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School of Health Sciences, University of South Australia, Adelaide, SA, AustraliaAustralian Centre for Precision Health, Cancer Research Institute, University of South Australia, Adelaide, SA, AustraliaWardliparingga Aboriginal Health Equity Theme, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
Wardliparingga Aboriginal Health Equity Theme, South Australian Health and Medical Research Institute, Adelaide, SA, AustraliaFaculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
School of Health Sciences, University of South Australia, Adelaide, SA, AustraliaAustralian Centre for Precision Health, Cancer Research Institute, University of South Australia, Adelaide, SA, Australia
Corresponding author at: Aboriginal Health Equity, South Australian Health and Medical Research Institute, North Terrace, PO Box 11060, Adelaide, SA 5001, Australia
Wardliparingga Aboriginal Health Equity Theme, South Australian Health and Medical Research Institute, Adelaide, SA, AustraliaFaculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
Māori and Pacific women in New Zealand and Aboriginal and Torres Strait Islander women in Australia are recognised as nurturers and leaders within their families and communities. However, women’s wellbeing, and that of their communities, are affected by a high burden of cardiovascular disease experienced at a younger age than women from other ethnic groups. There has been little focus on the cardiovascular outcomes and strategies to address heart health inequities among Māori, Pacific, Aboriginal and Torres Strait Islander women. The factors contributing to these inequities are complex and interrelated but include differences in exposure to risk and protective factors, rates of multi-morbidity, and substantial gaps within the health system, which include barriers to culturally responsive, timely and appropriate cardiovascular care. Evidence demonstrates critical treatment gaps across the continuum of risk and disease, including assessment and management of cardiovascular risk in young women and time-critical access to and receipt of acute services. Cardiovascular disease in women impacts not only the individual, but their family and community, and the burden of living with disease limits women’s capacity to fulfil their roles and responsibilities which support and sustain families and communities. Our response must draw on the strengths of Māori, Pacific, Aboriginal and Torres Strait Islander women, acknowledge health and wellbeing holistically, address the health and social needs of individuals, families and communities, and recognise that Indigenous women in New Zealand, Australia and across the Pacific must be involved in the design, development and implementation of solutions affecting their own health.
Māori, Pacific, Aboriginal and Torres Strait Islander women are respected and valued as nurturers and leaders within their communities, and are described in te reo Māori (the Māori language) as te whare tangata (the house of humanity) [
]. Māori women are indigenous to New Zealand and Aboriginal and Torres Strait Islander women to Australia. Pacific women are indigenous to island nations within the Pacific, and similar to Māori women in New Zealand, experience substantial inequities in health outcomes compared to non-Māori non-Pacific women in New Zealand.
In our modern, colonised societies the health inequities experienced by Māori, Pacific, Aboriginal and Torres Strait Islander women are the result of a complex interplay of ethnic, gender and other differentials. Our Indigenous women experience ‘intersectionality’ of disadvantage and discrimination, which are linked and intersect in dynamic and interactive ways to privilege or disadvantage people depending on their characteristics and contexts [
]. Disparities in key socio-ecological measures are well reported, spanning education and employment opportunities, access to high quality housing, income and community safety [
]. Despite these disparities, women continue to undertake the critical roles of leader, mother, carer and nurturer as they support and sustain families and communities, often carrying significant cultural responsibility within the kinship network [
Cardiovascular disease is the leading cause of death for Pacific, Aboriginal and Torres Strait Islander women, and the second highest for Māori women [
]. Most recent cardiovascular mortality statistics report age-standardised rates of 171.8 and 145.6 deaths per 100,000 population for Māori and Pacific women, respectively, compared to 82.2 deaths per 100,000 for women of European or Asian descent [
]. The rate for Aboriginal and Torres Strait Islander women is 237.8 deaths per 100,000 population, one and a half times higher than non-Indigenous women in Australia [
]. Together, cardiovascular disease and diabetes are the most important contributors to the life expectancy gap experienced by Indigenous women in Australia and New Zealand [
Differences in socio-ecological opportunities result in differential exposure to a range of psychological, behavioural and biological risk factors. Māori, Pacific, Aboriginal and Torres Strait Islander women also experience multiple barriers to accessing best-evidence, culturally and gender appropriate care. Given women’s increased responsibilities, services are often inadequate in their availability, accessibility and appropriateness [
]. This article explores the experiences of cardiovascular care, from risk assessment to acute care and secondary prevention for Māori, Pacific, Aboriginal and Torres Strait Islander women. We identify priorities to improve care and address inequities that build on the unique roles and strengths of our Indigenous women, recognise the socio-ecological context, are culturally responsive, and reflect an approach tailored to women’s specific needs.
