Final Report of AAAGP Research Meeting 2002
The Australian Association of Academic General Practice (AAAGP) is a representative body for general
practitioners (GPs) and their colleagues undertaking teaching and research in general practice. The
AAAGP has approximately 120 members, many of whom are affiliated with a University Department of
General Practice, who are at the forefront of primary care research and medical education. The AAAGP
provides information to others, maintains an internal discussion group, encourages general practice research
and is committed to building the research capacity of the wider general practice community. Since the
1999 Annual General Meeting, the AAAGP has hosted an annual research meeting which provides a forum
for researchers to develop their research knowledge and skills. The yearly research meeting places a
strong emphasis on research methods rather than simply publicising research outcomes. The specific aims
of the research meetings are to:
- Position the AAAGP membership and University Departments of General Practice and Rural
Health at the centre of general practice research effort;
- Improve the standard of general practice research and outcomes evaluation through enhancing
AAAGP membership skills and knowledge;
- Enhance senior researchers' capacity to provide constructive feedback on current work in
progress and encourage less experienced members in research endeavours;
- Develop a 'safe' environment in which to discuss the strengths and weaknesses of current work in
- Encourage cooperative research in general practice;
- Convene an annual Heads of Departments meeting; and
- Provide recommendations to the Commonwealth Department of Health and Aging regarding
research in general practice and enhanced working relationships between the Department and
research organisations such as AAAGP.
Presentations and workshops are selected by the AAAGP Committee on the grounds of research
importance and quality.
The AAAGP research meeting was organised by Professor Merilyn Liddell and Ms Stella Koritsas from
the Department of General Practice, Monash University.
Funding ($30,000) was provided by the Department of Health and Aging to cover some of the costs
associated with the research meeting, including venue hire, technical equipment hire, catering and
administrative support. The remaining funds were used to partially reimburse delegates for travel costs.
Continuing Professional Development Points (CPD points)
The Department of General Practice (Monash University) was successful in applying for CPD points for
the research meeting. GPs can claim 13 CPD points for attending the research meeting.
Research Meeting Program Outline
The research meeting was held immediately following the General Practice and Primary Health Care Research
Conference on Friday May 31st and Saturday 1st June at The Carlton Crest hotel
Friday May 31 2002
5.00 pm –
5.45 pm – 6.15 pm
research collaborations – what effective strategies can be used?
by Prof Merilyn Liddell
presentation by Prof Michael Kidd
by Prof Merilyn Liddell
presentation by Prof Chris Del Mar
to transport delegates to dinner
Dinner at the
Royal Melbourne Zoo
speaker Dr. John Fitzgerald: “Evidence based drug politics”
Lecturer in the Department of Criminology, the University of Melbourne.
for the Carlton Crest
June 1 2002
Underline indicates presenter.
8.45 am –
the National Institute of Primary Health Care Research.
by Dr Mark Nelson
presentation by Prof Doris Young
9.30 am –
Universities in vocational training for General Practice
by Dr Tracy Cheffins
presentation by Prof Chris Del Mar
10.15 am –
from the travelling fellow
Chondros, Biostatistician in Primary Care, Department of General Practice,
University of Melbourne
10.30 am –
Morning Tea Break
11.00 am –
paper sessions (20 minutes per presentation including discussion):
Are we measuring the wrong things in trials of antibiotics for ARIs?
The problems of not estimating severity, and selecting the “least
sick” into trials. Chris
Del Mar and J Doust.
After ANBP2 – ASPREE (ASPirin Reducing Events in the Elderly).
Single Patient Open Trials (SPOT). Charles Bridges-Webb.
Putting the second step first – the lead role of search skills in
promoting EBM. Peter
Schattner and Karen Young.
Targeted Health Initiatives for country people with Developmental
Disability. Bob Davis,
Teresa Iacono, John Humphreys and Neale Chandler.
Achieving good compliance and follow up in clinical trials.
Michael Yelland, Paul Glasziou, Jane Nikles and Elaine
What GPs do to get their job done: A social network perspective. Lucio
Conversation Analysis: A new voice for General Practitioners.
Barry McGrath, Peter Freebody and Jill Freiberg.
– 71.30 pm
– 2.30 pm
PHC RIS support for PHC RED. Ellen
McIntyre, Libby Kalucy and Louis Pilotto.
