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Objective Methods for meta-analysis of studies with individual participant data and continuous exposure variables are well described in the statistical literature but are not widely used in clinical and epidemiological research. The purpose of this case study is to make the methods more accessible. Study Design and Setting A two-stage process is demonstrated. Response curves are estimated separately for each study using fractional polynomials. The study-specific curves are then averaged pointwise over all studies at each value of the exposure. The averaging can be implemented using fixed effects or random effects methods. Results The methodology is illustrated using samples of real data with continuous outcome and exposure data and several covariates. The sample data set, segments of Stata and R code, and outputs are provided to enable replication of the results. Conclusion These methods and tools can be adapted to other situations, including for time-to-event or categorical outcomes, different ways of modelling exposure-outcome curves, and different strategies for covariate adjustment.

Objective To ascertain the association between vasomotor menopausal symptoms (VSM), hot flushes and night sweats, and cardiovascular disease, coronary heart disease and cerebrovascular disease. Study design The study sample comprised 8881 women (aged 45–50 years) with available hospital separation data from the 1946-51 cohort (1996–2016) of the ongoing Australian Longitudinal Study on Women’s Health, a national prospective cohort study. Main outcome measures First fatal or non-fatal cardiovascular disease, coronary heart disease, and cerebrovascular disease events were obtained through linkage with hospital admission data, the National Death Index, and Medicare Benefits Schedule. Hot flushes and night sweats were assessed via questionnaires at each main survey. Additionally, we calculated the duration of symptoms based on whether or not women reported vasomotor menopausal symptoms in each survey. Results There were 925 cardiovascular disease, 484 coronary heart disease and 154 cerebrovascular disease events. There was no consistent evidence of any association with vasomotor menopausal symptoms, hot flushes and night sweats. We did find marginally statistically significant associations between presence of night sweats and cardiovascular disease (Hazard Ratio = 1.18, 95 % Confidence Interval: 1.01–1.38), and between the duration of vasomotor menopausal symptoms [years] and coronary heart disease (Hazard Ratioper year = 1.03, 95 % Confidence Interval: 1.00–1.05). However, given the number of associations tested, these findings could very well have arisen by chance. Conclusion In this large longitudinal study with 20 years of follow-up and clinical outcomes we did not find a convincing association between vasomotor menopausal symptoms, hot flushes, night sweats and cardiovascular disease, coronary heart disease and cerebrovascular disease.

Introduction The purpose of this study was to examine the validity of self-report diabetes according to sociodemographic characteristics in participants of Ravansar Non-Communicable Diseases (RaNCD) cohort study. Methods The study population included 10182 adults (35–65 years old) participating in RaNCD. The ‘gold standard' for diagnosis of diabetes mellitus was taken as a history of relevant medicine use and/or measurement of fasting blood glucose indicating diabetes. Self-report data collected before the clinical examinations through interviews by well-trained staff. Sensitivity, specificity, and positive and negative predictive values were used to estimate the accuracy of self-report in diabetes. Results Of the 10182 individuals invited to participate in the RaNCD, 96 people were not willing to participate in the study (participation rate = 99.06%). The prevalence of diabetes by self-report and gold standard was 10.04% and 8.19% respectively. Among those who said they had diabetes, 389 (38.78%) did not have diabetes. Self-reported diabetes had sensitivity, specificity, positive and negative predictive values of 75.0%, 95.8%, 61.2% and 97.7%, respectively. Being female, aging, smoking, and having a family history of diabetes increased the chance of false positive; and being male, having a family history of diabetes, aging, and increasing BMI increased the chance of false negative. Conclusions Although the overall validity of self-report in diabetes seems to be acceptable in the study population with a correction factor of 25.3%, it should be noted that the is influenced by age, gender, and family history of diabetes.

BackgroundMenopausal vasomotor symptoms (ie, hot flashes and night sweats) have been associated with unfavorable risk factors and surrogate markers of cardiovascular disease, but their association with clinical cardiovascular disease events is unclear.ObjectiveTo examine the associations between different components of vasomotor symptoms, timing of vasomotor symptoms, and risk of cardiovascular disease.Study designWe harmonized and pooled individual-level data from 23,365 women in 6 prospective studies that contributed to the International Collaboration for a Life Course Approach to Women's Reproductive Health and Chronic Disease Events consortium. Women who experienced cardiovascular disease events before baseline were excluded. The associations between frequency (never, rarely, sometimes, and often), severity (never, mild, moderate, and severe), and timing (before or after age of menopause; ie, early or late onset) of vasomotor symptoms and incident cardiovascular disease were analyzed. Cox proportional hazards models were used to estimate hazard ratios and 95% confidence intervals.ResultsIn the adjusted model, no evidence of association was found between the frequency of hot flashes and incident cardiovascular disease, whereas women who reported night sweats "sometimes" (hazard ratio, 1.22; 95% confidence interval, 1.02-1.45) or "often" (hazard ratio, 1.29; 95% confidence interval, 1.05-1.58) had higher risk for cardiovascular disease. Increased severity of either hot flashes or night sweats was associated with higher risk of cardiovascular disease. The hazards ratios of cardiovascular disease in women with severe hot flashes, night sweats, and any vasomotor symptoms were 1.83 (95% confidence interval, 1.22-2.73), 1.59 (95% confidence interval, 1.07-2.37), and 2.11 (95% confidence interval, 1.62-2.76), respectively. Women who reported severity of both hot flashes and night sweats had a higher risk for cardiovascular disease (hazard ratio, 1.55; 95% confidence interval, 1.24-1.94) than those with hot flashes alone (hazard ratio, 1.33; 95% confidence interval, 0.94-1.88) and night sweats alone (hazard ratio, 1.32; 95% confidence interval, 0.84-2.07). Women with either early-onset (hazard ratio, 1.38; 95% confidence interval, 1.10-1.75) or late-onset (hazard ratio, 1.69; 95% confidence interval, 1.32-2.16) vasomotor symptoms had an increased risk for incident cardiovascular disease compared with women who did not experience vasomotor symptoms.ConclusionSeverity rather than frequency of vasomotor symptoms (hot flashes and night sweats) was associated with increased risk of cardiovascular disease. Vasomotor symptoms with onset before or after menopause were also associated with increased risk of cardiovascular disease.

