercise
v/books/NBK565468/) [Accessed 2 February guidelines for all Australians. Department of
2024]. Health and Aged Care, 2021 (https://www.healt
6. Bauman A, Chau J, van der Ploeg H, Hardy L. .gov.au/topics/physical-activity-and-exercise/ph
Physical activity measures for children and ysical-activity-and-exercise-guidelines-for-all-aust
adolescents – recommendations on population ralians) [Accessed 2 February 2024].
surveillance. An Evidence Check rapid review
brokered by the Sax Institute. Sax Institute, 2010
(https://www.health.nsw.gov.au/research/Docum
ents/09-physical-activity-measures-for-children-a
nd-adolescents.pdf) [Accessed 2 February 2024].
242
Thyroid
Thyroid
Metabolic | Thyroid
The prevalence of thyroid disease is approximately 10% in patients aged >50 years,1 with an additional
3.6% with unrecognised thyroid dysfunction (abnormal thyroid-stimulating hormone [TSH]).2
Autoimmune thyroid disease is the most common cause of thyroid dysfunction in Australia3 and
10–15% of the population have thyroid antibodies (more common in women than men).
 Screening

often
4,5
Screening for thyroid dysfunction in asymptomatic Not N/A
adults is not recommended. recommended
(strong)
5
Routine screening for thyroid dysfunction in pregnant Generally not N/A
women is not recommended because of insuacient recommended
evidence.
 Case Anding

often
243
Thyroid
Practice As early 5,6
Testing for thyroid dysfunction is recommended in point as

pregnant women with the following increased risks: possible
• a history of thyroid dysfunction after six
• symptoms or signs of thyroid dysfunction weeks
• a goitre gestation.
• known thyroid antibody positivity
• type 1 diabetes
Further information
Although early detection and treatment of people with thyroid disease may help prevent morbidity and
mortality, screening and treatment of asymptomatic patients can result in harm due to overdiagnosis
and overtreatment.
There is currently insuacient evidence to determine the beneBts and harms of screening asymptomatic
people for thyroid disease.4 Thyroid imaging is only indicated if there is concern regarding structural
abnormalities.
Although iodine deBciency was previously reported in Australia, iodised salt in bread became
mandatory in Australia and New Zealand in 2009, and iodine deBciency is now very rare.7
Primary congenital hypothyroidism is screened as part of Australia’s Newborn Bloodspot Screening

program (https://www.health.gov.au/our-work/newborn-bloodspot-screening/what-is-screened-in-the-pr
ogram) .

peoples
SpeciAc populations
Case Bnding tests may be appropriate in these populations where there may be a higher prevalence of
thyroid dysfunction:4,8
• people with associated conditions (type 1 diabetes, coeliac disease)

• Down syndrome
• family history of thyroid disease
• past history of thyroid disease
• symptoms or signs of thyroid dysfunction.
244
Thyroid
Resources
For GP and patient resources about thyroid tests (and information about subclinical hypothyroidism):
First do no harm: A guide to choosing wisely in general practice (https://www.racgp.org.au/clinical-resour
ces/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/Grst-do-no-harm/gp-resources/ma
nagement-of-subclinical-hypothyroidism) | RACGP
References
1. Walsh JP. Managing thyroid disease in general 5. Department of Health. Clinical practice
practice. Med J Aust 2016;205(4):179–84. doi: guidelines: Pregnancy care. Canberra: Australian
10.5694/mja16.00545. Government Department of Health, 2020 (http
2. Empson M, Flood V, Ma G, Eastman CJ, Mitchell P. s://www.health.gov.au/resources/pregnancy-car
Prevalence of thyroid disease in an older e-guidelines) [Accessed 5 March 2024].
Australian population. Intern Med J 6. The Royal Australian and New Zealand College
2007;37(7):448–55. doi: 10.1111/ of Obstetricians and Gynaecologists (RANZCOG).
.1445-5994.2007.01367.x. Subclinical hypothyroidism and hypothyroidism in
3. Australian Bureau of Statistics (ABS). Australian pregnancy (C-Obs 46). RANZCOG, 2018 (https://r
health survey: Biomedical results for nutrients. anzcog.edu.au/wp-content/uploads/2022/05/Su
ABS, 2011 (https://www.abs.gov.au/sta tistics/ bclinical-hypothyroidism-and-hypothyroidism-in-p
health/health-conditions-and-risks/australi an- regnancy.pdf) [Accessed 29 February 2024].
health-survey-biomedical-results-nutrients/late st- 7. Australian Institute of Health and Welfare. Folic
release) [Accessed 21 March 2023]. acid & iodine fortiBcation. Australian Government,
. LeFevre ML; U.S. Preventive Services Task Force. 2016 (https://www.aihw.gov.au/reports/food-nutr
Screening for thyroid dysfunction: U.S. Preventive ition/folic-acid-iodine-fortiBcation) [Accessed 5
Services Task Force recommendation statement. March 2024].
Ann Intern Med 2015;162(9):641–50. doi: 8. The Royal College of Pathologists of
10.7326/M15-0483. [Accessed 21 March 2023]. Australasia (RCPA). Thyroid function testing for
adult diagnosis and monitoring. RCPA, 2017 (http
s://www.rcpa.edu.au/getattachment/8d6639b7-a
f88-403c-a9ab-c5fe729757c1/Thyroid-Function-T
esting-for-Adult-Diagnosis-and-M.aspx)
245
Thyroid
246
Thyroid
Hip dysplasia (https://www.racgp.org.au/clinical-resources/clinical-guidelines/k

ey-racgp-guidelines/view-all-racgp-guidelines/preventive-activities-in-general-pra
ctice/musculoskeletal/hip-dysplasia) Osteoporosis (https://www.racgp.org.au/cl
s/preventive-activities-in-general-practice/musculoskeletal/osteoporosis)
Scoliosis (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-ra
cgp-guidelines/view-all-racgp-guidelines/preventive-activities-in-general-practic
e/musculoskeletal/scoliosis)
247
Hip dysplasia
Hip dysplasia
Musculoskeletal disorders | Developmental

dysplasia of the hip
Screening age bar
0-9* 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 ≥80
*Newborn to 6 months underneath this age bar

Developmental dysplasia of the hip (DDH) includes a wide spectrum of anatomical and functional
abnormalities of the hip joint.1 This occurs when there is an incorrect relationship of the femoral head
to the acetabulum, leading to poor development (dysplasia) of one or both, as well as the surrounding
supporting structures of the hip joint leading to instability.1 Global incidence is variable but estimated at
1–2/1000 live births.1 There is an increased incidence in females, breech position, family history.1,2
DDH in infancy has no signs or symptoms, thus screening and surveillance are required for early
diagnosis. Early diagnosis aims to avoid the more invasive treatments required in late diagnosis and the
long-term sequelae of growth disturbance and avascular necrosis.1,2 The aim of screening is to identify
hip dislocation of the hip or DDH before age 6 months. Screening does not need to continue outside of
hospital if the baby is being seen by a maternal child health service. GPs will generally see children for
DDH concerns upon referral from a maternal child health check.
248
Hip dysplasia
 Screening
1,2
Routine newborn and postnatal checks should be Practice At newborn and
performed to detect DDH. point postnatal checks
The assessment should include detection of limb
length discrepancy, examination for asymmetric
thigh or buttock (gluteal) creases, performing the
Ortolani test for stability (performed gently, and
which is usually negative after age 3 months), and
observing for limited abduction (generally positive
after age 3 months).
1,2
Routine universal ultrasonography screening for Practice N/A
DDH is not recommended. Ultrasound is only point
recommended for suspicion of DDH.
 Case Anding
1,2
There should be continuing periodic physical Practice Opportunistically.
examination surveillance throughout infancy. point
Further information
Case Bnding should continue after the immediate postnatal period as dysplasia can progress over the
Brst few months of life.
Screening for DDH should include assessing for leg length discrepancy, asymmetric gluteal folds,
Ortolani test and asymmetrical hip abduction. The Ortolani test should only be performed if a clinician
is conBdent in their technique and experienced at neonatal examination. Their utility is in the Brst 3
months of life. After the Brst 3 months a dislocated hip will be Bxed, and unilateral limited hip abduction
(<60 degrees) is the most sensitive examination Bnding. Asymmetric gluteal folds on their own are a
‘soft’ sign and should be considered in light of risk factors, other examination Bndings and concerns.
Once a child is walking, DDH may present as an abnormal gait.
249
Hip dysplasia
Imaging for investigation of abnormal examination or a high-risk infant up to 6 months of age should be
ultrasound of the hip by an experienced paediatric ultrasonographer, and plain AP view pelvis X-ray in
children over 6 months of age.

peoples
There are no speciBc recommendations or advice for Aboriginal and Torres Strait Islander people.
References
1. Marriott E, Twomey S, Lee M, Williams N. 2. Shaw BA, Segal LS. Evaluation and referral for
Variability in Australian screening guidelines for developmental dysplasia of the hip in infants.
developmental dysplasia of the hip. J Paediatr Paediatrics 2016; 138(6):e20163107.
Child Health 2021;57(12):1857–65.
250
Osteoporosis
Osteoporosis
Musculoskeletal disorders | Osteoporosis

Screening age bar - women
0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75–79 ≥80

Osteoporosis is a disease characterised by low bone mass and microarchitectural deterioration of bone
tissue, leading to bone fragility and increased fracture risk.1 For information about preventing falls, see
Falls (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-rac
gp-guidelines/preventive-activities-in-general-practice/injury-prevention/falls) .
Generally, osteoporosis is underdiagnosed. Because osteoporosis has no overt symptoms, it is often

not diagnosed until a fracture occurs. It is therefore diacult to determine the true prevalence of the
condition. Information about ‘diagnosed cases’ is likely to underestimate the actual prevalence of the
condition. An estimated 924,000 Australians have osteoporosis, based on self-reported data from the
Australian Bureau of Statistics (ABS) 2017–18 National Health Survey,2 and 20% of people aged ≥75
years have osteoporosis.3 The deBnition of osteoporosis given above includes people who were told by
a doctor or nurse that they had osteoporosis or osteopenia.3
Osteoporosis is more common in women than in men, with 29% of women aged ≥75 years having
osteoporosis in 2017–18 compared with 10% of men.3 The proportion of women with osteoporosis
increases with age, with those aged ≥75 years being most affected.
The goal of the prevention and treatment of osteoporosis is to reduce a person’s overall fracture risk,
not just to maintain bone density. Approximately 70% of fragility fractures occur in women,4 and
comprehensive treatment can halve (30–70%) the risk of subsequent fragility fracture.5 The absolute
risk reduction and value of treatment is highest in those at highest risk (eg those with a previous
fragility fracture), but the majority remain untreated in general practice and hospital settings.6,7
Osteoporosis is diagnosed on the presence of a fragility fracture (a fracture from the equivalent of a fall
from standing height or less, or a fracture that under normal circumstances would not be expected in a
healthy young man or woman). For epidemiological and clinical purposes, osteoporosis is deBned by
bone mineral density (BMD) as a T-score of ≤–2.5. However, age, lifestyle factors, family history and
some medications and diseases contribute to bone loss and an increased risk of fragility fractures. A
presumptive diagnosis of osteoporosis can be made without BMD measurement if an individual has a
fragility fracture not from another cause.
251
Osteoporosis
 Screening
8,9
Screening for osteoporosis with bone mineral Not N/A
density (BMD) measurement in the general recommended
population is not recommended at any age. (Strong)
Use FRAX® (https://fraxplus.org) to calculate Conditionally Do not 9,10
absolute fracture risk in people aged ≥50 years recommended routinely

with lifestyle and non-modiBable risk factors (eg repeat BMD +
parent with hip fracture). When the FRAX® risk FRAX® within
for major osteoporotic fracture (MOF) is ≥10%, 2 years
refer for dual energy X-ray absorptiometry (DXA). except in
If the risk for MOF is <10%, DXA is not special
recommended. circumstance.
Refer for BMD assessment by DXA for people

aged ≥50 years with diseases/chronic
conditions/medications associated with
increased fracture risk.
Restratify risk with FRAX® after DXA using BMD

reading and treat when: the BMD T-score is
≤–2.5, or when the BMD T-score is between –1.5
and –2.5 and the FRAX® risk for MOF is ≥20%
and/or the hip fracture risk is ≥3%.
11,12
Encourage regular weight-bearing and resistance Recommended N/A
exercise for the prevention of falls, bone loss (Strong)
and fracture risk reduction. For additional advice
on falls prevention refer to falls (https://www.rac
ey-racgp-guidelines/view-all-racgp-guidelines/pr
eventive-activities-in-general-practice/injury-prev
ention/falls) .
252
Osteoporosis
Calcium and vitamin D supplements should not Conditionally N/A 1,10
be used routinely in non-institutionalised elderly Recommended

people. The absolute beneBt of calcium and
vitamin D supplements in terms of fracture
reduction is low. There is evidence of signiBcant
beneBt in people at risk of deBciency, particularly
institutionalised individuals. Calcium and vitamin
D supplements should be offered to people
taking osteoporosis treatments if their dietary
calcium intake is <1300 mg/day.* Vitamin D
supplements should be recommended to correct
low serum vitamin D concentrations
(25-hydroxyvitamin D concentrations <50 nmol/
L).
*There is an average of 1300 mg calcium/day in

an older adult’s diet.13 For more information on
calcium intake and bone health in older adults,
refer to the Healthy Bones Australia (https://heal
thybonesaustralia.org.au/your-bone-health/calci
um/) website.
11,12
Encourage a healthy lifestyle (eg adequate Practice Point N/A
protein intake, smoking cessation and limiting
alcohol intake).
Further information
There have been three recent large population-based randomised control trials of screening in women
for the prevention of osteoporotic fractures: Screening in the Community to Reduce Fractures in Older
Women (SCOOP) in the UK,14 Risk-stratiBed Osteoporosis Strategy Evaluation (ROSE) in Denmark15 and
SALT Osteoporosis Study (SOS) in the Netherlands.16 The optimal thresholds of absolute fracture risk
and implementation strategies are inadequately deBned for the Australian context and there are no data
on screening for men. Accordingly, there is currently insuacient evidence to support a population-based
osteoporosis screening program in Australia.
Two of the most widely validated methods to estimate absolute fracture risk for osteoporotic fractures
relevant to the Australian population are the Garvan bone fracture risk calculator (https://www.garvan.or
g.au/promotions/bone-fracture-risk/calculator/) and the Fracture Risk Assessment tool (FRAX®). (http
s://fraxplus.org) These calculators can be used with and without BMD measurement, although the
Garvan bone fracture risk calculator has not been validated in an external cohort when BMD has not
been used in the calculator.17 Risk estimation is imperfect, with the tools being modest predictors of
fracture risk.18,19 Risk factors (eg falls, glucocorticoid use) not included in one or the other risk
algorithm require clinical judgement to modify the risk estimate.
253
Osteoporosis
If BMD is indicated, then it should be measured by bone density (DXA) scanning performed on two
sites, preferably anteroposterior spine and hip. Without bone-losing medical conditions (eg
hypogonadism, antigonadal therapy or corticosteroid use), BMD is unlikely to change signiBcantly in <2
years. The average decrease in T-score is usually approximately 0.1/year if there are no speciBc bone-
losing medical conditions.
Although there appears to be little or no effect of increased protein in healthy adults, for
institutionalised older adults a recent Australian study of the effectiveness of increasing calcium and
protein intake (<1 g/kg body weight protein per day) by providing residents with additional milk, yoghurt
and cheese showed a 11% reduction in the risk of falls, a 48% reduction in hip fractures and a 30%
reduction in all fractures.10

peoples
There is insuacient evidence to recommend a different screening or treatment approach in Aboriginal
and Torres Strait Islander peoples.
References
1. The Royal Australian College of General . Stevenson M, Lloyd-Jones M, De Nigris E, Brewer
Practitioners (RACGP). Clinical practice guideline N, Davis S, Oakley J. A systematic review and
for the prevention and treatment of osteoporosis economic evaluation of alendronate, etidronate,
in postmenopausal women and older men. risedronate, raloxifene and teriparatide for the
RACGP, 2010. prevention and treatment of postmenopausal
2. Australian Bureau of Statistics (ABS). National osteoporosis. Health Technol Assess
health survey: First results, 2017–18. ABS, 2018 2005;9(22):1–160. doi: 10.3310/hta9220.
(https://www.abs.gov.au/statistics/health/ [Accessed 30 October 2023].
health-conditions-and-risks/national-health- . Naik-Panvelkar P, Norman S, Elgebaly Z, et al.
survey/201 Osteoporosis management in Australian general
-18) [Accessed 21 February 2024]. practice: An analysis of current osteoporosis
treatment patterns and gaps in practice. BMC
3. Australian Institute of Health and Welfare
(AIHW). Chronic musculoskeletal conditions: Fam Pract 2020;21(1):32. doi: 10.1186/
Osteoporosis and minimal trauma fractures. s12875-020-01103-2. [Accessed 30 October
AIHW, 2023 (https://www.aihw.gov.au/reports/ch 2023].
ronic-musculoskeletal-conditions/musculoskelet . Teede HJ, Jayasuriya IA, Gilfillan CP. Fracture
al-conditions/contents/osteoporosis)
12 July 2023]. [Accessed prevention strategies in patients presenting to
Australian hospitals with minimal-trauma
4. Watts JJ, Abimanyi-Chom J, Sanders KM.
fractures: A major treatment gap. Intern Med J
Osteoporosis costing all Australians: A new
2007;37(10):674–79. doi: 10.1111/
burden of disease analysis – 2012 to 2022.
.1445-5994.2007.01503.x. [Accessed 30 October
Osteoporosis Australia, 2013 (https://healthybon
2023].
esaustralia.org.au/wp-content/uploads/2022/09/
burden-of-disease-analysis-2012-2022.pdf) . Scottish Intercollegiate Guidelines Network
[Accessed 30 October 2023]. (SIGN). Management of osteoporosis and the
prevention of fragility fractures. SIGN, 2021 (http
s://www.sign.ac.uk/our-guidelines/management-
of-osteoporosis-and-the-prevention-of-fragility-fra
ctures/) [Accessed 30 October 2023].
254
Osteoporosis
. Canadian Task Force on Preventive Health Care. 1 . Merlijn T, Swart KM, van Schoor NM, et al. The
Fragility fractures. Canadian Task Force on effect of a screening and treatment program for
Preventive Health Care, 2023 (https://canadiantas the prevention of fractures in older women: A
kforce.ca/guidelines/published-guidelines/fragilit randomized pragmatic trial. J Bone Miner Res
-fractures/) [Accessed 31 January 2024]. 2019;34(11):1993–2000. doi: 10.1002/jbmr.3815.
1 . The Royal Australian College of General [Accessed 12 October 2023].
Practitioners (RACGP); Healthy Bones Australia. 1 . Marques A, Ferreira RJ, Santos E, Loza E,
Osteoporosis management and fracture Carmona L, da Silva JA. The accuracy of
prevention in post-menopausal women and men osteoporotic fracture risk prediction tools: A
over 50 years of age. 3rd edn. RACGP, 2023. systematic review and meta-analysis. Ann Rheum
[Accessed 31 January 2024]. Dis 2015;74(11):1958–67. doi: 10.1136/
11. Cosman F, de Beur SJ, LeBoff MS, et al. Clinician’s annrheumdis-2015-207907. [Accessed 12
guide to prevention and treatment of October 2023].
osteoporosis. Osteoporos Int 1 . Nelson HD, Haney EM, Chou R, Dana T, Fu R,
2014;25(10):2359–81. doi: 10.1007/ Bougatsos C. Screening for osteoporosis:
s00198-014-2794-2. [Accessed 31 January 2024]. Systematic review to update the 2002 U.S.
12. Ebeling PRDR, Daly RM, Kerr DA, Kimlin MG. Preventive Services Task Force
Building healthy bones throughout life: An Recommendation. Report No.: 10-05145-EF-1.
evidence-informed strategy to prevent Agency for Healthcare Research and Quality, 2010
osteoporosis in Australia. Med J Aust (https://pubmed.ncbi.nlm.nih.gov/2072217
2013;199(S7):S1–46. doi: 10.5694/mjao12.11363. 6/) [Accessed 31 January 2024].
[Accessed 31 January 2024]. 1 . Rubin KH, Friis-Holmberg T, Hermann AP,
13. Healthy Bones Australia. Calcium & bone health. Abrahamsen B, Brixen K. Risk assessment tools
Healthy Bones Australia, 2023 (https://hea to identify women with increased risk of
lthybonesaustralia.org.au/your-bone-health/calci osteoporotic fracture: Complexity or simplicity? A
um/) [Accessed 12 October 2023]. systematic review. J Bone Miner Res
2013;28(8):1701–17. doi: 10.1002/jbmr.1956.
1 . Shepstone L, Lenaghan E, Cooper C, et al. [Accessed 31 January 2024].
Screening in the community to reduce fractures in
older women (SCOOP): A randomised controlled 2 . Healthy Bones Australia. Calcium & bone health.
trial. Lancet 2018;391(10122):741–47. doi: Healthy Bones Australia, 2023 (https://hea
10.1016/S0140-6736(17)32640-5. [Accessed 12 lthybonesaustralia.org.au/your-bone-health/calci
October 2023]. um/.) [Accessed 12 October 2023].
1 . Rubin KH, Rothmann MJ, Holmberg T, et al.

Effectiveness of a two-step population-based
osteoporosis screening program using FRAX: The
randomized Risk-stratified Osteoporosis Strategy
Evaluation (ROSE) study. Osteoporos Int
2018;29(3):567–78. doi: 10.1007/
s00198-017-4326-3. [Accessed 12 October 2023].
255
Scoliosis
Scoliosis
Musculoskeletal disorders | Scoliosis

Scoliosis is a common paediatric condition with a prevalence of up to 5%.1 True scoliosis is three-
dimensional, with rotation evident at the apex of the curve, and a Cobb angle (https://www.physio-pedi
a.com/Cobb_Angle) >10°. Lateral curvature, from issues such as poor posture, muscle spasm or leg
length discrepancy, can masquerade as scoliosis.2 The cause of structural scoliosis, where rotation is
present, is idiopathic in 75% of cases, neuromuscular (eg cerebral palsy, spina biBda, muscular
dystrophy) in 10% of cases, congenital (eg failure of formation or segmentation) in another 10% of
cases and due to many other rare causes in 5% of cases.2
Idiopathic scoliosis most commonly occurs between the ages of 10 and 18 years. A typical adolescent
idiopathic scoliosis patient is female with a convex right thoracic curve or convex left lumbar curve,
right shoulder elevated, right rib prominence, no neurological deBcits and no signiBcant pain.2 Although
boys and girls are equally affected with small curves, curves >40° are sevenfold more frequent in girls.1
Concerning curves include early onset scoliosis, premenarchal scoliosis with a curve >25° and
skeletally mature patients with curves >50°.2
 Screening
How
often
Screening for adolescent idiopathic scoliosis in children Not N/A 3
and adolescents aged 10-18 years is not recommended recommended

because of insuacient evidence. (Strong)
256
Scoliosis
Further information
In 2018, the US Preventive Services Task Force (USPSTF) found no direct evidence on screening for
adolescent idiopathic scoliosis and health outcomes.3 There was also inadequate evidence on the
association between reduction in spinal curvature in adolescence and long-term health outcomes in
adulthood.3
Further information on scoliosis assessment and management can be found in the article Paediatric
scoliosis: Update on assessment and treatment (https://www1.racgp.org.au/ajgp/2020/december/paedi
atric-scoliosis) .

peoples
There are no speciBc recommendations and advice for Aboriginal and Torres Strait Islander people.
References
1. Konieczny MR, Senyurt H, Krauspe R. 3. US Preventive Services Task Force (USPSTF).
Epidemiology of adolescent idiopathic scoliosis. Adolescent idiopathic scoliosis: Screening.
J Child Orthop 2013;7(1):3–9. doi: USPSTF, 2018 (https://www.uspreventiveservices
10.1007%2Fs11832-012-0457-4. taskforce.org/uspstf/recommendation/adolesce
2. Parr A, Askin G. Paediatric scoliosis: Update on nt-idiopathic-scoliosis-screening) [Accessed 2
assessment and treatment. Aust J Gen Pract February 2024].
2020;49(12):832–37. doi: 10.31128/
ajgp-06-20-5477.
257
Scoliosis
Reproductive and women’s

health
258
Scoliosis
Reproductive and women’s health
Preconception (https://www.racgp.org.au/clinical-resources/clinical-guidelines/
key-racgp-guidelines/view-all-racgp-guidelines/preventive-activities-in-general-pr
actice/reproductive-and-womens-health/preconception) First antenatal visit (htt
s/view-all-racgp-guidelines/preventive-activities-in-general-practice/reproductiv
e-and-womens-health/Brst-antenatal-visit) During pregnancy (https://www.racg
p-guidelines/preventive-activities-in-general-practice/reproductive-and-womens-
health/during-pregnancy) Interconception (https://www.racgp.org.au/clinical-res
ources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/preven
tive-activities-in-general-practice/reproductive-and-womens-health/interconcepti
on) Perinatal mental health (https://www.racgp.org.au/clinical-resources/clinica
l-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/preventive-activities-i
n-general-practice/reproductive-and-womens-health/perinatal-depression)
Postmenopause (https://www.racgp.org.au/clinical-resources/clinical-guideline
practice/reproductive-and-womens-health/postmenopause) Breast cancer (http
s://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guideline
s/view-all-racgp-guidelines/preventive-activities-in-general-practice/cancer/brea
st-cancer) Cervical cancer (https://www.racgp.org.au/clinical-resources/clinical-
guidelines/key-racgp-guidelines/view-all-racgp-guidelines/preventive-activities-i
n-general-practice/cancer/cervical-cancer) Ovarian cancer (https://www.racgp.o
rg.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-g
uidelines/preventive-activities-in-general-practice/cancer/ovarian-cancer)
259
Preconception
Preconception
Reproductive and women's health | Preconception
Screening age bar
0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75–79 ≥80