BEACH data. Helena Britt and Graeme Miller.
General practice research: matching
methods to the complexity of the issues. Gawaine Powell Davies,
Justin Beilby, Judy Proudfoot, Tanya Bubner.
Evaluating educational initiatives in Evidence- Based Primary Care:
What are we aiming to achieve? Lyndal
2.30 pm –
Key issues and recommendations arising from plenary
sessions, paper presentations and workshops.
Discussion of progress made on last year’s recommendations
by Margaret MacDonald.
3.30 pm –
Meeting Close and thanks
Prof Chris Del Mar
3.50 pm –
and food and beverages to be served during the meeting
equipment hire and support
and from the Carlton Crest for dinner – subsidised)
The remaining funds ($15,610.47) will be use to partially reimburse delegates travel expenses. A small
amount of this has also been set aside to assist non-Victorian rural participants to attend, in addition to their
subsidised flight. The amounts will be paid to university departments in the weeks following the meeting.
Summaries of plenary, paper and workshop sessions.
Several delegates were chosen to take notes during the plenary, paper and workshop sessions. They were
asked to identify issues and recommendations specific to the AAAGP. These are presented below.
Plenary session: National and International research collaborations.
Please note that the plenary session presented deviated from the program outline.
- NHMRC grant process: anomalies of system were highlighted, for example infrastructure and
- General practice and primary care researchers may be disadvantaged by NHMRC grant process
as it currently operates
- AAAGP issues include election of office bearers (including President)
- The RACGP crisis: Should we act? Supporting the research section of Perth Convention Oct2002, and 'GP of the Year' to be a researcher
- GPET: lack representation on the Board, vertical integration working party - 3 representatives
(Kidd, Beilby, Glasgow), innovations working party - 1 representative (Kidd), and
the Advisory Committee (1 of Trumble, Beilby, Del Mar).
Key recommendations for AAAGP:
- Lobby for dedicated panel in NHMRC to assess general practice and/or primary health care
- Increase the number of GPs on the NHMRC assessor database
- Ensure suitable assessors are identified, assessors must use correct keywords in profile
- AAAGP to scrutinise process
- Clarify status of projects suitable for funding, but outside Department of Health and Aged Care
- Promote collaborative research opportunities
- Effective strategies for collaboration include trust and respect, shared goods/values, flexible funding
- Need to be clear on who does what, so should consider a formal collaborative agreement
- Successful collaborations recognise the need for compromise
- NZ/UK/Australia meeting to improve quality of research training internationally by international
- Promote the exchange of postgraduate general practice research students
- Produce resources to build capacity, for example, writing, dissemination skills
Plenary session: AAAGP and the Australian Primary Health Care Research Institute
- Journey has been long and tortuous
- Concerns over the history of the process of development of APHCRI Advisory Committee
- Brief paper produced by the Research and Quality Section, GP Branch, Health Services Division
of Department of Health and Aged Care
- Budget of $3 million per annum, but $1 million of this will go to support the hub at Australian
National University (ANU) hub. Apart from the presence of the "hub"at the ANU, the rest of the
model is not set
- Proposed hub and spoke model of the institute is of concern
- Slow process – next advisory committee meeting 07/11/02
- Tension between short term strategic research and long term capacity building
- Merits of Netherlands CARE model
- "Being aggressive will get you the reverse of what you want" (Margaret McDonald)
Key recommendations for AAAGP:
- AAAGP should have input to APHCRI Advisory Committee
- AAAGP should have input into the structure and role of the hub and spokes, themes and priorities,
role of grants and scholarships
- AAAGP should make recommendations about the relation of the Institute to the rest of the system
- AAAGP should make recommendations regarding the allocation of funds, and whether NHMRC
funds will go to the Institute.
Plenary Session: Role of Universities in vocational training for General Practice.
- Need for vertical integration. A good example is Canada
- AAAGP should be proactive and take on a leadership role
- It is essential for Universities to be represented on Consortium Boards. Advantages include
vertical integration opportunities for University Departments, a say in workforce issues for
Departments, Universities can offer a career path for medical educators, and opportunities for
- Examples of local successes are James Cook, Northern Territory and Victoria
- Academic registrar posts need to be protected
- PIP Working Group lobbying for increased teaching support and remuneration
- Universities are not always supportive of general practice
- University bureaucracy may make GP/GP collaborations at a regional level difficult
Key recommendations tor AAAGP:
- Need to be more proactive in promoting vertical integration
- University Departments can offer a career path
- AAAGP should develop a model to promote vertical integration – "tell the good stories"
- AAAGP should take on an active role in running University consortia. AAAGP should be
represented on the Board of Consortia
Plenary session: Report from travelling fellow.