Objectives To assess the impact of dementia on the use of health and community services in the last 2 years of life by women who also had other major chronic conditions. Design Matched groups of women with a chronic condition who did or did not also have dementia, and who died or did not die for at least another 2 years. Setting and Participants Participants in the Australian Longitudinal Study on Women's Health who were born from 1921-1926. These women were from a random, nationally representative sample of 12,432 recruited in 1996 with follow-up until 2014. Methods Repeated survey data and linked administrative records were used to identify women with heart disease, chronic lower respiratory tract disease, and dementia. Use of aged care services, medical visits, and hospital admissions were compared among the matched groups. Results Women with dementia were more likely to move into residential aged care, especially in the months and years before death. Consequently, they made less use of community-based services. Numbers of general practitioner visits were similar for women with or without dementia, increasing substantially in the last 4 months of life. In contrast, women with dementia were less likely to see medical specialists and slightly less likely to be admitted to hospital, even in the last 4-6 months of life when hospitalization was more common. The findings were similar whether the comorbid condition was heart disease or chronic lower respiratory tract disease. Conclusions and Implications Use of other services is affected by use of residential aged care, so the comprehensive care of people with dementia requires understanding connections between sectors.

Objectives: Proton pump inhibitors (PPIs) are among the most prescribed medications worldwide, however, there is growing concern regarding potential negative effects on bone health. The aim was to examine the effect of dose and type of PPI use on subsequent use of osteoporosis medication and fractures in older Australian women. Methods: Data were included from 4432 participants (born 1921-26) in the 2002 survey of the Australian Longitudinal Study on Women's Health. Medication data were from the national pharmaceutical administrative database (2003-2012, inclusive). Fractures were sourced from linked hospital datasets available for four major States of Australia. Competing risk regression models used PPI exposure as a time-dependent covariate and either time to first osteoporosis medication prescription or fracture as the outcome, with death as a competing risk. Results: Of the 2328 PPI users and 2104 PPI non-users, 827 (36%) and 550 (26%) became users of osteoporosis medication, respectively. PPI use was associated with an increased risk of subsequent use of osteoporosis medication (adjusted sub-hazard ratio [SHR] = 1.28; 95% confidence interval [CI] = 1.13-1.44) and subsequent fracture (SHR = 1.29, CI = 1.08-1.55). Analysis with PPI categorized according to defined daily dose (DDD), showed some evidence for a dose-response effect (osteoporosis medication

Objectives To compare methods for analysis of longitudinal studies with missing data due to participant dropout and follow-up truncated by death. Study Design and Setting We analyzed physical functioning in an Australian longitudinal study of elderly women where the missing data mechanism could either be missing at random (MAR) or missing not at random (MNAR). We assumed either an immortal cohort where deceased participants are implicitly included after death or a mortal cohort where the target of inference is surviving participants at each survey wave. To illustrate the methods a covariate was included. Simulation was used to assess the effect of the assumptions. Results Ignoring attrition or restricting analysis to participants with complete follow up led to biased estimates. Linear mixed model was appropriate for an immortal cohort under MAR but not MNAR. Linear increment model and joint modeling of longitudinal outcome and time to death were the most robust to MNAR. For a mortal cohort, inverse probability weighting and multiple imputation could be used, but care is needed in specifying dropout and imputation models, respectively. Conclusion Appropriate analysis methodology to deal with attrition in longitudinal studies depends on the target of inference and the missing data mechanism.

To examine patterns of the incidence of diabetes, hypertension, and mortality by single units of body mass index (BMI) and 5-year age groups using longitudinal data from middle-aged and older women.Middle-aged (born between 1946 and 1951; N = 13,715) and older (born between 1921 and 1926; N = 12,432) participants in the Australian Longitudinal Study on Women's Health completed surveys in 1996 and at approximately 3-year intervals thereafter until 2011. Proportions of women with diabetes, hypertension, and mortality over 3-year intervals were estimated for each unit of BMI and 5-year age group (45 to50, 50 to55, 55 to60, 70 to75, 75 to80, and 80 to85 years) using generalized additive modeling with adjustment for time-varying covariates.Three-year incidence of diabetes (1.2%-3.6%), hypertension (5.2%-17.8%), and death (0.4%-9.5%) increased with age. For both diabetes and hypertension, the associations with BMI were curvilinear in middle-aged women and became almost linear in older women. With increasing age, the slope became steeper, and the increase started at lower BMI values. For hypertension, there was a marked increase in intercept from 75 years onward. In contrast, mortality risks were highest for low BMI (≤ 20) in all age groups. A clear U-shaped curve was observed only in the oldest age group.The shapes of the relationships between BMI and incidence of diabetes, hypertension, and mortality change with age, suggesting that weight management interventions should be tailored for different age groups.

Background To assess the validity and responsiveness of the FRAIL scale and investigate whether validity is related to the number of points used on the scale. Methods Participants were 12,432 women born in 1921–1926 from the Australian Longitudinal Study on Women's Health; surveyed up to 6 times from 1996 to 2011. The FRAIL scale is a 5-item measure and scored as a 6-, 3-, or 2-point measure. Face validity was determined by assessing relationships with age, construct validity was determined by assessing relationships with measures of disability (activities of daily living and independent activities of daily living), and responsiveness was determined by assessing relationships with changes in self-rated health. Results The proportion of women who reported their frailty as high (4 or 5 on a scale of 0 to 5) increased with age from 5.6% at age 73–78 years to 16.2% at age 85–90 years. The FRAIL scale was moderately correlated with disability, Spearman's rho ≥0.4 for activities of daily living and ≥0.5 for independent activities of daily living; slightly stronger associations were observed when it was scored as a 6-point measure. Mean change (95% confidence interval) in FRAIL 6-point scores decreased for women who reported improvements in self-rated health between successive surveys; by at least 0.08 (0.01, 0.15) and increased in those women who reported declines in self-rated health by at least 0.64 (0.57, 0.70). Conclusions The FRAIL scale is valid and responsive and is suitable for use in longitudinal studies of women in their 70s and older.