Approximately 10% of reproductive-age (15–44 years) women get pregnant each year in Australia.1
Estimates are that 40% of these pregnancies are unintended (a pregnancy that occurs when no children
or no more children are desired, which is deBned as unwanted, or a pregnancy that occurs earlier than
desired, which is deBned as mistimed).2 The current birth rate is 56 pre 1000 women of reproductive
age. Some 20% of births are from the lowest socioeconomic areas and 4.9% are Aboriginal and/or
Torres Strait Islander people.3 In 2020, the average age of all women who gave birth was 30.9 years,
with 26% of women giving birth aged over 35 years and 12% being aged under 25 years.3 Although
almost 1 in 10 (9.2%) mothers who gave birth in 2020 smoked at some time during their pregnancy,
22% of pregnant women who smoke quit smoking during the pregnancy.3 In addition, 27% of mothers
were overweight and 22% were obese.3 It is estimated that one in two (49%) women drank alcohol
before they knew they were pregnant, with one in four (25%) drinking after they knew they were
pregnant.4 Carriers of cystic Bbrosis (CF), spinal muscular atrophy (SMA) and fragile X syndrome (FXS)
are common in the Australian population.5 Approximately 1 in 20 people are carriers of one or more of
these conditions. Most carriers do not have a family history of relatives affected by the disorder and are
unaware that they are carriers.
 Screening
260
Preconception
Reproductive carrier screening Practice point Before 6
pregnancy
Reproductive carrier screening (including screening
for CF, SMA and FXS*) is recommended to anyone
planning pregnancy. Refer to the Genetics (http
s://www.racgp.org.au/clinical-resources/clinical-gui
delines/key-racgp-guidelines/view-all-racgp-guidelin
es/preventive-activities-in-general-practice/genetic
s) chapter for further information.
* MBS items (https://www9.health.gov.au/mbs/full

Display.cfm?type=item&q=73451&qt=item&criteri
a=73451) are available for carrier screening for
cystic Bbrosis, SMA and fragile X syndrome.
 Case Anding
Prepregnancy genetic counselling Practice point Before 6

pregnancy
Prepregnancy genetic counselling is recommended
for couples at increased risk of a heritable disorder
(see Preconception Box 1) based on the family
history or ethnic background.
Prepregnancy genetic counselling helps determine

a couple’s risk of an affected child and provides
information about options for carrier screening,
preimplantation genetic diagnosis, prenatal
diagnosis and postnatal management.
Refer to the Genetics (https://www.racgp.org.au/cli

nical-resources/clinical-guidelines/key-racgp-guidel
ines/view-all-racgp-guidelines/preventive-activities-i
n-general-practice/genetics) chapter for further
information.
261
Preconception
Assessment and stabilisation of pre-existing Practice point 6
medical and mental health conditions
Assess and stabilise pre-existing medical and

mental health conditions prior to pregnancy to
optimise pregnancy outcomes. Discuss how these
pre-existing conditions may affect, or be affected
by, a pregnancy.
Review current medication for potential for Practice point 7
teratogenicity in women and their partners This

should include prescribed and over-the-counter
medication, vitamins and other supplements.
Switch to and stabilise on safe pregnancy
alternatives where required.
Any cessation should balance the beneBts and

risks and may require referral to a specialist for
further consideration.
6
Vaccination Practice point
Check vaccination history and update vaccinations

for severe acute respiratory syndrome coronavirus
2 (SARSCoV-2), measles, mumps, rubella, varicella
zoster, diphtheria, tetanus and pertussis, as per
recommendations published in the Australian
immunisation handbook. (https://immunisationhand
book.health.gov.au/)
Consider hepatitis B, rubella and varicella

immunisation for women with incomplete
immunity.
6
Optimising weight and nutrition Practice point
All women, especially those who have become

pregnant in adolescence or have closely spaced
pregnancies (ie interpregnancy interval less than six
months) require nutritional assessment
and appropriate intervention (dietary modiBcation,
exercise and other therapies) in the preconception
period with an emphasis on optimising maternal
body mass index (BMI) and micronutrient reserves.
262
Preconception
Folic acid and iodine supplementation Practice point 6
Folic acid supplementation, at least 0.4 mg daily,

should be taken, for a minimum of one (1) month
before conception and for the Brst three (3) months
of pregnancy. Where there is an increased risk of
neural tube defect (anticonvulsant medication,
prepregnancy diabetes, previous child with or family
history of neural tube defect, BMI >30 kg/m2), a
5-mg daily dose of folic acid should be used.
Dietary supplementation of 150 mcg iodine should

be started prior to a planned pregnancy, or as soon
as possible after a woman Bnds out she is
pregnant.
Alcohol consumption and substance use Practice point 6
Provide advice that to prevent harm from alcohol to

their unborn child, women who are pregnant or
planning a pregnancy should not drink alcohol.
Counselling and pharmacotherapy for alcohol and/
or substance use should be considered for either or
both parents.
8
Effects of age on fertility and risk of chromosomal Practice point
abnormality
Educate women and their partners that despite

advances in assisted reproductive technology, the
chance of conception decreases and the risks of
chromosomal abnormalities and miscarriage
increase with maternal age.
9
Fertility awareness and optimising conception Practice point
Offer women and their partners advice regarding

fertility awareness and how to optimise the chance
of conception.
10
Interpregnancy intervals Conditionally
recommended
Women should be advised to avoid interpregnancy
intervals shorter than six months and counselled
about the risks of repeat pregnancy sooner than 18
months, especially after a caesarean section. Refer
to the Interconception chapter for further
information.
263
Preconception
First antenatal visit Practice point 7
Encourage an early (ideally before 10 weeks) Brst

antenatal appointment, if and when pregnancy
occurs.
Smoking cessation Recommended 7,11
(strong)
Identifying women and their partners who smoke,
or have recently stopped smoking, at their Brst
contact with a healthcare service, ideally in the
preconception setting, is strongly recommended.
Enquire about smoking history and current smoking
patterns, including exposure to second-hand
smoke. This information should be recorded so that
it is available for the remainder of the pregnancy.
Further information
Due to high rates of unplanned pregnancy, every woman of reproductive age should be considered for
preconception care (interventions that aim to identify and modify biomedical, behavioural and social
risks to a woman's health or pregnancy outcome through prevention and management).
Due to high rates of unplanned pregnancy, every woman of reproductive age should be considered for
preconception care (interventions that aim to identify and modify biomedical, behavioural and social
risks to a woman’s health or pregnancy outcome through prevention and management). A strategy
worth considering is the ‘One Key Question’ (OKQ) approach,12 where practitioners routinely ask women
of reproductive age, ‘Would you like to become pregnant in the next year?’ The clinician documents one
of four patient responses: ‘Yes’; ‘I’m OK either way’; ‘I’m not sure’; or ‘No’. Depending on the answer, the
clinician can then follow up with preconception care or an offer to discuss contraceptive methods and
reproductive life planning. The latter involves discussion as to whether the woman wants to have
children and, if so, the number, spacing and timing of them. The provision of effective contraception to
enable the implementation of this plan and reduce the risk of an unplanned pregnancy can then occur.
The use of this kind of questioning in general practice is acceptable to people of reproductive age.8,13
264
Preconception
Preconception Box 1. Common heritable and chromosomal disorders in Australia5,14

• Cystic Bbrosis (CF)
• Down syndrome
• Fragile X syndrome
• Haemoglobinopathies and thalassaemias
• Breast and ovarian cancer
• Colon cancer
• Familial hypercholesterolaemia (FH)
• Hereditary haemochromatosis (HHC)
• Spinal muscular atrophy (SMA)
Consideration may need to be given to environmental risks and risks associated with travel.

peoples
The new topic of Preconception care will be included in the new edition of the National guide to a
preventive health assessment for Aboriginal and Torres Strait Islander people, released mid-2024.
Antenatal care (http://ttps://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelin
es/view-all-racgp-guidelines/national-guide/chapter-2-antenatal-care) | National guide to a preventive
health assessment for Aboriginal and Torres Strait Islander people Fetal alcohol spectrum disorder (htt
ps://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guideli
nes/national-guide/chapter-3-child-health/fetal-alcohol-spectrum-disorder) | National guide to a
preventive health assessment for Aboriginal and Torres Strait Islander people
SpeciAc populations
GPs should be aware of the disparities in risk and outcomes in the populations they care for, but there is
no current evidence to suggest that variation in care by race or ethnicity can improve outcomes.10
Younger women, women of colour, women of culturally and linguistically diverse and migrant
backgrounds and those of low socioeconomic status are at risk of adverse pregnancy and overall poor
health outcomes.15 These women may be least likely to receive prepregnancy care despite their
disproportionate need.16
265
Preconception
Resources
Further information on carrier screening and when to refer: Reproductive carrier screening (https://ww
w.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/ge
nomics-in-general-practice/genetic-tests-and-technologies/reproductive-carrier-screening) , Genomics
in general practice | RACGP Information on fetal alcohol spectrum disorder (FASD), including
considerations for women planning pregnancy: FASD Hub Australia (https://www.fasdhub.org.au/) Fetal
alcohol spectrum disorder (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-g
uidelines/view-all-racgp-guidelines/national-guide/chapter-3-child-health/fetal-alcohol-spectrum-disord
er) | National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people
Advice and support for GPs helping patients to quit smoking: Supporting smoking cessation: A guide for
health professionals (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guideline
s/view-all-racgp-guidelines/supporting-smoking-cessation) | RACGP National public education program
with patient information on understanding fertility: Fertility Coalition (https://www.yourfertility.org.au/ab
out-us) The Royal Australian and New Zealand College of Obstetricians and Gynaecologists
(RANZCOG) best practice position statement with advice on the counselling of women prior to
pregnancy: Pre-pregnancy counselling (https://ranzcog.edu.au/wp-content/uploads/2022/05/Pre-pregna
ncy-Counselling-C-Obs-3a-Board-approved_March-2022.pdf) | RANZCOG
References
1. Australian Institute of Health and Welfare 6. The Royal Australian and New Zealand College
(AIHW). Australia's mothers and babies. AIHW, of Obstetricians and Gynaecologists (RANZCOG).
2023 (https://www.aihw.gov.au/reports/mothers- Pre-pregnancy counselling. RANZCOG, 2021 (http
babies/australias-mothers-babies) [Accessed 20 s://ranzcog.edu.au/wp-content/uploads/2022/0
April 2023]. 5/Pre-pregnancy-Counselling-C-Obs-3a-Board-app
2. Organon. Impact of unintended pregnancy. roved_March-2022.pdf) [Accessed 20 April 2023].
Organon, 2022 (https://www.organon.com/austra 7. Department of Health. Clinical practice
lia/wp-content/uploads/sites/16/2022/09/ORG0 guidelines: pregnancy care. Australian
1_Report_FINAL_28June2022.pdf) [Accessed 20 Government, 2020 (https://www.health.gov.au/re
April 2023]. sources/pregnancy-care-guidelines) [Accessed 2
3. Australian Institute of Health and Welfare February 2024].
(AIHW). Health of mothers and babies. AIHW, . Hammarberg K, Hassard J, de Silva R, Johnson
2023 (https://www.aihw.gov.au/reports/mothers- . Acceptability of screening for pregnancy
babies/health-of-mothers-and-babies) [Accessed intention in general practice: A population survey
20 April 2023]. of people of reproductive age. BMC Fam Pract.
2020;21(1):40. doi: 10.1186/
. Australian Institute of Health and Welfare
s12875-020-01110-3. [Accessed 2 February
(AIHW). Australia's children. AIHW, 2022 (http s://
2024].
www.aihw.gov.au/reports/children-youth/aust
ralias-children) [Accessed 2 June 2023]. . 9. Hampton K, Mazza D. Fertility – awareness,
knowledge, attitudes and practices of women
. The Royal Australian and New Zealand College of
attending general practice. Aust Nurs Midwifery J
Obstetricians and Gynaecologists (RANZCOG).
2016;24(1):42. [Accessed 2 February 2024].
Prenatal screening and diagnostic testing for fetal
chromosomal and genetic conditions. RANZCOG, 1 . American College of Obstetrics and
2018 (https://ranzcog.edu.au/wp-cont ent/ Gynecologists (ACOG). Interpregnancy care.
uploads/2022/05/Prenatal-Screening-and-Dia Obstetric care consensus number 8. ACOG, 2019
gnostic-Testing-for-Fetal-Chromosomal-and-Gene (https://www.acog.org/clinical/clinical-guidance/
tic-Conditions.pdf) [Accessed 2 June 2023]. obstetric-care-consensus/articles/2019/01/inter
pregnancy-care) [Accessed 20 April 2023].
266
Preconception
11. The Royal Australian College of General 14. The Royal Australian College of General
Practitioners (RACGP). Supporting smoking Practitioners (RACGP). Genomics in general
cessation: A guide for health professionals. 2nd practice. RACGP, 2022 Resources/Guidelines/
edn. RACGP, 2019 (https://www.racgp.org.au/clini Genomics-in-general-practice.pdf (https://www.ra
cal-resources/clinical-guidelines/key-racgp-guidel cgp.org.au/FSDEDEV/media/documents/Clinica
ines/view-all-racgp-guidelines/supporting-smokin l) [Accessed 2 February 2024].
-cessation) [Accessed 2 February 2024]. 1 . American College of Obstetrics and
12. Bellanca HK, Hunter MS. ONE KEY QUESTION®: Gynecologists (ACOG). ACOG committee opinion
Preventive reproductive health is part of high no. 649: Racial and ethnic disparities in obstetrics
quality primary care. Contraception 2013;88(1):3– and gynecology. Obstet Gynecol
6. doi: 10.1016/ 2015;126(6):e130–34. doi: 10.1097/
.contraception.2013.05.003. [Accessed 2 AOG.0000000000001213. [Accessed 2 February
February 2024]. 2024].
13. Fitch J, Dorney E, Tracy M, Black KI. Acceptability 1 . D'Angelo D, Williams L, Morrow B, et al.
and usability of 'One Key Question'® in Australian Preconception and interconception health status
primary health care. Aust J Prim Health of women who recently gave birth to a live-born
2023;29(3):268–75. doi: 10.1071/py22112. infant – Pregnancy Risk Assessment Monitoring
[Accessed 2 February 2024]. System (PRAMS), United States, 26 reporting
areas, 2004. MMWR Surveill Summ
2007;56(10):1–35. [Accessed 2 February 2024].
267
First antenatal visit
Reproductive and women's health | First

antenatal visit
Screening age bar
0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75–79 ≥80

Where possible, pregnant women should have their Brst antenatal visit within the Brst 10 weeks of
pregnancy.1 Regular antenatal care that commences in the Brst trimester in pregnancy has been
associated with better maternal health, fewer interventions in late pregnancy, and positive child health
outcomes.1–3
Most Australian women (79%) have antenatal care in their Brst trimester.2 Mothers less likely to have an
antenatal visit in their Brst trimester include women with four or more children, women aged <20 years,
and women who smoke during pregnancy, use illicit substances or who live in remote and very remote
areas.2
 Screening
268
With consent, undertake the following blood tests: Recommended At the Brst 1
• full blood count to look for anaemia and (strong) antenatal

haemoglobin disorders visit.
• check blood group and antibodies
• hepatitis B virus, as effective postnatal
intervention can reduce the risk of mother-
to-child transmission
• hepatitis C
• human immunodeBciency virus (HIV), as
effective interventions are available to
reduce the risk of mother-to-child
transmission
• syphilis
• rubella immunity to identify women at risk Conditionally

of contracting rubella and enable postnatal recommended
vaccination to protect future pregnancies.
1,4,5
With consent, test for: Recommended At the Brst
• asymptomatic bacteriuria using urine (strong) antenatal
culture testing wherever possible (as it is visit
the most accurate means of detecting
asymptomatic bacteriuria early in
pregnancy) as treatment is effective and
reduces the risk of pyelonephritis,
• proteinuria Practice point
• chlamydia in pregnant women aged

<30 years, using urine samples or self-
collected vaginal samples.
All pregnant women (ie regardless of age, ethnicity,

family history) should be provided with information
about prenatal screening tests (https://www.racgp.o
rg.au/clinical-resources/clinical-guidelines/key-racg
p-guidelines/view-all-racgp-guidelines/genomics-in-
general-practice/genetic-tests-and-technologies/pre
natal-testing) for chromosomal conditions such as
Down syndrome and for autosomal and X-linked
conditions. Screening options should be discussed
in the Brst trimester whenever possible.
269
Assess/screen all women at the `rst antenatal visit Recommended At the Brst 1
for: (strong) antenatal

• depression, using the Edinburgh Postnatal visit
Depression Scale (EPDS) (https://www.cop (repeat
e.org.au/health-professionals/health-profes screening
sionals-3/calculating-score-epds/) , as for
early as practical in pregnancy and repeat depression
at least once later in pregnancy at least
• smoking status and exposure to passive once later
smoking, and give the patient and her in
partner information about the risks to the pregnancy;
unborn baby associated with maternal and consider
passive smoking. If the patient smokes, screening
emphasise the beneBts of quitting as early for
as possible in the pregnancy and discuss intimate
any concerns she or her family may have partner
about stopping smoking violence
• intimate partner violence – explain to all more than
women that asking about family violence is once)
a routine part of antenatal care. Ask about
family violence only when alone with the
patient, using speciBc questions or
validated screening tools (https://www.racg
p.org.au/clinical-resources/clinical-guidelin
es/key-racgp-guidelines/view-all-racgp-guid
elines/abuse-and-violence/resources-1/use
ful-tools)
1
• blood pressure to identify existing high Conditionally At the Brst
blood pressure recommended antenatal
• clinical risk factors for pre-eclampsia visit.
◦ a history of pre-eclampsia
◦ chronic hypertension
◦ pre-existing diabetes
◦ autoimmune disease, such as
systemic lupus erythematosus
◦ antiphospholipid syndrome
◦ nulliparity
◦ BMI >30
◦ pre-existing kidney disease.
(Note: for pregnant women who are unsure of their

conception date, offer an ultrasound scan to
determine gestational age, detect multiple
pregnancies and accurately time fetal anomaly
testing.)
270
• alcohol use – provide advice not to Practice point At the Brst 1
consume alcohol during pregnancy, or antenatal

around the time of conception, to prevent visit.
potential harm to the developing baby
• use of illicit substances and misuse of
pharmaceuticals, and offer advice and
support regarding cessation
• current medication – review for potential
for teratogenicity in women and their
partners, including prescribed and over-the-
counter medication and vitamins and other
supplements. Switch to and stabilise on
safe pregnancy alternatives where required
• risk of hyperglycaemia, including patient’s:
◦ age
◦ body mass index (BMI)
◦ previous gestational diabetes or
high birth weight baby
◦ family history of diabetes
◦ presence of polycystic ovarian
syndrome and whether she is from
an ethnic group with high
prevalence of diabetes, such as
Aboriginal and Torres Strait
Islander peoples
• problems with previous pregnancies, such
as:
◦ infant death
◦ fetal loss
◦ birth defects (particularly neural
tube defects)
◦ low birth weight
◦ preterm birth
◦ gestational diabetes and any
ongoing risks that could lead to a
recurrence in this pregnancy or
future pregnancies
• risk of nutritional de`ciencies (eg vegan
diet, lactose intolerance, and calcium, iron
or vitamin D deBciency due to lack of sun
exposure)
• with consent, weight and height –
calculate BMI and give patient advice about
the beneBts of meeting the recommended
healthy weight gain during pregnancy.
Please refer to the Australian Pregnancy
271
care guidelines, Table D3: IOM

recommendations for weight gain in
pregnancy (https://app.magicapp.org/#/gui
deline/jm83RE/rec/EKeXzy) for
calculations for recommended weight gain
according to individual pre-pregnancy BMI.
 Case Finding
Ferritin testing and haemoglobin electrophoresis Practice point At the Brst 1
In high-risk populations (refer to SpeciBc antenatal

populations), consider offering ferritin testing and visit.
haemoglobin electrophoresis.
1
Proteinuria Practice point At each
Test for proteinuria at each antenatal visit in women antenatal
with risk factors, or clinical indications of pre- visit.
eclampsia, in particular raised blood pressure.
Thyroid Practice point At Brst 1

At Brst antenatal visit, assess for risk of thyroid antenatal
disease (refer to Box 1) and undertake thyroid- visit.
stimulating hormone test if risk is present.
For up-to-date immunisation recommendations during pregnancy, including COVID, ineuenza and
pertussis, please refer to Australian immunisation handbook – Vaccination for women who are
planning pregnancy, pregnant or breastfeeding (https://immunisationhandbook.health.gov.au/conte
nts/vaccination-for-special-risk-groups/vaccination-for-women-who-are-planning-pregnancy-pregna
nt-or-breastfeeding) and Immunisation recommendations for Non-Indigenous Australians without
risk factors for vaccine-preventable diseases (https://ncirs.org.au/sites/default/Bles/2023-11/NCIR
S_Immunisation%20schedule_non-Indigenous%20people_November%202023.pdf) .
272
Supplementation: Recommended N/A 1,6
Folic acid supplementation (strong)

Recommend dietary supplementation of 400 µg per
day folic acid, ideally from 1 month before
conception and throughout the Brst 3 months of
pregnancy to reduce the risk of neural tube defects.
Where there is an increased risk of neural tube
defect (anti-convulsant medication, pre-pregnancy
diabetes mellitus, previous child or family history of
neural tube defects, BMI >30), a 5 mg daily dose
should be used.
Calcium supplementation
Advise women at high risk of developing or pre-
eclampsia that calcium supplementation (at least
1000 mg daily) is beneBcial if dietary intake is low.
Calcium supplementation Conditionally N/A

Advise pregnant women at risk of hypertension to recommended
take a calcium supplement (at least 1000 mg daily).
Iodine supplementation Practice point N/A

Consider iodine supplementation 150 μg per day
throughout pregnancy* as requirements increase
during pregnancy.
Vitamin A, C and E supplementation Not N/A

Do not take high-dose supplements of vitamin A, C recommended
or E as they are of no beneBt in pregnancy, and in (strong)
the absence of an identiBed deBciency, may cause
harm.
7,8
Exercise, nutrition and weight management: Conditionally N/A
recommended
Aerobic and strength conditioning exercise
Advise pregnant women without contraindications
that they should participate in regular aerobic and
strength conditioning exercise during pregnancy.
Exercise prescription for the pregnant woman (http
s://www.health.gov.au/sites/default/Bles/document
s/2021/05/evidence-based-physical-activity-guideli
nes-for-pregnant-women.pdf) requires appropriate
consideration of the frequency, intensity, duration
and mode of exercise; and that exercise prescription
should consider the patient’s baseline Btness level.
Pelvic aoor exercises
All pregnant women are advised to do pelvic eoor
exercises during and after pregnancy.
273
Nutrition and weight management Practice point N/A 1
Advise on the beneBts of a healthy diet and regular

physical activity in preventing adverse outcomes,
including excessive weight gain. Discuss weight
management and caution against being overweight
or underweight. Recommend regular, moderate-
intensity exercise.
Other preventive advice: Conditionally N/A 1
recommended
Oral health
Advise women to have oral health checks and
treatment, if required, as good oral health is
important to a patient’s health and treatment can be
safely provided during pregnancy.
Low-dose aspirin
Advise women at moderate–high risk of pre-
eclampsia that low-dose aspirin from early
pregnancy may be of beneBt in its prevention.
Where appropriate, commence low-dose aspirin.
*Except for women with Grave’s disease
Further information
The following has been adapted from the Australian Pregnancy care guidelines, 5.2 Antenatal visits (ht
tps://app.magicapp.org/?language=en#/guideline/jm83RE) .
The Brst antenatal visit provides an opportunity to undertake important screening tests, vaccinations
and preventive activities. It is also an opportunity to discuss the patient’s wishes and plans and any
factors that may affect the pregnancy or birth. Given the volume of important screening, preventive
activities and information that needs to be conveyed, the Brst antenatal visit should be longer than later
antenatal visits.1 Another appointment can be arranged to cover other ‘Brst visit’ activities if there is
insuacient time at the Brst consultation.1
Provide patient-centred care

The Brst antenatal visit provides an opportunity to discuss patient expectations and preferences for
ongoing antenatal care and options for birth. GPs should also provide information and advice (verbally,
written, or other) on diet, exercise and local pregnancy care services, and discuss the recommended
tests and screens.
274
Ideally, the patient should be seen alone during the Brst antenatal visit (or at least once during
pregnancy) to provide an opportunity to disclose possible domestic violence, discuss the involvement
of their partner and/or family, and other aspects of the patient’s personal history.1
Health professionals should support women to take an active role in shared decision making about
their physical activity/exercise during and after pregnancy. All health professionals who provide care
during pregnancy should be familiar with contraindications, signs and symptoms that suggest physical
activity/exercise should be modiBed or avoided.1
Undertake a comprehensive history

A comprehensive history should include:1
• current pregnancy (planned, unplanned, wishes to proceed with or terminate the pregnancy)
• medical (history, medicines, family history [high blood pressure, diabetes, genetic conditions],
cervical smears, immunisation, breast surgery),
• obstetric (previous experience of pregnancy and birth)
• infant feeding experiences
• nutrition and physical activity
• smoking, alcohol and other substance misuse
• expectations, partner/family involvement, cultural and spiritual issues, concerns, knowledge,
pregnancy, birth, breastfeeding and infant feeding options
• factors that may affect the pregnancy or birth (eg female genital mutilation/cutting)
• psychosocial factors affecting the patient’s emotional health and wellbeing
• the patient’s support networks and information needs.
Provide a clinical assessment1

• Discuss conception and date of last menstrual period, and offer ultrasound scan for
gestational age assessment (carried out between 8 and 14 weeks of pregnancy).
• Measure height and weight and calculate BMI and provide advice on appropriate weight gain.
• Measure blood pressure.
• Test for proteinuria.
• Delay auscultation of fetal heart until after 12 weeks’ gestation if using a Doppler and 28
weeks’ gestation if using Doppler or a Pinard stethoscope.
• Assess risk of pre-eclampsia and advise women at risk that low-dose aspirin from early
pregnancy may be helpful in its prevention,
• Assess risk of preterm birth and provide advice on risk and protective factors.
• Administer the Edinburgh Postnatal Depression Scale (EPDS) at this visit or as early as
practical in pregnancy.
• Ask questions about psychosocial factors that affect mental health.
Undertake maternal health testing

Maternal health testing should be undertaken as per recommendations above.
275
Undertake an assessment
Assessment should include estimated date of birth/gestational age, any physical, social or emotional
risk factors, need for referrals, investigations, treatments or preventive care.
Further advice and actions

Provide:
• advice on options for antenatal care and place of birth

• general advice (also for the partner/family), including pregnancy symptoms
• if required, access to counselling and termination.
Structured exercise interventions

