Volume 174 Issue 8

Editorial Vocational part-time training: jobs for the girls and boys There is a clear demand from many levels of the medical profession that part-time training be available, viable and valuable MJA 2001; 174: 376-377 Medicine is different today — isn't it? Changing knowledge, changing technology, changing disease patterns, changing service delivery, changing consumer expectations — and a changing medical workforce. The medical workforce is changing in terms of gender balance, expectations regarding lifestyle, working conditions, ethnic/cultural background and age of entry to medical school. Medicine is the same as ever — isn't it? The same hierarchical structure, with men dominating at senior levels; the same culture of heroic individualism; the same male-female inequalities with selection/promotion/retention procedures; the same difficulties for women to reach their professional potential. Women are clustered in the lower-status areas of medicine, earn less money on average, make less contribution to the profession outside direct medical care, experience higher levels of stress, have many more family responsibilities, and are much more likely to modify their careers to accommodate the needs of their partners and families.1 One outcome is very clear — part-time trainees report satisfaction with their job and lifestyle. Less clear is the training outcome. Medicine, like society in general, is both different and the same. What is clear is that our younger colleagues, both women and men, are demanding real change in the structure, organisation and practice of medicine to allow them to have a more balanced lifestyle. One very important structural and organisational issue is the availability of part-time training during the long and demanding medical vocational pathway. Two articles2,3 in this issue of the Journal discuss job-sharing, which is one way of achieving part-time training. Job-sharing often involves more than one sharing arrangement — for example, alternating periods of a week or a fortnight, or splitting the week. Whitelaw and Nash2 note that job-sharers in paediatric training are more likely to share work on a weekly basis while raising children, but to share in longer blocks if preparing for exams. Gun3 found a job-sharing colleague with similar needs that meshed over some, but not all, of her training years. Whitelaw and Nash note that the perceptions of hospital managers and doctors-in-training differ on the availability of particular units for job-sharing; they also note that there are different eligibility requirements between hospitals, implying judgement about what are "acceptable" and "unacceptable" reasons for job-sharing.2 Whether a reason is "acceptable" may depend on the sex of the trainee, but, increasingly, men as well as women are beginning to request part-time training to give them the opportunity to combine training with care of children, study, and hobbies. There has been a gradual increase in the number of part-time trainees in recent years (especially in emergency medicine, paediatrics and psychiatry) — in 1999, part-time trainees made up 6.5% of the total.4 Interestingly, in general practice, traditionally considered a very flexible training area, there was a 50% drop in part-time training over the period 1995-2000. The specialties with minimal numbers of part-time trainees include anaesthetics, dermatology, obstetrics and gynaecology, radiology and surgery. The two articles illustrate a major difficulty in assessing part-time training: while Gun states that there were 17 part-time paediatric trainees in 1998 (a figure quoted from a report of the Medical Training Review Panel),3Whitelaw and Nash's survey identified 34 such trainees in the same year.2 The true proportion of trainees working part-time remains unclear, with differing periods of time per year spent in part-time training, and differing information provided by institutions and Colleges. More accurate collection of data and a clear definition of "part-time" training that differentiates it from "interrupted" training (eg, three months on and three off) are required. Perceived problems continue to be canvassed: Whom do you share with? Will the College agree (in practice as well as in principle)? Is your reason "good enough"? Are your colleagues resentful ("Why should s(he) have 'time off'? "What if I have to do extra to cover?")? Are your consultants cautious ("What about continuity of care?" "What about continuity of meeting the needs of my busy lifestyle?")