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Prevention in General Practice

Last updated 31 May 2026 · General Practice

📋 Key Information Summary

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  • Preventive care is the cornerstone of Australian general practice, with GPs uniquely positioned to deliver primary, secondary, and tertiary prevention across the lifespan.
  • Primary prevention aims to prevent disease before it occurs — includes immunisation, lifestyle counselling, chemoprophylaxis, and environmental modifications.
  • Secondary prevention detects disease at an early, asymptomatic stage — includes screening programmes (BowelScreen, BreastScreen, National Cervical Screening), and cardiovascular risk assessment.
  • Tertiary prevention reduces complications and disability in established disease — includes chronic disease management plans (GPMP/TCA), rehabilitation, and palliative care.
  • Leading causes of death in Australia (2022): ischaemic heart disease, dementia (including Alzheimer's), cerebrovascular disease, lung cancer, chronic lower respiratory disease, and diabetes mellitus.
  • Cardiovascular disease (CVD) remains the leading cause of death overall; absolute CVD risk assessment using the Australian CVD Risk Calculator is recommended from age 45 (30 for Aboriginal and Torres Strait Islander peoples).
  • The National Immunisation Program (NIP) provides free vaccines for children, adolescents, pregnant women, Aboriginal and Torres Strait Islander peoples, and adults ≥65 years; catch-up schedules are available.
  • Cancer screening programmes: National Bowel Cancer Screening Program (faecal immunochemical test, ages 50–74), BreastScreen Australia (mammography, ages 50–74), and National Cervical Screening Program (HPV test, ages 25–74).
  • Behaviour modification using the 5As framework (Ask, Assess, Advise, Assist, Arrange) is evidence-based for smoking cessation, alcohol reduction, physical activity, and weight management.
  • Smoking prevalence has declined to approximately 10% of Australian adults; however, Aboriginal and Torres Strait Islander smoking rates remain approximately 37%, demanding targeted interventions.
  • Alcohol-related harm is a leading preventable burden of disease; NHMRC guidelines recommend ≤10 standard drinks per week and ≤4 on any single day.
  • Aboriginal and Torres Strait Islander peoples experience significantly higher rates of chronic disease, lower life expectancy, and face barriers to preventive care including geographic remoteness, cultural safety concerns, and systemic racism.
  • GP Management Plans (GPMPs) and Team Care Arrangements (TCAs) under Medicare enable structured chronic disease prevention and management, with MBS items 721 and 723.

Introduction & Australian Epidemiology

Preventive medicine is a fundamental pillar of Australian general practice. The general practitioner serves as the primary point of contact for preventive health interventions across all age groups, from newborn screening through to end-of-life planning. Australia's healthcare system, through Medicare and the PBS, supports a range of preventive activities delivered in the primary care setting.

The Australian Burden of Disease Study (AIHW, 2023) demonstrates that a substantial proportion of the total disease burden is attributable to modifiable risk factors. Tobacco use, high body mass, dietary risks, alcohol use, physical inactivity, and high blood pressure collectively account for over one-third of the total burden. Addressing these risk factors through structured preventive care represents one of the most cost-effective strategies available to the healthcare system.

The Royal Australian College of General Practitioners (RACGP) Guidelines for Preventive Activities in General Practice (Red Book, 9th edition, 2018) provides the framework for evidence-based preventive activities in Australian primary care. This article synthesises those principles with current epidemiological data to guide clinical decision-making.

The Australian Health Landscape

Australia has one of the highest life expectancies globally (83.2 years, 2022), yet significant disparities exist. Aboriginal and Torres Strait Islander peoples have a life expectancy approximately 8 years lower than the non-Indigenous population. Chronic diseases — particularly cardiovascular disease, cancer, chronic respiratory disease, diabetes, and mental health conditions — account for approximately 87% of all deaths and 77% of the disease burden.

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Key disparity: Aboriginal and Torres Strait Islander Australians experience 2–3 times the burden of chronic disease compared with non-Indigenous Australians. Preventive interventions in this population must be culturally safe, community-led, and address the social determinants of health.

Primary, Secondary & Tertiary Prevention

Prevention in general practice is conceptualised across three levels, each targeting a different stage of the disease continuum. Understanding these levels guides the allocation of clinical effort and resources.