Advise women that structured lifestyle interventions improve maternal and infant outcomes and are
effective in preventing excessive weight gain (treadmill, stationary cycling, walking, dance, circuit
training, swimming), and recommend muscle strengthening exercises (including pelvic eoor exercises)
for around 60 minutes, three times a week at an intensity of 60–80% of maximum heart rate or 12–14
on the Borg scale and continued to 36–39 weeks of pregnancy.1
Pelvic Qoor
Pelvic eoor muscle exercises appear to reduce the risk of urinary incontinence in late pregnancy (odds
ratio [OR] 0.38; 95% conBdence interval [CI]: 0.20, 0.72; six studies; n = 624; low quality) and at 3–6
months postpartum (OR 0.71; 95% CI: 0.54, 0.95; Bve studies; n = 673; moderate quality) but do not
appear to affect the risk of faecal incontinence (OR 0.61; 95% CI: 0.30, 1.25; two studies; n = 867;
moderate quality).1
Foods to be consumed with caution during pregnancy

• Due to the risk of listeriosis, pre-prepared or pre-packaged cut fruit or vegetables should be
cooked. Pre-prepared salad vegetables (eg from salad bars, including fruit salads and cut
melon) should be avoided.
• Raw or undercooked meat, chilled pre-cooked meats, and pâté and meat spreads should be
avoided during pregnancy due to risk of listeriosis.
• Care needs to be taken with consumption of some Bsh species (eg shark/eake, marlin or
broadbill/swordBsh, orange roughy and catBsh) due to the potentially higher mercury content.
• Foods containing raw eggs should be avoided due to the risk of salmonella.
• Unpasteurised dairy products and soft, semi-soft and surface-ripened cheese should be
avoided due to the risk of listeriosis.
• Sugar-sweetened drinks are associated with dental conditions, such as caries.
• Food Standards Australia and New Zealand suggests limiting intake during pregnancy to 200
mg/day of caffeine FSANZ 2019, noting that caffeine is present in coffee (145 mg/50 mL
276
espresso; 80 mg/250 mL instant coffee), tea (50 mg/220 mL), colas (36 mg/375 mL), energy
drinks (80 mg/250 mL) and chocolate (10 mg/50g).
If a patient has a low dietary calcium intake, advise her to increase her intake of calcium-rich foods (htt
ps://www.eatforhealth.gov.au/nutrient-reference-values/nutrients/calcium) .
Box 1. First antenatal visit: Identifying women at high risk of thyroid dysfunction
While this is an evolving area of practice, the American Thyroid Association considers
women with the following to be at high risk of thyroid disease:1,9
• history of thyroid dysfunction
• symptoms or signs of thyroid dysfunction
• presence of a goitre
• known thyroid antibody positivity.
Other risk factors for thyroid disease include:1,9

• age >30 years
• history of type 1 diabetes or other autoimmune disorders
• history of pregnancy loss, preterm birth or infertility
• history of head or neck radiation or prior thyroid surgery
• family history of autoimmune thyroid disease or thyroid dysfunction
• BMI ≥40 kg/m2
• use of amiodarone, lithium or recent administration of iodinated radiologic
contrast
• two or more prior pregnancies
• residing in area of moderate to severe iodine deBciency.

peoples
2: Antenatal care (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/
view-all-racgp-guidelines/national-guide/chapter-2-antenatal-care) . (https://www.racgp.org.au/clinical-r
esources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/national-guide/chapter-2-a
ntenatal-care)
SpeciAc populations
It is recommended that in areas with an ongoing syphilis outbreak, pregnant women should be tested
for syphilis at:1
277
• the Brst antenatal visit

• 28 weeks
• 36 weeks
• time of birth
• six weeks after birth.
Additional time may be required at the Brst antenatal visit for women who have:1
• limited experience or understanding of the health system

• limited understanding of English
• hearing impairment requiring the use of Auslan
• past experiences that affect their trust in authorities or health professionals
• psychosocial circumstances that require more intensive support
• other conditions that require additional care (below).
Groups of women who may require additional care in pregnancy include those with:1
• existing conditions (eg overweight, underweight, cardiovascular disease, mental health,

disability, female genital mutilation/cutting)
• adverse experiences in previous pregnancies
• previous major surgery (including cardiac, gastrointestinal, bariatric and gynaecological)
• history of alcohol misuse or recreational drug use
• psychosocial factors including developmental delay, vulnerability or lack of social support or
previous experience of violence or social dislocation.
High-risk population groups for haemoglobin disorders include people from any of the following ethnic
backgrounds: 1 Southern European, African, Middle Eastern, Chinese, Indian subcontinent, Central and
South-east Asian, PaciBc Islander, New Zealand Māori, South American, Caribbean, and some northern
Western Australian and Northern Territory Aboriginal and Torres Strait Islander communities.
Resources
Information on prenatal screening and when to refer: Prenatal screening (https://www.racgp.org.au/clini
cal-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/genomics-in-general-pr
actice/genetic-tests-and-technologies/prenatal-testing) , (https://www.racgp.org.au/clinical-resources/
clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/genomics-in-general-practice/geneti
c-tests-and-technologies/prenatal-testing) Genomics in general practice (https://www.racgp.org.au/clini
cal-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/genomics-in-general-pr
actice/genetic-tests-and-technologies/prenatal-testing) | RACGP
Information on gestational diabetes, including diagnosis, management and follow-up: Gestational

diabetes mellitus (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guideline
s/view-all-racgp-guidelines/diabetes/gestational-diabetes) , Management of type 2 diabetes: A
handbook for general practice (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racg
p-guidelines/view-all-racgp-guidelines/diabetes/gestational-diabetes) | RACGP
278
Identifying, responding and supporting patients experiencing abuse and violence: Abuse and violence:
Working with our patients in general practice (https://www.racgp.org.au/clinical-resources/clinical-guideli
nes/key-racgp-guidelines/view-all-racgp-guidelines/abuse-and-violence/preamble) | RACGP
Information on investigations, treatments and outcomes for nausea, vomiting and hyperemesis
gravidarium: Guideline for the management of nausea and vomiting in pregnancy and hyperemesis
gravidarium (http://www.somanz.org/content/uploads/2020/07/NVP-GUIDELINE-1.2.20-1.pdf) | The
Society for Obstetric Medicine of Australia and New Zealand (SOMANZ)
The Safer Baby Bundle consists of Bve elements designed to reduce stillbirth rates after 28 weeks’
gestation: Safer Baby Bundle (http://stillbirthcre.org.au/safer-baby-bundle/) | Stillbirth Centre of
Research Excellence
Patient brochures with advice for eating well and staying active in pregnancy: Your Healthy Pregnancy
(https://www.health.gov.au/your-healthy-pregnancy) | Department of Health and Aged Care
References
1. Australian Living Evidence Collaboration. 7. Brown WJ, Hayman M, Haakstad LAH,.
Pregnancy care guidelines. ALEC, 2020 (https://w Evidence-based physical activity guidelines for
ww.health.gov.au/resources/pregnancy-care-guid pregnant women: Report for the Australian
elines) [Accessed 14 March 2024]. Government Department of Health, March 2020.
2. Australian Institute of Health and Welfare. Australian Government, Department of Health,
National Core Maternity Indicators. Cat. no. PER 2020 (https://www.health.gov.au/sites/default/Bl
. AIHW, 2022 (https://www.aihw.gov.au/report es/documents/2021/05/evidence-based-physica
s/mothers-babies/national-core-maternity-indicat l-activity-guidelines-for-pregnant-women.pdf)
ors) [Accessed 17 May 2023]. [Accessed 14 March 2024].
3. Australian Institute of Health and Welfare. 8. The Royal Australian and New Zealand College
Australia's mothers and babies. Cat. no. PER 101. of Obstetricians and Gynaecologists. Exercise
AIHW, 2022 (https://www.aihw.gov.au/reports/m during pregnancy. RANZCOG, 2020 (https://ranzc
others-babies/australias-mothers-babies) og.edu.au/wp-content/uploads/2022/05/Exercis
ccessed 17 May 2023]. e-during-pregnancy.pdf) [Accessed 14 March
2024].
. The Royal Australian College of General
Practitioners. Abuse and violence: Working with 9. Alexander EK, Pearce EN, Brent GA, et al. 2017
our patients in general practice (White Book). 5th Guidelines of the American Thyroid Association
edn. RACGP, 2021. [accessed 17 May 2023]. for the diagnosis and management of thyroid
disease during pregnancy and the postpartum.
. 5. The Royal Australian College of General
Thyroid 2017;27(3):315–389. doi: 10.1089/
Practitioners. Genomics in general practice.
thy.2016.0457. Erratum in: Thyroid
RACGP, 2022. [accessed 17 May 2023].
2017;27(9):1212. [Accessed 14 March 2024].
Obstetricians and Gynaecologists. Vitamin and
mineral supplementation and pregnancy.
RANZCOG, 2019 (https://ranzcog.edu.au/wp-cont
ent/uploads/2022/05/Vitamin-and-Mineral-Suppl
ementation-and-Pregnancy.pdf) [Accessed 14
March 2024].
279
During pregnancy
During pregnancy
Reproductive and women's health | During

pregnancy
Screening age bar
0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75–79 ≥80

In 2020 in Australia, 295,976 babies were born to 291,712 mothers.1 There has been an increase in
Australia of the average age of Brst-time mothers (28.3 years in 2010 to 29.6 years in 2020).1 It is
important that antenatal visits during pregnancy are eexible, patient-centred and planned collaboratively
according to the speciBc needs and wishes of the patient.2 Each antenatal visit provides an opportunity
to ask the patient about any issues or concerns they have, including any psychosocial support and
mental health issues.2 GPs should also offer information and education in preparation of labour and
breastfeeding.
 Screening
For recommendations on cell-free DNA (cfDNA)-based screening (also called Non-invasive prenatal
testing (NIPT) and carrier screening, see Genetics (https://www.racgp.org.au/clinical-resources/clini
cal-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/preventive-activities-in-general-practic
e/genetics) .
For recommendations on screening for depression – see Depression (https://www.racgp.org.au/clin
ical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/preventive-activitie
s-in-general-practice/mental-health/depression) (https://www.racgp.org.au/clinical-resources/clinic
al-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/preventive-activities-in-general-practic
e/mental-health/depression) and Perinatal mental health (https://www.racgp.org.au/clinical-resourc
es/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/preventive-activities-in-general-
practice/reproductive-and-womens-health/perinatal-depression) .

often
280
During pregnancy
Undertake the following blood tests: Practice point Between 2,3
• fasting plasma glucose or plasma glucose 1 24–28

hour and 2 hours after 75 g glucose loading weeks’
(glucose tolerance test) for testing for gestation
gestational diabetes (Note: glycated
haemoglobin (HbA1c) is not recommended
as a test for gestational diabetes due to a
lack of sensitivity.)
• Haemoglobin concentration (full blood At 28 2
count) weeks’
gestation
• Consider an antibody screen at 28 weeks in 4
those that are rhesus (Rh D) negative.
2
Repeat testing for syphilis is recommended for Recommended At 28–32
women at high risk of infection or reinfection.* (strong) weeks’
gestation
and at
the time
of birth
2
Alcohol and substance use Practice point Every
Asking about substance use at subsequent visits is antenatal
important as some women are more likely to report visit.
sensitive information only after a trusting relationship
has been established.
5
Intimate partner violence Recommended Consider
Routine screening for intimate partner violence is (strong) more
strongly recommended. Explain to all women that than
asking about family violence is a routine part of once.
antenatal care. Ask about family violence only when
alone with the patient, using speciBc questions or
validated screening tools (https://www.racgp.org.au/c
linical-resources/clinical-guidelines/key-racgp-guideli
nes/view-all-racgp-guidelines/abuse-and-violence/res
ources-1/useful-tools) used in your state/territory.
2,6
Fetal development and anatomy Conditionally At 18–20
Ultrasound screening to assess fetal development, recommended weeks’
anatomy and cervical length at 18–20 weeks’ gestation
gestation is recommended.
281
During pregnancy
Weight Practice point Every 1,2
At every antenatal visit, offer women the opportunity antenatal

to be weighed so that low or high gestational weight visit.
gain is identiBed, and risk of associated adverse
outcomes monitored. Obesity is a major risk factor
for poor maternal and fetal outcomes.
1,2
Blood pressure Practice point At every
Routinely measure blood pressure to identify new antenatal
onset hypertension. visit.
2
Fundal height Practice point At every
At each antenatal visit from 24 weeks, measure antenatal
fundal height in centimetres. visit
from 24
weeks.
*Due to changing disease patterns, please consult local guidelines.
 Case Anding

often
2
Proteinuria Practice point Every
In women with risk factors for or clinical indications antenatal
of pre-eclampsia – in particular, raised blood pressure visit.
– test for proteinuria at each antenatal visit.
For up-to-date immunisation recommendations in pregnancy, including COVID, ineuenza and

pertussis, please refer to the Australian immunisation handbook – Vaccination for women who are
planning pregnancy, pregnant or breastfeeding (http://immunisationhandbook.health.gov.au/conten
ts/vaccination-for-special-risk-groups/vaccination-for-women-who-are-planning-pregnancy-pregnan
t-or-breastfeeding) and Immunisation recommendations for non-Indigenous Australians without risk
factors for vaccine-preventable diseases (https://ncirs.org.au/sites/default/Bles/2023-11/NCIRS_Im
munisation%20schedule_non-Indigenous%20people_November%202023.pdf) .

often
282
During pregnancy
Supplementation Not N/A 2
• Vitamin A, C and E supplementation: Do not recommended

take high-dose supplements of vitamins A, C (strong)
or E as they are of no beneBt in pregnancy,
and in the absence of an identiBed
deBciency, may cause harm.
• Omega-3: Supplementation with omega-3 Conditionally N/A 2
long-chain polyunsaturated fatty acids (800 recommended

mg docosahexaenoic acid [DHA] and 100 mg
eicosapentaenoic acid [EPA] per day) may
reduce their risk of preterm birth, if they are
low in omega-3 (omega-3 fatty acids
are found predominantly in oily Bsh such as
mackerel, herrings, sardines, salmon and
tuna).*
2
• Iodine: Suggest that pregnant women take Practice point N/A
an iodine supplement of 150 µg each day.
Women with pre-existing thyroid conditions
should seek advice from their medical
practitioner before taking an iodine
supplement.
2
• Calcium: Advise women at high risk of Recommended N/A
developing pre-eclampsia that calcium (strong)
supplementation is beneBcial if dietary intake
is low. Refer to Box 1. Refer to Box 1.
2
Nutrition and exercise Practice point N/A
• Nutrition: Advise women that healthy dietary
patterns are characterised by high intake of
fruits, vegetables, legumes, wholegrains, Bsh,
seafood, unprocessed meats, dairy foods
and water. Diets with high intake of
sweetened foods and drinks, foods high in
saturated fats (eg fried foods), processed
meats and reBned grains are associated with
poorer outcomes.
283
During pregnancy
• Physical activity: Regular aerobic and Conditionally N/A 7,8
strength conditioning exercise is recommended

recommended for pregnant women without
contraindications.
• Pelvic aoor exercises: All pregnant women Practice point N/A

are advised to do pelvic eoor exercises
during and after pregnancy.
Other preventive activities and advice Practice point N/A 2
• Medications: Advise women that use of

prescription and over-the-counter medicines
should be limited to circumstances where
the beneBt outweighs the risk as few
medicines have been established as safe to
use in pregnancy. Cessation should be in
consultation.
2
• Low-dose aspirin: Low-dose aspirin (50–150 Conditionally N/A
mg) is recommended for women of recommended
moderate to high risk of developing pre-
eclampsia. Refer to the Australian Pregnancy
care guidelines – Identifying women with risk
factors for pre-eclampsia (https://app.magic
app.org/#/guideline/jm83RE/rec/jXxzzN) .
• Oral health: Advise women to have oral
health checks and treatment, if required, as
good oral health is important to a woman’s
health and treatment can be safely provided
during pregnancy.
• Seat belts: Inform pregnant women about
the correct use of seat belts; that is, three-
point seat belts ‘above and below the bump,
not over it’.
• Sexual activity: Advise pregnant women
without complications that safe sexual
activity in pregnancy is not known to be
associated with any adverse outcomes.
9,10
• Side sleeping: Advise side sleeping from 28 Practice point N/A
weeks’ pregnancy for prevention of stillbirth.
284
During pregnancy
Further information
In addition to screening and preventive activities, each antenatal visit provides an opportunity to review
care plan, identify women who require additional support and care, and for the patient to ask questions
and discuss any issues.2
Physical activity Reassure the patient that physical activity/exercise during pregnancy and the
postpartum period is safe, has health beneBts for the woman and her unborn child, and reduces the
risks of some pregnancy-related complications.7,8
Healthy environments Repeated exposure to hazardous toxins in the household and workplace
environment can affect fertility and increase the risk of miscarriage and birth defects.
• Discuss the avoidance of TORCH infections: Toxoplasmosis, Other (eg syphilis, varicella,
mumps, parvovirus and human immunodeBciency virus [HIV], listeriosis), Rubella,
Cytomegalovirus and Herpes simplex.
• Toxoplasmosis: Avoid cat litter, garden soil, raw/undercooked meat and unpasteurised milk
products; wash all fruit and vegetables.
• Cytomegalovirus, parvovirus B19 (`fth disease): Discuss the importance of frequent hand
washing. Those who work with children or in the healthcare sector can further reduce risk by
using gloves when changing nappies.
Nutrition Pregnancy and lactation pose nutrition risks due to increased nutrient demands. Maternal
nutritional status signiBcantly ineuences the nutritional wellbeing of both the fetus and the infant.11
Refer to Further information in ‘First antenatal visit (https://www.racgp.org.au/wip-sites/preventive-activ

ities-in-general-practice/reproductive-and-womens-health/Brst-antenatal-visit) ’ for information on foods
to be consumed with caution during pregnancy.
Moderate/high risk of pre-eclampsia
Moderate risk of pre-eclampsia includes any of the following:12
• nulliparity
• age ≥40 years
• pregnancy interval >10 years
• body mass index (BMI) ≥35 kg/m2 at Brst visit
• family history of pre-eclampsia
• multi-fetal pregnancy.
High risk of pre-eclampsia includes any of the following:12
• hypertensive disease during a previous pregnancy

• chronic kidney disease
• autoimmune disease such as systemic lupus erythematosus or antiphospholipid syndrome
• type 1 or type 2 diabetes
• chronic hypertension.
285
During pregnancy

peoples
2: Antenatal care (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/
view-all-racgp-guidelines/national-guide/chapter-2-antenatal-care) .
SpeciAc populations
Pregnant women who live in an area affected by an ongoing syphilis outbreak should be tested at each
of the following:2
• the Brst antenatal visit

• 28 weeks
• 36 weeks
• time of birth
• six weeks after the birth.
The Australian Pregnancy care guidelines have a list of targeted tests (https://app.magicapp.org/#/guid
eline/jm83RE/rec/Lrvd1l) to consider for women identiBed at increased risk.
Populations that may require extra or differing support services for pregnancy include:
• Aboriginal and Torres Strait Islander people2,13,14

• migrant and refugee women2
• women with severe mental illness2
• women aged <20 years2,14
• women in rural and remote areas2
• women with disability15
• women in a low socioeconomic environment and/or experiencing homelessness16–18
• single women16
• LGBTIQA+ people19
Resources
Identifying, responding and supporting patients experiencing abuse and violence: Abuse and violence –
Working with our patients in general practice (https://www.racgp.org.au/clinical-resources/clinical-guidel
ines/key-racgp-guidelines/view-all-racgp-guidelines/abuse-and-violence/preamble) (White Book) |
RACGP
286
During pregnancy
Information on gestational diabetes, including diagnosis, management and follow-up: Gestational

diabetes mellitus (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guideline
s/view-all-racgp-guidelines/diabetes/gestational-diabetes) , Management of type 2 diabetes: A
handbook for general practice (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racg
p-guidelines/view-all-racgp-guidelines/diabetes/gestational-diabetes) | RACGP
Further information on Omega-3 long chain polyunsaturated fatty acid (LCPUFA) supplementation in
pregnancy: Omega-3 fatty acid addition in pregnancy to reduce the risk of preterm birth, Handbook of
non-drug interventions (HANDI) (https://www.racgp.org.au/clinical-resources/clinical-guidelines/handi/h
andi-interventions/nutrition/omega-3-fatty-acid-addition-in-pregnancy-to-reduce) | RACGP
Information on investigations, treatments and outcomes for nausea, vomiting, and hyperemesis
gravidarium: Guideline for the management of nausea and vomiting in pregnancy and hyperemesis
gravidarium (https://www.somanz.org/content/uploads/2020/07/NVP-GUIDELINE-1.2.20-1.pdf) | The
Society for Obstetric Medicine of Australia and New Zealand (SOMANZ)
The Safer Baby Bundle, consisting of Bve elements designed to reduce stillbirth rates after 28 weeks’
gestation: Safer Baby Bundle (https://stillbirthcre.org.au/safer-baby-bundle/) | Stillbirth Centre of
Research Excellence
Current advice for healthcare professionals and hospitals undertaking obstetric care with anaesthesia
and analgesia services, to assist with safe and appropriate care for women during pregnancy and
labour: Joint RANZCOG/ANZCA/RACGP position statement on obstetric anaesthesia and analgesia
services (https://ranzcog.edu.au/wp-content/uploads/2022/05/Joint-RANZCOG-ANZCA-Position-State
ment-on-the-provision-of-Obstetric-Anaesthesia-and-Analgesia-Services.pdf) | Royal Australian and New
Zealand College of Obstetricians and Gynaecologists and Australian and New Zealand College of
Anaesthetists
For up-to-date information on immunisation recommendations: Vaccination for women who are
planning pregnancy, pregnant or breastfeeding, (https://immunisationhandbook.health.gov.au/content
s/vaccination-for-special-risk-groups/vaccination-for-women-who-are-planning-pregnancy-pregnant-or-
breastfeeding) The Australian immunisation handbook (https://immunisationhandbook.health.gov.au/co
ntents/vaccination-for-special-risk-groups/vaccination-for-women-who-are-planning-pregnancy-pregnant-
or-breastfeeding) | Australian Government Department of Health and Aged Care
Information about breastfeeding: Infant feeding guidelines: Information for health workers (https://ww
w.nhmrc.gov.au/about-us/publications/infant-feeding-guidelines-information-health-workers) | National
Health and Medical Research Council
Information for GPs and patients about alcohol in pregnancy: Every moment matters (https://everymom
entmatters.org.au/) | Foundation for Alcohol, Research and Education (FARE)
287
During pregnancy
References
1. Australian Institute of Health and Welfare. 10. The Royal Australian and New Zealand
Australia's mothers and babies. Cat. no. PER 101. College of Obstetricians and Gynaecologists.
AIHW, 2022 (https://www.aihw.gov.au/reports/m Common questions in pregnancy. RANZCOG,
others-babies/australias-mothers-babies) 2020. Available at: (https://ranzcog.edu.au/wp-co
[Accessed 29 May 2023]. ntent/uploads/2022/05/Common-Questions-in-Pr
2. Department of Health. Clinical practice egnancy.pdf) [Accessed 13 March 2024].
guidelines: Pregnancy care. Australian 11. National Health and Medical Research Council.
Government DoH, 2020. [Accessed 29 May 2023]. Australian dietary guidelines. NHMRC, 2013.
3. 3. The Royal Australian College of General [Accessed 13 March 2024].
Practitioners. Management of type 2 diabetes: A 12. National Institute for Health and Care Excellence.
handbook for general practice. RACGP, 2020. Hypertension in pregnancy: Diagnosis and
[Accessed 29 May 2023]. management. NICE, 2023. [Accessed 13 March
. National Blood Authority. Prophylactic use of Rh 2024].
D immunoglobulin in pregnancy care. NBA, 2021 13. National Aboriginal Community Controlled Health
(https://blood.gov.au/anti-d-0) [Accessed Organisation and The Royal Australian College of
13 May 2023]. General Practitioners. National guide to a
preventive health assessment for Aboriginal and
. The Royal Australian College of General
Torres Strait Islander people. 3rd edn. RACGP,
Practitioners. Abuse and violence: Working with
2018. [Accessed 13 March 2024].
our patients in general practice (White Book). 5th
edn. RACGP, 2021. [Accessed 13 May 2023]. 1 . Australian Institute of Health and Welfare.
Australia’s mothers and babies. AIHW, 2023 (http
Obstetricians and Gynaecologists. Measurement s://www.aihw.gov.au/reports/mothers-babies/au
of cervical length for the prediction of preterm stralias-mothers-babies) [Accessed 21 July
birth. RANZCOG, 2021 (https://ranzco 2023].
.edu.au/wp-content/uploads/2022/05/Measure 1 . Gleason J, Grewal J, Chen Z, Cernich AN, Grantz
ment-of-cervical-length-for-prediction-of-preterm- KL. Risk of adverse maternal outcomes in
birth-C-Obs-27_Board-approved-March-2022.pdf) pregnant women with disabilities. JAMA Netw
[Accessed 13 March 2024]. Open 2021;4(12):e2138414. doi: 10.1001/
jamanetworkopen.2021.38414. [Accessed 21
. Brown WJ, Hayman M, Haakstad LAH, et al.
Evidence-based physical activity guidelines for July 2023].
pregnant women: Report for the Australian 1 . Bedaso A, Adams J, Peng W, Sibbritt D.
Government Department of Health. Australian Prevalence and determinants of low social
Government DoH, 2020 (https://www.health.gov.a support during pregnancy among Australian
u/sites/default/files/documents/2021/05/eviden women: A community-based cross-sectional
ce-based-physical-activity-guidelines-for-pregnan study. Reprod Health 2021;18(1):158. doi:
-women.pdf) [Accessed 14 March 2024]. 10.1186/s12978-021-01210-y. [Accessed 21 July
2023].
Obstetricians and Gynaecologists. Exercise 1 . St Martin B, Spiegel A, Sie L, et al. Homelessness
during pregnancy. RANZCOG, 2020 (https://ranzc in pregnancy: perinatal outcomes. J Perinatol
og.edu.au/wp-content/uploads/2022/05/Exercis 2021;41(12):2742–48. doi: 10.1038/
-during-pregnancy.pdf) [Accessed 13 March s41372-021-01187-3. [Accessed 21 July 2023].
2024]. 1 . Haylett F, Murray S, Watson J, Theobald J. The
9. Stillbirth Centre of Research Excellence. The extent, nature and impact of homelessness on
Safer Baby Bundle. South Brisbane: CRE, 2023 (ht pregnant women and their babies. Parity 2022;
tps://stillbirthcre.org.au/about-us/our-work/the-s 35(5):10–11 (https://chp.org.au/parity/the-exten
afer-baby-bundle/) t-nature-and-impact-of-homelessness-on-pregnan
t-women-and-their-babies) [Accessed 13 March
2024].
288
During pregnancy
1 . Permezel J, Arnold ASC, Thomas J, et al.