Patty Chondros. At the Family Medicine Research Centre, Sydney.
- Ms Chondros spent two weeks at the Australian Institute for Health and Welfare GP
Statistics & Classification Unit, Family Medicine Research Centre, University of Sydney.
- 'Lonely life' of statisticians in Primary Health Care, as there are not many of them.
- Excellent feedback on success of scheme
Key recommendations tor AAAGP:
- AAAGP should publicise success and encourage further travelling fellow applications
- Host Department must be able to produce staff time and support
Paper session: Targeted Health Initiatives for country people with Developmental Disability.
Associate Professor Robert Davis, GP and Director of the Centre for Developmental Disability Health
- A main issue is the lack of services in rural or country areas for people with disabilities (include
intellectual disability, autism and cerebral palsy).
- The aim was to build local capacity for meeting the health care needs of people with developmental
disability and create networks and working liaisons between local, regional and metropolitan-based
services for developmental disability.
- Needs and priorities were determined by liaising with key organisations and stakeholders.
Interviews and focus groups were conducted with people with developmental disability, families,
support workers, allied health and education workers, and GPs
- The results of the qualitative analysis revealed common themes for people with Developmental
disability and their families: Knowing about and negotiating the service systems, attitudes of medical
professionals to them and their knowledge about the person with developmental disability, need to
travel to metropolitan services for assessment, delays in assessments and diagnosis, being kept
waiting for appointments, the importance of stable long term relationships with medical practitioners
and other professionals
- Service providers brought up issues of communicating with medical practitioners and working with
medical practitioners on a team. Educational needs identified included teambuilding, communication
between members on a team, aetiology of developmental disabilities, dual diagnosis and medication,
sexual relations and sexual health.
- GPs tended to have only a few people with developmental disability on their case loads, but were
aware of the extra time needed for consultations. They did not engage in multidisciplinary meetings
or case conferences regarding patients with developmental disability, and expressed concern about
communication with patients with developmental disability. There was knowledge of services
accessible to patients, but they wanted access to peers with expertise in developmental disability.
- CDDHV planned several expos in country areas (a regional centre and three rural towns) for local
services in developmental disability to display their services. This increased networking and
brought the groups together.
- Project sustainability requires ongoing support and access to resources and further funding for the
evaluation of the education and support model.
Paper session: Achieving good compliance and follow up in clinical trials.
Dr Micheal Yelland, GP and Senior Lecturer at the University of Queensland.
- The importance of compliance was highlighted and how it is essential to describe results and
- Effectiveness versus efficacy. Trials of efficacy test under ideal conditions and maximum
compliance rates are desirable. Trials of effectiveness test under 'normal' conditions, and normal
levels of (non) compliance desirable.
- Predictors of good compliance: participant's beliefs about susceptibility to condition and feelings of
vulnerability, perceived benefit from intervention, higher education level, quality of information
about the trial, and time spent explaining the trial
- Predictors of poor compliance: Drug or alcohol addiction, distance between home and clinic,
planned move within trial period, and pressure to enroll
- Reasons for non-compliance: Side effects, resistance to change, poor understanding of instructions,
lack of family or GP support, and change of heart
- Compliance can be improved by continuity of care, enlisting the help of relatives, and keeping a
record of hobbies/family/work. When things go wrong try including a trial brochure/folder (with
instructions for dealing with adverse events), contingency plan for treatment failure, reinviting
dropouts after an interval.
- Special populations can affect compliance, for example, age and culture
- Follow up can be improved by a reminder phone call before each visit, and for poor attenders, a
prompt call for missed visits.
- Follow up can also be enhanced by improving experiences at clinics, convenience of clinic hours,
and doing home visits. A patient folder with appointment dates, information sheets, copy of
consent forms and progress outcomes also helps.
Paper session: What GPs do to get their job done: A social network perspective
Mr Lucio Naccarella, PhD candidate, Department of General Practice University of Melbourne
- This research is part of a PhD examining how GPs work with other primary health care providers.