When Women Are Healthy, Family and Community Are Strong
Māori, Pacific, Aboriginal and Torres Strait Islander people’s conceptualisation of health and wellbeing can be defined as the cultural, social, psychological and physical wellbeing of an individual and her kinship network, reflecting the interconnectedness of the spiritual and physical aspects of the individual’s health to culture, kinship, and country [
]. As leaders, nurturers and carers, women hold the essential role of enabling and maintaining strong communities and cultivating and fostering future generations. Women draw on culture and kinship to carry out these responsibilities [
]. When family and community are strong, women are spiritually and physically healthy. Furthermore, when women are strong and healthy, so too are our communities.
Women and communities are impacted by reoccurring, enduring, and often intergenerational trauma, grief and stress. These are a result of loss of land and language, breakdown of culture and Indigenous concepts of family, and the ensuing impact on communities. Whilst there is still a limited understanding from a Western biomedical construct of the impacts of grief, worry and stress on cardiovascular disease, it is well understood within Māori, Pacific, Aboriginal and Torres Strait Islander worldviews of health [
]. Loss or limitation of available resources due to intergenerational and ongoing racism and oppression impact on women’s strength and wellbeing, and reduce their ability to care for and nurture family and community.
Providing Cardiovascular Services to Meet the Needs of our Indigenous Women
Inequities in cardiovascular outcomes for Māori, Pacific, Aboriginal and Torres Strait Islander women are the result of a complex interplay of socio-ecological, psychological, behavioural and biological risk factors and comorbidities [
]. Moreover, women experience barriers across the continuum of care and multiple sectors of the health system. To respond to this burden and foster healthy communities, it is critical that women are able to access culturally responsive, evidence-based services which meet their cultural and social needs across the continuum of care. Despite these identified needs, plans and strategies have had limited recognition of sex and gender differences in cardiovascular disease for these population groups, and the specific needs of Indigenous women [
]. Both the Australian Better Cardiac Care for Aboriginal and Torres Strait Islander people and the New Zealand Diabetes and Cardiovascular Disease Quality Improvement Plan fail to consider gender differences in burden of risk and disease, and access to and quality of services [
Psychological, behavioural and biological risk factors and high rates of multi-morbidity are driven by a multi-factorial mix of society, economics, ecology and Western culture [
Ministry of Health, ThinkPlace Exploring why young Māori women smoke: taking a new approach to understanding the experiences of people in our communities. Ministry of Health.
]. There are substantial ethnic and gender differences in access to the social resources necessary for maintaining women’s health, such as formal social supports and services, health information and knowledge, sense of safety within the community, and safety and social acceptance within the wider community. The health system’s responses to health promotion and risk and disease prevention and management are focussed at individuals, in stark contrast to Indigenous women’s conceptualisation of health and wellbeing [
]. Paradoxically, health programs and services are rarely based on family and community approaches, and fail to build on the role of women within this social structure [
A key factor in maintaining health is the provision of comprehensive primary health care which is culturally responsive and meets women’s socio-ecological needs. Whilst the Aboriginal community-controlled health sector in Australia strives to provide models of care centred around socio-ecological models of health, albeit with limited resources, mainstream primary health care services continue to focus on the individual’s risk and discrete risk factors. In New Zealand, the Waitangi Tribunal has received claims relating to health services and outcomes of national significance for Māori (Box 1). The first stage of claims (known as Wai 2575), completed in 2019, found a breach of Te Tiriti o Waitangi (Treaty of Waitangi) by failing to design and administer the current primary care system to actively address Māori health inequities and to give effect to the Treaty’s guarantee of tino rangatiratanga (autonomy, self-determination and sovereignty) [
The Waitangi Tribunal is a permanent commission of inquiry that hears claims of breaches by the Crown in relation to the Treaty of Waitangi, and makes recommendations on established breaches. The tribunal provides a legal process by which claims in the breach of the Treaty can be investigated, and was established in 1975 [
The need for comprehensive primary health care occurs in the context of high rates of associated chronic diseases. Co-morbidities increase the complexity of, and act as contraindications to, a range of cardiovascular treatments. For patients, multi-morbidity not only increases the burden of treatment, but is also associated with adverse physical and mental health outcomes, poor quality of life and high health care costs [
]. The presence of multi-morbidity reiterates the need to adopt a whole-of-body approach to health promotion and disease prevention. Policy and practice predominately focus on disease, yet women’s health status requires greater inter-disciplinary partnerships and multi-morbidity care plans.