? Will the hospital bear potential extra costs? Can you and your childcare arrangements cope with converting to full-time work to cover your partner's leave or sickness? Can you get to the 7 am ward round or journal club? Will you miss that special clinic or unit meeting that is always on your day off? Should you refuse secondment? What will happen next year? One outcome is very clear — part-time trainees report satisfaction with their job and lifestyle.2,3 Less clear is the training outcome. There is no intrinsic reason why part-time training, if appropriately balanced, should be less effective than full-time training. However, institutional satisfaction with part-time training is hard to measure given the barriers to implementation, the variable number of trainees from year to year, the different specialties and consultants involved, and the rapid, concurrent changes to service delivery and the organisation of the junior medical workforce (including changes associated with implementing "safe hours" policies). Obvious benefits to the hospital of part-time work include having a potential pool of trainees to cover each other for illness or holidays, and improving the work contribution of trainees.2 There is a clear demand from many levels of the profession that part-time training be available, viable and valuable. The reality is that availability is highly variable, viability often still depends on the trainees "proving themselves", but value is clear. The need for part-time training is part of a much wider debate about vocational medical training. We continue to grapple with the traditional needs of training organisations versus the personal and professional needs of trainees, the conflict between education and service in a tight fiscal environment, and the overall size, setting, distribution and safety of the junior medical workforce. Cultural change is required; a change of core values and norms "from within" to achieve commitment to new organisational structures5 so that the medical profession better meets the needs of, and thus reaps the most benefit from, its entire medical workforce. Jillian R Sewell President, Paediatrics and Child Health Division, Royal Australasian College of Physicians Member, Australian Medical Workforce Advisory Committee Working Party — Career Choice and Workforce Participation Dennerstein L. Roles and achievements: a survey of medical graduates. Melbourne: Key Centre for Women's Health in Society, 1989. Whitelaw CM, Nash MC. Job-sharing in paediatric training in Australia: availability and trainee perception. Med J Aust 2001; 174: 407-409. Gun MT. Part-time specialty training — my experience. Med J Aust 2001; 174: 410-412. Medical Training Review Panel. Fourth report. Canberra : MTRP and Commonwealth Department of Health and Aged Care, August 2000. Sinclair A. Doing leadership differently: gender power and sexuality in a changing business culture. Melbourne: Melbourne University Press, 1998. Make a comment

Jillian R Sewell

Editorial Can hepatitis C transmission be reduced in Australian prisons? Strategies to reduce the number of people who inject drugs and to minimise harm should help, but the cooperation of correctional authorities is essential MJA 2001; 174: 378-379 Approximately 20 000 people were incarcerated in Australia at the end of 1999.1 Another 20 000 had cycled through our prison systems in that year, but had been released by December 1999. This dynamic movement of people in and out of prisons not only increases the possibilities for transmission of infections such as hepatitis C virus (HCV) and HIV, but also makes it very difficult to detect transmission. Hepatitis C infection is endemic among Australian prisoners. In New South Wales prisons, approximately a third of male and two-thirds of female inmates are infected. Corrections Health Service had the second-highest number of hepatitis C notifications for an Area Health region in NSW in its debut report.2 HCV incidence is likely to be high in prison, but to date there have been few cases reported.3 Nevertheless, several studies have found that a history of imprisonment is associated with HCV infection.4 These findings, from both Australia3 and overseas,4 raise two questions: What is the incidence of HCV for various transmission modes in prison?; and Can HCV transmission be reduced in prison? Despite gaps in our knowledge, there is sufficient evidence to address the two most frequent modes of transmission: injecting drug use and tattooing. About a quarter of prisoners inject drugs while incarcerated.3 Virtually all drug injecting occurs with used injecting equipment shared among numerous partners. Therefore, the primary goal has to be to reduce drug injecting in prison. One way to achieve this is to reduce the number of drug injectors in prison.5 There is abundant evidence that community-based methadone treatment reduces injecting, crime and the subsequent incarceration of drug users,6 yet only a third of the demand for methadone treatment is met in the community.6 Another way to reduce the level of drug injecting in prison is to provide methadone maintenance treatment for prisoners. In one study, prisoners maintained on methadone injected half as often as those out of treatment, but only when doses reached 60 mg and treatment was provided for the entire term of the prison sentence.7 The NSW prison methadone program started in 1987, but meets only a quarter of the potential demand for treatment.5 Prison methadone programs have been recently introduced or expanded in Queensland, South Australia, Victoria, Tasmania and the Australian Capital Territory. Drug injecting in prison is also likely to be reduced if prisoners receive lesser punishment for the use of non-injectable drugs compared with injectable drugs. Yet prisoners receive the same penalty whether they test positive on urinalysis for cannabis or for heroin. Research into mandatory drug screening in United Kingdom prisons found that inmates moved from smoking cannabis (detectable in urine for