Experiences in the delivery of preconception and
pregnancy care for LGBTIQA+ people: A
systematic review and thematic synthesis of
patient and healthcare provider perspectives.
Midwifery 2023;123:103712. Doi: (http://10.1016/
.midw.2023.103712.)
289
Interconception
Interconception
Reproduction and women's health |

Interconception
Case Anding age bar
0-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 ≥80
Prevalence and context

Interconception, or interpregnancy care, can be deBned as the care provided to women and their
partners between pregnancies in order to improve outcomes for both women and infants.1,2 The
interconception period presents an opportunity to address medical issues (both physical and mental,
including intimate partner violence) that have arisen in the preceding pregnancy/pregnancies or
postpartum period (https://www.racgp.org.au/wip-sites/preventive-activities-in-general-practice/reprod
uctive-and-womens-health/perinatal-depression) , provide education regarding optimal pregnancy
spacing, provide contraception and consider and address lifestyle risk factors.2 Implementation of this
in reality can be challenging due to the competing priorities brought about by new parenthood.
Given the potential risk of adverse outcomes in both the mother and child, interpregnancy interval is a
modiBable risk factor.2 Interconception care is particularly important given the increasing rates of
chronic disease in people of childbearing age.2 GPs can prepare for interconception care during
pregnancy by developing a postpartum plan that includes the patient’s wishes for future pregnancies.1
The following recommendations should be considered alongside those provided in Preconception care
delines/preventive-activities-in-general-practice/reproductive-and-womens-health/preconception) .
 Case Anding
290
Interconception
Future fertility intentions Practice point Antenatally and 1, 3
Ask women about their future fertility after childbirth.

intentions and provide contraception and/or Opportunistically
preconception care planning accordingly. at other times.
Eligibility for contraception Conditionally After childbirth. 3
Review patient factors and existing medical recommended

conditions (including those that developed
during pregnancy), in relation to medical
eligibility for contraception is recommended.
For guidance on the possible methods of
contraception, see Further information.
Conditions during pregnancy Practice point After childbirth. 1
Review whether the woman:

• developed any conditions during a
previous pregnancy (e.g. gestational
diabetes, postpartum depression,
hypertension) or
• had any event occur during her labour
or delivery (e.g. postpartum
haemorrhage, traumatic birth)
• experienced any other pregnancy or
fetal outcome (e.g. small for
gestational age or preterm labour)
that could impact on a future pregnancy or her

future health or wellbeing and manage that
condition to prevent future adverse outcomes.
3
Contraception Practice point N/A
Additional contraceptive precaution is not
required if contraception is initiated
immediately or within 21 days after childbirth.
291
Interconception
Timing of commencement of contraception Conditionally N/A 3
• Initiating effective contraception as recommended

soon as possible after childbirth for
both breastfeeding and non-
breastfeeding women is
recommended. Sexual activity and
ovulation may resume very soon after
delivery.
• Women should be advised that
although contraception is not required
in the Brst 21 days after childbirth,
most methods can be safely initiated
immediately, with the exception of
combined hormonal contraception
(CHC).
Timing of Long Acting Reversible

Contraception (LARC) insertion after delivery
• Advising patients that intrauterine
contraception (IUC) and progestogen-
only implant (IMP) can be inserted
immediately after delivery is
recommended.
4,5,6
Interpregnancy intervals Conditionally N/A
Advise women to avoid interpregnancy recommended
intervals shorter than 6 months. See Further
information for risks of short interpregnancy
intervals.
Further information
Research has shown that many women are unaware of the risks of short interpregnancy intervals, and
this should be discussed with the woman as part of reproductive planning and/or postpartum care.2
Potential adverse outcomes due to a shorter (six months) interpregnancy

interval
Women with shorter interpregnancy intervals are more likely to experience:2,7–9
292
Interconception
• placental abruption
• placenta praevia
• uterine rupture (for women who previously had a caesarean section)
• gestational diabetes.
Potential adverse outcomes for neonates include:2,10–12
• increased risk of stillbirth

• small size for gestational age
• preterm delivery
• neonatal death.
The UK medical eligibility criteria for contraceptive use (https://www.fsrh.org/documents/ukmec-2016/)

provides guidance on the possible methods of contraception that can be used by patients with speciBc
health conditions or characteristics.
GPs should be aware that contraceptive implant soon after childbirth or the insertion of IUC at the time
of either vaginal or caesarean delivery is convenient and highly acceptable to women. This has been
associated with high continuation rates and a reduced risk of unintended pregnancy.3 An intrauterine
device (IUD) can be safely inserted at time of delivery, or within 10 minutes of delivery of the placenta,
or within the Brst 48 hours after uncomplicated caesarean section or vaginal birth. After 48 hours,
insertion should be delayed until 28 days after childbirth.3

peoples
There are no speciBc interconception recommendations for Aboriginal and Torres Strait Islander
peoples.
References
1. Louis JM, Bryant A, Ramos D, et al. 4. The Royal Australian and New Zealand College
Interpregnancy care. Am J Obstet Gynecol of Obstetricians and Gynaecologists (RANZCOG).
2019;220(1):B2–18. doi: (http://10.1016/j.ajog.20 Birth after previous caesarean section (C-Obs
18.11.1098.) 38). RANZCOG, 2019 (https://ranzcog.edu.au/wp-
2. Dorney E, Mazza D, Black KI. Interconception content/uploads/2022/05/Birth-after-previous-ca
care. Aust J Gen Pract 2020;49(6):317–22. doi: esarean-section.pdf) [Accessed 5 March 2024].
10.31128/AJGP-02-20-5242. 5. Royal College of Obstetricians and
3. Faculty of Sexual and Reproductive Healthcare Gynaecologists (RCOG). The investigation and
(FSRH). FSRH guideline: Contraception after management of the small-for-gestational-age
pregnancy. FSRH, 2020 (https://ranzcog.edu.au/ fetus: Green-top guideline no. 31. RCOG, 2014 (htt
wp-content/uploads/2022/05/Contraception-Afte ps://www.rcog.org.uk/media/t3lmjhnl/gtg_31.pd
-Pregnancy.pdf) [Accessed 5 March 2024]. f) [Accessed 5 March 2024].
293
Interconception
. Royal College of Obstetricians and 1 . Basso O, Olsen J, Knudsen LB, Christensen K.

Gynaecologists (RCOG). Birth after previous Low birth weight and preterm birth after short
caesarean birth: Green-top guideline no. 45. interpregnancy intervals. Am J Obstet Gynecol
RCOG, 2015 (https://www.rcog.org.uk/media/kpkj 1998;178(2):259–63. doi: 10.1016/
wd5h/gtg_45.pdf) [Accessed 5 March 2024]. S0002-9378(98)80010-0. [Accessed 5 March
2024].
. Getahun D, Oyelese Y, Salihu HM, Ananth CV.
Previous cesarean delivery and risks of placenta 11. Fuentes-Afflick E, Hessol NA. Interpregnancy
previa and placental abruption. Obstet Gynecol interval and the risk of premature infants. Obstet
2006;107(4):771–78. doi: 10.1097/ Gynecol 2000;95(3):383–90. doi: 10.1016/
1.AOG.0000206182.63788.80. [Accessed 5 S0029-7844(99)00583-9. [Accessed 5 March
March 2024]. 2024].
. Bujold E, Gauthier RJ. Risk of uterine rupture 12. Zhu BP, Le T. Effect of interpregnancy interval on
associated with an interdelivery interval between infant low birth weight: A retrospective cohort
18 and 24 months. Obstet Gynecol study using the Michigan Maternally Linked Birth
2010;115(5):1003–06. doi: 10.1097/ Database. Matern Child Health J
AOG.0b013e3181d992fb. [Accessed 5 March 2003;7(3):169–78. doi: 10.1023/
2024]. A:1025184304391. [Accessed 5 March 2024].
. Hanley GE, Hutcheon JA, Kinniburgh BA, Lee L.
Interpregnancy interval and adverse pregnancy
outcomes: An analysis of successive
pregnancies. Obstet Gynecol
2017;129(3):408–15. doi: 10.1097/
AOG.0000000000001891. [Accessed 5 March
2024].
294
Reproductive and women’s health |

Screening age bar
0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75–79 ≥80

The perinatal period (the time from conception to 12 months after birth) is a time of signiBcant change
for parents. Subsequently, it can be a high-risk time for the onset and relapse of mental health
conditions.1 It is estimated that perinatal depression and anxiety affects 1 in 5 mothers and 1 in 10
fathers/partners.1,2
 Screening
1
Assess psychosocial risk factors as early as Recommended As early
practical in pregnancy and again after the birth using (strong) as
the Antenatal Risk Questionnaire (ANRQ) (https://w practical
ww.cope.org.au/health-professionals/clinical-tools-h in
ealth-professionals/) . pregnancy,
again
after birth.
295
Screening women for a possible depressive or Recommended Complete 1
anxiety disorder using the Edinburgh Postnatal (strong) for the Brst
Depression Scale (EPDS) (https://www.cope.org.au/ depression postnatal
health-professionals/clinical-tools-health-profession screening
als/) is recommended. 6–12
Practice point
weeks
for anxiety
after birth
and repeat
screening
at least
once in
the Brst
postnatal
year.
Routinely screen for intimate partner violence. Recommended Consider 3,4
Explain to all women that asking about family (strong) more than
violence is routine part of postnatal care. Ask about once.
family violence only when alone with the woman,
using validated screening tools (https://www.racg
p.org.au/clinical-resources/clinical-guidelines/key-ra
cgp-guidelines/view-all-racgp-guidelines/abuse-and-
violence/resources-1/useful-tools) .
Further information
Perinatal depression
Common symptoms of perinatal depression:5
• Loss of interest or pleasure in everyday life

• Physical symptoms (eg lethargy, numbness)
• Cognitive symptoms (eg negative thinking)
• Behavioural symptoms (eg withdrawal)
• Emotional symptoms (eg tearfulness)
Depression in the perinatal period is identiBed by the presence of a number of symptoms experienced
over a period of time, typically two weeks or more. Moderate to severe perinatal depression can also
affect a parent’s ability to care for their baby and/or other children in their care.5 Any discussion of
suicide should be taken seriously, with treatment from a mental health professional or other appropriate
person immediately sought.6
296
Perinatal anxiety
Although pregnancy and the arrival of a new baby can be very exciting, most women experience some
worries about things like having a healthy pregnancy, delivering the baby, keeping their baby safe and
potential impacts on their relationship, career or Bnances. For some people, those worries can become
overwhelming and unmanageable.6
Common symptoms of perinatal anxiety:7
• Anxiety or fear that interrupts thoughts and interferes with daily tasks
• Panic attacks: outbursts of extreme fear and panic that are overwhelming and feel diacult to
bring under control
• Anxiety and worries that keep coming into the woman’s mind and are diacult to stop or control
• Constantly feeling irritable, restless or ‘on edge’
• Having tense muscles, a ‘tight’ chest and heart palpitations
• Finding it diacult to relax and/or taking a long time to fall asleep at night
• Anxiety or fear that stops the woman going out with her baby
• Anxiety or fear that leads the woman to check on her baby constantly
Information on key considerations before screening and psychosocial assessment (https://www.healt

h.gov.au/resources/pregnancy-care-guidelines/part-e-social-and-emotional-screening) is available at
the Pregnancy care guidelines.
Be aware that anxiety disorders are very common in the perinatal period and should be considered in
the broader clinical assessment.
Non-birthing partners
Information on assessing perinatal mental health in non-birthing partners (https://www.cope.org.au/he
alth-professionals/health-professionals-3/review-of-new-perinatal-mental-health-guidelines/) is
available in Part B – Screening and psychosocial assessment of the Centre of Perinatal Excellence’s
(COPE) Mental health care in the perinatal period Australian clinical practice guideline.

peoples
When screening Aboriginal and/or Torres Strait Islander women, consider language and the cultural
appropriateness of the tool.1,4 It is important to note that EPDS scores among Aboriginal and Torres
Strait Islander women may be ineuenced by factors such as understanding of the language used,
mistrust of mainstream services or fear of consequences of depression being identiBed (ie involvement
of child protection services).1 If use of the EPDS is considered inappropriate, involvement of an
Aboriginal Health Worker may facilitate assessment of symptoms of depressive or anxiety disorders.1
297
The Kimberley Mum’s Mood Scale (KMMS) (https://kahpf.org.au/kmms) has been developed for use in
Aboriginal and Torres Strait Islander populations; however, it has only been validated for use in the
Kimberley region and may not be applicable for Aboriginal and Torres Strait Islander women in other
areas.1
Where possible, seek guidance/support from an Aboriginal and/or Torres Strait Islander worker or
professional worker or professional when screening Aboriginal and/or Torres Strait Islander woman for
depression and anxiety.1
For further information, refer to the Prevention of depression (https://www.racgp.org.au/clinical-resourc

es/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/national-guide/chapter-17-mental-
health/prevention-of-depression) section in the National guide to a preventive health assessment for
Aboriginal and Torres Strait Islander people.
SpeciAc populations
Perinatal depression and anxiety are more commonly reported among the following population
subgroups:1,2
• people with a prior history of mental illness

• migrant women (including refugees, asylum seekers)
• women living in rural and remote areas
• women experiencing pregnancy in adolescence
• women experiencing intimate partner violence
• LGBTIQA+ parents
• women who experienced birth trauma.
For screening in women from a culturally and linguistically diverse (CALD) background, use
appropriately translated versions of the EPDS with culturally relevant cut-off scores. Consider language
and the cultural appropriateness of the tool.1
Resources
Further information on the identiBcation and management of abuse and violence: Abuse and violence –
working with our patients in general practice (https://www.racgp.org.au/clinical-resources/clinical-guideli
nes/key-racgp-guidelines/view-all-racgp-guidelines/abuse-and-violence/preamble) | RACGP Guideline
for the early identiBcation of mental health conditions in the perinatal period for women and/or their
partners Mental health care in the perinatal period: Australian clinical practice guideline (https://www.cop
e.org.au/health-professionals/health-professionals-3/review-of-new-perinatal-mental-health-guidelines/) |
COPE Guidelines on all aspects of pregnancy care, including social and emotional screening:
Pregnancy care guidelines (https://www.health.gov.au/resources/pregnancy-care-guidelines) |
Department of Health and Aged Care A broad collection of resources for GPs to help patients with
mental health illness: Resources for GPs (https://gpmhsc.org.au/ResourceSection/Index/aa96bb9f-b39
c-4c90-821f-5a9be3a42d20) | GPMHSC
298
References
1. Highet NJ; Expert Working Group and Expert 4. Department of Health and Aged Care. Clinical
Subcommittees. Mental health care in the practice guidelines: Pregnancy care. Australian
perinatal period: Australian clinical practice Government, 2020 (https://www.health.gov.au/re
guideline. COPE, 2023 (https://www.cope.org.au/ sources/pregnancy-care-guidelines) [Accessed
wp-content/uploads/2023/06/COPE_2023_Perina 22 February 2024].
tal_Mental_Health_Practice_Guideline.pdf)
Perinatal depression: A guide for health
2. PwC Consulting Australia. The cost of perinatal professionals. COPE, 2023 (https://www.cope.or
depression and anxiety in Australia. Gidget g.au/wp-content/uploads/2017/11/COPE_Perinat
Foundation Australia, 2019 (https://www.pc.gov.a al-Depression_Health-Prof-Fact-Sheet-2023.pdf)
u/__data/assets/pdf_file/0017/250811/sub75 [Accessed 22 February 2024].
2-mental-health-attachment.pdf) [Accessed 22
6. Black Dog Institute. Anxiety and depression
February 2024]. during pregnancy and the postnatal period (http
3. The Royal Australian College of General s://www.blackdoginstitute.org.au/wp-content/upl
Practitioners (RACGP). Abuse and violence – oads/2022/06/Depression-during-pregnancy.pd
working with our patients in general practice (The f) [Accessed 22 February 2024].
White Book). 5th edn. RACGP, 2021 (https://ww
w.racgp.org.au/clinical-resources/clinical-guidelin Perinatal anxiety: A guide for health
es/key-racgp-guidelines/view-all-racgp-guideline
professionals. COPE, 2023 (https://www.cope.or
s/abuse-and-violence/preamble) [Accessed 22 g.au/wp-content/uploads/2023/07/COPE_Perinat
February 2024].
al-Anxiety_Health-Prof-Fact-Sheet-2023.pdf)
299
Postmenopause
Postmenopause
Reproductive and women's health|

Postmenopause
Postmenopause begins 12 months after a woman’s Bnal menstrual period, with the average age of
natural menopause occurring at 51 years.1 Postmenopausal women can experience changes in
physiology and mental health.1–3 This time in a woman’s life provides an opportunity for the GP to
undertake preventive health checks and to communicate the risks of developing osteoporosis,
cardiovascular disease, and dementia associated with ageing.1,4 Refer to other relevant chapters in the
Red Book:
• Breast cancer (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guide

lines/view-all-racgp-guidelines/preventive-activities-in-general-practice/cancer/breast-cancer)
• Cardiovascular disease (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-ra
cgp-guidelines/view-all-racgp-guidelines/preventive-activities-in-general-practice/cardiovascula
r/cardiovascular-disease-cvd-risk)
• Cervical cancer (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-gui
delines/view-all-racgp-guidelines/preventive-activities-in-general-practice/cancer/cervical-canc
er)
• Dementia (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guideline
s/view-all-racgp-guidelines/preventive-activities-in-general-practice/mental-health/dementia)
• Depression (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelin
es/view-all-racgp-guidelines/preventive-activities-in-general-practice/mental-health/depressio
n)
• Frailty (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/vi
ew-all-racgp-guidelines/preventive-activities-in-general-practice/miscellaneous/frailty)
• Osteoporosis (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidel
ines/view-all-racgp-guidelines/preventive-activities-in-general-practice/musculoskeletal/osteop
orosis)
• Urinary incontinence (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racg
p-guidelines/view-all-racgp-guidelines/preventive-activities-in-general-practice/miscellaneous/
urinary-incontinence)
300
Postmenopause
Preventive activities and advice
How
often
The onset of menopause is an opportunity for a routine Practice point N/A 1
health assessment, education and primary prevention in

regard to general health and wellbeing, including
cardiovascular, bone and mental health.
1,4,5
Using menopausal hormone therapy (MHT), combined Generally not N/A
estrogen and progestin or estrogen alone for the recommended
primary prevention of cardiovascular disease (CVD) or
other chronic conditions* is generally not
recommended. Refer to further information.
*Coronary heart disease, breast cancer, fractures,
diabetes, colorectal cancer, thromboembolic events,
stroke, dementia, gallbladder disease, urinary
incontinence all-cause mortality.
Further information
CVD disease risk

It is unclear if the CVD risk that is associated with the age of menopause is independent of other
factors such as blood pressure or lipid proNles.6 However, the menopause appointment provides an
opportunity to explain the elevated risk of CVD associated with early menopause, the need for
increased monitoring and the importance of leading a healthy lifestyle.6
Hormone therapy as a preventive activity

While MHT has no net beneNt for the primary prevention of chronic conditions, it has been found to
increase bone density and reduce fracture risk.1 However, prevention of osteoporosis or fracture is not
a primary indication for MHT use, and it should be prescribed after the individual risk–beneNts have
been considered.5 Quality of life issues should be discussed and assessed together with the risks of
developing osteoporosis, cardiovascular disease, thromboembolism, and dementia associated with
ageing often coinciding with the menopause.1,7
301
Postmenopause
Early and premature menopause

Menopause before age 45 years is regarded as ‘early’ and before age 40 years as ‘premature’.1
Blood tests for diagnosis of menopause are typically not required; however, if early or premature
menopause is suspected, blood tests to exclude other causes of oligomenorrhoea or amenorrhoea are
appropriate.2
In addition to an increased risk of CVD6, women with premature menopause may also be at higher risk
of developing anxiety and or depressive disorders during menopause.1
For osteoporosis screening, case Nnding and prevention recommendations, please refer to the
Osteoporosis chapter or the RACGP and Osteoporosis Australia’s Osteoporosis prevention, diagnosis
and management in postmenopausal women and men over 50 years of age (https://www.racgp.org.au/cli
nical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/osteoporosis) .

peoples
There are no additional recommendations for this population group.
Resources
Guideline for the prevention, assessment, diagnosis, treatment and management of osteoporosis in
Australia:
Osteoporosis prevention, diagnosis and management in postmenopausal women and men over 50 years
of age (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racg
p-guidelines/osteoporosis) | RACGP (https://www.racgp.org.au/clinical-resources/clinical-guidelines/ke
y-racgp-guidelines/view-all-racgp-guidelines/osteoporosis) and Osteoporosis Australia
The following includes a aowchart to assess if the patient is pre-/peri-/postmenopausal:

A practitioner’s toolkit for the management of the menopause (https://www.menopause.org.au/images/st
ories/documents/management-menopause-toolkit.pdf) | Monash University (https://www.menopause.or
g.au/images/stories/documents/management-menopause-toolkit.pdf) School of Public Health and
Preventive Medicine
302
Postmenopause
References
1. The Royal Australian and New Zealand College of 5. Hemachandra C, Taylor S, Islam RM, Fooladi E,
Obstetricians and Gynaecologists. Managing Davis SR. A systematic review and critical
menopausal symptoms. RANZCOG, 2020. appraisal of menopause guidelines. BMJ Sex
Available at: (https://ranzcog.edu.au/wp-content/ Reprod Health 2024:bmjsrh-2023-202099. doi:
uploads/2022/05/Managing-menopausal-sympto 10.1136/bmjsrh-2023-202099. Epub ahead of
ms.pdf) [Accessed 13 April 2024]. print. PMID: 38336466. [Accessed 13 April 2024].
2. Magraith K, Stuckey B. Making choices at 6. Department of Health and Aged Care. Australian
menopause. Aust J Gen Pract guideline for assessing and managing
2019;48(7):457–62. doi: 10.31128/ cardiovascular disease risk. Department of
AJGP-02-19-4851. [Accessed 13 April 2024]. Health and Aged Care, 2023 (https://www.cvdche
3. Dalal PK, Agarwal M. Postmenopausal syndrome. ck.org.au) [Accessed 7 April 2024].
Indian J Psychiatry 2015;57(Suppl 2):S222–32. 7. The Royal Australian College of General
doi: 10.4103/0019-5545.161483. Practitioners and Osteoporosis Australia.
[Accessed 13 April 2024]. Osteoporosis prevention, diagnosis and
4. Gartlehner G, Patel SV, Reddy S, Rains C, management in postmenopausal women and
Schwimmer M, Kahwati L. Hormone therapy for men over 50 years of age. 2nd edn. RACGP, 2017.
the primary prevention of chronic conditions in [Accessed 7 April 2024].
postmenopausal persons: Updated evidence
report and systematic review for the US
Preventive Services Task Force. JAMA
2022;328(17):1747–65. doi: 10.1001/
jama.2022.18324. [Accessed 13 April 2024].
303
Breast cancer
Breast cancer
Cancer | Breast cancer

Screening and case Ending age bar
0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44* 45–49* 50–54 55–59 60–64 65-69 70–74 75–79 ≥80
*Case Nnding

Breast cancer is the most common cancer in women and the second most common cause of cancer
deaths in women in Australia. In 2022, it was estimated that 20,640 new cases of breast cancer would
be diagnosed in Australia (20,428 in women, 212 in men). The risk of being diagnosed with breast
cancer by the age of 85 years is currently estimated as 1 in 8 (or 13%) for women and 1 in 668 (or
0.15%) for men.1
An assessment should be undertaken to understand a patient’s individual degree of risk (see Table 1) in
order to provide evidence-based guidance for preventive activities. Breast cancer risk is not normally
distributed: most women have a low (<4%) lifetime risk.2
Table 1. Risk of breast cancer3
Moderately increased Potentially high riskA or carrying

Average or slightly
Risk level (<4% of the female mutation (<1% of the female
higher
population) population)
Risk in Approximately 1.5 Approximately 1.5–3 More than threefold times the
relation to times the times the population population average
the population average average Individual risk may be higher or
population lower if genetic test results are
average known
Lifetime Between 9% and Between 12% and 25% Between 25% and 50%
prevalence 12.5%
of breast
cancer up
to age 75
years
304
Breast cancer
Relevant • No • One Nrst-degree • Two Nrst- or second-

history conNrmed relative degree relatives on one
family diagnosed with side of the family
history of breast cancer at diagnosed with breast
breast age <50 years or ovarian cancer, plus
cancer (without the one or more of the
• One Nrst- additional following features on
degree features of the the same side of the
relative potentially high- family:
diagnosed risk group) ◦ additional
with breast • Two Nrst-degree relative(s) with
cancer at relatives, on the breast or
age ≥50 same side of the ovarian cancer
years family, ◦ breast cancer
• One diagnosed with diagnosed
second- breast cancer before age 40
degree (without the years
relative additional ◦ bilateral breast
diagnosed features of the cancer
with breast potentially high- ◦ breast and
cancer at risk group) ovarian cancer
any age • Two second- in the same
• Two degree relatives, woman
second- on the same ◦ Ashkenazi
degree side of the Jewish
relatives on family, ancestry
the same diagnosed with ◦ breast cancer
side of the breast cancer, at in a male
family least one at age relative
diagnosed <50 years • One Nrst- or second-
with breast (without the degree relative
cancer at additional diagnosed with breast
age ≥50 features of the cancer at age <45 years
years potentially high plus another Nrst- or
• Two Nrst- risk group) second-degree relative
or second- on the same side of the
degree family with sarcoma
relatives (bone/soft tissue) at
diagnosed age <45 years
with breast • Member of a family in
cancer at which the presence of a
age ≥50 high-risk breast cancer
years, but gene mutation (eg
on different BRCA1, BRCA2) has
sides (ie on been established
each side)
305
Breast cancer
of the
family
There are multiple risk factors for breast cancer (genetic, hormonal, lifestyle and environmental).3
However, BreastScreen, Australia’s national breast cancer screening program, focuses on age, inviting
all Australian women aged between 50 and 74 years for biennial mammographic screening. Women are
able to self-refer for biennial mammographic screening in BreastScreen from the age of 40 years.
Clinicians have an important role in identifying people with a strong family history of breast cancer, as
well as other cancers, associated with high-risk genetic variants (eg in BRCA1 and BRCA2) and offering
referral to a familial cancer service. The Genetics (https://www.racgp.org.au/clinical-resources/clinical-
guidelines/key-racgp-guidelines/view-all-racgp-guidelines/preventive-activities-in-general-practice/gene
tics/genetic-screening) chapter provides further information on family history and the use of the family
history questionnaire.
 Screening

often
2
Women at average risk or slightly higher than average Conditionally Every 2
risk of breast cancer should participate in recommended years
mammographic screening from ages 50 to 74 years
as part of the national BreastScreen program.
4
Screening by mammography is not recommended in Generally not N/A
women aged ≥75 years due to insuscient evidence to recommended
assess the balance of beneNts and harms.
5
Clinical breast examination for breast cancer Generally not N/A
screening of average risk women in general practice is recommended
not recommended.
6
Do not use magnetic resonance imaging (MRI) as a Not N/A
stand-alone screening test for women at average risk recommended
of breast cancer. (strong)
306
Breast cancer
Do not use thermography in breast cancer screening Not N/A 789
or as an adjunctive tool to mammography. recommended