Identifying and Managing Risk
Increasing the assessment of absolute cardiovascular risk for all New Zealanders and in Australia for Aboriginal and Torres Strait Islander people has been set as a priority in cardiovascular disease policy [
]. Guidelines recommend assessment for Māori, Pacific, Aboriginal and Torres Strait Islander populations at younger ages. In Australia, guidelines recommend assessment for both women and men at 35 years and over [
]. New Zealand assessment guidelines commence screening Māori and Pacific women at age 40, 10 years later than recommended among Māori and Pacific men [
]. Whilst sex-specific data is not available, which is a significant barrier to enabling improvements, coverage amongst the Pacific population was 89% and 85% amongst the Māori population [
]. The rates of cardiovascular risk assessment are significantly lower in Australia, with 36.1% of Aboriginal and Torres Strait Islander women receiving a general health assessment, compared to 30.7% of men [
Australian Institute of Health and Welfare Better cardiac care measures for Aboriginal and Torres Strait Islander people: fourth national report 2018–19 [Supplementary tables].
]. Despite Aboriginal and Torres Strait Islander women having a greater uptake of health assessments compared to men, evidence indicates women are not being assessed for cardiovascular risk and disease. The percentage of women with data recorded to calculate an absolute risk score was lower than men until age 65 [
Australian Institute of Health and Welfare National key performance indicators for Aboriginal and Torres Strait Islander primary health care: results to June 2018 [Supplementary tables - Preventative health].
]. This suggests absolute cardiovascular risk assessment for younger Aboriginal and Torres Strait Islander women has been under-utilised. Comparable rates are not available for the non-Indigenous population; however, it is evident that there is still significant work required to achieve assessment and management that meets population need.
A focus on risk assessment and management is warranted given the higher risk profile compared to women of other ethnicities. The mean 5-year absolute risk score is 1.7% higher for Pacific women after adjusting for age [
A comparative analysis of the cardiovascular disease risk factor profiles of Pacific peoples and Europeans living in New Zealand assessed in routine primary care: PREDICT CVD-11.
]. Almost 9% of Aboriginal and Torres Strait Islander women aged 18–74 are considered high-risk, compared to a national rate of 5.3% for women aged 18 years and over [
]. However, a glaring gap in our current knowledge is how risk and disease management is provided following the identification of risk factors.
Acute Care
Disparities in access to evidence-based time-critical care for acute coronary syndromes among Indigenous women are clearly evident. Disparities for women, and separately for Māori, Pacific, Aboriginal and Torres Strait Islander populations have been well documented [
Australian Institute of Health and Welfare Better cardiac care measures for Aboriginal and Torres Strait Islander people: fourth national report 2018–19 [Supplementary tables].
Impact of age, gender and indigenous status on access to diagnostic coronary angiography for patients presenting with non-ST segment elevation acute coronary syndromes in Australia.
]. Less discussed are the gender differentials within this. In New Zealand, the age-standardised ratio of observed to expected revascularisation (percutaneous coronary intervention [PCI] and/or coronary artery bypass graft) for ST-elevated myocardial infarction (STEMI) is 0.78 for Māori women and 0.86 for Pacific women, compared to 0.83 for Māori men and 0.98 (not statistically significantly different to other ethnicity groups) for Pacific men [
]. In Australia, the age-standardised proportion of STEMI patients receiving PCI is 63.0% for Aboriginal and Torres Strait Islander women, compared to 64.8% for male counterparts, and 67.7% for non-Indigenous women [
Australian Institute of Health and Welfare Better cardiac care measures for Aboriginal and Torres Strait Islander people: fourth national report 2018–19 [Supplementary tables].