weeks) to injecting heroin (detectable in urine for only a day or two) after mandatory drug testing was introduced.8 South Australia and Tasmania have introduced differential penalties for different drugs, with the aim of reducing drug injecting in prison. Victoria is considering a similar system. Another way to reduce drug injecting is to facilitate non-injecting routes of administration among injecting drug users. Preliminary results from a cognitive behavioural trial indicated that some injecting drug users will shift to non-injecting methods of use (A Wodak, Director, Alcohol and Drug Service, St Vincent's Hospital, Sydney, personal communication). Prisons, where injecting is so risky and common, are ideal settings for a trial of this intervention. Without doubt, the most controversial strategy is prison needle and syringe exchange programs. These programs have been successfully implemented in Switzerland, Germany and Spain in 17 different prisons.9 However, they reduce sharing of injecting equipment rather than drug injecting itself, and the problems of fatal overdose, abscesses, and inmates' involvement in the prison drug trade may persist. If prison needle and syringe exchange programs are unacceptable, then much more effort must be directed towards meeting the demand for drug treatment by prisoners. HCV transmission in prison may also occur through tattooing. One way to reduce tattoo-related hepatitis C transmission is to train select inmates in infection control procedures and to provide them with autoclaves and single-use ampoules of ink. Penalties for tattooing in prison should be removed. Allowing professional tattooists to visit prison is likely to be too expensive for inmates. So how can these strategies be implemented? The first step would have to be increasing the number of general practitioners who prescribe methadone both in the community and in prison. Less than 1% of GPs prescribe methadone in NSW.10 The opportunities for improvement here are enormous. Almost all other strategies listed above require the cooperation of prison authorities. Yet, correctional services administrators (comprising prison commissioners from each jurisdiction) have signalled their resistance to examining hepatitis C infection in prison by declining to even discuss recommendations made in the Review of the Third National HIV/AIDS Strategy.11 Until prison authorities are made to recognise that prisons play a significant role in the hepatitis C epidemic, it is unlikely that hepatitis C transmission will be reduced in Australian prisons. Kate A Dolan Senior Lecturer National Drug and Alcohol Research Centre University of New South Wales, Sydney, NSW Corrective Services, Australia. Canberra: Australian Bureau of Statistics, December 1999. (Catalogue no. 4512.0.) NSW Department of Health. Healthy people 2005: new directions for public health in NSW. NSW Public Health Bull 2000; 11: 198. Dolan K. The epidemiology of hepatitis C infection in prison populations [discussion paper]. Canberra: Commonwealth Department of Health and Aged Care, 2000. MacDonald M, Crofts N, Kaldor J. Transmission of hepatitis C virus: rates, routes and cofactors. Epidemiol Rev 1996; 18: 137-148. Dolan K. Surveillance and prevention of hepatitis C infection in Australian prisons. A discussion paper. Technical Report No. 95. Sydney: National Drug and Alcohol Research Centre, 2000. Ward J, Mattick R, Hall W. Methadone maintenance treatment and other opioid replacement therapies. Amsterdam: Harwood Academic Press, 1998. Dolan KA, Hall W, Wodak A. Methadone maintenance reduces injecting in prison. BMJ 1996; 312: 1162. Gore SM, Bird AG. Mandatory drug tests in prisons. BMJ 1995; 310: 595. Rutter S, Dolan K, Wodak A, Heilpern H. Prison syringe exchange: a review of international research and program development. Technical Report No. 112. Sydney: National Drug and Alcohol Research Centre, 2001. NSW Health Department. The NSW drug treatment services plan, 2000-2005: better health good health care. Sydney: NSW Health Department, 2000. Proving partnership. Review of the National HIV/AIDS Strategy 1996-97 to 1998-99. Canberra: Australian National Council on AIDS and Related Diseases, 1999. Make a comment

Kate A Dolan

Editorial The mental health of young Australians Are we as a nation taking seriously enough the task of preventing and treating mental illness in the young? MJA 2001; 174: 380-381 The United States Surgeon General recently warned that "The burden of suffering experienced by children with mental health needs and their families has created a health crisis in this country [USA]. Growing numbers of children are suffering needlessly because their emotional, behavioural, and developmental needs are not being met by those very institutions which were explicitly created to take care of them. It is time that we as a Nation took seriously the task of preventing mental health problems and treating mental illnesses in youth."1 What is Australia's scorecard in the area of children's mental health? In 1995, as part of the National Mental Health Strategy, the Federal Government funded a national survey to establish the prevalence of mental disorders, disability and service use in the Australian population. The adult component (ie, people over 17 years) was