(strong)
 Case Ending

often
Undertake mammographic screening from ages 40 to Conditionally At least 5
74 years for women at moderately increased risk. recommended every 2

years

often
3
Counsel all women that the following are associated Practice point N/A
with lower breast cancer risk:
• physical activity
• maintaining a normal body mass index (for
postmenopausal breast cancer)
• minimising alcohol consumption
• having children
• breastfeeding
5
It is recommended that all women, whether or not they Practice point N/A
undergo mammographic screening, are aware of how
their breasts normally look and feel, and promptly
report any new or unusual changes (such as a lump,
nipple changes, nipple discharge, change in skin
colour, skin texture, pain in a breast) to their GP. No
one method for women to use when checking their
breasts is recommended over another.
307
Breast cancer
Further information
Screening
For asymptomatic, average-risk women, BreastScreen Australia recommends screening mammograms
every two years for women aged 50–74 years and actively recalls women in this age bracket.2 However
women at average risk may choose to commence mammography through BreastScreen from the age
of 40 years.
For women at moderate risk, annual mammograms from age 40 years may be recommended. Annual
mammograms are not recommended for women with a single relative diagnosed at age >50 years,
because there is no clear evidence of beneNt.10
Ongoing surveillance strategies for women at high risk of breast cancer may include imaging with MRI.
A Medicare rebate (https://www9.health.gov.au/mbs/fullDisplay.cfm?type=item&q=63464&qt=item) is

available for MRI scans for asymptomatic patients aged <60 years at high risk of breast cancer.11
Reviews of evidence from randomised controlled trials of mammography estimate rates of

overdiagnosis of breast cancer of between 11% and 19%.12 More recent modelling data from the US
estimate that biennial screening from ages 40 to 74 years would result in 14 overdiagnosed cases of
breast cancer per 1000 women screened over the lifetime of screening (estimated range 4–37
overdiagnosed cases).13 Screening mammography in women aged 40–49 years reduces the risk of
dying of breast cancer, but the number of deaths averted is much smaller than in older women, and the
number of false-positive tests and unnecessary biopsies is larger.13
There is controversy on how to screen women with dense breasts. The current evidence is insuscient
to assess the balance of beneNts and harms of supplemental screening for breast cancer using breast
ultrasound or MRI in women identiNed to have dense breasts on an otherwise negative screening
mammogram.4
Thermography is associated with high false-positive and false-negative rates and is not recommended
as a screening modality. Polygenic risk scores to determine breast cancer risk may have a role in the
future, but are not currently recommended in general practice.
A single nucleotide polymorphism (SNP)-based breast cancer risk assessment test should only be
undertaken after an in‐depth discussion led by a clinical professional familiar with the implications of
genetic risk assessment and testing, including the potential insurance implications. Genetic testing
should be offered only with pre- and post-test counselling to discuss the limitations, potential beneNts
and possible consequences.14
Estimated risks for factors for which there is susciently strong evidence of an association with risk of
breast cancer (ie factors for which the body of evidence was classiNed as either ‘Convincing’ or
‘Probable’, are summarised in table 5.2 of the 2018 Cancer Australia publication Risk factors for breast
cancer: A review of the evidence.15
308
Breast cancer

peoples
For speciNc recommendations for Aboriginal and Torres Strait Islander people, please refer to the
Prevention and early detection of breast cancer (https://www.racgp.org.au/clinical-resources/clinical-gu
idelines/key-racgp-guidelines/view-all-racgp-guidelines/national-guide/chapter-15-prevention-and-early-
detection-of-cance/prevention-and-early-detection-of-breast-cancer) chapter in the National guide to a
SpeciEc populations
For women at potentially high risk or carrying a mutation, offer referral to a familial cancer clinic for
risk assessment, possible genetic testing and a risk reduction management plan.
Individualised surveillance and risk reduction plan, including consideration of associated risks for other
cancers (eg ovarian), may include:
• regular clinical breast examination and annual breast imaging with mammography, MRI or
ultrasound
• chemoprevention with selective oestrogen receptor modulators (SERMs; eg tamoxifen or
raloxifene) or aromatase inhibitors (eg exemestane and anastrozole)16
• mastectomy and/or salpingo-oophorectomy.
Resources
iPrevent (https://www.petermac.org/iprevent) is a validated tool to help in the assessment of breast
cancer risk.
References
1. Cancer Australia. Breast cancer –in Australia 4. U.S. Preventive Services Task Force (USPSTF).
statistics. Australian Government, 2024 (http://w Breast cancer: Screening. USPSTF, 2023 (http://w
ww.canceraustralia.gov.au/cancer-types/breast-c ww.uspreventiveservicestaskforce.org/uspstf/dra
ancer/statistics#:~:text=In%202022%2C%20it%2 ft-recommendation/breast-cancer-screening-adul
0is%20estimated,or%2013%25%20for%20female ts#fullrecommendationstart) [Accessed 19 May
[Accessed 21 February 2024]. 2023].
2. Department of Health and Aged Care. 5. Cancer Australia. Early detection of breast
BreastScreen Australia program. Australian cancer. (http://www.canceraustralia.gov.au/resou
Government, 2024 (http://www.health.gov.au/ rces/position-statements/early-detection-breast-
our-work/breastscreen-australia-program) cancer) [Position statement] Australian
[Accessed
21 February 2024]. Government, 2015 [Accessed 16 May 2023].
3. Cancer Australia. Breast cancer: The risk factors.
Australian Government, 2024 (http://ww
.breastcancerriskfactors.gov.au/) [Accessed
21
February 2024].
309
Breast cancer
6. Cancer Council. Magnetic resonance imaging 12. Henderson JT, Webber, EM, Weyrich M, Miller M,
screening in high-risk women. In: Screening: Melnikow J. Screening for breast cancer: A
Breast cancer prevention policy. Cancer Council, comparative effectiveness review for the U.S.
2014 (http://www.cancer.org.au/about-us/policy- Preventive Services Task Force. Evidence
and-advocacy/prevention-policy/national-cancer- synthesis no. 231. Agency for Healthcare
prevention-policy/breast-cancer/screening#magn Research and Quality, 2023. [Accessed 16 May
etic) [Accessed 16 May 2023]. 2023].
. Cancer Council. Thermography. In: Screening 13. Trentham-Dietz A, Chapman CH, Jinani J, et al.
breast cancer prevention policy. Cancer Council, Breast cancer screening with mammography: An
2014 (http://www.cancer.org.au/about-us/policy- updated decision analysis for the U.S. Preventive
and-advocacy/prevention-policy/national-cancer- Services Task Force. Agency for Healthcare
prevention-policy/breast-cancer/screening#therm Research and Quality, 2023.
ography) [Accessed 16 May 2023]. [Accessed 16 May 2023].
. Cancer Australia. Statement on use of 14. The Royal Australian College of General
thermography to detect breast cancer. Australian Practitioners (RACGP). Genomics in general
Government, 2010 (http://www.canceraustralia.g practice. RACGP, 2022 (https://www.racgp.org.a
ov.au/resources/position-statements/statement- u/getattachment/a7b97d5a-5b5f-4d4b-ab3b-efa9
use-thermography-detect-breast-cancer) c08b1d6d/Genomics-in-general-practice.aspx)
[Accessed 16 May 2023]. [Accessed 22 February 2024].
. Royal Australian and New Zealand College of 15. Cancer Australia. Risk factors for breast
Radiologists (RANZCR). Policy on use of cancer: A review of the evidence 2018. Australian
thermography to detect breast cancer. RANZCR, Government, 2018 (http://www.canceraustralia.g
2018 (http://www.ranzcr.com/college/document-l ov.au/publications-and-resources/cancer-australi
ibrary/policy-on-the-use-of-thermography-to-detec a-publications/risk-factors-breast-cancer-review-e
breast-cancer?searchword=thermography) vidence-2018) [Accessed 16 May 2023].
16. Cancer Australia. Risk-reducing medication
1 . Cancer Australia. Advice about familial aspects of for women at increased risk of breast cancer due
breast cancer and epithelial ovarian cancer. to family history. Australian Government, 2018 (ht
Australian Government, 2015 (http://ww tp://www.canceraustralia.gov.au/publications-an
.canceraustralia.gov.au/publications-and-resour d-resources/cancer-australia-publications/risk-re
ces/cancer-australia-publications/advice-about-f ducing-medication-women-increased-risk-breast-
amilial-aspects-breast-cancer-and-epithelial-ovari cancer-due-family-history) [Accessed 16 May
an-cancer) [Accessed 12 December 2023]. 2023].
11. Cancer Australia. MRI for high risk women.
Australian Government, n.d (http://www.cancerau
stralia.gov.au/clinical-best-practice/breast-cance
r/screening-and-early-detection/mri-high-risk-wo
men) [Accessed 16 May 2023].
310
Cervical cancer
Cervical cancer
Cancer | Cervical cancer

Screening age bar
0-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 ≥80

In 2021, cervical cancer was estimated to be the 13th most commonly diagnosed cancer recorded
among females, with 913 new cases of cervical cancer diagnosed in Australia.1 Aboriginal and Torres
Strait Islander women have a higher incidence of cervical cancer.
Under-screened women remain the most likely to develop cervical cancer. The main burden of cervical
cancer is in developing countries without screening programs or human papillomavirus (HPV)
vaccination.
The introduction of HPV vaccination in Australia has been instrumental in reducing HPV infection and
has placed Australia on track to reach the elimination of cervical cancer targets of 90:70:90
(vaccination: 90% of girls fully vaccinated with the HPV vaccine by age 15 years; screening: 70% of
women screened using a high-performance test by age 35 years, and again by age 45 years; treatment:
90% of women identiNed with cervical disease receive treatment) by 2030.2 GPs play an important role
in achieving these targets by providing vaccination and encouraging participation in the cervical cancer
screening program to ensure early detection. Population level targets are beyond the scope of the Red
Book, which focuses on recommendations that can be implemented in practice.
 Screening

often
3
Cervical screening is not recommended in women Screening not N/A
under the age of 25 years. recommended
(strong)
311
Cervical cancer
Evidence does not support screening for women aged Practice point N/A 3
less than 25, even when they have experienced early

sexual activity. However, for those who experience
their Nrst sexual activity at a young age (<14 years)
and who had not received the HPV vaccine before
sexual debut, a single HPV test between 20 and 24
years of age could be considered on an individual
basis but is not required.
Women and people with a cervix who have ever had Recommended Every 3
sexual contact aged between 25-74 years of age and (strong) Nve
are eligible for screening should have a HPV years.
screening test for cervical cancer. This can be on a
self-collected vaginal sample or on a clinician-
collected sample.
Women with a negative oncogenic HPV screen Practice point N/A 3
between the ages of 70–74 no longer require ongoing

routine screening.
3
Women who are 75 years or older who have never had Practice point N/A
a cervical screening test or have not had one in the
previous Nve years, may request a test and can be
screened. The sample can be clinician-collected or
self-collected, according to the woman’s choice.
Recommendations Grade How References

often
4
Administer one dose of the 9vHPV vaccine in Recommended From
immunocompetent adolescents and young adults (strong) age 9 to
from nine years of age and ensure catch up 26 years
vaccination up to 26 years. For more information,
refer to the Australian immunisation handbook (http
s://immunisationhandbook.health.gov.au/contents/vac
cine-preventable-diseases/human-papillomavirus-hpv)
.
312
Cervical cancer
Administering the HPV vaccine in adults aged ≥26 Generally not N/A 4
years is generally not recommended. recommended

However, some adults may beneNt from HPV
vaccination. When deciding whether to vaccinate
adults, consider:
• the likelihood of previous exposure to HPV
• the future risks of HPV exposure.
Further information
• A short course of topical oestrogen therapy could be considered in postmenopausal women,
people experiencing vaginal dryness, or trans men, prior to collecting the sample – for
example, daily for at least 2 weeks, ceasing 1–2 days prior to the appointment. The reason for
this should be explained (to reduce discomfort from the speculum and to improve the
diagnostic accuracy of any associated liquid-based cytology [LBC]).3
• When deciding whether to choose self-collection or clinician collection, people must be given
clear information by the supervising healthcare professional about the likelihood that HPV may
be detected and, if so, what follow-up will be required. If a person chooses self-collection, the
healthcare professional should provide information about how to collect the sample and how
they will receive the test results.3
• Cervical screening on a self-collected vaginal sample needs to be ordered and overseen by a
healthcare professional.* For details of self-collection, refer to the section on self-collected
vaginal samples in the National Cervical Screening Program: Guidelines for the management of
screen-detected abnormalities, screening in speciNc populations and investigation of abnormal
vaginal bleeding (https://www.cancer.org.au/clinical-guidelines/cervical-cancer/cervical-cancer-
screening/management-of-oncogenic-hpv-test-results/self-collected-vaginal-samples) .3
• When follow-up HPV testing is required after an initial positive oncogenic HPV test result, the
sample may be self-collected or collected by a clinician. The woman’s healthcare professional
should advise the woman of the follow-up that will be recommended if HPV is detected and
explain that a clinician-collected sample allows for reaex LBC to be performed on the same
sample. This potentially avoids the need for an additional visit to collect a cervical sample for
LBC. HPV testing is not repeated on the clinician-collected sample in this circumstance.3
• Among those attending for a routine screening test, approximately 2% have HPV16/18
detected and approximately 6% have HPV (not 16/18) detected, although the latter varies by
age.3
*Only doctors and nurse practitioners can sign the pathology request for tests under current Medicare
BeneNts Schedule (MBS) rules.

peoples
313
Cervical cancer
15: Prevention and early detection of cervical cancer (https://www.racgp.org.au/clinical-resources/clini

cal-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/national-guide/chapter-15-prevention-an
d-early-detection-of-cance/prevention-and-early-detection-of-cervical-cancer) .
SpeciEc populations
Screening in pregnancy5
• Routine antenatal and postpartum care should include a review of the woman’s cervical
screening history. Women who are due or overdue for screening should be screened.
• A woman can be safely screened at any time during pregnancy, provided that the correct
sampling equipment is used. An endocervical brush should not be inserted into the cervical
canal because of the risk of associated bleeding, which may distress women.
• All women who are due for cervical screening during pregnancy may be offered the option of
self-collection of a vaginal swab for HPV testing, after counselling by a healthcare professional
about the small risk of bleeding. Women testing positive for HPV (not 16/18) on a self-
collected sample should be advised to return so that a cervical sample for LBC can be
collected by the healthcare provider.
• For other speciNc populations, refer to the National Cervical Screening Program: Guidelines for
the management of screen-detected abnormalities, screening in speciNc populations and
investigation of abnormal vaginal bleeding (https://www.cancer.org.au/clinical-guidelines/cervi
cal-cancer/cervical-cancer-screening) .
Resources
National Cervical Screening Program: Guidelines for the management of screen-detected abnormalities,
screening in speciNc populations and investigation of abnormal vaginal bleeding (https://www.cancer.or
g.au/clinical-guidelines/cervical-cancer/cervical-cancer-screening) .
References
1. Australian Institute of Health and Welfare. Cancer 3. Cancer Council Australia. National Cervical
data in Australia. Cat. no. CAN 122. AIHW, 2023 Screening Program: Guidelines for the
(https://www.aihw.gov.au/reports/cancer/c management of screen-detected abnormalities,
ancer-data-in-australia) [Accessed 16 May 2022]. screening in speciNc populations and
2. Australian Centre for the Prevention of Cervical investigation of abnormal vaginal bleeding.
Cancer. National strategy for the elimination of Cancer Council Australia, 2022 (https://www.canc
cervical cancer in Australia: A pathway to achieve er.org.au/clinical-guidelines/cervical-cancer/cervi
equitable elimination of cervical cancer as a cal-cancer-screening) [Accessed 8 April 2024].
public health problem by 2035. Department of
Health and Aged Care, 2023 (https://www.healt
.gov.au/sites/default/files/2023-11/national-str
ategy-for-the-elimination-of-cervical-cancer-in-aus
tralia.pdf) [Accessed 8 April 2024].
314
Cervical cancer
4. Australian Technical Advisory Group on 5. Cancer Council Australia. National Cervical

Immunisation (ATAGI). Australian immunisation Screening Program: Guidelines for the
handbook. Human papillomavirus (HPV). management of screen-detected abnormalities,
Department of Health and Aged Care, 2023. screening in speciNc populations and
Available at: (https://immunisationhandbook.heal investigation of abnormal vaginal bleeding.
th.gov.au/contents/vaccine-preventable-disease Chaper 14: Screening in pregnancy. Cancer
s/human-papillomavirus-hpv) [Accessed 8 April Council Australia, 2022 (https://www.cancer.org.a
2024]. u/clinical-guidelines/cervical-cancer/cervical-can
cer-screening/screening-in-pregnancy) [Accessed
8 April 2024].
315
Ovarian cancer
Ovarian cancer
Cancer | Ovarian cancer

It is estimated that more than 1200 people were diagnosed with ovarian cancer in 2023 in Australia.1
 Screening

often
Screening for ovarian cancer in asymptomatic women Not N/A 2
is not recommended. recommended

(Strong)
Further information
In 2019, Cancer Australia found that there is currently no evidence available that screening for ovarian
cancer results in reduced mortality for women.2

peoples
There are no speciNc recommendations for Aboriginal and Torres Strait Islander people.
References
1. Cancer Council. Ovarian cancer. Australia: Cancer 2. Cancer Australia. Testing for ovarian cancer in
Council, 2023 (https://www.cancer.org.au/cancer- asymptomatic women. Australia: Cancer
information/types-of-cancer/ovarian-cancer) Australia, 2019 (https://www.canceraustralia.go
[Accessed 3 November 2023]. v.au/publications-and-resources/position-statem
ents/testing-ovarian-cancer-asymptomatic-wome
n) [Accessed 3 November 2023].
316
Ovarian cancer
Miscellaneous
317
Ovarian cancer
Miscellaneous
Frailty (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racg
p-guidelines/view-all-racgp-guidelines/preventive-activities-in-general-practice/m
iscellaneous/frailty) Hearing (https://www.racgp.org.au/clinical-resources/clinic
s-in-general-practice/miscellaneous/hearing) Sleep and sleep-related disorders
lines/view-all-racgp-guidelines/preventive-activities-in-general-practice/miscella
neous/sleep-and-sleep-related-disorders) Oral health (https://www.racgp.org.au/
clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guideli
nes/preventive-activities-in-general-practice/miscellaneous/oral-health) Urinary
incontinence (https://www.racgp.org.au/clinical-resources/clinical-guidelines/ke
y-racgp-guidelines/view-all-racgp-guidelines/preventive-activities-in-general-prac
tice/miscellaneous/urinary-incontinence) Vision (https://www.racgp.org.au/clini
cal-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/
preventive-activities-in-general-practice/miscellaneous/vision)
318
Frailty
Frailty
Miscellaneous | Frailty
Screening and case-Ending age bar
0-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 ≥80

Frailty generally occurs later in life and results in physiological decline. It is estimated that more than
20% of Australians will become frail as they age,1 with declines in multiple domains, including physical
function (eg weakness, slow walking speed, unintentional weight loss), cognition and nutritional status
(eg appetite loss).2 Older people who are frail are vulnerable to adverse health outcomes, including
procedural complications, falls, institutionalisation, disability and death.3,4 Frailty is on a spectrum, with
older people with mild frailty (becoming ‘slow’ and losing muscle strength) at increased risk of
becoming severely frail (resulting in loss of independence, and need for care in residential aged care
home).
Frailty can also occur in younger adults, particularly vulnerable people with disability or onset of illness;5
however, more research is needed in this area.6
 Screening
How
often
2
Consider screening for frailty as part of an assessment of Practice Every 12
elderly patients (aged ≥75 years) using a validated rapid point months.
frailty instrument suitable to the speciNc setting or context
(refer to Further information).
 Case Ending
How
often
319
Frailty
Consider screening for frailty as part of an assessment of Practice Every 1–3 2
patients (aged 65–74 and who have factors associated point years.
with frailty) using a validated rapid frailty instrument
suitable to the speciNc setting or context (refer to Further
information).

often
To slow or reverse the progression of frailty: Practice N/A 2
• offer a multi-component progressive physical point

activity program, including resistance and aerobic
exercise; consider early involvement of a
physiotherapist or exercise physiologist if
possible
• encourage optimised nutrition
• provide medication management
• encourage enhanced social connectedness.
Further information
Risk factors for frailty

There are a number of factors associated with increased risk of frailty. These include:4
• older age
• current smoker
• lower educational level
• current use of postmenopausal therapy
• not being married
• depression
• intellectual disability
• being of Aboriginal and Torres Strait Islander descent
• sedentary lifestyle
• undernutrition
• chronic disease
• multimorbidity
• polypharmacy
• obesity.
320
Frailty
Screening for frailty

A health assessment for people aged ≥75 years (https://www1.health.gov.au/internet/main/publishin
g.nsf/Content/mbsprimarycare_mbsitem_75andolder) provides a good opportunity for GPs to case-Nnd
people who are frail or pre-frail.
Screening for frailty helps to identify functional decline. Commonly used frailty scoring tools include the
following.4
• Frailty indicators (https://academic.oup.com/biomedgerontology/article/56/3/M146/545770?l

ogin=false) – ask about and score:
◦ unintentional weight loss (≥4 kg in the past year)
◦ self-reported exhaustion
◦ weakness (reduced grip strength)
◦ slow gait speed
◦ low physical activity.
Frailty = ≥3 of the above; pre-frailty = 1–2 of the above; not frail = none of the above.7
• Frailty index (https://academic.oup.com/biomedgerontology/article/62/7/722/581897?login=f

alse) – based on the accumulation of illnesses, functional deNcits, cognitive decline and social
circumstances, it involves answering >20 medical and functional questions.8
• Clinical Frailty Scale (http://www.managingmds.com/content/Clinical_Frailty_Scale.pdf) –
helpful scale that takes very little time.
• Edmonton Frail Scale (https://www.bgs.org.uk/sites/default/Nles/content/attachment/2018-0
7-05/efs.pdf) – scale that rates frailty from 0 to 17.9
• Frail Scale Risk Assessment (https://www.materresearch.org.au/News/Unlisted/Frail-Scale/Fr
ail-Scale-and-Decision-Tool_Qld.pdf) – scale that assesses fatigue, resistance, ambulation,
illness, and loss of weight.
• Other useful simple tests with variable speciNcity and sensitivity:10
◦ slow walking speed (>5 seconds to walk 4 metres)
◦ Timed Up & Go test (https://www.cdc.gov/steadi/pdf/TUG_Test-print.pdf) (>10
seconds to stand from a chair, walk 3 metres, turn around, walk back to the chair and
sit down again).
The screening tool may include a number of components, such as assessing:2,4
• slow gait speed

• unintentional weight loss
• mood
• accumulation of illnesses
• social circumstances
• cognitive disculties
• polypharmacy
• weakness
• exhaustion.
321
Frailty
Pathophysiology of frailty
For information on the pathophysiology of frailty, including further detail about the immune, endocrine,
stress and energy response systems changes that contribute to the development of frailty, please refer
to the ‘Frailty’ chapter (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guideli
nes/view-all-racgp-guidelines/silver-book/part-a/frailty) in the RACGP aged care clinical guide (Silver
Book) – Part A.

peoples
Resources
Further information about frailty in an aged care setting: Frailty (https://www.racgp.org.au/clinical-resou
rces/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/silver-book/part-a/frailty) |
RACGP aged care clinical guide (Silver book) – Part A | RACGP
References
1. Thompson, M, Theou O, Karnon J, et al. Frailty 6. Loecker C, Schmaderer M, Zimmerman L. Frailty
prevalence in Australia: Findings from four pooled in young and middle-aged adults: An integrative
Australian cohort studies. Australas J Ageing review. J Frailty Aging
2018;37: 155–58. doi: 10.1111/ajag.12483. 2021;10(4):327–33. doi: 10.14283/jfa.2021.14.
2. Dent E, Morley JE, Cruz-Jentoft AJ, et al. Physical PMID: 34549246.
frailty: ICFSR international clinical practice . Fried LP, Tangen CM, Walston J, et al. Frailty in
guidelines for identification and management. J older adults: Evidence for a phenotype. J Gerontol
Nutr Health Aging A Biol Sci Med Sci 2001;56(3):M146–56. doi:
2019;23(9):771–87. doi: 10.1007/ 10.1093/Gerona/56.3.m146.
s12603-019-1273-z. . Rockwood K, Mitnitski A. Frailty in relation to the
3. Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood accumulation of deficits. J Gerontol A Biol Sci
K. Frailty in older people. Lancet Med Sci 2007;62(7):722–27.
2013;381(9868):752–62. doi: (https://doi.org/1
. Wryko Z. Frailty at the front door. Clin Med
0.1016/S0140-6736(12)62167-9.)
(Lond) 2015;15(4):377–81.
1 . Turner G, Clegg A; British Geriatrics Society; Age
Practitioners. RACGP aged care clinical guide UK; Royal College of General Practitioners. Best
(Silver Book). 5th edn. RACGP, 2019. practice guidelines for the management of frailty:
5. Spiers GF, Kunonga TP, Hall A, et al. Measuring A British Geriatrics Society, Age UK and Royal
frailty in younger populations: A rapid review of College of General Practitioners report. Age
evidence. BMJ Open 2021;11:e047051. doi: Ageing 2014;43(6):744–47.
10.1136/bmjopen-2020-047051.
322
Hearing
Hearing
Miscellaneous | Hearing
It is estimated that 3.6 million Australians have some level of hearing loss (somewhat higher in men
than women1), with 1.3 million Australians living with a hearing condition that could have been
prevented.2 Although the prevalence of hearing loss tends to increase with age, it can affect people of
all ages, with signiNcant consequences on the physical, functional and mental health of the individual.
Causes of hearing loss are varied and include:2–4
• age-related hearing loss