]. There are ethnic disparities in the delivery of care with demonstrated need for revascularisation, and urgent attention is required to implementing solutions to address this need [
Minimal data exists on the utilisation of secondary prevention and cardiac rehabilitation by Māori, Pacific, Aboriginal and Torres Strait Islander women. There is, however, evidence that there are multiple barriers to accessing services for Māori, Pacific, Aboriginal and Torres Strait Islander people, including a lack of availability of services close to home, opening hours that reflect families’ needs, and services that are culturally responsive [
]. Given the young age at which Indigenous women experience cardiovascular disease, survivors often have employment, community and/or family commitments, limiting their ability to access many mainstream services. Many survivors have caring roles for family and community prior to their event, resulting in psychological, social and economic impacts of becoming ‘cared for’ [
]. Service coordination and communication barriers during acute care also limit the capacity of survivors to have a thorough knowledge of, access to, and engagement in, secondary prevention and rehabilitation [
National Health and Medical Research Council Strengthening cardiac Rehabilitation and Secondary Prevention for Aboriginal and Torres Strait Islander peoples.
Rheumatic heart disease (RHD) almost exclusively occurs in Māori and Pacific communities in New Zealand and Aboriginal and Torres Strait Islander communities in Australia. Māori and Pacific people are hospitalised for acute rheumatic fever (ARF) at up to 40 times the rate of non-Māori non-Pacific counterparts, and Aboriginal and Torres Strait Islander people hospitalised from ARF and RHD are at 7.2 times the rate of their non-Indigenous counterparts [
New Zealand guidelines for rheumatic fever: Diagnosis, management and secondary prevention of acute rheumatic fever and rheumatic heart disease: 2014 update.
RHDAustralia (ARF/RHD writing group) The 2020 Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease (3rd edition). Menzies School of Health Research.
]. RHD with previously undiagnosed ARF is often diagnosed during pregnancy, with symptoms resulting from increased cardiac workload, with poorly managed disease putting both mother and fetus at significant risk [
RHDAustralia (ARF/RHD writing group) The 2020 Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease (3rd edition). Menzies School of Health Research.
]. There have, however, been significant improvements in the treatment for young women, in particular decisions regarding choices of valvular repair or replacement with the involvement of women and their families, and family planning [
New Zealand guidelines for rheumatic fever: Diagnosis, management and secondary prevention of acute rheumatic fever and rheumatic heart disease: 2014 update.
RHDAustralia (ARF/RHD writing group) The 2020 Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease (3rd edition). Menzies School of Health Research.
]. The current guidelines for both New Zealand and Australia have detailed recommendations on management of RHD during pregnancy, including care pathways and referral algorithms) [
New Zealand guidelines for rheumatic fever: Diagnosis, management and secondary prevention of acute rheumatic fever and rheumatic heart disease: 2014 update.
RHDAustralia (ARF/RHD writing group) The 2020 Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease (3rd edition). Menzies School of Health Research.
]. The latest Australian guidelines include a new chapter on care for girls and women with ARF and RHD across the life span including transition to adult care and pre-conception, and expanded recommendations on care during pregnancy [
RHDAustralia (ARF/RHD writing group) The 2020 Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease (3rd edition). Menzies School of Health Research.
To improve cardiovascular health and wellbeing and achieve equity in health for Māori, Pacific, Aboriginal and Torres Strait Islander women, we must recognise that health is a holistic concept encompassing family and community, and the wellbeing of women is impacted not just by illness, but by social, environmental and other factors. This requires an approach that addresses inequities in the social determinants of health, gaps in the provision of care across the continuum, services, systems and structures that privilege non-Indigenous groups over others, and the need to have women and communities involved in the design, development and implementation of services.