conducted in 19972 and the child and adolescent survey (people aged 4-17 years) in 1998. Findings of the latter survey were released recently3 and are summarised in the Box. The strength of the child and adolescent survey was that it considered mental health problems in a variety of ways, including psychiatric diagnosis, service use, and the impact of mental disorders on quality of life. Limitations of the survey were that diagnoses were based solely on information from parents (some questionnaire data were obtained from adolescents but no information was sought from teachers), and only three conditions were examined. These shortcomings may explain, among others, the high rates of attention deficit hyperactivity disorder found — as many as 19.3% of boys aged 6-12 years were found to be suffering from this condition. Some findings are worth highlighting. First, the prevalence of mental health problems among the young (14%) is high and not much different from that found in adults (18%).2 That is, half a million Australians aged 4-17 years have serious emotional and behavioural problems.3 Second, these conditions impair their functioning and quality of life. Disturbed young people also behave in ways injurious to health much more often than their healthy counterparts. Third, only a quarter of those who need help receive it. Mental disorders impose a heavy burden on children, families and communities1,2,4 and often persist into adulthood. The cost to society in human and economic terms is great.1 There is broad agreement that we need to detect these problems early, provide effective treatment and attempt prevention.1,4 A four-pronged approach is necessary: Increase awareness that mental health problems are a major issue in child health and try to prevent them. This will help give children the chance for a healthy start in life.1 Improve the use of resources and access to services. For example, general practitioners could, with appropriate training, play a central role identifying and treating children with mental health problems. GPs (after schools, the second most common source of help) are well placed to take on this role, especially as disorders are often chronic, and contact with specialist services is likely to be only episodic.5 To do this, GPs will need better support — for example, rapid access to specialist telephone advice and to psychiatric assessment, and good liaison with child and adolescent community teams.5 Psychiatrists, psychologists and other mental health professionals need to be more accessible and responsive, particularly in crises.6 It is poignant that, while Australia prides itself on providing universal access to free healthcare, half of the parents needing help believe it is too expensive.3 Increase funding for mental health services for young people. In 1997-98, the last year for which data are available, State and Territory governments spent $1.4 billion on mental health services ($74 per capita).7 Of this sum, only $107 million (7%) was spent on the young, who make up a quarter of the Australian population — this amounts to an average of $23 per child, compared with $95 per adult.7 Increase the number of specialists in mental health and carry out more research. The shortage and maldistribution of specialists7,8 is well documented, and it is important to establish which treatments and service-delivery models work and which do not.1,4 We must ask ourselves whether we as a nation take seriously enough the task of preventing and treating mental illnesses in the young. The recent proliferation of programs8 promoting mental health suggests we are moving in the right direction, but it remains to be seen whether this is a measure of real commitment or just window dressing. The findings of the latest survey of mental disorders in young people3 will at least give us a baseline for comparison when the next national survey is conducted. Joseph M Rey Professor, Department of Psychological Medicine, University of Sydney Director, Child and Adolescent Mental Health Services Northern Sydney Health, Sydney, NSW Report of the Surgeon General's Conference on Children's Mental Health: a national action agenda. Washington, DC: US Public Health Service, 2000. Australian Bureau of Statistics. Mental health and wellbeing profile of adults, Australia 1997. Canberra: AGPS, 1998. Sawyer MG, Arney FM, Baghurst PA, et al. The mental health of young people in Australia. Canberra: AGPS, 2000. Raphael B. Promoting the mental health and wellbeing of children and young people. Discussion paper: key principles and directions. Canberra, AGPS, 2000. Garralda ME. Child and adolescent psychiatry in general practice. Aust N Z J Psychiatry (in press). Australian Medical Workforce Advisory Committee. The specialist psychiatry workforce in Australia. Sydney: AMWAC, 1999. (AMWAC Report 1999.7.) Commonwealth Department of Health and Aged Care. National mental health report 2000. Canberra, AGPS, 2000. National action plan for promotion, prevention and early intervention for mental health. Canberra: Commonwealth Department of Health and Aged Care, 2000. Make a comment Main findings of the 1998 Australian Federal Government survey on the mental health of young people3 From interviews with a representative sample of 4509 