• exposure to loud environments, including occupational environments (eg construction sites,
concert venues, bars, nightclubs)
• congenital or early onset childhood hearing loss
• complications from diseases such as measles, meningitis, rubella and mumps
• genetics
• ototoxic drugs that damage the inner ear
• smoking.
GPs are well placed to detect, diagnose and provide advice to help prevent hearing loss.
 Screening
5
Screening for hearing loss is not Generally not N/A
recommended in asymptomatic adults aged recommended
≥50 years.
 Case Ending
323
Hearing
Assess hearing in patients who present with Practice point Opportunistically. 5,6
conditions that may be associated with

hearing loss, such as:
• speech and behavioural concerns,
chronic ear infections and glue ear in
children
• questions, concerns or perceived
hearing loss in adults.
Refer to Further information.
Advise the following to help prevent hearing Practice point N/A 7
damage:
• avoid loud or sustained excessive
noise
• use hearing protection in high-noise
environments
• use volume controls for personal
devices as necessary
• avoid exposure to cigarette smoke in
children.
8
The following vaccinations may reduce Practice point N/A
incidence of acute otitis media and/or
acquired hearing loss:
• annual inauenza vaccination
(inactivated virus) is recommended in
any person aged ≥6 months,
• rubella, measles, Haemophilus
inauenzae type b, meningococcus in
children younger than 15 years,
• pneumococcal conjugate vaccination
(13vPCV) during infancy.
8
Preventive activities for pregnant women Practice point N/A
Offer testing for rubella immunity and syphilis
serology to prevent infections that may lead to
congenital hearing loss.
324
Hearing
Further information
Newborn screening
Each Australian state has an infant hearing screening program, which includes a test that is typically
completed in hospital after the baby is born.
Ensure parents of newborn infants are aware of the universal neonatal hearing screening program in
their relevant state and territory and have had their newborn screened for congenital hearing
impairment.8 For further information, please refer to the chapter Developmental delay and autism (http
s://www.racgp.org.au/wip-sites/preventive-activities-in-general-practice/development-and-behaviour/au
tism) .
Hearing assessment
It is important to assess hearing in patients who present with conditions that may be associated with
hearing loss, such as speech or behavioural concerns in children, or perceived hearing loss in adults.6
Audiometry is best practice for a thorough assessment. However, hearing loss can also be assessed
through:5
• single-question screening, asking ‘Do you have disculty with your hearing?’
• longer patient questionnaires, for example the Hearing handicap inventory – screening (HHIE-
S) (https://www.uspreventiveservicestaskforce.org/home/getNlebytoken/YbRBU___FZQZ32wg
bLdrEU) questionnaire for the elderly.
Hearing assessments such as whispered voice and Nnger rub are no longer recommended. This is
because the results can be variable, as they are user-dependent.5

peoples
High rates of persistent otitis media in infancy and childhood are associated with hearing loss across
the life course for Aboriginal and Torres Strait Islander people.
For speciNc recommendations for Aboriginal and Torres Strait Islander people, please refer to Hearing
loss (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racg
p-guidelines/national-guide/chapter-7-hearing-loss) in the National guide to a preventive health
assessment for Aboriginal and Torres Strait Islander people.
SpeciEc populations
People at greater risk of hearing loss include:2,5,8-13
325
Hearing
• older people (presbycusis)

• people who work in loud environments, such as construction sites, farms, factories, hospitality,
concert venues
• people who listen to loud music and use headphones for music or gaming
• Aboriginal and Torres Strait Islander children (refer to Chapter 7: Hearing loss (https://www.rac
gp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/
national-guide/chapter-7-hearing-loss) in the National guide to a preventive health assessment
for Aboriginal and Torres Strait Islander people for hearing recommendations in this
population)
• people with a family history of hearing loss
• people from refugee-like backgrounds. In Australia, rates of chronic suppurative otitis media
and cholesteatoma are much higher in the adult refugee population than in the broader
Australian population.11 In addition, refugee children and adolescents may have missed
screening for hearing problems.
Resources
Guidelines on the prevention, diagnosis and management of all forms of otitis media for Aboriginal and
Torres Strait Islander children (RACGP-endorsed clinical guideline): Otitis media guidelines (https://otitis
mediaguidelines.com/) (app) for Aboriginal and Torres Strait Islander children | Menzies Health
Screening questionnaire for the elderly: Hearing handicap inventory – screening (HHIE-S) (https://ww
w.uspreventiveservicestaskforce.org/home/getNlebytoken/YbRBU___FZQZ32wgbLdrEU) questionnaire
References
1. Australian Institute of Health and Welfare 6. The Royal Australian College of General
(AIHW). Australia’s health 2016. Catalogue no. Practitioners (RACGP). 2022 RACGP curriculum
AUS 199. AIHW, 2016 (https://www.aihw.gov.au/r and syllabus for Australian general practice.
eports/australias-health/australias-health-2016/c RACGP, 2022 (https://www.racgp.org.au/educatio
ontents/summary) [Accessed 31 January 2024]. n/education-providers/curriculum/curriculum-an
2. Department of Health and Aged Care. About ear d-syllabus/home) [Accessed 31 January 2024].
health. Australian Government, 2022 (http s:// 7. World Health Organization (WHO). Make
www.health.gov.au/topics/ear-health/about) listening safe. WHO, n.d (https://www.who.int/act
[Accessed 28 March 2023]. ivities/making-listening-safe) [Accessed 28
3. World Health Organization (WHO). Deafness and March 2023].
hearing loss. WHO, n.d - tab=tab_1 (https://w 8. National Aboriginal Community Controlled
ww.who.int/health-topics/hearing-loss) Health Organisation; The Royal Australian College
[Accessed 29 March 2023]. of General Practitioners (RACGP). National guide
4. Cunningham LL, Tucci DL. Hearing loss in adults. to a preventive health assessment for Aboriginal
N Engl J Med 2017;377(25):2465–73. doi: and Torres Strait Islander people. 3rd edn. RACGP,
10.1056/NEJMra1616601. [Accessed 29 March 2018 (https://www.racgp.org.au/clinical-resource
2023]. s/clinical-guidelines/key-racgp-guidelines/view-al
l-racgp-guidelines/national-guide/chapter-7-heari
5. US Preventive Services Task Force. Screening for
ng-loss) [Accessed 31 January 2024].
hearing loss in older adults: US Preventive
Services Task Force recommendation statement.
JAMA. 2021;325(12):1196–201. doi: 10.1001/
jama.2021.2566. [Accessed 29 March 2023].
326
Hearing
. Hearing Health Sector Committee. Roadmap for 11. Foundation House. Hearing, vision and oral
hearing health. Hearing Health Sector Committee, health. Australian refugee health practice guide.
2019 (https://www.health.gov.au/site s/default/ Foundation House, 2024 (https://refugeehealthgu
files/documents/2021/10/roadmap-fo ide.org.au/hearing-vision-and-oral-health/)
hearing-health.pdf) [Accessed 29 March 2023]. [Accessed 30 March 2023].
1 . Dehankar SS, Gaurkar SS. Impact on hearing due 12. The Royal Children’s Hospital Melbourne
to prolonged use of audio devices: A literature (RCH). Education assessment. RCH, 2021 (http
review. Cureus 2022;14(11):e31425. doi: 10.7759/ s://www.rch.org.au/immigranthealth/clinical/Edu
cureus.31425. [Accessed 29 March 2023]. cation_assessment/) [Accessed 30 March 2023].
13. Benson J, Mwanri L. Chronic suppurative
otitis media and cholesteatoma in Australia’s
refugee population. Aust Fam Physician
2012;41(12):978–80. [Accessed 30 March 2023].
327
Sleep and sleep-related disorders
Miscellaneous | Sleep and sleep-related

disorders
Suscient and good-quality sleep is essential for health and wellbeing. In prevalence studies, nearly half
(48%) of all Australian adults report at least two sleep-related problems, such as inadequate sleep or
sleep disorders.1 Sleep-related problems can be due to a number of predisposing, precipitating and
perpetuating factors2 and conditions, such as obstructive sleep apnoea (OSA) or insomnia. OSA and
insomnia can co-exist. Sleep-related problems are also associated with an increased risk of type 2
diabetes, cardiovascular disease, coronary heart disease, anxiety, depression and stroke.1,3,4 GPs can
advise patients on the importance of practising good sleep hygiene.
 Screening
5
Screening for OSA in the general population is Generally not N/A
not recommended because of insuscient recommended
evidence to assess the balance of beneNts
and harms.
Screening for insomnia in the general Generally not N/A 2
population is not recommended because recommended

there is no evidence.
 Case Ending
328
Case Nnding for OSA is recommended in Practice point Opportunistically. 2
people with symptoms (eg daytime

sleepiness, fatigue, snoring, disrupted sleep)
and in people with common risk factors (age
>50 years, overweight or obesity, excessive
alcohol intake). Commercial drivers and pilots
are a priority group for case Nnding.
Questionnaires that can be used to identify

patients who may have OSA include the:
• Epworth Sleepiness Scale (https://w
ww.sleepprimarycareresources.org.a
u/questionnaires/ess)
• OSA50 (https://www.sleepprimarycar
eresources.org.au/questionnaires/os
a50) questionnaire
• STOP-Bang Questionnaire (https://w
ww.sleepprimarycareresources.org.a
u/questionnaires/stop-bang) .
Questionnaires that can be used to identify

symptoms of insomnia disorder include the:
• Sleep Condition Indicator (https://ww
w.sleepprimarycareresources.org.au/
questionnaires/sci) (SCI)
• Insomnia Severity Index (https://ww
w.sleepprimarycareresources.org.au/
questionnaires/isi) (ISI)
• Dysfunctional beliefs and attitudes
about sleep (DBAS) scale (https://d1t
jqcfmshvvz2.cloudfront.net/staging/
DBAS-16.pdf)
• Daytime insomnia symptom scale
(DISS) (https://d1tjqcfmshvvz2.cloud
front.net/staging/DISS.pdf)
• Flinders Fatigue Scale (https://d1tjqc
fmshvvz2.cloudfront.net/staging/Flin
ders-Fatigue-Scale_2021-11-11-2256
34_ffzc.pdf)
329
Advise behaviour modiNcations for patients Practice point N/A 2, 6, 7
with OSA risk factors, including:

• limiting alcohol and certain common
sedatives and antianxiety/
antidepressant medications (eg
benzodiazepines)
• a 5–15% weight reduction for
overweight or (morbidly) obese
patients.
330
Advise patients to practice good sleep habits Practice point N/A 2, 8, 9
to help prevent sleep problems:

• Maintain a regular wake up time,
regardless of a poor night sleep
• When sleep is of insuscient duration
during the week (or work days),
catch-up sleep on weekends (or non-
work days) is important for health
• Resolve concerns or worries before
bedtime
• Avoid going to bed until you are
drowsy and ready to sleep
• Try not to force sleep
• Avoid daytime naps, especially if they
are longer than 20–30 minutes or
occur late in the day
• Reserve the bedroom for sleep and
intimacy and adjust the bedroom
environment as needed to decrease
stimuli (eg reduce ambient light, turn
off the television or radio)
• Avoid bright light immediately before
bed or while in bed, including
television and mobile phone use
• Avoid visual access to a clock
throughout the night
• Allow suscient time in bed to gain
an adequate amount of sleep
• Avoid caffeinated beverages after
lunch
• Avoid alcohol in the late afternoon
and evening
• Avoid large meals immediately
before bed
• Avoid smoking or other nicotine
intake, particularly during the evening
• Avoid pets sleeping in the bedroom
• Exercise regularly for at least 20
minutes, preferably more than 1–2
hours prior to bedtime
• Do not stay in bed if you do not fall
asleep quickly (stimulus control
therapy) and encourage relaxing
activities before bedtime
331
Further information
Obstructive sleep apnoea

OSA is among the most common sleep disorders found in the general population worldwide.1 The
prevalence of undiagnosed OSA is high,10 and it is associated with considerable morbidity.
The symptoms of OSA are varied, but can include2,5:
• excessive daytime sleepiness, fatigue or falling asleep during the day, despite length of sleep
• snoring (which may be loud or irregular)
• choking or gasping during sleep
• witnessed breathing cessation
• sleep disruption and frequent awakenings
• nocturia
• disculty with concentration, memory and other executive functions
• depressed mood
• decreased work performance.
Untreated OSA can have signiNcant impacts, including:3,11
• cardiovascular morbidity and mortality (including hypertension, coronary artery disease, stroke,
atrial Nbrillation, congestive heart failure)
• increased risk of motor vehicle accidents
• increased risk of occupational accidents
• cognitive impairment
• diabetes
• lost work days
• decreased quality of life
• mortality.
Some of the common risk factors for OSA include:1,2
• male sex
• age >50 years
• modiNable risk factors such as smoking, overweight and obesity and alcohol use
• postmenopause (women).
There is currently insuscient evidence to screen the asymptomatic general population for OSA. Instead,
initial assessment for symptomatic patients should encompass patient history, questionnaires and
physical examination.
332
Insomnia
Insomnia causes problems falling or staying asleep, and can be categorised as acute (less than three
months in duration) or chronic (more than three months duration). There are several predisposing,
precipitating and perpetuating factors (https://www.sleepprimarycareresources.org.au/insomnia/sum
mary) that may contribute to the development of insomnia disorder.2 Insomnia can greatly impact a
person’s quality of life and overall health.
Acute insomnia generally occurs due to a psychological or physiological stressor, and typically resolves
once the stressor has been removed or the patient has adapted to the stressor.2 It is important to
reassure the patient that acute insomnia does not develop into chronic insomnia most of the time, and
to manage the stressor that is causing the sleep disculties.2
Women experiencing menopause and perimenopause may experience insomnia.12
Chronic insomnia is present for at least three nights per week for three or more months, occurs despite
adequate opportunity for sleep and causes signiNcant distress or impairment in daytime functioning.2
The assessment of insomnia disorder is based on patient-reported sleep history (https://www.sleeppri

marycareresources.org.au/insomnia/assessment-sleep-history) and questionnaires (https://www.sleep
primarycareresources.org.au/insomnia/assessment-questionnaires) .
Please see the Resources tab for more information on behavioural therapies for insomnia.

peoples
The new topic of Sleep will be included in the new edition of the National guide to a preventive health
assessment for Aboriginal and Torres Strait Islander people, released mid-2024.
SpeciEc populations
The prevalence of OSA is increased in patients:2
• with type 2 diabetes

• with hypertension and cardiovascular disease
• prescribed sedative medications.
Case Nnding for OSA may be beneNcial in commercial vehicle drivers and pilots.2
In addition to factors that may increase the risk of insomnia, a report to the Sleep Health Foundation
found several factors associated with the highest prevalence rates of insomnia in the Australian
population,13 including:
• lower income
• Nnancial stress
333
• unemployment
• retirement
• being unable to work due to disability.
The Sleep Primary Care Resources include a comprehensive list of risk factors that contribute to the
development of:
• obstructive sleep apnoea (https://www.sleepprimarycareresources.org.au/osa/presentation-an

d-risk-factors)
• insomnia disorder (https://www.sleepprimarycareresources.org.au/insomnia/steps-in-assess
ment-and-management/risk-factors-and-development) .
Resources
Evidence-based resources and information to assess and manage adult patients with OSA and
insomnia: Sleep Health Primary Care Resources (https://www.sleepprimarycareresources.org.au/) |
Australasian Sleep Association
Non-drug behavioural interventions for patients experiencing insomnia and sleep problems: Cognitive
behavioural therapy for chronic insomnia (https://www.racgp.org.au/clinical-resources/clinical-guidelin
es/handi/handi-interventions/cogntive-and-behavioural-therapies/cognitive-behavioural-therapy-for-chr
onic-insomnia) in Handbook of non-drug interventions (HANDI) | RACGP Brief behavioural therapy:
Insomnia in adults (https://www.racgp.org.au/clinical-resources/clinical-guidelines/handi/handi-interve
ntions/cogntive-and-behavioural-therapies/brief-behavioural-therapy-insomnia-in-adults) in Handbook of
non-drug interventions (HANDI) | RACGP Behavioural intervention: Infant sleep problems and maternal
mood (https://www.racgp.org.au/clinical-resources/clinical-guidelines/handi/handi-interventions/cognt
ive-and-behavioural-therapies/behavioural-intervention-infant-sleep-problems-and) in Handbook of non-
drug interventions (HANDI) | RACGP
Guidance on sleep hygiene, stimulus control, sleep restriction therapy, relaxation and cognitive
therapies: GP guide to behavioural therapy for insomnia (https://www.racgp.org.au/clinical-resources/cl
inical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/drugs-of-dependence/part-b/resource
s/resource-g-gp-guide-to-behavioural-therapy-for-ins) | RACGP
Evidence-based guidance on the use of benzodiazepines: Prescribing drugs of dependence in general

practice, Part B: Benzodiazepines (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-rac
gp-guidelines/view-all-racgp-guidelines/drugs-of-dependence/part-b/) | RACGP (https://www.racgp.org.a
u/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/drugs-of-depend
ence/part-b/)
References
1. Australian Institute of Health and Welfare. 2. Zwar N, Soenen S. Sleep health primary care
Sleep problems as a risk factor for chronic resources. Australasian Sleep Association, 2023
conditions. Australian Government, 2021 (http (https://www.sleepprimarycareresources.org.a
s://www.aihw.gov.au/reports/risk-factors/sleep-p u/) [Accessed 30 March 2023].
roblems-as-a-risk-factor/summary) [Accessed 30
March 2023].
334
3. Zhang Y, Jiang X, Liu J, Lang Y, Liu Y. The 10. Australian Institute of Health and Welfare.
association between insomnia and the risk of Sleep-related breathing disorders with a focus on
metabolic syndrome: A systematic review and obstructive sleep apnoea. Australian Government,
meta-analysis. J Clin Neurosci 2021;89:430–36. 2021 (https://www.aihw.gov.au/reports/chronic-r
doi: (http://10.1016/j.jocn.2021.05.039.) espiratory-conditions/sleep-related-breathing-dis
4. Dean Y, Shebl M, Rouzan S, et al. Association orders/summary) [Accessed 30 March 2023].
between insomnia and the incidence of 11. Patil S, Ayappa I, Caples S, Kimoff RJ, Patel SR,
myocardial infarction: A systematic review and Harrod CG. Treatment of adult obstructive sleep
meta-analysis. Clin Cardiol 2023;46(4):376–85. apnea with positive airway pressure: An American
doi: 10.1002/clc.23984. Academy of Sleep Medicine systematic review,
5. Jin J. Screening for obstructive sleep apnea in meta-analysis, and GRADE assessment. J Clin
adults. JAMA 2017;317(4):450. doi: 10.1001/ Sleep Med 2019;15(2):301–34. doi: 10.5664/
jama.2016.20362. jcsm.7638. [Accessed 30 March 2023].
6. Qaseem A Holty J, Owens D, et al. Management 12. McNamara S, Nichols T, Dash S, de Courten M,
of obstructive sleep apnea in adults: A clinical Calder RV. Sleep: A core pillar of health and
practice guideline from the American College of wellbeing. Improving population sleep health to
Physicians. Ann Intern Med 2013;159:471. doi: reduce preventable illness and injury. A policy
10.7326/ evidence brief. Mitchell Institute and Victoria
0003-4819-159-7-201310010-00704. University, 2023 - a core pillar of health and
wellbeing Policy Evidence Brief Oct 2023.pdf (htt
. Randerath WJ, Verbraecken J, Andreas S. Non-
ps://assets-global.website-Nles.com/64b4b7e38d
CPAP therapies in obstructive sleep apnoea. Eur
da973fdbb7faf2/655d2c759df1245300e276a3_Sl
Respir J 2011;37:1000. doi: 10.1183/
eep%20%20-%20a%20core%20pillar%20of%20he
09031936.00099710.
alth%20and%20wellbeing%20Policy%20Evidenc
. The Royal Australian College of General e%20Brief%20Oct%202023.pdf) [Accessed 22
Practitioners (RACGP). Prescribing drugs of February 2024].
dependence in general practice. Part B –
13. Reynolds A, Appleton S, Gill T, et al. Chronic
benzodiazepines. RACGP, 2015 (https://
insomnia disorder in Australia: A report to the
www.racg
Sleep Health Foundation. Sleep Health
.org.au/clinical-resources/clinical-guidelines/ke
y-racgp-guidelines/view-all-racgp-guidelines/drug Foundation, 2019 (https://www.sleephealthfound
s-of-dependence/part-b/summary-of-recommend ation.org.au/special-sleep-reports/chronic-insom
ations) [Accessed 30 March 2023]. nia-disorder-in-australia) [Accessed 22 February
9. Sletten TL, Weaver MD, Foster RG, et al. The 2024].
importance of sleep regularity: a consensus
statement of the National Sleep Foundation sleep
timing and variability panel. Sleep Health
2023;9(6):801–20. doi: (http://10.1016/j.sleh.202
3.07.016.)
335
Oral health
Oral health
Miscellaneous | Oral health

Good oral health is important for a person’s physical health and wellbeing,1 with the adverse effects of
poor oral health extending beyond the teeth and gums of the individual. While tooth decay, periodontal
disease and tooth loss1,2 are the most common oral health diseases, poor oral health can cause pain,
infection, disculties with speech and eating, is associated with chronic disease and contributes poor
mental health and wellbeing.1,3 Additionally, poor oral health and decay in early childhood is also
associated with impaired growth, decreased weight gain, poor school performance and future dental
caries.4 SigniNcant barriers to dental care remain in Australia, which also contributes to poor dental
health.
 Screening
5
Screening for oral cancer in the general Generally not N/A
population is not recommended, because of recommended
insuscient evidence. Please refer to the Oral
cancer (https://www.racgp.org.au/clinical-res
ources/clinical-guidelines/key-racgp-guideline
s-in-general-practice/cancer/oral-cancer)
chapter for further information.
Routine screening for dental caries performed Generally not N/A 4
by GPs and their teams in children aged <5 recommended

years is not recommended, because of
insuscient evidence.
Routine screening examinations for dental Generally not N/A 6
caries performed by GPs and their teams in recommended

the general population is not recommended.
336
Oral health
 Case Ending
Examination of the mouth and lips in smokers Practice point Opportunistically. 5
aged >50 years, heavy drinkers or patients that

chew tobacco or betel nut. This should
include:
• visual inspection of the face, neck,
lips, labial mucosa, buccal mucosa,
gingiva, aoor of the mouth, tongue
and palate
• palpating the regional lymph nodes,
tongue and aoor of the mouth.
Refer to an appropriate specialist or dentist

where issues or concerns are suspected.
3,5,7,8,9
Encourage patients to undertake the following Practice point N/A
preventive activities to avoid tooth decay and
periodontal disease:
• have a good oral hygiene routine
(brushing teeth twice a day with a
auoridated toothpaste, with daily
aossing)
• limit sugary food in diet
• limit soft drinks, sports drinks and
alcoholic drinks
• quit smoking
• undertake regular dental check-ups
• use mouth guards for any contact
sports.
Assess whether patients are exposed to

auoride in their drinking water. Additional
auoride therapies might be suitable depending
on risk – refer to the Guidelines for the use of
auorides in Australia: Update 2019 (https://onl
inelibrary.wiley.com/doi/full/10.1111/adj.1274
2) .
337
Oral health
Avoid putting babies and children to bed with Practice point N/A 9
a bottle.
Further information
Conditions that may require extra preventive care include3:
• medications and conditions that are known to cause xerostomia (or dry mouth)
• human immunodeNciency virus (HIV) infection
• patient belonging to other special populations (listed below).
For guidance on the use of auoridated toothpaste and auoridated products for children, please refer to
the Guidelines for the use of auorides in Australia: Update 2019 (https://onlinelibrary.wiley.com/doi/full/
10.1111/adj.12742) .

peoples
For speciNc recommendations for Aboriginal and Torres Strait Islander people, please refer to
the National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people:
Chapter 8: Oral and dental health (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-rac
gp-guidelines/view-all-racgp-guidelines/national-guide/chapter-8-oral-and-dental-health) .
SpeciEc populations
Advise pregnant women to visit a dentist for treatment of all active dental decay and periodontal
disease. For recommendations, refer to the During pregnancy (https://www.racgp.org.au/clinical-resour
ces/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/preventive-activities-in-general-pr
actice/reproductive-and-womens-health/during-pregnancy) chapter.
Australia’s National Oral Health Plan 2015–2024 (https://www.health.gov.au/resources/publications/he

althy-mouths-healthy-lives-australias-national-oral-health-plan-2015-2024?language=en) highlights
several priority populations, which are the groups that experience the most signiNcant barriers to
accessing oral healthcare and the greatest burden of oral disease. They are:1
• people who are socially disadvantaged or on low incomes, which includes

◦ low income and/or receiving some form of government income assistance
◦ refugees
◦ homeless people
◦ some people from culturally and linguistically diverse backgrounds
◦ people in institutions or correctional facilities
• people living in regional and remote Australia
• people with additional and/or specialised healthcare needs, including
338
Oral health
• people living with mental illness

• people with physical, intellectual and developmental disabilities
• people with complex medical needs
• frail older people.
Some populations experience signiNcant Nnancial and access barriers to preventive dental care and
treatment in Australia. GPs have the opportunity to identify people who may require extra preventive
care, support and education
Resources
Guidelines on the self-use of auoride products in Australia: Guidelines for the use of auorides in
Australia: Update 2019 (https://onlinelibrary.wiley.com/doi/full/10.1111/adj.12742) | LG Do, Australian
Research Centre for Population Oral Health (https://onlinelibrary.wiley.com/doi/full/10.1111/adj.1274
2)
Resources
1. Australian Institute of Health and Welfare. Oral health and dental care in Australia. Cat. no. DEN
231. AIHW, 2023. Available at https://www.aihw.gov.au/reports/dental-oral-health/oral-health-
and-dental-care-in-australia (https://www.aihw.gov.au/reports/dental-oral-health/oral-health-an
d-dental-care-in-australia) [Accessed 27 March 2023].
2. The Royal Australian College of General Practitioners. 2022 RACGP curriculum and syllabus for
Australian general practice. RACGP, 2022.
3. National Aboriginal Community Controlled Health Organisation and The Royal Australian
College of General Practitioners. National guide to a preventive health assessment for
Aboriginal and Torres Strait Islander people. 3rd edn. RACGP, 2018.
4. Chou R, Pappas M, Dana T, et al. Screening and interventions to prevent dental caries in
children younger than age Nve years: A systematic review for the U.S. Preventive Services Task
Force. Agency for Healthcare Research and Quality (US), 2021. Available at:
https://www.ncbi.nlm.nih.gov/books/NBK575915 (https://www.ncbi.nlm.nih.gov/books/NBK57
5915/) [accessed 27 March 2023].
5. Olson C, Burda B, Beil T, et al. Screening for oral cancer: A targeted evidence update for the U.S.
Preventive Services Task Force. Agency for Healthcare Research and Quality (US), 2013.
Available at https://www.ncbi.nlm.nih.gov/books/NBK132472 (https://www.ncbi.nlm.nih.gov/b
ooks/NBK132472/) [accessed 27 March 2023].
6. US Preventive Services Task Force. Oral health in adults: Screening and preventive
interventions. Final recommendation statement. USPSTF, 2023. Available at
https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/oral-health-adults-
screening-preventive-interventions (https://www.uspreventiveservicestaskforce.org/uspstf/rec
ommendation/oral-health-adults-screening-preventive-interventions) [Accessed 27 October
2023].
7. Do LG, Australian Research Centre for Population Oral Health. Guidelines for use of auorides in
Australia: Update 2019. Aust Dent J 2020; 65(1):30–38. doi: 10.1111/adj.12742.
8. The Australian Dental Association. Guidelines for the fabrication, use and maintenance of
sports mouthguards. 5th edn. ADA, 2022. Available at https://www.ada.org.au/getmedia/
339
Oral health
595ad4e4-9889-4e66-9be6-d433140f4d71/ADA_Guidelines_Mouthguard-Fabrication.pdf (http
s://www.ada.org.au/getmedia/595ad4e4-9889-4e66-9be6-d433140f4d71/ADA_Guidelines_Mo
uthguard-Fabrication.pdf) [Accessed 13 April 2024].
9. Welti R, Chinotti M, Walsh O, et al. Oral health messages for Australia: A national consensus
statement. Aust Dent J 2023;68(4):247–54. doi: 10.1111/adj.12973.
340
Urinary incontinence
Miscellaneous | Urinary incontinence