Primary Prevention
Preventing Disease Before Onset
Interventions that prevent the occurrence of disease in susceptible individuals. Targets healthy or at-risk populations before pathology develops.
Setting: Every GP consultation — anticipatory guidance, immunisation, lifestyle counselling
Secondary Prevention
Early Detection & Treatment
Screening and early intervention to detect disease in its pre-symptomatic or early symptomatic stage, enabling treatment before complications arise.
Setting: Scheduled health assessments, screening programmes, chronic disease reviews
Tertiary Prevention
Reducing Complications & Disability
Interventions aimed at reducing the impact of established disease, preventing further deterioration, and improving quality of life and functional capacity.
Setting: GPMP/TCA reviews, specialist coordination, rehabilitation, palliative care

Primary Prevention in Practice

Primary prevention encompasses a broad range of activities delivered opportunistically and through planned consultations:

  • Immunisation: All NIP-scheduled vaccines for children, adolescents, adults, and special groups
  • Lifestyle counselling: Smoking cessation, alcohol reduction, nutrition, physical activity, weight management
  • Chemoprophylaxis: Pre-exposure prophylaxis (PrEP) for HIV, folate supplementation in pregnancy, oral anticoagulation in atrial fibrillation to prevent stroke
  • Injury prevention: Falls risk assessment and intervention in older adults, seatbelt and helmet counselling
  • Environmental modification: Occupational health and safety counselling, UV protection advice
  • Preventive prescribing: Statins for high absolute CVD risk, antihypertensives, metformin for pre-diabetes with high-risk features

Secondary Prevention in Practice

Secondary prevention is delivered through national screening programmes and targeted case-finding:

Screening Programme Target Population Test / Interval Provider / MBS
National Bowel Cancer Screening Program (NBCSP) Ages 50–74 (mailed every 2 years) Faecal immunochemical test (FIT) Population Health Services (free kit by mail); GP follow-up of positive results
BreastScreen Australia Women and trans persons aged 50–74 (every 2 years); may start from 40 Bilateral mammography State-based BreastScreen services (free); GP referral for symptomatic patients (MBS item 59306)
National Cervical Screening Program (NCSP) Women and people with a cervix aged 25–74 HPV test (primary) every 5 years; self-collection available since 2022 GP or practice nurse (MBS item 69004 — cervical screening test; MBS item 69011 — self-collected sample)
Cardiovascular risk assessment All adults ≥45 years (≥30 for Aboriginal and Torres Strait Islander peoples) Australian CVD Risk Calculator (australiancvdrisk.com.au) — lipid profile, BP, smoking, diabetes, family history GP (MBS item 701 — standard consultation; MBS item 721 — GPMP for high-risk patients)
Type 2 diabetes risk assessment Adults ≥40 years; all Aboriginal and Torres Strait Islander adults; those with risk factors AUSDRISK questionnaire → fasting glucose / HbA1c if score ≥12 GP (MBS item 699 — type 2 diabetes risk evaluation)
STI screening Sexually active adults <30 years; Aboriginal and Torres Strait Islander peoples; MSM Chlamydia NAAT (urine/vulvovaginal/rectal); HIV, syphilis serology; hepatitis B serology GP (MBS items vary by pathology test)

Tertiary Prevention in Practice

Tertiary prevention is integral to chronic disease management in Australian general practice and includes:

  • GPMP (MBS item 721) and TCA (MBS item 723): Structured care plans for patients with chronic conditions (≥6 months), enabling coordinated multidisciplinary care and access to allied health services (up to 5 allied health visits per year under Medicare)
  • Annual health assessments: MBS item 715 (Aboriginal and Torres Strait Islander health check), MBS item 707 (prolonged health assessment for ages ≥75), MBS item 701 (standard consultation review)
  • Cardiac rehabilitation: Post-MI, post-revascularisation programmes
  • Diabetes cycle of care: Quarterly HbA1c, annual eye/foot/kidney reviews
  • Palliative care planning: Advance care directives, goals-of-care discussions, symptom management
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MBS preventive health items: Key items include 701 (standard), 703 (brief), 705 (long), 707 (prolonged health assessment ≥75), 715 (Aboriginal and Torres Strait Islander health check), 721 (GPMP), 723 (TCA), and 732 (review of GPMP/TCA). Item 699 covers diabetes risk evaluation.