Addressing Social Determinants
Responding to the social determinants in service provision
Health services across the continuum of care need to recognise and respond to the socio-ecological factors which impact on Māori, Pacific, Aboriginal and Torres Strait Islander women’s health. Health promotion and primary prevention programs should not be delivered in isolation; health providers must work with other sectors to integrate services that respond to women’s health, cultural, social and economic needs. Services and programs should incorporate facilities which provide socioeconomic supports into programs and connect women with social services required for health and wellbeing. Barriers limiting access to services as a result of the social determinants can be addressed across multiple sectors, such as reducing the upfront and opportunity costs of accessing services. Program evaluations and research should measure and assess the impact of social determinants on women’s health and the effectiveness of interventions to enable improved social circumstances within supportive, culturally responsive structures and services.
Recognising the Unique Roles and Strengths of Women
Understanding women’s priorities
Women’s responsibilities within family and community can make it difficult to access health services. In addition, cardiovascular services are often targeted at an older demographic, not reflecting this population’s younger profile of risk and disease. It is important to structure services to be flexible and adaptive to meet the needs of women. For example, secondary rehabilitation programs which are offered in the home, at times and locations available and accessible to women, or using telehealth to deliver alternative models of care are likely to improve access and outcomes among Indigenous women. One such model is the Heart Guide Aotearoa program, a patient self-management education initiative within a whānau and home-based program, which has increased participation in the Māori community [
Embracing the role of women as leaders, nurturers, carers and mothers
There are opportunities in service delivery to embrace the role of women in communities, particularly within health promotion and disease prevention activities. Services should recognise that in Māori, Pacific, Aboriginal and Torres Strait Islander cultures, the collective is an important structure which is required as an approach in delivery of care. Instead, current services are largely targeted at the individual. Family based models of care which support women to adopt and promote healthy choices for themselves and their families, such as the whānau ora model of care in New Zealand, is an example of what works (Box 2, Figure 1) [
The Whānau Ora model of care seeks to improve the wellbeing of whānau and families by focusing on the empowerment of whānau/families, as opposed to a deficit paradigm of care targeted at the individual. The model of care facilitates collaboration of health and social services to provide a coordinated approach to improving the health, education, housing, employment and relationships whānau and family [
The Whānau Ora programme commenced in 2010, with community-based provider collectives receiving funding to provide care to whānau/families, utilising the model of care and based on local whanau priorities and needs [
The Whānau Ora program has demonstrated positive health outcomes for Māori and Pacific whānua, with eligible clients of primary health care utilising the Whānau Ora programme achieving equivalent CVD risk assessment, despite socio-economic inequities [
Indigenous women’s cultures are centred on strong kinship networks and communities. Women draw strongly on the support of networks which result from this connectedness, and such support groups provide opportunities for knowledge sharing, health promotion activities and engagement with services. In addition to existing informal support structures, health services should establish support groups for women and build on existing community networks for health promotion, disease prevention, support and provision of rehabilitation and secondary prevention services.
Starting disease prevention early
Given the relatively high-risk profile of young Indigenous women and the focus on families, there is a clear opportunity to target healthy heart messages when women have young families. This can improve awareness of chronic disease risk, support uptake of cardiovascular risk assessment and management with the engagement of women and promote individual and family health and wellbeing. In addition, this type of approach conforms to an intergenerational transfer of knowledge as women nurture children and older people.
Culturally Safe Care
Engage communities in the design of programs
Services which engage Indigenous communities in design often embrace the worldviews of these communities. Health can be identified as a secondary benefit, such as programs which have been built to centre on re-connecting women with cultural knowledge and traditional cultural practices, with improved diet and exercise as secondary outcomes.
Focus on culturally responsive health services
Individual and institutional racism remain significant barriers to accessing care and there are well-documented gaps in the cultural safety and responsiveness of health services. For health services to be fully utilised by Indigenous women, there remains significant work to be undertaken to ensure services are safe and meet the cultural needs of women. Health professionals need to consider their own biases and how these influence the provision of care to Indigenous women. In Australia, there is an increasing demand for health services to demonstrate the provision of culturally appropriate care which involves and engages with Aboriginal and Torres Strait Islander communities, and clients and families [
Australian Commission on Safety and Quality in Health Care National safety and quality health service standards user guide for Aboriginal and Torres Strait Islander health.