Treelet transform (TT) is a proposed alternative to factor analysis for deriving dietary patterns. Before applying this method to nutrition data, further analyses are required to assess its validity in nutritional epidemiology. We aimed to compare dietary patterns from factor analysis and TT and their associations with diabetes incidence. Complete data were available for 7349 women (50–55 y at baseline) from the Australian Longitudinal Study on Womens Health. Exploratory factor analysis and TT were performed to obtain patterns by using dietary data collected from an FFQ. Generalized estimating equations analyses were used to examine associations between dietary patterns and diabetes incidence. Two patterns were identified by both methods: a prudent and a Western dietary pattern. Factor analysis factors are a linear combination of all food items, whereas TT factors also include items with zero loading. The Western pattern identified by factor analysis showed a significant positive association with diabetes [highest quintile: OR = 1.94 (95% CI: 1.25, 3.00); P-trend = 0.001). Both factor analysis and TT involve different assumptions and subjective decisions. TT produces clearly interpretable factors accounting for almost as much variance as factors from factor analysis. However, TT patterns include food items with zero loading and therefore do not represent overall dietary patterns. The different dietary pattern loading structures identified by both methods result in different conclusions regarding the relationship with diabetes. Results from this study indicate that factor analysis might be a more appropriate method for identifying overall dietary patterns associated with diabetes compared with TT. J. Nutr. 143: 392–398, 2013.

Objective To examine the extent to which the odds of birth, pregnancy, or adverse birth outcomes are higher among women aged 28 to 36 years who use fertility treatment compared with untreated women. Design Prospective, population-based. Setting Not applicable. Patient(s) Participants in the ALSWH born in 1973 to 1978 who reported on their infertility and use of in vitro fertilization (IVF) or ovulation induction (OI). Intervention(s) Postal survey questionnaires administered as part of ALSWH. Main Outcome Measure(s) Among women treated with IVF or OI and untreated women, the odds of birth outcomes estimated by use of adjusted logistic regression modeling. Result(s) Among 7,280 women, 18.6% (n = 1,376) reported infertility. Half (53.0%) of the treated women gave birth compared with 43.8% of untreated women. Women with prior parity were less likely to use IVF compared with nulliparous women. Women using IVF or OI, respectively, were more likely to have given birth after treatment or be pregnant compared with untreated women. Women using IVF or OI were as likely to have ectopic pregnancies, stillbirths, or premature or low birthweight babies as untreated women. Conclusion(s) More than 40% of women aged 28–36 years reporting a history of infertility can achieve births without using treatment, indicating they are subfertile rather than infertile.

Background Women change contraception as they try to conceive, space births, and limit family size. This longitudinal analysis examines contraception changes after reproductive events such as birth, miscarriage or termination among Australian women born from 1973 to 1978 to identify potential opportunities to increase the effectiveness of contraceptive information and service provision. Methods Between 1996 and 2009, 5,631 Australian women randomly sampled from the Australian universal health insurance (Medicare) database completed five self-report postal surveys. Three longitudinal logistic regression models were used to assess the associations between reproductive events (birth only, birth and miscarriage, miscarriage only, termination only, other multiple events, and no new event) and subsequent changes in contraceptive use (start using, stop using, switch method) compared with women who continued to use the same method. Results After women experienced only a birth, or a birth and a miscarriage, they were more likely to start using contraception. Women who experienced miscarriages were more likely to stop using contraception. Women who experienced terminations were more likely to switch methods. There was a significant interaction between reproductive events and time indicating more changes in contraceptive use as women reach their mid-30s. Conclusion Contraceptive use increases after the birth of a child, but decreases after miscarriage indicating the intention for family formation and spacing between children. Switching contraceptive methods after termination suggests these pregnancies were unintended and possibly due to contraceptive failure. Women’s contact with health professionals around the time of reproductive events provides an opportunity to provide contraceptive services.

Background Vision and hearing decline with age. Loss of these senses is associated with increased risk of falls, injuries from falls, mortality and decreased health-related quality of life (HRQOL). Our objective was to determine if there are gender differences in the associations between visual and hearing impairment and these outcomes. Methods 2340 men and 3014 women aged 76–81 years from the Health in Men Study and the Australian Longitudinal Study on Women's Health were followed for an average of 6.36 years. Dependent variables were self-reported vision and hearing impairment. Outcome variables were falls, injuries from falls, physical and mental components of HRQOL (SF-36 PCS and MCS) and all-cause mortality. Results Vision impairment was more common in women and hearing impairment was more common in men. Vision impairment was associated with increased falls risk (odds ratio (OR) = 1.77, 95% CI = 1.35–2.32 in men; OR = 1.82, 95% CI = 1.44–2.30 in women), injuries from falls (OR = 1.69, 95% CI = 1.23–2.34 in men, OR = 1.79, 95% CI = 1.38–2.33 in women), and mortality (hazard ratio (HR) = 1.44; 95% CI = 1.17–1.77 in men; HR = 1.50, 95% CI = 1.24–1.82 in women) and declines in SF-36 PCS and MCS. Hearing impairment was associated with increased falls risk (OR = 1.38, 95% CI = 1.08–1.78 in men; OR = 1.45, 95% CI = 1.08–1.93 in women) and declines in SF-36 PCS and MCS. Overall there were no gender differences in the association between vision and hearing impairment and the outcomes. Conclusion In men and women aged 76–81 years, there were no gender differences in the association between self-reported vision and hearing impairment and the outcomes of falls, mortality and HRQOL.

Background Physical functioning is an important determinant of mortality and morbidity in older adults and there may be differences by gender and marital status. This study compared disability, measured by the ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs), between older men and women who are either partnered or not partnered. Methods Participants included 5497 women and 1072 men aged 82–87 years from cross sectional surveys conducted in 2008 (the Health in Men Study and the Australian Longitudinal Study on Women's Health). Ordinal logistic regression was used to examine the relationship between disability and gender by marital status, adjusting for self-reported chronic conditions. Results Women reported a higher prevalence of most chronic conditions than men. Unpartnered men had significantly higher odds of reporting difficulty in dressing the lower body and doing heavy housework, and significantly lower odds of reporting difficulty managing money and preparing meals than partnered men. Unpartnered and partnered women had significantly lower odds of reporting difficulty in dressing the lower body, walking inside the house, using the toilet, preparing meals, taking medications, using the telephone and performing leisure activities than partnered men. However, unpartnered and partnered women had significantly higher odds of reporting difficulty with eating, shopping, and doing light or heavy housework than did partnered men. Conclusions Differences between partnered and unpartnered older men and women in difficulty with ADLs and IADLs were identified, with women reporting less difficulty overall, regardless of partner status.