Common Causes of Death in Australia

Understanding the leading causes of mortality in Australia is essential for directing preventive effort. The Australian Bureau of Statistics (ABS) reported 190,939 registered deaths in 2022. The following table summarises the leading causes of death nationally:

Rank Cause of Death ICD-10 Chapter Key GP Prevention Activities
1 Ischaemic heart disease (IHD) I20–I25 CVD risk assessment, BP management, statin therapy, smoking cessation, diabetes management
2 Dementia (including Alzheimer's disease) F01, F03, G30 Cardiovascular risk factor management, cognitive screening (≥65), social engagement, physical activity
3 Cerebrovascular disease (stroke) I60–I69 BP control, anticoagulation in AF, atrial fibrillation screening (≥65), statin therapy
4 Lung cancer C34 Smoking cessation (most impactful), low-dose CT screening for high-risk individuals (clinical trials/international guidelines)
5 Chronic lower respiratory diseases (COPD, asthma) J40–J47 Smoking cessation, influenza/pneumococcal vaccination, spirometry for early COPD detection
6 Diabetes mellitus E10–E14 AUSDRISK screening, HbA1c monitoring, weight management, cardiovascular risk reduction
7 Colorectal cancer C18–C20 NBCSP participation, colonoscopy follow-up of positive FIT, family history assessment (Lynch syndrome referral)
8
Breast cancer C50 BreastScreen referral, breast awareness education, genetic risk assessment (BRCA referral)
9 Suicide and self-harm X60–X84 Mental health screening (DASS-21, K10), safety planning, Mental Health Treatment Plan (MBS item 2710), referral to crisis services
10 Prostate cancer C61 Informed discussion of PSA testing from age 50 (40 if family history), shared decision-making
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Preventable burden: Up to 38% of Australia's total disease burden is attributable to modifiable risk factors (AIHW, 2023). The GP consultation represents a critical — often underutilised — opportunity for preventive intervention at every visit.

Leading Causes of Death in Aboriginal and Torres Strait Islander Peoples

The mortality profile for Aboriginal and Torres Strait Islander Australians differs significantly from the non-Indigenous population, with chronic diseases manifesting at younger ages:

  • Ischaemic heart disease (accounting for a disproportionately higher share than in non-Indigenous Australians)
  • Diabetes mellitus (5–6 times the non-Indigenous rate)
  • Lung cancer and chronic respiratory disease (linked to higher smoking prevalence)
  • Suicide and self-harm (particularly in younger age groups, 15–34 years)
  • Chronic kidney disease (leading cause of end-stage renal disease in remote communities)
  • Intentional assault and transport accidents

Behaviour Modification

Behavioural risk factors — tobacco use, harmful alcohol consumption, physical inactivity, poor nutrition, and overweight/obesity — are the leading contributors to preventable disease burden in Australia. The general practice consultation provides an ideal setting for brief interventions using evidence-based frameworks.

The 5As Framework

The 5As model (Ask, Assess, Advise, Assist, Arrange) is endorsed by the RACGP and the National Preventive Health Strategy for use across all behavioural risk factors:

1
Ask
Systematically screen for behavioural risks at every appropriate consultation. Use validated tools: AUDIT-C (alcohol), ASSIST (tobacco/other substances), AUSDRISK (diabetes risk), waist circumference.
2
Assess
Evaluate readiness to change using the Stages of Change model. Assess severity of the risk behaviour and identify co-existing factors (mental health, social determinants).
3
Advise
Provide clear, non-judgemental, personalised advice about the health risks of current behaviour and the benefits of change. Use motivational interviewing techniques.
4
Assist
Offer practical support: set goals, develop an action plan, prescribe pharmacotherapy where indicated, refer to Quitline (13 78 48), dietitians, exercise physiologists, or psychologists.
5
Arrange
Schedule follow-up consultations to review progress, reinforce positive changes, manage setbacks, and adjust the management plan. Use recalls and reminders.