Urinary incontinence is deNned as the involuntary loss of urine. It can have a considerable impact on
health and the overall quality of life.1 Urinary incontinence is more common in women than in men.1 The
Continence Foundation of Australia estimates that 80% of those with urinary incontinence in the
community are women.2
Although bedwetting (enuresis) is common in children, the prevalence and severity of urinary
incontinence tends to increase with age. It is estimated that severe urinary incontinence affects
approximately 5% of people aged 65–84 years, and this increases by more than Nvefold for those aged
≥85 years (28%).3,4 However, these numbers are likely to be underestimated, because urinary
incontinence tends to be under-reported and undertreated.3
 Screening
Recommendation Grade How
Routine urinary incontinence screening in the general population has insuscient Practice point N/A
evidence.
 Case Ending
Recommendation Grade How
341
Ask about the occurrence of urinary incontinence in women and people who are at Conditionally Oppo
higher risk (see SpeciNc populations). recommended
The 3 Incontinence Questions (3IQ)
1. During the last three months, have you leaked urine (even a small amount)?
☐ Yes
☐ No – questionnaire completed
2. During the last three months, did you leak urine (check all that apply):
☐ a. When you were performing some physical activity, such as coughing, sneezing,
lifting, or exercise?
☐ b. When you had the urge or feeling that you needed to empty your bladder, but you
could not get the toilet fast enough?
☐ c. Without physical activity and without a sense of urgency?
3. During the last three months, did you leak urine most often (check only one):
☐ a. When you are performing some physical activities, such as coughing, sneezing,
lifting, or exercise?
☐ b. When you had the urge or feeling that you needed to empty your bladder, but you
could not get to the toilet fast enough?
☐ c. Without physical activity or a sense of urgency?
☐ d. About as equally as often with physical activities as with a sense of urgency?
DeRnitions of the type of urinary incontinence are based on responses to Question 3:
Response to Question 3 Type of incontinence
a. Most often with physical activity. Stress only or stress

predominant.
b. Most often with the urge to empty Urge only or urge predominant.
the bladder.
c. Without physical activity or sense of Other cause only or other cause

urgency. predominant.
d. About equally with physical activity Mixed.

and sense of urgency.
342
Further information
Types of urinary incontinence

There are four common types of urinary incontinence. When diagnosing a patient with incontinence, it
is important to distinguish between urge incontinence and stress incontinence because treatment and
management differ.7
• Stress incontinence is the leaking of urine that may occur during exercise, coughing, sneezing,
laughing, walking, lifting or playing sport. This is more common in women, although it also
occurs in men, especially after prostate surgery. Pregnancy, childbirth and menopause are the
main contributors to stress incontinence.
• Urge incontinence is a sudden and strong need to urinate. It is often associated with frequency
and nocturia, and is often due to having an overactive or unstable bladder, neurological
condition, constipation, enlarged prostate or a history of poor bladder habits.
• Mixed incontinence is a combination of stress and urge incontinence and is most common in
older women.
• OverUow incontinence results from bladder outaow obstruction or injury. Its symptoms may be
confused with those of stress incontinence.
Case Ending
Although there is no evidence to screen for urinary incontinence in the general, asymptomatic
population, GPs should take a proactive approach by asking about urinary symptoms in at-risk groups
during routine appointments. This is because many patients can be embarrassed by urinary
incontinence and not raise the issue with their GP.1 Some patients may also see it as a ‘normal part of
ageing’ and not realise that treatments are available.1
A list of people who may be at risk of urinary incontinence is given in SpeciNc populations.
It is important to approach the topic with sensitivity. Consider probing statements, such as ‘Other
people with [state conditions of higher risk here] have had problems with their waterworks [bladder
control]…’
Prevention of urinary incontinence

Changes that patients can make in order to prevent urinary incontinence can include:8
• losing weight
• quitting smoking
• reducing caffeine and alcohol intake
• addressing constipation by eating plenty of Nbre, fruits and vegetables
• exercising for 30 minutes most days
• practising good toilet habits.
343
It is important that people at risk drink plenty of water, because reducing water intake can worsen
bladder control issues.
There is some evidence to suggest that pelvic aoor exercises may reduce the prevalence of urinary
incontinence in antenatal women in late pregnancy and postpartum.10 However, the evidence is
insuscient to determine whether pelvic aoor exercises are an effective preventive activity to prevent
urinary incontinence more than one year after birth.9 People with urinary incontinence can be at risk of
falls,3,10 mental health3,4 and skin conditions.11

peoples
There are no additional recommendations for this speciNc population.
SpeciEc populations
People at higher risk of urinary incontinence include:3,4,6
• Women, in particular, women who:

◦ are prenatal and postnatal,
◦ have had children vaginally, had an assisted delivery or delivered a large baby
◦ are overweight or obese
◦ have had a hysterectomy
◦ report constipation
• Men who have had prostate surgery
• Those with respiratory conditions, diabetes, stroke, heart conditions, recent surgery,
neurological disorders, disability and multimorbidity
• Those on polypharmacy and on medications that may aggravate urinary incontinence
• Frail elderly people or long-term residents of care facilities.
Evidence is limited about the prevalence of incontinence among culturally and linguistically diverse and
sex and gender diverse communities.4
Resources
Guidance about urinary incontinence in the setting of supported accommodation: Urinary incontinence
delines/silver-book/part-a/urinary-incontinence) , RACGP aged care clinical guide (Silver Book) – Part A
GP resource about pelvic aoor muscle training for women with stress, urge or mixed urinary
incontinence: Pelvic aoor muscle training: urinary incontinence (https://www.racgp.org.au/clinical-resou
rces/clinical-guidelines/handi/conditions/musculoskeletal/pelvic-aoor-muscle-training-urinary-incontin
ence) , Handbook of non-drug interventions (HANDI) | RACGP
344
References
1. Pizzol D, Demurtas J, Celotto S, et al. Urinary 7. National Institute for Health and Care
incontinence and quality of life: A systematic Excellence (NICE). Urinary incontinence and
review and meta-analysis. Aging Clin Exp Res. pelvic organ prolapse in women: Management.
2021;33(1):25-35. doi: 10.1007/ NICE guideline (https://www.nice.org.uk/guidanc
s40520-020-01712-y. e/ng123) [NG123]. NICE, 2019 [Accessed 2
2. Deloitte Access Economics. The economic February 2024].
impact of incontinence in Australia. Continence 8. Continence Foundation of Australia. About
Foundation of Australia; 2011 (https://www.conti continence: Prevention. Continence Foundation
nence.org.au/resource/deloitte-access-economic of Australia, 2021 (https://www.continence.org.a
report-economic-impact-incontinence-australi u/about-continence/prevention) [Accessed 27
a?v=7396) [Accessed 2 February 2024]. April 2023].
3. The Royal Australian College of General . Woodley SJ, Boyle R, Cody JD, Mørkved S, Hay‐
Practitioners (RACGP). RACGP aged care clinical Smith EJC. Pelvic floor muscle training for
guide (Silver Book). 5th edn. RACGP, 2019 (http prevention and treatment of urinary and faecal
s://www.racgp.org.au/silverbook) [Accessed 2 incontinence in antenatal and postnatal women.
February 2024]. Cochrane Database Syst Rev
2017;12(12):CD007471. doi: 10.1002/
4. Australian Institute of Health and Welfare
14651858.CD007471.pub3. [Accessed 27 April
(AIHW). Incontinence in Australia. AIHW; 2013 (ht
2023].
tps://www.aihw.gov.au/reports/disability/incontin
ence-in-australia/summary) [Accessed 2 1 . Moon S, Chung HS, Kim YJ, et al. The impact of
February 2024]. urinary incontinence on falls: A systematic review
and meta-analysis. PLoS One
5. Nelson HD, Cantor A, Pappas M, Miller L.
2021;16(5):e0251711. doi: 10.1371/0251711.
Screening for urinary incontinence in women: A
systematic review for the Women's Preventive
Services Initiative. Ann Intern Med 11. Bliss DZ, Mathiason MA, Gurvich O, et al.
2018;169(5):311–19. doi: 10.7326/M18-0225. Incidence and predictors of incontinence-
[Accessed 2 February 2024]. associated skin damage in nursing home
residents with new-onset incontinence. J Wound
6. Brown JS, Bradley CS, Subak LL, et al. The
Ostomy Continence Nurs 2017;44(2):165–71. doi:
sensitivity and specificity of a simple test to
10.1097/WON.0000000000000313. [Accessed 27
distinguish between urge and stress urinary
April 2023].
incontinence. Ann Intern Med. 2006 May
16;144(10):715–23. doi: 10.7326/
0003-4819-144-10-200605160-00005. [Accessed
2 February 2024].
345
Vision
Vision
Miscellaneous | Vision
Screening age bar
0-9* 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 ≥80
*Between 3 and 5 years.

It is estimated that over 13 million Australians had one or more chronic (long-term) eye conditions in
2017–18, with chronic eye conditions affecting 93% of people aged ≥65 years.1 Conditions such as
cataracts, macular degeneration, glaucoma and diabetic retinopathy can lead to blindness if left
untreated.1 Declining vision impacts the everyday quality of life of the patient2 and contributes to injury
and morbidity.3 Open-angle glaucoma prevalence increases with age after age 40 years and is more
common in people of Caucasian, Asian and African ethnicity.
Aboriginal and Torres Strait Islander peoples aged >40 years have nearly three times the rate of vision
loss of other Australians.4,5
 Screening
346
Vision
Vision screening in children to detect amblyopia, or Conditionally Once, 6
its risk factors, is recommended. recommended between the

ages of 3
Risk factors include: and 5 years
• strabismus
• uncorrected refractive errors (eg myopia,
hyperopia and astigmatism)
• anisometropia
• media opacity.
Additional risk factors include:

• family history in a Nrst-degree relative
• prematurity
• low birth weight
• maternal substance abuse
• maternal smoking during pregnancy
• low levels of parental education.
7,8
Visual acuity screening in the general population is Generally not N/A
not recommended, because of insuscient recommended
evidence.
9
Glaucoma screening in the general population Generally not N/A
(without increased risk factors) is not recommended
recommended, because of insuscient evidence.
6
Vision screening in children aged <3 years is not Generally not N/A
recommended, because of insuscient evidence. recommended
7
Screening for primary open-angle glaucoma in the Generally not N/A
general population aged ≥40 years is not recommended
recommended, because of insuscient evidence.
 Case Ending
347
Vision
Identify people aged >50 years at high risk of Conditionally Frequency 9,10
glaucoma and refer to an optometrist/ recommended of follow up

ophthalmologist for further assessment. determined
by the
People at higher risk of glaucoma include patients individual
aged >50 years with: patient’s eye
• diabetes assessment.
• myopia
• long-term steroid use
• migraine and peripheral vasospasm
• abnormal blood pressure
• history of eye trauma.
11
Advise good eye care to help prevent eye strain Practice point N/A
and vision problems:
• reduce ocular exposure to ultraviolet B
light to reduce risk of cataracts (e.g.,
wearing a hat and sunglasses when
outdoors),
• wear any prescribed glasses or contact
lenses,
• wearing eye protection (particularly for
people with occupations or hobbies who
may be at risk of getting objects or
chemicals in their eyes),
• rest eyes if using screens for long periods
of time to reduce eye strain,
• quit smoking,
• eat plenty of fruits and vegetables.
348
Vision
Further information
Vision screening: Children aged <3 years

Newborn vision screening in Australia is typically undertaken in hospitals, soon after the baby is born.
However, there is insuscient evidence to recommend routine vision screening in primary care in
children aged <3 years. Children aged <3 years are often unable to cooperate with some of the clinical
screening tests performed in general practice, such as visual acuity testing, and therefore may lead to
false positive results.6
Vision screening: Children aged 3–5 years

The purpose of vision screening between the ages of 3 and 5 years is to detect any vision problems, but
primarily to detect amblyopia. Amblyopia is more commonly known as ‘lazy eye’. It typically only occurs
in one eye, but occasionally occurs in both.
Optometry Australia guidelines (https://www.optometry.org.au/wp-content/uploads/Professional_supp

ort/Guidelines/optometry_australia_paediatric_eye_health_and_vision_care_guidelines_-_august_201
6.pdf) recommend the following techniques to measure acuity in children aged 3–5 years. The Broken
Wheel Test is a possible alternative if the below tests cannot be conducted:12
• Patti Pics or Lea Chart at 3 metres or 6 metres

• Snellen chart at 6 metres – use multiple-line presentation or crowding bars to increase
sensitivity of detection of amblyopia. Single-line presentations with crowding bars can also be
considered.
Glaucoma
Glaucomas are a group of relatively common optic neuropathies in which there is pathological loss of
retinal ganglion cells, progressive loss of sight and associated alteration in the retinal nerve Nbre layer
and optic nerve head. While there is no evidence for population screening for primary open-angle
glaucoma,9 GPs have an important role in identifying those at increased risk for glaucoma and advising
them to attend regular, fully comprehensive eye examinations with an optometrist. Open-angle
glaucoma can be identiNed with optimal coherence tonography (high sensitivity), automated visual Neld
testing (high sensitivity), tonometry (lower sensitivity) and visualisation of the optic disc (lower
sensitivity). Management to reduce intraoccular pressure slows progression of glaucoma. However,
there are currently no tools available that can identify patients’ individual risk, or for whom screening
may be more beneNcial.9
Assessing Etness to drive

The Austroads Assessing Fitness to Drive guidelines include a subsection on Vision and eye disorders
(https://austroads.com.au/publications/assessing-Ntness-to-drive/ap-g56/vision-and-eye-disorders/me
dical-standards-for-licensing-11) . This provides information on the effects of vision and eye disorders
349
Vision
on driving, assessment and management guidelines, and medical standards for licensing.

peoples
following sections from Chapter 6: Eye health of the National guide to a preventive health assessment
for Aboriginal and Torres Strait Islander people:
• Visual acuity (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guideli

nes/view-all-racgp-guidelines/national-guide/chapter-6-eye-health/visual-acuity)
• Trachoma and trichiasis (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-r
acgp-guidelines/view-all-racgp-guidelines/national-guide/chapter-6-eye-health/trachoma-and-tr
ichiasis)
SpeciEc populations
People at greater risk of visual impairment and loss include:8
• older people
• people with diabetes
• people with family history of vision impairment
• smokers (current or previous).
Older people
It should be determined whether the patient is wearing up-to-date prescription spectacles. Also assess
whether there is a possibility of falls, or if the patient is no longer capable of managing a bifocal, trifocal
or multifocal prescription.
Resources
Guidelines for screening and preventive care in Aboriginal and Torres Strait Islander people:
Visual acuity (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/vie
w-all-racgp-guidelines/national-guide/chapter-6-eye-health/visual-acuity) , National guide to a preventive
health assessment for Aboriginal and Torres Strait Islander people (https://www.racgp.org.au/clinical-res
ources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/national-guide/chapter-6-eye-he
alth/visual-acuity) | RACGP
Trachoma and trichiasis (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-gui
delines/view-all-racgp-guidelines/national-guide/chapter-6-eye-health/trachoma-and-trichiasis) ,
National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people (http
s://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guideline
s/national-guide/chapter-6-eye-health/trachoma-and-trichiasis) | RACGP
350
Vision
Screening guidelines for diabetes-related eye disease, such as diabetic retinopathy: Microvascular
complications: Diabetes-related eye disease (https://www.racgp.org.au/clinical-resources/clinical-guide
lines/guidelines-by-topic/view-all-guidelines-by-topic/chronic-disease/diabetes/microvascular-complica
tions-diabetes-related-eye-d) , Management of type 2 diabetes: A handbook for general practice (http
s://www.racgp.org.au/clinical-resources/clinical-guidelines/guidelines-by-topic/view-all-guidelines-by-topi
c/chronic-disease/diabetes/microvascular-complications-diabetes-related-eye-d) | RACGP Guidelines
for assessing Ntness to drive: Assessing Ntness to drive (https://austroads.com.au/publications/asses
sing-Ntness-to-drive/ap-g56/about-this-publication) | Austroads (https://austroads.com.au/publication
s/assessing-Ntness-to-drive/ap-g56/about-this-publication) The Royal Australian and New Zealand
College of Ophthalmologists (RANZCO) referral pathways for age-related macular degeneration,
diabetic retinopathy and glaucoma management: Collaborative care (https://ranzco.edu/home/health-p
rofessionals/collaborative-care-2/) | RANZCO (https://ranzco.edu/home/health-professionals/collabora
tive-care-2/)
References
1. Australian Institute of Health and Welfare. Eye . Clarke EL, Evans JR, Smeeth L. Community
health. Cat. no. PHE 260. Canberra: AIHW, 2021. screening for visual impairment in older people.
Available at: (https://www.aihw.gov.au/reports/ey Cochrane Database Syst Rev
health/eye-health) [Accessed 27 April 2023]. 2018;2(2):CD001054. doi: 10.1002/
14651858.CD001054.pub3. [Accessed 27 April
2. Purola P, Koskinen S, Uusitalo H. Impact of vision
on generic health-related quality of life – A 2023].
systematic review. Acta Ophthalmol . Chou R, Bougatsos C, Jungbauer R, et al.
2023;101(7):717–28. doi: 10.1111/aos.15676. Screening for impaired visual acuity in older
[Accessed 27 April 2023]. adults: A systematic review for the US Preventive
3. National Aboriginal Community Controlled Health Services Task Force. Evidence Synthesis, No.
Organisation; The Royal Australian College of 213. Agency for Healthcare Research and Quality
General Practitioners. National guide to a (US), 2022 (https://www.ncbi.nlm.nih.gov/books/
preventive health assessment for Aboriginal and NBK580929) [Accessed 8 April 2024].
Torres Strait Islander people. 3rd edn. RACGP, . US Preventive Services Task Force; Mangione C,
2018. [Accessed 27 April 2023]. Barry M, et al. Screening for primary open-angle
4. Australian Institute of Health and Welfare. Eye glaucoma: US Preventive Services Task Force
health measures for Aboriginal and Torres Strait Recommendation Statement. JAMA
Islander people 2022: Interactive data. AIHW, 2022;327(20):1992–97. doi: 10.1001/
2023 (https://www.aihw.gov.au/reports/indigeno jama.2022.7013. [Accessed 8 April 2024].
us-australians/indigenous-eye-health-measures-2 1 . Patient. Primary open-angle glaucoma:
22 data/contents/about) [Accessed 27 April Symptoms, assessment and management.
2023]. Patient, 2022 (https://patient.info/doctor/primar
5. Foreman J, Xie J, Keel S, et al. The prevalence y-open-angle-glaucoma) [Accessed 8 April 2024].
and causes of vision loss in Indigenous and non- 11. Vision Australia. Maintaining eye health.
Indigenous Australians: The National Eye Health Vision Australia, 2023 (https://www.visionaustrali
Survey. Ophthalmology 2017;124(12):1743–52. a.org/services/eye-conditions/eye-health)
doi: 10.1016/j.ophtha.2017.06.001. [Accessed 27 [Accessed 27 April 2023].
April 2023].
12. Optometry Australia. Clinical practice guide:
6. Jonas DE, Amick HR, Wallace IF, et al. Vision Paediatric eye health and vision care. Optometry
screening in children ages 6 months to 5 years: A Australia, 2016 (https://www.optometry.org.au/w
systematic review for the US Preventive Services p-content/uploads/Professional_support/Guideli
Task Force. JAMA 2017;318(9):845–58. doi: nes/optometry_australia_paediatric_eye_health_a
10.1001/jama.2017.9900. PMID: 28873167. nd_vision_care_guidelines_-_august_2016.pdf)
[Accessed 27 April 2023]. [Accessed 27 April 2023].
351
Vision
Supplementary material
352
Acknowledgements
Acknowledgements
ConRict of interests
This publication has been produced in accordance with the rules and processes outlined in the RACGP
Conaict of Interest and Related Party Transactions Policy.
Acknowledgements
The RACGP gratefully acknowledges the generous contribution of the following authors, contributors
and experts in the development of this guideline.
Red Book Executive Committee
Professor Danielle Mazza AM Chair, Red Book Executive Committee Red Book co-clinical lead –
Women’s health, breast cancer, cervical cancer Head, Department of General Practice, School of Public
Health and Preventive Medicine, Faculty of Medicine Nursing and Health Sciences, Monash University
Professor Mark Morgan Member, Red Book Executive Committee Red Book clinical lead –
Miscellaneous Chair, RACGP Expert Committee – Quality Care Professor of General Practice and Head
of MD program, Faculty of Health Sciences and Medicine, Bond University Professor Nicholas Zwar
Member, Red Book Executive Committee Executive Dean, Health Sciences and Medicine, Faculty of
Health Sciences and Medicine, Bond University Professor Paul Glasziou AO Member, Red Book
Executive Committee Institute Director, Institute for Evidence-Based Healthcare Research Professor,
Faculty of Health Sciences and Medicine, Bond University
Red Book Editorial Committee
Professor Jon Emery Red Book clinical lead – Cancer and genetics Herman Professor of Professor of
Primary Care Cancer Research, University of Melbourne Professor Nigel Stocks Red Book clinical lead
– Cardiovascular Head of the Discipline of General Practice, University of Adelaide Dr James Best Red
Book clinical lead – Development and behaviour General Practitioner Chair, Child and Young Person's
Health – RACGP SpeciNc Interest Group Dr George Forgan-Smith Red Book clinical lead – Infectious
diseases General Practitioner Professor Kelsey Hegarty Red Book clinical lead – Injury prevention
Professor, Family Violence Prevention, Royal Women’s Hospital and University of Melbourne Director,
Safer Families Centre of Research Excellence Associate Professor Caroline Johnson Red Book clinical
lead – Mental health and substance abuse Academic Specialist – Primary Care (Medical Education),
General Practice and Primary Care, University of Melbourne Professor Mark Harris AO Red Book
clinical lead – Metabolic Centre for Primary Health Care and Equity, University of New South Wales Dr
Dan Ewald Red Book clinical lead – Musculoskeletal disorders General Practitioner and Public Health
Physician Adjunct Associate Professor, Medical School, University of Sydney Member, RACGP Expert
Committee – Quality Care Associate Professor Magdalena Simonis Red Book co-Clinical lead –
Women’s health Senior Honorary Clinical Research Fellow and Medical Student Teaching, Department
of General Practice, University of Melbourne Member, RACGP Expert Committee – Quality Care
353
Acknowledgements
Chapter contributors
Professor Anne Cust Contributor Red Book – Skin cancer Cancer Epidemiologist Deputy Director of the
Daffodil Centre Professor Dimity Pond Contributor Red Book – Falls; Dementia General Practitioner
Chair, RACGP Expert Committee – Research Dr Michael Tam Contributor Red Book – Alcohol;
Depression Director, Primary and Integrated Care Unit, South Western Sydney Local Health District
Conjoint Senior Lecturer, School of Population Health, University of New South Wales Member, RACGP
Expert Committee – Quality Care Associate Professor Rowena Ivers Contributor Red Book – Alcohol;
and Smoking and nicotine vaping Academic Leader Community Based Health Education and Chair of
Phase 3 Graduate School of Medicine, School of Medicine, Faculty of Science, Medicine and Health,
University of Wollongong Member, RACGP Expert Committee – Quality Care Dr Gary Deed Contributor
Red Book – Diabetes General Practitioner Chair, Diabetes – RACGP SpeciNc Interest Group Member,
RACGP Expert Committee – Quality Care Dr Monica Taylor Contributor Red Book – Hip dysplasia
General Practitioner Dr Karen Spielman Contributor Red Book – Eating disorders General Practitioner
Primary Care Mental Health Advisor, Inside Out Institute for Eating Disorders
Methodology expert
Dr Agnes Wilson, PhD Director, hereco
RACGP project team
Mr Stephan Groombridge National Manager, Practice Management, Standards and Quality Care Ms Su
San Mok Program Manager, Quality Care Ms Lynelle Cogan Senior Project Oscer, Quality Care Ms
Sue Gedeon Senior Project Oscer, Quality Care
Reviewers
The RACGP gratefully acknowledges the expert reviewers and representatives from the organisations
who contributed scholarly feedback. Members of the RACGP Aboriginal and Torres Strait Islander
Health faculty Marie Hobden Foundation for Alcohol, Research and Education Dr Marguerite Tracy
General Practitioner, University of Sydney and member, RACGP Expert Committee – Quality Care Ania
Mazurkiewicz Emerging Minds, National Workforce Centre for Child Mental Health Dannii Dougherty
National Heart Foundation of Australia Dr Brett Montgomery General Practitioner Joanna McGlone
Cancer Council Australia Dr Lucie Monet General Practitioner, HealthPathways SA Dr Sandy Minck
General Practitioner Dr Kenneth McCroary General Practitioner and member, RACGP Expert Committee
– Quality Care Jennie Haarsager Queensland Health Dr Claire Nightingale University of Melbourne
and Cancer Australia Associate Professor Vivienne Milch Cancer Australia Sophia Avery WA Cervical
Cancer Prevention Program Associate Professor Christopher D Hogan Coeliac Australia – Medical
Advisory Committee Professor Barbara Leggett Gastroenterological Society of Australia Meike
Fruechtl Gastroenterological Society of Australia Associate Professor Joel Rhee General Practitioner,
University of New South Wales, member, RACGP Expert Committee – Research, and Chair, Cancer and
Palliative Care – RACGP SpeciNc Interest Group Breonny Robson Kidney Health Australia Julia
Schindlmayr Dieticians Australia Julie Krieger Australasian Society of Developmental Paediatricians
Dr Georgia Rigas General Practitioner, St George Private Hospital, Kogarah, Sydney Joanna Munro
354
Acknowledgements
Health and Wellbeing Queensland Dr Cathryn Hester General Practitioner and Chair, RACGP
Queensland faculty council Professor Claire Jackson Centre For Health System Reform and
Integration, University of Queensland and Mater Research Institute Dr Jenny Job University of
Queensland and Mater Research Institute Dr Sue Page General Practitioner and Strategic Adviser for
NDIS Dr Leela Arthur General Practitioner, Brisbane South HealthPathways Adrienne Hoare (Project
Manager) on behalf of the Hepatitis B Program Manager (Sami Stewart), HBV National Advisory Group
and key sector partners Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine Brett
Stevens (Project Manager) on behalf of the Hepatitis C Program Manager (Phoebe Schroder), HCV
National Advisory Group and key sector partners Australasian Society for HIV, Viral Hepatitis and Sexual
Health Medicine Courtney Gibbs (Sexual Health Program Manager) on behalf of the Sexual Health
National Advisory Group Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine Dr
Nathan Ryder NSW Health, NSW STI Programs Unit Professor Dorothy Keefe Cancer Australia Lauren
Dalton National Centre for Immunisation Research and Surveillance Australia Royal Australian and
New Zealand College of Obstetricians and Gynaecologists Paige Preston Lung Foundation Australia
Adjunct Professor Peter Heathcote Prostate Cancer Foundation of Australia and Co-chair, PSA
Guidelines Review Anne Savage CEO, Prostate Cancer Foundation of Australia Professor Jeff Dunn
AO Prostate Cancer Foundation of Australia Yixin Tan Editor, Therapeutic Guidelines Jane O’Connor
Senior Editor, Therapeutic Guidelines Associate Professor Weranja Ranasinghe Urological Society of
Australia and New Zealand Associate Professor David Smith Daffodil Centre, Cancer Council NSW and
University of Sydney Adjunct Clinical Associate Professor Moira Junge CEO, Sleep Health Foundation
Professor Jane Hocking Melbourne School of Population and Global Health, University of Melbourne
Professor Jenny Doust Australian Women and Girls’ Health Research Centre, University of Queensland
Dr Loren Rose Royal Australian and New Zealand College of Ophthalmologists Dr Audrey Murugesan
Royal Australian and New Zealand College of Ophthalmologists Dr Caroline Catt Royal Australian and
New Zealand College of Ophthalmologists and Chair, Australian and New Zealand Paediatric
Ophthalmology Society Dr Helene Cass Royal Australian and New Zealand College of
Ophthalmologists Healthy Male Australia
355
Disclaimer
Disclaimer
Guideline disclaimer
The information set out in this publication is current at the date of Nrst publication and is intended for
use as a guide of a general nature only and may or may not be relevant to particular patients or
circumstances. Nor is this publication exhaustive of the subject matter. Persons implementing any
recommendations contained in this publication must exercise their own independent skill or judgement
or seek appropriate professional advice relevant to their own particular circumstances when so doing.
Compliance with any recommendations cannot of itself guarantee discharge of the duty of care owed
to patients and others coming into contact with the health professional and the premises from which
the health professional operates. Whilst the text is directed to health professionals possessing
appropriate qualiNcations and skills in ascertaining and discharging their professional (including legal)
duties, it is not to be regarded as clinical advice and, in particular, is no substitute for a full examination
and consideration of medical history in reaching a diagnosis and treatment based on accepted clinical
practices. Accordingly, The Royal Australian College of General Practitioners Ltd (RACGP) and its
employees and agents shall have no liability (including without limitation liability by reason of
negligence) to any users of the information contained in this publication for any loss or damage
(consequential or otherwise), cost or expense incurred or arising by reason of any person using or
relying on the information contained in this publication and whether caused by reason of any error,
negligent act, omission or misrepresentation in the information.
Recommended citation
The Royal Australian College of General Practitioners. Guidelines for preventive activities in general
practice. 9th edn, updated. East Melbourne, Vic: RACGP, 2018.
The Royal Australian College of General Practitioners Ltd 100 Wellington Parade East Melbourne,
Victoria 3002 Australia Tel 03 8699 0414 Fax 03 8699 0400 www.racgp.org.au (https://www.racgp.or
g.au/)
356
Provided under licence