Death rates in Australia are higher in rural than urban areas. Our objective is to examine causes of death of urban and rural women to gain insight into potential explanations for differences in mortality. Participants were a community-based random sample of women (n=12,400) aged 70-75 years when recruited in 1996 to the Australian Longitudinal Study on Women's Health. The main variables used were: area of residence classified according to the Australian Standard Geographic Classification (ASGC), survival to 31 October 2006, cause of death, selected risk factors. The total number of deaths at 31 October 2006 was 2,803 and total number of women still alive was 9,597. Mortality was higher for women in rural areas overall (hazard ratio (HR)=1.09; 95% confidence interval (CI): 1.01-1.18) and for most major causes of death compared to urban women. In particular, death rates were substantially higher for lung cancer (HR=1.52; 95% CI: 1.03-2.25) and chronic obstructive pulmonary disease (COPD) (HR=1.83; 95% CI: 1.25-2.69). Nevertheless there were almost no differences among the groups for current smoking or smoking history. Prevalence of overweight and obesity was slightly higher and levels of physical activity lower among women in remote areas. There is little evidence that differences in mortality are due to the risk factors considered. Alternative explanations such as inequities in health services and environmental hazards should be considered. People in rural areas may suffer from a double disadvantage of poorer health services and exposure to health hazards that are less common in urban areas.

Objective To investigate the mental and general health of infertile women who had not sought medical advice for their recognized infertility and were therefore not represented in clinical populations. Design Longitudinal cohort study. Setting Population based. Patient(s) Participants in the Australian Longitudinal Study on Women's Health aged 28–33 years in 2006 who had ever tried to conceive or had been pregnant (n = 5,936). Intervention(s) None. Main Outcome Measure(s) Infertility, not seeking medical advice. Result(s) Compared with fertile women (n = 4,905), infertile women (n = 1,031) had higher odds of self-reported depression (odds ratio [OR] 1.20, 95% confidence interval [CI] 1.01–1.43), endometriosis (5.43, 4.01–7.36), polycystic ovary syndrome (9.52, 7.30–12.41), irregular periods (1.99, 1.68–2.36), type II diabetes (4.70, 1.79–12.37), or gestational diabetes (1.66, 1.12–2.46). Compared with infertile women who sought medical advice (n = 728), those who had not sought medical advice (n = 303) had higher odds of self-reported depression (1.67, 1.18–2.37), other mental health problems (3.14, 1.14–8.64), urinary tract infections (1.67, 1.12–2.49), heavy periods (1.63, 1.16–2.29), or a cancer diagnosis (11.33, 2.57–49.89). Infertile women who had or had not sought medical advice had similar odds of reporting an anxiety disorder or anxiety-related symptoms. Conclusion(s) Women with self-reported depression were unlikely to have sought medical advice for infertility. Depression and depressive symptoms may be barriers to seeking medical advice for infertility.

Results: On average, women gained weight at the rate of 0.93% per year (95% CI0.89, 0.98) or 605 g/year (95% CI580, 635) for a 65-kg woman. Over the 10-year study period, partnered women with one baby gained almost 4 kg more, and those with a partner but no baby gained 1.8 kg more, than

Stuttering involves disruptions to normal verbal behavior. The rate that these disruptions occur within individuals who stutter varies across time and also with speaking situation. Therefore multiple samples of speech are commonly taken from individuals, in an attempt to obtain a realistic estimate of the severity of their condition. Stuttering rates are commonly reported as the proportion of syllables stuttered. Traditionally, general linear models have been used to analyze and compare stuttering rates. However, the distribution of this type of data is not normal, the duration of the individual speech samples is not usually taken into account, and repeated measurements on individuals are often aggregated prior to analysis. We propose that these issues can be resolved by using a negative binomial mixed model approach. In this paper, we argue why this is sensible and then show that the model is practical to implement, drawing on data from two randomized controlled trials of interventions for treatment of stuttering. We also show how to estimate sample size for our proposed model based on a negative binomial distribution.

Objective ; Older people may act as sensitive indicators of the effectiveness of health systems. Our objective is to distinguish between the effects of socio-economic and behavioural factors and use of health services on urban-rural differences in mortality and health of elderly women. Methods : Baseline and longitudinal analysis of data from a prospective cohort study. Participants were a community-based random sample of women (n=12778) aged 70-75 years when recruited in 1996 to the Australian Longitudinal Study on Women's Health. Measures used were: urban or rural residence in Australian States and Territories, socio-demographic characteristics, health related behaviour, survival up to 1 October 2006, physical and mental health scores and use of medical services. Results : Mortality was higher in rural than in urban women (hazard ratio, HR 1.14; 95% CI, 1.03,-1.26) but there were no differences between States and Territories. There were no consistent baseline or longitudinal differences between women for physical or mental health, with or without adjustment for socio-demographic and behavioural factors. Rural women had fewer visits to general practitioners (odds ratio, OR=0.54; 95% Cl, 0.48-0.61) and medical specialists (OR=0.60; 95% Cl, 0.55-0.65). Conclusions : Differences in use of health services are a more plausible explanation for higher mortality in rural than urban areas than differences in other factors. Implications. Older people may be the 'grey canaries' of the health system and may thus provide an 'early warning system' to policy makers and governments. Journal Compilation

INTRODUCTION: Little research has examined recognized pregnancy losses in a general population. Data from an Australian cohort study provide an opportunity to quantify this aspect of fecundity at a population level. METHOD: Participants in the Australian Longitudinal Study on Women's Health who were aged 28-33 years in 2006 (n = 9,145) completed up to 4 mailed surveys over 10 years. Participants were categorized according to the recognized outcome of their pregnancies, including live birth, miscarriage/stillbirth, termination/ectopic, or no pregnancy. RESULTS: At age 18-23, more women reported terminations (7%) than miscarriages (4%). By 28-33 years, the cumulative frequency of miscarriage (15%) was as common as termination (16%). For women aged 28-33 years who had ever been pregnant (n = 5,343), pregnancy outcomes were as follows: birth only (50%); loss only (18%); and birth and loss (32%), of which half (16%) were birth and miscarriage. A comparison between first miscarriage and first birth (no miscarriage) showed that most first miscarriages occurred in women aged 18-23 years who also reported a first birth at the same survey (15%). Half (51%) of all first births and first miscarriages in women aged 18-19 ended in miscarriage. Early childbearers (

The Australian Government has supported the establishment of a Deployment Health Surveillance Program for the Australian Defence Force. Although some health screening mechanisms already exist for Australian Defence Force personnel, until now health data have been used largely for clinical management at an individual level and have not been aggregated to identify trends in health and risk factors in the shorter or longer term. We identify challenges for and potential benefits of health surveillance in the military context, describe features of the Program and progress to date. Retrospective and cross-sectional projects based on deployments to the Near North Area of Influence since 1997 are under way. A planned prospective model of health surveillance for those deploying to the Middle East promises more timely attention to any emerging health problems for military personnel and veterans.