Smoking Cessation

Tobacco smoking remains Australia's single largest preventable cause of death and disease, responsible for approximately 20,000 deaths annually. Current adult smoking prevalence is approximately 10% (2022–2023 National Drug Strategy Household Survey), though rates are significantly higher among Aboriginal and Torres Strait Islander peoples (~37%), people experiencing mental illness (~30–40%), and people in lower socioeconomic groups.

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Varenicline
Champix® · Pfizer · Nicotinic receptor partial agonist
Adult dose 0.5 mg PO OD for days 1–3 → 0.5 mg PO BD for days 4–7 → 1 mg PO BD for 11 weeks (12-week course total). May repeat for 12 weeks if relapse.
Paediatric dose Not recommended <18 years
Renal adjustment eGFR <30 mL/min: 0.5 mg BD (do not increase to 1 mg BD); haemodialysis: 0.5 mg OD
Key cautions Nausea (most common, ~30%), neuropsychiatric effects (monitor mood changes), vivid dreams
PBS status ✔ PBS General Benefit — Authority required for initial and repeat courses
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Nicotine Replacement Therapy (NRT)
Nicabate® / Nicorette® · Various · Nicotinic receptor agonist
Forms available Patch (16-hour or 24-hour), gum (2 mg or 4 mg), lozenge (1 mg, 2 mg, 4 mg), oral spray, inhalator
Combination therapy Patch (steady-state) + short-acting form (gum/lozenge/spray for breakthrough cravings) — most effective approach
Duration 8–12 weeks; taper if using patches
PBS status ✔ PBS General Benefit — patches are PBS-listed; other forms available OTC
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Bupropion
Zyban® · GlaxoSmithKline · Noradrenaline/dopamine reuptake inhibitor
Adult dose 150 mg PO OD for days 1–6 → 150 mg PO BD (≥8 hours apart) for 7–9 weeks (12-week course total)
Key cautions Seizure risk (0.1% — contraindicated in seizure disorder, eating disorders, abrupt benzodiazepine/alcohol withdrawal); insomnia, dry mouth
Renal adjustment eGFR <30: 150 mg OD
PBS status ✔ PBS General Benefit — Authority required
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Quitline referral: Quitline (13 78 48) provides free, evidence-based telephone counselling. GPs can submit a referral via the Quitline fax/online referral pathway. Aboriginal and Torres Strait Islander-specific quit support is available through Tackling Indigenous Smoking (TIS) programmes.

Alcohol Reduction

Alcohol use is responsible for approximately 4.5% of Australia's total burden of disease. The 2020 NHMRC Australian Guidelines to Reduce Health Risks from Drinking recommend:

  • Healthy adults: No more than 10 standard drinks per week AND no more than 4 standard drinks on any single day
  • Children and young people under 18: Should not drink alcohol
  • Women who are pregnant, planning pregnancy, or breastfeeding: Should not drink alcohol

Screening tool: AUDIT-C (3 questions) — a score ≥3 (women) or ≥4 (men) warrants full AUDIT (10 questions) and clinical assessment. Brief intervention (5–15 minutes) in primary care reduces alcohol consumption in at-risk drinkers.

Pharmacotherapy for alcohol dependence:

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Naltrexone
Revia® · Alphapharm · Opioid antagonist
Adult dose 50 mg PO OD (or 100 mg Mon/Wed/Fri alternative). Start after ≥7 days opioid-free.
PBS status ⚠ PBS Authority Required
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Acamprosate
Campral EC® · Mylan · Glutamate modulator
Adult dose 666 mg PO TDS (with meals). Weight ≥60 kg required for full dose.
Renal adjustment CrCl 30–50 mL/min: 333 mg TDS; CrCl <30: contraindicated
PBS status ⚠ PBS Authority Required

Physical Activity & Nutrition

The Australian Government Department of Health recommends:

  • Adults 18–64 years: 150–300 minutes of moderate-intensity or 75–150 minutes of vigorous-intensity physical activity per week, plus muscle-strengthening activities on ≥2 days per week
  • Adults ≥65 years: 30 minutes of moderate-intensity physical activity on most (preferably all) days, including balance and strength training
  • Children and young people (5–17 years): ≥60 minutes of moderate-to-vigorous activity daily; limit sedentary recreational screen time to <2 hours/day
  • Nutrition: Emphasise the Australian Dietary Guidelines — 5 serves of vegetables, 2 serves of fruit, wholegrain cereals, lean protein, reduced salt (<5 g/day), limited added sugar and saturated fat

Referral pathways: Medicare-funded allied health visits (up to 5 per calendar year under a GPMP/TCA, MBS item 10950) include dietitian, exercise physiologist, and physiotherapy services. The Active Australia programme and state-based programmes provide additional community resources.