parents and questionnaires returned by 1490 adolescents aged 13-17 years, the following information was obtained: 14.1% of 4-17-year-olds had experienced mental health problems in the previous six months. The prevalence of three specific mental disorders during the previous year had been — Depressive disorder 3.7% — Conduct disorder 3.0% — ADHD 11.2% (Inattentive subtype, 5.8%; hyperactive-impulsive subtype, 2.0%; combined subtype, 3.3%) Young people living in sole-parent and low-income families had higher rates of problems. In adolescents, rates of suicidal ideation, suicide attempts, cigarette smoking, and alcohol and cannabis use increased steeply with increasing emotional and behavioural problems. Twenty-five per cent of children and adolescents with problems had used at least one service (broadly defined) in the previous six months. The three services attended most often were counselling at school or in a special class, GPs and paediatricians. Half of the parents reported that help was too expensive, and almost half did not know where to seek help. Only 6% reported that social stigma was a barrier to seeking help. Among the adolescents, 38% preferred to manage the problems themselves, 18% believed nothing could help, 17% did not know where to get help, and 14% were worried about the social stigma. ADHD = attention deficit hyperactivity disorder. Back to text

Joseph M Rey

Editorial Heart Week 2001: "Get active"! A call to action Include physical activity advice in consultations, especially for those at risk of heart disease MJA 2001; 174: 381-382 The focus of the National Heart Foundation Heart Week, the first week of May, is physical activity and heart disease. This is timely given recent evidence that inactivity is a major risk factor for coronary heart disease (CHD), and that the population risk attributable to inactivity appears to be similar to the risk posed by smoking, raised lipid levels or hypertension.1,2The evidence Much of the epidemiological evidence relates to primary prevention and comes from good-quality observational (cohort) studies. The better-designed studies show stronger relationships and a dose-response relationship between inactivity and CHD; the benefits of increasing activity levels accrue particularly for people who have been inactive.1 Evidence from meta-analyses suggests that people who remain sedentary have about twice the risk of CHD of those who participate in regular activity.3 Replication studies in diverse populations since 1990 have reinforced this evidence. There is consistent evidence that women benefit almost as much as men from regular, moderate-intensity physical activity, as do older adults.4,5 It appears that only recent or current physical activity is beneficial, rather than athleticism in earlier life.6 For all age groups, adopting physical activity reduces the risk of CHD deaths, leading to the maxim that "it is never too late to start being active".5,7 Some of this cardiovascular benefit occurs even at levels of physical activity below those required for aerobic (fitness or cardiorespiratory) training, at levels as low as 50% of the maximal predicted heart rates for age.1,8 However, for the general population, more vigorous activity results in additional benefits. There is also evidence that physical activity may prevent ischaemic stroke.9 The mechanism may be through reducing the risk of thrombus formation, or the effects of physical activity may be mediated through reducing blood pressure levels. These protective effects reducing the incidence and mortality from CHD are independent of the influence of physical activity on other cardiovascular risk factors. Nonetheless, there are direct benefits on other risk factors, with moderate activity contributing to lowered blood pressure, increased high density lipoprotein (HDL) cholesterol level, and improvements to the fibrinolytic system.1,8 More sustained physical activity may also help with weight loss. Physical activity has similar benefits for many patients with established coronary artery disease. In those who become active, these benefits include increased fitness, improved oxygen consumption, and decreases in ischaemic responses.8Biological mechanisms: Researchers have begun to explore the biological mechanisms to explain the benefits of physical activity in preventing CHD. There is controlled-trial evidence that sustained vigorous activity can lead to some regression of atherosclerosis.8,10 Exercise may improve coronary endothelial-dependent vasodilatation responses, possibly leading to recruitment of collateral vessels in ischaemic heart disease.11 However, further work is needed to define the exact biological mechanisms. For patients with CHD, there is clinical evidence of increased functional capacity and improved myocardial perfusion after exercise training, and there may even be some benefits for those with uncomplicated heart failure.8 Cardiac rehabilitation: Although the benefits of cardiac rehabilitation are generally accepted,12 these are multifaceted programs, and the individual benefits of the exercise component are difficult to disentangle from the overall program benefit. The key issue here is that, after myocardial infarction, a much higher proportion of patients in Australia need to