Data from the Australian Longitudinal Study on Women's Health were used to study the order of events leading to informal caregiving and changes in labour force participation in mid-aged women, taking into account health and socioeconomic status. This analysis included 9857 women who responded to the third (2001) and fourth (2004) surveys and provided data for the caring and employment variables used. Caring was defined as providing care for an ill, frail or disabled person at least 7 h/wk. Between 2001 and 2004, the proportion of women caring increased from 12 to 14%. Paid employment participation decreased from 67 to 62% in 2004. Logistic regression model results show that taking up caring between 2001 and 2004 was not statistically significantly associated with employment status in 2001. Among women who took up caring, however, hours spent in paid employment in 2001 was negatively associated with hours spent caring in 2004. Amongst women working in 2001, taking up caring between 2001 and 2004 was associated with reduced participation in paid employment. In conclusion, among mid-aged women, transitions into caregiving were irrespective of time spent in paid employment, but were followed by a decrease in labour force participation. Policies could aim to support continuing labour force participation during caregiving by creating flexible working arrangements; re-employment programs could support women who quit work in getting back to paid employment after a period of caregiving.

Objective:To examine changes in smoking behaviour among young women over four life stages: leaving home; employment or attending college or university; marriage; and parenthood. Methods:Young women participating in the Australian Longitudinal Study on Women's Health completed postal questionnaires in 1996 and 2000. Results:Unmarried women who moved out of their parents' home between 1996 and 2000 had higher odds of adopting smoking than those who had not lived with their parents at either time (OR 1.8, 95% CI 1.2–2.6). Married women had lower odds of resuming smoking after quitting (OR 0.4, 95% CI 0.2–0.7) than unmarried women. Women who were pregnant in 2000 had higher odds of quitting smoking (OR 3.8, 95% CI 2.5–5.6) and women who were pregnant in 1996 and not in 2000 had higher odds of starting to smoke again (OR 3.2, 95% CI 1.6–6.2) than women who were not pregnant. The odds of being a current smoker or adopting smoking were significantly greater for women who binge drank alcohol or used cannabis and other illicit drugs. Conclusions:Adoption, maintenance and cessation of smoking among young women is strongly related to major life stage transitions, illicit drug use and alcohol consumption. Implications:Life changes such as marriage and actual or contemplated pregnancy provide opportunities for targeted interventions to help women quit smoking and not relapse after having a baby. Legislation to control smoking on licensed premises would reduce the social pressure on women to smoke.

OBJECTIVE: To assess differences among the menopausal transitions and symptoms experienced by women participating in the Australian Longitudinal Study on Women's Health, according to their countries of birth. METHODS: Data from 8,466 women aged 45-50 in 1996, who responded to surveys in 1996 and 1998 and had not had a hysterectomy, were analysed. Women were categorised by country of birth and cross-sectionally by menopausal status at Survey 1 and 2, as well as longitudinally by transition through menopause between Surveys 1 and 2. Four endocrine-related and 10 general symptoms were assessed. RESULTS: Women bom in Asia were twice as likely as Australian-bom women to be post-menopausal at Survey 1, twice as likely to become post-menopausal between surveys, less likely to remain peri-menopausal, and less likely to report hot flushes and night sweats. Odds ratios for each symptom at Survey 2 were near unity for all country of birth groups compared with Australian bom women, with or without adjustment for symptoms at Survey 1, menopausal transition category, behaviour, lifestyle and demographics. CONCLUSIONS: Asian-born women entered menopause earlier and passed through it more quickly, but once this was taken into account all women showed the same prevalences of symptoms. There may be differences between ethnic groups that influence the timing of menopause, but the subjective experience appears similar. IMPLICATIONS: The timing of menopause may be affected by biological or dietary differences. Asian-bom women's lower reported prevalence of symptoms may be explained by a more rapid peri-menopausal transition. With increasing numbers of Asian-Australian women reaching menopause, an understanding of country-of-birth differences has implications for public health

Introduction: Premature menopause and early menopause are known risk factors for adverse health outcomes in later life. While cigarette smoking is an established risk factor for earlier age at menopause, the overall size and strength of its relationship with premature or early menopause is yet to be fully elucidated.Objectives: To quantify the magnitude of the relationship between cigarette smoking status with the age at final menstrual period (FMP).Methods: The International collaboration for a Life course Approach to reproductive health and Chronic disease Events (InterLACE) enables the use of pooled data on 51 450 women from nine longitudinal observational studies in the UK, Scandinavia, Australia and Japan. Age at FMP was confirmed by at least 12 months of cessation of menses and categorised as: premature menopause (FMP before age 40), early menopause (FMP 40–44 years), 45–49 years, 50–51 years, 52–53 years, or 54 or more years. Cigarette smoking was categorised as current smoker, past smoker, or never smoker. Multinomial logistic regression was used to identify associations with age categories for FMP, after adjusting for birth year, age at menarche, education level, marital status, parity, and body mass index during midlife.Findings: Overall 18% of the women were smokers, with a mean age at FMP of 48.9 years (SD 4.2). The mean (SD) for never or past smokers was 50.1 (4.2) years. Current smokers were at a higher risk of having premature menopause (RRR 1.48, 95% CI 1.17 to 1.88), early menopause (1.70, 1.43 to 2.03), FMP at 45–49 years (1.43, 1.31 to 1.56) compared with never smokers. Past smokers had similar risks as never smokers.Conclusions: This study identified robust evidence for the effect of cigarette smoking on the timing of menopause before the age of 50, with the effect being highest for early menopause. Findings underscore support for smoking prevention and quitting programmes for women of reproductive age.

Objective: To assess consent to record linkage, describe the characteristics of consenters and compare self-report versus Medicare records of general practitioner use. Method. Almost 40,000 women in the Australian Longitudinal Study on Women's Health were sent a request by mail for permission to link their Medicare records and survey data. Results: 19,700 women consented: 37% of young (18-23 years), 59% of mid-age (4550 years) and 53% of older women (70-75 years). Consenters tended to have higher levels of education and, among the older cohort, were in better health than nonconsenters. Women tended to under-report the number of visits to general practitioners. Conclusions: Record linkage of survey and Medicare data on a large scale is feasible. The linked data provide information on health and socio-economic status which are valuable for understanding health service utilisation. Implications: Linked records provide a powerful tool for health care research, particularly in longitudinal studies.