Weight Management

Approximately 67% of Australian adults are overweight or obese (BMI ≥25 kg/m²). The RACGP recommends:

  • Waist circumference as a routine measurement (men >94 cm increased risk, >102 cm substantially increased; women >80 cm increased risk, >88 cm substantially increased)
  • Brief behavioural counselling (5As) at every opportunity
  • Referral to dietitian and exercise physiologist for structured weight management
  • Consider pharmacotherapy for BMI ≥30 or ≥27 with comorbidities when lifestyle measures alone are insufficient
  • Bariatric surgery referral for BMI ≥40 or ≥35 with significant comorbidities refractory to other treatments
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Motivational interviewing: The GP's most powerful tool is the therapeutic relationship. Express empathy, develop discrepancy between current behaviour and patient goals, roll with resistance, and support self-efficacy. Open-ended questions, affirmations, reflections, and summaries (OARS) are the core skills.

Immunisation & Cancer Prevention

National Immunisation Program (NIP) Schedule

The NIP provides funded vaccines for specific age groups and risk categories. The schedule is updated regularly by the Australian Technical Advisory Group on Immunisation (ATAGI). Key cohorts and vaccines include:

Age / Cohort Vaccines (selected key entries) Notes
Birth Hepatitis B (H-B-Vax II Paediatric) Within 24 hours of birth; additional doses per schedule
6 weeks to 18 months DTPa-hepB-IPV-Hib, PCV13, Rotavirus, MenB, Hib-MenC 6 weeks, 4 months, 6 months, 12 months, 18 months
4 years DTPa-IPV (4th dose) Prior to school entry
12–13 years (school-based) HPV vaccine (Gardasil 9® — single dose from 2023 ATAGI advice), dTpa, MenACWY Single-dose HPV for immunocompetent; 3-dose schedule for immunocompromised
Pregnant women dTpa (20–32 weeks each pregnancy), Influenza (any trimester), RSV (Abrysvo® — from 24 weeks gestation, 2025 NIP addition) Pertussis during each pregnancy regardless of prior vaccination; influenza in any trimester
Adults ≥65 years Influenza (annual), pneumococcal (23vPPV — one dose, with possible PCV20 upgrade), shingles (Shingrix® — 2 doses from age 65) Shingrix preferred over Zostavax; funded for 65–69 (catch-up to 79)
Aboriginal and Torres Strait Islander peoples All age-appropriate NIP vaccines + additional: influenza from 6 months, pneumococcal (additional doses in childhood), hepatitis A (in high-risk settings), adult pneumococcal from 50 Enhanced schedule reflects higher disease burden
Immunocompromised persons Live vaccines contraindicated (except MMR in specific circumstances). Ensure inactivated influenza, pneumococcal, hepatitis B. Household contacts should be up to date. Consult ATAGI Clinical Handbook for specific immunosuppression categories
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Contraindicated live vaccines in immunocompromised patients: MMR, varicella, zoster (Zostavax), yellow fever, BCG, oral rotavirus. Shingrix (recombinant, non-live) is safe in immunocompromised individuals and is preferred for all eligible patients.

Cancer Prevention Strategies

Cancer accounts for approximately 30% of all deaths in Australia. The general practitioner plays a central role in cancer prevention through vaccination, screening, risk assessment, and lifestyle counselling.

HPV Vaccination (Gardasil 9®)

Prevents infection with HPV types 6, 11, 16, 18, 31, 33, 45, 52, 58 — responsible for ~90% of cervical cancers, ~90% of genital warts, and a significant proportion of oropharyngeal, anal, penile, and vulvovaginal cancers. Single-dose schedule (from 2023) for immunocompetient individuals aged 12–26. NIP-funded; catch-up available for those who missed school-based programmes. Two doses (0, 6–12 months) for immunocompromised patients; three doses for those initiating ≥26 years.