The aim is to develop a measurement approach to understand relationships and patterns of
interactions between GPs and primary health care providers.
- GPs are thought to be isolated, even though their work has a large degree of interdependence
- Informal relationships not being valued by government
- There is a gap in research about the nature of interdependent relationships of general practice.
May help define the nature of "network" required by government policy and research priority
- Expanding government thinking to take into account the nature of day to day process
- The traditional goals of Social Network Analysis are to visualize relationships, study factors
influencing relationships, draw out implications of relational data, and make recommendations to
improve working relationships (i.e., communication, workflow etc).
- Case study interviews will be conducted with-GP, PN, PM, Receptionist & GP Network
members. There will be a Pilot study (2 clinics) and the Main Study.
- The significance of study: Highlight relationships that exist as they underpin capacity of an integrated
PHC system; will inform patterns that enhance service provision and conditions to assist working
together; will inform how to disseminate/diffuse evidence into practice; will inform development,
implementation and evaluation of policies, structures and programs to encourage GPs to work with
other PHC providers.
Paper session: Conversation Analysis: A new voice for General Practitioners.
Associate Professor Barry McGrath, Department of Rural Health, The University of Melbourne.
- Discusses the use of conversation analysis in GP consultation. Conversation Analysis (CA)
provides insights into the communication taking place
- Although it has a forty year history, it has been used sparingly in Australia.
- There are complex theoretical issues
- CA examines the work which words do in the interactions between speakers through the study of
transcripts of audio-taped interactions.
- The meanings of utterances lie in how the listener responds to the previous turn of speaking, not in
an external attribution of intent by a researcher. CA studies the turns of talk and searches for the
interpretations made by the speakers through the careful scrutiny of interactions.
- This study represents an initial step in the use of CA within the Australian general practice setting.
- The research combines CA with action research so that those GPs whose consultations are
audiotaped may review transcripts and analyses and provide feedback.
- The approach has been used as the basis of a unique QA activity for all Australian GPs through the
use of health informatics.
- The research will lead to the development of typologies which may be used at undergraduate,
postgraduate and continuing medical education. The findings and typologies will require further
refinement and evaluation.
Paper session: Problems with analysing trials of antibiotics for ARIs
Professor Chris Del Mar, GP and Director of Centre for General Practice, Medical School, University of
- Trials of ARIs have been developed in an environment in which antibiotic use was already
established. Thus trials have been of "no-antibiotic" vs usual care (antibiotics). This might influence
recruitment (less severely affected vs more).
- In ARI trials there are issues of non recruitment of high severity. The amount of illness can be
represented by severity as well as time (eg. severity x time). There needs to be more sophisticated
data collection about severity, duration and disease
- The aim of the research was to model the effect of using both time and severity as independent
- Re-examined the trials selected for the Cochrane meta-analysis of "antibiotics for acute otitis
media in children", looking for evidence of patients excluded on the basis of being too ill. The
researchers also looked for evidence of severity influencing outcome
- The researchers found that estimating differences between two-dimensional constructs by single
dimensions is likely to yield under-estimates if severity contributes an important amount to the
illness. Past trials may have under-estimated the effects of many interventions for symptoms.
- Predictors that will predict the severity and duration of ARIs must be determined
Paper session: After ANBP2 – ASPREE (ASPrin Reducing Events in the Elderly).
Dr Mark Nelson, GP and Senior Researcher, Department of General Practice, Monash University
- The aim was to build a proposal for a general practice-based double-blind placebo controlled trial
to determine the effect of low-dose aspirin for the primary prevention of major cardiovascular
events, mortality, cognitive decline, quality of life, major bleeding episodes and cost-effectiveness in
elderly subjects. This study will utilise the unique resource established for ANBP2 to conduct
large-scale trials in general practice.
- The evidence for the benefits of low-dose aspirin on cardiovascular outcomes in primary
prevention has come from five major morbidity/mortality trials, whose participants were
predominantly middle-aged males. Data are lacking in the elderly and females
- Patients more likely to return to GP than specialist services
- Lack of evidence for low dose aspirin in elderly specially women
- ASPREE will investigate subjects aged > 70 years with hypertension, elevated total cholesterol, or
smoking and without established CVD.