Terms and conditions of use
This resource is provided under licence by the RACGP. Full terms are available on the licence terms
page (https://www.racgp.org.au/licence-terms) .
In summary, you must not edit or adapt it or use it for any commercial purposes.
You must also acknowledge the RACGP as the owner.
357
Appendices
358
Appendices
Appendix 1 - Methods report (https://www.racgp.org.au/wip-sites/preventive-activities-in-general-practi
ce/appendices/appendix-1-methods-report)
359
Appendix 1 - Methods report
Background
GRADE methods
GRADE is an internationally recognised systematic and transparent approach for developing and
presenting summaries of evidence and deriving evidence-based recommendations. GRADE methods
are used by many international organisations, including the World Health Organization and the
Cochrane Collaboration. The NHMRC also recommends GRADE for the development of Australian
guidelines.
GRADE methods were developed with the aim of standardising summaries of evidence, and the
development and presentation of clinical practice guidelines around the world. The approach leads to
the generation of evidence-based recommendations that are graded in terms of strength (strong or
conditional) and direction (for or against).
Using GRADE principles for developing the Red book 10th

edition
Although the robustness of the full GRADE approach is not in question, adopting a full GRADE approach
is time and resource intensive, and challenging for the breath of screening and prevention topics
covered by the Red book. (For example, it is estimated that adopting a full GRADE approach to develop
recommendations de novo across the 64 topics proposed for the Red Book would take more than two
years and cost in excess of $1 million.) GRADE is designed to assess prespeciNed outcomes that are
based on an underlying clinical question (usually developed in the PICO [population, intervention,
comparator/control and outcomes] format). The development of guidance in the Red Book has not
been framed in this way, and the Red Book instead relies on speciNcation of the topics to be covered.
Based on the above, the RACGP decided to adopt a pragmatic approach for the development of the Red
Book 10th edition, reaecting option six for the published criteria for using GRADE: The strength of
recommendations should be assessed using two categories (For or Against an option) and deNnitions for
each category such as strong and conditional that are consistent with the deNnitions used by the GRADE
Working Group (although different terminology may be used).1,2 Details of the approach (methods and
process) for using GRADE principles in a pragmatic meta-guideline approach to update the Red Book
10th edition are described below.
360
Approach for the development of the Red book 10th

edition
The approach for developing the recommendations in the Red Book 10th edition consisted of the
following steps:
1. Scoping the topics to be covered by Red Book 10th edition

2. Identifying and assessing source guidelines (for recency, relevance and quality)
3. Extracting potentially suitable source recommendations (only those relevant to prevention and
screening)
4. Assessing potentially suitable source recommendations with consideration of:
◦ applicability to the Australian general practice context
◦ the feasibility of implementing the recommendations
◦ a comparison with recommendations and practice points in the Red Book 9th edition
◦ consistency with recommendations in other guidelines on the same topic
◦ the evidence base underpinning the recommendations
5. Adopting, adapting or discarding selected source recommendations through a considered
judgement process involving the chapter leads, topic working groups and/or the Red Book
Executive Committee
Where no source recommendations were available, advice was sought from chapter leads about
possible landmark studies, or whether any trials were underway, and targeted literature searches may
have been undertaken where necessary. Where evidence was identiNed, it was assessed and de novo
recommendations were developed if appropriate.
Scoping the topics to be covered

The list of topics to be covered in Red Book 10th edition was developed by reviewing the existing
coverage in the Red Book 9th edition, and through deliberation and consensus of the Executive
Committee. Consideration was given to areas that were not covered in the Red Book 9th edition, with a
total of 20 new topics addressed in the Red Book 10th edition (see “What’s New in the 10th edition of
the Red book (https://www.racgp.org.au/wip-sites/preventive-activities-in-general-practice/what-s-new-i
n-the-10th-ed-red-book) ”).
Selecting source guidelines

In identifying prevention and screening recommendations contained within relevant evidence-based
guidelines developed by others (referred to as ‘source guidelines’), preference was given to high-quality
Australian guidelines, followed by high-quality international guidelines that were judged to be applicable
to Australian general practice. This approach avoided duplicating existing syntheses of the research
literature and avoided the need to critically appraise primary research that had already been assessed
361
using reliable processes and tailored to the Australian setting. Australian and international evidence-
based guideline repositories were systematically searched. These repositories included websites of the
following organisations:
• Australian NHMRC
• Australian Government Department of Health and Aged Care
• UK National Institute for Health and Care Excellence (NICE)
• New Zealand Guidance Group (NZGG)
• Scottish Intercollegiate Guidelines Network (SIGN)
• USPSTF
• Canadian Task Force on Preventive Health Care (CTFPHC)
The criteria for assessing the suitability and quality of source guidelines following their identiNcation
are detailed in the table below.
Source Guideline Selection Criteria
Publication type (i.e., a clinical practice guideline developed using a recognised, evidence-based
approach such as GRADE, NICE methods, NHMRC FORM etc.)
Relevance to the clinical area that is in scope
Guidance applicable to a general practice setting
Published since 1 January 2016
Data extraction from accepted source guidelines

Following acceptance of a guideline as a source guideline (either Australian or international), the
following key information about the recommendation was entered into the data extraction template:
• the recommendation (including its strength and grade)

• the year of publication and date of evidence search
• the method used to identify and appraise evidence underpinning the recommendation
• the quality of the body of evidence/level of evidence (where reported by the source guideline).
Recommendations from multiple source guidelines were extracted where available.
Topics with no source guidelines

For existing Red Book 9th edition topics with no new recommendations from source guidelines,
targeted literature searches were conducted for landmark randomised controlled trials (RCTs)
published since 2016. For new topics with no new source recommendations, targeted literature
searches were conducted for high-quality systematic reviews published since 2010. For existing Red
Book 9th edition topics, the Nndings from the targeted literature searches were used to supplement the
362
existing recommendation, and were mapped to a GRADE-like recommendation for the Red Book 10th
edition. For topics where no source guideline was identiNed, targeted searches of systematic reviews of
evidence were conducted and consensus guidance (ie practice points) was developed where
appropriate.
Selecting source recommendations and practice points

Extracted source recommendations were compared with existing recommendations and practice points
from the Red Book 9th edition. Judgements regarding the suitability of new source recommendations
were made in the context of any existing Red Book guidance. Key considerations in selecting the Nnal
list of source recommendations were that:
• source recommendations were applicable for Australian general practice

• source recommendations from different source guidelines were consistent with each other (ie
advised actions in the same direction)
• differences between existing guidance and new source recommendations were highlighted
and underlying reasons for the differences identiNed
• any aspects of care for that topic that were not addressed by the source recommendations (ie
topic gaps) were identiNed.
In situations where inconsistencies across possible source recommendations could be resolved by the
chapter lead and topic working group, the matter was raised with the Red Book Executive Committee
for discussion and resolution. In making the Nnal selection of source recommendations for the chapter,
the chapter lead and the Red Book Executive Committee actively considered whether any apparent
changes in the direction of guidance since the Red Book 9th edition was reasonable. Changes were
highlighted and documented; for example, the publication of new primary studies may have changed a
recommendation from being neutral to being in favour of the use of an intervention. Another example of
changes to recommendations may have been related to changes to public funding of preventative or
screening activities since the publication of the Red Book 9th edition.
Process of developing Red book 10th edition

recommendations
The relevant chapter lead and the Red Book Executive Committee met virtually throughout 2022 and
2023 to consider the existing recommendations and potential source recommendations, and to review
the suitability of adopting or adapting or discarding source recommendations. At these meetings, the
underlying grade of recommendations and the level of evidence supporting the recommendation were
key parts of the review. Feedback on individual chapters was provided by the Red Book Executive
Committee.
363
Mapping adopted or adapted source recommendations to

GRADE-like recommendations
Each adopted/adapted source recommendation was mapped to a GRADE-like strength using a deNned
set of Red Book GRADE-like decision rules (see Grading conventions for recommendations in the Red
Book 10th edition). At times, developers of source guidelines used transparent methods to develop
evidence-based recommendations but relied on the wording of each recommendation to convey
strength rather than assigning a formal grade (typical in NICE guidelines from the UK). In these
situations, the strength of the source recommendation was inferred, and this was used as the basis of
the mapping for that recommendation. Examples of mapping ungraded source recommendations to
Red Book 10th edition GRADE-like recommendations are detailed below. Assessing the suitability of
potential recommendations from source guidelines and transitioning to GRADE-like recommendations
occurred through a considered judgement process by chapter leads in collaboration with the Red Book
Executive Committee for all chapters in the Red Book 10th edition.
Grading conventions for recommendations in the Red

book 10th edition
Although the GRADE working group advises that the strength of recommendations should be assessed
using two categories (for or against an option) and deNnitions for each category, such as ‘strong’ and
‘conditional’, for improved implementation across general practice settings, that terminology has been
slightly modiNed for the Red Book 10th edition. ‘Recommended (Strong)’ or ‘Not recommended
(Strong)’ was used in Red Book 10th edition for strong recommendations, and ‘Conditionally
recommended’ or ‘Generally not recommended’ was used for conditional recommendations, where
there may be uncertainty over the balance of beneNts (eg when the evidence quality was low or very low
or when personal preferences or costs were expected to impact the decision). Strong
recommendations are those for which the RACGP is very conNdent that the desirable effects of an
intervention outweigh its undesirable effects (strong recommendation for an intervention) or that the
undesirable effects of an intervention outweigh its desirable effects (strong recommendation against
an intervention). A strong recommendation implies that most people will be best served by the
recommended course of action. Strong recommendations are typically based on high-certainty
evidence (ie high conNdence in the estimate of the effect of an intervention). Strong recommendations
may recommend in favour of an intervention (when there is high conNdence of net beneNt) or against an
intervention (when there is high conNdence of net harm). However, there are circumstances in which a
strong recommendation could have been made based on low- or very low-certainty evidence or when
there is absence of evidence. Conditional recommendations are those for which the RACGP regards the
desirable effects to probably outweigh the undesirable effects (conditional recommendation in favour
of an intervention), or undesirable effects to probably outweigh the desirable effects (conditional
recommendation against an intervention), but appreciable uncertainty exists. Conditional
recommendations (termed ‘Conditionally recommended’ or ‘Generally not recommended’ in the Red
Book 10th edition) are made when the certainty of evidence is lower, when the margin between
desirable and undesirable consequences is small and the balance depends on patient values and
preferences, or when there is high variability in the values and preferences of patients. In certain cases
364
where a conditional recommendation for an intervention is made, clinicians are encouraged to engage
in shared decision making to recognise that different choices will be appropriate for individual patients
and to help each person arrive at a management decision consistent with their values and preferences.
Practice points have been provided to address important aspects of care that are not addressed by
relevant source guidelines, or where evidence was lacking.
GRADE-like decision rules for Red book 10th edition

The Red book GRADE-like decision rules for consistently mapping grading across various source
guidelines are described below.
Mapping grading from source recommendations developed

using GRADE methods to Red book 10th edition GRADE-like
recommendations
The tables below describe the mapping of source recommendations developed using the GRADE
approach to GRADE-like recommendation grading in the Red Book 10th edition. The key domains from
the GRADE evidence-to-decision table of the source guideline were explicitly considered (ie values and
preferences of people receiving preventive care; equity considerations; acceptability; feasibility of
implementation; resource use/cost implications). ModiNcations to the wording of source
recommendations may have been proposed by chapter leads or the Red Book Executive Committee to
reaect such considerations. If the wording of the source recommendation is changed but the intention
of the recommendation is not, then it is likely that the same strength will apply to the recommendation
in the Red Book 10th edition. Where there were concerns regarding the directness of the source
recommendation (eg it is from an international guideline and reaects a different health setting), the Red
Book 10th edition recommendation may have been mapped to a lower strength than the source
recommendation. Any downgrading of the strength of recommendations is clearly documented. The
following table details the transition of GRADE source recommendations to Red Book 10th edition
GRADE-like conventions:
Source recommendation (GRADE) strength and Recommendation in Red book 10th

direction edition strength and direction
Strong in favour Recommended (Strong)
Conditional in favour Conditionally recommended
Conditional against Generally not recommended
Strong against Not recommended (Strong)
365

using NHMRC FORM methods to Red book 10th edition
GRADE-like recommendations
The table below describes the mapping of source recommendations developed using NHMRC FORM
methods to GRADE-like recommendation grading in the Red Book 10th edition. As for mapping from
GRADE source recommendations to the Red Book 10th edition GRADE recommendations (see above),
when mapping a source recommendation from FORM, consideration was given to the directness/
applicability of the source recommendation to Australian general practice.
Source recommendation (FORM) strength and Recommendation in Red book 10th

A (in favour) Recommended (Strong)
B (in favour) Conditionally recommended
C (in favour) Conditionally recommended
D (in favour) Conditionally recommended
D (against) Generally not recommended
C (against) Generally not recommended
B (against) Generally not recommended
A (against) Not recommended (Strong)
Mapping ungraded source recommendations to Red book

10th edition GRADE-like recommendations
The table below describes the mapping of source recommendations that are ungraded to GRADE-like
recommendation grading in the Red Book 10th edition. Some examples of the types of phrasing that
can be used to convey the strength of recommendations in source guidelines are given below.
Sometimes ‘recommendations’ are actually evidence statements (eg ‘There is insuscient evidence to
recommend for or against xxx …’). If a source recommendation was phrased in this way, it was
transformed into an active voice during the mapping process. The phrasing used across different
source guidelines was inconsistent at times and some degree of interrogation of the source guideline
366
was required to gain a sense of the underlying evidence base and the intention of the authors with their
choice of wording. The following table details the transition of ungraded recommendations to Red Book
10th edition GRADE-like conventions:
Source recommendation (ungraded) strength Recommendation in Red book 10th

and direction edition strength and direction
‘It is recommended that xxx should be done …’

Recommended (Strong)
‘Do xxx …’
‘Consider doing xxx …’ Conditionally recommended
‘Xxx may or may not be done …’ Generally not recommended
‘Xxx is not recommended …’ Generally not recommended
‘Xxx should not be done…’

Not recommended (Strong)
‘Do not do xxx …’

using U.S. Preventive Services Task Force methods to Red
book 10th edition GRADE-like recommendations
The USPSTF has a four-tiered grading system (Grades A–D) and an ‘insuscient evidence’ category.
When mapping USPSTF to GRADE-like recommendations in the Red Book 10th edition, consideration
was given to the directness/applicability of the source recommendation to Australian general practice.
The following table details the transition of grading of USPSTF recommendations to Red Book 10th
edition GRADE-like conventions:
Source recommendation (USPSTF) strength Recommendation in Red book 10th

A (in favour) Recommended (Strong)
B (in favour) Conditionally recommended
C (in favour) Conditionally recommended
D (in favour) Conditionally recommended
D (against) Generally not recommended
367
I (insuscient evidence) Not recommended (Strong)
Mapping from the Canadian Task Force on Preventive

Health Care recommendations to Red book 10th editionth
edition GRADE recommendations
The Canadian Task Force on Preventive Health Care (CTFPHC) recommendations are graded according
to GRADE. Whether a recommendation is strong or conditional is based on considerations such as
certainty in the effects of an intervention, including magnitude, as well as estimates of how patients
value and prioritise outcomes, the variability of these estimates and the wise use of resources.
The CTFPHC previously used the term ‘weak recommendation’, but has replaced this with the term
‘conditional recommendation’ to improve understanding and facilitate implementation of guidance,
based on feedback from clinician knowledge users. One reason for this change was the value that the
CTFPHC places on shared decision making, together with a need to better clarify when implementation
of a recommendation depends on circumstances such as patient values, resource availability or other
contextual considerations. Conditional recommendations based on patient values and preferences
require clinicians to recognise that different choices will be appropriate for different patients and that
those decisions must be consistent with each patient’s values and preferences.
When mapping the CTFPHC recommendations to the Red Book 10th edition grading convention,
consideration was given to the directness/applicability of the source recommendation to Australian
general practice. The following table details the transition of grading of CTFPHC GRADE
recommendations to Red Book 10th edition GRADE-like conventions:
Source recommendation (CTFPHC) strength Recommendation in Red book 10th

Strong recommendation Recommended (Strong)
Strong recommendation (against) Not recommended (Strong)
Conditional recommendation Conditionally recommended
Conditional recommendation (against) Generally not recommended
Mapping from the Medical Services Advisory Committee
368
evidence-based policy advice to Redbook 10th edition

GRADE recommendations
The Medical Services Advisory Committee (MSAC (http://www.msac.gov.au/) ) is a national health
technology assessment committee and, as such, does not produce clinical practice guidelines.
However, evidence assessments undertaken for the committee typically follow Cochrane and/or GRADE
methods for review and appraisal of primary evidence. MSAC is responsible for providing advice to
government on public funding of some preventive activities, notably regarding national screening
programs, such as those for cervical cancer. The funding recommendations by MSAC are essentially
binary: accept or reject. If the most recent recommendation available from MSAC is ‘Defer’, it is
proposed that such recommendations are handled as if they are a rejection. The following table details
the transition of grading of MSAC funding decisions to Red Book 10th edition GRADE-like conventions:
Source recommendation (MSAC) strength and Recommendation in Red book 10th

Accept Recommended
Reject Not recommended (Strong)
Deferred with no Nnal recommendation available

Not recommended (Strong)
yet
Mapping from the American Diabetes Association

recommendations to Red book 10th edition GRADE
recommendations
The American Diabetes Association (ADA) has a four-tiered grading system (Grades A–C and Grade E,
expert opinion category). Recommendations are assigned ratings of A, B or C depending on the quality
of evidence. Expert opinion (E) is a separate category for recommendations for which there is no
evidence from clinical trials, for which clinical trials may be impractical or for which there is conaicting
evidence. Recommendations with an ‘A’ rating are based on large, well-designed clinical trials or well-
done meta-analyses. Recommendations with lower levels of evidence may be equally important but are
not as well supported. The level of evidence supporting a given recommendation is noted either as a
heading for a group of recommendations or in parentheses after a given recommendation. The
following table details the transition of ADA grading to Red Book 10th edition GRADE-like conventions:
Source recommendation (ADA) strength and Recommendation in Red book 10th

A Recommended (Strong)
369
B Conditionally recommended
C Conditionally recommended
E (expert consensus or clinical experience) Practice point
Handling different strengths within a Red book

recommendation
In certain instances, different elements of a Red Book recommendation were derived from different
source recommendations. Different elements of a Red Book recommendation have different colour
coding to reaect the different sources, with practice points speciNcally called out.
References
1. GRADE. Welcome to the GRADE working group. 3. Schünemann H. Criteria for applying or using
GRADE, 2023 (https://www.gradeworkinggroup.or GRADE. GRADE working group, 2016 (https://ww
g/) [Accessed 16 October 2023]. w.gradeworkinggroup.org/docs/Criteria_for_usin
2. National Health and Medical Research Council g_GRADE_2016-04-05.pdf) [Accessed 16 October
(NHMRC). Guideline development. NHMRC, n.d (h 2023].
ttps://www.nhmrc.gov.au/research-policy/guideli 4. Klarenbach S, Sims-Jones N, Lewin G, et al.
ne-development) [Accessed 16 October 2023]. Recommendations on screening for breast
cancer in women aged 40–74 years who are not
at increased risk for breast cancer. CMAJ
2018;190:E1441–51. doi: 10.1503/cmaj.180463.
370

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1. Table of Abbreviations .......................................................................................................................

ACIR Australian Childhood Immunisation Register

ACQUIP Ambulatory Care Quality Improvement Project

ADA American Diabetes Association

AHMAC Australian Health Ministers Advisory Council

ANRQ Antenatal Risk Questionnaire

ATAGI Australian technical Advisory Group on Immunisation

AUDIT-C Alcohol Use Disorder Identi@cation Test – Consumption

BBV Blood-borne virus

BCC Basal cell carcinoma

BMD Bone mineral density

BMI Body mass index

BPD Borderline personality disorder

CAC Coronary artery calcium

CALD Culturally and linguistically diverse

CDC Centers for Disease Control and Prevention

CHAT Community health approaches to

CHC Combined hormonal contraception

COPE Centre of Perinatal Excellence

CTFPHC Canadian Task Force on Preventive Health Care

CVS Chorionic villus sampling

DASH Dietary Approaches to Stop Hypertension

DASS Depression Anxiety Stress Scales

DBAS Dysfunctional beliefs and attitudes about sleep

DDH Developmental dysplasia of the hip

DLCN Dutch Lipid Clinic Network

DXA Dual energy X-ray absorptiometry

EPDS Edinburgh Postnatal Depression Scale

ERSPC European Randomized study of Screening for Prostate Cancer

FASD Fetal alcohol spectrum disorder

FBG Fasting blood glucose

FPU First pass urine

FRAX® Fracture Risk Assessment Tool

FSRH Faculty of Sexual and Reproductive Healthcare

FXS Fragile X syndrome

GPCOG General Practitioner Assessment of Cognition

GPMHSC General Practice Mental Health Standards Collaboration

GRADE Grading of Recommendations, Assessment, Development and Evaluation

HANAA Here and Now Aboriginal Assessment

HANDI Handbook of Non-Drug Interventions

HCV Hepatitis C Virus

HIV Human immunode@ciency virus

HPV Human papillomavirus

IGT Impaired glucose tolerance

IPAV Intimate partner abuse and violence

KDCP Koori dementia care project

LARC Long Acting Reversible Contraception

LBC Liquid Based Cytology

MBS Medicare Bene@ts Schedule

MET Metabolic equivalent of task

MHT Menopausal hormone therapy

MRI Magnetic resonance imaging

MSAC Medical Services Advisory Committee

NBCSP National Bowel Cancer Screening Program

NCIRS National Centre for Immunisation Research and Surveillance

NDIS National Disability Insurance Scheme

NHMRC National Health and Medical Research Council

NHS National Health Service

NICE The National Institute for Health and Care Excellence

NIPS National Immunisation Program Schedule