Hepatitis B Vaccination

Prevents hepatitis B-related hepatocellular carcinoma. Birth dose funded under NIP. High-risk adults (healthcare workers, people who inject drugs, household contacts, people from endemic countries, MSM, people with chronic liver disease) should be vaccinated and tested for seroconversion. Funded under NIP for all infants and catch-up for <20 years.

National Cancer Screening Programmes

Bowel Cancer Screening (NBCSP)

Faecal immunochemical test (FIT) mailed biennially to all Australians aged 50–74. Participation rate ~44% — GP endorsement is the strongest predictor of participation. Positive FIT requires colonoscopy referral (do not repeat FIT). MBS item 32224 (colonoscopy post-positive screening test).

Cervical Screening (NCSP)

Primary HPV test every 5 years from age 25–74. Self-collection option available since July 2022 (MBS item 69011), improving access for under-screened populations. Partial HPV-positive results require reflex liquid-based cytology. HPV 16/18 positivity → direct colposcopy referral. Other oncogenic HPV → repeat in 12 months.

UV Protection & Skin Cancer Prevention

Australia has the highest rate of skin cancer in the world. Two in three Australians will be diagnosed with skin cancer by age 70. Key preventive messages:

  • Slip, Slop, Slap, Seek, Slide — sun-protective behaviours when UV index ≥3
  • Avoid solariums (banned in all Australian states and territories since 2016)
  • Regular skin self-examination and clinical skin checks for high-risk individuals (history of melanoma, immunosuppression, multiple naevi, fair skin, family history)
  • GPs should perform opportunistic skin assessments and use dermoscopy for suspicious lesions; excise or biopsy as indicated
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Prostate-specific antigen (PSA) testing: There is no national population-based screening programme. The RACGP recommends GPs offer informed, shared decision-making about PSA testing to asymptomatic men from age 50 (40 with family history). Discuss potential benefits (early detection) and harms (overdiagnosis, false positives, unnecessary biopsy). MBS item 66653 covers PSA testing.

Special Populations

Preventive care must be tailored to the unique needs of specific population groups. The following outlines key considerations for major special populations in Australian general practice.

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Paediatrics

Routine developmental surveillance at 1, 2, 4, 6, 12, 18 months and 4 years (Blue Book / Personal Health Record)
Complete NIP schedule — use the Australian Immunisation Register (AIR) to track catch-up
Newborn screening (heel-prick test) for metabolic, endocrine, and haematological conditions
Hearing screening (OAE at birth; follow-up with diagnostic ABR if indicated)
Oral health: fluoride supplementation where water fluoridation <0.6 ppm; dental referral from 12 months
Growth monitoring using WHO growth charts (0–2 years) and CDC/BMJ charts (2–18 years)
Sun-safe education from infancy; no direct sun exposure for infants <12 months
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Older Adults (≥65 years)

Annual influenza vaccination, pneumococcal vaccination, shingles (Shingrix® from 65)
Falls risk assessment (Morse Fall Scale or Timed Up and Go test) — multifactorial intervention if risk identified
Cognitive screening — use the General Practitioner Assessment of Cognition (GPCOG) or MMSE; refer if concerns
MBS item 707 (prolonged health assessment) — comprehensive annual assessment for ≥75 years
Polypharmacy review (≥5 medications) — deprescribing where appropriate; use STOPP/START criteria
Advance care planning — encourage all patients ≥65 to discuss and document preferences
Osteoporosis screening: consider DEXA for women ≥70 and men ≥80; FRAX tool for fracture risk assessment
Vision and hearing assessment (annual or biennial); functional capacity (ADLs, IADLs)
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Immunocompromised Patients

Avoid live vaccines (Zostavax, MMR, varicella, yellow fever, BCG, oral rotavirus)
Shingrix® (non-live recombinant) — funded for eligible patients on immunosuppressive therapy
Enhanced influenza vaccination (consider double-dose or adjuvanted formulations in transplant recipients — specialist guidance)
Pneumococcal vaccination: PCV13 + 23vPPV (or PCV20 if available) — consult ATAGI Clinical Handbook
Household contacts must be fully vaccinated (cocoon strategy)
COVID-19 vaccination: additional doses as per ATAGI advice for severely immunocompromised
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Pregnancy