The objective of this study was to use a population-based register of acute cardiac events to investigate the association between survival after an acute event and history of smoking and alcohol consumption. The population was all residents of the Lower Hunter Region of Australia aged 25 to 69 years who suffered myocardial infarction or sudden cardiac death between 1986 and 1994. Among 10,170 events, 2504 resulted in death within 28 days. After adjusting for sex, age and medical history, current smokers had a similar risk of dying after an acute cardiac event to never-smokers [odds ratio (OR)=1.10, 95% confidence interval (CI) 0.94-1.29]. People who consumed more than 8 alcoholic drinks per day on more than 2 days per week (OR=1.93, 95% CI 1.39-2.69) and former moderate to heavy drinkers (OR=4.59, 95% CI 3.65-5.76) were more likely to die than people who were nondrinkers. The results of this large community study, suggesting no effect of smoking on case fatality and an increased risk of death after an acute cardiac event for heavy drinkers and former moderate to heavy drinkers, highlight the importance of a population view of case fatality. These results can also shed some light on reasons for the paradoxical results from clinical trials.

Objective: To assess geographical equity in the availability, accessibility and out-of-pocket costs of general practitioner (GP) services for women in Australia. Method: Data on general practice consultations during 1995 and 1996 for women aged 18-23 years (n=5,260), 45-50 years (n=7,898) and 70-75 years (n=6,542) in the Australian Longitudinal Study on Women's Health were obtained from the Health Insurance Commission. A sub-study of 4,577 participants provided data on access to health services. Results: Older women were more likely to have no out-of-pocket costs for their GP consultations, but in all age groups, the proportion was lower in rural areas than in urban areas (older age: 60% rural areas, 76% capital cities; mid-age: 24% rural areas, 40% capital cities; young age: 35% rural areas, 52% capital cities). Among mid-aged women, the median out-of-pocket cost per consultation ranged from $2.11 in capital cities to $6.48 in remote areas. Women living in rural and remote areas gave lower ratings for the availability, accessibility and affordability of health services than women living in urban areas. Conclusions This study has shown a striking gradient in financial and nonfinancial barriers to health care associated with area of residence. Implications: The geographical imbalance in the supply and distribution of GP services in Australia has long been recognised but inequities in the affordability of services must also be addressed. Longitudinal survey data and Health Insurance Commission data provide a means to evaluate policies designed to improve access to health services in rural and remote areas.

To examine associations between cigarette smoking and menstrual symptoms and miscarriage among young women.The study sample consists of 14,779 women aged 18-23 years who participated in the mailed baseline survey for the Australian Longitudinal Study on Women's Health, conducted in 1996. The main outcome measures are self reported menstrual symptoms and miscarriages.Current smokers and ex-smokers had an increased risk of menstrual symptoms and miscarriages compared with women who had never smoked, with the highest risk occurring in heavy smokers (adjusted odds ratios for those smokingor = 20 cigarettes per day: premenstrual tension 1.5 (95% confidence interval 1.3 to 1.7), irregular periods 1.5 (1.3 to 1.8), heavy periods 1.6 (1.4 to 1.9), severe period pain 1.5 (1.4 to 1.7), one or more miscarriages 2.0 (1.5 to 2.8). The odds ratios generally increased with numbers of cigarettes smoked and a younger age of starting to smoke.This study suggests that young women who smoke are at higher risk of a range of menstrual problems and miscarriage than those who have never smoked. The immediacy of this risk (in contrast to the longer term risks of chronic disease) can be used to improve the relevance of anti-smoking campaigns targeted to young women.

Objective: To determine which sociodemographic factors. health-related behaviours and physical health conditions are associated with non-drinking, binge drinking and hazardous/harmful drinking in young Australian women. Methods: Cross-sectional data were obtained from the baseline survey of 14,762 young women (aged 18-23 years) enrolled in the Women's Health Australia study in 1996. Associations between a range of drinking patterns and sociodemographic factors, health-related behaviours and health conditions were examined. Results: Half the women were 'low intake' drinkers, a third 'rarely drank' and 9% were non-drinkers; however, 70% reported binge drinking with one-quarter of the binge drinkers doing so at least weekly. Nondrinkers were more likely than drinkers to be married, pregnant, non-smokers, born in non-English speaking countries, to live in the Northern Territory, and to have lower levels of education, employment, and private health insurance. Low intake/binge weekly' drinkers (12%) and 'hazardous/ harmful' drinkers (5%) were more likely than 'low risk' drinkers to be unmarried; to live in shared accommodation, alone or with their parents; to live in rural or remote areas; to have ever had any sexually transmitted infection; to be current smokers or ex-smokers and to have used unhealthy weight-control practices. Conclusions: The results confirm findings from other countries about the importance of social conditions as determinants of alcohol consumption by young women. Implications: Health promotion to reduce young women's alcohol consumption needs to be carefully targeted to take account of their demographies, living environments and beliefs.

Adopting new approaches that build on existing activities was the recommendation of The National Health Priority Areas Report on cardiovascular health, released on 4th August 1999. The report, prepared biennially for Australian Health Ministers, presented the following key recommendations for further improving the cardiovascular health of Australians: establishing a long-term national focus on heart disease; coordinating primary prevention programs across Australia; establishing a national mechanism for the production of better practice guidelines; broadening the focus of cardiovascular disease programs to give more emphasis to stroke; addressing issues of inequalities of health status among disadvantaged groups; and expanding the activities of the National Centre for Monitoring Cardiovascular Disease to allow for future strategic planning.

A population-based observational study of men and women aged 35-69 years in the Hunter Region of New South Wales, Australia, was conducted to assess the impact of risk-factor modification and increased drug therapy on the trends in major coronary events and case fatality. From 1985 to 1993, there were 3006 coronary deaths and 6450 nonfatal major coronary events. Rates of death and nonfatal myocardial infarction declined, but there was an increase in hospital admissions for prolonged chest pain. Reductions in cigarette smoking, diastolic blood pressure, total cholesterol, and increased use of aspirin can fully explain the 3.3% (95% confidence interval [CI] 2.4, 4.2) average annual reduction in rates of major coronary events for men and the 4.1% (95% CI 2.7, 5.5) reduction for women. In contrast, increased use of aspirin, beta-blockers, fibrinolytic therapy, and angiotensin-converting enzyme inhibitors explain less than half of the 8.9% (95% CI 5.9, 11.8) and 6.9% (95% CI 2.7, 10.9) average annual reduction in case fatality in hospital for men and women, respectively. These trends suggest a decline in severity of coronary heart disease consistent with reductions in risk-factor levels and improved acute medical treatment.