Many Indigenous women are aware that cardiovascular disease has a significant impact on their communities and that they are at risk of disease. Women seek information from practitioners on risk factors, their own profile of risk, and how to reduce their risk, and health practitioners should work to ensure clear two-way communication and engagement with women to ensure they are able to act on information of risk and disease profile. This may include the use of interpreters and specifically tailored resources that have been developed with women. Improving health literacy is the role of the health system, and should include strategies to reduce complexity and barriers to access, as well as building workforce capability to improve information and communication.
Coordinated care across the life course for women with ARF and RHD
It is important to ensure continuity of care from diagnosis of ARF through secondary prevention and management of ARF to management of RHD, and from childhood to adulthood. Particularly for family planning and during pregnancy, the delivery of care under a coordinated multidisciplinary team, with informed involvement of the woman and family are critical to positive outcomes [
RHDAustralia (ARF/RHD writing group) The 2020 Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease (3rd edition). Menzies School of Health Research.
]. Continuity of care from paediatric to adult cardiology service with information systems which enable this is equally important. This can be achieved through control programs which engage women in adherence to Benzathine penicillin G, ensure clinical follow-up, facilitate specialist review, and support the transition to adult cardiology services, as well as increasing awareness of RHD among providers, supporting education and health promotion, facilitating primary prevention of ARF, and monitoring outcomes [
RHDAustralia (ARF/RHD writing group) The 2020 Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease (3rd edition). Menzies School of Health Research.
Timely recognition of acute myocardial infarction (AMI)
Presentation with an acute event at a younger age combined with symptoms more commonly seen in women, such as upper back, neck, arm and jaw pain, fatigue, weakness, and nausea, can mean that there are delays in timely recognition of AMI for these women [
]. As a specialist area, there is a responsibility to ensure the broader workforce has the appropriate knowledge to effectively identify women, particularly younger women, with a suspected myocardial infarction (MI).
Action as a Cardiology Community
The double-glazed glass ceiling
The challenges in becoming a leader in the health sector have been documented for women and for Māori, Pacific, Aboriginal and Torres Strait Islander people [
]. This glass ceiling is double-glazed for Indigenous women. Despite this, the evidence is clear that having diversity in leadership roles enhances performance and improves delivery of services to under-served populations [
]. It is crucial that we cultivate and advance these women within the cardiovascular health sector.
Closing the data gap
Whilst there is a growing source of reliable data on ethnic, sex and gender differentials across Australia and New Zealand, there is little available data on how the intersectionality of disparities impact the cardiovascular health of Indigenous women. Improved understanding of where differentials exist through high-quality data will enable service delivery to better meet the needs of women.
Conclusion
Its critically important that we provide best-evidence cardiovascular care which is culturally appropriate and meets the needs of Māori, Pacific, Aboriginal and Torres Strait Islander women. There are opportunities across the continuum of risk and disease and all sectors of the system. A priority must be to identify risk and prolong the time to onset or even prevent onset of disease, as living with a chronic condition impacts women’s ability to be leaders, carers and nurturers. The way in which we care for women can be built on the principles of the collective, a holistic understanding of cardiovascular risk and protective factors, providing services which are culturally responsive for women, and valuing the respected role of women. Addressing the evident gaps in cardiovascular care and responding to redress socio-ecological disparities experienced by women will have significant benefits not just for the individual, but for Māori, Pacific, Aboriginal and Torres Strait Islander families and communities.
Funding Sources
KMc is supported by a National Health and Medical Research Council Post-Graduate Scholarship (GNT1134198). AB is supported by a National Health and Medical Research Council Senior Research Fellowship (GNT1137563).
Conflicts of Interest
There are no conflicts of interest to disclose.
References
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National key performance indicators for Aboriginal and Torres Strait Islander primary health care: results to June 2018 [Supplementary tables - Preventative health].
A comparative analysis of the cardiovascular disease risk factor profiles of Pacific peoples and Europeans living in New Zealand assessed in routine primary care: PREDICT CVD-11.
Impact of age, gender and indigenous status on access to diagnostic coronary angiography for patients presenting with non-ST segment elevation acute coronary syndromes in Australia.
New Zealand guidelines for rheumatic fever: Diagnosis, management and secondary prevention of acute rheumatic fever and rheumatic heart disease: 2014 update.
The 2020 Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease (3rd edition). Menzies School of Health Research.
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