Folic acid 400–500 µg daily (5 mg if high-risk: previous NTD, antiepileptic medication, BMI ≥30, diabetes) — start ≥1 month pre-conception
Iodine supplement 150 µg daily during pregnancy and breastfeeding
NIP vaccines: dTpa (20–32 weeks gestation each pregnancy), influenza (any trimester), RSV (Abrysvo® — from 24 weeks, from 2025)
Rubella susceptibility testing (offer MMR post-partum if non-immune)
Antenatal screening: blood group/antibodies, FBC, iron studies, VDRL, HIV, hep B, hep C, chlamydia (if risk factors), MSU, GTT (24–28 weeks)
Mental health screening (Edinburgh Postnatal Depression Scale — EPDS) at booking and postnatally
Alcohol, smoking, and drug use screening — brief intervention and referral
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Chronic Kidney Disease

Annual urine ACR and eGFR for all patients with diabetes, hypertension, or cardiovascular disease
BP target <130/80 mmHg (ACEi or ARB first-line if albuminuria)
SGLT2 inhibitor (e.g., dapagliflozin, empagliflozin) — PBS-listed for CKD with albuminuria (independent of diabetes)
Statin therapy for cardiovascular risk reduction (CKD is a CVD risk equivalent)
Avoid nephrotoxins where possible: minimise NSAIDs, adjust renally-cleared medications
Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander peoples experience significantly higher rates of preventable chronic disease, lower life expectancy (8.0 years gap for males, 5.8 years gap for females), and face persistent barriers to accessing preventive healthcare. Closing the Gap targets emphasise preventive care, early detection, and culturally safe service delivery.

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Critical disparities: Aboriginal and Torres Strait Islander Australians experience 2–3 times the rate of type 2 diabetes, cardiovascular disease, chronic kidney disease, and rheumatic heart disease compared to non-Indigenous Australians. Preventive health interventions in this population must be prioritised, culturally appropriate, and community-led.
MBS Item 715 — Health Assessment
Annual comprehensive health check for all Aboriginal and Torres Strait Islander peoples (no age restriction). Covers physical, psychological, and social wellbeing. Available once per 9-month period. Should be offered at every opportunity and is the gateway to chronic disease management, referral, and follow-up. GP should ensure the assessment is culturally safe, involves family if desired, and is conducted by or with an Aboriginal and/or Torres Strait Islander health practitioner where possible.
Enhanced Immunisation
Additional NIP vaccines include: influenza from 6 months of age (vs. 6 months for at-risk non-Indigenous), hepatitis A (2-dose schedule for children in high-risk communities), additional pneumococcal doses in early childhood, adult pneumococcal vaccination from age 50 (vs. 65 for non-Indigenous), and zoster vaccine from 50 years in eligible populations. Aboriginal and Torres Strait Islander immunisation rates have improved significantly but remain lower in remote areas.
CVD Risk Assessment from Age 30
Absolute cardiovascular risk assessment using the Australian CVD Risk Calculator should commence from age 30 (vs. 45 for non-Indigenous). Aboriginal and Torres Strait Islander peoples have a disproportionately higher burden of CVD at younger ages, often with clustering of risk factors (diabetes, smoking, obesity, renal disease).
Smoking Cessation — TIS Programmes
Tackling Indigenous Smoking (TIS) regional teams provide community-based smoking cessation support, yarning-based interventions, and workforce training. Smoking prevalence is approximately 37% in Aboriginal and Torres Strait Islander adults (vs. ~10% non-Indigenous). NRT and varenicline are PBS-listed and available; culturally appropriate delivery is essential. Renal-dose adjustment may be required in communities with high CKD prevalence.
Remote & Rural Access
Aboriginal Community Controlled Health Organisations (ACCHOs) provide comprehensive primary healthcare in many remote and regional communities. Telehealth (MBS items 91790, 91800, 91801) extends specialist access. Royal Flying Doctor Service and specialist outreach programmes support preventive care. Point-of-care testing (POCT) for HbA1c, lipids, and eGFR is available in some remote communities through the Quality Assurance for Aboriginal and Torres Strait Islander Medical Services (QAAMS) programme.
Cultural Safety & Trust
Systemic racism, historical mistrust (including stolen generations), and cultural disconnection remain significant barriers. Strategies include: employing Aboriginal and Torres Strait Islander health workers and practitioners; ensuring culturally safe clinical environments; using yarning-based approaches; involving family and community; acknowledging Country and history; completing cultural competency training (mandatory in many jurisdictions). The RACGP's Specific Interests: Aboriginal and Torres Strait Islander Health faculty provides GP guidance.
Rheumatic Heart Disease (RHD)
RHD is virtually eliminated in non-Indigenous Australia but persists as a significant health issue in Aboriginal and Torres Strait Islander communities, particularly in the Northern Territory, Queensland, and Western Australia. Primary prevention: early treatment of Group A streptococcal pharyngitis and skin infections. Secondary prevention: benzathine penicillin G (BPG) 21-day injections for confirmed RHD. The RHD Endgame Strategy targets elimination by 2031.
Trachoma Elimination
Australia is the only high-income country where trachoma remains endemic, occurring in remote Aboriginal communities. The SAFE strategy (Surgery, Antibiotics, Facial cleanliness, Environmental improvement) is operational. GPs should be aware of trachoma screening programmes and refer appropriately. WHO elimination target: <5% prevalence in children.