The objective of this study was to determine the rate of the decline in risk of a major coronary event after quitting cigarette smoking. It was a population-based case-control study of men and women aged 35 to 69 years in Newcastle, Australia, and men and women aged 35 to 64 years in Auckland, New Zealand, between 1986 and 1994. Cases were 5,572 people identified in population registers of coronary events and controls were 6,268 participants in independent community-based risk factor prevalence surveys from the same study populations. There was a rapid reduction in risk after quitting cigarette smoking. The risk of suffering a major coronary event for men who were current cigarette smokers was 3.5 (95% CI 3.0-4.0) times higher than the risk for never smokers but this fell to 1.5 (95% CI 1.1-1.9) for men who had quit for 1-3 years. Women who were current cigarette smokers were 4.8 (95% CI 4.0-5.9) times more likely to suffer a major coronary event than never smokers and this fell to 1.6 (95% CI 1.0-2.5) for women who had quit for 1-3 years. Those who had quit cigarette smoking for 4-6 years or more had a similar risk to never smokers. These results reinforce the importance of smoking cessation. The public health message is that the benefit of giving up smoking occurs rapidly.

Objectives. We sought to estimate the risk of death and recurrent myocardial infarction associated with the use of calcium antagonists after myocardial infarction in a population-based cohort study. Background. Calcium antagonists are commonly prescribed after myocardial infarction, but their long-term effects are not well established. Methods. Patients 25 to 69 years old with a suspected myocardial infarction were identified and followed up through a community-based register of myocardial infarction and cardiac death (part of the World Health Organization Monitoring Trends and Determinants in Cardiovascular Disease [MONICA] Project in Newcastle, Australia). Data were collected by review of medical records, in-hospital interview and review of death certificates. Results. From 1989 to 1993, 3,982 patients with a nonfatal suspected myocardial infarction were enrolled in the study. At hospital discharge, 1,001 patients were treated with beta-adrenergic blocking agents, 923 with calcium antagonists, 711 with both beta-blockers and calcium antagonists and 1,346 with neither drug. Compared with patients given beta-blockers, patients given calcium antagonists were more likely to suffer myocardial infarction or cardiac death (adjusted relative risk [RR] 1.4, 95% confidence interval [CI] 1.0 to 1.9), cardiac death (RR 1.6, 95% CI 1.0 to 2.7) and death from all causes (RR 1.7, 95% CI 1.1 to 2.6). Compared with patients given neither beta-blockers nor calcium antagonists, patients given calcium antagonists were not at increased risk of myocardial infarction or cardiac death (RR 1.0, 95% CI 0.8 to 1.3), cardiac death (RR 0.9, 95% CI 0.6 to 1.2) or death from all causes (RR 1.0, 95% CI 0.7 to 1.3). No excess in risk of myocardial infarction or cardiac death was observed among patients taking verapamil (RR 0.9, 95% CI 0.6 to 1.6), diltiazem (RR 1.1, 95% CI 0.8 to 1.4) or nifedipine (RR 1.3, 95% CI 0.7 to 2.2) compared,vith patients taking neither calcium antagonists nor beta-blockers. Conclusions. These results are consistent with randomized trial data showing benefit from beta blockers after myocardial infarction and no effect on the risk of recurrent myocardial infarction and death with the use of calcium antagonists. Comparisons between beta-blockers and calcium antagonists favor beta blockers because of the beneficial effects of beta-blockers and not because of adverse effects of calcium antagonists. (C) 1998 by the American College of Cardiology.

Young (18-22 years) and middle-aged (45-49 years) women living in urban and rural areas of New South Wales completed a brief food frequency questionnaire as part of a wider health survey. Urban women in both age groups consumed meat less frequently than women in rural areas, and women in the less populated rural areas were more likely to eat green and yellow vegetables and least likely to eat dried beans. There were few other geographic differences in food habits. Middle-aged women consumed reduced-fat milk, fruit, vegetables, fish, biscuits and cakes significantly more frequently, and rice, pasta, full-cream milk, fried food and take-away food less frequently than younger women. Smokers in both age groups consumed fresh fruit, vegetables and breakfast cereals significantly less frequently than non-smokers, and women with low levels of habitual physical activity consumed fresh fruit and cereals less frequently than more active women. The findings suggest that strategies aimed at changing eating behaviours should be age-group-specific and targeted specifically to smokers and less active women.

In studies assessing the trends in coronary events, such as the World Health Organization (WHO) MONICA Project (multinational MONItoring of trends and determinants of CArdiovascular disease), the main emphasis has been on coronary deaths and non-fatal definite myocardial infarctions (MI). It is, however, possible that the proportion of milder MIs may be increasing because of improvements in treatment and reductions in levels of risk factors. We used the MI register data of the WHO MONICA Project to investigate several definitions for mild non-fatal MIs that would be applicable in various settings and could be used to assess trends in milder coronary events. Of 38 populations participating in the WHO MONICA MI register study, more than half registered a sufficiently wide spectrum of events that it was possible to identify subsets of milder cases. The event rates and case-fatality rates of MI are clearly dependent on the spectrum of non-fatal MIs, which are included. On clinical grounds we propose that the original MONICA category "non-fatal possible MI" could be divided into two groups: "non-fatal probable MI" and "prolonged chest pain." Non-fatal probable MIs are cases, which in addition to "typical symptoms" have electrocardiogram (ECG) or enzyme changes suggesting cardiac ischemia, but not severe enough to fulfil the criteria for non-fatal definite MI. In more than half of the MONICA Collaborating Centers, the registration of MI covers these milder events reasonably well. Proportions of non-fatal probable MIs vary less between populations than do proportions of non-fatal possible MIs. Also rates of non-fatal probable MI are somewhat more highly correlated with rates of fatal events and non-fatal definite MI. These findings support the validity of the category of non-fatal probable MI. In each center the increase in event rates and the decrease in case-fatality due to the inclusion of non-fatal probable MI was larger for women than men. For the WHO MONICA Project and other epidemiological studies the proposed category of non-fatal probable MIs can be used for assessing trends in rates of milder MI.