complete supervised rehabilitation programs than is currently the case. Risk of acute cardiac events: One well-known paradox is the issue of the increased risk of acute cardiac events in unfit sedentary people who embark on vigorous exercise regimens.13 Although the risk of sudden cardiac events is transiently increased (during and for a half hour after strenuous exertion), this acute increment in risk is much reduced for moderate activity. Overall, even among CHD patients, the long term benefits of activity vastly outweigh the short term risks. Furthermore, it has been shown that the overall risk for primary cardiac arrest is much lower among those who are moderately active.14 Thus, among cardiac patients, vigorous activity should be started with caution and in supervised settings, whereas moderate physical activity should be easier to initiate. In conclusion, almost half of Australian adults do not achieve the health goal of moderate participation in physical activity. Recent trends have shown that physical activity levels are declining (as obesity rates are increasing), and that women, those least advantaged and non-English speakers are more likely to be inactive.15 There is a clear mandate to include physical activity advice in consultations, especially for those at risk of heart disease. Brief advice about activity, delivered in the surgery, can positively influence physical activity levels.16 Adherence to structured activity programs is poor, so that constant reinforcement is useful, as well as recommending types of activity which can become part of everyday life. Some patients will be very active, but still develop CHD. However, on balance, increasing activity is a worthwhile investment of medical practitioners' time. For Heartweek 2001, go for a regular walk, and recommend it to almost every patient! Recommendations for physical activity* Recommendations for the general community are that every Australian adult should accumulate half an hour of moderate-intensity activity on most days of the week. Examples of moderate-intensity activities include regular walking at 4km/hour energetic gardening or lawn mowing swimming doubles tennis, and, possibly golf. These are achievable by most people. *Commonwealth Department of Health and Aged Care. National physical activity guidelines for Australians. Canberra: AGPS, 1999. Adrian E Bauman Professor of Public Health and Epidemiology School of Community Medicine University of New South Wales, Sydney, NSW Terry J Campbell Professor of Medicine University of New South Wales (St Vincent's Hospital), Sydney, NSW United States Department of Health and Human Services. The Surgeon General's report on physical activity and health. Washington, DC: US Government Printing Office, 1996. Bauman A. The use of population attributable risk (PAR) in understanding the health benefits of physical activity. Br J Sports Med 1998; 32: 279-280. Berlin JA, Colditz GA. The meta-analysis of physical activity in the prevention of coronary heart disease. Am J Epidemiol 1990; 132: 612-627. Manson J, Hu FB, Rich-Edwards JW, et al. A prospective study of walking as compared with vigorous exercise in the prevention of coronary heart disease in women. N Engl J Med 1999; 341: 650-658. Wannamethee SG, Shaper AG, Walker M. Physical activity and mortality in older men with diagnosed coronary heart disease. Circulation 2000; 102: 1358. Sherman SE, D'Agostino RB, Silbershatz H, Kannel WB. Comparison of past versus recent physical activity in the prevention of premature death and coronary artery disease. Am Heart J 1999; 138: 900-907. Blair SN, Kohl H, Barlow CE, et al. Changes in physical fitness and all-cause mortality. A prospective study of healthy and unhealthy men. JAMA 1995; 273: 1093-1098. Shephard RJ, Balady GJ. Exercise as cardiovascular therapy. Circulation 1999; 99: 963-972. Shinton R, Sagar G. Lifelong exercise and stroke. BMJ 1993; 307: 231-234. Hambrecht R, Niebauer J, Marburger C. Various intensities of leisure time physical activity in patients with coronary heart disease: effects on cardiorespiratory fitness and progress of coronary atherosclerotic lesions. J Am Coll Cardiol 1993; 22: 468-477. Hambrecht R, Wolf A, Gielen S, et al. Effect of exercise upon coronary endothelial function in patients with coronary artery disease. N Engl J Med 2000; 342: 454-460. O'Connor GT, Buring JE, Yusuf S, et al. An overview of randomized trials of rehabilitation with exercise after myocardial infarction. Circulation 1989; 80: 234-244. Albert CM, Mittleman MA, Chae CU, et al. Triggering of sudden death from cardiac causes by vigorous exertion. N Engl J Med 2000; 343: 1355-1361. Lemaitre RN, Siscovick DS, Raghunathan TE, et al. Leisure-time physical activity and the risk of primary cardiac arrest. Arch Intern Med 1999; 159: 686-690. Armstrong T, Bauman A, Davies J. Physical activity patterns of Australian adults: results of the 1999 National Physical Activity Survey. Canberra: Australian Institute of Health and Welfare, 2000. (AIHW Catalogue No. CVD 10.) Halbert JA, Silagy CA, Finucane PM, et al. Physical activity and cardiovascular risk factors: effect of advice from an exercise specialist in Australian general practice. Med J Aust 2000; 173: 84-87. Make a comment

Adrian E Bauman · Terry J Campbell