📚 References

  1. 1. Royal Australian College of General Practitioners (RACGP). Guidelines for Preventive Activities in General Practice (Red Book). 9th ed. Melbourne: RACGP; 2018.
  2. 2. Australian Institute of Health and Welfare (AIHW). Australian Burden of Disease Study 2023: Impact and causes of illness and death in Australia. Canberra: AIHW; 2023.
  3. 3. Australian Bureau of Statistics (ABS). Causes of Death, Australia, 2022. ABS Cat. No. 3303.0. Canberra: ABS; 2023.
  4. 4. National Health and Medical Research Council (NHMRC). Australian Guidelines to Reduce Health Risks from Drinking Alcohol. Canberra: NHMRC; 2020.
  5. 5. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health and Aged Care. Updated 2024. Available at: immunisationhandbook.health.gov.au.
  6. 6. Department of Health and Aged Care, Australian Government. National Immunisation Program (NIP) Schedule. Updated 2025. Available at: health.gov.au.
  7. 7. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
  8. 8. National Stroke Foundation of Australia. Clinical Guidelines for Stroke Management. Melbourne: Stroke Foundation; 2022.
  9. 9. Department of Health, Australian Government. Australia's Physical Activity and Sedentary Behaviour Guidelines for Adults (18–64 years). Canberra: Department of Health; 2019.
  10. 10. National Health and Medical Research Council (NHMRC). Australian Dietary Guidelines. Canberra: NHMRC; 2013.
  11. 11. Cancer Council Australia. National Cancer Prevention Policy. Sydney: Cancer Council Australia; 2018. Updated recommendations available at: cancer.org.au.
  12. 12. Lung Foundation Australia and Cancer Council Australia. Lung Cancer Screening: Position Statement. 2023.
  13. 13. RACGP. Management of Type 2 Diabetes: A Handbook for General Practice. Melbourne: RACGP; 2020.
  14. 14. National Aboriginal Community Controlled Health Organisation (NACCHO). National Aboriginal and Torres Strait Islander Health Plan 2021–2031. Canberra: Australian Government; 2021.
  15. 15. Australian Bureau of Statistics (ABS). National Health Survey 2022. ABS Cat. No. 4364.0. Canberra: ABS; 2023.
for PBS-listed medicines at participating pharmacies.
Cultural safety
Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.
Medication adherence
Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.
Specific conditions
Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.
Referral pathways
Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

  1. 1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
  2. 2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
  3. 3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
  4. 4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
  5. 5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
  6. 6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
  7. 7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
  8. 8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
  9. 9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
  10. 10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
  11. 11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
  12. 12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
  13. 13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).
for PBS-listed medicines at participating pharmacies.
Cultural safety
Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.
Medication adherence
Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.
Specific conditions
Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.
Referral pathways
Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

  1. 1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
  2. 2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
  3. 3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
  4. 4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
  5. 5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
  6. 6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
  7. 7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
  8. 8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
  9. 9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
  10. 10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
  11. 11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
  12. 12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
  13. 13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).