Objectives. This study sought to examine whether lipoprotein(a) concentrations were risk factors for a first acute and recurrent myocardial infarction.Background. There is conflicting evidence concerning the risk of acute myocardial infarction from lipoprotein(a). No studies have examined the risk of recurrent acute myocardial infarction from lipoprotein(a), and few have addressed the risk in women.Methods. This was a population-based case-control study of 893 men and women 35 to 69 years old participating in the World Health Organization Monitoring Trends and Determinants in Cardiovascular Disease (MONICA) Project in Newcastle, Australia in 1993 to 1994. Case and control patients were classified into those with and without a previous myocardial infarction, and median lipoprotein(a) concentrations were compared after adjusting for other variables. Quintiles of lipoprotein(a) concentration were also examined.Results. Compared with control subjects without a previous myocardial infarction, median lipoprotein(a) concentrations increased from case patients with a first myocardial infarction (15 mg/liter higher, 95% confidence interval [CI] −36 to 60) to control patients with a previous myocardial infarction (159 mg/liter higher, 95% CI 40 to 278) and case patients with a previous myocardial infarction (60 mg/liter higher, 95% CI −16 to 136, p < 0.01, test for trend). Women had significantly higher lipoprotein(a) concentrations than men (median 71 mg/liter higher, 95% CI 23 to 118). The highest quintile of lipoprotein(a) (>550 mg/liter) was a significant risk factor for a first acute myocardial infarction (odds ratio [OR] 1.77, 95% CI 1.03 to 3.03); but in those with a previous myocardial infarction, the highest quantile was not associated with recurrent myocardial infarction (OR 0.84, 95% CI 0.30 to 2.37).Conclusions. High lipoprotein(a) concentrations may be a marker of vascular or tissue injury or may be associated with other genetic or environmental factors that cause acute myocardial infarction. Currently, lipoprotein(a) measurement cannot be recommended for assessment of risk for acute myocardial infarction.

A slightly modified version of the Quality-of-Life after Myocardial Infarction (QLMI) questionnaire developed by Oldridge and colleagues was applied in a self-administered mode to patients with suspected acute myocardial infarction (AMI) in a randomized controlled trial of secondary prevention. Acceptability of the questionnaire was good, with 93% of responders answering all items. Factor analysis suggested three quality-of-life (QL) dimensions which we called "emotional", "physical" and "social". These differed somewhat from the dimensions proposed by Oldridge and colleagues. However, a sensitivity analysis showed relative invariance of results to weighting schemes. Scores on our three dimensions were responsive to differences between the treatment groups, and demonstrated construct validity based on associations between the measured QL and variables expected to affect QL. We conclude that the QLMI questionnaire has good potential as an instrument for assessing QL in post-AMI patients and that it can be successfully self-administered.

The hypothesis that 6 months after acute myocardial infarction, adoption of secondary prevention activities would be higher, quality of life better, and blood cholesterol lower in patients randomly allocated to a mail-out intervention program than in those receiving usual care was tested. Patients were aged < 70 years, admitted to hospitals in and around Newcastle, Australia with a suspected heart attack and discharged alive from the hospital. Cluster randomization, based on the patient's family practitioner, was used to allocate consenting patients to an intervention or usual care group. A low-cost mail-out program was designed to help patients reduce dietary fat, obtain regular exercise by walking and (for smokers only) to quit smoking. Supplementary telephone contact was also used. In addition, a letter was sent to the family doctor regarding the benefit of aspirin and beta blockers for secondary prevention. Of eligible patients, 71% participated, and 79% of the 213 intervention subjects and 87% of the 237 usual care ones returned a 6-month follow-up questionnaire. Self-reported fat intake was significantly lower, an "emotional" score obtained from a quality-of-life questionnaire was significantly higher in the intervention than in the usual care group, and "physical" and "social" scores for quality of life were slightly higher. Blood cholesterol level and other variables were not different between the groups at 6 months. Simple low-cost programs providing support and advice on lifestyle change may be beneficial, particularly in improving patients' perceived quality of life.

The purpose of this study was to examine the extent and severity of coronary stenosis in an Australian population. The subjects were autopsy cases among people aged 20-69 yrs dying in and out of hospital in the Newcastle area of New South Wales in 1985-86. Three groups were compared: coronary deaths, deaths from other natural causes and deaths due to external causes. Cross-sectional luminal narrowing in each major subepicardial artery was measured by stereological point counting. Stenosis was found, as expected, to be more severe in males than in females, increased with age and was greatest in those who died from coronary disease. Even in non-coronary deaths mean percentage luminal narrowing in the narrowest segments ranged from about 40% in people aged 20-29 yrs to over 60% in those aged 60-69 yrs. Narrowing was more pronounced in the left anterior descending artery and least in the left circumflex artery. To the extent that results from this autopsy study can be generalized to the whole population, these findings illustrate that, despite declining mortality from ischemic heart disease in Australia, coronary atherosclerosis remains a widespread problem.

A population-based case-control study (involving 1282 cases and 2068 controls) was conducted to examine the risk of myocardial infarction or coronary death after cigarette smokers quit smoking. The odds ratios for current smokers were significantly elevated compared to non-smokers (OR = 2.7 for men and OR = 4.7 for women). For ex-smokers odds ratios declined rapidly after quitting and after about 3 years they were not significantly different from unity. Fibrinogen concentrations measured in the controls only were higher in current smokers and ex-smokers up to 2 years after quitting than in non-smokers and after that time were similar to levels in non-smokers; however, most of the differences among categories of smokers were not statistically significant. These results support the hypothesis that risk of a coronary event in ex-smokers declines rapidly after quitting and within 2-3 years is similar to the risk for non-smokers.

public CR services, many were unaware of the NHMRC guidelines and no mainstream service had fully implemented its recommendations. Workforce turnover and capacity issues severely constrain efforts to improve CR service delivery. Conclusions:Substantial deficitswere identified in linking Aboriginal people post cardiac event into CR services that offer a comprehensive approach to reduce subsequent cardiac events and hospitalisation. Alternative approaches are needed. We recommend further development of CR partnerships between Aboriginal and mainstream services. Programswith a focus on cardiovascular risk reduction should be an important component of thegovernment focus on improving self-management and strengthening community based care for chronic disease. doi:10.1016/j.hlc.2009.05.643