- Departments of General Practice at the Universities of Queensland, Sydney, Adelaide, Western
Australia, and Monash acted as host institutes for this trial.
- Cluster recruitment by Divisions of General Practice on demographic basis
- Trial using standard system PBS for medication
- Community GPs management of assessment
- Co-Investigators 2600 GPs, sample size of 6000 subjects.
- Large scale trials are possible in Australia GP in normal working practices
Paper session: Single Patient Open trials
Charles Bridges-Webb, GP and Emeritus Professor, Department of General Practice, The University of
- Trials of treatment are not uncommon in general practice when the GP is uncertain which of two
recognised treatments is optimum for a patient.
- Single patient open trials (SPOT) provide a more systematic and rigorous way of assessing the
benefits of each treatment to the patient, using research principles to improve patient care.
- Topics suitable for SPOT include analgesics or NSAIDS for pain relief, or avoidance of side
effects with oral contraception.
- A simple protocol to allow general practitioners to undertake a SPOT on a topic of interest to them
with a patient of their own was discussed.
- SPOT can lead to patient benefit and more patient focussed practice by inclusion of patients in
determination of outcomes and measures, without blinding or use of placebos as needed in more
Paper session: Putting the second step first – the lead role of search skills on promoting EBM
Associate Professor Peter Schattner, Monash University and GP
- Study proposes to evaluate the impact of a program designed to promote and upskill GPs to
search for evidence using the Internet.
- The program will teach GPs to search for EBM, and use restricted entry portals of high quality
- The informatics officer will be trained to access clinical evidence based on electronic databases
- GPs will either receive personalised intervention or receive it three months later. Changes in
searching behaviour will be documented before and after the intervention.
- Sustainability will be measured by repeating the searching survey six months after the intervention.
- This is a work-in-progress.
Workshop: PHC RIS support for PHCRED
Ellen McIntyre, Senior Research Fellow with the Primary Health Care Research and Information Service.
- Overseas speakers should go to other sites
- Links to North America IT/GP experiences
- Perhaps the PHCRIS website should reflect wider PHC issues more than GP/Divisions
- Market PHCRIS conference internationally, including North America
- Should there be a network website for PHCRIS/ framework
- One page to prepare poster
- Send people to NAPCRG
- Travelling fellowship/sabbatical
Workshop: BEACH Data
Associate Professor Helena Britt, Director of the Family Medicine Research Centre and the AIHW GP
Statistics and Classification unit at the University of Sydney.
- Part of the AIHW GP Statistics & Classification Unit, Family Medicine Research Centre,
University of Sydney.
- BEACH stands for Bettering the Evaluation and Care of Health
- BEACH aims to provide a reliable and valid continuous national data source of timely GP–patient
encounter information, and to assess patient risk factors and health states and their relationship to
morbidity and health service activity.
- BEACH methods include paper based data collection of encounter data, National GP random
sample (drawn by DHAC), 1,000 GPs per year, 20 per week x 50 weeks a year - ever changing,
100 consecutive encounters per GP, all types of encounters included, post-stratification weighting
GP type + activity level), and National data for 100,000 encounter records p.a.
- BEACH variables include G.P Characteristics: age, sex, country of graduation, years in
general practice, FRACGP, currently in training program, practice location (State,RRMA, ARIA, SIEFA), practice size, and use of computers
- Patient characteristics: Age, Sex, Status to the practice, NESB, Aboriginal, Torres
Straight Islander, Health care card holder, VA card holder, and reasons for encounter
- Encounter details: Problems managed, status, management of each problem, medications, procedures/ clinical treatments, referrals, pathology, and imaging
- BEACH pharmaceutical data (Drug name, strength, dose, frequency, number of repeats,
prescribed/ advised/ supplied, and new V's continued
- BEACH output- major reports: Annual reports (AIHW-USYD) ( yr 4 in prep), Specific topic
reports (AIHW-USYD), Pathology ordering by GPs, Its different in the bush', Imaging orders by
GPs, Patients with cardiovascular disease (in preparation), male patients in general practice (in
preparation), COGNOS Cubes
- Full reports available through www.fmrc.org.au
- Copies available from AusInfo
- Uses of data: Planning your research, comparing your sample for
generalisability, measurement of change, development of clinical guidelines, identifying issues of quality
for u/grad, post/grad, CME
- This unique Australian database is being underutilised. More GP researchers should be
made aware of it.
Workshop: General Practice research: Matching methods to the complexity of the issues.
Mr Gawaine Powell Davies, Coordinator of The Centre for General Practice Integration Studies,
University of New South Wales.
- The workshop examined the aspects of practices and the way they work that influence the quality
of care of chronic disease. It also discussed interventions external to practice likely to influence
quality of care.
- Consumer perspectives identified – critical incidents and marginalised consumers. Often
observation methods and in depth methods are required here.
- Sociological perspectives identified: values/beliefs/power structures/communities, responsibility,
personal beliefs, understanding of communities. Appropriate methodologies include observational
case studies and theoretical frameworks
- Business perspectives identified: business plan, information management, time management, change
management, funding sources. Appropriate methods include getting baseline data on current
business, definition of roles, and analysis of management systems.
- The University of Adelaide and New South Wales will be working on these issues in the next few
years and reporting to future AAAGP research meetings.
Workshop: Evaluating educational initiatives in Evidence-Based Primary Care: What are we
aiming to achieve?
Dr Lyndal Trevena, GP and Lecturer in the Department of General Practice, University of Sydney.
- There is a need for a uniform evaluation tool, however problematic because of different types
of educational activities
- Validated tool (developed in UK) critiqued for appropriateness. Would need to be localised,
tests knowledge, not behaviour, and very long and daunting.
- AAAGP should consider a collaborative approach to EBP by endorsing the Evidence Based
Primary Care group and assisting in a shared approach to evaluation.
Closing plenary: General discussion and recommendations
Please note that the closing plenary session deviated from the program outline. The session focused on
discussion around the AAAGP preferred model for the APHCRI.
- Objectives and role of this model is to validate and build on what Departments of General Practice
have already done.
- APHCRI objectives are to conduct high quality research in primary care, interface/integrated care,
and emphasise chronic illness, methodological challenges, and applicability/implementation.
- The objectives should also include high quality training of PhD researchers with a clinical
epidemiological focus and a social/behavioural focus.
- A model was presented which recommends themed programs, and criteria for these programs:
- Prevention and health promotion, chronic illness (course and optimal management, self management
and social support)
- Quality and effectiveness of primary health care (evidence-based
- Health inequalities and social determinant (rural and indigenous)
- Organisation and economics of primary care (integration and policy
- Management structure: Again, a model was presented for discussion. This model included four
governing committees, general board, executive board, finance and organisation committee, PhD
and training committee.
- In terms of education, the research school would be part of the scientific community and comprise
senior and junior researchers. There would be thematic coherence and promotion of research
quality and quality PhD training.
- The PhD training program would be individualised.
- Senior researchers should have a PhD, acknowledged expert in the field, have a substantial number
of international publication over a longer period, be successful in initiating projects and obtaining
external funding. They should also have a good record in training and supervising junior
- Junior researchers should be involved in daily project management and authorship of research
articles. The possibility to combine professional training and PhD study should be considered.
- Important to avoid duplication (role of Australian Institute of Primary Care (AIPC) at La
- Build on strengths or develop the less strong
- Virtual or single institutions
- Sharing of strengths and resources
- Avoid increasing the gap between strong and weak departments
- Role of Hub versus PHCRIS
- Learn from the past, example, GPEP
- Roles of the hub – includes coordination and information sharing
- Development of shared training in development activities across institutions for all PhD students
- Distinction between governance and management
- Clear role distinction
- Clear responsibilities
- Clear reporting
- Need to elaborate all key stakeholders' need to revisit and align governance structure to Australian
- Views of stakeholders about the research functions and output on the institute
- Link research and practice both ways
- There needs to be agreement on the mission. The mission needs to be more measurable, and link
research to improving objectives. The themes need more detail on specific content.
- A draft model will be posted on the AAAGP website and open for discussion and input. A
education and training directions need to be developed
- AAAGP needs to be involved in more research collaborations (national and international).
- AAAGP needs to be more proactive in raising the quality and profile of research.
- AAAGP should also focus on dissemination of research findings, and supporting researchers to
disseminate their findings widely.
- AAAGP should ensure representation on Committees, Boards and Consortium. These include
postgraduate training (GPET) and the further development of PHCRED and the
- AAAGP should be instrumental in promoting University Departments.
Please participate in creating
an action plan to address these recommendations.